1-866-344-4442 (TRS 711)
Mon., Tue., Thu., Fri.: 8 a.m. to 6 p.m. Wed: 10 a.m. to 6 p.m.

Information about tiering

Fallon Health is committed to giving all of our members access to a network of high-quality, cost-efficient plan physicians and hospitals

Tiering for physicians—Direct Care and Select Care

Physicians who are specialists are tiered. Primary care providers (PCPs) are not tiered. 

All specialist tiering is based on quality and/or cost-efficiency measures. Fallon tiers the following specialties: allergy/immunology, cardiology, dermatology, endocrinology, gastroenterology, general surgery, hematology and oncology, nephrology, neurology, OB/GYN, orthopedic surgery, ophthalmalogy, otolaryngology, podiatry, pulmonary disease, rheumatology, and urology. The tiering works as follows:

*** Tier 1

Providers who meet excellent quality and/or cost efficiency standards.

Members pay the lowest copayment.

** Tier 2

Providers who meet good quality and/or cost efficiency standards.

Members pay the mid-level copayment.

* Tier 3

Providers contracted through an Academic Medical Center or specialty hospital, who do not participate in Fallon's Direct Care product.

Members will pay a higher copayment.

Not tiered

This designation includes providers that belong to a specialty or subspecialty that is not being tiered by Fallon Health.

These specialists are subject to a Tier-2 copayment.

 

Tiering for hospitals - Select Care only

Hospitals are tiered for the Select Care network only. The tiering works as follows:

*** Tier 1 (excellent)

Hospitals practicing at the most cost-efficient level.

You will pay the lowest copayment when you use a Tier 1 hospital.

** Tier 2 (good)

 Hospitals practicing at a good to above-average level of cost-efficiency.

You will pay the prevalent (mid-level) copayment when you use a Tier 2 hospital.

* Tier 3 (standard)

Hospitals practicing at a standard level of cost-efficiency.

You will pay a higher copayment when you use a Tier 3 hospital.