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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.