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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

How does tiering work?

Physicians - Direct Care and Select Care

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. Primary care providers (PCPs) are not tiered. 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 (NT): 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.

Hospitals - Select Care 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.