Plan documents

Simply click on the links below to download the document you are interested in.

Summary of Benefits

A Summary of Benefits is a booklet that lists and compares plan benefits.

For Worcester County and portions of Franklin County:

For Barnstable, Bristol, Essex, Middlesex, Norfolk, Plymouth and Suffolk Counties:

For Hampden and Hampshire Counties:

Compare your plan options

These documents show benefit and cost information in a chart format so that you can compare your plan options.

Provider and Pharmacy Directories

These directories provide lists of network providers, including physicians, specialists, hospitals, pharmacies and other providers. Some providers may have been added or removed from this list after the directory was created. Use our "Find a Pharmacy" or "Find a doctor" tool for the most up-to-date information. (This link takes you away from the Fallon Senior Plan website.)

If you would like a Provider Directory or Pharmacy Directory mailed to you, complete our online form.

How to get care from out-of-network providers (for HMO plans)
You may get services from out-of-network providers when providers of specialized services are not available in network. For services to be covered from an out-of-network provider, your in-network provider (usually your PCP) must request prior authorization (approval in advance) from Fallon Senior Plan. The prior authorization request will be reviewed by Fallon Health's Utilization Management Program staff who are trained to understand the specialist’s area of expertise and will attempt to ascertain if that service is available within Fallon Senior Plan’s network of specialists. If the service is not available within your plan’s network, your request will be approved. There may be certain limitations to the approval, such as just one initial consultation visit or a specified type or amount of services. If the specialist’s services are available within your plan’s network, the request for services outside of the network may be denied as “services available in network.” As with any denial, you will have the option to appeal the determination.

How to get care from out-of-network providers (for HMO-POS plans)
With our HMO-POS plans, you are covered for certain out-of-network services. Some out-of-network specialty services will be covered at the same cost-sharing as in-network services, while other services, such as inpatient hospitalization, will be covered at a different cost-sharing. Additionally, certain covered services, such as primary care, may only be received from in-network providers. You can get certain covered services from an out-of-network provider; however, that provider must participate in Medicare and accept you as a patient. We cannot pay a provider who has decided not to participate in Medicare. You may need to get a referral or prior authorization for certain services.

Evidence of Coverage

An Evidence of Coverage is a booklet that we provide once you become a member. It’s part of your contract with us and it describes your complete benefits as well as how to use the plan.

You can find information about our grievance, coverage determination and appeal (and exceptions for Part D if the plan includes Part D) processes in your Evidence of Coverage. Please refer to the section called "What to do if you have a problem or complaint (coverage decisions, appeals, compliants)."

You can also find information about your rights and responsibilities as a member of our plan in your Evidence of Coverage. Please refer to the section called "Your rights and responsibilities."

Other documents and information

Medicare Plan ratings
The Medicare Program rates how well Medicare health and drug plans perform in different categories (for example, detecting and preventing illness, ratings from patients, patient safety, drug pricing and customer service). The information in this document is an overall plan rating of our plan's performance.

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Dental Services Copayments
This addendum provides you with the copayments that you are responsible for when you get covered dental care from a plan dentist.

Annual Notice of Changes (ANOC)

An ANOC is a document which explains any changes in your coverage, costs, or service area that will be effective on January 1, 2017.

Fallon Health is an HMO/HMO-POS plan with a Medicare contract. Enrollment in Fallon Health depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The pharmacy network and/or the provider network may change at any time. You will receive notice when necessary. To view the PDF files above, you may need to download a free copy of Adobe® Acrobat Reader software on your computer. (This link takes you away from the Fallon Senior Plan website.)

H9001_F_2017_21 Approved 10172016
The information on this page was last updated on 10/1/2016.

Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., Monday–Friday. (Oct. 1–Feb. 14, seven days a week.)

Other resources and tools

Medicare Part D online forms