Product reference and member ID card guide Form

Product Reference Guide Fallon Health Member ID cards At Fallon Health, our priority is making sure our members get the care they need and deserve. And that’s why we’re proud to partner with
providers like you who offer high-quality care. At Fallon Health, it’s our goal to keep you informed about our products, policies, and member benefits. This guide is designed to help you identify Fallon Health’s member ID cards and corresponding plan details such as the referral process, copayments, and deductibles. Specific plan information may vary on individual cards, but you can always access the provider tools at fallonhealth.org/providers, or contact Provider Relations for further information. Effective: January 2026 fallonhealth.org/providers • 1-866-275-3247

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fallonhealth.org/providers • 1-866-275-3247 Our products The checked boxes indicate the Fallon Health plans you are contracted for as of __/__/____. Your Provider Relations Representative will mark the contracted plans and date. Please call Provider
Relations at 1-866-275-3247, prompt 4, if you have additional questions. Medicare Advantage plans:  Fallon Medicare Plus™ HMO..................................................................................................................4  Fallon Medicare Plus™ Premier HMO..................................................................................................6 Medicare Supplement plans:  Fallon Medicare Plus™ Supplement.....................................................................................................7 Individual and small group plans:  Fallon Health Community Care (MA Health Connector)..............................................................8 MassHealth Accountable Care Organization (ACO) plans:  Berkshire Fallon Health Collaborative (BFHC)................................................................................ 10  Fallon 365 Care.........................................................................................................................................11  Fallon Health-Atrius Health Care Collaborative (FACC).............................................................. 12 MassHealth Standard eligible seniors:  NaviCare® HMO SNP............................................................................................................................. 13 PACE program:  Summit ElderCare®.................................................................................................................................14

fallonhealth.org/providers • 1-866-275-3247
3 Important information for all Fallon Health plans • Use the procedure code look-up tool available on fallonhealth.org/providertools/ ProcedureCodeLookup to determine authorization requirements for office and facility-based procedures. • The PCP or specialist must obtain prior authorization, and the facility must
provide notification to Fallon Health.

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fallonhealth.org/providers • 1-866-275-3247 Fallon Medicare Plus ™ Medicare Advantage HMO plans Fallon Medicare Plus Medicare Advantage plans provide members with more
coverage than Original Medicare alone. This HMO network plan is for
Medicare beneficiaries across the state—from Boston to the Berkshires. Some important things to note about Fallon Medicare Plus: • Fallon Medicare Plus is for Medicare beneficiaries who live in our service area†. • There are 4 Medicare Advantage plans— • Fallon Medicare Plus Blue, Orange, and Green HMO plans • Fallon Medicare Plus Saver No Rx HMO Fallon Medicare Plus HMO John Sample ID 000000000000000 Health Plan (80840) 7942203101 PCP visit: Specialist visit: Emergency room: Same-day surgery: Part D Rx: N DB: CMS: H9001 xxx Fallon Medicare Plus HMO John Sample ID 000000000000000 Health Plan (80840) 7942203101 PCP visit: Specialist visit: Emergency room: Same-day surgery: Part D Rx: Y
RXBIN: 610011 RXPCN: CTRXMEDD RXGRP: FCHPMCR DB:
CMS: H9001 xxx Fallon Medicare Plus HMO John Sample ID 000000000000000 Health Plan (80840) 7942203101 PCP visit: Specialist visit: Emergency room: Same-day surgery: Part D Rx: Y
RXBIN: 610011 RXPCN: CTRXMEDD RXGRP: FCHPMCR DB:
CMS: H9001 xxx Fallon Medicare Plus HMO John Sample ID 000000000000000 Health Plan (80840) 7942203101 PCP visit: Specialist visit: Emergency room: Same-day surgery: Part D Rx: Y
RXBIN: 610011 RXPCN: CTRXMEDD RXGRP: FCHPMCR DB:
CMS: H9001 xxx †The Fallon Medicare Plus service area includes all of Massachusetts except Dukes and Nantucket counties.

fallonhealth.org/providers • 1-866-275-3247
5 Allowances range from $250 to $500 by plan. • Fallon Medicare Plus Saver No Rx HMO members will have a yellow ID card. All other member ID cards will correlate to the color of that member’s plan. • Members must choose a PCP from the Fallon Medicare Plus HMO network. • Members must receive PCP referrals for specialty care within the Fallon Medicare Plus HMO network of providers. • $0 annual wellness visit and $0 annual supplemental physical exam. • No medical deductible. • Use the procedure code look-up tool available on fallonhealth.org/providertools/ProcedureCodeLookup to determine authorization requirements for office and facility-based procedures. • Most plans include Medicare Part D prescription drug coverage. The Benefit Bank is included with our Green, Blue, and Saver No Rx plans. Members have up to $500/year —depending on their plan—to pay for dental care, prescription eyewear and hearing aids, and fitness/gym memberships. Plus, Green and Saver No Rx members get an additional $175 to buy over-the-counter health care items.

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fallonhealth.org/providers • 1-866-275-3247 NH NY CT RI Fallon Medicare Plus ™
Premier HMO A Medicare Advantage HMO plan
for employer or union groups Fallon Medicare Plus Premier HMO is a Medicare Advantage plan that provides members with more coverage than Original Medicare alone. This HMO network plan is for Medicare beneficiaries who receive coverage through an employer group or union. The program service area includes Massachusetts† as well as some cities and towns outside of the state. Some important things to note about Fallon Medicare Plus Premier: • Members must choose a PCP from the Fallon Medicare Plus Premier HMO network. • Members must receive PCP referrals for specialty care within the Fallon Medicare Plus Premier HMO network of providers. • $0 annual wellness visit and $0 annual supplemental physical exam. • Most plans have a $0 medical deductible.1 • Use the procedure code look-up tool available on fallonhealth.org/providertools/ProcedureCodeLookup
to determine authorization requirements for office and facility-based procedures. • Plans include Medicare Part D prescription drug coverage. All Premier plans include a Benefit Bank with $250/year that can be used to pay for dental care, prescription eyewear, fitness memberships, and fitness/gym memberships. Fallon Medicare Plus HMO John Sample ID 000000000000000 Health Plan (80840) 7942203101 PCP visit: Specialist visit: Emergency room: Same-day surgery: Part D Rx: Y
RXBIN: 610011 RXPCN: CTRXMEDD RXGRP: FCHPEGWP DB:
CMS: H9001 xxx 1 Members who receive coverage through the City of Worcester are subject to a combined $300 deductible,
per benefit period, for inpatient hospital care and inpatient psychiatric hospital services. †The Fallon Medicare Plus service area includes all of Massachusetts except Dukes and Nantucket counties.

fallonhealth.org/providers • 1-866-275-3247
7 Fallon Medicare Plus ™
Supplement Medigap plan options With Fallon’s Medicare Supplement (Medigap) plans—FMP Supplement Core,
FMP Supplement 1A, and FMP Supplement 1—members have the freedom to see the providers they want to see, when they want to see them. There are no network restrictions and little-to-no out-of-pocket expenses. No PCP. No referrals. No copayments.* Some important things to note about Fallon Medicare Plus Supplement plans: • For individual consumers who are Medicare-eligible. • Excludes Medicare Part D prescription drug coverage. • Members may see any provider they choose who accepts Medicare. Fallon Medicare Plus Supplemental plan members get: • SilverSneakers®, includes a free gym membership and access
to online classes, workouts, and instructional videos. • Care Connect offers 24/7 phone access to registered nurses
who will recommend where you should receive care or will help
connect you to your doctor. Fallon Medicare Plus Supplement 1A John Sample ID 000000000000000 Providing secondary coverage to Medicare. Deductibles apply to certain services. Fallon Medicare Plus Supplement Core John Sample ID 000000000000000 Providing secondary coverage to Medicare. Deductibles apply to certain services. Fallon Medicare Plus Supplement 1 John Sample ID 000000000000000 Providing secondary coverage to Medicare.

• Part A and/or Part B deductibles may apply.

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fallonhealth.org/providers • 1-866-275-3247 Community Care Fallon Health’s affordable Health Connector
plans for individuals and small groups in Berkshire, Bristol,
Hampden, Middlesex, Plymouth, Suffolk, and Worcester counties,
and part of Norfolk County. Fallon Health’s Community Care is designed for the subsidized and unsubsidized individual and small group markets and is available on the Massachusetts Health Connector. Some important things to note about Community Care: • The Community Care network includes: • Members of Community Care must choose a PCP from the Community Care network and must receive PCP referrals for specialty care within the Community Care network of providers. Members don’t need
a referral to see a Reliant Medical Group specialist if they have a Reliant Medical Group PCP. • $0 annual wellness visits are included with this plan. • Community Care members receive free annual wellness visits and
eye exams; have access to It Fits!, our fitness reimbursement program; Oh Baby!, which provides free prenatal vitamins, electric breast pumps, convertible car seats, and other free gifts for expectant parents; CareConnect, our 24/7 nurse call line; telehealth services, including Teladoc; and other benefits and services
to stay healthy.

John Sample ID
000000000000000 RX [Y/N] DB [Y/N] PCP visit
xx Specialist visit
xx Emergency room
xx Same-day surgery
xx Inpatient
xx Prescription
xx/xx/xx Deductible:
$xxxx/xxxx Out-of-pocket max:
$xxxx/xxxx

Regional/Limited network Community Care • Athol Memorial Hospital • Baystate Medical Center • Berkshire Health Systems—Berkshire Medical Center • Berkshire Health Systems—Fairview Hospital • Beth Israel Deaconess Medical Center (Boston, Needham, and Plymouth) • Boston Medical Center • Boston Children’s Hospital • Brockton Hospital • Cambridge Health Alliance—Cambridge Hospital • Cambridge Health Alliance—Everett Hospital • Charlton Memorial Hospital • Henry Heywood Memorial Hospital • Holyoke Medical Center • Lawrence Hospital • Lowell General Hospital • MelroseWakefield Hospital • MetroWest Medical Center—Framingham • Milford Regional Medical Center • Mount Auburn Hospital • New England Baptist Hospital • Saint Vincent Hospital • South Coast Health Network • St. Luke’s Hospital • Sturdy Memorial Hospital • Tobey Hospital • Tufts Medical Center • UMass Memorial—HealthAlliance-Clinton

 Hospital

• Other local providers

fallonhealth.org/providers • 1-866-275-3247
9 Accountable Care Organization (ACO)
for MassHealth eligible members Definitions Accountable Care Organizations (ACOs) – a group of doctors, hospitals, and other health care providers, who come together voluntarily to provide better, more coordinated care, and better patient experience for an assigned patient population. Accountable Care Organization Partner (ACO Partner) – PCPs and a health plan. Hospitals, specialists, behavioral health providers, long-term support services, and social service providers may join or partner with an ACO. Accountable Care Partnership Plan – a partnership among Fallon Health and the doctors, hospitals, and other health care providers from our ACO provider partners (e.g., Reliant Medical Group, Berkshire Health Systems, Atrius Health, etc.). Affiliate providers – providers who are not members of the ACO but have formally agreed to participate in the ACO network and provide specialty care to ACO members who are referred to them by Core Providers. Core Providers – providers who have specifically joined the ACO and maintain responsibility for providing better, more coordinated care for the assigned ACO member population. Network Provider or Provider – an appropriately credentialed and licensed individual, facility, agency, institution, organization, or other entity that has an agreement with the contractor, or any subcontractor, for the delivery of services covered under the contract. Provider Network – the collective group of network providers who have entered into provider contracts with the contractor for the delivery of ACO covered services. This includes, but is not limited to, primary care, behavioral, pharmacy, and ancillary service providers.

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fallonhealth.org/providers • 1-866-275-3247 Berkshire Fallon Health
Collaborative An Accountable Care Organization (ACO) for MassHealth eligible members Berkshire Fallon Health Collaborative (BFHC) is a MassHealth ACO—a partnership between Fallon Health and Partnership for Health in the Berkshires PHO, which includes Berkshire Health Systems, Inc., Community Health Programs, Inc., and the majority of Berkshire County community physician practices. Fallon Health is a leading health care services company that has been providing care to MassHealth members for over 45 years. Its mission is, Improving health and inspiring hope. Members of BFHC will have all their health care managed by their PCPs. Some important things to note about Berkshire Fallon Health Collaborative: • Members receive most of the same services covered under the MassHealth program, plus additional benefits and healthy “extras” offered by Fallon Health. • This plan provides services for substance use disorder and mental health benefits. • Members have access to the Oh Baby! program, which offers a free convertible toddler car seat to expecting parents. Plus, women who are pregnant receive reimbursement for completed childbirth or sibling classes and other free educational resources. • Members receive support and counseling services for tobacco addiction through Fallon Health’s Quit to Win program. • Case Management programs are available for those with complex conditions, and Disease Management programs for heart disease, diabetes, chronic obstructive pulmonary disease, and asthma. • This plan offers Teladoc®, a benefit allowing your patients to speak with a U.S. board-certified doctor by phone, video or mobile app—just in case they can’t get in touch with you for non-emergent situations. • Members must choose a PCP from the BFHC network. • PCP referrals are not required for specialty care when referred to a BFHC Core provider. • PCP referrals are required for BFHC Affiliate providers. • Out-of-network services, including specialty care visits, require prior
authorization from the Plan. • Fallon Health will allow 30 days for a retroactive entry of a PCP referral. Visit fallonhealth.org/Berkshires for more information. *Members are not eligible for It Fits! or infertility treatment. John Sample ID
000000000000000 RX [Y/N] DB [Y/N] COPAYS PCP visit
$ 0 Specialist visit
$ 0 Emergency room
$ 0 Same-day surgery
$ 0 Inpatient
$ 0 Prescription $ 1  /  3.65 MassHealth ID#: Berkshire
Fallon Health Collaborative

fallonhealth.org/providers • 1-866-275-3247
11 Fallon 365 Care An Accountable Care Organization (ACO)
for MassHealth eligible members Fallon 365 Care is a MassHealth ACO—a partnership between Fallon Health and
Reliant Medical Group. As a MassHealth ACO, Fallon 365 Care is responsible for coordinating
member care, enhancing the role of the Primary Care Provider (PCP), and delivering a more integrated and improved member experience. The Fallon 365 Care service area includes cities and towns in Worcester, Middlesex, Hampden, and Norfolk counties. The Fallon 365 Care provider network consists of all Reliant Medical Group (RMG), in addition to a small affiliate network of providers. Some important things to note about Fallon 365 Care: • Members receive most of the same services covered under the MassHealth program, plus additional benefits and healthy “extras” offered by Fallon Health. • This plan provides services for substance use disorder and mental health benefits. • Members have access to the Oh Baby! program, which offers a free convertible toddler car seat to expecting parents. Plus, women who are pregnant receive reimbursement for completed childbirth or sibling classes and other free educational resources. • Members receive support and counseling services for tobacco addiction through Fallon Health’s Quit to Win program. • Case Management programs are available for those with complex conditions, and Disease Management programs for heart disease, diabetes, chronic obstructive pulmonary disease, and asthma. • This plan offers Teladoc®, a benefit allowing your patients to speak with a U.S. board-certified doctor by phone, video or mobile app—just in case they can’t get in touch with you for non-emergent situations. • Members must choose a PCP from the Fallon 365 Care primary network. • Fallon 365 Care affiliated providers will require a referral which is generated out of ProAuth by the PCP. • Fallon Health will allow 30 days for a retroactive entry of a PCP referral. • Out-of-network services require prior authorization. Visit fallonhealth.org/365care for more information. Members are not eligible for It Fits! or infertility treatment. John Sample ID
000000000000000 RX [Y/N] DB [Y/N] COPAYS PCP visit
$ 0 Specialist visit
$ 0 Emergency room $ 0 Same-day surgery $ 0 Inpatient
$ 0 Prescription $ 1  /  3.65 MassHealth ID#: Fallon 365 Care

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fallonhealth.org/providers • 1-866-275-3247 Fallon Health-Atrius Health
Care Collaborative (FACC) An Accountable Care Organization (ACO) for MassHealth eligible members Fallon Health-Atrius Health Care Collaborative (FACC) is a MassHealth ACO—a partnership between Fallon Health and Atrius Health. As a MassHealth ACO, FACC is responsible for coordinating member care, enhancing the role of the Primary Care Provider (PCP), and delivering a more integrated and improved member experience. The FACC service area includes cities and towns in Worcester, Middlesex, Essex, Suffolk, Norfolk, and Plymouth counties. The FACC provider network consists of all Atrius Health, in addition to a small affiliate network of providers. Some important things to note about Fallon Health-Atrius Health Care Collaborative: • Members receive most of the same services covered under the MassHealth program, plus additional benefits and healthy “extras” offered by Fallon Health. • The plan provides services for substance use disorder and mental health benefits. • Members have access to the Oh Baby! Program, which offers a free convertible toddler car seat to expecting parents. Plus, women who are pregnant receive reimbursement for completed childbirth or sibling classes and other free educational resources. • Members receive support and counseling services for tobacco addiction through Fallon Health’s Quit to Win program. • Case Management programs are available for those with complex conditions, and Disease Management programs for heart disease, diabetes, chronic obstructive pulmonary disease, and asthma. • The plan offers Teladoc®, a benefit allowing your patients to speak with a U.S. board-certified doctor by phone, video or mobile app—just in case they can’t get in touch with you for non-emergent situations. • Members must choose a PCP from the FACC primary network. • FACC affiliated providers will require a referral which is generated out of ProAuth by the PCP’s office. • Fallon Health will allow 30 days for a retroactive entry of a PCP referral. • Out-of-network services require prior authorization. Visit fallonhealth.org/atriushealth for more information. John Sample ID
000000000000000 RX [Y/N] DB [Y/N] COPAYS PCP visit
$ 0 Specialist visit
$ 0 Emergency room
$ 0 Same-day surgery
$ 0 Inpatient
$ 0 Prescription $ 1  /  3.65 MassHealth ID#: Fallon Health- Atrius Health Care Collaborative Members are not eligible for It Fits! or infertility treatment.

fallonhealth.org/providers • 1-866-275-3247
13 NaviCare ® HMO SNP A Medicare Advantage Special Needs Plan NaviCare HMO SNP provides coordinated medical, prescription, and
support care for people who are 65 or older, live in the service area, and have MassHealth Standard, as well as Medicare Parts A and B. Additionally, they can’t be enrolled in another health insurance plan, except Medicare. The NaviCare service area includes all of Massachusetts, with the exception of Dukes and Nantucket counties. Some important things to note about NaviCare: • NaviCare HMO SNP is for members who are enrolled in Medicare Parts A and B, and enrolled in, or eligible for, MassHealth Standard. • NaviCare includes all MassHealth Standard and Medicare Parts A, B, and D (Rx) covered benefits, items, and services—plus more. • Members do not pay a plan premium, deductible, copayments, or coinsurance. • Members must choose a PCP from the NaviCare network, and they must receive PCP referrals for
specialty care within the NaviCare network of providers. • Members of the Care Team work in tandem with you to help your patients meet their health goals.
The Care Team gives you professionals to consult with and a coordinated care plan to reference,
to have the best information possible for your patients. • NaviCare includes unlimited free rides to and from medical appointments and other places where members receive health care. Members with qualifying chronic conditions may also have access to 100 one-way rides to run errands, visit friends, attend religious services, etc. • Behavioral Health Case Managers are also members of the Care Team when needed, making sure that NaviCare members’ behavioral health needs are addressed and met.

NaviCare HMO SNP John Sample ID 000000000000000 Health Plan (80840) 7942203101 Care Coordinator Phone
1-877-700-6996 (TRS 711) MEMBER CANNOT BE CHARGED: PCP visit: $0 Specialist visit: $0 Emergency visit: $0 Same-day surgery: $0 Rx: Y RXBIN: 610011
RXPCN: CTRXMEDD
RXGRP: FCHPSCODL DB: Y CMS: H8928 001

14 fallonhealth.org/providers • 1-866-275-3247 Summit ElderCare ® Fallon Health’s PACE program Summit ElderCare is a Program of All-Inclusive Care for the Elderly (PACE) that provides
medical care, social supports, adult day health, in-home services, transportation, and health
insurance in one program—for people who are age 55 and older, and who qualify for a nursing home level of care. The program allows participants to stay in their homes and have social ties to their communities while providing them with the coordinated care and services they need. Program participants have access to a PACE Center (there are several Summit ElderCare PACE Centers across the state) where onsite care is available. Our PACE Centers also provide adult day health services that include specialized activities and areas for those with Alzheimer’s disease, dementia, or other cognitive impairments. To be eligible, a potential participant must also live in our service area. Service area details are available at fallonhealth.org/summit. Some important things to note about Summit ElderCare: • The program is available to any person who is 55 years and older, lives in the service area, meets the Medicaid nursing facility clinical eligibility criteria, and is able to live safely at home as determined by
the Summit ElderCare Care Team. • Participants do not pay copayments, coinsurance, or deductibles for approved care. Note: If a participant is not dual eligible, they may be responsible for a portion of their monthly premium. • Care is administered by providers who are either employed by, or who have a contract with Summit ElderCare—except emergency care. • In an emergency, participants should go to the nearest emergency room for care. • Participants have access to health care and services at a Summit ElderCare PACE Center, where medical, nursing, rehabilitation, and personal care needs are coordinated. • All services require prior authorization from the PACE Care Team. • Participants receive 100% coverage for hospitalization and all
medically necessary prescription drugs, as authorized by the
Care Team. • Participants and their caregivers also receive 24-hour telephone
access to a member of their Care Team. A Program of All-Inclusive
Care for the Elderly (PACE)
offered by Fallon Health Summit ElderCare ® John Sample ID
000000000000000 Office visit
$0 Emergency room
$0 Inpatient
$0 Prescribed medications
$0 Part D Rx: Y RXBIN: 610011 RXPCN: CTRXMEDD RXGRP: FCHPPCE CMS: H2219 {001 or 002}

fallonhealth.org/providers • 1-866-275-3247
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fallonhealth.org/providers • 1-866-275-3247 This is not an approved marketing, advertising or outreach document. It is meant for training use or referral education, and not for marketing or outreach for prospects or enrollees. 23-665-005 Rev. 02 1/26 H8928260360T