Your doctors and network

The City of Worcester Advantage plans are HMO plans, which means that in order for you to receive coverage for services, you need to see in-network providers. If you choose to see a provider who is not in your network, services will not be covered. The only exception is emergency care—with the City of Worcester Advantage plans, you are covered for worldwide emergency care, no matter where you receive it.

The Advantage plan and the Direct plan each have their own network of providers. They are designed to help you get the care you need.

The Advantage plan

  • The Advantage plan network has more than 45,000 providers throughout Massachusetts, southern New Hampshire, and southwestern Vermont, including doctors at UMass Memorial, Reliant Medical Group and CMIPA. Most likely, we have your doctor with the Advantage plan.

Tier 1 and Tier 2 providers

  • With the Advantage plan, doctors and hospitals are "tiered," which means that they are categorized. You pay a lower copayment when you go to Tier 1 doctors for office visits. You also pay a lower copayment when you go to Tier 1 hospitals for inpatient hospitalizations or same-day surgeries.

    Tier 1: This tier includes local providers affiliated with UMass Memorial, Saint Vincent Hospital and Reliant Medical Group.

    Tier 2: This tier includes all other providers and hospitals in the Advantage plan network.

The Direct plan

The Direct plan has a high-performing and concentrated network of doctors and community-based hospitals. Because this network offers members more coordinated, cost-efficient care, your premiums, copayments and deductible may be lower than the Advantage plan.

Peace of Mind Program™*

When someone in your family is sick, you never feel more vulnerable. Our Peace of Mind Program™ allows Direct plan members to get a second opinion and, if they choose, receive care from a specialist at these renowned Boston medical centers.

There are some eligibility requirements for the Peace of Mind program:

  • You must be a Direct plan member.
  • You must have seen a specialist, in your network, for the same condition within the past three months.  
  • The specialty services you are seeking must be covered services (see your Member Handbook/Evidence of Coverage for a listing of services covered with your plan). Services that are not available through the Peace of Mind Program include primary care services, mental health, substance abuse, dental care, chiropractic services, obstetrics, speech therapy and infertility services. 
  • Your PCP must request a prior authorization from The City of Worcester Advantage for you to see a Peace of Mind Program specialist.

Your PCP cannot deny you the right to request access to your Peace of Mind Program benefit. If you have difficulty receiving a referral from your PCP, call The City of Worcester Advantage customer service team at 1-855-216-5924.

* The Peace of Mind Program may be used for all specialty care except infertility services, mental health, substance abuse, chiropractic services, dental care, or speech therapy. Patients may not use the Peace of Mind Program for any primary care services, including internal medicine, family practice, pediatrics or obstetrics.

Important information

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Advantage plan

Direct plan