A non-government entity
Fallon Medicare Plus Green (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Fallon Medicare Plus Green (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Fallon Medicare Plus Green (HMO) in 2026, please refer to our full plan details page.
Fallon Medicare Plus Green (HMO) is a HMO plan offered by Fallon Community Health Plan, Inc. available for enrollment in 2025 to people living in Massachusetts except Dukes and Nantucket Counties. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Fallon Medicare Plus Green (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Fallon Medicare Plus Green (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Fallon Medicare Plus Green (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $67.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $300.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $5200.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Fallon Medicare Plus Green (HMO) plan features an annual drug deductible of $300. Under this plan, Tier 1 preferred generics and Tier 6 select care drugs are available with no copay for standard pharmacy and mail order fills. Tier 2 generic drugs are also highly affordable, costing a low $7 copay for a one-month supply. Tier 3 preferred brand drugs require a $47 copay for a one-month supply through standard pharmacies and mail order. For higher-tier prescriptions, Tier 4 non-preferred drugs require a 34% coinsurance, while Tier 5 specialty drugs carry a 29% coinsurance.
Additional Benefits
The Fallon Medicare Plus Green (HMO) plan offers robust healthcare coverage with predictable out-of-pocket costs, featuring fixed copayments and no coinsurance for most core medical services. Primary care visits require a $10 copay, specialist visits range from $20 to $40, and inpatient hospital stays carry a $300 daily copay for the first five days with no copay for subsequent days. Emergency room visits have a $110 copay, which is waived if admitted, while urgently needed services require a $25 copay. For supplemental benefits, members enjoy routine dental exams, cleanings, and preventive care with no copay, alongside an annual $150 eyewear allowance and a $175 over-the-counter benefit. Routine hearing and eye exams require a $40 copay, while prescription hearing aids are covered with copayments between $695 and $2,645. Additionally, home health services and initial skilled nursing stays feature no copay, whereas durable medical equipment and dialysis services require a 20% coinsurance.
Inpatient Hospital See details
Fallon Medicare Plus Green (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, featuring a $300 daily copay for days 1 to 5 and no copay for days 6 to 90. This benefit is partially covered, as upgrades, non-Medicare-covered acute stays, and additional psychiatric days are not covered.
Outpatient Services See details
Fallon Medicare Plus Green (HMO) covers outpatient hospital services with a $325 copay and ambulatory surgical center services with a $300 copay, both featuring no coinsurance. Outpatient substance abuse services carry a $40 copay per session with no coinsurance, while outpatient blood services are provided with no copay and no coinsurance.
Partial Hospitalization See details
Fallon Medicare Plus Green (HMO) covers partial hospitalization services with no copay and no coinsurance. Prior authorization and a referral are required to access this covered benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Fallon Medicare Plus Green (HMO), requiring a $225 copay and no coinsurance for ground and air ambulance services under prior authorization. Transportation services are partially covered with a $35 copay and no coinsurance for unlimited one-way chairvan trips from a hospital to a skilled nursing facility, but transportation to other health-related locations is not covered.
Emergency Services See details
Emergency services are covered by Fallon Medicare Plus Green (HMO) with a $110 copay and no coinsurance, and the copay is waived if admitted to the hospital within 72 hours. Urgently needed services have a $25 copay and no coinsurance, while worldwide emergency and urgent care require a $110 copay, and worldwide emergency transportation carries a $225 copay with no coinsurance.
Primary Care See details
Fallon Medicare Plus Green (HMO) covers primary care physician visits with a $10 copay and specialist services with a $20 to $40 copay, both with no coinsurance. Covered physical, occupational, mental health, and psychiatric therapies require copays between $20 and $40 with no coinsurance, while podiatry and chiropractic services are not covered. Telehealth services feature no copay to a $40 copay, and opioid treatment is available with no copay and no coinsurance.
Preventive Services See details
Fallon Medicare Plus Green (HMO) offers partially covered preventive services with no copay and no coinsurance for annual physical exams, kidney disease education, and standard screenings. While some additional benefits require a $25 copay for health education or a 20% coinsurance for chemotherapy wigs (up to $350 annually), several sub-services are not covered, including alternative therapies, counseling, and in-home safety assessments.
Hearing Services See details
Fallon Medicare Plus Green (HMO) partially covers hearing services, including one annual routine hearing exam with a $40 copay and no coinsurance, and up to two prescription hearing aids per year with a copay ranging from $695 to $2,645 and no coinsurance. Fitting and evaluation for hearing aids, over-the-counter (OTC) hearing aids, and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Fallon Medicare Plus Green (HMO), with other eye exam services being excluded from coverage. Routine eye exams are covered once per year with a $40 copay and no coinsurance, while eyewear is covered with no copay and no coinsurance up to a $150 annual maximum.
Dental Services See details
Dental services are partially covered by Fallon Medicare Plus Green (HMO), featuring no copay and no coinsurance for routine exams, cleanings, and fluoride, although other preventive services, maxillofacial prosthetics, implants, and orthodontics are not covered. Medicare-covered dental services require a $40 copay, and covered comprehensive services have copays ranging from $31 to $990, with no coinsurance required across all covered benefits.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Fallon Medicare Plus Green (HMO) with no copay, though prior authorization is required. Under this plan, Part B insulin has a $0 to $35 copay and no coinsurance, while chemotherapy and other Part B drugs require no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Fallon Medicare Plus Green (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Fallon Medicare Plus Green (HMO) with no copay and a 20% coinsurance for durable medical equipment, prosthetics, and medical supplies, all requiring prior authorization. While diabetic equipment is covered with no copay and no coinsurance, diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Fallon Medicare Plus Green (HMO) with no coinsurance, though prior authorization and referrals are required. Diagnostic services feature no copay, but diagnostic procedures, tests, and lab services are not covered. Covered diagnostic radiological services require a $250 copay, while therapeutic radiological services and outpatient x-ray services are not covered.
Home Health Services See details
Fallon Medicare Plus Green (HMO) covers home health services with no copay and no coinsurance, though prior authorization and a referral are required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Fallon Medicare Plus Green (HMO) plan, as standard cardiac, intensive cardiac, pulmonary, and SET for PAD services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Fallon Medicare Plus Green (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization and a referral are required. There is no copay for days 1 to 20 and days 45 to 100, a $150 copay for days 21 to 44, and additional days beyond the standard Medicare limit are not covered.
Other Services See details
Fallon Medicare Plus Green (HMO) partially covers other services, featuring an over-the-counter (OTC) benefit with no copay and no coinsurance up to a maximum benefit of $175.00 per year. Acupuncture and meal benefits are not covered under this plan.
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