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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 2025, 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 2025.
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 $68.00. 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 $175.00 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 has a $175 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, in the initial coverage phase, you'll pay a $7 copay for preferred generic drugs at a standard pharmacy. For non-preferred drugs, you'll pay 31% coinsurance. Specialty tier drugs have no copay.
Additional Benefits
The Fallon Medicare Plus Green (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $300 copay for the first 5 days, with no copay for additional days, and outpatient services come with a copay between $40 and $275. The plan also covers ambulance and transportation services, as well as emergency services with copays ranging from $5 to $225. Additional benefits include coverage for primary care with a $5 copay, hearing exams with a $40 copay, and vision services with a $40 copay for eye exams. Dental services have copays from $20 to $990, and home health services have no copay. The plan also covers home infusion and dialysis services with coinsurance, and diagnostic radiological services with a $250 copay.
Inpatient Hospital See details
Inpatient hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a $300 copay for days 1-5 and no copay for days 6-90; Non-Medicare-covered Stay for Inpatient Hospital-Acute and Upgrades for Inpatient Hospital-Acute are not covered, and Additional Days for Inpatient Hospital Psychiatric is not covered. Additional days for Inpatient Hospital-Acute are covered with no copay.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services and ambulatory surgical center services have a $275 copay, and individual and group sessions for outpatient substance abuse have a $40 copay.
Partial Hospitalization See details
Partial Hospitalization is covered with prior authorization and a doctor referral.
Ambulance and Transportation Services See details
The Fallon Medicare Plus Green (HMO) plan covers ambulance and transportation services. Ground and air ambulance services have a $225 copay, while transportation services to a plan-approved health-related location have a $35 copay.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Fallon Medicare Plus Green (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services has a $5 copay, and Worldwide Emergency Transportation has a $225 copay. There is no coinsurance for any of these services.
Primary Care See details
The Fallon Medicare Plus Green (HMO) plan covers Primary Care Physician Services with a $5 copay, Chiropractic Services with a $20 copay (requires a doctor referral), Occupational Therapy Services with a $20 copay, Physician Specialist Services with a $20-$40 copay (prior authorization and a doctor referral are required), Mental Health Specialty Services with a $40 copay for individual and group sessions, Physical Therapy and Speech-Language Pathology Services with a $20 copay (authorization and referral are required), and Additional Telehealth Benefits with a $0-$40 copay (doctor referral is required). Podiatry Services are not covered.
Preventive Services See details
Preventive services are covered, including annual physical exams, with no copay or coinsurance. Health education has a $25 copay, while wigs for hair loss related to chemotherapy have a 20% coinsurance up to a $350 maximum. Other services like in-home safety assessments, therapeutic massage, and counseling services are not covered.
Hearing Services See details
Hearing services under the Fallon Medicare Plus Green (HMO) plan include hearing exams with a $40 copay, with routine hearing exams covered once per year. Prescription hearing aids are covered, with a copay between $695 and $2645, but fitting/evaluation for hearing aids, prescription hearing aids for the inner, outer, or over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $40 copay, eyewear with a combined maximum benefit of $150 per year, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are covered once per year.
Dental Services See details
Dental Services are covered under the Fallon Medicare Plus Green (HMO) plan, with a $40 copay for Medicare Dental Services. Other diagnostic services have a copay between $20-$40, while restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, fixed, and oral and maxillofacial surgery have copays ranging from $31-$990. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including insulin, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a copay between $0 and $35, and for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Fallon Medicare Plus Green (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment benefits are covered under the Fallon Medicare Plus Green (HMO) plan, with a 20% coinsurance for durable medical equipment, prosthetic devices, and medical supplies, and no copay. Durable medical equipment for use outside the home, diabetic supplies, and diabetic therapeutic shoes/inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Fallon Medicare Plus Green (HMO) plan. Diagnostic services and lab services are not covered, while diagnostic radiological services have a copay of $250, and therapeutic radiological services and outpatient X-ray services are not covered.
Home Health Services See details
Home Health Services are covered by the Fallon Medicare Plus Green (HMO) plan with no copay or coinsurance, but additional hours of care and personal care services are not covered. This benefit requires prior authorization and a referral.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Fallon Medicare Plus Green (HMO) plan. This includes Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Fallon Medicare Plus Green (HMO) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20, a $150 copay for days 21-44, and no copay for days 45-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items with a maximum plan benefit of $255 per year, and it also includes Nicotine Replacement Therapy (NRT) and Naloxone coverage as a Part C OTC benefit. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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