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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 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 $78.00. 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) prescription drug plan features an annual drug deductible of $300. Members benefit from no copay on Tier 1 preferred generic drugs and Tier 6 select care drugs. For other medications, standard one-month copays start at $7 for Tier 2 generics and $47 for Tier 3 preferred brands. For higher-tier medications, members pay a 34% coinsurance for Tier 4 non-preferred drugs and a 29% coinsurance for Tier 5 specialty drugs. Ordering a three-month supply of Tier 2 or Tier 3 drugs through standard mail order offers cost savings, capping copays at $14 and $94 respectively.
Additional Benefits
The Fallon Medicare Plus Green (HMO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no copays for routine preventive services, home health care, and primary care visits that require only a $10 copay. For more intensive care, inpatient hospital stays require a $300 daily copay for days 1 through 5 and no copay for days 6 through 90, while outpatient hospital services carry a $325 copay. Emergency room visits have a $110 copay, which is waived if you are admitted within 72 hours, and urgent care visits require a $25 copay. This plan also provides partial coverage for essential specialty services, including routine dental care with no copay and comprehensive dental options with varying copays and no coinsurance. Routine eye and hearing exams are available with a $40 copay, alongside allowances for eyewear and prescription hearing aids. Additionally, members benefit from a $175 annual allowance for over-the-counter items with no copay, while durable medical equipment and dialysis services require a 20% coinsurance.
Inpatient Hospital See details
Fallon Medicare Plus Green (HMO) covers inpatient hospital services with no coinsurance, requiring a $300 daily copayment for days 1 through 5 and no copayment for days 6 through 90 for both acute and psychiatric stays. Unlimited additional acute care days are covered with no copayment, but additional psychiatric days, upgrades, and non-Medicare-covered acute stays 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 requiring prior authorization and referrals with no coinsurance. Outpatient substance abuse services have a $40 copay per session with no coinsurance, while outpatient blood services are covered with no copay, deductible, or coinsurance.
Partial Hospitalization See details
Fallon Medicare Plus Green (HMO) covers partial hospitalization benefits with no copay and no coinsurance. Prior authorization and a referral are required to access this coverage.
Ambulance and Transportation Services See details
Fallon Medicare Plus Green (HMO) covers ground and air ambulance services with a $225 copay and no coinsurance, though prior authorization is required. Transportation services are partially covered with a $35 copay and no coinsurance for unlimited one-way chairvan rides from a hospital to a skilled nursing facility, but transportation to any other health-related location is not covered.
Emergency Services See details
Fallon Medicare Plus Green (HMO) covers emergency services with a $110 copay and no coinsurance, which is waived if you are admitted to the hospital within 72 hours. Urgently needed services carry a $25 copay and no coinsurance, while worldwide emergency and urgent care have a $110 copay, and worldwide emergency transportation has a $225 copay, all with no coinsurance.
Primary Care See details
Fallon Medicare Plus Green (HMO) covers primary care physician services with a $10 copay and specialist visits with a $20 to $40 copay, both with no coinsurance. Physical, occupational, and speech therapies require a $20 copay and mental health sessions require a $40 copay, all with no coinsurance, while podiatry and chiropractic services are not covered.
Preventive Services See details
Fallon Medicare Plus Green (HMO) covers preventive services, offering annual physical exams, kidney disease education, and other routine screenings with no copay and no coinsurance. Additional preventive benefits are partially covered, with health education requiring a $25 copay and chemotherapy wigs requiring a 20% coinsurance, while services like in-home safety assessments, alternative therapies, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered by Fallon Medicare Plus Green (HMO), featuring routine hearing exams with a $40 copay, no coinsurance, and a required referral. Prescription hearing aids are covered up to two per year with no coinsurance and a copay ranging from $695 to $2,645, but hearing aid evaluations, OTC hearing aids, and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by Fallon Medicare Plus Green (HMO), as other eye exam services are not covered. Covered benefits include one routine eye exam per year with a $40 copay and no coinsurance, and eyewear with no copay and no coinsurance up to a $150 annual maximum for contact lenses, upgrades, and one pair of eyeglasses.
Dental Services See details
Dental services are partially covered by Fallon Medicare Plus Green (HMO), offering preventive care like exams, cleanings, and x-rays with no copay and no coinsurance, and Medicare-covered dental with a $40 copay and no coinsurance. Comprehensive options like restorative and endodontic services are covered with copays ranging from $31 to $990 and no coinsurance, but other preventive services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Fallon Medicare Plus Green (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B insulin drugs have a copay of $0 to $35 and no coinsurance, while other Part B chemotherapy and radiation drugs carry a coinsurance of 0% to 20%.
Dialysis Services See details
Dialysis services are covered under the Fallon Medicare Plus Green (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Fallon Medicare Plus Green (HMO) covers durable medical equipment and prosthetics with no copay and 20% coinsurance, both requiring prior authorization. While some diabetic equipment services are covered with no copay and no coinsurance, diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Fallon Medicare Plus Green (HMO) partially covers diagnostic and radiological services with no coinsurance, though prior authorization and referrals are required. Covered diagnostic services carry no copay, and diagnostic radiological services require a minimum $250.00 copay, but diagnostic procedures, lab services, therapeutic radiological services, and outpatient X-rays are not covered.
Home Health Services See details
Fallon Medicare Plus Green (HMO) covers home health services with no copay and no coinsurance. Prior authorization and a referral are required to access this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Fallon Medicare Plus Green (HMO) plan, as all related sub-services, including intensive cardiac, pulmonary, and SET for PAD services, are excluded from coverage.
Skilled Nursing Facility (SNF) See details
Fallon Medicare Plus Green (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 to 20 and days 45 to 100, and a $150 daily copay for days 21 to 44. This benefit is limited to 100 days per benefit period as additional days are not covered, requires prior authorization and a referral, and does not require a prior three-day inpatient hospital stay.
Other Services See details
Fallon Medicare Plus Green (HMO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum annual benefit of $175. Acupuncture, meal benefits, and other miscellaneous services are not covered under this plan.
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