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Fallon Medicare Plus Blue (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Fallon Medicare Plus Blue (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 Blue (HMO) in 2025, please refer to our full plan details page.
Fallon Medicare Plus Blue (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 Blue (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 Blue (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 Blue (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $197.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3400.00 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 Blue (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays or coinsurance amounts depending on the drug tier and pharmacy used. For example, generic drugs have a $7 or $42 copay, while brand name drugs have a $95 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Fallon Medicare Plus Blue (HMO) plan offers a range of benefits, including inpatient and outpatient hospital services, with varying copays. Emergency services are covered, as are primary care physician visits with a $10 copay. Additionally, the plan includes coverage for preventive, hearing, vision, and dental services. The plan also provides coverage for ambulance services, with a $125 copay for both ground and air transport, and transportation to health-related locations with a $35 copay. Home health services are covered with no copay, and skilled nursing facility (SNF) services are covered with copays that vary based on the length of stay. However, some services, such as cardiac rehabilitation, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric care, are covered, with a $200 copay per stay and a service-specific out-of-pocket maximum of $400; Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Non-Medicare-covered Stay for Inpatient Hospital Psychiatric benefits are covered.
Outpatient Services See details
Outpatient Services include coverage for all 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 $120 copay, while Individual and Group Sessions for Outpatient Substance Abuse have a copay between $20 and $20.
Partial Hospitalization See details
Partial Hospitalization is covered by the Fallon Medicare Plus Blue (HMO) plan, but requires prior authorization and a doctor referral. The plan covers this benefit.
Ambulance and Transportation Services See details
The Fallon Medicare Plus Blue (HMO) plan covers ambulance and transportation services, with a $125 copay for both ground and air ambulance services. Transportation services to plan-approved health-related locations have a $35 copay, and transportation to any other health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Fallon Medicare Plus Blue (HMO) plan. Emergency Services has a $120 copay, Urgently Needed Services has a $10 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have copays of $120, $120, and $125, respectively.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with a $10 copay, Chiropractic Services with a $15 copay (referral required, routine care not covered), Occupational Therapy Services with a $15 copay (authorization and referral required, no coinsurance), Physician Specialist Services with a $15-$20 copay (prior authorization and referral required), Mental Health Specialty Services with a $20 copay for individual and group sessions, Physical Therapy and Speech-Language Pathology Services with a $15 copay (authorization and referral required, no coinsurance), Additional Telehealth Benefits with a $0-$20 copay (referral required), and Opioid Treatment Program Services. Podiatry Services are not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services with no copay. Additional preventive services include Health Education with a $10 copay, Wigs for Hair Loss Related to Chemotherapy with 10% coinsurance up to $350, and Fitness Benefit with a maximum benefit of $500. Some services, such as In-Home Safety Assessment, are not covered.
Hearing Services See details
Hearing Services include Routine Hearing Exams with a $20 copay, and the plan covers one exam per year. Prescription Hearing Aids are covered, with a copay between $695 and $2645, and the plan covers two hearing aids per year, but Fitting/Evaluation for Hearing Aid, Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, and OTC Hearing Aids are not covered.
Vision Services See details
Fallon Medicare Plus Blue (HMO) covers vision services, including eye exams with a $20 copay. This plan also covers eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, with a combined maximum benefit of $150 per year for eyewear upgrades.
Dental Services See details
Dental services are covered, including Medicare dental services with a $20 copay. Other covered dental services include oral exams with a limit of 2 visits per year, dental x-rays, other diagnostic dental services with a $20-$40 copay, prophylaxis (cleaning) with a limit of 2 visits per year, fluoride treatment with a limit of 2 visits per year, restorative services with a $31-$856 copay, adjunctive general services with a $39-$157 copay, endodontics with a $107-$990 copay, periodontics with a $80-$953 copay, prosthodontics (removable) with a $37-$865 copay, prosthodontics (fixed) with a $76-$860 copay, and oral and maxillofacial surgery with a $77-$667 copay. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. For Medicare Part B Insulin Drugs, you'll pay a copay between $0 and $35. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, you may pay between 0% and 10% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Fallon Medicare Plus Blue (HMO) plan. The plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment is covered by Fallon Medicare Plus Blue (HMO), including Durable Medical Equipment (DME) with 10% coinsurance and Prosthetics/Medical Supplies, also with 10% coinsurance for Medicare-covered items. Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
The Fallon Medicare Plus Blue (HMO) plan provides diagnostic and radiological services, but diagnostic procedures/tests, lab services, therapeutic radiological services, and outpatient X-ray services are not covered. Diagnostic Radiological Services have a copay of at most $150.00, while Medicare-covered Therapeutic Radiological Services have a copay.
Home Health Services See details
Home Health Services are covered by the Fallon Medicare Plus Blue (HMO) plan with no copay and no coinsurance, but require authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Fallon Medicare Plus Blue (HMO) plan, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. A doctor's referral is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Fallon Medicare Plus Blue (HMO) plan, but require prior authorization and a doctor's referral. For days 1-20, there is a $15 copay, for days 21-44, the copay is $75, and for days 45-100, there is no copay.
Other Services See details
Other Services are not covered by the Fallon Medicare Plus Blue (HMO) plan, including acupuncture, over-the-counter items, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and several other services. No authorization or referrals are required for these services.
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