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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 2026, 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 2026.
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 $207.00. 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 features no drug deductible, allowing your prescription coverage to begin immediately. Under this plan, you will pay no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs at standard pharmacies or via mail order. For Tier 2 generic medications, standard pharmacy copays start at $7 for a one-month supply, with mail-order options offering savings on three-month supplies for just $14. Tier 3 preferred brand drugs require a $47 copay for a one-month supply at standard pharmacies or through mail order. Higher-tier prescriptions involve coinsurance rather than flat copays, with Tier 4 non-preferred drugs requiring 35% coinsurance and Tier 5 specialty drugs requiring 33% coinsurance for a one-month supply. These clear cost-sharing tiers make it easy to budget your annual healthcare expenses with Fallon Medicare Plus Blue (HMO).
Additional Benefits
The Fallon Medicare Plus Blue (HMO) plan offers robust coverage for essential medical services, generally featuring low copays and no coinsurance for many benefits. Members pay a $200 copay per stay with no coinsurance for inpatient hospital services, while primary care visits require a $10 copay and specialist visits cost $15 to $20. Outpatient hospital services carry a $200 copay, and emergency room visits are covered with a $120 copay, which is waived if you are admitted. Routine preventive care, home health services, and partial hospitalization are available with no copay, and dental care includes preventive services with no copay alongside comprehensive options. The plan also covers routine vision and hearing exams for a $20 copay, plus allowances for eyewear and hearing aids. Durable medical equipment is covered with a 10% coinsurance and no copay, helping to keep out-of-pocket costs manageable for necessary medical supplies.
Inpatient Hospital See details
Fallon Medicare Plus Blue (HMO) covers inpatient acute and psychiatric hospital services with a $200 copay per Medicare-covered stay and no coinsurance. This benefit is partially covered, as unlimited additional acute days are included with no copay, but non-Medicare-covered acute stays and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services under Fallon Medicare Plus Blue (HMO) feature no coinsurance across all covered services, including outpatient hospital visits with a $200 copay and ambulatory surgical center services with a $175 copay. Additionally, outpatient substance abuse sessions require a $20 copay and no coinsurance, while outpatient blood services are covered with no copay, no deductible, and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Fallon Medicare Plus Blue (HMO) with no copay and no coinsurance, though prior authorization and a referral are required.
Ambulance and Transportation Services See details
Fallon Medicare Plus Blue (HMO) covers ground and air ambulance services with a $125 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 trips from a hospital to a skilled nursing facility, but transportation to any other health-related location is not covered.
Emergency Services See details
Emergency services are covered by Fallon Medicare Plus Blue (HMO) with a $120 copay, which is waived if you are admitted to the hospital within 72 hours, and urgently needed services are covered with a $10 copay, both with no coinsurance. Worldwide emergency and urgent services are also covered with a $120 copay, and worldwide emergency transportation is covered with a $125 copay, with no coinsurance.
Primary Care See details
Fallon Medicare Plus Blue (HMO) covers primary care physician visits with a $10 copay and no coinsurance, and specialist services with a $15 to $20 copay and no coinsurance. Physical, occupational, and speech therapies are covered with a $15 copay and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Fallon Medicare Plus Blue (HMO) covers preventive services with no copay and no coinsurance for annual physical exams, kidney disease education, and standard Medicare-covered preventive services. Additional preventive benefits are partially covered, excluding in-home safety assessments, personal emergency response systems (PERS), alternative therapies, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home safety modifications, and counseling. Covered supplemental services include health education for a $10 copay and wigs for chemotherapy-related hair loss with a 10% coinsurance up to $350 annually.
Hearing Services See details
Hearing services are partially covered by Fallon Medicare Plus Blue (HMO), offering one routine hearing exam per year with a $20 copay and no coinsurance, and up to two prescription hearing aids annually with a copay ranging from $695 to $2,645 and no coinsurance. However, fitting and evaluation exams, OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aid types are not covered.
Vision Services See details
Vision services are partially covered by Fallon Medicare Plus Blue (HMO) because other eye exam services are not covered, though one annual routine eye exam is available for a $20 copay and no coinsurance. Eyewear is covered with no copay, no coinsurance, and no deductible, offering up to a $150 annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
Fallon Medicare Plus Blue (HMO) partially covers dental services with no coinsurance, offering preventive care like exams, cleanings, and x-rays with no copay. While Medicare-covered and comprehensive dental services are available with copays ranging from $20 to $990, other preventive dental, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Fallon Medicare Plus Blue (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have a coinsurance of 0% (no coinsurance) to 10%, while Part B insulin drugs feature a copay of $0.00 to $35.00 and no coinsurance.
Dialysis Services See details
Dialysis services are covered under the Fallon Medicare Plus Blue (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Fallon Medicare Plus Blue (HMO) covers durable medical equipment, prosthetic devices, and medical supplies with no copay and 10% coinsurance, requiring prior authorization. For diabetic equipment, some services are covered with no copay and no coinsurance, but diabetic supplies and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Fallon Medicare Plus Blue (HMO) partially covers diagnostic and radiological services with no coinsurance, though referrals and prior authorization are required. Diagnostic services have no copay, but diagnostic procedures, tests, lab services, therapeutic radiological services, and outpatient X-ray services are not covered, while covered diagnostic radiological services require a minimum $150 copay.
Home Health Services See details
Fallon Medicare Plus Blue (HMO) covers home health services with no copay and no coinsurance, although a referral and prior authorization are required.
Cardiac Rehabilitation Services See details
Fallon Medicare Plus Blue (HMO) covers Cardiac Rehabilitation Services with no copay and no coinsurance when a referral is obtained, though only some services are covered in practice. Specifically, cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered under this plan.
Skilled Nursing Facility (SNF) See details
Fallon Medicare Plus Blue (HMO) covers skilled nursing facility (SNF) services with no coinsurance, requiring a daily copay of $15 for days 1 through 20, $75 for days 21 through 44, and no copay for days 45 through 100. Prior authorization and referrals are required, though a prior three-day inpatient hospital stay is not, and additional days beyond the standard 100 days are not covered.
Other Services See details
Fallon Medicare Plus Blue (HMO) does not cover Other Services, meaning members must pay the full cost for acupuncture, over-the-counter (OTC) items, and meal benefits as these services are not covered.
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