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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 $111.00. 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 a $0 drug deductible, allowing your prescription drug coverage to begin immediately. You will pay no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs through standard pharmacies or standard mail order. For Tier 2 generic medications, standard pharmacy and mail order costs start at a $7 copay for a one-month supply. For Tier 3 preferred brand drugs, you will pay a $47 copay for a one-month supply at standard pharmacies or through mail order. Higher-tier prescriptions require coinsurance instead of a flat copay, with Tier 4 non-preferred drugs requiring 35% coinsurance and Tier 5 specialty drugs requiring 33% coinsurance for a one-month supply. Standard mail order provides additional savings on three-month supplies for Tier 2 and Tier 3 drugs.
Additional Benefits
The Fallon Medicare Plus Blue (HMO) plan offers robust coverage with predictable out-of-pocket costs for essential medical services. Members pay a $200 copay per stay for inpatient hospital care and no coinsurance, while primary care visits require a $10 copay and specialist visits cost between $15 and $20. Emergency care is available for a $120 copay, and outpatient hospital services feature a $200 copay, both with no coinsurance. Routine preventive care, annual physical exams, and home health services are fully covered with no copay and no coinsurance. Additionally, the plan provides routine dental cleanings and eyewear with no copay, alongside routine vision and hearing exams for a $20 copay. Durable medical equipment and dialysis require no copay but carry coinsurance rates of 10% and 20% respectively.
Inpatient Hospital See details
Fallon Medicare Plus Blue (HMO) covers inpatient acute and psychiatric hospital stays with a $200 copay per stay and no coinsurance. This benefit is partially covered, as upgrades and non-Medicare-covered stays for acute care, as well as additional days for psychiatric care, are not covered.
Outpatient Services See details
Fallon Medicare Plus Blue (HMO) covers outpatient services with no coinsurance, including outpatient hospital services for a $200 copay and ambulatory surgical center services for a $175 copay. Outpatient substance abuse sessions require a $20 copay with no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Fallon Medicare Plus Blue (HMO) covers partial hospitalization services 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, subject to prior authorization. Transportation services are partially covered with a $35 copay and no coinsurance for plan-approved 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
Fallon Medicare Plus Blue (HMO) covers emergency services with a $120 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 72 hours. Urgently needed care requires a $10 copay and no coinsurance, while worldwide emergency and urgent services have a $120 copay and worldwide emergency transportation has a $125 copay, all with no coinsurance.
Primary Care See details
Fallon Medicare Plus Blue (HMO) covers primary care visits for a $10 copay and specialist visits for a $15 to $20 copay, both with no coinsurance. Physical, occupational, speech, mental health, and psychiatric services are covered with copays ranging from $15 to $20 and no coinsurance, while opioid treatment features no copay and no coinsurance. Podiatry is not covered, and for chiropractic services, only some services are covered as routine and other chiropractic services are not covered.
Preventive Services See details
Fallon Medicare Plus Blue (HMO) partially covers preventive services, offering no copay and no coinsurance for annual physical exams, kidney disease education, and other preventive screenings. While health education is covered with a $10 copay and no coinsurance and chemotherapy wigs with 10% coinsurance and no copay, the plan does not cover in-home safety assessments, PERS, alternative therapies, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, home modifications, and counseling.
Hearing Services See details
Fallon Medicare Plus Blue (HMO) offers partially covered hearing services, including one routine hearing exam annually for a $20 copay and no coinsurance, requiring a referral. Up to two prescription hearing aids are covered per year with no coinsurance and a copay ranging from $695.00 to $2,645.00, though fitting and evaluations, OTC hearing aids, and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Fallon Medicare Plus Blue (HMO) partially covers vision services with no deductibles, though other eye exam services are not covered. Routine eye exams are covered with a $20 copay and no coinsurance, while eyewear is available with no copay, no coinsurance, and a $150 annual maximum benefit.
Dental Services See details
Fallon Medicare Plus Blue (HMO) partially covers dental services with no coinsurance, offering routine preventive care like cleanings and exams for no copay, and other diagnostic services for a $20 to $40 copay. Covered comprehensive services require prior authorization and have copays ranging from $31 to $990 with no coinsurance. 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 and other drugs require a 0% to 10% coinsurance, while Part B insulin is covered with a $0 to $35 copay 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 and prosthetics with no copay and a 10% coinsurance, subject to prior authorization. Diabetic equipment is covered with no copay and no coinsurance, but the benefit is only partially covered as diabetic supplies and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Fallon Medicare Plus Blue (HMO) with no coinsurance, requiring prior authorization and referrals. Covered diagnostic services have no copay, though diagnostic procedures, tests, and lab services are not covered. Diagnostic radiological services require a $150 copay, but therapeutic radiological and outpatient x-ray services are not covered.
Home Health Services See details
Home health services are fully covered under Fallon Medicare Plus Blue (HMO) with no copay and no coinsurance. Members should note that both prior authorization and a referral are required to receive these services.
Cardiac Rehabilitation Services See details
Fallon Medicare Plus Blue (HMO) covers some Cardiac Rehabilitation Services with no copay and no coinsurance when a referral is obtained, though specific services like Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD are not covered.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) services are covered by Fallon Medicare Plus Blue (HMO) with no coinsurance, featuring a daily copay of $15 for days 1 to 20, $75 for days 21 to 44, and no copay for days 45 to 100. Prior authorization and referrals are required, a prior three-day hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
Other Services are covered under Fallon Medicare Plus Blue (HMO), but acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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