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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 $101.00. 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 an enhanced alternative drug benefit. This plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have a $7 copay, while non-preferred drugs have 33% coinsurance. Specialty tier drugs have no copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Fallon Medicare Plus Blue (HMO) plan offers a variety of benefits, including coverage for inpatient and outpatient hospital stays, with varying copays depending on the service. It also covers primary care, preventive, hearing, vision, and dental services, each with its own set of copays. This plan provides coverage for ambulance, emergency, and transportation services, as well as home health, dialysis, and medical equipment. Additional benefits include coverage for skilled nursing facilities, and home infusion bundled services.
Inpatient Hospital See details
The Fallon Medicare Plus Blue (HMO) plan covers inpatient hospital stays, including services not usually covered by Medicare, with a $200 copay for Medicare-covered stays 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. Inpatient Hospital Psychiatric benefits are covered, with a $200 copay for Medicare-covered stays and a service-specific out-of-pocket maximum of $400, while Additional Days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. 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's referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services includes coverage for ground and air ambulance services, each with a $125 copay, and transportation services with a $35 copay; however, transportation services to any health-related location are not covered. Ground and air ambulance services have a service-specific out-of-pocket maximum of $500.00.
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 have a $120 copay, Urgently Needed Services have a $10 copay, and Worldwide Emergency Services have a $120 copay for Worldwide Emergency and Urgent Coverage, and a $125 copay for Worldwide Emergency Transportation.
Primary Care See details
The Fallon Medicare Plus Blue (HMO) plan covers primary care physician services with a $10 copay, chiropractic services with a $15 copay (referral required), occupational therapy services with a $15 copay (authorization and referral required), 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), additional telehealth benefits with a $0-$20 copay (referral required), and opioid treatment program services. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services include coverage for Medicare-covered services with no copay, annual physical exams, and additional preventive services. Additional preventive services may include a copay for health education, and coinsurance for wigs for hair loss related to chemotherapy. Other services like in-home safety assessments, alternative therapies, and counseling services are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $20 copay, and prescription hearing aids, but the plan does not cover fitting/evaluation for hearing aids, prescription hearing aids - inner ear, prescription hearing aids - outer ear, prescription hearing aids - over the ear, or OTC hearing aids. Prescription hearing aids (all types) have a minimum copay of $695.00 and a maximum copay of $2645.00.
Vision Services See details
Fallon Medicare Plus Blue (HMO) covers vision services, including eye exams with a $20 copay, and eyewear with a combined maximum benefit of $150 every year. Contact lenses, eyeglass lenses, and eyeglass frames are covered, and upgrades are also covered.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $20 copay. Other Dental Services include Oral Exams, Dental X-Rays, Other Diagnostic Dental Services with a $20-$40 copay, Prophylaxis (Cleaning), and Fluoride Treatment. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery are covered with copays ranging from $31 to $990. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. Medicare Part B Insulin Drugs have a copay between $0 and $35, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 10%.
Dialysis Services See details
Dialysis Services are covered by the Fallon Medicare Plus Blue (HMO) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 10% coinsurance, Prosthetic Devices and Medical Supplies with 10% coinsurance, and Diabetic Equipment, though some services are not covered. 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 Blue (HMO) plan. Diagnostic procedures and tests, lab services, therapeutic radiological services, and outpatient X-ray services are not covered, while diagnostic radiological services have a copay of at most $150.
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 technically covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. A doctor referral is required to receive these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Fallon Medicare Plus Blue (HMO) plan. For days 1-20, the copay is $15, 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; this includes acupuncture, over-the-counter items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, and more. No authorization or referrals are required for these services.
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