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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 $174.00. 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 prescription drug deductible, allowing your coverage to begin immediately. Under this plan, there is no copay for Tier 1 preferred generic drugs or Tier 6 select care drugs filled at standard pharmacies or through mail order. For Tier 2 generic drugs, you will pay a $7 copay for a one-month supply, with standard mail order offering a three-month supply for a $14 copay. Tier 3 preferred brand drugs require a $47 copay for a one-month supply, which can be extended to a three-month supply for a $94 copay via standard mail order. For higher-tier medications, Tier 4 non-preferred drugs require a 35% coinsurance, while Tier 5 specialty drugs carry a 33% coinsurance for a one-month supply.
Additional Benefits
The Fallon Medicare Plus Blue (HMO) plan offers comprehensive medical coverage with predictable costs, featuring no coinsurance for most primary, specialist, and hospital services. Members pay a $10 copay for primary care visits, while specialist visits range from a $15 to $20 copay. Inpatient hospital stays require a $200 copay per stay, and emergency room visits carry a $120 copay, both with no coinsurance. Routine preventive care, home health, and cardiac rehabilitation services are fully covered with no copay and no coinsurance. Routine dental exams require no copay, while comprehensive dental care and prescription hearing aids are available with varying copays and no coinsurance. Additionally, there are no deductibles for vision or hearing benefits, though dialysis and durable medical equipment require 20% and 10% coinsurance 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, requiring prior authorization for both and referrals for acute care. The inpatient hospital benefit is partially covered because 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, requiring a $200 copay for outpatient hospital services and a $175 copay for ambulatory surgical center services. Outpatient substance abuse sessions have a $20 copay with no coinsurance, and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Fallon Medicare Plus Blue (HMO) covers partial hospitalization services with no copay and no coinsurance. Prior authorization and a referral are required to receive these services.
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, featuring a $35 copay and no coinsurance for unlimited plan-approved trips, though transportation to any 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, which is waived if you are admitted to the hospital within 72 hours. Urgently needed services are covered with a $10 copay and no coinsurance, while worldwide emergency and urgent care are covered with a $120 copay ($125 for emergency transportation) and no coinsurance.
Primary Care See details
Primary Care benefits under Fallon Medicare Plus Blue (HMO) include primary care visits for a $10 copay and specialist visits for a $15 to $20 copay, both with no coinsurance. Physical, occupational, and speech therapies require a $15 copay, while mental health and psychiatric services have a $20 copay, all with no coinsurance. Chiropractic and podiatry services are not covered, but telehealth is offered with no copay to a $20 copay and no coinsurance.
Preventive Services See details
Fallon Medicare Plus Blue (HMO) covers annual physicals, kidney disease education, and other preventive services with no copay and no coinsurance. Additional preventive benefits are partially covered, featuring a $10 copay for health education and a 10% coinsurance for chemotherapy wigs, while services like alternative therapies, adult day health, and in-home safety assessments are not covered.
Hearing Services See details
Fallon Medicare Plus Blue (HMO) partially covers hearing services, offering one routine hearing exam annually with a $20 copay and no coinsurance, alongside up to two prescription hearing aids per year with no coinsurance and copays ranging from $695 to $2,645. There is no deductible for these services, but fitting and evaluation exams, over-the-counter (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, featuring a $20 copay and no coinsurance for one routine annual eye exam, though other eye exam services are not covered. Eyewear is covered with no copay or coinsurance, providing up to a $150 annual maximum benefit for contacts, frames, lenses, and upgrades.
Dental Services See details
Fallon Medicare Plus Blue (HMO) partially covers dental services, providing preventive care like oral exams and cleanings with no copay and no coinsurance. Comprehensive dental services, such as restorative care and oral surgery, are covered with no coinsurance and copays ranging from $31 to $990 (prior authorization required), while implants, orthodontics, maxillofacial prosthetics, and other preventive services are not covered.
Home Infusion bundled Services See details
Fallon Medicare Plus Blue (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this plan, Medicare Part B insulin drugs have a copay of $0 to $35 and no coinsurance, while chemotherapy and other Part B drugs feature no copay and a coinsurance of 0% to 10%.
Dialysis Services See details
Dialysis Services are covered by Fallon Medicare Plus Blue (HMO) 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. Diabetic equipment is partially covered with no copay and no coinsurance, though 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, requiring prior authorization and referrals for all covered services. Covered diagnostic radiological services carry a $150 copay while other covered diagnostic services have no copay, but diagnostic procedures, lab services, therapeutic radiology, and outpatient X-rays are not covered.
Home Health Services See details
Home Health Services are covered by Fallon Medicare Plus Blue (HMO) with no copay and no coinsurance, although prior authorization and a referral are required.
Cardiac Rehabilitation Services See details
Fallon Medicare Plus Blue (HMO) provides cardiac rehabilitation services with no copay and no coinsurance, although a referral is required. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Fallon Medicare Plus Blue (HMO) covers Skilled Nursing Facility (SNF) stays with no coinsurance, requiring a $15 copay for days 1 to 20, a $75 copay for days 21 to 44, and no copay for days 45 to 100. Prior authorization and referrals are required, but a prior three-day hospital stay is not, and additional days beyond the standard 100-day benefit period are not covered.
Other Services See details
Other Services are not covered under the Fallon Medicare Plus Blue (HMO) plan, as acupuncture, over-the-counter (OTC) items, and meal benefits are all excluded from coverage.
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