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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 $164.00. 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. During the initial coverage phase, your cost for drugs will vary depending on the tier and pharmacy. For example, you will pay a $7 copay for preferred generic drugs at standard pharmacies and a $42 copay for standard generic drugs at standard pharmacies. Specialty tier drugs have no copay.
Additional Benefits
The Fallon Medicare Plus Blue (HMO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays. Emergency services and ambulance services are covered, and primary care visits have a low copay. This plan also includes preventive services with no copay for Medicare-covered services, along with vision and dental benefits. Hearing exams and hearing aids are covered, as well as home health services and skilled nursing facility stays with copays depending on the length of stay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a $200 copay for a Medicare-covered stay, and a service-specific out-of-pocket maximum of $400.00. Additional Days for Inpatient Hospital-Acute are also covered with no copay, while Non-Medicare-covered Stay for Inpatient Hospital Psychiatric is 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 by Fallon Medicare Plus Blue (HMO). Outpatient hospital services and ambulatory surgical center services have a $120 copay, while individual and group sessions for outpatient substance abuse have a $20 copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Fallon Medicare Plus Blue (HMO) plan, but requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Fallon Medicare Plus Blue (HMO) plan, including ground and air ambulance services with a $125 copay. Transportation Services to a plan-approved health-related location are covered with a $35 copay, but transportation to any 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 have a $120 copay, and Urgently Needed Services have a $10 copay, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $120 copay, and Worldwide Emergency Transportation has a $125 copay.
Primary Care See details
Primary Care for 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, Physician Specialist Services with a $15-$20 copay (prior authorization and referral required), and Mental Health Specialty Services with a $20 copay for individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a $15 copay (authorization and referral required), Additional Telehealth Benefits have a $0-$20 copay (referral required), while Podiatry Services are not covered.
Preventive Services See details
Preventive services include coverage for Medicare-covered services with no copay, annual physical exams, additional preventive services, kidney disease education services, and other preventive services. Health education has a $10 copay, while wigs for hair loss related to chemotherapy have a 10% coinsurance and a maximum plan benefit coverage amount of $350. Weight management programs and fitness benefits are covered, with a maximum plan benefit coverage amount of $500. In-home safety assessments, personal emergency response systems, alternative therapies, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers, enhanced disease management, telemonitoring services, home and bathroom safety devices, and counseling services are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $20 copay, limited to one exam per year, and prescription hearing aids with a copay between $695 and $2645 for up to two hearing aids per year. Fitting/evaluation for hearing aids, prescription hearing aids (inner ear, outer ear, and over the ear), and OTC hearing aids are not covered.
Vision Services See details
The Fallon Medicare Plus Blue (HMO) plan covers vision services, including routine eye exams with a $20 copay. The plan also covers eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, and has a combined maximum benefit of $150 per year for eyewear.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $20 copay, and other dental services with no maximum plan benefit coverage. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and fluoride treatments are covered. Orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are also covered, with varying copays. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
The Fallon Medicare Plus Blue (HMO) plan covers Home Infusion bundled Services, including Medicare Part B Insulin Drugs with a copay between $0 and $35, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0% and 10%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Fallon Medicare Plus Blue (HMO) plan. You will pay a 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment is covered by Fallon Medicare Plus Blue (HMO), including Durable Medical Equipment with a 10% coinsurance and Prosthetics/Medical Supplies with a 10% coinsurance, but 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/tests, lab services, therapeutic radiological services, and outpatient x-ray services are not covered, while diagnostic radiological services have a copay of at most $150.00.
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 some services are not covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. A doctor 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, there is a $75 copay, and for days 45-100, there is no copay. Additional days beyond Medicare-covered, and non-Medicare-covered stays are not covered.
Other Services See details
Other Services are not covered by the Fallon Medicare Plus Blue (HMO) plan. Specific services that are not covered include acupuncture, over-the-counter items, meal benefits, and several others.
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