A non-government entity
Fallon Medicare Plus Orange (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Fallon Medicare Plus Orange (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 Orange (HMO) in 2026, please refer to our full plan details page.
Fallon Medicare Plus Orange (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 Orange (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 Orange (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 Orange (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 a $400.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $7550.00 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 Orange (HMO) plan features a $400 annual prescription drug deductible. Members enjoy no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs filled at standard pharmacies or through standard mail order. Tier 2 generic drugs are also highly affordable, requiring just a $7 copay for a one-month supply. For brand-name and specialty prescriptions, Tier 3 preferred brand drugs have a $47 copay for a one-month supply. Tier 4 non-preferred drugs require a 35% coinsurance, while Tier 5 specialty drugs carry a 28% coinsurance for a one-month supply. Standard mail-order options for Tier 2 and Tier 3 drugs offer additional savings on three-month supplies.
Additional Benefits
The Fallon Medicare Plus Orange (HMO) plan offers comprehensive medical coverage with predictable costs, featuring no copay for preventive services and a low $10 copay for primary care visits. Specialty care visits range from a $20 to $50 copay, while emergency room visits require a $115 copay that is waived if you are admitted. For hospital stays, members pay a $385 copay for the first few days of inpatient care with no copay thereafter, while outpatient hospital services carry a $450 copay. This plan also includes key dental, vision, and hearing benefits with no coinsurance for routine care. Preventive dental cleanings and exams have no copay, routine vision and hearing exams require a $50 copay, and eyewear is covered up to $150 annually. Additionally, home health care is covered with no copay, while durable medical equipment and dialysis services require a 20% coinsurance.
Inpatient Hospital See details
Fallon Medicare Plus Orange (HMO) covers inpatient hospital services with no coinsurance, requiring a $385 copay for days 1 to 7 of acute stays (with no copay thereafter) and a $385 copay for days 1 to 4 of psychiatric stays (with no copay for days 5 to 90). Note that certain services, including non-Medicare-covered acute stays, acute upgrades, and additional psychiatric days, are not covered.
Outpatient Services See details
Fallon Medicare Plus Orange (HMO) covers outpatient hospital services with a $450 copay and ambulatory surgical center services with a $400 copay, both with no coinsurance. Outpatient substance abuse sessions have a $40 copay and no coinsurance, while outpatient blood services are available with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by Fallon Medicare Plus Orange (HMO) with no copay and no coinsurance. To access this benefit, both prior authorization and a referral are required.
Ambulance and Transportation Services See details
Fallon Medicare Plus Orange (HMO) partially covers ambulance and transportation services, featuring a $325 copay and no coinsurance for ground and air ambulance services. Transportation to plan-approved locations, such as one-way chairvan transfers from a hospital to a Skilled Nursing Facility, is covered with a $35 copay and no coinsurance, while transportation to any other health-related location is not covered.
Emergency Services See details
Emergency services are covered by Fallon Medicare Plus Orange (HMO) with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 72 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with copays ranging from $115 to $325 and no coinsurance.
Primary Care See details
Primary care benefits under Fallon Medicare Plus Orange (HMO) include primary care physician visits for a $10 copay and specialist visits for a $20 to $50 copay, both with no coinsurance. Physical, occupational, and speech therapies require a $20 copay, mental health and psychiatric services have a $40 copay, and telehealth ranges from no copay to a $50 copay, all with no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by Fallon Medicare Plus Orange (HMO), featuring annual physicals and kidney disease education with no copay and no coinsurance, alongside health education for a $10 copay and no coinsurance. Chemotherapy wigs are covered with a 20% coinsurance and no copay (up to $350 annually), but fitness, weight management, alternative therapies, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, counseling, home safety devices, in-home safety assessments, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services are partially covered by Fallon Medicare Plus Orange (HMO), which offers one routine hearing exam per year for a $50 copay and no coinsurance, though hearing aid fittings and evaluations are not covered. Prescription hearing aids are covered with no coinsurance and a copay ranging from $695 to $2,645, but OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Fallon Medicare Plus Orange (HMO) provides partially covered vision services, as routine eye exams are covered once per year with a $50 copay and no coinsurance, but other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $150 annual limit for contact lenses, upgrades, or one pair of eyeglasses (lenses and frames) per year.
Dental Services See details
Fallon Medicare Plus Orange (HMO) dental benefits are partially covered with no coinsurance, offering no copay for preventive services like cleanings and exams, and copays ranging from $20.00 to $990.00 for diagnostic, restorative, and comprehensive treatments. Sub-services that are not covered by this plan include other preventive dental services, maxillofacial prosthetics, implant services, and orthodontics.
Home Infusion bundled Services See details
Fallon Medicare Plus Orange (HMO) covers home infusion bundled services with no copay, although prior authorization is required. Under this benefit, Part B insulin drugs have a $0 to $35 copay and no coinsurance, while other Part B chemotherapy and radiation drugs require a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Fallon Medicare Plus Orange (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Fallon Medicare Plus Orange (HMO) covers durable medical equipment and prosthetics with no copay and a 20% coinsurance, subject to prior authorization. While diabetic equipment is covered with no copay and no coinsurance, diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Fallon Medicare Plus Orange (HMO) diagnostic and radiological services are partially covered with no coinsurance, though prior authorization and referrals are required. Some diagnostic services are covered with no copay, but diagnostic procedures, tests, and lab services are not covered; diagnostic radiological services require a minimum $350 copay, while therapeutic radiological and outpatient X-ray services are not covered.
Home Health Services See details
Fallon Medicare Plus Orange (HMO) covers Home Health Services with no copay and no coinsurance. Prior authorization and a referral are required to receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Fallon Medicare Plus Orange (HMO) with no copay and no coinsurance, though a referral is required. Only some services are covered under this benefit, as standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Fallon Medicare Plus Orange (HMO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring no copay for days 1 through 20 and a $188 daily copay for days 21 through 100. Prior authorization and referrals are required for this benefit, and additional days beyond the standard 100 Medicare-covered days are not covered.
Other Services See details
Other services are not covered under the Fallon Medicare Plus Orange (HMO) plan, which does not provide coverage for acupuncture, over-the-counter (OTC) items, or meal benefits.
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