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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 2025, 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 2025.
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 $200.00 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 has a $200 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, if you use a standard pharmacy, you will pay a $7 copay for preferred generic drugs, $42 for standard generic, and $95 for preferred brand drugs. Non-preferred drugs have a 30% coinsurance, and specialty tier drugs have no copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase.
Additional Benefits
The Fallon Medicare Plus Orange (HMO) plan offers comprehensive coverage with a variety of benefits. You'll have no copay for primary care, home health, and skilled nursing facility services for the first 20 days. The plan also covers outpatient services, ambulance services, emergency services, vision, and dental, with varying copays depending on the service. Additional benefits include hearing services, preventive services, and home infusion services. The plan also covers medical equipment, diagnostic and radiological services, and other services like over-the-counter items. However, cardiac rehabilitation services are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization and a doctor referral. For Inpatient Hospital-Acute, you'll pay a $390 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you'll pay a $390 copay for days 1-4, and no copay for days 5-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and additional days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by the Fallon Medicare Plus Orange (HMO) plan. Outpatient Hospital Services and Ambulatory Surgical Center (ASC) Services have a $350 copay, while Individual and Group Sessions for Outpatient Substance Abuse have a copay between $40 and $40.
Partial Hospitalization See details
Partial Hospitalization is covered under the Fallon Medicare Plus Orange (HMO) plan. Prior authorization and a doctor referral are required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Fallon Medicare Plus Orange (HMO) plan. Ground and air ambulance services each have a $295 copay, while transportation services to a health-related location have a $35 copay. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Fallon Medicare Plus Orange (HMO) plan. Emergency Services have a $100 copay, Urgently Needed Services have a $10 copay, and Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $100 copay, while Worldwide Emergency Transportation has a $295 copay; all of these services have no coinsurance.
Primary Care See details
The Fallon Medicare Plus Orange (HMO) plan covers primary care physician services with no copay. Chiropractic services require a referral, and have a $15 copay for routine care. Occupational therapy services require authorization and a referral, with a $20 copay. Physician specialist services require prior authorization and a referral, and have a copay between $20 and $45. Mental health and psychiatric services, including individual and group sessions, have a $40 copay. Physical therapy and speech-language pathology services require authorization and a referral, and have a $20 copay. Additional telehealth benefits, including services not usually covered by Medicare plans, require a referral and have a copay between $0 and $45.
Preventive Services See details
Preventive services including Medicare-covered services, annual physical exams, and additional preventive services are covered. Health education has a $10 copay, while wigs for hair loss related to chemotherapy have a 20% coinsurance up to a $350 maximum.
Hearing Services See details
Hearing services are covered by the Fallon Medicare Plus Orange (HMO) plan, including routine hearing exams for a $45 copay and prescription hearing aids with a copay between $695 and $2645. Fitting/Evaluation for Hearing Aid, Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear and OTC Hearing Aids are not covered.
Vision Services See details
The Fallon Medicare Plus Orange (HMO) plan covers vision services including eye exams with a $45 copay, and eyeglasses with a combined maximum benefit of $150 every year. Routine eye exams are covered once per year, while contact lenses and upgrades are also covered.
Dental Services See details
The Fallon Medicare Plus Orange (HMO) plan covers Medicare dental services with a $45 copay, and other dental services including oral exams, dental x-rays, other diagnostic dental services with a copay of $20-$40, prophylaxis (cleaning), and fluoride treatments. The plan also covers restorative services with a copay of $31-$856, adjunctive general services with a copay of $39-$157, endodontics with a copay of $107-$990, periodontics with a copay of $80-$953, prosthodontics (removable) with a copay of $37-$865, prosthodontics (fixed) with a copay of $76-$860, and oral and maxillofacial surgery with a copay of $77-$667. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a copay between $0 and $35. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Fallon Medicare Plus Orange (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance and requires prior authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered, and there are preferred manufacturers for Diabetic Equipment.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic services have no copay, but Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a maximum copay of $300, but Therapeutic Radiological Services and Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by the Fallon Medicare Plus Orange (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Both a referral and authorization are required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Fallon Medicare Plus Orange (HMO) plan. This includes Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Fallon Medicare Plus Orange (HMO) plan. You will have no copay for days 1-20, and a $188 copay for days 21-100.
Other Services See details
The Fallon Medicare Plus Orange (HMO) plan's "Other Services" benefit covers over-the-counter items with a maximum benefit of $150 per year, and offers nicotine replacement therapy and Naloxone coverage. However, acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, EPSDT services, private duty nursing services, and other services are not covered.
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