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Fallon Medicare Plus Orange (HMO)

H9001 - 038 - 0

(4 / 5)

Fallon Medicare Plus Orange (HMO) is a Medicare Advantage Plan by Fallon Health.

This page features plan details for 2025 Fallon Medicare Plus Orange (HMO) H9001 – 038 – 0 available in Massachusetts except Dukes and Nantucket counties.

Locations

Fallon Medicare Plus Orange (HMO) is offered in the following locations.

Barnstable County, Massachusetts

Berkshire County, Massachusetts

Bristol County, Massachusetts

Click to see more locations

Plan Overview

Fallon Medicare Plus Orange (HMO) offers the following coverage and cost-sharing.

Insurer:	Fallon Health
Health Plan Deductible:	$0
MOOP:	$7,550 In-network
Drugs Covered:	Yes

Ready to sign up for Fallon Medicare Plus Orange (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Fallon Medicare Plus Orange (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$0.00	$	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Fallon Medicare Plus Orange (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$200.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $200.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Std. Pharm	Std. Mail
1) Preferred Generic
2) Generic	$7.00 Copay	$7.00 Copay
3) Preferred Brand	$42.00 Copay	$42.00 Copay
4) Non-Preferred Drug	$95.00 Copay	$95.00 Copay

60 Day

Tier	Std. Pharm	Std. Mail
1) Preferred Generic
2) Generic	$14.00 Copay	$14.00 Copay
3) Preferred Brand	$84.00 Copay	$84.00 Copay
4) Non-Preferred Drug	$190.00 Copay	$190.00 Copay

90 Day

Tier	Std. Pharm	Std. Mail
1) Preferred Generic
2) Generic	$21.00 Copay	$14.00 Copay
3) Preferred Brand	$126.00 Copay	$84.00 Copay
4) Non-Preferred Drug	$285.00 Copay	$190.00 Copay

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Fallon Medicare Plus Orange (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Comprehensive Dental

Adjunctive General Services
- In-Network: No Coins – 39.00-157.00 Copay (Authorization Required)
Endodontics
- In-Network: No Coins – 107.00-990.00 Copay (Authorization Required)
Oral and Maxillofacial Surgery
- In-Network: No Coins – 77.00-667.00 Copay (Authorization Required)
Periodontics
- In-Network: No Coins – 80.00-953.00 Copay (Authorization Required)
Prosthodontics, fixed
- In-Network: No Coins – 76.00-860.00 Copay (Authorization Required)
Prosthodontics, removable
- In-Network: No Coins – 37.00-865.00 Copay (Authorization Required)
Restorative Services
- In-Network: No Coins – 31.00-856.00 Copay (Authorization Required)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay
Fluoride Treatment
- In-Network: No Coins – No Copay
Oral Exams
- In-Network: No Coins – No Copay
Other Diagnostic Dental Services
- In-Network: No Coins – 20.00-40.00 Copay
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Outpatient x-rays
- $0 copay (Authorization Required, Referral Required)
Lab services
- $0 copay (Authorization Required, Referral Required)
Diagnostic radiology services (e.g., MRI)
- $300 copay (Authorization Required, Referral Required)
Diagnostic tests and procedures
- $0 copay (Authorization Required, Referral Required)

Doctor visits

Primary
- $0 copay
Specialist
- $20-45 copay per visit (Authorization Required, Referral Required)

Emergency care/Urgent care

Emergency
- $100 copay per visit (always covered)
Urgent care
- $10 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $45 copay (Referral Required)
Routine foot care
- Not covered

Ground ambulance

- $295 copay

Health plan deductible

- $0

Hearing

Fitting/evaluation
- Not covered
Hearing aids OTC
- Not covered
Hearing aids
- $695-2,645 copay (Limits Apply)
Medicare-Covered Hearing Exam
- $45 copay (Referral Required)

Inpatient hospital coverage

- $390 per day for days 1 through 5
  $0 per day for days 6 through 90 (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $7,550 In-network

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen)
- 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- 20% coinsurance per item (Authorization Required)
Diabetes supplies
- $0 copay (Authorization Required)

Medicare Part B drugs

Other Part B drugs
- 0-20% coinsurance (Authorization Required)
Chemotherapy
- 0-20% coinsurance (Authorization Required)

Mental health services

Inpatient hospital – psychiatric
- $390 per day for days 1 through 4
  $0 per day for days 5 through 90 (Authorization Required)
Outpatient group therapy visit
- $40 copay
Outpatient individual therapy visit with a psychiatrist
- $40 copay (Authorization Required)
Outpatient group therapy visit with a psychiatrist
- $40 copay (Authorization Required)
Outpatient individual therapy visit
- $40 copay

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $350 copay per visit (Authorization Required, Referral Required)

Preventive care

- $0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit
- $20 copay (Authorization Required, Referral Required)
Occupational therapy visit
- $20 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $188 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

- $35 copay

Vision

Eyeglass frames
- $0 copay (Limits Apply)
Routine eye exam
- $0 copay (Limits Apply)
Upgrades
- $0 copay (Limits Apply)
Contact lenses
- $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)
Other
- Not covered
Eyeglass lenses
- $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

- Covered