Fallon Medicare Plus Saver No Rx (HMO)
H9001 - 039 - 0
(4 / 5)
Fallon Medicare Plus Saver No Rx (HMO) is a Medicare Advantage (Part C) Plan by Fallon Health.
This page features plan details for 2024 Fallon Medicare Plus Saver No Rx (HMO) H9001 – 039 – 0 available in Massachusetts except Dukes and Nantucket counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Fallon Medicare Plus Saver No Rx (HMO) is offered in the following locations.
Plan Overview
Fallon Medicare Plus Saver No Rx (HMO) offers the following coverage and cost-sharing.
| Insurer: | Fallon Health |
| Health Plan Deductible: | |
| MOOP: | $6,700.00 |
| Drugs Covered: | No |
Ready to sign up for Fallon Medicare Plus Saver No Rx (HMO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Fallon Medicare Plus Saver No Rx (HMO) qualifies for a monthly Medicare Give Back Benefit of $40.00.
| Premium Reduction: | $40.00 |
Premium Breakdown
Fallon Medicare Plus Saver No Rx (HMO) has a monthly premium of $35.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $35.00 | $40.00 | $169.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Fallon Medicare Plus Saver No Rx (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $6,700 In-network |
| No |
| In-network | No |
| $275 copay per visit (Authorization is required.) (Referral is required.) |
| Primary | $15 copay per visit (Not applicable.) (Not applicable.) |
| Specialist | $20-40 copay per visit (Authorization is required.) (Referral is required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $15 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $250 copay (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is required.) |
| Hearing exam | $40 copay (Authorization is not required.) (Referral is required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids | $695-2,645 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | $20-40 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Restorative services | $31-856 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $34-990 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $80-953 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | $37-506 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0-865 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $40 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $20 copay (Authorization is required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is required.) |
| $250 copay (Not applicable.) (Not applicable.) |
| $35 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Foot exams and treatment | $40 copay (Authorization is not required.) (Referral is required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $0-35 copay (Authorization is required.) (Not applicable.) |
| $315 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $315 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
Ready to sign up for Fallon Medicare Plus Saver No Rx (HMO) ?
Table of Contents
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