Fallon Medicare Plus Saver No Rx HMO (HMO) is a Medicare Advantage (Part C) Plan by Fallon Health.
This page features plan details for 2023 Fallon Medicare Plus Saver No Rx HMO (HMO) H9001 – 039 – 0 available in Massachusetts except Dukes and Nantucket counties.
Fallon Medicare Plus Saver No Rx HMO (HMO) is offered in the following locations.
Fallon Medicare Plus Saver No Rx HMO (HMO) offers the following coverage and cost-sharing.
Insurer: | Fallon Health |
Health Plan Deductible: | $0.00 |
MOOP: | $7,550 In-network |
Drugs Covered: | No |
Ready to sign up for Fallon Medicare Plus Saver No Rx HMO (HMO) ?
Part B | Part C | Part B Give Back | Total |
---|---|---|---|
$164.90 | $35.00 | $0.00 | $199.90 |
Fallon Medicare Plus Saver No Rx HMO (HMO) also provides the following benefits.
In-Network: No |
Diagnostic services: | $6-40 copay (limits may apply) (authorization not required) (referral not required) |
Endodontics: | $34-990 copay (no limits) (authorization not required) (referral not required) |
Extractions: | $37-506 copay (no limits) (authorization not required) (referral not required) |
Non-routine services: | Not covered (no limits) |
Periodontics: | $80-953 copay (no limits) (authorization not required) (referral not required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | $0-865 copay (limits may apply) (authorization not required) (referral not required) |
Restorative services: | $31-856 copay (limits may apply) (authorization not required) (referral not required) |
Cleaning: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
Dental x-ray(s): | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
Fluoride treatment: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
Office visit: | $25.00 (authorization not required) (referral not required) |
Oral exam: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
Diagnostic radiology services (e.g., MRI): | $250 copay (authorization required) (referral required) |
Diagnostic tests and procedures: | $0 copay (authorization required) (referral not required) |
Lab services: | $0 copay (authorization required) (referral not required) |
Outpatient x-rays: | $0 copay (authorization required) (referral required) |
Primary: | $25 copay per visit |
Specialist: | $20-40 copay per visit (authorization required) (referral required) |
Emergency: | $90 copay per visit (always covered) |
Urgent care: | $25 copay per visit (always covered) |
Foot exams and treatment: | $40 copay (authorization not required) (referral required) |
Routine foot care: | Not covered |
$200 copay |
$0.00 |
In-Network: No |
Fitting/evaluation: | Not covered (no limits) |
Hearing aids: | $695-2,645 copay (limits may apply) (authorization not required) (referral not required) |
Hearing exam: | $40 copay (authorization not required) (referral required) |
$300 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral required) |
$275 copay per visit (authorization required) (referral required) |
$7,550 In-network |
Diabetes supplies: | $0 copay (authorization required) |
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) |
Chemotherapy: | 20% coinsurance (authorization required) |
Other Part B drugs: | 20% coinsurance (authorization required) |
Inpatient hospital – psychiatric: | $300 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) |
Outpatient group therapy visit: | $40 copay (authorization not required) (referral not required) |
Outpatient group therapy visit with a psychiatrist: | $40 copay (authorization required) (referral not required) |
Outpatient individual therapy visit: | $40 copay (authorization not required) (referral not required) |
Outpatient individual therapy visit with a psychiatrist: | $40 copay (authorization required) (referral not required) |
No |
$0 copay (authorization not required) (referral not required) |
Occupational therapy visit: | $20 copay (authorization required) (referral required) |
Physical therapy and speech and language therapy visit: | $20 copay (authorization required) (referral required) |
$0 per day for days 1 through 20 $150 per day for days 21 through 44 $0 per day for days 45 through 100 (authorization required) (referral required) |
$35 copay (no limits) (authorization not required) (referral not required) |
Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglass frames: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglass lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization not required) (referral not required) |
Other: | Not covered (no limits) |
Routine eye exam: | $40 copay (limits may apply) (authorization not required) (referral not required) |
Upgrades: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Covered (authorization not required) (referral not required) |
Ready to sign up for Fallon Medicare Plus Saver No Rx HMO (HMO) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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