Fallon Medicare Plus Saver No Rx HMO (HMO)

H9001 - 039 - 0
4.5 out of 5 stars (4.5 / 5)

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.

IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:

Locations

Fallon Medicare Plus Saver No Rx HMO (HMO) is offered in the following locations.

Plan Overview

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) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

Premium Breakdown

Fallon Medicare Plus Saver No Rx HMO (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
$164.90 $35.00 $0.00 $199.90
Please Note:
  • 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 (HMO) also provides the following benefits.

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

In-Network: No

Dental (comprehensive)

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)

Dental (preventive)

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 procedures/lab services/imaging

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)

Doctor visits

Primary: $25 copay per visit
Specialist: $20-40 copay per visit (authorization required) (referral required)

Emergency care/Urgent care

Emergency: $90 copay per visit (always covered)
Urgent care: $25 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment: $40 copay (authorization not required) (referral required)
Routine foot care: Not covered

Ground ambulance

$200 copay

Health plan deductible

$0.00

Health plan deductibles (other)

In-Network: No

Hearing

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)

Hospital coverage (inpatient)

$300 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required) (referral required)

Hospital coverage (outpatient)

$275 copay per visit (authorization required) (referral required)

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

$7,550 In-network

Medical equipment/supplies

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)

Medicare Part B drugs

Chemotherapy: 20% coinsurance (authorization required)
Other Part B drugs: 20% coinsurance (authorization required)

Mental health services

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)

Optional supplemental benefits

No

Preventive care

$0 copay (authorization not required) (referral not required)

Rehabilitation services

Occupational therapy visit: $20 copay (authorization required) (referral required)
Physical therapy and speech and language therapy visit: $20 copay (authorization required) (referral required)

Skilled Nursing Facility

$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)

Transportation

$35 copay (no limits) (authorization not required) (referral not required)

Vision

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)

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

Covered (authorization not required) (referral not required)

Ready to sign up for Fallon Medicare Plus Saver No Rx HMO (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

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