Fallon Medicare Plus Super Saver HMO (HMO)

H9001 - 040 - 0
4.5 out of 5 stars (4.5 / 5)

Fallon Medicare Plus Super Saver HMO (HMO) is a Medicare Advantage (Part C) Plan by Fallon Health.

This page features plan details for 2023 Fallon Medicare Plus Super Saver HMO (HMO) H9001 – 040 – 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 Super Saver HMO (HMO) is offered in the following locations.

Plan Overview

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

Insurer:Fallon Health
Health Plan Deductible:$0.00
MOOP:$7,550 In-network
Drugs Covered:Yes
Please Note:
  • This plan does not charge an annual deductible for all drugs. The $505 annual deductible only applies to drugs on certain tiers.

Ready to sign up for Fallon Medicare Plus Super Saver 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 Super Saver HMO (HMO) has a monthly premium of $52.00. 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
$164.90 $4.60 $47.40 $0.00 $216.90
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 Super Saver HMO (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $505.00
Initial Coverage Limit: $4,660.00
Catastrophic Coverage Limit: $7,400.00
Drug Benefit Type: Enhanced
Gap Coverage: No
Formulary Link: Formulary Link

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 25% LIS 50% LIS 75% LIS Full
$47.40 $38.30 $29.30 $20.20 $11.10

Initial Coverage Phase

After you pay your $505.00 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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.

Gap Coverage Phase

After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.

Tier Cost
All other tiers (Generic)25%
All other tiers (Brand-name)25%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Drug TypeCost Share
Generic drugs$4.15 copay or 5% (whichever costs more)
Brand-name drugs$10.35 copay or 5% (whichever costs more)

Additional Benefits

Fallon Medicare Plus Super Saver 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: Not covered (no limits)
Endodontics: Not covered (no limits)
Extractions: Not covered (no limits)
Non-routine services: Not covered (no limits)
Periodontics: Not covered (no limits)
Prosthodontics, other oral/maxillofacial surgery, other services: Not covered (no limits)
Restorative services: Not covered (no limits)

Dental (preventive)

Cleaning: Not covered (no limits)
Dental x-ray(s): Not covered (no limits)
Fluoride treatment: Not covered (no limits)
Oral exam: Not covered (no limits)

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI): $275 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: $30 copay per visit
Specialist: $20-50 copay per visit (authorization required) (referral required)

Emergency care/Urgent care

Emergency: $90 copay per visit (always covered)
Urgent care: $30 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment: $50 copay (authorization not required) (referral required)
Routine foot care: Not covered

Ground ambulance

$275 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: $50 copay (authorization not required) (referral required)

Hospital coverage (inpatient)

$370 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required) (referral required)

Hospital coverage (outpatient)

$350 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: $370 per day for days 1 through 4
$0 per day for days 5 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
$160 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: $50 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 Super Saver 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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