Fallon Medicare Plus Orange (HMO)
Health Insurance Company: Fallon Health
Medicare Advantage Plan Details
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Emergency Room
$100 copay per visit (always covered)
Ambulance Coverage
$295 copay
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: $0 copay
Medicare-covered lab services: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): $300 copay
Medicare-covered x-ray services: $0 copay
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: $350 copay per visit
Hospitalization Coverage
Inpatient hospital-acute:
$390 per day for days 1 through 5
$0 per day for days 6 through 90
Inpatient hospital psychiatric:
$390 per day for days 1 through 4
$0 per day for days 5 through 90
Rehabilitation Coverage
Occupational therapy services:
$20 copay
Physical therapy and speech and language therapy services:
$20 copay
Urgent Care Coverage
$10 copay per visit (always covered)
Skilled Nursing Facility (SNF)
$0 per day for days 1 through 20
$188 per day for days 21 through 100
Mental Health Coverage
Medicare-covered individual sessions: $40 copay
Medicare-covered group sessions: $40 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Vision Benefits
Eye exams:
Routine eye exams: $0 copay
Eyewear:
Contact Lenses: $0 copay
Eyeglasses: $0 copay
Hearing Benefits
Hearing exams:
Routine hearing exams: $45 copay
Hearing aids:
Hearing aids (all types): $695-2,645 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$7.00 copay (30-day supply)
$21.00 copay (90-day supply)
Tier 3: Preferred Brand
$42.00 copay (30-day supply)
$126.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$95.00 copay (30-day supply)
$285.00 copay (90-day supply)
Tier 5: Specialty Tier
30% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$7.00 copay (30-day supply)
$14.00 copay (90-day supply)
Tier 3: Preferred Brand
$42.00 copay (30-day supply)
$84.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
$95.00 copay (30-day supply)
$190.00 copay (90-day supply)
Tier 5: Specialty Tier
30% coinsurance (30-day supply)
More Additional Benefits
Plan Links
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