Fallon Medicare Plus Saver No Rx (HMO) 2024 Benefit Details for Plan H9001-039-0 in Barnstable County, MA
Fallon Medicare Plus Saver No Rx is a 2024 HMO Medicare Advantage plan {with_without_pdp} prescription drug plan benefits (Part D).
This Fallon Health option offers the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may also include additional, valuable benefits not covered by Part A or Part B.
See more Medicare Advantage Plans in Barnstable County, Massachusetts.
Plan Basics | |
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Plan ID: | H9001 039 0 |
Plan Type: | Local HMO |
Plan Year: | 2024 |
Premium: | $35.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $6,700/yr |
Part B Reduction: | $40.00/mo |
Drug Plan Benefit: | Not Included |
Rx Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | Barnstable County, MA |
Insured By: | Fallon Health |
Summary of Benefits |
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Health Plan Cost Sharing
This Fallon Health Medicare Advantage plan has cost-sharing. These are costs you must pay out-of-pocket when you use approved health services.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
The following table summarizes the most common out-of-pocket costs you will incur if you join this plan unless you go out-of-network:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $15 Copay |
Specialist: | $40 Copay Authorization Required, Referral Required |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $40 Copay Referral Required |
Routine foot care: | Not Covered |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $15 Copay Referral Required |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $90 Copay |
Urgent care: | $15 Copay |
Ground ambulance: | $250 Copay |
Inpatient hospital coverage: | $315.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient hospital coverage: | $275 Copay Authorization Required, Referral Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $40 Copay |
Outpatient group therapy visit with a psychiatrist: | $40 Copay |
Inpatient hospital - psychiatric: | $315.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy visit: | $40 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $20 Copay Authorization Required, Referral Required |
Occupational therapy visit: | $20 Copay Authorization Required, Referral Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $250 Copay Authorization Required, Referral Required |
Lab services: | $0 |
Outpatient x-rays: | $0 |
Diagnostic tests and procedures: | $0 |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Fallon Medicare Plus Saver No Rx Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Fallon Health includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | Covered Limits may apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | Not Covered |
Vision | Maximum vision benefit: | $150.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | Covered Limits may apply |
Routine eye exam (In-Network) | $40 Copay |
Contact lenses (In-Network) | Covered Limits may apply |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Rating Marks
The following table shows the quality ratings for this Fallon Health plan. Each year CMS rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories based on a 5-star rating system. Here are the most recent ratings for Fallon Medicare Plus Saver No Rx.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Additional Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
- Fallon Medicare Plus Green
- Fallon Medicare Plus Blue
- Fallon Medicare Plus Saver No Rx
- Fallon Medicare Plus Super Saver
- Fallon Medicare Plus Green
Contact Fallon Health
Plan Website: | http://fallonhealth.org/medicare |
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Formulary Information: | http://fallonhealth.org/pharmacyfinder |
Pharmacy Information: | Fallon Health Pharmacy Page |
Prospective Members: | (800)325-5669 |
TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
Citations & References
- Fallon Health, http://fallonhealth.org/medicare, Last Accessed February 20, 2024
- Medicare.gov, "Your health plan options", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
About This H9001-039-0 Plan Detail Page
The data on this Fallon Medicare Plus Saver No Rx plan detail page is derived from the 2024 Landscape Source Files, Plan Benefit Package, and Medicare Part C and Part D Performance Data published by CMS.
The author interprets these files, and their associated data dictionary, with great care, making every attempt to communicate the data submitted by Fallon Health to CMS as clearly and accurately as possible. Given the complexity of the data, the author recommends that all potential enrollees request an official Summary of Benefits from Fallon Health, at (800)325-5669, prior to enrollment.