Fallon Medicare Plus Blue (HMO) H9001-031-18 Plan Details
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*CMS rated this Fallon Health plan (H9001-031-18) 4 (Good) out of 5 stars.
Fallon Medicare Plus Blue (HMO) is a Medicare Advantage plan with a prescription drug plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January 1.
Fallon Medicare Plus Blue Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H9001-031-18 |
| Plan Type: | HMO |
| Plan Year: | 2025 |
| Premium: | $164.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 3,400.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | See List |
| Insured By: | Fallon Health |
| Summary of Benefits |
|---|
Fallon Health Out-of-Pocket Costs
This Fallon Health Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H9001-031-18.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | $10 Copay |
| Specialist: | $20 Copay Prior Authorization Required, Referral Required |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $120 Copay |
| Urgent care: | $10 Copay |
| Ground ambulance: | $125 Copay |
| Inpatient hospital care: | $200.00 per stay |
| Skilled Nursing Facility: | $15.00 per day for days 1 through 20 $75.00 per day for days 21 through 44 $0.00 per day for days 45 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $20 Copay Referral Required |
| Routine Foot Care: | Not Covered |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $15 Copay Referral Required |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $20 Copay |
| Outpatient group therapy: | $20 Copay |
| Inpatient psychiatric hospital care: | $200.00 per stay |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $15 Copay Prior Authorization Required, Referral Required |
| Occupational therapy: | $15 Copay Prior Authorization Required, Referral Required |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | Not Covered |
| Durable medical equipment: | 10% Coinsurance Prior Authorization Required |
| Prosthetics: | 10% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $150 Copay Prior Authorization Required, Referral Required |
| Lab services: | Not Covered |
| Outpatient x-rays: | Not Covered |
| Diagnostic tests and procedures: | Not Covered |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 10% Coinsurance |
| Other Part B drugs (Medicare-covered): | 10% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | $20 Copay Prior Authorization Required |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Not Covered |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | $ to $20 Copay |
| Routine eye exam (in-network) | $ to $20 Copay 1 Every year |
| Eyewear benefits | None |
Feel free to download our Fallon Medicare Plus Blue Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
Fallon Medicare Plus Blue includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans offer greater coverage than basic plans, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the premium details of this prescription drug plan.
| Basic Part D Premium: | $46.90 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $46.90 |
| Low Income Premium Subsidy: | $52.52 |
| Low Income Premium Subsidy CMS Pays: | $46.90 |
| Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. You must pay this amount at the pharmacy before Fallon Health begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Fallon Medicare Plus Blue has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | Out of Network |
|---|---|---|---|
| Preferred Generic | $0.00 | $0.00 | $0.00 |
| Generic | $7.00 | $7.00 | $7.00 |
| Preferred Brand | $42.00 | $42.00 | $42.00 |
| Non-Preferred Drug | $95.00 | $95.00 | $95.00 |
| Specialty Tier | 33.00% | 33.00% | 33.00% |
| Select Care Drugs | $0.00 | $0.00 | $0.00 |
| *The Part D deductible does not apply. | |||
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 using a 5-star rating system. Here are the most recent ratings for Fallon Medicare Plus Blue .
| CMS Measure | Star Rating |
|---|---|
| 2025 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 |
Plan Availability
Fallon Medicare Plus Blue (H9001-031-18) is available in the following locations (click to open):
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- H9001-031-18: Fallon Medicare Plus Blue ()
- H9001-030-15: Fallon Medicare Plus Green ()
- H9001-030-16: Fallon Medicare Plus Green ()
- H9001-030-18: Fallon Medicare Plus Green ()
- H9001-031-16: Fallon Medicare Plus Blue ()
- H9001-039-0: Fallon Medicare Plus Saver No Rx ()
- H9001-038-0: Fallon Medicare Plus Orange ()
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Fallon Health
| Website: | Fallon Health Plan Page |
|---|---|
| Providers: | Fallon Health Providers Page |
| Formulary: | Fallon Health Formulary Page |
| Pharmacy: | Fallon Health Pharmacy Page |
| New Member Health Plan Help: | (888)377-1980 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (888)377-1980 |
| New Member Part D 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 Part C program on www.medicare.gov or call 1-800-MEDICARE.
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
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.