Fallon Senior Plan HMO plans

Fallon Senior Plan HMO monthly plan premiums

You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. If you receive extra help with your Medicare premiums, your costs may be lower.

Saver plans

Standard plans

Plus plans

No drug
plans

Fallon Senior Plan Saver 
$0

Fallon Senior Plan Standard
$72

Fallon Senior Plan Plus
$132

Basic Rx
plans

Fallon Senior Plan Saver Basic Rx
$28

Fallon Senior Plan Standard Basic Rx
$100

Fallon Senior Plan Plus Basic Rx
$160

Enhanced Rx plans

Fallon Senior Plan Saver Enhanced Rx
$28

Fallon Senior Plan Standard Enhanced Rx
$100

Fallon Senior Plan Plus Enhanced Rx
$160

Saver plans

Standard plans

Plus plans

Inpatient hospital care

$175 per day for
days 1 – 5.
$0 for additional days.

$125 per day for
days 1 – 5.
$0 for additional days.

$100 per stay.
Separate $300 out-of-pocket limits for acute/ rehabilitation hospital stays and mental health hospital stays.

Skilled nursing facility care

$20 per day for
days 1 – 20.
$0 for additional days.

$20 per day for
days 1 – 20.
$0 for additional days.

$20 per day for
days 1 – 20.
$0 for additional days.

Doctor office visits

$15 per visit.

$15 per visit.

$10 per visit.

Specialist office visits

$25 per visit.

$20 per visit.

$15 per visit.

Outpatient services/ surgery

$0 to $100 per surgery.

$0 to $75 per surgery.

$0 to $50 per surgery.

Ambulance services

$50 for Medicare-covered ambulance services.

$50 for Medicare-covered ambulance services.

$50 for Medicare-covered ambulance services.

Emergency room visits (copayment waived if admitted within 72 hours for the same condition)

$50 per visit.
Worldwide coverage.

$50 per visit.
Worldwide coverage.

$50 per visit.
Worldwide coverage.

Diagnostic tests, X-rays, and lab services

$0 copayment for Medicare-covered:
- lab services
- diagnostic procedures and tests
- X-rays
- therapeutic radiology services

$0 to $50 copayment for Medicare-covered diagnostic radiology services.

$0 copayment for Medicare-covered:
- lab services
- diagnostic procedures and tests
- X-rays
- therapeutic radiology services

$0 to $50 copayment for Medicare-covered diagnostic radiology services.

$0 copayment for Medicare-covered:
- lab services
- diagnostic procedures and tests
- X-rays
- therapeutic radiology services

$0 to $50 copayment for Medicare-covered diagnostic radiology services.

Dental services

$10 for each routine checkup.
$19 to $51 for fillings.

$10 for each routine checkup.
$19 to $51 for fillings.

$10 for each routine checkup.
$19 to $51 for fillings.

Vision services

$15 to $25 for 1 routine eye exam every two years.
Up to 1 pair of glasses every two years.

$15 to $20 for 1 routine eye exam every two years.
Up to 1 pair of glasses every two years.

$10 to $15 for 1 routine eye exam every two years.
Up to 1 pair of glasses every two years.

Basic Rx plans

Enhanced Rx plans

Deductible

$295

No deductible

Initial coverage copayments
for up to a 30-day supply
(until your yearly drug costs paid by both you and Fallon Senior Plan reach $2,700)

Tier 1:  $5
Tier 2:  $20
Tier 3:  $40

Tier 1:  $10
Tier 2:  $30
Tier 3:  $55

Coverage gap
(after yearly drug costs reach $2,700 and until your own costs reach $4,350)

You pay 100% of drug costs

You pay 100% of drug costs

Catastrophic coverage
(after your own costs reach $4,350)

You pay the greater of:
$2.40 for generic or a preferred brand drug and $6.00 for all other drugs, or 5% coinsurance

You pay the greater of:
$2.40 for generic or a preferred brand drug and $6.00 for all other drugs, or 5% coinsurance