SimpliveraCoverage Companion

Standard High Bronze: Community Care Connector Bronze #1

Fallon Community Health Plan · 2027 plan year

Expanded BronzeHSA eligible
Ind. deductible
$3,000
Family deductible
$6,000
Ind. OOP max
$12,000
Family OOP max
$24,000

Other cost-sharing reduction variants for this plan:

Standard Bronze On Exchange PlanZero Cost Sharing Plan Variation

More Fallon Community Health Plan plans in MA

Standard Platinum: Community Care Connector PlatinumStandard High Gold: Community Care Connector High GoldNon-Standard Low Gold: Community Care Connector Low GoldStandard Silver: Community Care Connector High Silver IICommunity Care Catastrophic

Live premium estimate

$

Benefits & cost sharing

Primary Care

BenefitIn-network
Preventive Care/Screening/ImmunizationNo charge
Primary Care Visit to Treat an Injury or Illness$30.00 Copay after deductible

Specialist

BenefitIn-network
Specialist Visit$65.00 Copay after deductible

Hospital

BenefitIn-network
Emergency Room Services$500.00 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)$1000.00 Copay per Stay after deductible
Outpatient Surgery Physician/Surgical ServicesNo Charge after deductible
Urgent Care Centers or Facilities$65.00 Copay after deductible

Pharmacy

BenefitIn-network
Generic Drugs$30.00
Non-Preferred Brand Drugs$100.00 Copay after deductible
Preferred Brand Drugs$65.00 Copay after deductible
Specialty Drugs$100.00 Copay after deductible

Mental Health

BenefitIn-network
Mental/Behavioral Health Inpatient Services$1000.00 Copay per Stay after deductible
Mental/Behavioral Health Outpatient Services$30.00 Copay after deductible

Other

BenefitIn-network
Abortion for Which Public Funding is ProhibitedNo charge
Accidental Dental$30.00 Copay after deductible
Allergy Testing$65.00 Copay after deductible
Bariatric Surgery$1000.00 Copay after deductible
Basic Dental Care - Child25.00%
ChemotherapyNo Charge after deductible
Chiropractic Care$30.00 Copay after deductible
Delivery and All Inpatient Services for Maternity Care$1000.00 Copay after deductible
Dental Check-Up for ChildrenNo charge
Diabetes Education$30.00 Copay after deductible
DialysisNo Charge after deductible
Durable Medical Equipment20.00% Coinsurance after deductible
Emergency Transportation/AmbulanceNo Charge after deductible
Eye Glasses for ChildrenNo charge
Habilitation Services$65.00 Copay after deductible
Hearing Aids20.00% Coinsurance after deductible
Home Health Care ServicesNo Charge after deductible
Hospice ServicesNo Charge after deductible
Imaging (CT/PET Scans, MRIs)$400.00 Copay after deductible
Infertility Treatment$250.00 Copay after deductible
Infusion TherapyNo Charge after deductible
Inpatient Physician and Surgical ServicesNo Charge after deductible
Laboratory Outpatient and Professional Services$50.00 Copay after deductible
Major Dental Care - Child50.00%
Nutritional Counseling$30.00 Copay after deductible
Orthodontia - Child50.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)$30.00 Copay after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)$500.00 Copay after deductible
Outpatient Rehabilitation Services$65.00 Copay after deductible
Prenatal and Postnatal CareNo charge
Prosthetic Devices20.00% Coinsurance after deductible
RadiationNo Charge after deductible
Reconstructive Surgery$1000.00 Copay after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy$65.00 Copay after deductible
Rehabilitative Speech Therapy$65.00 Copay after deductible
Routine Eye Exam (Adult)No charge
Routine Eye Exam for ChildrenNo charge
Routine Foot Care$30.00 Copay after deductible
Skilled Nursing Facility$1000.00 Copay per Stay after deductible
Substance Abuse Disorder Inpatient Services$1000.00 Copay per Stay after deductible
Substance Abuse Disorder Outpatient Services$30.00 Copay after deductible
Transplant$1000.00 Copay after deductible
Treatment for Temporomandibular Joint Disorders$65.00 Copay after deductible
Weight Loss ProgramsNo charge
Well Baby Visits and CareNo charge
X-rays and Diagnostic Imaging$100.00 Copay after deductible

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