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Capital Health Plan Advantage Plus (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Health Plan Advantage Plus (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Capital Health Plan Advantage Plus (HMO) in 2026, please refer to our full plan details page.
Capital Health Plan Advantage Plus (HMO) is a HMO plan offered by Guidewell Mutual Holding Corporation available for enrollment in 2025 to people living in Leon and surrounding counties. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Capital Health Plan Advantage Plus (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Capital Health Plan Advantage Plus (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Capital Health Plan Advantage Plus (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $34.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $250.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
Sign up for Capital Health Plan Advantage Plus (HMO)
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Drug Coverage
The Capital Health Plan Advantage Plus (HMO) features an annual drug deductible of $250. Under this plan, members enjoy no copay for Tier 1 preferred generic and Tier 6 select care drugs at standard pharmacies or through standard mail order. Tier 2 generic drugs are also highly affordable, starting at a $7 copay for a one-month supply. For brand-name medications, Tier 3 preferred brands require a $45 copay, while Tier 4 non-preferred drugs have a $95 copay for a one-month supply. Tier 5 specialty drugs require a 30% coinsurance for a one-month supply at standard pharmacies. Ordering three-month supplies of Tier 2, 3, and 4 drugs through standard mail order offers additional savings.
Additional Benefits
The Capital Health Plan Advantage Plus (HMO) offers comprehensive medical coverage with predictable costs, featuring no copay and no coinsurance for primary care doctor visits. Inpatient hospital stays require a $250 daily copay for the first five days and no copay for days six through 90, while outpatient hospital services carry a $300 copay. Emergency room visits have a $125 copay, which is waived if you are admitted within 24 hours, and urgent care services require a $20 copay. This plan also includes valuable everyday benefits, such as dental care with no copay up to a $725 annual maximum and eyewear coverage up to $200 annually with no copay. Additionally, members can access unlimited one-way health transportation and home health services with no copay or coinsurance. Over-the-counter items are also covered with no copay through reimbursement, helping you save on daily wellness essentials.
Inpatient Hospital See details
Capital Health Plan Advantage Plus (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $250 daily copay for days 1 through 5 and no copay for days 6 through 90. Unlimited additional days are covered, but upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Capital Health Plan Advantage Plus (HMO) covers outpatient services with no coinsurance, featuring a $300 copay for outpatient hospital services, a $150 copay for ambulatory surgical center visits, and a $30 copay for outpatient substance abuse sessions. Outpatient blood services are also covered with no copay and no coinsurance, though referrals are required for surgical and hospital services.
Partial Hospitalization See details
Capital Health Plan Advantage Plus (HMO) covers partial hospitalization services with a copay of $30 or $40 and no coinsurance. Depending on the service, prior authorization and a referral may be required.
Ambulance and Transportation Services See details
Capital Health Plan Advantage Plus (HMO) covers ground and air ambulance services with a $290 copay and no coinsurance. Unlimited one-way transportation to any health-related location is also covered with no copay and no coinsurance, though transportation to plan-approved health-related locations is not covered.
Emergency Services See details
Capital Health Plan Advantage Plus (HMO) covers emergency services with a $125 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgently needed services with a $20 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $125, $20, and $290 respectively.
Primary Care See details
Capital Health Plan Advantage Plus (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits, mental health, psychiatric, and opioid treatment services require a $30 copay and no coinsurance. Physical, occupational, and speech therapy services have a $20 copay with no coinsurance, whereas chiropractic and podiatry services are not covered.
Preventive Services See details
Capital Health Plan Advantage Plus (HMO) partially covers preventive services with no copay and no coinsurance for Medicare-covered zero-dollar services and fitness benefits, but excludes annual physicals, in-home safety assessments, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, home modifications, and counseling. Covered kidney disease education and diabetes training require a $10 copay and no coinsurance, while glaucoma screenings carry a $10 to $30 copay and no coinsurance. Referrals are required for kidney disease education and digital rectal exams.
Hearing Services See details
Capital Health Plan Advantage Plus (HMO) provides partially covered hearing services, including routine hearing exams for a $30 copay and no coinsurance, while fitting and evaluation services are not covered. Prescription and OTC hearing aids are covered with no copay and no coinsurance, though inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Capital Health Plan Advantage Plus (HMO) offers partially covered vision services, which include one routine eye exam per year for a $10.00 to $30.00 copay and no coinsurance, and eyewear covered up to a $200.00 annual maximum with no copay and no coinsurance. Other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Capital Health Plan Advantage Plus (HMO) offers dental services featuring no copay and no coinsurance for preventive and comprehensive care up to a $725 annual maximum. Medicare-covered dental services are also covered with a $30 copay and no coinsurance, subject to referral and prior authorization requirements.
Home Infusion bundled Services See details
Capital Health Plan Advantage Plus (HMO) covers home infusion bundled services with no copay, though associated Medicare Part B chemotherapy, radiation, and other drugs carry a coinsurance between 0% and 20%. Additionally, Medicare Part B insulin drugs are covered under this benefit with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered by Capital Health Plan Advantage Plus (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Health Plan Advantage Plus (HMO) covers medical equipment with no copay, including durable medical equipment, prosthetics, and diabetic supplies. A 20% coinsurance applies to durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes, while diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Capital Health Plan Advantage Plus (HMO), as diagnostic procedures, lab services, and outpatient X-ray services are not covered. Covered diagnostic services have no copay and no coinsurance, while diagnostic radiological services require a minimum $100 copay with no coinsurance, and therapeutic radiological services require a 20% minimum coinsurance with no copay.
Home Health Services See details
Home Health Services are covered by Capital Health Plan Advantage Plus (HMO) with no copay and no coinsurance, though a referral is required to receive care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with no coinsurance under the Capital Health Plan Advantage Plus (HMO), but some services are covered while cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) services are not covered. Prior authorization and referrals are required for these services.
Skilled Nursing Facility (SNF) See details
Capital Health Plan Advantage Plus (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $200 daily copay for days 21 to 100. Prior authorization and referrals are required, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
Other Services are partially covered by Capital Health Plan Advantage Plus (HMO), offering over-the-counter (OTC) items with no copay and no coinsurance via reimbursement. Acupuncture, meal benefits, and nicotine replacement therapy are not covered under this plan, though naloxone is eligible for coverage.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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