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Capital Health Plan Preferred Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Health Plan Preferred Advantage (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 Preferred Advantage (HMO) in 2025, please refer to our full plan details page.
Capital Health Plan Preferred Advantage (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 2025.
It's important to know that Capital Health Plan Preferred Advantage (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 Preferred Advantage (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 Preferred Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $86.00. 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 $200.00 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 $5500.00 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:
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Drug Coverage
The Capital Health Plan Preferred Advantage (HMO) plan has a $200 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For a 30-day supply, you can expect to pay a $7 copay for preferred generic drugs at a standard pharmacy or through mail order, a $45 copay for standard generic drugs, and a $95 copay for preferred brand drugs. For non-preferred drugs, you will pay 30% coinsurance, and for specialty drugs, there is no copay.
Additional Benefits
The Capital Health Plan Preferred Advantage (HMO) plan offers comprehensive coverage, including inpatient hospital stays with a $400 copay, outpatient services with varying copays, and emergency services with a $125 copay. This plan also covers a range of services such as primary care with no copay, hearing and vision services with copays, and dental services with an $800 annual maximum benefit. Additional benefits include home health services with no copay, skilled nursing facility stays with copays, and home infusion services with copays and coinsurance. The plan also covers dialysis services with 20% coinsurance, medical equipment with 20% coinsurance, and diagnostic radiological services with a copay or coinsurance. However, some services like cardiac rehabilitation and certain other services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including services not usually covered by Medicare plans, with a $400 copay per stay. Additional days are covered, but non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services have a $200 copay, Ambulatory Surgical Center Services have a $100 copay, and Individual and Group Sessions for Outpatient Substance Abuse have a copay between $20 and $20.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization and a doctor referral. The copay for this benefit is $25.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Capital Health Plan Preferred Advantage (HMO) plan. Ground and Air Ambulance Services have a copay of $290, with no coinsurance, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. For Emergency Services, there is a $125 copay and no coinsurance; for Urgently Needed Services, there is a $20 copay and no coinsurance. Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $20 copay, and Worldwide Emergency Transportation has a $290 copay.
Primary Care See details
The Capital Health Plan Preferred Advantage (HMO) plan covers primary care physician services with no copay, while chiropractic services have a $20 copay. Occupational therapy services, physician specialist services, and other health care professional services have a $20 copay, and physical therapy and speech-language pathology services have a $20 copay. Additional Telehealth benefits have a copay between $0 and $20. Mental health and psychiatric services have a $20 copay for individual and group sessions, and Opioid Treatment Program services have a $20 copay.
Preventive Services See details
The Capital Health Plan Preferred Advantage (HMO) plan covers preventive services, but does not cover annual physical exams. Kidney Disease Education Services have a $10 copay, and Other Preventive Services include services with a copay, such as Glaucoma Screening with a $10-$20 copay and Diabetes Self-Management Training with a $10 copay.
Hearing Services See details
Hearing services include hearing exams with a $20 copay, and prescription and OTC hearing aids; however, fitting/evaluation for hearing aids, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. Routine hearing exams are limited to one per year.
Vision Services See details
Vision Services includes coverage for eye exams with a copay of $10-$20, and eyewear with a combined maximum benefit of $200 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered, including Medicare Dental Services with a $20 copay, and other dental services with a maximum plan benefit of $800 per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery are covered. Orthodontic services are covered under Diagnostic and Preventive Dental.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Capital Health Plan Preferred Advantage (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment benefits are covered under the Capital Health Plan Preferred Advantage (HMO) plan, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance with authorization required, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, while Diabetic Supplies have a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered under the Capital Health Plan Preferred Advantage (HMO) plan. Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. Diagnostic Radiological Services have a copay of at most $100, and Therapeutic Radiological Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Capital Health Plan Preferred Advantage (HMO) with no copay and no coinsurance, but a referral is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Capital Health Plan Preferred Advantage (HMO) plan. Prior authorization and a doctor referral are required for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Capital Health Plan Preferred Advantage (HMO) plan, but require prior authorization and a doctor's referral. For days 1-20, the copay is $10, and for days 21-100, the copay is $200. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, but does not cover Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. The plan provides OTC items as a supplemental benefit under Part C and covers Naloxone, but does not cover Nicotine Replacement Therapy (NRT).
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