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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 2026, 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 2026.
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 $96.00. 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 $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:
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Drug Coverage
The Capital Health Plan Preferred Advantage (HMO) features a $200 annual drug deductible. Under this plan, you will pay no copay for Tier 1 Preferred Generic and Tier 6 Select Care Drugs at standard pharmacies and through standard mail order. For Tier 2 Generic drugs, standard pharmacy copays start at $7 for a one-month supply, with savings available for three-month mail-order refills. Tier 3 Preferred Brand drugs require a $45 copay for a one-month supply, while Tier 4 Non-Preferred Drugs have a $95 copay. Specialty medications in Tier 5 require a 30% coinsurance for a one-month supply at standard pharmacies.
Additional Benefits
The Capital Health Plan Preferred Advantage (HMO) offers comprehensive medical coverage with no copay for primary care visits, home health services, and select diagnostic tests. For more intensive care, members pay a $400 copay per inpatient hospital stay and a $200 copay for outpatient hospital services, both with no coinsurance. Emergency care is available with a $125 copay, while specialist and urgent care visits require a $20 copay. This plan also features robust supplemental benefits, including dental and vision coverage with no copay up to specified annual limits, and no-copay hearing aids. Additionally, members benefit from unlimited health-related transportation and over-the-counter items at no cost, though a 20% coinsurance applies to dialysis and durable medical equipment.
Inpatient Hospital See details
Capital Health Plan Preferred Advantage (HMO) partially covers inpatient hospital services, requiring a $400 copay per stay and no coinsurance for acute and psychiatric care. While unlimited additional Medicare-covered days are included, upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Capital Health Plan Preferred Advantage (HMO) covers outpatient services with no coinsurance, featuring a $200 copay for outpatient hospital services and a $100 copay for ambulatory surgical center services, both of which require a referral. Additionally, outpatient substance abuse services have a $20 copay and no coinsurance per session, while outpatient blood services require a referral but feature no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Capital Health Plan Preferred Advantage (HMO) covers partial hospitalization services with a copay of either $20.00 or $25.00 and no coinsurance. Prior authorization and a referral are required for the services with a $25.00 copay.
Ambulance and Transportation Services See details
Capital Health Plan Preferred Advantage (HMO) covers ground and air ambulance services with a $290 copay and no coinsurance. Transportation services are partially covered, offering unlimited one-way rides to any health-related location with no copay and no coinsurance, though transportation to plan-approved health-related locations is not covered.
Emergency Services See details
Capital Health Plan Preferred Advantage (HMO) covers emergency services with a $125 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $20 copay, both with 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 Preferred Advantage (HMO) offers primary care physician services and select telehealth benefits with no copay and no coinsurance. Specialist visits, physical and occupational therapy, opioid treatment, and mental health services require a $20 copay and no coinsurance, while podiatry and routine chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Capital Health Plan Preferred Advantage (HMO) with no coinsurance, featuring no copay for additional preventive services, a $10 copay for kidney disease education, and copays from $10 to $20 for other screenings. While select benefits like memory fitness are included, several sub-services such as annual physical exams, in-home safety assessments, and medical nutrition therapy are not covered.
Hearing Services See details
Capital Health Plan Preferred Advantage (HMO) partially covers hearing services, featuring routine hearing exams with a $20 copay and no coinsurance, though fitting and evaluation exams are not covered. Both prescription and OTC hearing aids are available with no copay and no coinsurance, but inner ear, outer ear, and over the ear prescription hearing aids are excluded from coverage.
Vision Services See details
Vision services are covered by Capital Health Plan Preferred Advantage (HMO) and include one routine eye exam yearly with a $10.00 to $20.00 copay and no coinsurance, though other eye exam services are not covered. Eyewear is partially covered with no copay or coinsurance up to a $200.00 annual maximum for contact lenses and eyeglasses, but individual eyeglass lenses, frames, and upgrades are not covered.
Dental Services See details
Dental services are covered by Capital Health Plan Preferred Advantage (HMO), including Medicare-covered dental care for a $20 copay and no coinsurance. Other preventive and comprehensive dental services, such as cleanings, exams, implants, and orthodontics, are covered with no copay and no coinsurance up to an annual maximum of $825.
Home Infusion bundled Services See details
Capital Health Plan Preferred Advantage (HMO) covers home infusion bundled services with no copay and no coinsurance, though associated Medicare Part B chemotherapy, radiation, and other drugs require a 0% to 20% coinsurance and no copay. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered by Capital Health Plan Preferred Advantage (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Health Plan Preferred Advantage (HMO) covers medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, with no copays. A 20% coinsurance applies to most of these items, including durable medical equipment, prosthetics, medical supplies, and diabetic shoes, while diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Capital Health Plan Preferred Advantage (HMO) partially covers diagnostic and radiological services, offering covered diagnostic services with no copay or coinsurance, though lab services and diagnostic procedures are not covered. Diagnostic radiological services require a $100.00 copay, therapeutic radiological services have a 20% coinsurance, and outpatient X-ray services are not covered.
Home Health Services See details
Home Health Services are covered by Capital Health Plan Preferred Advantage (HMO) with no copay and no coinsurance, although a referral is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by Capital Health Plan Preferred Advantage (HMO) with no coinsurance and no copay, though some services are not covered in practice, including standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
Capital Health Plan Preferred Advantage (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $200 daily copay for days 21 through 100. Prior authorization and referrals are required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Capital Health Plan Preferred Advantage (HMO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture, meal benefits, and nicotine replacement therapy are not covered.
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