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Capital Health Plan Silver Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Health Plan Silver 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 Silver Advantage (HMO) in 2026, please refer to our full plan details page.
Capital Health Plan Silver 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 Silver 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 Silver 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 Silver Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $25.00. You must continue to pay paying your reduced 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 $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:
Sign up for Capital Health Plan Silver Advantage (HMO)
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Drug Coverage
The Capital Health Plan Silver Advantage (HMO) features an annual prescription drug deductible of $250. You can enjoy no copay on Tier 1 preferred generics, Tier 2 generics, and Tier 6 select care drugs when filled through preferred pharmacies or standard mail order. For standard pharmacies, one-month copays for Tier 1 and Tier 2 drugs start at $10 and $14, respectively. Brand-name and specialty medications are also covered, with Tier 3 preferred brands requiring a $40 copay and Tier 4 non-preferred drugs requiring a $93 copay for a one-month supply at preferred pharmacies. Standard mail order offers additional savings on three-month supplies for Tier 3 and Tier 4 drugs. Specialty Tier 5 drugs require a 30% coinsurance for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The Capital Health Plan Silver Advantage (HMO) offers comprehensive medical coverage with no copay for primary care doctor visits and a $30 copay for specialist, physical therapy, and mental health appointments. For hospital care, inpatient stays require a $275 daily copay for days 1 through 6 and no copay for subsequent days, while emergency room visits carry a $125 copay. Outpatient hospital services, ambulatory surgery, and ambulance rides are also covered under flat copayments with no coinsurance, keeping your out-of-pocket costs predictable. Additionally, this plan provides valuable extra benefits including routine dental, vision, and hearing care, featuring no copay for preventive dental services, select eyewear, and over-the-counter hearing aids. Members also benefit from no copay for home health services, unlimited one-way health-related transportation, and select over-the-counter items. For specialized needs like durable medical equipment and dialysis, the plan charges a 20% coinsurance with no copay.
Inpatient Hospital See details
Capital Health Plan Silver Advantage (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $275 daily copay for days 1 through 6 and no copay for days 7 and beyond. Prior authorization and referrals are required for these services, while upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Capital Health Plan Silver Advantage (HMO) covers outpatient hospital services with a $350 copay and no coinsurance, and ambulatory surgical center services with a $250 copay and no coinsurance. Outpatient substance abuse services are covered with a $30 copay and no coinsurance, while outpatient blood services have no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Capital Health Plan Silver Advantage (HMO) covers partial hospitalization services with no coinsurance and a copay of either $30.00 or $40.00. Prior authorization and a referral are required for services under the $40.00 copay.
Ambulance and Transportation Services See details
Capital Health Plan Silver 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, while plan-approved health-related location transportation is not covered.
Emergency Services See details
Capital Health Plan Silver Advantage (HMO) covers emergency services with a $125 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $20 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $125, $20, and $290 respectively.
Primary Care See details
Capital Health Plan Silver Advantage (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits, mental health sessions, and physical therapy require a $30 copay and no coinsurance. Podiatry services are not covered, chiropractic services are only partially covered, and telehealth benefits are available with a $0 to $30 copay and no coinsurance.
Preventive Services See details
Preventive services are partially covered by Capital Health Plan Silver Advantage (HMO) with no coinsurance, featuring no copay for select benefits and copays ranging from $10 to $30 for kidney disease education, glaucoma screenings, and diabetes training. Several sub-services are not covered under this plan, including annual physical exams, weight management, therapeutic massage, alternative therapies, and in-home safety assessments.
Hearing Services See details
Hearing services are partially covered by Capital Health Plan Silver Advantage (HMO), offering routine hearing exams once per year for a $30 copay and no coinsurance, with no deductible. Over-the-counter and prescription hearing aids are covered with no copay and no coinsurance, but fitting and evaluation services, as well as inner ear, outer ear, and over-the-ear prescription hearing aids, are not covered.
Vision Services See details
Capital Health Plan Silver Advantage (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, though other eye exam services are not covered. Eyewear is also partially covered with no copay, no coinsurance, and a $200.00 annual maximum for contact lenses and complete eyeglasses, but separate eyeglass lenses, frames, and upgrades are excluded.
Dental Services See details
Dental services are covered by Capital Health Plan Silver Advantage (HMO), requiring a $30 copay and no coinsurance for Medicare-covered dental care. Other preventive and comprehensive dental services are covered with no copay and no coinsurance, up to an annual maximum benefit of $625.
Home Infusion bundled Services See details
Capital Health Plan Silver Advantage (HMO) covers home infusion bundled services with no copay and no coinsurance. Within this benefit, Medicare Part B chemotherapy, radiation, and other drugs require no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered by Capital Health Plan Silver Advantage (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Health Plan Silver Advantage (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance, with prior authorization required for certain items. Diabetic equipment and supplies are also covered with no copay, carrying a 20% coinsurance for therapeutic shoes and inserts, and a 0% (no coinsurance) to 20% coinsurance for other diabetic supplies.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Capital Health Plan Silver Advantage (HMO), though diagnostic procedures, tests, lab services, and outpatient X-ray services are not covered. Some diagnostic services are covered with 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 along with a copay.
Home Health Services See details
Home health services are covered under the Capital Health Plan Silver Advantage (HMO) with no copay and no coinsurance, although a referral is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by Capital Health Plan Silver Advantage (HMO) with no copay and no coinsurance, although prior authorization and referrals are required. While some services are covered, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy for symptomatic peripheral artery disease are not covered.
Skilled Nursing Facility (SNF) See details
Capital Health Plan Silver 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 100 days are not covered.
Other Services See details
Other Services are partially covered by Capital Health Plan Silver Advantage (HMO), which provides over-the-counter (OTC) items with no copay and no coinsurance. However, acupuncture, meal benefits, and other additional services are not covered.
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