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Capital Health Plan Giveback Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Health Plan Giveback 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 Giveback Advantage (HMO) in 2026, please refer to our full plan details page.
Capital Health Plan Giveback Advantage (HMO) is a HMO plan offered by Guidewell Mutual Holding Corporation available for enrollment in 2026 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 Giveback 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 Giveback 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 Giveback 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 $100.00. 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 $6700.00 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 Giveback Advantage (HMO) features an annual drug deductible of $250. This Medicare plan offers excellent savings on lower-tier medications, featuring no copay for Tier 1 preferred generics and Tier 2 generics at preferred pharmacies, as well as no copay for Tier 6 select care drugs. Standard mail-order services also provide no copay for Tier 1 and Tier 6 prescriptions, helping you save on routine medications. For higher-tier prescriptions, copays and coinsurance will apply during the initial coverage phase. Tier 3 preferred brands carry a $40 copay at preferred pharmacies and standard mail order, while Tier 4 non-preferred drugs require a $93 copay at preferred pharmacies. Specialty drugs in Tier 5 require a 30% coinsurance at both preferred and standard pharmacies for a one-month supply.
Additional Benefits
The Capital Health Plan Giveback Advantage (HMO) offers affordable medical coverage with no copay and no coinsurance for primary care visits, while specialist visits require a $30 copay. For acute hospital stays, members pay a $350 daily copay for days one through seven, with no copay for additional days and no coinsurance. Emergency room visits have a $125 copay that is waived upon admission, and urgent care services require a $20 copay. Routine vision and hearing exams are covered with low copays, and eyewear is provided with no copay up to a $200 annual limit. Home health services feature no copay, whereas dialysis and durable medical equipment require no copay and a 20% coinsurance. Skilled nursing facility care is covered with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $200 daily copay for days 21 to 100.
Inpatient Hospital See details
Inpatient hospital services are covered by Capital Health Plan Giveback Advantage (HMO) with no coinsurance, requiring a $350 daily copay for days 1-7 of acute stays and days 1-5 of psychiatric stays, with no copay for additional days. Prior authorization and referrals are required, and upgrades or non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Capital Health Plan Giveback Advantage (HMO) with no coinsurance, featuring a $350 copay for outpatient hospital services and a $250 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $30 copay with no coinsurance, while outpatient blood services are provided with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered by the Capital Health Plan Giveback Advantage (HMO) with no coinsurance, requiring a copay of either $30 or $40. The $40 copay option requires prior authorization and a referral, while the $30 copay option does not.
Ambulance and Transportation Services See details
Capital Health Plan Giveback Advantage (HMO) partially covers ambulance and transportation services, with a $290 copay and no coinsurance for ground and air ambulance services requiring prior authorization. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Capital Health Plan Giveback Advantage (HMO) covers emergency services with a $125 copay and no coinsurance, with the copay waived if 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 Giveback Advantage (HMO) covers primary care physician services with no copay and no coinsurance, while specialists, mental health, and physical therapy require a $30 copay and no coinsurance. Chiropractic and podiatry services are not covered, but telehealth benefits are available with copays ranging from $0 to $30 and no coinsurance.
Preventive Services See details
Preventive Services are partially covered by Capital Health Plan Giveback Advantage (HMO), featuring no copay and no coinsurance for Medicare-covered zero-dollar services, health education, and memory fitness benefits. Other covered services, such as glaucoma screenings and kidney disease education, require no coinsurance and copays ranging from $10 to $30, while annual physical exams and in-home safety assessments are not covered.
Hearing Services See details
Hearing services are partially covered by Capital Health Plan Giveback Advantage (HMO), offering one routine hearing exam per year with a $30 copay and no coinsurance, while fitting and evaluation services are not covered. Some prescription hearing aid services are covered, but prescription hearing aids—including inner ear, outer ear, and over the ear types—and over-the-counter hearing aids are not covered.
Vision Services See details
Capital Health Plan Giveback Advantage (HMO) partially covers vision services, offering one routine eye exam per year with a $10 to $30 copay and no coinsurance, while other eye exams are not covered. Eyewear is covered with no copay and no coinsurance up to a $200 annual maximum for contact lenses and eyeglasses, though individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Capital Health Plan Giveback Advantage (HMO) partially covers dental services, with coverage limited to Medicare-covered dental services for a $30.00 copay and no coinsurance. Routine and comprehensive dental services, including oral exams, cleanings, x-rays, and restorative work, are not covered.
Home Infusion bundled Services See details
Capital Health Plan Giveback Advantage (HMO) covers home infusion bundled services with no copay and no coinsurance. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while Medicare Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Capital Health Plan Giveback Advantage (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Health Plan Giveback Advantage (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance, subject to prior authorization. Diabetic equipment and services are also covered with no copay, carrying a 20% coinsurance for therapeutic shoes or inserts and between no coinsurance and 20% coinsurance for diabetic supplies.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered under the Capital Health Plan Giveback Advantage (HMO), with diagnostic procedures, lab services, and outpatient X-ray services excluded from coverage. Covered diagnostic services require a referral and have no copay and no coinsurance, while diagnostic radiological services require a $100 copay and no coinsurance, and therapeutic radiological services require a copay and 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Capital Health Plan Giveback Advantage (HMO) with no copay and no coinsurance, though a referral is required to receive these services.
Cardiac Rehabilitation Services See details
Capital Health Plan Giveback Advantage (HMO) offers cardiac rehabilitation with no coinsurance, though only some services are covered. Standard cardiac rehabilitation (with a $40 copay), intensive cardiac rehabilitation (with a $40 copay), pulmonary rehabilitation (with a $20 copay), and supervised exercise therapy for peripheral artery disease (with a $10 copay) are not covered, and prior authorization and referrals are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Capital Health Plan Giveback Advantage (HMO) 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, a three-day prior hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
Other services are not covered by the Capital Health Plan Giveback Advantage (HMO), which does not provide coverage for acupuncture, over-the-counter items, or meal benefits.
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