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Capital Health Plan Silver Advantage (HMO)

H5938 - 008 - 0

(4.5 / 5)

Capital Health Plan Silver Advantage (HMO) is a Medicare Advantage Plan by Capital Health Plan.

This page features plan details for 2025 Capital Health Plan Silver Advantage (HMO) H5938 – 008 – 0 available in Leon and surrounding counties.

Locations

Capital Health Plan Silver Advantage (HMO) is offered in the following locations.

Calhoun County, Florida

Florida

Franklin County, Florida

Click to see more locations

Plan Overview

Capital Health Plan Silver Advantage (HMO) offers the following coverage and cost-sharing.

Insurer:	Capital Health Plan
Health Plan Deductible:	$0
MOOP:	$5,500 In-network
Drugs Covered:	Yes

Ready to sign up for Capital Health Plan Silver Advantage (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.

Capital Health Plan Silver Advantage (HMO) qualifies for a monthly Medicare Give Back Benefit of $23.00.

Premium Reduction:

$23.00

Premium Breakdown

Capital Health Plan Silver Advantage (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$0.00	$23.00	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Capital Health Plan Silver Advantage (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$10.00 Copay
2) Generic	$7.00 Copay	$14.00 Copay	$7.00 Copay
3) Preferred Brand	$40.00 Copay	$47.00 Copay	$40.00 Copay
4) Non-Preferred Drug	$93.00 Copay	$100.00 Copay	$93.00 Copay
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance
6) Select Care Drugs

60 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$20.00 Copay
2) Generic	$14.00 Copay	$28.00 Copay	$14.00 Copay
3) Preferred Brand	$80.00 Copay	$94.00 Copay	$80.00 Copay
4) Non-Preferred Drug	$186.00 Copay	$200.00 Copay	$186.00 Copay
5) Specialty Tier
6) Select Care Drugs

90 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$30.00 Copay
2) Generic	$21.00 Copay	$42.00 Copay	$17.50 Copay
3) Preferred Brand	$120.00 Copay	$141.00 Copay	$100.00 Copay
4) Non-Preferred Drug	$279.00 Copay	$300.00 Copay	$232.50 Copay
5) Specialty Tier
6) Select Care Drugs

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Capital Health Plan Silver Advantage (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: Yes, contact plan for further details

Comprehensive Dental

Adjunctive General Services
- In-Network: No Coins – No Co pay (Limits Apply)
Endodontics
- In-Network: No Coins – No Co pay (Limits Apply)
Implant Services
- In-Network: No Coins – No Co pay (Limits Apply)
Maxillofacial Prosthetics
- In-Network: No Coins – No Co pay (Limits Apply)
Oral and Maxillofacial Surgery
- In-Network: No Coins – No Co pay (Limits Apply)
Orthodontics
- In-Network: No Coins – No Co pay (Limits Apply)
Periodontics
- In-Network: No Coins – No Co pay (Limits Apply)
Prosthodontics, fixed
- In-Network: No Coins – No Co pay (Limits Apply)
Prosthodontics, removable
- In-Network: No Coins – No Co pay (Limits Apply)
Restorative Services
- In-Network: No Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay (Limits Apply)
Fluoride Treatment
- In-Network: No Coins – No Copay (Limits Apply)
Oral Exams
- In-Network: No Coins – No Copay (Limits Apply)
Other Diagnostic Dental Services
- In-Network: No Coins – No Copay (Limits Apply)
Other Preventive Dental Services
- In-Network: No Coins – No Copay (Limits Apply)
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI)
- $100 copay (Authorization Required, Referral Required)
Lab services
- $0 copay (Referral Required)
Outpatient x-rays
- $0 copay (Authorization Required, Referral Required)
Diagnostic tests and procedures
- $0 copay (Referral Required)

Doctor visits

Primary
- $0 copay
Specialist
- $30 copay per visit (Referral Required)

Emergency care/Urgent care

Emergency
- $125 copay per visit (always covered)
Urgent care
- $20 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $30 copay
Routine foot care
- Not covered

Ground ambulance

- $290 copay

Health plan deductible

- $0

Hearing

Fitting/evaluation
- Not covered
Medicare-Covered Hearing Exam
- $30 copay
Hearing aids
- $0 copay (Limits Apply)
Hearing aids OTC
- $0 copay (Limits Apply)

Inpatient hospital coverage

- $275 per day for days 1 through 6
  $0 per day for days 7 through 90 (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $5,500 In-network

Medical equipment/supplies

Diabetes supplies
- 0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)
- 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

Chemotherapy
- 0-20% coinsurance
Other Part B drugs
- 0-20% coinsurance

Mental health services

Inpatient hospital – psychiatric
- $275 per day for days 1 through 6
  $0 per day for days 7 through 90 (Authorization Required, Referral Required)
Outpatient individual therapy visit
- $30 copay
Outpatient individual therapy visit with a psychiatrist
- $30 copay
Outpatient group therapy visit
- $30 copay
Outpatient group therapy visit with a psychiatrist
- $30 copay

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $350 copay per visit (Referral Required)

Preventive care

- $0 copay

Rehabilitation services

Occupational therapy visit
- $30 copay (Referral Required)
Physical therapy and speech and language therapy visit
- $30 copay (Referral Required)

Skilled Nursing Facility

- $10 per day for days 1 through 20
  $200 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

- Not covered

Vision

Contact lenses
- $0 copay (Limits Apply)
Eyeglass lenses
- Not covered
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)
Other
- Not covered
Routine eye exam
- $10-30 copay (Limits Apply)
Upgrades
- Not covered
Eyeglass frames
- Not covered

Wellness programs (e.g., fitness, nursing hotline)

- Covered