Capital Health Plan Advantage Plus (HMO)
Available to residents of Jefferson County, FL for 2026. Contract H5938, plan 001, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Jefferson County
- Plan website
- Browse the Capital Health Plan Advantage Plus (HMO) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $34.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $34.00? |
| Monthly premium with full Extra Help (LIS) | $29.20? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $4,500.00? |
| Drug deductible | $250.00Tier 1, 2 and 6 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H5938-001-0 |
| Offered by | Capital Health Plan |
| Parent organization | Guidewell Mutual Holding Corporation |
| Formulary drugs | 3,539 |
| Formulary exception tier | 4? |
| Pharmacy search | www.capitalhealth.com/Medicare |
| Member services | (877)247-6512TTY (877)870-8943 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H5938 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $30 copay(referral required) |
| Other health care professional | $30 copay(referral required) |
| Additional telehealth services | $0–$30 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | Not covered |
| Kidney disease education | $10 copay(referral required) |
| Glaucoma screening | $10–$30 copay(referral required) |
| Diabetes self-management training | $10 copay(referral required) |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0 copay(referral required) |
| Lab services | $0 copay(referral required) |
| Diagnostic radiology (e.g. MRI, CT) | $100 copay(authorization and referral required) |
| Therapeutic radiology | 20% coinsurance(authorization and referral required) |
| Outpatient x-rays | $0 copay(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | $125 copay |
| Urgent care | $20 copay |
| Worldwide emergency coverage | $125 copay |
| Worldwide urgent care | $20 copay |
| Worldwide emergency transportation | $290 copay |
| Hospital care | |
| Inpatient hospital stay | $250 per day for days 1–5; $0 per day for days 6–90(authorization and referral required) |
| Outpatient hospital services | $300 copay(referral required) |
| Outpatient observation | $0 copay |
| Ambulatory surgical center | $150 copay(referral required) |
| Outpatient blood services | $0 copay(referral required) |
| Skilled nursing and home health | |
| Skilled nursing facility | $10 per day for days 1–20; $200 per day for days 21–100(authorization and referral required) |
| Home health care | $0 copay(referral required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $20 copay(referral required) |
| Physical therapy and speech-language therapy | $20 copay(referral required) |
| Cardiac rehabilitation | $40 copay(authorization and referral required) |
| Pulmonary rehabilitation | $20 copay(authorization and referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $250 per day for days 1–5; $0 per day for days 6–90(authorization and referral required) |
| Outpatient mental health, individual session | $30 copay |
| Outpatient mental health, group session | $30 copay |
| Psychiatrist, individual session | $30 copay |
| Psychiatrist, group session | $30 copay |
| Partial hospitalization | $40 copay(authorization and referral required) |
| Intensive outpatient program | $30 copay |
| Outpatient substance use, individual session | $30 copay |
| Outpatient substance use, group session | $30 copay |
| Opioid treatment program | $30 copay |
| Ambulance and transportation | |
| Ground ambulance | $290 copay(authorization required) |
| Air ambulance | $290 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 0%–20% coinsurance |
| Diabetic therapeutic shoes or inserts | 20% coinsurance |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $30 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $30 copay(authorization and referral required) |
| Preventive dental plan limit | $725 plan limit every year |
| Oral exams | $0 copay |
| Cleanings | $0 copay |
| Fluoride treatment | $0 copay |
| Dental x-rays | $0 copay |
| Other diagnostic dental services | $0 copay |
| Other preventive dental services | $0 copay |
| Restorative services (fillings, crowns) | $0 copay |
| Endodontics (root canals) | $0 copay |
| Periodontics (gum disease) | $0 copay |
| Dentures and other removable prosthodontics | $0 copay |
| Maxillofacial prosthetics | $0 copay |
| Implants | $0 copay |
| Bridges and other fixed prosthodontics | $0 copay |
| Oral and maxillofacial surgery | $0 copay |
| Orthodontics | $0 copay |
| Adjunctive general services | $0 copay |
| Vision? | |
| Eye exam (Medicare-covered) | $10–$30 copay |
| Routine eye exam | $10–$30 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $200 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $30 copay |
| Routine hearing exam | $30 copay(limits apply) |
| Hearing aid fitting and evaluation | Not covered |
| Hearing aids (all types) | $0 copay |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $35 copay |
| Chemotherapy and radiation drugs | 0%–20% coinsurance |
| Other Part B drugs | 0%–20% coinsurance |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Covered (allowance not stated) |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay(limits apply) |
| Health education | $0 copay(limits apply) |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | $0 copay(limits apply) |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay(limits apply) |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | $0 copay(limits apply) |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $7.00 |
| Tier 3 | $45.00 |
| Tier 4 | $95.00 |
| Tier 5 | 30% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $7.00 | $7.00 | $7.00 | $21.00 | $21.00 | $17.50 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $7.00 | $7.00 | $7.00 | $21.00 | $21.00 | $17.50 |
| Tier 3: Preferred Brand | $45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $112.50 |
| Tier 4: Non-Preferred Drug | $95.00 | $95.00 | $95.00 | $285.00 | $285.00 | $237.50 |
| Tier 5: Specialty Tier | 30% | 30% | n/a | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 8 other FL counties
Benefits in plain text
Capital Health Plan Advantage Plus (HMO) (H5938-001-0) is a 2026 HMO Medicare Advantage plan offered by Capital Health Plan, available to residents of Jefferson County, FL.
The monthly premium is $34.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $29.20.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $4,500.00.
The drug deductible is $250.00. Tier 1, 2 and 6 exempt.
The plan's formulary lists 3,539 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $7.00; tier 3: $45.00; tier 4: $95.00; tier 5: 30%; tier 6: $0.00.
CMS gives the plan's contract (H5938) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.