Capital Health Plan Advantage Plus (HMO)
Available to residents of Jefferson County, FL for 2027. 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
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Renewed for 2027. CMS carries this plan forward from 2026. Every FL plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $39.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $39.00? |
| Monthly premium with full Extra Help (LIS) | $31.70? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $6,000.00? |
| Drug deductible | $400.00Tier 1, 2 and 6 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | HMO? |
| Contract / plan | H5938-001-0 |
| Offered by | Capital Health Plan |
| Parent organization | Guidewell Mutual Holding Corporation |
| Formulary tiers | 6 |
| 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)
- 4.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4 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 | $45 copay(referral required) |
| Other health care professional | $0–$45 copay(referral required) |
| Additional telehealth services | $0–$45 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | Not covered |
| Kidney disease education | $10 copay(referral required) |
| Glaucoma screening | $10–$45 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) | $0–$150 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 | $130 copay |
| Urgent care | $30 copay |
| Worldwide emergency coverage | $130 copay |
| Worldwide urgent care | $30 copay |
| Worldwide emergency transportation | $290 copay |
| Hospital care | |
| Inpatient hospital stay | $275 per day for days 1–7; $0 per day for days 8–90(authorization and referral required) |
| Outpatient hospital services | $300 copay(referral required) |
| Outpatient observation | $0 copay |
| Ambulatory surgical center | $200 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 | $275 per day for days 1–7; $0 per day for days 8–90(authorization and referral required) |
| Outpatient mental health, individual session | $45 copay |
| Outpatient mental health, group session | $45 copay |
| Psychiatrist, individual session | $45 copay |
| Psychiatrist, group session | $45 copay |
| Partial hospitalization | $40 copay(authorization and referral required) |
| Intensive outpatient program | $45 copay(authorization and referral required) |
| Outpatient substance use, individual session | $45 copay |
| Outpatient substance use, group session | $45 copay |
| Opioid treatment program | $45 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) | $45 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $45 copay(authorization and referral required) |
| Preventive dental plan limit | $625 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–$45 copay |
| Routine eye exam | $10–$45 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) | $45 copay |
| Routine hearing exam | $45 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, CY2027). 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 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $7.00 |
| Tier 3 · Preferred Brand | $45.00 |
| Tier 4 · Non-Preferred Drug | 25% |
| Tier 5 · Specialty Tier | 25% |
| Tier 6 · Select Care Drugs | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| 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 | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 25% | 25% | 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 |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Breast Cancer Screening · C01 | 5 out of 5 stars for Breast Cancer Screening | 5 out of 5 stars for Breast Cancer Screening |
| Colorectal Cancer Screening · C02 | 5 out of 5 stars for Colorectal Cancer Screening | 5 out of 5 stars for Colorectal Cancer Screening |
| Annual Flu Vaccine · C03 | 4 out of 5 stars for Annual Flu Vaccine | 5 out of 5 stars for Annual Flu Vaccine |
| Improving or Maintaining Physical Health · C04 | 4 out of 5 stars for Improving or Maintaining Physical Health | 2 out of 5 stars for Improving or Maintaining Physical Health |
| Improving or Maintaining Mental Health · C05 | 5 out of 5 stars for Improving or Maintaining Mental Health | 4 out of 5 stars for Improving or Maintaining Mental Health |
| Monitoring Physical Activity · C06 | 4 out of 5 stars for Monitoring Physical Activity | 4 out of 5 stars for Monitoring Physical Activity |
| Managing Chronic (Long Term) Conditions | ||
| Osteoporosis Management in Women who had a Fracture · C10 | 4 out of 5 stars for Osteoporosis Management in Women who had a Fracture | 5 out of 5 stars for Osteoporosis Management in Women who had a Fracture |
| Diabetes Care – Eye Exam · C11 | 5 out of 5 stars for Diabetes Care – Eye Exam | 5 out of 5 stars for Diabetes Care – Eye Exam |
| Diabetes Care – Blood Sugar Controlled · C12 | 5 out of 5 stars for Diabetes Care – Blood Sugar Controlled | 5 out of 5 stars for Diabetes Care – Blood Sugar Controlled |
| Kidney Health Evaluation for Patients with Diabetes · C13 | 4 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes | 5 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes |
| Controlling High Blood Pressure · C14 | 3 out of 5 stars for Controlling High Blood Pressure | 4 out of 5 stars for Controlling High Blood Pressure |
| Reducing the Risk of Falling · C15 | 2 out of 5 stars for Reducing the Risk of Falling | 2 out of 5 stars for Reducing the Risk of Falling |
| Improving Bladder Control · C16 | 5 out of 5 stars for Improving Bladder Control | 5 out of 5 stars for Improving Bladder Control |
| Plan All-Cause Readmissions · C17 | 3 out of 5 stars for Plan All-Cause Readmissions | 4 out of 5 stars for Plan All-Cause Readmissions |
| Statin Therapy for Patients with Cardiovascular Disease · C18 | 2 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease | 3 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease |
| Transitions of Care · C19 | 5 out of 5 stars for Transitions of Care | 4 out of 5 stars for Transitions of Care |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 3 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | 3 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | 5 out of 5 stars for Getting Needed Care | 5 out of 5 stars for Getting Needed Care |
| Getting Appointments and Care Quickly · C22 | 5 out of 5 stars for Getting Appointments and Care Quickly | 5 out of 5 stars for Getting Appointments and Care Quickly |
| Customer Service · C23 | 5 out of 5 stars for Customer Service | 5 out of 5 stars for Customer Service |
| Rating of Health Care Quality · C24 | 5 out of 5 stars for Rating of Health Care Quality | 5 out of 5 stars for Rating of Health Care Quality |
| Rating of Health Plan · C25 | 5 out of 5 stars for Rating of Health Plan | 5 out of 5 stars for Rating of Health Plan |
| Care Coordination · C26 | 3 out of 5 stars for Care Coordination | 3 out of 5 stars for Care Coordination |
| Member Complaints and Changes in the Health Plan's Performance | ||
| Complaints about the Health Plan · C27 | 5 out of 5 stars for Complaints about the Health Plan | 5 out of 5 stars for Complaints about the Health Plan |
| Members Choosing to Leave the Plan · C28 | 5 out of 5 stars for Members Choosing to Leave the Plan | 5 out of 5 stars for Members Choosing to Leave the Plan |
| Health Plan Quality Improvement · C29 | 3 out of 5 stars for Health Plan Quality Improvement | 4 out of 5 stars for Health Plan Quality Improvement |
| Health Plan Customer Service | ||
| Plan Makes Timely Decisions about Appeals · C30 | 5 out of 5 stars for Plan Makes Timely Decisions about Appeals | 5 out of 5 stars for Plan Makes Timely Decisions about Appeals |
| Reviewing Appeals Decisions · C31 | 5 out of 5 stars for Reviewing Appeals Decisions | 5 out of 5 stars for Reviewing Appeals Decisions |
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Complaints about the Drug Plan · D02 | 5 out of 5 stars for Complaints about the Drug Plan | 5 out of 5 stars for Complaints about the Drug Plan |
| Members Choosing to Leave the Plan · D03 | 5 out of 5 stars for Members Choosing to Leave the Plan | 5 out of 5 stars for Members Choosing to Leave the Plan |
| Drug Plan Quality Improvement · D04 | 4 out of 5 stars for Drug Plan Quality Improvement | 4 out of 5 stars for Drug Plan Quality Improvement |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 5 out of 5 stars for Rating of Drug Plan | 5 out of 5 stars for Rating of Drug Plan |
| Getting Needed Prescription Drugs · D06 | 4 out of 5 stars for Getting Needed Prescription Drugs | 4 out of 5 stars for Getting Needed Prescription Drugs |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 5 out of 5 stars for MPF Price Accuracy | 5 out of 5 stars for MPF Price Accuracy |
| Medication Adherence for Diabetes Medications · D08 | 2 out of 5 stars for Medication Adherence for Diabetes Medications | 3 out of 5 stars for Medication Adherence for Diabetes Medications |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 4 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | 4 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) |
| Medication Adherence for Cholesterol (Statins) · D10 | 3 out of 5 stars for Medication Adherence for Cholesterol (Statins) | 4 out of 5 stars for Medication Adherence for Cholesterol (Statins) |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 3 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | 3 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 3 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 4 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H5938 shares it.
Also available in 8 other FL counties
Benefits in plain text
Capital Health Plan Advantage Plus (HMO) (H5938-001-0) is a 2027 HMO Medicare Advantage plan offered by Capital Health Plan, available to residents of Jefferson County, FL.
The monthly premium is $39.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $31.70.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $6,000.00.
The drug deductible is $400.00. Tier 1, 2 and 6 exempt.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $7.00; tier 3 (Preferred Brand): $45.00; tier 4 (Non-Preferred Drug): 25%; tier 5 (Specialty Tier): 25%; tier 6 (Select Care Drugs): $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 plan Landscape file and the CMS plan benefit package (PBP) files.