Capital Health Plan Silver Advantage (HMO)
H5938 - 008 - 0
(4.5 / 5)
Capital Health Plan Silver Advantage (HMO) is a Medicare Advantage (Part C) Plan by Capital Health Plan.
This page features plan details for 2024 Capital Health Plan Silver Advantage (HMO) H5938 – 008 – 0 available in Leon and surrounding counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Capital Health Plan Silver Advantage (HMO) is offered in the following locations.
Plan Overview
Capital Health Plan Silver Advantage (HMO) offers the following coverage and cost-sharing.
| Insurer: | Capital Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,850 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Capital Health Plan Silver Advantage (HMO) ?
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 $36.00.
| Premium Reduction: | $36.00 |
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 |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $36.00 | $138.70 |
- 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 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
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 | $ |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
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 $5,030.00. 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 | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $10.00 copay | $0.00 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% | 33% | ||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $30.00 copay | $0.00 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) | $0.00 copay | $0.00 copay | $0.00 copay |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | |
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | |
| Generic drugs | ||||
| Brand-name drugs |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, 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.
| $0 |
| In-network | No |
| $3,850 In-network |
| No |
| In-network | Yes, contact plan for further details |
| $350 copay per visit (Authorization is not required.) (Referral is required.) |
| Primary | $10 copay per visit (Not applicable.) (Not applicable.) |
| Specialist | $45 copay per visit (Authorization is not required.) (Referral is required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $135 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $20 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is not required.) (Referral is required.) |
| Lab services | $0 copay (Authorization is not required.) (Referral is required.) |
| Diagnostic radiology services (e.g., MRI) | $100 copay (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is required.) |
| Hearing exam | $45 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Routine eye exam | $10-45 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $30 copay (Authorization is not required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $30 copay (Authorization is not required.) (Referral is required.) |
| $250 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $45 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is not required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is not required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is not required.) (Not applicable.) |
| $275 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $275 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| $20 per day for days 1 through 20 $150 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
Ready to sign up for Capital Health Plan Silver Advantage (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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