2012 CHP Advantage Plus (HMO)

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877-247-6512
850-523-7441
850-383-3534 (TTY)
1-877-870-8943 (TTY)

Call us seven days a week
8 a.m. - 8 p.m.

2140 Centerville Pl
1491 Governor's Square Blvd
1545 Raymond Diehl Rd
Tallahassee

Mailing address:
Post Office Box 15349
Tallahassee FL 32317-5349

Capital Health Plan is a health plan with a Medicare contract. The contract is renewed annually and the availability of coverage beyond the current year is not guaranteed.

Benefits, formulary, pharmacy, network premium and/or copayments/coinsurance may change on January 1, 2013. Please contact Capital Health Plan for details.

Please call Capital Health Plan Member Services Department to obtain documents in alternate formats or languages.

To ensure that beneficiaries receive appropriate care, Capital Health Plan will follow policies and procedures as directed by CMS (Centers for Medicare and Medicaid Services) in the event of an emergency situation designated by the Department of Health and Human Services.

H5938_WEB 002 CMS Approved 10032011. 

Copayments/Coinsurance

"Copayment" means that you pay a fixed amount each time you receive a medical service. You pay a copayment at the time you get the medical service.

"Coinsurance" means that you pay a percent of the total cost of a medical service. You pay a coinsurance at the time you get the medical service.

Please consult the Summary of Benefits to view the details of your costs and to compare your benefits with Original Medicare.

The chart below shows what you will pay for services with Capital Health Plan Advantage Plus (HMO). 

Capital Health Plan Advantage Plus
Premium $30 per month
Primary Care $10 per visit
Specialty Care $30 per visit
Chiropractic Care $20 per visit
Medicare Covered Preventive Services $0
Urgent Care $20 per visit
Emergency Room Visit (Worldwide) $50 per visit
Inpatient Hospital Coverage

$150 per day (days 1-5)

$0 per day (days 6-90)  (no limit on days)

$750 maximum for each stay

Skilled Nursing Facility

$0 per day (days 1-6)

$100 per day (days 7-100) (Limited to 100 days

per benefit period)

Outpatient Surgery $100 per procedure
Home Health Care $0
Ambulance Services $100 per transport
Durable Medical Equipment 20% of the cost
Diabetes Supplies 20% of the cost
MRI  / CT / PET / Thallium Scans $100 per scan
Lab & X-Ray $0
Radiation Therapy 20% of the cost
Routine Eye Exams $10
Eyeglass or Contact Reimbursement $150 (every 2 years)
Health Club Membership Reimbursement Up to $150 (yearly)
Annual Out of Pocket Maximum (Medical Only) $3400
Prescription Drug Coverage (Part D) Initial Coverage Limit (up to $2930 total drug cost) you pay:
30-Day Retail

Tier 1 - $7 / 30-day supply

Tier 2 - $35 / 30-day supply

Tier 3 - $60 / 30-day supply

Tier 4 - $250 or 25% (whichever costs less)

90-Day Retail

Tier 1 - $21 / 90-day supply

Tier 2 - $105 / 90-day supply

Tier 3 - $180 / 90-day supply

Tier 4 – Not Available

90-Day Mail Order

Tier 1 - $17.50 / 90-day supply

Tier 2 - $87.50 / 90-day supply

Tier  3 - $150 / 90-day supply

Tier 4 – Not Available

Gap coverage (after reaching Initial Coverage Limit of $2930) you pay:

86% of Generics

50% of Brand Name Drugs (plus dispensing fee)

Catastrophic Coverage (after $4700 out of pocket) you pay:

Generic- $2.60 or 5% (whichever is greater)

All others- $6.50 or 5% (whichever is greater)

For coverage details and additional copayments/coinsurance please see the Capital Health Plan Advantage Plus (HMO) and Capital Health Plan Preferred Advantage (HMO) Summary of Benefits or the Capital Health Plan Advantage Plus (HMO) Evidence of Coverage.  Conditions and limitations may apply.

Last updated: 10/01/2011