Benefits & Coverage

The Summary of Benefits compares Capital Health Plan Advantage Plus (HMO) and Capital Health Plan Preferred Advantage (HMO) with Original Medicare.

You can compare Capital Health Plan Advantage Plus (HMO) with Capital Health Plan Preferred Advantage (HMO) and Original Medicare using the Summary of Benefits. The chart in the Summary of Benefits lists important health benefits. For each benefit, you can see what our plan covers and what Original Medicare covers.

Our members receive all of the benefits that Original Medicare offers. We also offer additional benefits, which may change from year to year.

You have choices in your health care. As a Medicare beneficiary, you can choose from different Medicare options. One option is Original (fee-for-service) Medicare. Another option is a Medicare Advantage health plan, like Capital Health Plan Preferred Advantage (HMO). You may have other options, too. You make the choice. No matter what you decide, you are still in the Medicare Program.

You may join or leave a plan only at certain times. For more information, please call Capital Health Plan at one of the telephone numbers listed on this page or call Medicare at 1-800-MEDICARE (1-800-633-4227) for more information (TTY users should call 1-877-486-2048.) You may call Medicare 24 hours a day, 7 days a week.

Your Evidence of Coverage (pdf 1.82 MB) gives the details about your Medicare health coverage and explains how to get the care that you need.  The Evidence of Coverage includes plan conditions and limitations. 

The services we cover when you are outside our service area or network are care for a medical emergency, urgently needed care, renal dialysis, and care that Capital Health Plan or a plan provider has approved in advance.

Members are covered for medical emergencies anywhere in the world. A "medical emergency" is when you believe that your health is in serious danger. A medical emergency includes severe pain, a bad injury, a serious illness, or a medical condition that is quickly getting much worse.

For information about Out-of-Network Coverage for Prescription Drugs, please read about Out-of-Network Pharmacies.

Pharmacy Network

Members must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply. If you go to a pharmacy that is not in our network, you might have to pay more for your prescriptions. You also might have to follow special rules before getting your prescription to have the prescription covered under our plan. Network pharmacies are listed in our Directory of Physicians, Service Providers and Pharmacies (pdf 331.57 kB) .

Provider Network

Capital Health Plan has formed a network of primary care physicians, specialists, hospitals, and other health care providers. Members can choose a staff primary care physician located at our Governor's Square or Centerville Place Health Centers or they may choose an affiliate primary care physicians.  Plan providers are listed in our Directory of Physicians, Service Providers & Pharmacies (pdf 1.73 MB) and can change at any time. You must use plan providers except in emergency or urgent care situations or for out-of-area dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Capital Health Plan will be responsible for the costs.

Cost sharing refers to premium and amounts that a member pays when services are received.  Cost sharing includes copayments and coinsurance.