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Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Highmark Wholecare Medicare Assured Diamond (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) in 2025, please refer to our full plan details page.
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) is a HMO D-SNP plan offered by Highmark Health available for enrollment in 2025 to people living in SW NW NE Central Pennsylvania Counties. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Highmark Wholecare Medicare Assured Diamond (HMO D-SNP).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Highmark Wholecare Medicare Assured Diamond (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $42.70. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $5.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9350.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan has a $590 deductible for prescription drugs. After the deductible, you will pay the costs for your drugs based on the tier and pharmacy you use, but the specific amounts are not provided in this summary. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. If you qualify for the low-income subsidy, you may have reduced premium costs.
Additional Benefits
The Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan offers comprehensive coverage with a variety of benefits. This plan includes coverage for inpatient hospital stays with a copay, outpatient services with 26% coinsurance, and emergency services with a copay. Additional benefits include coverage for primary care, preventive services, hearing, vision, and dental services. The plan also provides coverage for home health services, skilled nursing facility stays, and home infusion services.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute with a copay of $1950 for a Medicare-covered stay, and Inpatient Hospital Psychiatric with a copay of $1850 for a Medicare-covered stay. Additional Days for Inpatient Hospital-Acute, Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, and outpatient substance abuse services, each with a 26% coinsurance. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial hospitalization is covered by the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan, but requires prior authorization. You will pay 26% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance services are covered with no copay, but with a 26% coinsurance for both ground and air ambulance services. Transportation services to plan-approved health-related locations are covered for up to 76 one-way trips per year, with no copay or coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered under the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan, with a $110 copay and no coinsurance, and Urgently Needed Services are covered with a $45 copay and no coinsurance. Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are not covered.
Primary Care See details
Primary Care includes coverage for Primary Care Physician Services with a coinsurance between 0% and 26%, Chiropractic Services with 26% coinsurance and routine care, Occupational Therapy Services with 26% coinsurance, Physician Specialist Services with a coinsurance between 0% and 26%, Mental Health Specialty Services with a coinsurance of 26% for individual and group sessions, Podiatry Services with a coinsurance between 0% and 26% for routine foot care, Other Health Care Professional with 26% coinsurance, Psychiatric Services with 26% coinsurance for individual and group sessions, Physical Therapy and Speech-Language Pathology Services with 26% coinsurance, Additional Telehealth Benefits with a coinsurance between 0% and 26%, and Opioid Treatment Program Services with 26% coinsurance. Routine Chiropractic Care is limited to 36 visits per year.
Preventive Services See details
Preventive Services, including Medicare-covered services, annual physical exams, and other preventive services, are covered. This plan also covers health education, personal emergency response systems, additional sessions of smoking and tobacco cessation counseling (2 visits), fitness benefits, remote access technologies, home and bathroom safety devices and modifications (up to $263 per month), glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. In-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, enhanced disease management, telemonitoring services, and counseling services are not covered.
Hearing Services See details
Hearing services include routine hearing exams and fitting/evaluation for hearing aids, with a coinsurance of at most 26% for routine hearing exams, and no coinsurance for fitting/evaluation. Prescription hearing aids are partially covered, while OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a 26% coinsurance, and for eyewear, including contact lenses, eyeglass lenses, eyeglass frames, and upgrades. Contact lenses and eyeglass frames are limited to one per year, with a maximum benefit of $600 per year.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with 26% coinsurance and Other Dental Services with a maximum plan benefit of $8,000 per year. Oral exams are limited to 1 visit every six months, dental x-rays are limited to 1 per six months, and prophylaxis (cleaning) is limited to 4 visits per year. Fluoride treatment, adjunctive general services, maxillofacial prosthetics, implant services, prosthodontics fixed, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, is covered. Durable medical equipment has a 20% coinsurance, and durable medical equipment for use outside the home is not covered. Prosthetics and medical supplies have a 20% coinsurance, while diabetic supplies and therapeutic shoes/inserts also have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan. Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services have a coinsurance of at most 26%, while Therapeutic Radiological Services have a coinsurance of at most 20%, and all services have no copay.
Home Health Services See details
Home Health Services are covered by the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
The Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan's "Other Services" benefit covers Over-the-Counter (OTC) items, with a maximum benefit of $263.00 every month. However, acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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