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Highmark Wholecare Medicare Assured Ruby (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Highmark Wholecare Medicare Assured Ruby (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 Ruby (HMO D-SNP) in 2025, please refer to our full plan details page.
Highmark Wholecare Medicare Assured Ruby (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 Ruby (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 Ruby (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 Ruby (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 Ruby (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $48.40. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $4.00. 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 $6700.00 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 Ruby (HMO D-SNP) plan has a $590 deductible for prescription drugs. After you meet your deductible, you will pay the costs for drugs in each tier until your total drug costs reach $2000, at which point you enter the next coverage phase. This plan's premium may be reduced if you qualify for the low-income subsidy, or "Extra Help".
Additional Benefits
The Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan offers a variety of benefits with varying costs. Hospital stays have a copay of $250 for days 1-6, and then no copay for days 7-90, while emergency services have a $125 copay. Outpatient services, such as doctor visits, have copays ranging from $0 to $25. This plan also includes coverage for dental, hearing, and vision services. Dental services have copays between $25 and $250, while hearing exams have a $25 copay. Vision services include eye exams with a $0-$25 copay. Additionally, the plan provides coverage for ambulance services, with a $250 copay, and offers transportation to plan-approved health locations.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization; for days 1-6, the copay is $250, and there is no copay for days 7-90. 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 Outpatient Hospital Services with a $200 copay, Observation Services with a $250 copay, Ambulatory Surgical Center (ASC) Services with a $200 copay, and Outpatient Substance Abuse Services with individual and group sessions having a copay between $25 and $25. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, including services not usually covered by Medicare plans, are covered. Ground and air ambulance services have a $250 copay, and transportation services to a plan-approved health-related location are covered for up to 30 one-way trips per year, with mileage reimbursement when a personal car is used, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan, with a $125 copay and no coinsurance, and Urgently Needed Services are covered with a $25 copay and no coinsurance. Worldwide Emergency Services, including coverage, urgent coverage, and transportation, are not covered.
Primary Care See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers Primary Care Physician services, Chiropractic Services with a $15 copay, Occupational Therapy Services with a $20 copay, Physician Specialist Services with a $25 copay, Mental Health Specialty Services with a $25 copay for individual and group sessions, Podiatry Services with a $25 copay, Other Health Care Professional services with a $25 copay, Psychiatric Services with a $25 copay for individual and group sessions, Physical Therapy and Speech-Language Pathology Services with a $20 copay, Additional Telehealth Benefits with a $0-$25 copay, and Opioid Treatment Program Services. Routine foot care is covered.
Preventive Services See details
Preventive services are covered, including Medicare-covered zero-dollar preventive services, annual physical exams, and additional preventive services. This plan also covers health education, personal emergency response systems, additional smoking and tobacco cessation counseling (2 visits), fitness benefits (memory fitness), remote access technologies, home and bathroom safety devices with a maximum benefit of $82.00 per month, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit.
Hearing Services See details
Hearing Services include routine hearing exams with a $25 copay and fitting/evaluation for hearing aids, both of which are unlimited. Prescription Hearing Aids are covered, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered. OTC Hearing Aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$25, contact lenses, eyeglass lenses, and eyeglass frames. The plan covers one routine eye exam, one pair of contact lenses, and one pair of eyeglass lenses or frames per year. The plan does not cover eyeglasses (lenses and frames) and upgrades.
Dental Services See details
The Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan covers a range of dental services. Medicare Dental Services have a copay of $25.00 - $250.00, while other services, including oral exams, dental x-rays, prophylaxis (cleaning), endodontics, periodontics, prosthodontics (removable), and oral and maxillofacial surgery, are also covered. Fluoride treatment, adjunctive general services, maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered. Orthodontic Services have a maximum plan benefit of $3500.00 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan. 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 Ruby (HMO D-SNP) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical equipment is covered by the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan, with Durable Medical Equipment (DME) and Prosthetic Devices subject to a 20% coinsurance and no copay, while Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Medical Supplies also have a 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan. Diagnostic Procedures/Tests and Lab Services are not covered, while Diagnostic Radiological Services have a copay of at most $175, Therapeutic Radiological Services have a copay of at most $60, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services are covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Therefore, this plan does not offer any coverage for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan. There is no copay for days 1-20, but there is a $214 copay for days 21-100.
Other Services See details
The Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan does not cover acupuncture or Dual Eligible SNPs with Highly Integrated Services, but it does cover over-the-counter (OTC) items, with a maximum benefit of $82.00 per month, and a meal benefit for chronic illnesses. Additionally, the plan does not cover 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.
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