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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 2026, 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 out of 5 stars in 2026.
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 $17.60. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $3.00. 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 $615.00 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 $8000.00 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) prescription drug plan features an annual drug deductible of $615. This deductible is the amount you are required to pay out-of-pocket for your covered medications before the plan begins to cover its share of the costs. Specific drug coverage tier details, including individual copayments and coinsurance amounts, are currently unavailable for this plan. To fully understand your potential out-of-pocket expenses, you should consult the plan's formulary to see how your specific medications are classified.
Additional Benefits
The Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan offers comprehensive medical coverage with no copays for primary care, home health services, and skilled nursing facility stays. Inpatient hospital stays require a $275 daily copay for the first six days, followed by no copay for days seven through ninety. Outpatient hospital visits, emergency care, and specialist appointments are covered with predictable copayments and no coinsurance, though services like dialysis and durable medical equipment require a 10 to 20 percent coinsurance. This plan also includes key supplemental benefits to help manage daily health costs, featuring no copays for routine preventive care, over-the-counter items, and chronic illness meals. Dental, vision, and hearing benefits are covered, offering up to a $2,000 annual limit for preventive and comprehensive dental services and a $150 allowance for eyewear with no copays. While many routine services are highly affordable, some specialized treatments like cardiac rehabilitation and acupuncture are not covered under this plan.
Inpatient Hospital See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) partially covers inpatient hospital services with no coinsurance, requiring a $275 daily copay for days 1 through 6 and no copay for days 7 through 90. Prior authorization is required, and additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Highmark Wholecare Medicare Assured Ruby (HMO D-SNP), featuring a $250 copay and no coinsurance for outpatient hospital and observation services, and a $225 copay with no coinsurance for ambulatory surgical center services. Outpatient substance abuse sessions require a $30 copay and no coinsurance, while outpatient blood services have no copay but require a 20% coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) with a $55.00 copay and no coinsurance. Prior authorization is required to receive these services.
Ambulance and Transportation Services See details
Ambulance services are covered by Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) with a $250 copay and no coinsurance for both ground and air transportation, which require prior authorization. Additional transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers emergency services with a $115 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed services are covered with a $25 copay and no coinsurance, but worldwide emergency, urgent, and transportation services are not covered.
Primary Care See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers primary care and opioid treatment with no copay and no coinsurance, while specialists, therapy, and mental health services require copays ranging from $10.00 to $30.00 and no coinsurance. Chiropractic care is partially covered, offering up to four routine visits per year for a $15.00 copay and no coinsurance, but other chiropractic services are not covered.
Preventive Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers preventive services, such as annual physical exams and kidney disease education, with no copay and no coinsurance. Additional preventive benefits are partially covered with no copay and no coinsurance, though services like in-home safety assessments, medical nutrition therapy, weight management, and alternative therapies are not covered.
Hearing Services See details
Hearing services covered by Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) include routine exams with a $30 copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance, though OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers routine eye exams with a $0 to $30 copay and no coinsurance, and eyewear with no copay or coinsurance, including up to $150 for contact lenses or eyeglass frames and one pair of lenses annually. This benefit is partially covered, as other eye exam services, upgrades, and combined eyeglasses (lenses and frames) are not covered.
Dental Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) offers partially covered dental services with a $30 to $250 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered preventive and comprehensive services up to a $2,000 annual limit. Fluoride treatments, other diagnostic or preventive services, adjunctive general services, maxillofacial prosthetics, implants, fixed prosthodontics, and orthodontics are not covered.
Home Infusion bundled Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from 0% (no coinsurance) to 20%.
Dialysis Services See details
Dialysis Services are covered by the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) with no copays, though coinsurance is required for all items. Durable medical equipment and prosthetics or medical supplies carry a 20% coinsurance and require prior authorization, while diabetic equipment and therapeutic shoes or inserts carry a 10% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Highmark Wholecare Medicare Assured Ruby (HMO D-SNP), with prior authorization required for all services. Diagnostic procedures and lab services require a $5.00 copay and no coinsurance, outpatient x-rays carry a $20.00 copay and no coinsurance, while diagnostic radiological services require a minimum 10% coinsurance and therapeutic radiological services require a minimum $60.00 copay and coinsurance.
Home Health Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers Skilled Nursing Facility (SNF) services with no copay and no coinsurance, though prior authorization is required. The plan allows for admission with less than a three-day inpatient hospital stay, but does not cover additional days beyond the standard Medicare-covered limit.
Other Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) partially covers other services, offering over-the-counter (OTC) items and chronic illness meal benefits with no copay and no coinsurance. Acupuncture is not covered under this plan.
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