A non-government entity
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 SE 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 $39.60. 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 $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:
Sign up for Highmark Wholecare Medicare Assured Diamond (HMO D-SNP)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan has a $590 deductible for prescription drugs. After you meet your deductible, you will pay the costs for your drugs, but the exact amounts are not specified in this summary. Once your total drug costs reach $2000, you will enter the next coverage phase. If you qualify for the low-income subsidy, your Part D premium will be $39.60. After your yearly out-of-pocket drug costs reach $2000, you will pay nothing for your Medicare Part D covered drugs.
Additional Benefits
The Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan offers a wide range of benefits. This plan covers inpatient hospital stays with a copay, outpatient services, partial hospitalization with coinsurance, and ambulance services with coinsurance. Emergency and urgently needed services have copays, and primary care services have coinsurance. Preventive services are included, and the plan covers hearing and vision services with coinsurance, and dental services with coinsurance and an annual maximum. Additional benefits include home infusion, dialysis, and medical equipment with coinsurance, and diagnostic and radiological services with coinsurance. Home health and skilled nursing facility services are covered with a copay, and the plan also covers over-the-counter items and meal benefits.
Inpatient Hospital See details
Inpatient Hospital benefits cover both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, but additional days, non-Medicare covered stays, and upgrades for each are not covered. The copay for a Medicare-covered stay is $1,950 for Inpatient Hospital-Acute and $1,850 for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services, observation services, ambulatory surgical center services, and outpatient substance abuse services, all 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 and Transportation Services are covered under the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan. Ground and air ambulance services have a 26% coinsurance, and there is no copay. Transportation services to a plan-approved health-related location are covered for up to 76 one-way trips per year, using various modes of transportation, with no copay or coinsurance.
Emergency Services See details
Emergency Services, including Urgently Needed Services, are covered under the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan. Emergency Services have a $110 copay and no coinsurance, while Urgently Needed Services have a $45 copay and no coinsurance. Worldwide Emergency Services are not covered.
Primary Care See details
Primary Care Physician Services and Physician Specialist Services have a coinsurance of 0% to 26%, while Chiropractic Services, Occupational Therapy Services, Physical Therapy and Speech-Language Pathology Services, and Other Health Care Professional have a 26% coinsurance. Individual and Group Sessions for Mental Health Specialty Services and Psychiatric Services, and Opioid Treatment Program Services have a 26% coinsurance. Routine foot care has a coinsurance of 0% to 26%. Additional Telehealth benefits have a coinsurance of 0% to 26%.
Preventive Services See details
The Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan covers preventive services including annual physical exams, health education, personal emergency response systems, additional sessions of smoking and tobacco cessation counseling, a fitness benefit, remote access technologies, home and bathroom safety devices and modifications, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs. Home and bathroom safety devices and modifications have a maximum plan benefit coverage amount of $263 per month. Some services, such as 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 hearing exams with a coinsurance of at most 26%, and fitting/evaluation for hearing aids. Prescription hearing aids are partially covered, with Prescription Hearing Aids (all types) covered and inner ear, outer ear, and over the ear hearing aids not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams with a 26% coinsurance, contact lenses (1 pair per year), eyeglass lenses (1 pair per year), and eyeglass frames (1 frame per year) with a maximum plan benefit coverage amount of $600, and upgrades. Eyeglasses (lenses and frames) are not covered.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a 26% coinsurance, and other dental services up to an $8,000 annual maximum. Oral exams are limited to 1 every six months, dental x-rays are limited to 1, and prophylaxis (cleaning) is limited to 4 per year. Fluoride treatments, maxillofacial prosthetics, implant services, prosthodontics fixed, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered by the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan, with a 20% coinsurance for Durable Medical Equipment, Prosthetic Devices, Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts; there is no copay for these services. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. 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%; there is no copay for any of these services.
Home Health Services See details
Home Health Services are covered by the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan, with no copay or coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan. Specifically, 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 are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) plan, with a $0 copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays for SNF, are not covered.
Other Services See details
Other Services includes Over-the-Counter (OTC) Items with a maximum benefit of $263.00 every month, and Meal Benefit for chronic illnesses. 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.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved