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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 2026, 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 out of 5 stars in 2026.
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 $8.90. 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 $9250.00 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 features an annual prescription drug deductible of $615. This deductible represents the amount you must pay out-of-pocket for your covered medications before the plan begins to pay its share. Because this is a Dual Eligible Special Needs Plan, your actual out-of-pocket costs and benefits may vary depending on your level of Medicaid eligibility. Specific drug tier details, copayments, and coinsurance amounts are not currently available for this plan. To understand your exact prescription copays and coverage stages, it is recommended to review the plan's complete formulary or contact the provider directly. This ensures you have the most accurate cost estimates for your specific medications under this Medicare Advantage plan.
Additional Benefits
The Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) offers comprehensive medical coverage featuring no copays for many essential services, including inpatient hospital stays, primary care visits, and home health services. For outpatient care, diagnostic tests, and specialist visits, members generally pay no copay alongside a 24% coinsurance. Emergency care is subject to a $115 copay, while urgently needed services require a $40 copay, both of which count toward the plan-level deductible. This plan also provides valuable supplemental benefits, including dental care with no copay up to a $6,500 annual maximum and routine transportation of up to 24 one-way trips per year at no cost. Vision and hearing exams are covered with no copay and a 24% coinsurance, while covered eyewear and hearing aids are available with no copay and no coinsurance. Additionally, members can access durable medical equipment with no copay and a 20% coinsurance, alongside covered over-the-counter items.
Inpatient Hospital See details
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) partially covers inpatient hospital services, providing acute and psychiatric hospital stays with no copay and no coinsurance. Prior authorization is required, and the plan does not cover additional hospital days, non-Medicare-covered stays, or room upgrades.
Outpatient Services See details
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) covers outpatient services, including outpatient hospital, ambulatory surgical center, substance abuse, and blood services, with no copay and a 24% coinsurance. Prior authorization is required for outpatient hospital and ambulatory surgical center services.
Partial Hospitalization See details
Partial hospitalization is covered by Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) with no copay and a 24% coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) covers ground and air ambulance services with a 24% coinsurance and no copay. Routine transportation is partially covered, offering up to 24 one-way trips per year to plan-approved locations with no copay or coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency services are covered by Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) with a $115 copay and no coinsurance, and urgently needed services have a $40 copay and no coinsurance, with both counting toward the plan-level deductible. Some worldwide emergency services are covered, but worldwide emergency coverage, worldwide urgent coverage, and worldwide emergency transportation are not covered.
Primary Care See details
Primary care services under the Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) are covered with no copay and coinsurance ranging from no coinsurance to 24%. This benefit includes specialist visits, mental health, physical therapy, and partially covered routine chiropractic care, with some services requiring prior authorization.
Preventive Services See details
Preventive services are partially covered by Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) with no copay and no coinsurance for covered benefits like annual physical exams and kidney disease education. However, several supplemental preventive services are not covered, including medical nutrition therapy, weight management programs, alternative therapies, adult day health services, and in-home safety assessments.
Hearing Services See details
Hearing services are covered by Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) with no deductible, featuring hearing exams for no copay and a 24% coinsurance for routine exams. Prescription hearing aids are partially covered with no copay and no coinsurance, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) offers partially covered vision services, featuring routine eye exams with no copay and 24% coinsurance, though other eye exam services are not covered. Covered eyewear, including contact lenses and individual lenses and frames, has no copay and no coinsurance, but combined eyeglasses (lenses and frames) are not covered.
Dental Services See details
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) offers partially covered dental services with an annual maximum benefit of $6,500, featuring no copay and 24% coinsurance for Medicare-covered dental, and no copay and no coinsurance for other covered services like exams, cleanings, x-rays, restorative care, endodontics, periodontics, removable prosthodontics, and oral surgery. Uncovered sub-services include other diagnostic, fluoride, other preventive, adjunctive general, maxillofacial prosthetics, implants, fixed prosthodontics, and orthodontics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs carry a 0% to 20% coinsurance with no copay, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered by Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) with no copay and a 20% coinsurance.
Medical Equipment See details
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) covers durable medical equipment, prosthetics, medical supplies, and diabetic equipment with no copay and a 20% coinsurance. Prior authorization is required for durable medical equipment and prosthetics, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) with no copays, subject to prior authorization. Covered diagnostic procedures, lab services, diagnostic radiology, and outpatient X-rays require a minimum 24% coinsurance, while therapeutic radiological services require a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) covers cardiac rehabilitation services with no copay and a 24% coinsurance. Although some services are covered, specific programs such as cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) with no copay and no coinsurance, though prior authorization is required. The plan allows SNF admission without a prior three-day inpatient hospital stay, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Highmark Wholecare Medicare Assured Diamond (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 benefit.
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