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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 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 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 $42.60. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.00. 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. Once you meet your deductible, you will pay the costs for your drugs, which vary depending on the specific drug tier and pharmacy. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs. If you qualify for the low-income subsidy, you may also have a reduced premium.
Additional Benefits
The Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan offers a range of benefits, including inpatient hospital stays with a $250 copay for days 1-6, and no copay for days 7-90, outpatient services with varying copays, and ambulance services with a $250 copay. This plan also covers a wide array of services such as primary care, hearing, vision, and dental, with specific copays for each. Preventative services are covered with no copay. Additional benefits include home health services with no copay, coverage for medical equipment with 20% coinsurance, and a monthly allowance for over-the-counter items. This plan also provides coverage for home infusion bundled services, and skilled nursing facility (SNF) services with no copay for days 1-20. This plan may be a good option for those who want a plan with a variety of benefits.
Inpatient Hospital See details
Inpatient hospital benefits are covered under the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan, with a copay of $250 for days 1-6 and no copay for days 7-90. Additional days for inpatient hospital-acute, non-Medicare-covered stays, upgrades, and additional days for inpatient hospital psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all 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 a copay of $25 for both individual and group sessions. 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 are covered, including ground and air ambulance, and transportation services to plan-approved health-related locations. Ground and air ambulance services have a $250 copay, while transportation services to a plan-approved health-related location cover up to 30 one-way trips per year via taxi, rideshare, bus/subway, van, or medical transport, with mileage reimbursement for personal car use. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, with a $125 copay and no coinsurance. Urgently Needed Services are also covered, with a $25 copay and no coinsurance. Worldwide Emergency Services, including Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, are not covered.
Primary Care See details
The Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan covers primary care, chiropractic services with a $15 copay, occupational therapy services with a $20 copay, specialist services with a $25 copay, mental health specialty services with a $25 copay, podiatry services with a $25 copay, other healthcare professional services with a $25 copay, psychiatric services with a $25 copay, 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 Chiropractic care is limited to 12 visits per year.
Preventive Services See details
The Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan covers a variety of preventive services, including Medicare-covered services with no copay, an annual physical exam, health education, personal emergency response systems, remote access technologies, home and bathroom safety devices, additional sessions of smoking and tobacco cessation counseling, a fitness benefit, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Home and bathroom safety devices and modifications have a maximum plan benefit coverage amount of $82.00 per month, and additional smoking cessation counseling is covered for 2 sessions. The plan does not cover 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.
Hearing Services See details
Hearing services include routine hearing exams with a $25 copay, fitting/evaluation for hearing aids, and prescription hearing aids (all types) with no coinsurance. Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$25, and eyewear benefits including contact lenses, eyeglass lenses, and eyeglass frames. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a copay of $25 to $250, Oral Exams with 1 visit every six months, Dental X-Rays, Prophylaxis (Cleaning) with 4 visits every year, Orthodontic Services up to $3500 per year, Restorative Services, Endodontics with 1 visit every year, Periodontics with 1 visit every two years, Prosthodontics, removable, and Oral and Maxillofacial Surgery. 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 by the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan, which includes coverage for Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered, with 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, including Durable Medical Equipment with a 20% coinsurance and no copay, and Prosthetics/Medical Supplies with a 20% coinsurance and no copay. Durable Medical Equipment for use outside the home and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Diagnostic Procedures/Tests and Lab Services are not covered. For Diagnostic Radiological Services, the copay is at most $175, for Therapeutic Radiological Services, the copay is at most $60, and for Outpatient X-Ray Services, the copay is $20.
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. 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 Ruby (HMO D-SNP) plan. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) items with a maximum benefit of $82.00 per month, and a 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.
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