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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 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 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 $13.10. 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 coverage includes an annual drug deductible of $615. This deductible is the amount you must pay out-of-pocket for covered medications before the plan begins to pay. Specific drug coverage tier details, including copays and coinsurance rates, are not available for this plan. To determine how your specific prescriptions are covered and to estimate your costs, it is best to review the plan's formulary.
Additional Benefits
The Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) plan offers comprehensive medical coverage with affordable cost-sharing options, including no copays for primary care visits, home health, and skilled nursing facility care. For inpatient hospital stays, members pay a $275 daily copay for the first six days and no copay for days seven through ninety. Outpatient hospital services and emergency care are accessible with predictable copayments of $250 and $115 respectively, with no coinsurance required. This plan also provides robust supplemental benefits, featuring no copays for routine dental care up to a $2,000 annual limit and up to $150 annually for eyewear. Routine hearing exams require a $30 copay, while qualifying prescription hearing aids are covered with no copay. Additionally, members benefit from no copays on over-the-counter items and chronic illness meals, while durable medical equipment is covered with a twenty percent coinsurance.
Inpatient Hospital See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers inpatient acute and psychiatric hospital stays 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 or non-Medicare-covered stays are not covered.
Outpatient Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers outpatient services, including outpatient hospital and observation stays for a $250 copay and no coinsurance, and ambulatory surgical center services for a $225 copay and no coinsurance. Outpatient substance abuse sessions require a $30 copay and no coinsurance, while outpatient blood services are available with no copay and a 20% coinsurance.
Partial Hospitalization See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required to receive coverage for this benefit.
Ambulance and Transportation Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) partially covers ambulance and transportation services, providing Medicare-covered ground and air ambulance services with a $250 copay and no coinsurance, which require prior authorization. Routine transportation services to plan-approved or other 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, which is waived if admitted within 24 hours, and urgently needed services with a $25 copay and no coinsurance. For worldwide emergency services, some services are covered but worldwide emergency coverage, worldwide urgent coverage, and worldwide emergency transportation are not covered.
Primary Care See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers primary care physician services and opioid treatment with no copay and no coinsurance, while specialist visits require a $30 copay with no coinsurance. Other services like therapy, podiatry, and mental health have copays ranging from $10 to $30 with no coinsurance, though chiropractic care is only partially covered because other chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) with no copay and no coinsurance for covered services such as annual physical exams, kidney disease education, and select fitness benefits. However, excluded sub-services include in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, home-based palliative care, in-home support, caregiver support, enhanced disease management, telemonitoring, and counseling.
Hearing Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers one annual routine hearing exam with a $30 copay and no coinsurance, as well as unlimited fitting evaluations. Prescription hearing aids are covered with no copay and no coinsurance for up to two devices every three years, but this benefit is only partially covered as inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Highmark Wholecare Medicare Assured Ruby (HMO D-SNP), featuring one annual routine eye exam with a $0 to $30 copay and no coinsurance, while other eye exams are not covered. Covered eyewear includes contact lenses, eyeglass lenses, and frames up to $150 annually with no copay and no coinsurance, though upgrades and combined eyeglasses are not covered.
Dental Services See details
Dental services are partially covered by Highmark Wholecare Medicare Assured Ruby (HMO D-SNP), with Medicare-covered dental requiring a $30 to $250 copay and no coinsurance, and other covered dental services requiring no copay and no coinsurance. While many preventive and comprehensive services are covered up to a $2,000 annual limit for select services, fluoride, implants, orthodontics, fixed prosthodontics, maxillofacial prosthetics, adjunctive general services, and other diagnostic or preventive services 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 and no coinsurance, though prior authorization and step therapy are required. Under this benefit, Part B insulin has a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers medical equipment with no copays, featuring a 20% coinsurance for durable medical equipment and prosthetics, and a 10% coinsurance for diabetic supplies and shoes. Prior authorization is required for durable medical equipment and prosthetics, and diabetic supplies are limited to select manufacturers.
Diagnostic and Radiological Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers diagnostic and radiological services, with prior authorization required for both. Diagnostic procedures, tests, and lab services require a $5.00 copay with no coinsurance, while radiological services involve a 10% coinsurance for diagnostic radiology, a $60.00 copay for therapeutic radiology, and a $20.00 copay for outpatient X-rays.
Home Health Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) provides coverage for Cardiac Rehabilitation Services with no copay and no coinsurance. Although some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered under this plan.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is partially covered by Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) with no copay and no coinsurance, although prior authorization is required. A prior three-day inpatient hospital stay is not required for admission, but additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) partially covers other services, providing over-the-counter (OTC) items and chronic illness meal benefits with no copay and no coinsurance. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and other miscellaneous services are not covered.
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