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Highmark Health Options Duals (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Highmark Health Options Duals (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 Health Options Duals (HMO D-SNP) in 2026, please refer to our full plan details page.
Highmark Health Options Duals (HMO D-SNP) is a HMO D-SNP plan offered by Highmark Health available for enrollment in 2026 to people living in SW NW and Hardy Counties. The overall rating for this plan is not yet available for 2026.
It's important to know that Highmark Health Options Duals (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 Health Options Duals (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 Health Options Duals (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 Health Options Duals (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $32.70. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 Health Options Duals (HMO D-SNP) prescription drug plan has an annual drug deductible of $615. This deductible is the amount you must pay out-of-pocket for your covered medications before the plan begins to cover its share of the costs. Specific information regarding drug tier classifications, copayments, and coinsurance rates is not currently available for this plan. To find out how your specific medications are covered, it is best to consult the plan's formulary or contact the provider directly. Knowing the $615 deductible is an essential factor when deciding if this plan aligns with your annual healthcare budget and prescription needs.
Additional Benefits
The Highmark Health Options Duals (HMO D-SNP) plan offers comprehensive medical coverage with no copays and no coinsurance for inpatient hospital stays, home health services, and skilled nursing facility care. For most outpatient services, primary care, specialist visits, and diagnostic testing, members will pay no copay and a 20% coinsurance. Emergency room visits require a $115 copay and urgently needed care has a $40 copay, both of which feature no coinsurance. Members also benefit from routine dental care with no copay and no coinsurance up to a $2,500 annual limit, as well as routine vision and hearing exams with no copay and a 20% coinsurance. The plan also covers up to 24 one-way routine transportation trips per year and over-the-counter items with no copay and no coinsurance. Prescription hearing aids and home infusion services are also covered with no copays or coinsurance.
Inpatient Hospital See details
Highmark Health Options Duals (HMO D-SNP) covers inpatient acute and psychiatric hospital stays with no copays and no coinsurance, although prior authorization is required. This benefit is partially covered, as upgrades, additional days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Highmark Health Options Duals (HMO D-SNP) covers outpatient services, including outpatient hospital, ambulatory surgical center, substance abuse, and blood services, with no copay and a 20% coinsurance. Prior authorization is required for outpatient hospital and ambulatory surgical center services.
Partial Hospitalization See details
Highmark Health Options Duals (HMO D-SNP) covers partial hospitalization services with no copay and a 20% coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
Highmark Health Options Duals (HMO D-SNP) covers ambulance services with a 20% coinsurance and no copay, requiring prior authorization for both ground and air transport. Transportation services are partially covered, offering up to 24 one-way trips per year to plan-approved health-related locations with no copay and no coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Highmark Health Options Duals (HMO D-SNP) covers emergency services with a $115.00 copay and no coinsurance, and urgently needed services with a $40.00 copay and no coinsurance, both of which count toward the plan-level deductible. While worldwide emergency services are technically covered, worldwide emergency, urgent, and transportation services are not covered in practice.
Primary Care See details
Highmark Health Options Duals (HMO D-SNP) covers primary care, specialist visits, mental health, and therapy services with no copay and a 20% coinsurance. Chiropractic services are not covered, but routine podiatry is covered for up to 6 visits per year with no copay and a 20% coinsurance.
Preventive Services See details
Preventive services are partially covered by Highmark Health Options Duals (HMO D-SNP) with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, and diabetes self-management. However, several supplemental preventive services are not covered, including in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, disease management, telemonitoring, and counseling.
Hearing Services See details
Hearing services are partially covered by Highmark Health Options Duals (HMO D-SNP), featuring routine hearing exams with no copay and 20% coinsurance once per year. Prescription hearing aids are covered with no copay and no coinsurance up to two every three years, but inner ear, outer ear, over-the-ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Highmark Health Options Duals (HMO D-SNP) provides partially covered vision services with no deductibles, no copays, and a 20% coinsurance for routine eye exams and contact lenses. Covered annual benefits include one routine eye exam, one pair of contact lenses (up to $200), one pair of eyeglass lenses, and one frame (up to $200), while other eye exams, combined eyeglasses, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Highmark Health Options Duals (HMO D-SNP), offering Medicare-covered dental with no copay and 20% coinsurance, and other covered services with no copay and no coinsurance up to a $2,500 annual limit. Covered services include oral exams, cleanings, x-rays, restorative care, endodontics, periodontics, removable prosthodontics, and oral surgery, while fluoride, implants, orthodontics, and fixed prosthodontics are not covered.
Home Infusion bundled Services See details
Highmark Health Options Duals (HMO D-SNP) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. 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% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Highmark Health Options Duals (HMO D-SNP) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Highmark Health Options Duals (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 Health Options Duals (HMO D-SNP) with no copay and a minimum 20% coinsurance, subject to prior authorization. This coverage includes diagnostic procedures, lab services, outpatient X-rays, and both diagnostic and therapeutic radiological services.
Home Health Services See details
Highmark Health Options Duals (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 covered by Highmark Health Options Duals (HMO D-SNP) with no copay, though in practice only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered and require a 20% coinsurance.
Skilled Nursing Facility (SNF) See details
Highmark Health Options Duals (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 without a prior three-day inpatient hospital stay, but additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Highmark Health Options Duals (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 benefit.
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