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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 2025 to people living in Kent, New Castle, Sussex. 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 $31.20. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $0.60. 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 Health Options Duals (HMO D-SNP) Medicare plan features an annual prescription drug deductible of $615. This deductible represents the amount you must pay out-of-pocket for your medications before the plan begins to pay its share. Understanding this upfront cost is a key factor when evaluating if this plan fits your healthcare budget. Specific drug tier coverage and copayment details are not available for this plan. We recommend checking the plan's formulary directly to confirm how your specific prescription medications are covered under this deductible.
Additional Benefits
The Highmark Health Options Duals (HMO D-SNP) plan offers comprehensive medical coverage with many essential services requiring no copayments. Inpatient hospital stays, home health services, and skilled nursing facility care are covered with no copay and no coinsurance. For outpatient care, primary care visits, and diagnostic services, members will pay no copay alongside a twenty percent coinsurance. This plan also provides strong supplemental benefits, including dental, vision, and hearing care with no deductibles or copays for key services. Members can take advantage of a three thousand dollar annual maximum for select dental services and a four hundred dollar allowance for frames or contact lenses. Emergency room visits carry a one hundred fifteen dollar copay, while urgent care services require a forty dollar copay.
Inpatient Hospital See details
Highmark Health Options Duals (HMO D-SNP) partially covers inpatient acute and psychiatric hospital services with no copay and no coinsurance, though prior authorization is required. Additional days, room upgrades, and non-Medicare-covered stays are not covered under this benefit.
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. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Highmark Health Options Duals (HMO D-SNP) with a 20% coinsurance and no copay for ground and air ambulance services, which require prior authorization. Routine transportation services to plan-approved or health-related locations are not covered under this plan.
Emergency Services See details
Highmark Health Options Duals (HMO D-SNP) covers emergency services with a $115 copay and no coinsurance, and urgently needed services with a $40 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 Health Options Duals (HMO D-SNP) covers primary care, specialist, therapy, and mental health services with no copay and 20% coinsurance. Chiropractic services are partially covered, offering up to six routine visits per year with other chiropractic services excluded, while routine podiatry is also limited to six visits per year.
Preventive Services See details
Highmark Health Options Duals (HMO D-SNP) covers preventive services, offering annual physical exams and kidney disease education with no copay and no coinsurance. Additional preventive benefits are partially covered with no copay and no coinsurance for memory fitness and home safety devices, though sub-services like health education, personal emergency response systems, and nutritional therapy are not covered. Other services, including glaucoma screenings and diabetes self-management training, have no copay and a 20% coinsurance.
Hearing Services See details
Highmark Health Options Duals (HMO D-SNP) covers hearing services with no deductible, offering routine hearing exams once per year with no copay and a 20% coinsurance, alongside unlimited fitting evaluations. Prescription hearing aids are partially covered with no copay or coinsurance for up to two devices every three years, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision Services are covered by Highmark Health Options Duals (HMO D-SNP) with no copay, no deductibles, and a 20% coinsurance for routine eye exams and contact lenses. This partially covered benefit includes annual routine exams, eyeglass lenses, frames (up to $400), and contact lenses (up to $400), while other eye exam services and packaged eyeglasses (lenses and frames) are not covered.
Dental Services See details
Highmark Health Options Duals (HMO D-SNP) provides partially covered dental services with no copay and 20% coinsurance for Medicare-covered dental, and no copay or coinsurance for select preventive and comprehensive services up to a $3,000 annual maximum. Sub-services that are not covered under this plan include fluoride, other diagnostic and preventive services, adjunctive general services, maxillofacial prosthetics, implants, fixed prosthodontics, and orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled services are covered by Highmark Health Options Duals (HMO D-SNP) with no copay, requiring prior authorization and step therapy. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a coinsurance of 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by Highmark Health Options Duals (HMO D-SNP) 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 20% coinsurance, though prior authorization is required. Covered benefits include outpatient diagnostic procedures, lab services, diagnostic and therapeutic radiological services, and outpatient X-rays.
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
Highmark Health Options Duals (HMO D-SNP) covers Cardiac Rehabilitation Services with no copay, although some services are covered while standard Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) are not covered and require a 20% coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Highmark Health Options Duals (HMO D-SNP) with no copay and no coinsurance, though prior authorization is required. This benefit 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) provides partial coverage for other services, offering over-the-counter items and chronic illness meal benefits with no copay and no coinsurance. Acupuncture is not covered under this plan.
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