Highmark Wholecare Medicare Assured Ruby (D-SNP) Plan Details for Berks County, PA
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*CMS rated this Highmark Wholecare Medicare Assured plan (H5932-009-0) 4.5 (Good+) out of 5 stars.
Highmark Wholecare Medicare Assured Ruby (D-SNP) is a Dual-Eligible Medicare Advantage Special Needs Plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin Ja
This plan is required to provide all of the same benefits as Original Medicare, but out-of-pocket costs are different. This private health insurance option may include extra benefits not covered by Medicare Part A or Part B.
Eligible individuals must meet all Dual-Eligible SNP qualification requirements to join this Highmark Wholecare Medicare Assured D-SNP plan.
| Plan Basics | |
|---|---|
| Plan ID: | H5932-009-0 |
| Plan Type: | HMO D-SNP |
| Plan Year: | 2025 |
| Premium: | $48.40/mo Plus your Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 6,700.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | $590.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Berks County, PA |
| Insured By: | Highmark Wholecare Medicare Assured |
| Summary of Benefits |
|---|
Health Plan Cost Sharing & Benefits
The following table is a summary of the most common out-of-pocket costs you will incur if you join this Highmark Wholecare Medicare Assured plan:
| Healthcare Service | Member Cost |
|---|---|
| Doctor Visits (In-Network) | |
| Primary: | $0 |
| Specialist: | $25 Copay |
| Preventive care: | $0 |
| Foot Care (In-Network) | |
| Foot exams and treatment (Medicare-covered): | $25 Copay |
| Routine foot care: | $25 Copay |
| Chiropractic Care (In-Network) | |
| Medicare-covered chiropractic care: | $15 Copay Prior Authorization Required |
| Routine chiropractic care: | $15 Copay Prior Authorization Required |
| Emergency Care / Urgent Care | |
| Emergency room care: | $125 Copay |
| Urgent care: | $25 Copay |
| Ground ambulance: | $250 Copay |
| Inpatient hospital coverage: | $250.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
| Outpatient hospital coverage: | $200 Copay Prior Authorization Required |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $214.00 per day for days 21 and beyond |
| Optional supplemental benefits: | Not Covered |
| Mental Health Services (In-Network) | |
| Outpatient individual therapy visit with a psychiatrist: | $25 Copay |
| Outpatient group therapy visit with a psychiatrist: | $25 Copay |
| Inpatient hospital - psychiatric: | $250.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
| Outpatient group therapy visit: | $25 Copay |
| Outpatient individual therapy visit: | $0 |
| Rehabilitation Services (In-Network) | |
| Physical therapy and speech and language therapy visit: | $20 Copay Prior Authorization Required |
| Occupational therapy visit: | $20 Copay Prior Authorization Required |
| Medical Equipment / Supplies (In-Network) | |
| Diabetes supplies: | $0 |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Prior Authorization Required |
| Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
| Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
| Diagnostic radiology services (e.g., MRI): | $175 Copay Prior Authorization Required |
| Lab services: | $0 |
| Outpatient x-rays: | $20 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | $0 |
| Medicare Part B Drugs (In-Network) | |
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Highmark Wholecare Medicare Assured Ruby Summary of Benefits information.
Supplemental Health Plan Benefits (H5932-009-0)
The following is a summary of the supplemental benefits Highmark Wholecare Medicare Assured includes with this plan:
| Supplemental Healthcare Service | Member Cost |
|---|---|
| Preventive Dental | |
| Oral exam (In-Network) | Not Covered |
| Fluoride treatment (In-Network) | Not Covered |
| Dental x-ray(s) (In-Network) | Not Covered |
| Cleaning (In-Network) | Not Covered |
| Comprehensive Dental | |
| Periodontics (In-Network) | Not Covered |
| Non-routine services (In-Network) | Not Covered |
| Diagnostic services (In-Network) | Not Covered |
| Extractions (In-Network) | Not Covered |
| Endodontics (In-Network) | Not Covered |
| Restorative services (In-Network) | Not Covered |
| Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
| Hearing | |
| Fitting/evaluation (In-Network) | Covered Limits may apply |
| Hearing aids (In-Network) | Not Covered |
| Hearing exam (In-Network) | Covered Limits may apply |
| Vision | Maximum vision benefit: | $2.00 Every two years |
| Eyeglasses (frames and lenses) (In-Network) | Not Covered |
| Routine eye exam (In-Network) | Covered Limits may apply |
| Contact lenses (In-Network) | Not Covered |
Prescription Drug Plan Costs & Benefits
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. The following table outlines the details of this plan's prescription drug plan premium.
| Basic Part D Premium: | |
| Supplemental Part D Premium: | |
| Total Part D Premium: | |
| Part D Premium with Full LIS Assistance: |
The Social Security Extra Help page has more information about the low-income subsidy (LIS) and how to enroll in the program.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $590.00. This is the amount you must pay at the pharmacy before Highmark Wholecare Medicare Assured begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Highmark Wholecare Medicare Assured Ruby has out-of-pocket costs that you must pay when you pick up your prescriptions. The following table shows you those costs.
| Drug Tier | Preferred | Standard |
|---|---|---|
| $0 copay on all covered generic and brand-name prescriptions. | ||
CMS Rating Marks
Each year CMS rates Medicare Special Needs Plans in nine broad categories based on a 5-star system. The table below shows the quality ratings for this Highmark Wholecare Medicare Assured plan.
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Additional D-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
- Highmark Wholecare Medicare Assured Ruby
- Highmark Wholecare Medicare Assured Diamond
- Highmark Wholecare Medicare Assured Ruby
- Highmark Wholecare Medicare Assured Diamond
Contact Highmark Wholecare Medicare Assured
| Plan Website: | http://www.highmarkwholecare.com |
|---|---|
| Formulay Information: | http://www.highmarkwholecare.com |
| Pharmacy Information: | Highmark Wholecare Medicare Assured Pharmacy Page |
| Prospective Members: | (877)935-2168 |
| TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Health Plan Compatibility
Medicare Advantage Special Needs Plans (SNPs) are generally incompatible with most other health insurance options. Enrolling in an SNP plan while having Medicare Part A and/or Medicare Part B will result in disenrollment from Original Medicare. Additionally, it is not possible to simultaneously hold a Medicare Supplement Insurance policy and be part of an SNP plan.
Members of a D-SNP maintain their current Medicaid plan and Medicaid benefits. Veterans with VA Health Benefits might have the option to receive care at a nearby VA hospital.
Citations & References
- Highmark Wholecare Medicare Assured, http://www.highmarkwholecare.com, Last Accessed October 13, 2023
- Medicaid.gov, "Medicaid & CHIP in Pennsylvania", Last Accessed October 1, 2024
- CMS.gov, Landscape Source Files, Last Accessed October 2, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed October 2, 2024
- CMS.gov, Plan Benefits Package, Last Accessed October 5, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.