AmeriHealth Caritas Next Silver Premier + No Referrals

17414NC0010012
Silver
HMO

AmeriHealth Caritas Next Silver Premier + No Referrals is a Silver HMO plan by AmeriHealth Caritas Next.

Locations

AmeriHealth Caritas Next Silver Premier + No Referrals is offered in the following counties.

Plan Overview

This is a plan overview for 2025 version of AmeriHealth Caritas Next Silver Premier + No Referrals 17414NC0010012.
Insurer: AmeriHealth Caritas Next
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 17414NC0010012

Cost-Sharing Overview

AmeriHealth Caritas Next Silver Premier + No Referrals offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for AmeriHealth Caritas Next Silver Premier + No Referrals?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

AmeriHealth Caritas Next Silver Premier + No Referrals offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what AmeriHealth Caritas Next Silver Premier + No Referrals covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Accidental Injury and Emergency Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Accidental Injury and Emergency Only
National Network: No

Additional Benefits and Cost-Sharing

AmeriHealth Caritas Next Silver Premier + No Referrals includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$55.00 Not ApplicableNot Applicable 100.00% Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member’s schedule of benefits.
Specialist Visit
Covered
$110.00 Not ApplicableNot Applicable 100.00% Dermatology virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member’s schedule of benefits.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$55.00 Not ApplicableNot Applicable 100.00% Additional information can be found on the member’s schedule of benefits
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50.00%Not Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50.00%Not Applicable 100.00%
Hospice Services
Covered
No Charge Not ApplicableNot Applicable 100.00% Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation. Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
Not Applicable 50.00%Not Applicable 100.00%3.0 Treatment(s) per Lifetime Artificial insemination, in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and services for procurement and storage of donor semen/eggs are not covered Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. The lifetime maximums are described in medical policies, which are guides considered when making coverage determinations.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 50.00%Not Applicable 100.00% Excludes services provided by a close relative or a member of the household.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$80.00 Not Applicable$80.00 Not Applicable Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member’s schedule of benefits
Home Health Care Services
Covered
Not Applicable 50.00%Not Applicable 100.00% Excludes homemaker services, such as cooking and housekeeping; Dietitian services or meals; Services that are provided by a close relative or a member of the household.
Emergency Room Services
Covered
Not Applicable 50.00%Not Applicable 50.00%
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00%Not Applicable 50.00% Excludes services provided primarily for the convenience of travel, transportation to or from a doctor’s office or dialysis center, transportation for the purpose of receiving services that are not considered covered services.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00%Not Applicable 100.00% Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therapy.
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00%Not Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 50.00%Not Applicable 100.00% For surgical treatment of morbid obesity. Before pursuing bariatric surgery, a complete nutritional, behavioral, and medical evaluation must be completed, and requirements must be met. Bariatric surgery must be medically necessary to be eligible for coverage. Limited to one procedure per lifetime.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50.00%Not Applicable 100.00%60.0 Days per Benefit Period Covered health services do not include custodial, domiciliary care, or long-term care admissions.
Prenatal and Postnatal Care
Covered
No Charge Not ApplicableNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50.00%Not Applicable 100.00% Dependent children not covered for abortion. Abortion services available for first 16 weeks of pregnancy.
Mental/Behavioral Health Outpatient Services
Covered
$55.00 Not ApplicableNot Applicable 100.00% Excludes counseling with relatives about a patient. Includes biofeedback. Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member’s schedule of benefits.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00%Not Applicable 100.00% Excludes, Inpatient confinements that are primarily intended as a change of environment; Counseling with relatives of a patient.
Substance Abuse Disorder Outpatient Services
Covered
$55.00 Not ApplicableNot Applicable 100.00% Excludes counseling with relatives about a patient. Includes biofeedback. Virtual care visits offered through AmeriHealth Caritas Next Virtual Care 24/7 are covered at No Charge, member deductible does not apply. Additional information can be found on the member’s schedule of benefits.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00%Not Applicable 100.00% Excludes, Inpatient confinements that are primarily intended as a change of environment; Counseling with relatives of a patient.
Generic Drugs
Covered
$35.00 Not ApplicableNot Applicable 100.00% Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document. Certain off-label uses of cancer drugs will be covered in accordance with state law.
Preferred Brand Drugs
Covered
$200.00 Not ApplicableNot Applicable 100.00% Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document. Certain off-label uses of cancer drugs will be covered in accordance with state law.
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00%Not Applicable 100.00% Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document. Certain off-label uses of cancer drugs will be covered in accordance with state law.
Specialty Drugs
Covered
Not Applicable 50.00%Not Applicable 100.00% Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document. Certain off-label uses of cancer drugs will be covered in accordance with state law.
Outpatient Rehabilitation Services
Covered
Not Applicable 50.00%Not Applicable 100.00%30.0 Visit(s) per Benefit Period Applied Behavior Analysis (ABA) therapy; Cognitive therapy; Speech therapy for stammering or stuttering; Group classes for pulmonary rehabilitation; music therapy, remedial reading, recreational or activity therapy, all forms or special education and supplies or equipment used similarly; maintenance therapy; massage therapy. Combined 30 visit limit for occupational and physical therapies and chiropractic services.
Habilitation Services
Covered
Not Applicable 50.00%Not Applicable 100.00%30.0 Visit(s) per Benefit Period Cognitive Therapy. Group classes for pulmonary rehabilitation. Combined 30 visit limit for occupational and physical therapies and chiropractic services.
Chiropractic Care
Covered
Not Applicable 50.00%Not Applicable 100.00%30.0 Visit(s) per Benefit Period 30 visit limits for PT and OT combined (including chiropractic).
Durable Medical Equipment
Covered
Not Applicable 50.00%Not Applicable 100.00% Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment.
Hearing Aids
Covered
Not Applicable 50.00%Not Applicable 100.00%1.0 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids, once every 36 months.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00%Not Applicable 100.00% Lab tests that are not ordered by Doctor or Other Provider
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable 100.00% AHC covers any preventive services required by federal and state laws or regulations at no charge to the member.
Routine Foot Care
Covered
$110.00 Not ApplicableNot Applicable 100.00%
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
Not Applicable 50.00%Not Applicable 100.00%1.0 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
Not Applicable 50.00%Not Applicable 100.00%1.0 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$55.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Benefit Period
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$55.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Benefit Period Charges for care not provided in an office setting. Infusion therapy or chelation therapy. Services of a chiropractor or osteopath that are not within their scope of practice, as defined by state law. Combined 30 visit limit for occupational and physical therapies and chiropractic services.
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 50.00%Not Applicable 100.00% Lab tests that are not ordered by a Doctor or Other Provider.
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00%Not Applicable 100.00% Lab tests that are not ordered by a Doctor or Other Provider.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 50.00%Not Applicable 100.00% The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organs or tissues. Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient’s coverage. Reasonable costs for travel and lodging are covered and will be reimbursed for a covered transplant based on AmeriHealth guidelines available from our transplant coordinator.
Accidental Dental
Covered
Not Applicable 50.00%Not Applicable 100.00% Excludes injury related to chewing or biting.
Dialysis
Covered
Not Applicable 50.00%Not Applicable 100.00%
Allergy Testing
Covered
$110.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 50.00%Not Applicable 100.00%
Radiation
Covered
Not Applicable 50.00%Not Applicable 100.00%
Diabetes Education
Covered
No Charge Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 50.00%Not Applicable 100.00% Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan. Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery.
Infusion Therapy
Covered
Not Applicable 50.00%Not Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00%Not Applicable 100.00% Coverage is not provided for orthodontic braces, crowns, bridges, dentures, treatment for periodontal disease, dental root form implants, or root canals. Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.
Nutritional Counseling
Covered
No Charge Not ApplicableNot Applicable 100.00% Nutritional counseling visits are separate from the obesity-related office visits.
Reconstructive Surgery
Covered
Not Applicable 50.00%Not Applicable 100.00% Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.
Gender Affirming Care
Not Covered
Clinical Trials
Covered
Not Applicable 50.00%Not Applicable 100.00%
Diagnosis and Treatment of Lymphedema
Covered
Not Applicable 50.00%Not Applicable 100.00% Over-the-counter compression or elastic knee-high or other stocking products.
Diabetes Care Management
Covered
Not Applicable 50.00%Not Applicable 100.00% Includes routine foot care.
Dental Anesthesia
Covered
Not Applicable 50.00%Not Applicable 100.00%
Congenital Anomaly, including Cleft Lip/Palate
Covered
Not Applicable 50.00%Not Applicable 100.00%
Sexual Dysfunction
Covered
Not Applicable 50.00%Not Applicable 100.00% Sexual Dysfunction For Treatment of Organic Disease
Sterilization
Covered
Not Applicable 50.00%Not Applicable 100.00% Tubal Ligation is covered in full under Preventive Care.
Blood and Blood Services
Covered
Not Applicable 50.00%Not Applicable 100.00% We will cover the cost of the collection or obtainment of blood or blood products from a blood donor, including the Member in the case of autologous blood donation. We will cover the cost of transfusions of blood, plasma, blood plasma expanders and other fluids injected into the bloodstream. Benefits are provided for the cost of storing a Member?s own blood only when it is stored and used for a previously scheduled procedure.
Anesthetics
Covered
Not Applicable 50.00%Not Applicable 100.00%
Cardiac Rehabilitation
Covered
Not Applicable 50.00%Not Applicable 100.00%30.0 Visit(s) per Benefit Period Limited to 30 visits per benefit period. More available beyond the initial allotment if deemed medically necessary.
Pulmonary Rehabilitation
Covered
Not Applicable 50.00%Not Applicable 100.00%36.0 Treatment(s) per Benefit Period Limited to 2 – 1 hour treatments per day, up to 36 treatments within a benefit period. More available beyond the initial allotment if deemed medically necessary.
Orthotic Devices for Positional Plagiocephaly
Covered
Not Applicable 50.00%Not Applicable 100.00%
Organ Donor Search
Covered
Not Applicable 50.00%Not Applicable 100.00% If a transplant is provided from a living donor to the recipient MEMBER who will receive the transplant: Benefits are provided for reasonable and necessary services related to the search for a donor. Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient’s coverage.

Free Preventive Services

There is no copayment or coinsurance for any of the following AmeriHealth Caritas Next Silver Premier + No Referrals preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for AmeriHealth Caritas Next Silver Premier + No Referrals including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for AmeriHealth Caritas Next Silver Premier + No Referrals?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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