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Freestanding Select Rx Benefits at a Glance
AmeriHealth Forms Online — Delaware
Standard
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Select
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Deductible/Coinsurance
Forms are in PDF format.
Option
$0/$25/$50
$5/$10/$25
$5/$10/$25
$5/$10/$25
$5/$10/50%
$5/$15/$25
$5/$15/$35
$5/$15/$50
$5/$15/50%
$5/$20/$35
$5/$20/$50
$5/$20/50%
$5/$30/$50
$10/$20/$35
$10/$20/$50
$10/$30/$50
$15/$35/$50
$20/$40/$60