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PPO Prescription Benefits at a Glance: Groups 2 – 99

AmeriHealth Forms Online — New Jersey

Type Option
Standard $7/50%
Standard 50%/$125
Standard EPO Rx $100/$7/50%/$125
Standard EPO Rx $100/50%/$125
Standard EPO Rx $150/$7/50%/$125
Standard EPO Rx $150/50%/$125
Standard EPO Rx $7/50%
Standard EPO Rx 50%
Select $10/$20/$35
Select $10/$40/$60
Select $100/$15/$15
Select $100/$15/$25
Select $100/$15/$25/$35
Select $15/$25/$35
Select $15/$35/$50
Select $20/$40/$60
Select $200/$15/$15
Select $200/$15/$25
Select $200/$15/$25/$35
Select $5/$15/$25
Select $5/$20/$35
Select $5/$25/$50
Select $7/$35/$50
Select EPO Rx $10/$40/$60
Select EPO Rx $100/$10/$40/$60
Select EPO Rx $150/$10/$40/$60
Select EPO Rx $250/$10/$40/$60
Select EPO Rx $250/$7/50%/$125
Select EPO Rx $250/50%/$125
Deductible/Copay $100/$15/$15
Deductible/Copay $100/$15/$25
Deductible/Copay $100/$15/$25/$35
Deductible/Copay $200/$15/$15
Deductible/Copay $200/$15/$25
Deductible/Copay $200/$15/$25/$35