Health Maintenance Organization (HMO) — Groups 2 – 50 AmeriHealth Forms Online — New Jersey Option Copay Integrated Rx HMO $15/$30 $0/Day $15   HMO $15/$30 $200/Day $15   HMO $20/$40 $0/Day $20   HMO $20/$40 $300/Day $20   HMO $25/$50 $500/Day $25   HMO $30/$50 $0/Day $20   HMO $30/$50 $400/Day $30   HMO 10 $10   HMO 10 Premium $10   HMO 15 $15   HMO 15 Premium $15   HMO 20 $20   HMO 20 Premium $20   HMO 30 $30   HMO 30 Premium $30   HMO 40 $40   HMO 40 Premium $40   HMO Coinsurance Option 1 $20   HMO Coinsurance Option 2 $30   HMO Coinsurance Option 3 $30   HMO Coinsurance Option 4 $20   HMO Coinsurance Option 5 $25   HMO Coinsurance Option 6 $30