Freestanding Prescription Benefits at a Glance AmeriHealth Forms Online — New Jersey Type Option Standard $1/$3 Standard $10/$20 Standard $2/$10 Standard $2/$6 Standard $4/$8 Standard $5/$10 Standard $5/$15 Standard $5/$20 Standard $6/$10 Standard $7/50%/$125 Standard $7/50%/$250 Standard $8/$14 Standard 50%/$125 Select $5/$20/50% Select FS Select RX $10/$20/$35 w/Orals Select FS Select RX $10/$20/$50 w/Orals Select FS Select RX $10/$40/$60 w/Orals Select FS Select RX $15/$25/$35 w/Orals Select FS Select RX $15/$35/$50 w/Orals Select FS Select RX $20/$40/$60 w/Orals Select FS Select RX $5/$10/$35 w/Orals Select FS Select RX $5/$10/$35 w/Orals Select FS Select RX $5/$10/$50 w/Orals Select FS Select RX $5/$10/50% w/Orals Select FS Select RX $5/$15/$25 w/Orals Select FS Select RX $5/$15/$35 w/Orals Select FS Select RX $5/$15/$50 w/Orals Select FS Select RX $5/$15/50% w/Orals Select FS Select RX $5/$20/$35 w/Orals Select FS Select RX $5/$20/$50 w/Orals Select FS Select RX $7/$35/$50 w/Orals Deductible/Copay $200/$15/$25/$35 Deductible/Coinsurance FS Deductible/Copay 2 Tier $100/$15/$15 w/Orals Deductible/Coinsurance FS Deductible/Copay 2 Tier $100/$15/$25 w/Orals Deductible/Coinsurance FS Deductible/Copay 2 Tier $20/$15/$15 w/Orals Deductible/Coinsurance FS Deductible/Copay 2 Tier $200/$15/$25 w/Orals Deductible/Coinsurance FS Deductible/Copay 3 Tier $100/$15/$25/$35 w/Orals Deductible/Coinsurance FS Deductible/Copay 3 Tier $200/$15/$25/$35 w/Orals