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Region 15 - Kentucky, Indiana


Advantage Star Plan
TierNameCo-pay
Tier 1Generics $5.50 co-pay
Tier 2 Preferred Brand 25% co-pay
Tier 3 Specialty25% co-pay
Tier 4 Non-Preferred 45% co-pay
Monthly Premium: $31.00
Advantage Freedom Plan
TierNameCo-pay
Tier 1 Generics $4.50 co-pay
Tier 2 Preferred Brand 35% co-pay
Tier 3 Specialty 33% co-pay
Tier 4 Non-Preferred 45% co-pay
Monthly Premium: $29.10




Star MaterialsFreedom Materials
Comprehensive Formulary*Comprehensive Formulary*
Summary of Benefits*Summary of Benefits*
Evidence of Coverage*Evidence of Coverage*








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