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Region 15 - Kentucky, Indiana


Advantage Star Plan
TierNameCo-pay
Tier 1Preferred Generics $5.25
Tier 2 Preferred Brand 25% co-pay
Tier 3 Specialty25% co-pay
Tier 4 Non-Preferred 45% co-pay
Monthly Premium: $38.00
Advantage Freedom Plan
TierNameCo-pay
Tier 1 Value Generics $2.50 co-pay (Only Available at CVS/Pharmacy) $5.00 co-pay at all other network pharmacies
Tier 2 Generics $5.00 co-pay
Tier 3 Preferred Brand33% co-pay
Tier 4 Specialty 33% co-pay
Tier 5 Non-Preferred 45% co-pay
Monthly Premium: $49.20




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








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