Champion Ally
MAPD HMO
| Benefit | Champion Ally |
|---|---|
| Monthly Premium |
$0 |
| Deductible |
None |
| MOOP |
$199 |
| Primary Care Physician |
$0 |
| Specialists |
$0 |
| Diagnostic Radiology, Lab |
$0 |
| Annual Wellness Visit |
$0, up to one (1) annual exam |
| Dialysis |
20% |
| Urgent Care |
$0 |
| Emergency Room |
$70 |
| Inpatient Hospital |
$0 |
| Outpatient Hospital |
$100 |
| Benefit | Champion Ally |
|---|---|
| OTC / Healthy Food / Utilities |
$300 Allowance every (3) three months |
| Transportation |
$0, 24 one-way plan-approved locations |
| Dental |
$3000 Allowance |
| Routine Eye Exam |
$0 Exam |
| Vision Eyewear (frames/lenses/contacts) |
$335 Eyewear Allowance |
| Routine Hearing Exam |
$0 Exam |
| Hearing Aid |
$149 Aids |
| Respite |
N/A |
| PERS |
$0 |
| Benefit | Champion Ally |
|---|---|
| Tier 1 - Preferred Generics |
$0 |
| Tier 2 - Non-Preferred Generics |
Participating Retail Pharmacy: $3 Mail Order: $6 |
| Tier 3 - Preferred Brand |
Participating Retail Pharmacy: $47 Mail Order: $94 |
| Tier 4 - Non-Preferred Brands |
Participating Retail Pharmacy: $100 Mail Order: $200 |
| Tier 5 - Specialty Drugs |
33% (A 100-day supply is not available in Tier 5) |
| Tier 6 - Select Care |
$0 |
| Insulin |
$20, one-month supply |
| Benefit | Champion Ally |
|---|---|
| Summary of Benefits | Download |
| Over-the-Counter Catalog | Download |
| Healthy Foods Catalog | Download |
| Dental Fee Schedule | Download |
| Clinical Criteria | Download |
| Verification of Chronic Condition Form | Download |
| Health Risk Assessment Form | Download |
| Enrollment Form | Download |
| Authorization for Disclosure of Protected Health Information | Download |
| Evidence of Coverage (EOC) | Download |
| Enrollment Kit | Download |
This page was last updated on 9/1/2026. Pending CMS approval.
