Don’t Qualify for a Chronic Condition Special Needs Plan
MAPD HMO
Champion Ally
Medicare or Medicare and Medi-Cal (Medicaid)
Enroll NowCalifornia
Champion Ally - Medicare Advantage Plan
Champion Health Plan offers Champion Ally which is a great choice for Medicare beneficiaries that don’t qualify for a Chronic Condition Special Needs plan (C-SNP). This plan reduces the cost of prescription drugs while adding additional services and benefits.
California Counties Available
- Imperial County
- Fresno County
- Kern County
- Los Angeles County
- Madera County
- Orange County
- Riverside County
- San Bernardino County
- San Diego County
| Doctor & Care Cost | 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 |
| Plan Benefits | 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 |
| Prescription Drug Costs | 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 $60, three-month supply |
| Plan Resources | 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 |
