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Champion Ally (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Champion Ally (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Champion Ally (HMO) in 2026, please refer to our full plan details page.
Champion Ally (HMO) is a HMO plan offered by Champion Health Plans-USA, LLC. available for enrollment in 2026 to people living in CAR, CHU, CLA and WAS counties. The overall rating for this plan is not yet available for 2026.
It's important to know that Champion Ally (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Champion Ally (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Champion Ally (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $199.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Champion Ally (HMO) Medicare plan offers prescription drug coverage with a $0 drug deductible, allowing your benefits to start immediately. Members pay no copay for Tier 1 preferred generic and Tier 6 select care drugs for both 1-month and 3-month supplies at standard pharmacies and through standard mail order. Tier 2 generic medications are also highly affordable, with a $3 copay for a 1-month supply at standard pharmacies and a $6 copay for a 3-month standard mail order. For higher-tier medications, Tier 3 preferred brand drugs require a $47 copay for a 1-month supply, while Tier 4 non-preferred brands have a $100 copay. Standard mail order offers savings on 3-month supplies, costing $94 for Tier 3 and $200 for Tier 4. Specialty drugs in Tier 5 require a 33% coinsurance for a 1-month supply at standard pharmacies.
Additional Benefits
The Champion Ally (HMO) plan offers robust coverage with no copayments and no coinsurance for many essential services, including primary care, specialist visits, home health care, and diagnostic testing. Acute inpatient hospital stays and many outpatient services also feature no copay, though psychiatric hospital stays and outpatient hospital visits require a $100 copay. For specialized recovery, skilled nursing facility stays have no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100. This plan also includes valuable supplemental benefits, such as preventive dental care with no copay up to a $3,000 annual limit and comprehensive dental services with 20% to 40% coinsurance. Members benefit from routine vision and hearing exams with no copay, a $335 annual allowance for eyeglasses, and up to 24 one-way transportation trips per year to approved locations with no copay. Prescription hearing aids are available for a $149 copay, and routine acupuncture is covered with no copay for up to 30 treatments annually.
Inpatient Hospital See details
Champion Ally (HMO) partially covers inpatient hospital services with no coinsurance, though additional days, upgrades, and non-Medicare-covered stays are not covered. Acute inpatient hospital stays have no copay, while psychiatric inpatient stays require a $100 copay for days 1 through 10 and no copay for days 11 through 90.
Outpatient Services See details
Champion Ally (HMO) covers outpatient services with no coinsurance, requiring a $100 copay for outpatient hospital services and no copay for outpatient observation, ambulatory surgical center, substance abuse, and blood services. Prior authorization and referrals are required for most of these covered outpatient benefits.
Partial Hospitalization See details
Partial hospitalization is covered by Champion Ally (HMO) with no copay and no coinsurance, although prior authorization and a referral are required.
Ambulance and Transportation Services See details
Champion Ally (HMO) covers ambulance services with a copay of $0 to $125 plus coinsurance for ground transport, and a 20% coinsurance plus copay for air transport. Transportation services are partially covered, offering up to 24 one-way trips per year to plan-approved locations with no copay and no coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Champion Ally (HMO) covers emergency services with a $70 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with no copay or coinsurance. Worldwide emergency and urgent services are partially covered up to a $10,000 maximum with no copay or coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Champion Ally (HMO) covers primary care, specialist visits, mental health, and therapy services with no copay and no coinsurance. Chiropractic services are partially covered, offering up to 20 routine visits per year with no copay and no coinsurance, while other chiropractic services and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by Champion Ally (HMO) with no copay and no coinsurance for covered services, including annual physical exams, kidney disease education, and glaucoma screenings. However, several supplemental benefits are not covered, such as medical nutrition therapy, in-home safety assessments, weight management programs, and therapeutic massage.
Hearing Services See details
Hearing services are partially covered by Champion Ally (HMO), featuring no deductible, no copay, and no coinsurance for routine hearing exams and fitting evaluations. Prescription hearing aids are covered for a $149 copay with no coinsurance for up to two aids every three years, though inner ear, outer ear, over the ear, and over-the-counter hearing aids are not covered.
Vision Services See details
Champion Ally (HMO) provides partially covered vision services with no copay, no coinsurance, and no deductible for covered services, including one routine eye exam and eyeglasses (lenses and frames) up to a $335 annual limit. However, other eye exam services, contact lenses, individual eyeglass lenses, and individual eyeglass frames are not covered.
Dental Services See details
Dental services are partially covered by Champion Ally (HMO), offering preventive and diagnostic care with no copay and no coinsurance up to a $3,000 annual limit. Covered comprehensive services require no copay and 20% to 40% coinsurance, though adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Champion Ally (HMO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin has a copay of $0.00 to $24.00 and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a 0% to 20% coinsurance with no copay.
Dialysis Services See details
Dialysis Services are covered under Champion Ally (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Champion Ally (HMO) covers durable medical equipment (DME) and prosthetics with no copay and 0% to 20% coinsurance, subject to prior authorization. Diabetic equipment, supplies, and therapeutic shoes are fully covered with no copay and no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Champion Ally (HMO) with no copays and no coinsurance for diagnostic procedures, lab tests, therapeutic radiological services, and X-rays. Prior authorization and referrals are required for diagnostic services.
Home Health Services See details
Home health services are covered by Champion Ally (HMO) with no copay and no coinsurance, though prior authorization and a referral are required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by Champion Ally (HMO) with no copay and no coinsurance, but only some services are covered in practice as standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Champion Ally (HMO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring a referral and prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, and a $218 daily copay applies for days 21 through 100, with no coverage for additional days beyond the Medicare limit.
Other Services See details
Champion Ally (HMO) provides partial coverage for other services, offering acupuncture with no copay and no coinsurance for up to 30 treatments per year. Over-the-counter (OTC) items, meal benefits, and other additional services are not covered under this plan.
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