Documents and Forms

Summary of Benefits

This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage.

Troy Medicare (HMO)
Troy Medicare for Dual-eligible Beneficiaries (D-SNP)

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need. This is an important document, so keep a link to it handy.

Troy Medicare (HMO)
Troy Medicare for Dual-eligible Beneficiaries (D-SNP)

Plan Forms

Prior Authorization Request Form

Use this form when you want to ask for a coverage determination about a medical claim.

View Prior Authorization Request Form

Grievance/Appeal Form

Use this form when you want to make an appeal.

View Grievance/Appeal Form

Enrollment Form

Complete this form to sign up for a Troy Medicare plan.

Enrollment Form

Appointment of Representation Form

Usually, there should not be a PA needed. But in rare cases, here is the form to request a prior authorization.

View Appointment of Representation Form

Prescription Drug Coverage Determination Request Form

Use this form when you want to ask for a coverage determination about a prescription drug.

View Prescription Drug Coverage Determination Request Form

Prescription Drug Redetermination Request Form

Use this form when you want to appeal a coverage determination about a prescription drug.

View Prescription Drug Redetermination Request Form

Plan Annual Notice of Change (ANOC) - HMO


The ANOC includes any changes in coverage, costs, or service area that will be effective in January.

Troy Medicare (HMO) Annual Notice of Change (ANOC)

Plan Annual Notice of Change (ANOC) - DSNP

Troy Medicare for Dual Eligible Beneficiaries (ANOC)

2022 Medicare Star Ratings


2022 Medicare Star Ratings

Electronic Plan Forms

Electronic Prescription Drug Coverage Determination Request - Member

Use this online form when you want to ask for a coverage determination about a prescription drug.

Prescription Drug Coverage Determination Form - Member

Electronic Prescription Drug Coverage Redetermination Request - Member

Use this online form when you want to appeal a coverage determination about a prescription drug.

Prescription Drug Coverage Redetermination Form - Member

Electronic Prescription Drug Coverage Determination Request - Provider

Use this online form when you are a provider and you want to ask for a coverage determination about a prescription drug.

Prescription Drug Coverage Determination Form - Provider

Electronic Prescription Drug Coverage Redetermination Request - Provider

Use this online form when you are a provider and you want to appeal a coverage determination about a prescription drug.

Prescription Drug Coverage Redetermination Form - Provider