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.
Evidence of Coverage
This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2023. 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.
Addendum to Troy Medicare Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Evidence of Coverage and Summary of Benefits
Addendum to Troy Medicare (HMO) Evidence of Coverage and Summary of Benefits
Plan Forms
Prior Authorization Request Form
For members: Use this form if you want to ask for a coverage decision on a service, benefit, or item.
Appointment of Representation Form
Use this form to appoint a representative to handle an appeal or grievance on the member's behalf.
Prescription Drug Coverage Determination Request Form
Use this form when you want to ask for a coverage determination about a prescription drug.
Prescription Drug Redetermination Request Form
Use this form when you want to appeal a coverage determination about a prescription drug.
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.
Electronic Prescription Drug Coverage Redetermination Request - Member
Use this online form when you want to appeal a coverage determination about a prescription drug.