Plan Information

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.

View Summary of Benefits

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2020. 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.

View Evidence of Coverage

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 Troy Medicare (HMO)

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