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) 2023
Troy Medicare for Dual-eligible Beneficiaries (D-SNP) 2023

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

Troy Medicare (HMO) 2023
Troy Medicare for Dual-eligible Beneficiaries (D-SNP) 2023

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.

For Providers:

Online Prior Authorization Request Form

Grievance/Appeal Form

Use this for when you want to make a complaint or appeal a denied service or benefit.

View Grievance/Appeal Form

Community Resources

Community Resources

Pre-Enrollment Checklist

Checklist prior to enrolling in a Troy plan.

Pre-Enrollment Checklist

Appointment of Representation Form

Use this form to appoint a representative to handle an appeal or grievance on the member's behalf.

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

2023 Medicare Star Ratings

2023 Medicare Star Ratings

LIS Premium Subsidy Chart

LIS Premium Subsidy Chart

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