Troy Medicare was started by pharmacists and physicians, and therefore we pride ourselves in offering prescription drug coverage through our network of community pharmacies.
Our pharmacy network includes non-preferred and preferred pharmacies. You can go to either type of network pharmacy to receive your covered prescriptions drugs, however, your cost share is lower at a preferred pharmacy.
Over-the-Counter (OTC) Benefit
There is a quarterly $40 allowance for Medicare eligible Over-the-Counter drugs and health-related items. These items are medications and health-related items that are available without prescription, not covered by Medicare and used to treat a health-related condition.
This includes items such as adhesive or elastic bandages, and OTC drugs such as antihistamines and analgesics. This does not include medical supplies used with insulin for diabetes treatment.
Prescription Drug Coverage Rights
Troy Medicare is committed to making sure you get the prescription drugs you need. Your experience is important to us. If you experience unhappiness or dissatisfaction with Troy Medicare, a plan provider or staff, or your coverage, you have certain rights.
Your Grievance Rights
If you are dissatisfied with something, you can file a complaint or grievance with the plan. You have three ways to file a complaint or grievance with Troy Medicare:
- You can call us at 1-888-494-TROY (8769). We will try to resolve your dissatisfaction over the phone.
- You also can file a grievance in writing or use our grievance form. Go to the Documents and Forms page for the Grievance/Appeal form, complete it and mail it to us.
- You can also use the contact us page. We will call you to get additional information and try to resolve the issue over the phone.
If we can’t resolve the issue, we will work with you to resolve within 30 days. We also can take an extension of 14 days, if needed. We will let you know if we need to take an extension.
Your Coverage Determination and Redetermination Rights
There are some instances where you are prescribed a drug that requires a prior authorization, or has step therapy requirements, or has a quantity limit. Your formulary or drug list will tell you if a drug on our list has one of these utilization requirements.
Prior Authorization: Troy Medicare (HMO) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Troy Medicare (HMO) before you fill your prescriptions. If you don’t get approval, Troy Medicare (HMO) may not cover the drug.
Step Therapy: In some cases, Troy Medicare (HMO) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Troy Medicare (HMO) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Troy Medicare (HMO) will then cover Drug B.
Quantity Limit: For certain drugs, Troy Medicare (HMO) limits the amount of the drug that Troy Medicare (HMO) will cover. For example, Troy Medicare (HMO) provides 30 tablets per prescription for Digoxin. This may be in addition to a standard one-month or three-month supply.
If you identify or are prescribed a drug that requires a prior authorization, step therapy, or has a quantity limit, you have the right to request a prescription drug coverage determination to get the drug covered without any utilization requirements.
There are other instances where you can request that we make an exception. An exception is a determination when a drug is not on our formulary or you want the drug at a lower co-pay, (a tier exception).
There are a couple ways to file a coverage determination or exception request:
- You can call us at 1-888-494-TROY (8769). If you request a coverage determination, we will document your request and forward it to our pharmacy prior authorization department for review and response to you. If you received a denial notification and request a redetermination, we will document and forward your request to our pharmacy appeals department.
- You also can file a coverage determination request in writing or use our Coverage Determination Request Form. You can file a redetermination in writing or use our Redetermination Request form. Go to the Documents and Forms page for these forms, complete it and mail it to us.
Our Prescription Drug Transition Process
Troy has partnered with PerformRx as our Pharmacy Benefits Manager (PBM). PerformRx, on behalf of Troy Medicare will provide an appropriate transition process with regard to:
- the transition of new enrollees into prescription drug plans following the annual coordinated election period;
- the transition of newly eligible Medicare beneficiaries from other coverage;
- the transition of enrollees who switch from one plan to another after the start of the contract year;
- enrollees residing in long-term care (LTC) facilities;
- enrollees who change treatment settings due to changes in level of care; and
- current enrollees affected by negative formulary changes across contract years, consistent with the requirements set forth in Centers of Medicare and Medicaid Services (CMS) guidance for participation in the Medicare Part D Drug Program.
If you meet any of the above criteria, and your drug is not on the drug list or is restricted, here are things you can do:
- You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.
- You can change to another drug.
- You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.
- You may be able to get a temporary supply.
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the drug list or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
1. The change to your drug coverage must be one of the following types of changes:
- The drug you have been taking is no longer on the plan's drug list.
- The drug you have been taking is now restricted in some way.
2. You must be in one of the situations described below:
a. For members who were in the plan last year and aren't in a long-term care (LTC) facility:
- We will cover a temporary supply of your drug during the first 90 days of the calendar year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. You must fill the prescription at a network pharmacy.
- For members who are new to the plan and aren’t in an LTC facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we allow multiple fills to provide up to a maximum of a 30-day supply of medication. You must fill the prescription at a network pharmacy.
b. For members who were in the plan last year and reside in an LTC facility:
- We will cover a temporary supply of your drug during the first 90 days of the calendar year. The total supply will be for a maximum of a 31-day supply depending on the dispensing increment. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the LTC pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
c. For members who are new to the plan and reside in an LTC facility:
- We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The total supply will be for a maximum of a 31-day supply depending on the dispensing increment. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. (Please note that the LTC pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
d. For members who have been in the plan for more than 90 days, reside in an LTC facility, and need a supply right away:
- We will cover a 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above LTC transition supply.
- Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug.
- For example, members who:
- Enter LTC facilities from hospitals, who are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short-term planning considered (often under eight hours).
-Are discharged from a hospital to a home.
-End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary.
-End an LTC facility stay and return to the community.
If a member has more than one change in level of care in a month, the pharmacy must call our plan to request an extension of the transition policy.
During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.
If you have any questions about transition, or request a transition supply, please call PerformRx at 1-866-423-8065.
Medication Therapy Management
Troy has partnered with PerformRx℠ to offer medication therapy management programs at no additional cost for members who:
- Have multiple medical conditions
- Are taking many prescription drugs
- Have high drug costs
A team of pharmacists and doctors developed these MTM programs to help provide better prescription drug coverage for plan members. For example, these programs help us ensure that our members are using the proper drugs to treat their medical conditions and help Troy spot possible medication errors.
Troy offers MTM programs for members who meet certain criteria. As a Troy member, we may notify you of being enrolled in the program. Troy hopes that you will participate in any program offered to help you manage your medications. Remember, you do not need to pay anything extra to participate. If you are selected as an eligible participant for an MTM program, Troy will send you information about the specific program, including how to disenroll if you choose not to take part.
If you wish to participate in the program, our pharmacy benefits manager, PerformRx, will be reaching out to you. You will be contacted either via phone by our clinical staff or via direct mail with informational materials. Our outreach to you should take less than 30 minutes to complete. You will be eligible for both the comprehensive medication review, which will be a review of all your medications and therapy programs, and a targeted medication review, which will target your specific conditions.
We will provide you an overview of the MTM program, a medication action plan based on your medications and educational information based on the specific conditions which you have. If you opt into this program, we will also be contacting your primary care provider (PCP) to discuss your current treatments to work to improve your conditions and outcomes. You will be able to get any information we receive from our consultations with your physicians.
Every 3 months, we will send you materials for you to review. We ask that you review this information and provide us any updates so that we are aware of your current information. At your request we will also provide a comprehensive medication review. You may also receive additional information targeted at your specific conditions. These reviews can be helpful in reviewing your current drug treatment to ensure that you are receiving the best care.
To learn more, or to obtain MTM documents, call PerformRx at 1-888-349-0501 or 1-888-765-6351 (TDD/TTY) between 8:30 a.m. and 5 p.m. (EST), Monday through Friday
Opioid use disorder treatment services are covered under Part B of Original Medicare. Members of our plan receive coverage for these services through our plan. There is a $0 copayment for Opioid Treatment Program services. Covered services include:
- FDA-approved opioid agonist and antagonist treatment medications and the dispensing and administration of such medications, if applicable
- Substance use counseling
- Individual and group therapy
- Toxicology testing