Coverage and Benefits
Who Can Join?
To enroll in Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) you must be eligible for Medicare Part A and Part B and receive certain levels of assistance from the North Carolina Medical Assistance program (FBDE, SLMB Plus, QMB Plus or QMB). If you receive both Medicare and Medicaid benefits, this means you are a Dual-eligible beneficiary.
Additionally, you need to reside in one of the following counties in North Carolina: Alexander, Anson, Bladen, Buncombe, Burke, Caldwell, Catawba, Chatham, Columbus, Cumberland, Durham, Franklin, Granville, Harnett, Haywood, Henderson, Hoke, Iredell, Jackson, Lee, McDowell, Mitchell, Montgomery, Moore, Orange, Person, Polk, Richmond, Robeson, Sampson, Scotland, Swain, Transylvania, Vance, or Yancey counties in North Carolina.
Summary of Benefits
One of the best things about Troy Medicare for Dual-eligible Beneficiaries is the $0 copay for generic and brand medications.
- Here is the booklet with the 2023 Summary of Benefits
- Here is the booklet with the 2024 Summary of Benefits
Evidence of Coverage
An Evidence of Coverage (EOC) is a document that provides information on the plan, providers, benefits information including what is covered and how much you as a member has to pay for those benefits, how to ask us to cover a service, how to file an appeal if we deny coverage for a service you think should be covered, and how to file a grievance if you are dissatisfied with the plan or a plan provider or pharmacy.
Certain benefits require an approval in advance. When a benefit needs approval in advance, you or your provider can submit a medical coverage determination request. These benefits are marked with an asterisk in your Evidence of Coverage booklet, Chapter 4, Benefit Listing.
Your relationship with your Primary Care Provider (PCP) is very important. Your PCP will coordinate your care and make referrals to specialists or for diagnostic services. You do not need a referral for specialist visits, but it is advised to see your PCP first to make sure you are going to the right specialist.
OTC Benefits ($1,300/year)
We have partnered with Solutran to provide access to Medicare covered Over-the-Counter products.
Hearing Benefits up to $750
We have partnered with Hearing Care Solutions to provide hearing exams and if needed, hearing aids.Read More about the Hearing Benefits
We have partnered with Liberty Dental to provide preventive and comprehensive dental services to our members.Read the Dental Benefits Brochure
We have a reimbursement benefit up to $200 towards eyewear and up to $50 for an annual eye exam.Read the Vision Benefits Brochure
$0 copay for up to 32 one-way trips
We have partnered with SafeRide to provide up to 32 one-way trips with a $0 copay. To book a ride, call (855) 932 5419.
In-Home Support Services
We offer our members at no cost, in-home support services to connect members who need these additional services. Support services for companionship and activities of daily living including, but not limited to: Assisting members with coordinating transportation, grocery shopping, appointment scheduling, care gap reminders and light house help.
Troy Medicare has partnered with Sesame to provide you access to a free telehealth benefit in 2023! Sesame is an online telehealth provider that delivers same-day convenient, high-quality, medical care. Services include:
- Primary care
- Same-day urgent care
- Prescription refills
- Acute and chronic consults
- Skin Consults
Documents and Forms
Want to sign up for a plan? Need to share your health information with a loved one? We've got forms for all that and more.