Plan Information

Documents and Forms

Troy Medicare provides official plan documents, directories, forms, and member resources on this page. You can download PDFs directly or select "View details" to learn more about a document and how to use it.

Most Requested Documents

Health Risk Survey

To meet Medicare requirements, Troy Medicare asks that every member complete a Health Risk Survey. Please answer the survey as completely as possible. Your responses will not affect your enrollment, benefits, or copays.

What happens next?

Once we receive your completed survey, a dedicated Troy Medicare Care Manager will call you. During the call, the Care Manager will:

Review the health information you provided.
Answer any questions you have.
Discuss ways to support you in managing your health conditions or medications.
Help address any difficulties or assistance you may need.

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. 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.

LIS Premium Summary Chart

This chart shows the monthly premium amounts for Troy Medicare members who qualify for the Low-Income Subsidy (Extra Help) program. It breaks down costs by subsidy level so you can see exactly what your monthly premium will be.

Annual Notice of Change

This document explains what will be different about your Troy Medicare plan in the upcoming year, including changes to benefits, costs, coverage rules, and the provider and pharmacy networks.

Medicare Star Ratings

The Medicare Star Ratings document shows our plan's quality score based on ratings from the Centers for Medicare & Medicaid Services (CMS). These ratings reflect member experience, care quality, and plan administration, helping you understand how Troy Medicare performs compared to other Medicare Advantage plans.

Prescription Drug Plan Forms

Prescription Drug Coverage Determination Form - Member/Provider

Use this form when you want to ask for a coverage determination about a prescription drug.

Prescription Drug Coverage Redetermination Form - Member/Provider

Use this form when you want to appeal a coverage determination about a prescription drug.

Electronic Plan Forms

Electronic Prescription Drug Coverage Determination Form - 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.

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.

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.

Electronic Reimbursement Form - Member

This form is available for our members of Troy Medicare plans to submit requests for reimbursement; please use this form or if you have questions on other ways to submit or how to use this form, please contact Member Services.