Evidence of Coverage

The Evidence of Coverage (EOC) is the official, legally binding document that explains everything about your Troy Medicare plan in full detail. It serves as a comprehensive contract between you and Troy Medicare, describing the rules you need to follow to receive covered care, every service and prescription drug benefit available under your plan, your share of costs for each type of service, and your rights and responsibilities as a member.

The EOC is organized into chapters that cover specific topics such as how to get medical care and prescription drugs, what services require prior authorization, how emergency and urgent care are handled, and what to do if you disagree with a coverage decision. Each chapter provides detailed explanations that go well beyond the overview found in other plan documents.

Unlike the Summary of Benefits, which gives you a high-level snapshot of your plan's benefits and costs, the EOC is the complete, authoritative reference. If there is ever a question about whether a service is covered, what your cost-sharing will be, or what rules apply to a particular situation, the EOC is the definitive source of information.

Troy Medicare is required by the Centers for Medicare & Medicaid Services (CMS) to provide this document to all members. A new EOC is issued each plan year to reflect any changes in benefits, costs, or plan rules that take effect on January 1.

The Evidence of Coverage typically contains chapters covering the following topics:

• Getting started as a member — your membership card, how to contact Troy Medicare, and important plan contacts.
• Important rules for getting care — how the provider network works, referrals, prior authorization requirements, and out-of-area coverage rules.
• Medical benefits — a detailed list of covered services including preventive care, hospital stays, skilled nursing, mental health, and more.
• Prescription drug coverage — how the formulary works, pharmacy rules, coverage stages, and the Medicare prescription drug payment plan.
• Your costs — premiums, deductibles, copays, coinsurance, and the out-of-pocket maximum for your plan.
• Rights and responsibilities — your privacy rights, nondiscrimination protections, and how to file a complaint or appeal.
• Leaving the plan — how and when you can disenroll, and what happens to your coverage.

Who Should Use It

• Members

  Current Troy Medicare members who need detailed information about covered services, costs, rules for getting care, and member rights and responsibilities. The EOC is especially useful when you need to understand a specific benefit, check whether a service requires prior authorization, or review your cost-sharing for an upcoming procedure.

• Brokers

  Licensed agents who need to reference specific plan rules, limitations, or coverage details when advising current enrollees or helping beneficiaries evaluate their options during enrollment periods.

• Providers

  Healthcare providers verifying specific coverage rules, prior authorization requirements, or cost-sharing details for treatment planning. Providers may also use the EOC to confirm whether a service is covered before delivering care.

How to Use It

1. Download the PDF for your plan type (HMO or D-SNP) using the links at the top of this page.
2. Use the table of contents at the beginning of the document to navigate to the chapter or section you need.
3. Review the specific chapter for detailed information about covered services, exclusions, limitations, and any conditions that apply.
4. Check the cost-sharing details for your expected copays, coinsurance, and deductibles before receiving care.
5. Review the prior authorization and referral rules to ensure you follow the correct steps before scheduling a service or procedure.
6. Keep this document as a reference throughout your plan year — you may need it when making decisions about your care or resolving a coverage question.
7. Contact Troy Medicare at 1-833-419-TROY (8769) if you have questions about any section of the EOC. Our member services team can help explain any part of the document.

The EOC is updated each year. If your plan benefits, costs, or rules change for the upcoming plan year, those changes will be reflected in the new EOC sent to you before January 1. You will also receive an Annual Notice of Change (ANOC) that summarizes what is different from the current year.

If you lose your copy of the EOC or need a replacement, you can download it from this page at any time or call Troy Medicare to request a printed copy be mailed to you at no cost.