Prescription Drugs

Troy Medicare was started by pharmacists and physicians, and therefore we pride ourselves in offering prescription drug coverage through our network of community pharmacies. For Dual Eligible beneficiaries, Troy Medicare offers $0 copays for all medications (generics and brands).

• View 2023 Online Searchable Drug List and Formulary
• View 2024 Troy Medicare (HMO) Online Searchable Drug List and Formulary
• View 2024 Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Online Searchable Drug List and Formulary
• View 2023 Formulary for All Troy Plans
• View 2024 Troy Medicare (HMO) Comprehensive Formulary
• View 2024 Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Comprehensive Formulary

To request a printed copy of the List of Covered Drugs (Formulary), please contact Member Services at 1-888-494-TROY (8769). (TTY users should call 711.) Our hours of operation are:

• During the months of April through September, we are available from 8:00 am to 8:00 pm, Monday through Friday.
• During the months of October through March, we are available from 8:00 am to 8:00 pm, seven (7) days a week.

You can go to all the pharmacies on this list, but your costs for some drugs may be less at pharmacies in this list that offer preferred cost sharing. We have marked these pharmacies with "PREFERRED" under the Cost Sharing column to distinguish them from other pharmacies in our network that offer standard cost sharing.

• View 2023 Pharmacy Directory
• View 2024 Pharmacy Directory

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Part D out of network coverage information

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When can you use a pharmacy that is not in the plan’s network?
Your prescription may be covered in certain situations. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Please check first with Member Services to see if there is a network pharmacy nearby. You will most likely be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.

Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
We would cover prescriptions at an out of network pharmacy as a result of getting emergency, urgent, or approved care while out of the plan’s service area, but within the United States or its Territories. The plan has nationwide pharmacies to assist with prescription needs. If you have a question or are having trouble getting a prescription filled, please contact us directly.

In these situations, please check first with Member Services to see if there is a network pharmacy nearby. You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.

How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal cost share) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost.

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There is a $65 quarterly allowance for Troy Medicare (HMO) and a
$325 quarterly allowance for Troy Medicare for Dual-eligible Beneficiaries (D-SNP HMO) on 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.
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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.

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.

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Part D Quality Assurance Policy

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We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care.

We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as:

• Possible medication errors
• Drugs that may not be necessary because you are taking another drug to treat the same condition
• Drugs that may not be safe or appropriate because of your age or gender
• Certain combinations of drugs that could harm you if taken at the same time
• Prescriptions for drugs that have ingredients you are allergic to
• Possible errors in the amount (dosage) of a drug you are taking
• Unsafe amounts of opioid pain medications

If we see a possible problem in your use of medications, we will work with your provider to correct the problem.
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Your Grievance Rights

How to make a complaint (“grievance”):

1. Contact Member Services as soon as possible either by telephone or in writing. We must receive your complaint within 60 days of the event that caused the complaint. 

2. Call Member Services at 1-888-494-TROY (8769) or TTY 711. We are available 8am-8pm Eastern Time, Monday – Friday, and from October 1 through March 31, we are available 7 days a week. We will take your complaint and try to give you an answer on the same phone call.  If we cannot resolve your complaint on the phone call, we have up to 30 days to resolve it. If we need more time to resolve the complaint, we will notify you.

3) Send us your signed written complaint or print the grievance/appeal form.

• FAX to: 1-919-375-3533.
• Mail to:
  Troy Medicare
  PO Box 1265 Westborough, MA 01581

5) You can also tell Medicare about your complaint.  You can send a complaint about Troy Medicare directly to Medicare on their website. To send a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx

6) You may also call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048, 24 hours a day, 7 days a week.

For more information about grievances, please see the Evidence of Coverage, Section 10.3.

You have the right to make a complaint if we let you know that we ended your membership in our plan.  We must tell you our reasons in writing for ending your membership and actions you can take if you believe the information is wrong. We must also explain how you can make a complaint about our decision to end your membership. Call Member Services if you need further help. 

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Your Right to Appoint a Representative

You can ask someone to act on your behalf if you need something to help you make a complaint, ask for a coverage decision from Troy Medicare, or file a Level 1 appeal.  If you want a friend, relative, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form. 

You can also use this link to the form [www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf  It must be signed by you and by the person who you would like to act on your behalf. Your appointed representative must send us this form with the complaint or the request for a coverage/payment decision or appeal. This form does not give the appointed person any other rights but to stand in for you for these purposes. 

You have the Right to Ask for a Prescription Drug Coverage Decision

Typically, your provider will send us a request for a prescription drug coverage decision with his/her supporting statement if the drug requires a prior authorization or a formulary exception. 

You also have the right to request a coverage decision if you believe the prescription drug should be offered or paid by Troy Medicare, or to request reimbursement of a drug you paid for out of pocket.  We will decide within 14 calendar days or earlier, depending on the type of request. 

To request a coverage or payment (reimbursement) decision for a Part D prescription drug, complete this form. Mail or FAX it to us using the contact information on the form.

• If we say yes to your request: The prescription drug is covered for you. We will call you and send you a letter approving coverage. If you haven’t paid for the prescription drug, we will authorize your pharmacy to fill the prescription.  If you paid for the prescription drug, we would reimburse you.

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• If we say no to your request: 

• Some drugs are never covered by Medicare. If the prescription drug is not covered by Medicare, we are unable to approve your request. You have the right to make a complaint, but the appeal process does not apply. 
• If we do not have a supporting statement from your prescriber, or you do not meet the criteria for approval, we will deny your request. We will call you and send you a letter that says we will not authorize or pay for the prescription drug and the reasons why it is not covered.  

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You have the Right to Ask for a Prescription Drug Appeal

If Troy Medicare denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal). You must ask for the appeal within 60 days of the date on the Notice of Denial of Medicare Drug Coverage. Use this form when you want to appeal a coverage determination about a prescription drug.

If we say no to your request: 

• Some drugs are never covered by Medicare. If the prescription drug is not covered by Medicare, you do not have the right to appeal. You have the right to make a complaint. 
• If we believe the coverage decision was incorrect, we will overturn it and approve coverage or payment for your prescription drug.
• If we do not have a supporting statement from your prescriber, or you do not meet the criteria for approval, we will uphold the denial of our coverage decision. We will send you a letter that says we will not authorize or pay for the prescription drug and the reasons why it is not covered. We will provide you with information on how to request a review from a third-party redetermination reviewer. 

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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:

1. the transition of new enrollees into prescription drug plans following the annual coordinated election period;
2. the transition of newly eligible Medicare beneficiaries from other coverage;
3. the transition of enrollees who switch from one plan to another after the start of the contract year;
4. enrollees residing in long-term care (LTC) facilities;
5. enrollees who change treatment settings due to changes in level of care; and
6. 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.
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Troy has a program that can help our members with complex health needs. Our program is called a Medication Therapy Management (MTM) program. This program is voluntary and free.
A team of pharmacists and doctors developed the program for us to help make sure that our members get the most benefit from the drugs they take. This includes  members who take medications for different medical conditions or have high drug costs. Other members are in a Drug Management Program (DMP) to help members use their opioids safely.
A pharmacist or other health professional will give you a comprehensive review of all your medications. During the review, you can talk about your medications, your costs, and any problems or questions you have about your prescription and over-the-counter medications. You’ll get a written summary which has a recommended to-do list that includes steps you should take to get the best results from your medications. You’ll also get a medication list that will include all the medications you’re taking, how much you take, and when and why you take them.
In addition, members in the MTM program will receive information on the safe disposal of prescription medications that are controlled substances. It’s a good idea to talk to your doctor about your recommended to-do list and medication list. Bring the summary with you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Also, keep your medication list up to date and with you (for example, with your ID) in case you go to the hospital or emergency room.
If we have a program that fits your needs, we will automatically enroll you in the MTM program and send you information. If you decide not to participate, please notify us and we will withdraw you. If you have any questions about this program, please contact Member Services.
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Drug Management Program (DMP)

We have a program that helps make sure members safely use prescription opioids and other frequently abused medications called a Drug Management Program (DMP). If you use opioid medications that you get from several doctors or pharmacies, or if you had a recent opioid overdose, we may talk to your doctors to make sure your use of opioid medications is appropriate and medically necessary.

Working with your doctors, if we decide your use of prescription opioid medications is not safe, we may limit how you can get those medications. If we place you in our DMP, the limitations may be:

• Requiring you to get all your prescriptions for opioid medications from a certain pharmacy(ies)
• Requiring you to get all your prescriptions for opioid medications from a certain doctor(s)
• Limiting the number of opioid medications, we will cover for you

If we plan on limiting how you may get these medications or how much you can get, we will send you a letter in advance. The letter will explain the limitations we think should apply to you. You will have an opportunity to tell us which doctors or pharmacies you prefer to use, and about any other information you think is important for us to know. After you’ve had the opportunity to respond, if we decide to limit your coverage for these medications, we will send you another letter confirming the limitation. If you think we made a mistake or you disagree with our determination or with the limitation, you and your prescriber have the right to appeal. If you appeal, we will review your case and give you a decision. If we continue to deny any part of your request related to the limitations that apply to your access to medications, we will automatically send your case to an independent reviewer outside of our plan.

You will not be placed in our DMP if you have certain medical conditions, such as active cancer-related pain or sickle cell disease, you are receiving hospice, palliative, or end-of-life care, or live in a long-term care facility.

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