Summary of Benefits

The Summary of Benefits (SB) is a document provided by Troy Medicare that gives you a clear, high-level overview of your Medicare Advantage plan. It outlines the benefits included in your plan, the services that are covered, and the costs you can expect to pay — such as copays, coinsurance, and deductibles. The SB is designed to help you quickly understand what your plan offers without needing to read through the full plan contract.

Each Troy Medicare plan — the HMO and the Dual Eligible Special Needs Plan (D-SNP) — has its own Summary of Benefits. The document is formatted as a table that lists benefit categories alongside the associated member costs, making it easy to scan and compare services at a glance. It is one of the first documents you should review when evaluating or enrolling in a plan.

The SB is not a complete list of every covered service, exclusion, or limitation. For the full details of your plan's coverage rules and member responsibilities, please refer to the Evidence of Coverage (EOC), which serves as the comprehensive plan contract. If there is ever a conflict between the SB and the EOC, the EOC takes precedence.

Troy Medicare is required by the Centers for Medicare & Medicaid Services (CMS) to provide this document to all current and prospective members. A new Summary of Benefits is published each plan year to reflect any updates in benefits, costs, or covered services effective January 1.

The Summary of Benefits covers the key benefit categories of your Troy Medicare plan, including:

• Monthly plan premium — the amount you pay each month to be enrolled in the plan.
• Deductibles — the amount you must pay out of pocket before the plan begins to cover certain services.
• Maximum out-of-pocket costs — the most you will pay for covered services in a plan year.
• Doctor and specialist visits — copays for primary care, specialists, and telehealth visits.
• Preventive care — coverage for screenings, vaccines, and annual wellness visits.
• Hospital and emergency care — costs for inpatient stays, emergency room visits, and urgent care.
• Prescription drug coverage — cost-sharing by drug tier, including preferred and non-preferred pharmacies.
• Additional benefits — supplemental benefits such as dental, vision, hearing, fitness, and over-the-counter allowances.

Who Should Use It

• Members

  Current and prospective members who want a quick reference for plan benefits, copays, and covered services. The SB is especially helpful when comparing Troy Medicare plans, checking costs before a visit, or reviewing what supplemental benefits are included in your plan.

• Brokers

  Licensed agents comparing plan options or presenting benefit details to prospective enrollees. The SB provides a convenient, CMS-approved format for walking beneficiaries through their coverage options during enrollment periods.

• Providers

  Healthcare providers verifying covered services and member cost-sharing for treatment planning. Providers may reference the SB to get a quick understanding of a patient's plan before consulting the full Evidence of Coverage for more detailed rules.

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. Review the benefit categories listed in the table to understand what services are covered under your plan.
3. Check the cost-sharing column to see your expected copays or coinsurance for each service, including whether the service requires a referral or prior authorization.
4. Compare plans side by side if you are deciding between the Troy Medicare HMO and D-SNP options — download both documents and review the differences in benefits and costs.
5. For complete coverage details, exclusions, and plan rules, refer to the Evidence of Coverage.
6. Contact Troy Medicare at 1-888-494-TROY (8769) if you have questions about a specific benefit or service. Our member services team is available to help you understand your coverage.

The Summary of Benefits is updated each year. If plan benefits, costs, or covered services change for the upcoming plan year, the new SB will reflect those changes. You will also receive an Annual Notice of Change (ANOC) that highlights what is different from the current year before the new plan year begins.

If you need a printed copy of the Summary of Benefits, you can call Troy Medicare to request one at no cost. You can also download and print the PDF from this page at any time.