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.
If you are interested in enrolling in Troy Medicare for Dual-eligible Beneficiaries (D-SNP), you can do so online by clicking on the Enroll button or you can call us at 1-888-494-TROY (8769) TTY:711
Summary of Benefits
- Here is the booklet with the 2024 Summary of Benefits
- Here is the booklet with the 2025 Summary of Benefits
Secure Member Portal
Our secure Troy Medicare member portal has resources to help you manage your plan with a personalized view of your health benefits. By clicking on the link below, you can register for a Troy Medicare member portal account for 24/7 access to review plan materials, view your personal information, download forms, and more.
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.
Prior Authorizations
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.
Referrals
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.
Extra Benefits
OTC Benefits
We have partnered with Solutran to provide access to Medicare covered Over-the-Counter products.
2024: OTC Benefits up to $1,300 per year
2025: OTC Benefits up to $1,380 per year
Hearing Benefits
We have partnered with Hearing Care Solutions to provide hearing exams and if needed, hearing aids.
Read More about the Hearing Benefits
2024: Hearing benefits up to $750 per year
2025: Hearing benefits up to $825 per year
Dental Benefits
We have partnered with Liberty Dental to provide preventive and comprehensive dental services to our members.
Read the Dental Benefits Brochure
Vision Benefits
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.
Telehealth Benefit
You’ve got options when it comes to your care. When you don’t feel well, the last thing you want to do is go anywhere. That’s why we try to make things easier by offering telehealth visits. Whether you have the flu or allergies or you are looking for confidential support for depression or substance use, you can talk with a provider online by phone or video, in the comfort of your home. All you need is your phone, tablet or computer.
With your Troy Medicare plan, you have benefit coverage for free telehealth visits when:
- You use a PCP or Specialist in the Troy network who offers telehealth services
- You coordinate a telehealth visit with one of our Troy Care Management team
Ask your provider if they offer telehealth visits or call our Care Management department at (910)-878-2730 for assistance.
In addition, Troy has partnered with Sesame Care to provide you with even greater access to telehealth services.
- Primary care
- Same-day urgent care
- Prescription refills
- Acute and chronic consults
- Skin Consults
Here’s how you schedule a Sesame telehealth appointment:
- Call 877-947-6411 to reach Sesame’s Customer Service team. The customer service team is available 8 AM - 8 PM EST Monday-Friday and 9 AM - 6 PM on the weekends. If you reach the voicemail, follow the instructions and leave a message and someone will get back to you shortly.
- The customer Service Team Member will help you schedule and book an appointment at a time that works best for you.
- You will receive an email and a text message confirming the appointment and instructions to join the telehealth visit.
- At the time of your appointment, join the meeting on your phone, tablet, or laptop or the provider will call you to get the care you need!
Troy Medicare is committed to helping you get the care you need outside of your provider’s office with telehealth visits. Ask your provider if they offer telehealth visits or call our Care Management department at (910)-878-2730 for assistance. You can also call our Member Services Department at 888-494-8769 for more information. TTY users call 711.
If you are experiencing a medical emergency, you should seek appropriate emergency medical assistance such as calling 911.
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.