A non-government entity
Troy Medicare (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Troy Medicare (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Troy Medicare (HMO) in 2025, please refer to our full plan details page.
Troy Medicare (HMO) is a HMO plan offered by Troy Holdings, Inc. available for enrollment in 2025 to people living in Piedmont and Mountain Regions. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Troy Medicare (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Troy Medicare (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Troy Medicare (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3950.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Troy Medicare (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay for each prescription, which varies depending on the drug tier and pharmacy type. For example, preferred generic drugs have a $5 copay at a preferred pharmacy, while standard generic drugs have a $25 copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. However, if you qualify for the low-income subsidy, your premium may be reduced.
Additional Benefits
The Troy Medicare (HMO) plan offers a variety of benefits with varying costs. Inpatient hospital stays have a $400 copay for the first five days, and then no copay for the following days, while outpatient services, like hospital visits, have a copay of $350. Emergency services have a $120 copay, and ambulance services have a $255 copay for ground transport. This plan covers primary care, including specialist visits, with copays ranging from $20 to $45, and preventative services such as annual physical exams. Hearing and vision services include routine exams with no copay, and dental services are covered with 20% coinsurance. The plan also covers home health services with no copay, and skilled nursing facility stays with no copay for the first 20 days.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with a $400 copay for days 1-5, and no copay for days 6-90. Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are covered, with 5 additional days per benefit period. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services, are covered under the Troy Medicare (HMO) plan. Outpatient Hospital Services, Observation Services, and Ambulatory Surgical Center (ASC) Services each have a $350 copay, while Individual and Group Sessions for Outpatient Substance Abuse have a copay between $45 and $45.
Partial Hospitalization See details
Partial Hospitalization is covered by the Troy Medicare (HMO) plan, but requires prior authorization. You will have an $85 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services. Ground ambulance services have a $255 copay, while air ambulance services have a 20% coinsurance; transportation services to a plan-approved health-related location are covered for up to 24 one-way trips per year, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services with the Troy Medicare (HMO) plan include a $120 copay, and no coinsurance. Urgently Needed Services have no copay and no coinsurance, but Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are not covered.
Primary Care See details
The Troy Medicare (HMO) plan covers Primary Care Physician Services, Chiropractic Services (with a $20 copay), Occupational Therapy Services (with a $20 copay), Physician Specialist Services, Mental Health Specialty Services (with a $45 copay for individual and group sessions), Other Health Care Professional (with a $45 copay), Psychiatric Services (with a $45 copay for individual and group sessions), Physical Therapy and Speech-Language Pathology Services (with a $20 copay), Additional Telehealth Benefits, and Opioid Treatment Program Services. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Troy Medicare (HMO) plan covers preventive services, including an annual physical exam, health education, re-admission prevention, fitness benefit, enhanced disease management, kidney disease education services, and other preventive services such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit. In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams and fitting/evaluation for hearing aids have no copay, and prescription hearing aids are covered under the Hearing Exams Category - 18a. Prescription hearing aids (all types) are covered for 2 visits every two years. OTC hearing aids, prescription hearing aids - inner ear, prescription hearing aids - outer ear, and prescription hearing aids - over the ear are not covered.
Vision Services See details
Vision services include routine eye exams, eyewear, contact lenses, and eyeglasses (lenses and frames). Routine eye exams are covered once per year, with a maximum benefit of $50, and no copay or coinsurance. Eyewear is covered with a combined maximum benefit of $200 per year, and no copay or coinsurance. Contact lenses and eyeglasses (lenses and frames) are covered once per year, and have no copay or coinsurance. However, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Troy Medicare (HMO) plan covers dental services with 20% coinsurance. Oral exams are covered up to 2 visits per year, dental x-rays are covered with limitations, prophylaxis (cleaning) is covered up to 2 times per year, and fluoride treatment is covered once per year. Other services, such as maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Troy Medicare (HMO) plan, including Medicare Part B Insulin Drugs with a copay between $0 and $35. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Troy Medicare (HMO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts with a 20% coinsurance, but Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a copay of $10, and Diagnostic Radiological Services with a copay of up to $50. Outpatient X-Ray Services have a $10 copay, and Therapeutic Radiological Services have a coinsurance of 20%. Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by the Troy Medicare (HMO) plan with no copay and no coinsurance, but require authorization. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Troy Medicare (HMO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Troy Medicare (HMO) plan, with a $0 copay for days 1-20 and a $214 copay for days 21-100. Additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services with the Troy Medicare (HMO) plan includes coverage for over-the-counter (OTC) items with a maximum plan benefit of $20.00 every month, but acupuncture, meal benefits, dual eligible SNPs with highly integrated services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, case management (long term care), institution for mental disease services for individuals 65 or older, services in an intermediate care facility for individuals with intellectual disabilities, case management, tobacco cessation counseling for pregnant women, freestanding birth center services, respiratory care services, family planning services, nursing home services, home and community based services, personal care services, and self-directed personal assistance services are not covered.
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