Medicare Reference Documents

Below are some resources that you may need specifically for Oregon. These are documents that may be helpful at different times during your membership: 

Summary of Benefits

This booklet gives you a summary of costs and coverage in your plan. The complete list of services, limitations and exclusions are included in the Evidence of Coverage.

  • Trillium Advantage Pioneer Rx (PPO) - 2017
  • Trillium Advantage Dual (HMO SNP) - 2017
  • Trillium Advantage TLC ISNP (HMO SNP) - 2017
  • Trillium Advantage TLC Community ISNP (HMO SNP) - 2017

Evidence of Coverage

  • This will provide you with details on Medicare coverage and additional Trillium Advantage benefits.
  • Out-of-Network Coverage Rules: Chapter 3
  • Exclusions & Limitations: Chapter 4, Section 3
  • Prior Authorization: Chapter 3 (medical) and Chapter 5 (prescription drug)
  • Appeals & Grievances: Chapter 9
  • Disenrollment: Chapter 10
  • Trillium Advantage Pioneer Rx (PPO) - 2017
  • Trillium Advantage Dual (HMO SNP) - 2017
  • Trillium Advantage TLC ISNP (HMO SNP) - 2017
  • Trillium Advantage TLC Community ISNP (HMO SNP) - 2017

Annual Notice of Change

If you are already a member of Trillium Advantage, this booklet will tell you about changes to your plan's costs and benefits for the coming year.

  • Trillium Advantage Pioneer Rx (PPO) - 2017
  • Trillium Advantage Dual (HMO SNP) - 2017
  • Trillium Advantage TLC ISNP (HMO SNP) - 2017
  • Trillium Advantage TLC Community ISNP (HMO SNP) - 2017

Comprehensive Formulary

This is the complete list of prescription drugs covered by Trillium Advantage.

  • Trillium Advantage Pioneer Rx (PPO) - 2017
  • Trillium Advantage Dual (HMO SNP) - 2017
  • Trillium Advantage TLC ISNP (HMO SNP) - 2017
  • Trillium Advantage TLC Community ISNP (HMO SNP) - 2017

Prescription Drug Mail Order Form

Use this order form to enroll and receive prescription drugs by mail.

Other Resources

  • Provider & Pharmacy Directory Information -  PPO | HMO SNP
    • This is an introduction to the provider and pharmacy directory, including an explanation of the provider symbols found in the directory. 
  • Appointing a Representative
    • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
       
  • Multi-language Interpreter Services - 2017
    • We have free interpreters to answer questions in multiple languages: 1-844-867-1156.

By clicking on the links below you will be leaving the Trillium Advantage website.

Call Member Services at 1-844-867-1156 for help if you have questions. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m On weekends and holidays, an automated system will handle your call.


Last Updated: 04/07/2017
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