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65Plus Plan Documents

Agent of Record

Members can fill out our Agent of Record form to change their insurance representative.


Use our handy Countdown to Medicare Checklist to prepare for your transition to Medicare coverage. The Medicare Checklist is available here

Bank Authorization to Withdraw Funds

Save yourself the trouble of mailing in checks for your 65Plus premium payments!

Complete the Bank Authorization to Withdraw Funds form to have payments automatically deducted from either your checking or savings account. Mail the Bank Authorization to Withdraw Funds form to Health Tradition and automatic payments will start the following month. Monthly automatic bank withdrawals are made on the 5th of the month.

  • For checking accounts, attach a voided check.

  • For savings accounts, please attach a letter from your bank including the routing number and savings account number.

Cancellation Form

A member may terminate their 65Plus coverage by written request or by filling out the 65Plus Cancellation of Coverage form. Written requests or completed cancellation forms should be sent to Health Tradition Health Plan.

Health Tradition cannot accept verbal requests to cancel coverage. Enrollment into another Medicare Supplement or Medicare Advantage plan does not automatically cancel your coverage with 65Plus.

Change Plan Form

A member can change their 65Plus plan option by filling out the 65Plus Plan Change Form or by written request. Completed Plan Change Forms should be sent to Health Tradition Health Plan. 

Health Tradition cannot accept verbal requests to change plan options.

Complaint and Grievance Forms

If you have questions or complaints about any aspect of Health Tradition 65Plus you may try and resolve the problem by directly contacting our Customer Service team at 877-823-1823 (toll-free) for assistance. If the complaint cannot be resolved informally, you or an authorized representative have the right to appeal the Plan’s decision by filing a formal written Grievance. You or your authorized representative may submit a Grievance along with copies of any supporting documents to Health Tradition Health Plan.

Creditable Coverage Disclosure Notice

This disclosure notice applies to 65Plus members with group #65000-003 and #65000-006 regarding their current 65Plus prescription drug coverage and Medicare. The 65Plus prescription drug benefit pays 80% of charges for outpatient prescription drugs after the $6,250 deductible has been met for that calendar year. Outpatient prescription drugs must be received at a participating pharmacy in order to apply the out-of-pocket cost toward the $6,250 deductible.

Health Tradition Health Plan has determined that the prescription drug coverage offered by 65Plus is, on average for all plan participants, not expected to pay out as much as standard Medicare prescription drug coverage (Part D) pays. Therefore, it is considered Non-Creditable Coverage. Learn more at Non-Creditable Drug Coverage Notice.

Consent Forms


Use our Find-a-Doctor tool or download our printable provider directories below:

Health Insurance 101

Download the Health Insurance 101 resource document explaining many of the concepts and terms used in your Medicare plan documents.

Member Handbook

Get familiar with your handbook for an overview of your 65Plus plan, details about your covered benefits, exclusions and limitations. For full detailed information, reference your HT 65Plus Policy document.

View or download your 65Plus Member Handbook now.

Outline of Coverage

The 65Plus Outline of Coverage summarizes the plan's most important features. This document along with your policy document work together to describe covered services provided by 65Plus.

Wisconsin Guide to Health Insurance for People with Medicare

This Wisconsin Guide to Health Insurance for People with Medicare gives an overview of the Medicare program and the health and prescription drug insurance available to those on Medicare in Wisconsin. It also includes a helpful glossary of terms and acronyms that are important in understanding the Medicare program.


This is an advertisement for insurance. In offering Medicare Select insurance, neither Health Tradition Health Plan nor its agents are connected with Medicare.

HT MC 3028