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Plan Documents and Information

Welcome to Aspirus Health Plan. We’ve teamed up with Aspirus Health to help you get quality care and excellent service. We’re committed to serving central Wisconsin, and we’re always here to support you.

Need help? Call us at 715-631-7411 or Toll-free at 1-855-931-4850 (TTY users call 1-855-931-4852), 8 am – 8 pm, seven days a week.

2022 Plans

Medicare Plans

Formulary (list of covered drugs)
Dental Plan Overview (PDF)
Dental Enrollment Form (external link)
Health and Wellness Program
Gender Identity Form (PDF)
Quality Highlights

Member Release of Information Form (PDF)
Statement of Representative Form (PDF)
Power of Attorney short form (PDF, external link)
Member reimbursement form (PDF)
Mental health and substance use disorder

Automatic Payment Form (PDF)
Search Preferred Pharmacy Network
Medication Therapy Management (MTM) for plans with a Part D component

Essential Rx (PPO)

Annual Notice of Changes (PDF)
Evidence of Coverage (PDF)
Summary of Benefits (PDF)

Provider and Pharmacy Directory (PDF)
Primary Care Clinic List (PDF)
TruHearing Hearing Aid Benefit Information (PDF)

Plan Rating Information (PDF)

Elite Rx (PPO)

Annual Notice of Changes (PDF)
Evidence of Coverage (PDF)
Summary of Benefits (PDF)

Provider and Pharmacy Directory (PDF)
Primary Care Clinic List (PDF)
TruHearing Hearing Aid Benefit Information (PDF)

Plan Rating Information (PDF)

Elite (PPO)

Annual Notice of Changes (PDF)
Evidence of Coverage (PDF)
Summary of Benefits (PDF)

Provider Directory (PDF)
Primary Care Clinic List (PDF)
TruHearing Hearing Aid Benefit Information (PDF)

Plan Rating Information (PDF)

Additional documents

Instructions for Appointing a Representative (PDF)

2021 Plans

Medicare Plans

Formulary (list of covered drugs)
Dental Plan Overview (PDF)
Dental Enrollment Form (PDF)
Health and Wellness Program
Gender Identity Form (PDF)
Quality Highlights

Member Release of Information Form (PDF)
Statement of Representative Form (PDF)
Power of Attorney short form (PDF, external link)
Member reimbursement form (PDF)
Mental health and substance use disorder

Automatic Payment Form (PDF)
Medication Therapy Management (MTM) for plans with a Part D component

Essential Rx (PPO)

Evidence of Coverage (PDF)
Summary of Benefits (PDF)

Provider and Pharmacy Directory (PDF)
Primary Care Clinic List (PDF)
TruHearing Hearing Aid Benefit Information (PDF)

Elite Rx (PPO)

Evidence of Coverage (PDF)
Summary of Benefits (PDF)

Provider and Pharmacy Directory (PDF)
Primary Care Clinic List (PDF)
TruHearing Hearing Aid Benefit Information (PDF)

Elite (PPO)

Evidence of Coverage (PDF)
Summary of Benefits (PDF)

Provider Directory (PDF)
Primary Care Clinic List (PDF)
TruHearing Hearing Aid Benefit Information (PDF)

Additional documents

Services requiring authorization (PDF)
Addendum to 2021  Summary of Benefits (PDF)
Instructions for Appointing a Representative (PDF)

H6874_50262_092021
10/2021

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