Policy Forms


State Policies Available
Arizona EPIC_AZ_PlanA_1710, EPIC_AZ_PlanC_1710, EPIC_AZ_PlanF_1710, EPIC_AZ_PlanG_1710, EPIC_AZ_PlanN_1710.
Arkansas E_AR_A_2111, E_AR_C_2111, E_AR_F_2111, E_AR_G_2111, E_AR_N_2111.
Colorado EPIC_PlanA_1710 CO, EPIC_PlanC_1710 CO, EPIC_PlanF_1710 CO, EPIC_PlanG_1710 CO, EPIC_Plan N_1710 CO.
Delaware W_DE_A_2111, W_DE_C_2111, W_DE_F_2111, W_DE_G_2111, W_DE_N_2111.
Florida EPIC_FL_PlanA_1710, EPIC_FL_PlanC_1710, EPIC_FL_PlanF_1710,EPIC_FL_PlanG_1710, EPIC_FL_PlanK_1710, EPIC_FL_PlanL_1710, EPIC_FL_PlanN_1710.
Illinois WPS_IL_PlanA_1710, WPS_IL_PlanC_1710, WPS_IL_PlanF_1710, WPS_IL_PlanG_1710, WPS_IL_PlanN_1710.
Indiana WPS_PlanA_1710, WPS_PlanC_1710, WPS_PlanF_1710, WPS_PlanG_1710, WPS_PlanN_1710.
Iowa Plan A-28145-088-1601, Plan C-28146-088-1601, Plan F-28147-088-1601, Plan G-30877-088-1711, Plan M-28148-088-1601, Plan N-28149-088-1601.
Kansas EPIC_KS_PlanA_1710, EPIC_KS_PlanC_1710, EPIC_KS_PlanF_1710, EPIC_KS_PlanG_1710, EPIC_KS_PlanN_1710.
Kentucky E_KY_A_2111, E_ KY_C_2111, E_ KY_F_2111, E_ KY_G_2111, E_KY_N_2111.
Maryland E_MD_A_2111, E_MD_F_2111, E_MD_G_2111, E_MD_N_2111.
Michigan Plan A –28140-051-160, Plan C –28141-051-1601, Plan F –28142-051-1601, Plan G –28143-051-1601, Plan N –28144-051-1601.
Missouri EPIC_PlanA_1710, EPIC_PlanC_1710, EPIC_PlanF_1710, EPIC_PlanG_1710, EPIC_PlanN_1710.
Montana W_MT_A_2111, W_MT_C_2111, W_MT_F_2111, W_MT_G_2111, W_MT_N_2111.
Nebraska EPIC_NE_PlanA_1711, EPIC_NE_PlanC_1711, EPIC_NE_PlanF_1711, EPIC_NE_PlanG_1711, EPIC_NE_PlanN_1711.
Nevada E_NV_A_2111, E_NV_C_2111, E_NV_F_2111, E_NV_G_2111, E_NV_N_2111.
North Dakota E_ND_A_2111, E_ND_C_2111, E_ND_F_2111, E_ND_G_2111, E_ND_N_2111.
Ohio WPS_OH_PlanA_1710, WPS_OH_PlanC_1710, WPS_OH_PlanF_1710, WPS_OH_PlanG_1710, WPS_OH_PlanN_1710.
Oklahoma EPIC_OK_PlanA_1710, EPIC_OK_PlanC_1710, EPIC_OK_PlanF_1710, EPIC_OK_PlanG_1710, EPIC_OK_PlanN_1710.
Pennsylvania PA_PlanA_1710, PA_PlanB_1710, PA_PlanC_1710, PA_PlanF_1710, PA_PlanG_1710, PA_PlanN_1710.
South Dakota E_SD_A_2111, E_SD_C_2111, E_SD_F_2111, E_SD_G_2111, E_SD_N_2111.
Tennessee EPIC_TN_PlanA_1710, EPIC_TN_PlanC_1710, EPIC_TN_PlanF_1710, EPIC_TN_PlanG_1710, EPIC_TN_PlanN_1710.
Texas EPIC_TX_PlanA_1710, EPIC_TX_PlanC_1710, EPIC_TX_PlanF_1710, EPIC_TX_PlanG_1710, EPIC_TX_PlanN_1710.
Vermont W_VT_A_2111, W_VT_C_2111, W_VT_F_2111, W_VT_G_2111, W_VT_N_2111.
Virginia E_VA_A_2111, E_VA_C_2111, E_VA_F_2111, E_VA_G_2111, E_VA_N_2111.
West Virginia E_WV_A_2111, E_WV_C_2111, E_WV_F_2111, E_WV_G_2111, E_WV_N_2111.
Wisconsin Basic Plan - 28132-051-1601, Part A Deductible Rider - 28133-051-1601, 28134-051-1601, Part B Excess Rider - 28137-051-1601, Home Health Rider - 28138-051-1601, Foreign Travel Rider - 28139-051-1701, Part B Coinsurance / Copayment Rider - 28136-051-1601, Part B Deductible Rider - 28135-051-1601 (only available to those eligible for Medicare prior to 1/1/2020).