Policy Forms

Medicare supplement policy and rider form numbers for WPS Health plans, listed by state.

The form numbers below identify the Medicare supplement policies and riders approved for use in each state. Refer to your policy or certificate for the specific form number that applies to your coverage.

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).