Request hearing health plan information

Please complete the form and our EPIC Sales Team (sales@epichearing.com) will follow up with you.

Contact Name

Phone Number

Contact Email

Group Name

Requested Effective Date

Number of eligible Plan Participants/Members

Company State

Company Zip Code

Business Type or SIC Code

Current Hearing Carrier

Current Hearing Benefits

Upload Attachments(Optional)

Hearing Health Preferred Plans

Plan Options	Description	Cost to plan sponser
Fully Insured (Voluntary or Employer Paid	Fully Insured (Voluntary or Employer Paid	$$
ASO	Group sponsored coverag including benefit allowances of your choice	$-$$$
Co-Pay (PMPM)	ASO benefit paired with a PMPM fee with access to low-priced formulary	$-$$$
Discount Only	Access to discounted pricing formulary, saving membersup to 50% MSRP	$

Plan Type

Member Type Looking for Coverage