Individual & Family Plan Application Form

Covered CA On Exchange

If you believe you qualify for a subsidy based on your income, you’ll be able to chose between our Platinum90 HMO, Gold80 HMO, Silver94 HMO, Silver87 HMO, Silver73 HMO, Silver70 HMO, Bronze60 HMO, Bronze60 HDHP HMO Health Plans.

If you used our Shop & Compare Tool and were estimated you qualify for a subsidy based on your income, use this form.

If you’re unsure or want to learn more about our One Medical program?
Contact our Sales team.

If you are new to Covered California or already have a Covered CA account, click Apply Online.

Off Exchange

If you are applying for either the Jade15 HMO Platinum, Amber50 HMO Silver, Platinum90 HMO, Gold80 HMO, Silver70 HMO, Bronze60 HMO, Bronze60 HDHP HMO Health Plan, and you do not believe you qualify for a subsidy based on your income, fill out this form.

If you used our Shop & Compare Tool and were not told you qualify for a subsidy based on your income, use this form.

If you’re unsure or want to learn more about our One Medical program?
Contact our Sales team.