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< Edit Your Plan Option

Help us direct you to the correct page by selecting an option below:

Edit Your Plan Option

I would like to change my selected plan.

Edit Option

Start Over Completely

I would like to start over and explore other plans.

Start Over

Submitting Your Application

We can only accept your application during an annual open enrollment period or within 60 days of a qualifying life event. Some life events allow you to apply 60 days prior to the event. See the plan’s policy document for more information.
We cannot process your application until we receive your full first month’s premium payment.
Please complete, sign, and date your application. All adults, including dependents age 18 and over, must sign. If the primary applicant is under age 18, a guarantor, parent, or legal guardian also must sign.
See the Coverage Start Date Section for information on when your coverage starts. Please allow five to seven business days to process your application. Do not cancel any existing coverage until we issue your policy, you accept it, and your first payment has been processed.
This application will become a part of your contract. Please make a copy for your personal records.

Save and Exit

If you want to save your information, please complete all required fields on this page and select the Continue button. Then you can exit your application by closing your browser.

To exit without saving, simply close your browser.

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1-800-670-5935
Monday - Thursday 8 a.m. to 5 p.m. CST and Fridays 9 a.m. to 5 p.m. CST

TTY users, please call 711 and ask for the number listed above.

Email

[email protected]

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Medica Corporate Headquarters
401 Carlson Parkway
Minnetonka, MN 55305
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