• Medication Assistance Program Client Attestation Form (CDPH 8723) (PDF)​ with all applicable boxes checked and required fields (i.e., family size)

• Current health insurance plan billing statement(s) for medical, dental, and/or vision combination plans , as applicable, and/or letter from your insurance plan with the 2024 premium amount

• Medication Assistance Program Fax Coversheet (CDPH8730) (PDF)​, if faxing

Within two business days of renewing your insurance coverage through an off-exchange health plan, you must submit your health plan documents to your local Medication Assistance Program Enrollment Worker, or directly to the CDPH Medication Assistance Program.

Please note: Clients who enroll in an off-exchange health plan must submit documents to the CDPH Medication Assistance Program by 

November 30, 2023 a January 1, 2024 start date. If you submit documents to CDPH after this date, it is recommended you make the initial premium payment to secure your health insurance. Otherwise, you may not receive a January 1, 2024 effective date.

How to Submit Documents

Work with your local Medication Assistance Program Enrollment Worker to submit documents electronically (this is the fastest and preferred method), or  

Email, fax, or mail the documents to CDPH: 

• Email:               CDPHMedAssistFax@cdph.ca.gov
  
• Fax:                   (844) 421-8008
• Mail:                  CDPH – Insurance Assistance
                              P.O. Box 997426, MS 7704
                              Sacramento, CA 95899
  
  

Open Enrollment Dates 

• November 1, 2023 to January 31, 2024

Tax Penalty

Having health coverage is the law. If you don’t have it, you may have to pay a penalty to the California Franchise Tax Board. The penalty for not having coverage the entire year will be at least *$850 per adult, and $425 per dependent child under 18 in the household, when you file your 2023 state income tax return in 2024. 

The penalty will be applied by the California Franchise Tax Board. ​For additional information or questions regarding this tax penalty, please visit the State of California State Franchise Tax Board and use their Penalty Estimator Tool, or contact your tax advisor.

​Questions?

For questions about Medication Assistance Program eligibility and enrollment, please call: 

• Your local Medication Assistance Program Enrollment Worker, or 
• The Medication Assistance Program Client Services call center at (844) 421-7050. Client Services staff are available Monday–Friday, 8 A.M.–5 P.M. (excluding holidays).