Plan Materials

Brochures

• 2025 – Plan choices by location – English (PDF) (IFP on- and off-exchange)
• 2025 – IEX Sales Brochure – English (PDF)
• 2025 – IEX Sales Brochure – En Español (Spanish) (PDF)
• 2025 – IEX Ambetter HMO Sales Brochure – English (PDF)
• 2025 – IEX Ambetter HMO Sales Brochure – En Español (Spanish) (PDF)
• 2025 – IEX Ambetter PPO Sales Brochure – English (PDF)
• 2025 – IEX Ambetter PPO Sales Brochure – En Español (Spanish) (PDF)

2025 Disclosures

Ambetter HMO

• 2025 – Ambetter HMO Disclosure for Covered California – English (PDF)

Ambetter PPO

• 2025 – Ambetter PPO Disclosure for Covered California – English (PDF)

2025 Pediatric Dental and Vision

• 2025 – Pediatric Dental and Vision (Ambetter HMO) – English (PDF)
• 2025 – Pediatric Dental and Vision (Ambetter PPO) – English (PDF)

Brochures

• 2025 – Plan choices by location – English (PDF) (IFP on- and off-exchange)
• 2025 – IFP Sales Brochure – English (PDF)
• 2025 – IFP Sales Brochure – En Español (Spanish) (PDF)

Enrollment Tools

• 2025 Desk Topper – English (PDF)
• 2025 Rate Guide – English (PDF)

Individual & Family Plans (IFP) Enrollment Applications – Effective January 1, 2025

Ambetter HMO

• 2025 – Ambetter HMO Enrollment Application – English (PDF)
• 2025 – Ambetter HMO Enrollment Application – En Español (Spanish) (PDF)
• 2025 – Ambetter HMO Enrollment Application – Chinese (PDF)
• 2025 – Ambetter HMO Enrollment Application – Korean (PDF)

Ambetter PPO

• 2025 – Ambetter PPO Enrollment Application – English (PDF)
• 2025 – Ambetter PPO Enrollment Application – En Español (Spanish) (PDF)
• 2025 – Ambetter PPO Enrollment Application – Chinese (PDF)
• 2025 – Ambetter PPO Enrollment Application – Korean (PDF)

2025 Disclosures

Ambetter HMO

• 2025 – Ambetter HMO Disclosure – English (PDF)

Ambetter PPO

• 2025 – Ambetter PPO Disclosure – English (PDF)

Dental and Vision

• 2025 – Adult Dental and Vision Coverage with HMO Health Plans (PDF)
• 2025 – Adult Dental and Vision Coverage with PPO Health Plans (PDF)
• 2025 – Pediatric Dental and Vision (Ambetter HMO) (PDF)
• 2025 – Pediatric Dental and Vision (Ambetter PPO) (PDF)

Ambetter HMO

• Platinum 90 Ambetter HMO Plan Overview – English (PDF)
• Platinum 90 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Gold 80 Ambetter HMO Plan Overview – English (PDF)
• Gold 80 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Silver 70 Ambetter HMO Plan Overview – English (PDF)
• Silver 70 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Bronze 60 Ambetter HMO Plan Overview – English (PDF)
• Bronze 60 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Minimum Coverage Ambetter HMO Plan Overview – English (PDF)
• Minimum Coverage Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Silver 73 Ambetter HMO Plan Overview – English (PDF)
• Silver 73 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Silver 87 Ambetter HMO Plan Overview – English (PDF)
• Silver 87 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Silver 94 Ambetter HMO Plan Overview – English (PDF)
• Silver 94 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)

Ambetter PPO

• Platinum 90 Ambetter PPO Plan Overview – English (PDF)
• Platinum 90 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Gold 80 Ambetter PPO Plan Overview – English (PDF)
• Gold 80 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Silver 70 Ambetter PPO Plan Overview – English (PDF)
• Silver 70 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Bronze 60 Ambetter PPO Plan Overview – English (PDF)
• Bronze 60 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Bronze 60 HDHP Ambetter PPO Plan Overview – English (PDF)
• Bronze 60 HDHP Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Minimum Coverage Ambetter PPO Plan Overview – English (PDF)
• Minimum Coverage Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Silver 73 Ambetter PPO Plan Overview – English (PDF)
• Silver 73 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Silver 87 Ambetter PPO Plan Overview – English (PDF)
• Silver 87 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Silver 94 Ambetter PPO Plan Overview – English (PDF)
• Silver 94 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)

Ambetter HMO

• Platinum 90 Ambetter HMO Plan Overview – English (PDF)
• Platinum 90 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Gold 80 Ambetter HMO Plan Overview – English (PDF)
• Gold 80 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Silver 70 Ambetter HMO Plan Overview – English (PDF)
• Silver 70 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Bronze 60 Ambetter HMO Plan Overview – English (PDF)
• Bronze 60 Ambetter HMO Plan Overview – En Español (Spanish) (PDF)
• Minimum Coverage Ambetter HMO Plan Overview – English (PDF)
• Minimum Coverage Ambetter HMO Plan Overview – En Español (Spanish) (PDF)

Ambetter PPO

• Platinum 90 Ambetter PPO Plan Overview – English (PDF)
• Platinum 90 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Gold 80 Ambetter PPO Plan Overview – English (PDF)
• Gold 80 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Silver 70 Ambetter PPO Plan Overview – English (PDF)
• Silver 70 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Bronze 60 Ambetter PPO Plan Overview – English (PDF)
• Bronze 60 Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Bronze 60 HDHP Ambetter PPO Plan Overview – English (PDF)
• Bronze 60 HDHP Ambetter PPO Plan Overview – En Español (Spanish) (PDF)
• Minimum Coverage Ambetter PPO Plan Overview – English (PDF)
• Minimum Coverage Ambetter PPO Plan Overview – En Español (Spanish) (PDF)

HMO

• 2025 – Platinum 90 Ambetter HMO SBC – English (PDF)
• 2025 – Gold 80 Ambetter HMO SBC – English (PDF)
• 2025 – Minimum Coverage Ambetter HMO SBC – English (PDF)
• 2025 – Bronze 60 Ambetter HMO SBC – English (PDF)
• 2025 – Silver 70 Ambetter HMO SBC – English (PDF)
• 2025 – Silver 73 Ambetter HMO SBC – English (PDF)
• 2025 – Silver 87 Ambetter HMO SBC – English (PDF)
• 2025 – Silver 94 Ambetter HMO SBC – English (PDF)

PPO

• 2025 – Silver 70 Ambetter PPO SBC – English (PDF)
• 2025 – Silver 73 Ambetter PPO SBC – English (PDF)
• 2025 – Silver 87 Ambetter PPO SBC – English (PDF)
• 2025 – Silver 94 Ambetter PPO SBC – English (PDF)
• 2025 – Gold 80 Ambetter PPO SBC – English (PDF)
• 2025 – Platinum 90 Ambetter PPO SBC – English (PDF)
• 2025 – Bronze 60 Ambetter PPO SBC – English (PDF)
• 2025 – Bronze 60 HDHP Ambetter PPO SBC – English (PDF)
• 2025 – Minimum Coverage Ambetter PPO SBC – English (PDF)

HMO

• 2025 – Platinum 90 Ambetter HMO SBC – English (PDF)
• 2025 – Gold 80 Ambetter HMO SBC – English (PDF)
• 2025 – Silver 70 Off Exchange Ambetter HMO SBC – English (PDF)
• 2025 – Minimum Coverage Ambetter HMO SBC – English (PDF)
• 2025 – Bronze 60 Ambetter HMO SBC – English (PDF)

Ambetter PPO

• 2025 – Silver 70 Off Exchange Ambetter PPO SBC – English (PDF)
• 2025 – Gold 80 Ambetter PPO SBC – English (PDF)
• 2025 – Platinum 90 Ambetter PPO SBC – English (PDF)
• 2025 – Bronze 60 Ambetter PPO SBC – English (PDF)
• 2025 – Bronze 60 HDHP Ambetter PPO SBC – English (PDF)
• 2025 – Minimum Coverage Ambetter PPO SBC – English (PDF)

HMO AI-AN

• 2025 – Platinum 90 Ambetter HMO AI-AN SBC – English (PDF)
• 2025 – Gold 80 Ambetter HMO AI-AN SBC – English (PDF)
• 2025 – Silver 70 Ambetter HMO AI-AN SBC – English (PDF)
• 2025 – Bronze 60 Ambetter Limited Cost Share HMO AI-AN SBC – English (PDF)
• 2025 – Bronze 60 Ambetter $0 Cost Share HMO AI-AN SBC – English (PDF)
• 2025 – $0 Cost Share Ambetter HMO AI-AN SBC – English (PDF)

PPO AI-AN

• 2025 – Silver 70 Ambetter PPO AI-AN SBC – English (PDF)
• 2025 – Gold 80 Ambetter PPO AI-AN SBC – English (PDF)
• 2025 – Platinum 90 Ambetter PPO AI-AN SBC – English (PDF)
• 2025 – Bronze 60 Ambetter PPO AI-AN SBC – English (PDF)
• 2025 – Bronze 60 HDHP Ambetter PPO AI-AN SBC – English (PDF)
• 2025 – $0 Cost Share Ambetter PPO AI-AN SBC – English (PDF)

HMO

• 2024 – Platinum 90 Ambetter HMO SBC – English (PDF)
• 2024 – Gold 80 Ambetter HMO SBC – English (PDF)
• 2024 – Minimum Coverage Ambetter HMO SBC – English (PDF)
• 2024 – Bronze 60 Ambetter HMO SBC – English (PDF)
• 2024 – Silver 70 Ambetter HMO SBC – English (PDF)
• 2024 – Silver 73 Ambetter HMO SBC – English (PDF)
• 2024 – Silver 87 Ambetter HMO SBC – English (PDF)
• 2024 – Silver 94 Ambetter HMO SBC – English (PDF)

PPO

• 2024 – Silver 70 Ambetter PPO SBC – English (PDF)
• 2024 – Silver 73 Ambetter PPO SBC – English (PDF)
• 2024 – Silver 87 Ambetter PPO SBC – English (PDF)
• 2024 – Silver 94 Ambetter PPO SBC – English (PDF)
• 2024 – Gold 80 Ambetter PPO SBC – English (PDF)
• 2024 – Platinum 90 Ambetter PPO SBC – English (PDF)
• 2024 – Bronze 60 Ambetter PPO SBC – English (PDF)
• 2024 – Bronze 60 HDHP Ambetter PPO SBC – English (PDF)
• 2024 – Minimum Coverage Ambetter PPO SBC – English (PDF)

HMO

• 2024 – Platinum 90 Ambetter HMO SBC – English (PDF)
• 2024 – Gold 80 Ambetter HMO SBC – English (PDF)
• 2024 – Silver 70 Off Exchange Ambetter HMO SBC – English (PDF)
• 2024 – Minimum Coverage Ambetter HMO SBC – English (PDF)
• 2024 – Bronze 60 Ambetter HMO SBC – English (PDF)

Ambetter PPO

• 2024 – Silver 70 Off Exchange Ambetter PPO SBC – English (PDF)
• 2024 – Gold 80 Ambetter PPO SBC – English (PDF)
• 2024 – Platinum 90 Ambetter PPO SBC – English (PDF)
• 2024 – Bronze 60 Ambetter PPO SBC – English (PDF)
• 2024 – Bronze 60 HDHP Ambetter PPO SBC – English (PDF)
• 2024 – Minimum Coverage Ambetter PPO SBC – English (PDF)

HMO AI-AN

• 2024 – Platinum 90 Ambetter HMO AI-AN SBC – English (PDF)
• 2024 – Gold 80 Ambetter HMO AI-AN SBC – English (PDF)
• 2024 – Silver 70 Ambetter HMO AI-AN SBC – English (PDF)
• 2024 – Bronze 60 Ambetter HMO Limited Cost Share AI-AN SBC – English (PDF)
• 2024 – Bronze 60 Ambetter HMO $0 Cost Share AI-AN SBC – English (PDF)
• 2024 – $0 Cost Share Ambetter HMO AI-AN SBC – English (PDF)

PPO AI-AN

• 2024 – Silver 70 Ambetter PPO AI-AN SBC – English (PDF)
• 2024 – Gold 80 Ambetter PPO AI-AN SBC – English (PDF)
• 2024 – Platinum 90 Ambetter PPO AI-AN SBC – English (PDF)
• 2024 – Bronze 60 Ambetter PPO AI-AN SBC – English (PDF)
• 2024 – Bronze 60 HDHP Ambetter PPO AI-AN SBC – English (PDF)
• 2024 – $0 Cost Share Ambetter PPO AI-AN SBC – English (PDF)

• SDBC – Adult Dental HMO Plan (PDF)
• SDBC – Adult Dental PPO Plan (PDF)

• SDBC – Adult Dental HMO & HSP Plans (PDF)
• SDBC – Adult Dental PPO & EPO Plans (PDF)
• SDBC – Pediatric Dental EPO & Ambetter PPO Plans (PDF)
• SDBC – Pediatric Dental HMO & HSP Plans (PDF)
• SDBC – Pediatric Dental PPO Plans (PDF)

Ambetter HMO (Covered California)

• 2025 – Bronze 60 Ambetter HMO – English (PDF)
• 2025 – Gold 80 Ambetter HMO – English (PDF)
• 2025 – Minimum Coverage Ambetter HMO – English (PDF)
• 2025 – Platinum 90 Ambetter HMO – English (PDF)
• 2025 – Silver 70 Ambetter HMO – English (PDF)
• 2025 – Silver 73 (CSR) Ambetter HMO – English (PDF)
• 2025 – Silver 87 (CSR) Ambetter HMO – English (PDF)
• 2025 – Silver 94 (CSR) Ambetter HMO – English (PDF)

Ambetter PPO (Covered California)

• 2025 – Bronze 60 Ambetter PPO – English (PDF)
• 2025 – Bronze 60 HDHP Ambetter PPO – English (PDF)
• 2025 – Gold 80 Ambetter PPO – English (PDF)
• 2025 – Minimum Coverage Ambetter PPO – English (PDF)
• 2025 – Platinum 90 Ambetter PPO – English (PDF)
• 2025 – Silver 70 Ambetter PPO – English (PDF)
• 2025 – Silver 73 (CSR) Ambetter PPO – English (PDF)
• 2025 – Silver 87 (CSR) Ambetter PPO – English (PDF)
• 2025 – Silver 94 (CSR) Ambetter PPO – English (PDF)

Ambetter HMO (Off Marketplace)

• 2025 – Bronze 60 Ambetter HMO – English (PDF)
• 2025 – Bronze 60 Ambetter HMO Plus with Dental and Vision – English (PDF)
• 2025 – Gold 80 Ambetter HMO – English (PDF)
• 2025 – Gold 80 Ambetter HMO Plus with Dental and Vision – English (PDF)
• 2025 – Minimum Coverage Ambetter HMO – English (PDF)
• 2025 – Minimum Coverage Ambetter HMO Plus with Dental and Vision – English (PDF)
• 2025 – Platinum 90 Ambetter HMO – English (PDF)
• 2025 – Platinum 90 Ambetter HMO Plus with Dental and Vision – English (PDF)
• 2025 – Silver 70 Off Exchange Ambetter HMO – English (PDF)
• 2025 – Silver 70 Off Exchange Ambetter HMO Plus with Dental and Vision – English (PDF)

Ambetter PPO (Off Marketplace)

• 2025 – Bronze 60 Ambetter PPO – English (PDF)
• 2025 – Bronze 60 Ambetter PPO with Dental and Vision – English (PDF)
• 2025 – Bronze 60 HDHP Ambetter PPO – English (PDF)
• 2025 – Bronze 60 HDHP Ambetter PPO with Dental and Vision – English (PDF)
• 2025 – Gold 80 Ambetter PPO – English (PDF)
• 2025 – Gold 80 Ambetter PPO with Dental and Vision – English (PDF)
• 2025 – Minimum Coverage Ambetter PPO – English (PDF)
• 2025 – Minimum Coverage Ambetter PPO with Dental and Vision – English (PDF)
• 2025 – Platinum 90 Ambetter PPO – English (PDF)
• 2025 – Platinum 90 Ambetter PPO with Dental and Vision – English (PDF)
• 2025 – Silver 70 Off Exchange Ambetter PPO – English (PDF)
• 2025 – Silver 70 Off Exchange Ambetter PPO with Dental and Vision – English (PDF)

HMO AI-AN

• 2025 – $0 Cost Share Ambetter HMO AI-AN – English (PDF)
• 2025 – Bronze 60 Ambetter $0 Cost Share HMO AI-AN – English (PDF)
• 2025 – Bronze 60 Ambetter Limited Cost Share HMO AI-AN – English (PDF)
• 2025 – Gold 80 Ambetter HMO AI-AN – English (PDF)
• 2025 – Platinum 90 Ambetter HMO AI-AN – English (PDF)
• 2025 – Silver 70 Ambetter HMO AI-AN – English (PDF)

PPO AI-AN

• 2025 – $0 Cost Share Ambetter PPO AI-AN – English (PDF)
• 2025 – Bronze 60 HDHP Ambetter PPO AI-AN – English (PDF)
• 2025 – Bronze 60 Ambetter PPO AI-AN – English (PDF)
• 2025 – Gold 80 Ambetter PPO AI-AN – English (PDF)
• 2025 – Platinum 90 Ambetter PPO AI-AN – English (PDF)
• 2025 – Silver 70 Ambetter PPO AI-AN – English (PDF)

Ambetter HMO (Covered California)

• 2024 – Bronze 60 Ambetter HMO – English (PDF)
• 2024 – Gold 80 Ambetter HMO – English (PDF)
• 2024 – Minimum Coverage Ambetter HMO – English (PDF)
• 2024 – Platinum 90 Ambetter HMO – English (PDF)
• 2024 – Silver 70 Ambetter HMO – English (PDF)
• 2024 – Silver 73 (CSR) Ambetter HMO – English (PDF)
• 2024 – Silver 87 (CSR) Ambetter HMO – English (PDF)
• 2024 – Silver 94 (CSR) Ambetter HMO – English (PDF)

Ambetter PPO (Covered California)

• 2024 – Bronze 60 Ambetter PPO – English (PDF)
• 2024 – Bronze 60 HDHP Ambetter PPO – English (PDF)
• 2024 – Gold 80 Ambetter PPO – English (PDF)
• 2024 – Minimum Coverage Ambetter PPO – English (PDF)
• 2024 – Platinum 90 Ambetter PPO – English (PDF)
• 2024 – Silver 70 Ambetter PPO – English (PDF)
• 2024 – Silver 73 (CSR) Ambetter PPO – English (PDF)
• 2024 – Silver 87 (CSR) Ambetter PPO – English (PDF)
• 2024 – Silver 94 (CSR) Ambetter PPO – English (PDF)

Ambetter HMO (Off Marketplace)

• 2024 – Bronze 60 Ambetter HMO – English (PDF)
• 2024 – Bronze 60 Ambetter HMO Plus with Dental and Vision – English (PDF)
• 2024 – Gold 80 Ambetter HMO – English (PDF)
• 2024 – Gold 80 Ambetter HMO Plus with Dental and Vision – English (PDF)
• 2024 – Minimum Coverage Ambetter HMO – English (PDF)
• 2024 – Minimum Coverage Ambetter HMO Plus with Dental and Vision – English (PDF)
• 2024 – Platinum 90 Ambetter HMO – English (PDF)
• 2024 – Platinum 90 Ambetter HMO Plus with Dental and Vision – English (PDF)
• 2024 – Silver 70 Off Exchange Ambetter HMO – English (PDF)
• 2024 – Silver 70 Off Exchange Ambetter HMO Plus with Dental and Vision – English (PDF)

Ambetter PPO (Off Marketplace)

• 2024 – Bronze 60 Ambetter PPO – English (PDF)
• 2024 – Bronze 60 Ambetter PPO with Dental and Vision – English (PDF)
• 2024 – Bronze 60 HDHP Ambetter PPO – English (PDF)
• 2024 – Bronze 60 HDHP Ambetter PPO with Dental and Vision – English (PDF)
• 2024 – Gold 80 Ambetter PPO – English (PDF)
• 2024 – Gold 80 Ambetter PPO with Dental and Vision – English (PDF)
• 2024 – Minimum Coverage Ambetter PPO – English (PDF)
• 2024 – Minimum Coverage Ambetter PPO with Dental and Vision – English (PDF)
• 2024 – Platinum 90 Ambetter PPO – English (PDF)
• 2024 – Platinum 90 Ambetter PPO with Dental and Vision – English (PDF)
• 2024 – Silver 70 Off Exchange Ambetter PPO – English (PDF)
• 2024 – Silver 70 Off Exchange Ambetter PPO with Dental and Vision – English (PDF)

Compliance Forms

• Authorization for Disclosure of Protected Health Information - English (PDF)
• Authorization for Disclosure of Protected Health Information - Spanish (PDF)
• Authorization for Disclosure of Protected Health Information - Chinese (PDF)
• Authorization for Disclosure of Protected Health Information - Korean (PDF)

• Glossary of Health Coverage and Medical Terms - English (PDF)
• Glossary of Health Coverage and Medical Terms - Spanish (PDF)
• Glossary of Health Coverage and Medical Terms - Chinese (PDF)
• Glossary of Health Coverage and Medical Terms - Korean (PDF)
• Glossary of Health Coverage and Medical Terms - Navajo (PDF)

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.