* Required Fields
Check if you do not have your Subscriber ID
A premium payment will be considered as having been received by Molina Healthcare, Inc. upon actual receipt of the payment from your designated bank or from your payment card.
The statement from your bank or payment card that payment was made to Molina Healthcare, Inc. is your receipt that Molina Healthcare, Inc. received the payment.
If your authorization is rejected, dishonored, returned, reversed or adjusted by your bank or payment card for any reason, you will be responsible for any charges imposed by your bank or the payment card if we submit the payment authorization a second time.
Please provide a valid date in the format mmddyy, mmddyyyy, m/d/yy, m/d/yyyy, mm/dd/yy or mm/dd/yyyy
Your Exchange Subscriber ID can be found on your Member ID Card. You may also use the Account Number on your monthly invoice.
VIEW LARGER IMAGE