For these transactions, complete a Priority Health enrollment form (353KB PDF) and attach supporting documentation if needed.
- Medicare plan enrollments or disenrollments
- Vision-only, dental-only or disability-only enrollments without medical coverage
- Enrolling members in a surviving spouse class, early retiree class, retiree class or sponsored dependent medical/pharmacy plan (for small group - 2-50 eligible employees - only);
- Member-level eligibility/split contracts (where a dependent chooses different benefits from the employee)
- Add a benefit (dental or vision) to an existing contract - use the dental/vision enrollment form (770KB PDF)
For these transactions, complete a Priority Health change form (157KB PDF) and attach supporting documentation if needed.
- Add dependent over age 19
- Add dependent due to:
- Loss of coverage
- Disability (Submit Social Security Administration (SSA) approval letter with enrollment. If not approved, call Billing & Enrollment at 800.471.2504, option 2,or a physician's statement form.)
- Court-appointed guardianship (limited or permanent only - temporary guardianship is not eligible)
- Change Social Security number
- Change to full-time/part-time
- Remove a benefit (dental or vision) from an existing contract