COVID-19 Frequently asked questions

OTC tests will be covered at the point of sale through our pharmacy benefit manager, Express Scripts Intl (ESI). Through ESI’s network of pharmacies, members can bring their test to the pharmacy counter and have them bill it to their insurance. If members encounter any issues, they can submit for test reimbursement.

If you have a MyPriority or employer-sponsored plan with pharmacy benefits through Priority Health and you purchase an over the counter (OTC) COVID-19 test from an authorized retailer, you will be eligible for reimbursement if:*

• The at-home test you received is approved by the Food and Drug Administration.
• You fill out and submit the reimbursement form, with the UPCs (barcode on the test kit packaging) and original receipts from the authorized pharmacies or retailers as proof of purchase.
• Lastly, there is a limit of 8 tests or 4 kits per member per month.
• Note: We are unable to reimburse for purchases from non-authorized sources including neighbors, Facebook Marketplace, etc.

*Exception: Members whose pharmacy benefits are not administered through Priority Health.

Screening is defined as a series of questions a medical professional uses to determine if a COVID-19 test is appropriate. If you are having symptoms and you are screened for COVID-19 by a medical provider through a virtual visit or in-person, your co-pays and deductibles are waived if it results in the ordering/administering of a test.

Important details:

• We encourage our members with symptoms to use virtual care to help reduce the risk of spreading or contracting the illness.
• Copays and deductibles are waived if it results in the ordering/administering of a test.
• Check with your doctor for virtual care options or log in to your member account for other recommended virtual care options. Download the Priority Health app which is available on the App Store and Google Play.
• If you're experiencing COVID-19 symptoms, complete a COVID-19 screening by a local medical provider (family doctor or PCP) either through a virtual visit or in-person. The results of the screening will indicate if the medical provider should order/administer a test. Testing is covered at 100% if ordered by a medical provider.

If a COVID-19 test of any kind is ordered by a medical provider that is medically necessary, your member cost share (copays, coinsurance or deductibles) for this test will be waived.

Important details:

• The test must be ordered by a medical provider for your health plan to cover the costs of the test.
• Your plan will cover the cost of one test per day, as described above, whether the provider is in or out of network.
• Medically necessary is determined and appropriately coded by your ordering provider.
• Medically necessary does not include tests as a condition of employment or returning to work.

If you are experiencing symptoms, first speak to your health care provider to help you understand if you need testing and how to receive it.

The state also has online resources you can access that will provide information on testing centers and steps to take.

As of October 1, 2021, coverage for COVID-19 treatment returned to your pre-pandemic standard benefit. This means that if you or a covered dependent is admitted to the hospital with COVID-19, your standard benefits for treatment will apply. We encourage you to receive care from providers in your plan’s network.

Important details:

• Screening and testing will continue to be free to our members as long as we remain in a national emergency.
• The vaccine will continue to be free and covered under Priority Health's Preventive Health Care Guidelines.
• The vaccines have proven to be extremely effective at preventing the transmission of COVID-19 and severe illness or death.
• We believe getting vaccinated is the most effective way for our members to keep themselves, their families, and their community safe.
• Covered treatment may be inpatient or outpatient, however, this does not apply to prescriptions. There are currently no official drug treatments for COVID-19.
• Need help finding an in-network provider? Log in to your member account to use your find a doctor tool or call your Priority Health customer service team.

*Employer plans that are self-insured determine benefit coverage for their employees and dependents at their discretion

**COVID-19 treatment* was available to our members with no out-of-pocket health plan costs (copays, deductibles or coinsurance) when received from an in-network provider between the dates of March 11, 2020 and September 30, 2021.

The COVID-19 vaccine will be covered at 100% for our members when received through an in-network provider. This means that our members will have $0 out-of-pocket health plan costs (copays, deductibles or coinsurance) if they choose to receive the vaccine.

The COVID-19 booster shots and additional doses will be covered at 100% for our members when received through an in-network provider. This means that our members will have $0 out-of-pocket health plan costs (copays, deductibles or coinsurance) if they choose to receive the vaccine.*

*Exception: Members enrolled in grandfathered and retiree commercial plans should check their plan documents to determine vaccine coverage. 

If you are out of state and need emergency medical assistance related to COVID-19, testing, diagnosis and treatment of COVID-19 will be covered as outlined above.

Included in most Priority Health plans is Assist America^® for emergency travel assistance whenever you are more than 100 miles away from home. Assist America covers the costs of all services related to getting quality emergency medical care while traveling, such as medical referrals, critical care monitoring, emergency evacuation and more. Assist America is not insurance and services do not replace medical insurance.

• OOC members are covered* for Urgent and Emergency care as stated by their plan.
• Contact Assist America first for guidance on your options.
• The usual process will apply where if you seek care, you may be asked to pay up front.
• You should get a detailed receipt and then file a form to get reimbursed by Priority Health.
• Testing will be covered, and co-pays and deductibles for the COVID-19 treatment will be waived.

*Note: Priority Health Medicaid members do not have any out-of-country benefits and services received outside of the United States cannot be reimbursed.

Virtual care provides access to care wherever you are, 24/7 and goes beyond COVID-19 related care for other areas such as behavioral health care or checkups. We encourage our members to use virtual care, when appropriate, to help prevent further spread of COVID-19 and avoid overwhelming health care providers and facilities.

Important details:

• Priority Health members who have an employer sponsored plan should reference their plan documents, found in their member account or by calling customer service, for their virtual care standard benefit and to confirm their cost share responsibility.
• All MyPriority (Individual ACA market) members returned to pre-COVID-19 standard plan benefits for virtual visits for primary care and specialists as of March 1, 2021, and behavioral health visits as of May 1, 2021.
• As of January 1, 2021, we added $0 virtual visits* for behavioral health so all Priority Health Medicare Advantage members can see in-network primary care, specialists and behavioral health providers and pay a $0 copay as part of their medical benefits through 2021. Out-of-network virtual visits are typically not covered but have been due to COVID-19 as a service to our members. This exemption will continue through July 31, 2021. After that, out-of-network virtual visits will not be covered.
• Virtual care services, including behavioral health services, are covered for Medicaid members using in network providers.
• All members should refer to their plan documents for further benefit details.

*Excluding the Vital plan, which has 20% coinsurance for virtual visits.

If you’re a Priority Health member, download the Priority Health app (available on the App Store and Google Play) or log in to your member account to access virtual care options.

*Availability of these services at no cost will be dependent on social distancing guidelines.

How does it work?

• Contact CVS* to ask about these home delivery options using CVS.com, CVS mobile app, or by contacting your local CVS pharmacy directly.
• Once you’re set up, CVS uses UPS or FedEx to deliver your prescriptions within 1-2 days.
• There are is no limit to a specific amount of days’ supply. You can get anything from a few days up to a 90-day supply (although we recommend setting up 90-day refills).

*CVS is not an in-network pharmacy for Medicaid and Healthy Michigan members. CVS is not a preferred Medicare pharmacy which means your cost share for drugs may be higher.

How does it work?

• Walgreens Express™ delivery is available for all Priority Health members.
• Contact your local Walgreens for details.
• Once you’re set up you’ll be able to prepay for your prescriptions and receive them as soon as the next day via FedEx.
• Orders received by 4pm on Friday, as well as requests made during the weekend, have an expected delivery day of Tuesday or Wednesday.
• Prescriptions are not delivered on Sundays or holidays.

How does it work?

• Contact your primary Meijer pharmacy to set up your home delivery option.
• The standard Rx delivery time varies between 1-2 days.
• Rx next day delivery is available from select Meijer pharmacies and the usual $8 fee is being waived at this time.
• Also, "Touch free" service is being offered. This means no signature is required at the time of delivery. Payment for the prescription copay is on your mobile device of over the phone.
• Meijer is delivering controlled substances and refrigerated items.
• Available for all Priority Health members.

Other local pharmacies may have a “home-delivery” option. Check with your pharmacist for options.

If you already have an automatic 90-day refill set up, then no need to change a thing. You get discounted rates and your prescriptions delivered in the mail to your home already. Note: If you have a Medicare plan, you can find your 90-day refill information here.

*Mail order is not available for Medicaid members.

For Medicaid members:

You can use the Find a Doctor tool to find an in-network pharmacy for your plan. Out-of-state pharmacies dispensing medications for the Medicaid population who are not actively enrolled in Michigan's CHAMPS program may need additional assistance for Priority Health to process a prescription claim.