Unavailable transactions

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 FSA-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, vision or FSA) to an existing contract

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