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 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