Understanding your benefits

Most everything you need is in your  member account. Review your benefits information, coverage documents*, procedures and much more. You'll find the benefits and services included and excluded from your coverage, copayments and other charges, restrictions on services outside the network, how to submit claims, how to submit a complaint or appeal a decision, including external review procedures and how we evaluate new technology for inclusion as a covered benefit.

You can also find information about in-network doctors, getting primary care and specialty care like behavioral health and hospital services, getting care after normal office hours and receiving emergency care, including when you're out of our service area.

Don't have a member account? Sign up for one here.

To access your information on the go, download the Priority Health app in the Apple Store or Google Play Store.

*Coverage documents are not yet available in the member account for all employers.

If you take prescriptions*, review our Approved Drug List. We regularly review new drugs and note changes or updates to help make sure you're receiving safe and effective care. We partner with Express Scripts, the nation's largest pharmacy benefits manager, so you can get the most competitive rates.

In the Priority Health app, you're able to easily access Rx Manager to check prescriptions and more. We also provide information about our prescription coverage and pharmacy management procedures.

*Depending on your plan type, you may or may not have prescription benefits included in your plan. Check your plan documents in your member account for details.

Learn how we're committed to keeping your health information private. . View our Notice of Privacy Practices and our Privacy Policy.

Our goal is to cover care that meets high medical standards and is also cost-effective. This is called utilization management. If you have questions regarding our process or decisions, contact us for help.

Know that all utilization management decisions are based on appropriateness of care and service and existence of coverage and that no financial incentives or rewards exist for issuing denials.

View our Grievance Procedure so you can stay informed if you have any questions, concerns or requests about your Priority Health plan.

Review summary information regarding our Quality Improvement Program performance and quality results. View our Quality Improvement Program. An executive summary of our quality improvement program achievements can be requested by sending us a message through your member portal, click here.

Do you suffer from an ongoing condition like asthma, heart disease, diabetes or substance use? Learn what programs are available to help you manage chronic illnesses, how to use the services and how to become eligible. View our Care management program here.

Knowing how to take action against fraud, waste and abuse is important. If you suspect fraud, waste or abuse you can take one of the following actions:

• Report fraud, waste and abuse
• Medicaid members: Report fraud, waste and abuse
• Submit a Fraud, Waste or Abuse complaint form
• Call the 24-hour Compliance Helpline at 800.560.7013
• Read more about how to prevent fraud, waste and abuse

If you have had, or are going to have a mastectomy, you may be entitled to certain benefits. Learn more.

Access our clinical practice guidelines which your doctor may use to talk with you about goals, preferences and priorities, and to provide you with information on the most effective methods of screening, diagnosis and treatment of certain acute or chronic conditions. View the clinical practice guidelines here.

View our Notice of Availability of Language Assistance Services and Auxiliary Aids and Services here.

Your rights as a Priority Health member 

As a member of a medical plan, you have the right to: 

• Prompt medical care appropriate for your condition, including emergency care if necessary. 

• Discuss all treatment options available to you, regardless of what your plan covers. 

• Information about us, our services, our health care providers and your rights and responsibilities. 

• Collaborate with physicians and other health care providers when making decisions about the care you receive. 

• Be treated with respect. 

• Have your privacy protected. 

• Have your medical and financial records be kept confidential, whether in electronic or written form. We will not disclose information from your medical records without your consent, except as allowed. Read our Notice of Privacy Practices for more information about this.  

• Be notified quickly if we release information about you in response to a court order. 

• Inspect your medical records and those of your minor dependents. Your right as a parent or legal guardian to see your minor dependent's medical records without the minor's consent may be limited by state or federal law. 

• Register a complaint or file a grievance with us, or with the Commissioner of the Office of Financial and Insurance Regulation, if you experience a problem with us or with a health care provider. For more information, go to the Grievances & appeals section of this website. 

• Initiate a legal proceeding if you experience a problem with us or with health care providers after you have exhausted the grievance process. 

• Review a summary of Priority Health's annual report, and inspect the full report on file with the Office of Financial and Insurance Regulation. 

• Suggest changes to our Member Rights and Responsibilities policies. In addition, wellness program members have the right to: 

• Information about Priority Health (including programs and services provided on behalf of your employer or plan sponsor), Priority Health staff and its qualifications, and any contractual relationships 

• Decline participation or disenroll from programs and services offered by Priority Health 

• Be supported by Priority Health in making health care decisions with your doctors, therapists, and other health care practitioners 

• Be treated courteously and respectfully by the Priority Health staff 

• File a complaint with Priority Health and receive instructions on how to use the complaint process, including being informed of the organization's standards of timeliness for responding to and resolving issues of quality and complaints. For more information, go to the Grievances & appeals section of this website. 

• Receive understandable information. 

Your responsibilities as a health plan member 

Your responsibilities as a member of a medical plan 

You can find a complete list of your responsibilities as a Priority Health medical plan member in your coverage documents. You are responsible for: 

• Reading the coverage documents that explain your health plan and the accompanying member materials. 

• Understanding and complying with the terms and conditions of your plan. 

• Calling us with questions. 

• Priority Health Medicare, PriorityHMO^SM, PriorityEPO^SM and PriorityPOS^SM members: Coordinating all medical services through your primary care physician (PCP) or other primary health care provider, except in the case of a medical emergency. 

• Using participating health care providers for all services and supplies not requiring prior approval, or, if your plan allows you to use non-participating/out-of-network providers, then understanding the costs of services you choose to get from them. "Participating providers" are health care providers that are contracted to accept your Priority Health plan. They are listed in the Find a Doctor online provider directory.
   

To use Find a Doctor: 

1. Log in or create a member account 

1. Select Find care in the top menu 

1. Click Find a doctor or specialist. 

Note that out-of-network PCPs or specialists must be authorized before a visit (called “prior authorization”). Your in-network PCP can help coordinate all referrals to specialists. 

• Getting prior approval for medical services when required by your plan and complying with the limits of any approval of services. Note: Services that generally require pre-approval or "prior authorization" are listed in your coverage documents, and also listed in this handbook, here. 

• Contacting participating health care providers to arrange for medical appointments, and notifying them in a timely manner if an appointment must be canceled. 

• Paying your copayments at the time service is provided. 

• Presenting your ID card to a health care provider before you receive a service. 

• Collaborating with your doctors and other health care providers to make informed decisions about the care you receive and to understand your health problems and health risks. 

• Following the instructions and working toward the treatment goals that you and your doctor or other health care provider agree upon. You may participate in developing your treatment goals when possible. Priority Health or your health care providers may ask you to agree to a written treatment plan to ensure you understand it. 

• Supplying your doctors and other health care providers and Priority Health with the information we need to make sure you receive proper care. 

• Notifying health care providers and us if you have other health insurance coverage. 

• Providing accurate information on your application or enrollment form and in any other information provided to us. 

• Notifying us of any change in address. 

• Notifying us if your ID card is stolen. 

• Cooperating with us to prevent the unauthorized use of your ID card and to prevent anyone from obtaining benefits in your place. 

• Treating health care providers and their staffs with respect. 

Your responsibilities as a member of a wellness program 

• Following the care advice offered by Priority Health 

• Providing Priority Health with information necessary to carry out its services 

• Notifying Priority Health and your doctor or other primary health care provider if you decide to disenroll from the program