CurrentPriority HealthPolicy N/A

Preventive Health Care Services — Coverage Criteria

Defines preventive health services and lists preventive vaccines, medications, and contraceptives covered for Priority Health employer group and individual plans, and notes plan exceptions and prior authorization requirement for $0 cost-share overrides.

Policy Summary

PayerPriority Health

PolicyPreventive Health Care Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for a $0 cost-share override to confirm a preventive diagnosis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Manyvaccines listed for pediatrics and adults

Multiplecontraceptive products listed

6m–5yfluoride coverage age range

40–75ystatin medication age range

2/365dbowel-prep fills

Prior auth$0 cost-share override

Coverage rules and plan exceptions

Coverage and Plan Exceptions

Coverage for preventive services is included for most Priority Health employer group and individual plans, with exceptions.

General coverage: Most Priority Health employer group and individual plans include preventive care at no cost to members.

Plan exceptions: MyPriority short-term plans do not include preventive care OR Grandfathered plans may exclude preventive care or have specific costs OR Some employers may exclude contraceptives from their health plans.

Do not assume coverage without plan verification; verify member plan type before billing as preventive.

Prior Authorization

Administrative requirement

Prior auth for override:

Policy Summary

PayerPriority Health

PolicyPreventive Health Care Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for a $0 cost-share override to confirm a preventive diagnosis.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Most Priority Health employer group and individual plans include preventive care at no cost to members; however, plan-specific exceptions apply and should be verified before assuming coverage. MyPriority short-term plans do not include preventive care services. Grandfathered plans (typically employer-sponsored plans unchanged since 2010) may exclude preventive care or require specific member costs for certain preventive services. Additionally, some employers may exclude contraceptives from their health plans, so confirm benefits and any cost-sharing with the member’s plan.

Providers should verify the member’s plan type and document that the service is being provided as preventive when submitting claims. When a plan excludes preventive care or applies specific cost provisions (for example, under a grandfathered plan or employer exclusion), standard preventive coverage rules do not apply and charges may not be waived.

Provider responsibilities and prior authorization

Prior Authorization

Prior Authorization Required for $0 Cost-Share Override

Prior authorization is required for a zero-dollar ($0) cost-share override to confirm that the service is being provided for a preventive diagnosis.

Note

Documentation Required

Plan verification and preventive diagnosis documentation

Verify the member's plan type before providing preventive services. Most Priority Health employer group and individual plans include preventive care at no cost to members, but some plans (for example, MyPriority short-term plans, certain grandfathered plans, or employer plans that exclude specific services such as contraceptives) may not cover preventive care or may have different cost-sharing. Document in the medical record that the service is preventive and include the preventive diagnosis code when requesting a $0 cost-share override or when submitting claims.

Confirm member plan includes preventive care (not MyPriority short-term, not excluded grandfathered plan).
Document preventive diagnosis and include it in prior authorization or claim submissions.

Denial Risk

Denial Risk for Missing Prior Authorization

Failure to obtain prior authorization for a $0 cost-share override may result in claim denial or the member being held financially responsible for the service.

Policy background and intent

Preventive health care services are intended to prevent disease or detect it early when treatment is most effective; this policy aligns covered services and age ranges with recommended preventive frameworks and lists the vaccines, medications, and products that Priority Health covers as preventive care for applicable plans. Providers must confirm plan eligibility because coverage and member cost-sharing depend on plan type and any employer or grandfathered plan exceptions.

This document enumerates covered preventive vaccines, medications, contraceptives, and selected products, and specifies administrative requirements such as prior authorization for a zero-dollar ($0) cost-share override to confirm a preventive diagnosis.

OpenPayer

Preventive Health Care Services — Coverage Criteria

Coverage rules and plan exceptions

Covered vaccines, medications, and related coding

Provider responsibilities and prior authorization

Key definitions

Policy background and intent