Prior Approval Checklist and Exhibits

Unless noted otherwise, the following documents are in Excel format.

• Checklist - Section 3231(e)(1) and Section 4308(c) Rate Adjustment Filings (PDF)
• Exhibit 1 - General Information
• Exhibit 2 - Summary of Average Claim Trend and Administrative Expenses
• Exhibit 3 - Narrative Summary
• Exhibit 4 - Summary of Proposed Percentage Rate Changes:
  • Part A - Base Medical Plan with Non-Rolling Rate Structure
  • Part B - Base Medical Plan with Rolling Rate Structure
  • Part C - Drug Riders Available with Base Medical Products (Non-Rolling Rate Structure)
  • Part D - Drug Riders Available with Base Medical Products (Rolling Rate Structure)
• Exhibit 5 - Distribution of Contracts Affected by Proposed Rate Adjustments:
  • Part A - Non-Rolling Rate Structure
  • Part B - Rolling Rate Structure
• Exhibit 6 - Summary of Policy Form and Product Changes
• Exhibit 7 - Historical Data