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2024 Plan Year Documents

2024 Plan Year Documents for Farm Bureau Select Rx
Summary of Benefits
Annual Notice of Change (ANOC)
Evidence of Coverage
Pharmacy Directory
Comprehensive Formulary
Comprehensive Formulary - Large Print
Prior Authorization Criteria
Step Therapy Criteria
Quantity Limits Criteria
2023 LIS Premium Summary
CMS Star Ratings
Enrollment Form
 

2024 Plan Year Documents for Farm Bureau Essential Rx
Summary of Benefits
Annual Notice of Change (ANOC)
Evidence of Coverage
Pharmacy Directory
Comprehensive Formulary
Prior Authorization Criteria
Step Therapy Criteria
Quantity Limits Criteria
2024 LIS Premium Summary
CMS Star Ratings
Enrollment Form
 

Other Forms & Documents
Member Reimbursement Drug Claim Form
Appointment of Representative Form
Coverage Determination Request Form
Request for Redetermination
Request for Reconsideration
SSA Extra Help Information
Personal Medication List
Sales Kits
Pre Enrollment Checklist
Optum Home Delivery FAQ
Safe Disposal Language
Authorization for Release of Protected Health Information
Disenrollment Form
Personal Medication List

Premium Billing/Payment
Premium Payments FAQ
Bank Withdrawal Form
RRB Withhold Form