The documents and forms shown here are PDF (Portable Document Format) files.  They can be viewed with Adobe Reader. If you don't already have this viewer on your computer, download Adobe Reader for free from the Adobe website.

2023 Plan Year Documents

2023 Plan Year Documents for Farm Bureau Select 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
2023 LIS Premium Summary
CMS Star Ratings
Enrollment Form
 

2023 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
2023 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

Premium Billing/Payment
Premium Payments FAQ
Bank Withdrawal Form