Documents & Forms
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2024 Plan Year Documents for Farm Bureau Advantage HMO
- Summary of Benefits
- Annual Notice of Change - Central Tennessee
- Annual Notice of Change - Knoxville Tennessee
- Annual Notice of Change - Tri-Cities Tennessee
- Evidence of Coverage - Central Tennessee (Updated 3/11/24)
- Evidence of Coverage - Knoxville Tennessee (Updated 3/11/24)
- Evidence of Coverage - Tri-Cities Tennessee (Updated 3/11/24)
- Provider Directory - Central Tennessee (Updated 4/9/24)
- Provider Directory - Knoxville Tennessee (Updated 4/9/24)
- Provider Directory - Tri-Cities Tennessee (Updated 4/9/24)
- Pharmacy Directory (Updated 3/30/24)
- Comprehensive Formulary (Updated 4/26/24)
- Comprehensive Formulary - Large Print (Updated 4/26/24)
- Medical - Prior Authorization Procedure Codes (Updated 4/1/24)
- Prescription Drug - Prior Authorization Criteria (Updated 4/26/24)
- Step Therapy Criteria (Updated 4/26/24)
- Quantity Limits Criteria (Updated 4/26/24)
- CMS Star Ratings
- Pre-enrollment checklist
- Enrollment Form
- Sales Kit
2024 Other Forms & Documents
- Member Reimbursement Drug Claim Form
- Appointment of Representative Form
- Coverage Determination/Prior Authorization Request Form – Drugs
- Request for Redetermination
- Request for Redetermination - Drugs
- SSA Extra Help Information
- Scope of Appointment
- Authorization for Release of Protected Health Information
- Coverage Determination/Prior Authorization Request Form – Medical
- Medicare Advantage Member Health Care Claim Form
- Disenrollment Form
- Supplemental Benefits Contacts
- Personal Medication List
- Appeals Form
- MTMP Enrollment Mailer
- Recommended To-Do-List
- Prescription Drug Home Delivery Form and FAQ’s
- OTC Catalog