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Farm Bureau Health Plans

EDUCATION & RESOURCES

2024 Farm Bureau Advantage HMO Documents & Forms Permission to Contact Provider Directory Dental Benefits Vision Benefits Fitness Benefit -Silver & Fit Formulary
How Medicare Works Enrollment/Disenrollment Appeals Filing a Grievance How to Appoint a Representative Premium Payment Terms & Conditions Medicare's Extra Help Program Medication Therapy Management (MTM) Coverage Determination Transition Policy

MEDICARE RESOURCES

Medicare.gov Medicare Complaint Form Medicare Prescription Drug Coverage Determinations Best Available Evidence for Low-Income Subsidy

2024 Farm Bureau Advantage HMO

Farm Bureau Advantage HMO is our brand new Medicare plan offering for 2024. Enrollment for 2024 begins October 15, 2023.

With Farm Bureau Advantage HMO, your medical, hospital and prescription drug coverage are combined into one affordable plan. You’ll have access to cost-saving extras not covered by Original Medicare like dental, vision, hearing, OTC, a fitness program and expanded telehealth benefits.

And as a member of the Farm Bureau Health Plans family, you’ll enjoy reliable support from our helpful customer service team right here in Columbia, TN.

Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Monthly Plan Premium
$0
$0
$0
Annual Medical Deductible
$0
$0
$0
Maximum Out of Pocket
$5,300 annually
$3,200 annually
$3,200 annually
Inpatient Hospital Coverage
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Inpatient Hospital Coverage
$300 days 1 - 5, $0 days 6 - 90
$300 days 1 - 5, $0 days 6 - 90
$300 days 1 - 5, $0 days 6 - 90
Outpatient Hospital Coverage
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Ambulatory Surgery Center
$225
$175
$175
Outpatient Surgery (Hospital)
$250
$250
$250
Doctor Visits
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Primary Care Provider
$0
$0
$0
Specialist
$30
$25
$30
Preventative Care
$0
$0
$0
Emergency Care
$100
$100
$100
Urgently Needed Services
$30
$30
$30
Worldwide Emergency Coverage**
$100
$100
$100
Telehealth Services
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Primary Care Provider
$0
$0
$0
Specialist
$30
$25
$30
Diagnostic Tests and Procedures*
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Primary Care Provider
$0
$0
$0
Specialist
$20
$25
$30
Hospital
$100
$100
$100
Laboratory Services*
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Primary Care Provider
$0
$0
$0
Specialist
$0
$0
$0
Freestanding Laboratory
$0
$0
$0
Urgent Care
$30
$30
$30
Hospital
$30
$30
$30
X-rays*
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Primary Care Provider
$0
$0
$0
Specialist
$30
$25
$30
Hospital
$50
$50
$50
Advanced Imaging Services*
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Primary Care Provider
$75
$75
$75
Specialist
$75
$75
$75
Freestanding Facility
$75
$75
$75
Hospital
$200
$200
$200
Therapeutic Radiological Services
$50
$50
$50
Hearing Services**
(Routine hearing exams and hearing aid copayments are not subject to the out-of-pocket maximum)
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Routine Hearing Exam one visit per year
$0
$0
$0
Hearing Aids
$599 - $899 per ear, per year copayment
$599 - $899 per ear, per year copayment
$599 - $899 per ear, per year copayment
Dental Services**
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Preventative two prophylaxis yearly
$0
$0
$0
Comprehensive
20% - 50% coinsurance
20% - 50% coinsurance
20% - 50% coinsurance
Benefit limit
$3,500
$3,500
$3,500
Vision Services**
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Routine Eye Exam
1 per year $0
1 per year $0
1 per year $0
Eyewear
$200 allowance
$200 allowance
$200 allowance
Mental Health Services*
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Inpatient Care
$300 days 1- 5, $0 days 6 - 90
$300 days 1- 5, $0 days 6 - 90
$300 days 1- 5, $0 days 6 - 90
Individual Sessions
$30
$30
$30
Group Sessions
$20
$20
$20
Ambulance*
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Air
20% coinsurance
20% coinsurance
20% coinsurance
Ground
$270 per one way trip
$270 per one way trip
$270 per one way trip
Other Services
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Skilled Nursing Facility*
$0 days 1 - 20, $203 days 21 - 100
$0 days 1 - 20, $203 days 21 - 100
$0 days 1 - 20, $203 days 21 - 100
Physical Therapy/Occupational Therapy/Speech Therapy**
$30
$30
$30
Medicare Part B Drugs
20% coinsurance
20% coinsurance
20% coinsurance
Over The Counter (OTC) Drug Card******
$150 allowance per quarter
$150 allowance per quarter
$150 allowance per quarter
Chiropractic Services - Medicare covered***
$20
$20
$20
Durable Medical Equipment (DME)****
20% coinsurance
20% coinsurance
20% coinsurance
Diabetic Supplies*****
$0
$0
$0
Fitness Club Membership
$10 home fitness kit, $25 annual fitness membership
$10 home fitness kit, $25 annual fitness membership
$10 home fitness kit, $25 annual fitness membership
Podiatry Services*
$30
$30
$30
Transportation
Non-covered
Non-covered
Non-covered

 

* Services may require Prior Authorization and may require a Primary Care Physician (PCP) Referral.

** Does not count toward your out of pocket maximum.

*** Medicare Covered Benefits only. Routine care and other chiropractic services not covered.

**** Most DMEs require Prior Authorization and a Referral from you PCP.

***** Diabetic supplies are limited to specific manufacturers. Test strips and monitors: One Touch, Accu-Check. Continuous glucose monitors available from Freestyle Libre or Dexcom after completing a prior authorization.

****** Amounts do not roll over to next 3 month period.

Prescription Drug Coverage
Central Tennessee
Tri-Cities Tennessee
Knoxville Tennessee
What you pay
What you pay
What you pay
Part D Deductible
$0
$0
$0
Tier 1: Preferred Generic
$0
$0
$0
Tier 2: Generic
$7
$5
$5
Tier 3: Preferred Brand
$47
$47
$47
Tier 4: Non-Preferred Drug
$100
$100
$100
Tier 5: Specialty Tier
33%
33%
33%
Mail Order 100 Day Supply: Tier 1 Preferred Generic
$0
$0
$0
Mail Order 100 Day Supply: Tier 2 Generic
$0
$0
$0
Mail Order 100 Day Supply: Tier 3 Preferred Brand
$141
$141
$141
Mail Order 100 Day Supply: Tier 4 Non-Preferred Drug
$300
$300
$300
Mail Order 100 Day Supply: Tier 5 Specialty Tier
Not covered
Not covered
Not covered
Select Insulins - 30 days
$35
$35
$35
Initial Coverage Limit (ICL)

Initial Coverage Limit is $5,030.00. During the Initial Coverage state, the plan pays its share of the cost of your covered prescriptions and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription. Please review the Evidence of Coverage online for more information on the phases of the benefit.

Coverage Gap Stage

You stay in this stage until your out of pocket costs reach a total of $8,000.00. When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs. You pay 25% of the negotiated price and a portion of the dispensing fees for brand name drugs. Please
review the Evidence of Coverage online for more information on the Coverage Gap Stage.


Coverage Gap Stage coinsurance requirements do not apply to Part D covered insulin products and most adult Part D vaccines, including shingles, tetanus, and travel vaccines. You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier.

Catastrophic Coverage Stage

Catastrophic Coverage Limit is $8,000.00. Catastrophic coverage begins after your total yearly drug cost reaches $8,000.00. During this time, the plan pays all of the cost for your drugs. Please reference the Evidence of Coverage, available online, for complete information regarding the Catastrophic Coverage Stage.

Insulin is covered at no more than $35 per month or 30 day supply regardless of coverage tier. Insulin drugs are covered under Tier 3 and Tier 4.

The following plan documents will help you find more information about Farm Bureau Advantage HMO. All documents are PDF (Portable Document Format) and 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.

Summary of Benefits (PDF) (updated 10/1/23)

The Summary of Benefits provides an overview of the plan benefits.

Enrollment Form (PDF) (updated 10/1/23)

If you would like to enroll for one of our plans, you can complete the Enrollment Form and mail it to us.

Evidence of Coverage - Central Tennessee (PDF) (updated 4/8/24)

The Evidence of Coverage explains your plan benefits, your rights and responsibilities, and provides you with important contact information.

Evidence of Coverage - Knoxville Tennessee (PDF) (updated 4/8/24)

The Evidence of Coverage explains your plan benefits, your rights and responsibilities, and provides you with important contact information.

Evidence of Coverage - Tri-Cities Tennessee (PDF) (updated 4/8/24)

The Evidence of Coverage explains your plan benefits, your rights and responsibilities, and provides you with important contact information.

Pharmacy Directory (PDF) (updated 3/6/24)

The Pharmacy Directory provides you with a list of network pharmacies and their locations.

Comprehensive Formulary (PDF) (updated 4/1/24)

The Comprehensive Formulary is the list of drugs covered by this plan. The formulary also tells you if a drug is restricted.

Comprehensive Formulary - Large Print (PDF) (updated 4/1/24)

The Comprehensive Formulary is the list of drugs covered by this plan. The formulary also tells you if a drug is restricted.

Prior Authorization Criteria (PDF) (Updated 10/1/23)

The Prior Authorization Criteria explains what is needed to review certain drugs that require prior authorization.

Step Therapy Criteria (PDF) (Updated 10/1/23)

The Step Therapy Criteria explains what is needed to review certain drugs that require step therapy.

Quantity Limits Criteria (PDF) (Updated 10/1/23)

The Quantity Limits Criteria explains what is needed to review certain drugs with quantity limits.

CMS Star Ratings (PDF)

The Medicare program uses a 5 star system to rate all prescription drug plans based on quality and performance.