Documents & Forms
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2023 Plan Year Documents for Farm Bureau Advantage HMO
- Summary of Benefits (Updated 6/13/23)
- Evidence of Coverage - Central Tennessee (Updated 4/27/23)
- Evidence of Coverage - Knoxville Tennessee (Updated 4/27/23)
- Evidence of Coverage - Tri-Cities Tennessee (Updated 4/27/23)
- Evidence of Coverage Errata (Updated 3-13-23)
- Provider Directory - Central Tennessee (Updated 9/13/23)
- Provider Directory - Knoxville Tennessee (Updated 9/13/23)
- Provider Directory - Tri-Cities Tennessee (Updated 9/13/23)
- Dental Provider Directory (Updated 9/7/23)
- VSP Provider Directory - Central Tennessee (Updated 11/14/23)
- VSP Provider Directory - Knoxville Tennessee (Updated 11/14/23)
- VSP Provider Directory - Tri-Cities Tennessee (Updated 11/14/23)
- TruHearing Provider Directory (8-7-23)
- Pharmacy Directory (Updated 11/6/23)
- Comprehensive Formulary (Updated 11/1/23)
- Comprehensive Formulary - Large Print (Updated 11/1/23)
- Medical - Prior Authorization Procedure Codes (Updated 11/2/23)
- Prescription Drug – Prior Authorization Criteria (Updated 11/1/23)
- Step Therapy Criteria (Updated 11/1/23)
- Quantity Limits Criteria (Updated 11/1/23)
- CMS Star Ratings (Updated 3/7/23)
- Pre-enrollment checklist (Updated 9/27/22)
- Enrollment Form (Updated 1/26/23)
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
- Evidence of Coverage - Knoxville Tennessee
- Evidence of Coverage - Tri-Cities Tennessee
- Provider Directory - Central Tennessee
- Provider Directory - Knoxville Tennessee
- Provider Directory - Tri-Cities Tennessee
- Pharmacy Directory
- Comprehensive Formulary (Updated 12/1/23)
- Comprehensive Formulary - Large Print (Updated 12/1/23)
- Medical - Prior Authorization Procedure Codes
- Prescription Drug - Prior Authorization Criteria (Updated 12/1/23)
- Step Therapy Criteria (Updated 12/1/23)
- Quantity Limits Criteria (Updated 11/1/23)
- CMS Star Ratings
- Pre-enrollment checklist
- Enrollment Form
- Sales Kit
2023 Other Forms & Documents
- Member Reimbursement Drug Claim Form (Updated 9/27/22)
- Appointment of Representative Form (Updated 9/27/22)
- Coverage Determination Request Form (Updated 1/11/23)
- Request for Redetermination (Updated 10/6/22)
- SSA Extra Help Information(Updated 9/27/22)
- Scope of Appointment (Updated 9/27/22)
- Authorization for Release of Protected Health Information (Updated 12/2/22)
- Prior Authorization Form (Updated 12/6/22)
- Medicare Advantage Subscriber Health Care Claim Form (Updated 1/17/23)
- Disenrollment Form (Updated 8/25/23
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
2023 Premium Billing/Payment
- Late Enrollment Penalty (LEP) Premium - Billing FAQ (Updated 6/1/23)
- Bank Withdrawal Form (Updated 6/7/23)