Documents & Forms
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2023 Plan Year Documents for Farm Bureau Advantage HMO
- Summary of Benefits (Updated 11/3/22)
- 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 5/1/23)
- Provider Directory - Knoxville Tennessee (Updated 5/1/23)
- Provider Directory - Tri-Cities Tennessee (Updated 5/1/23)
- Dental Provider Directory (Updated 4/3/23)
- VSP Provider Directory - Central Tennessee (Updated 4/21/23)
- VSP Provider Directory - Knoxville Tennessee (Updated 4/21/23)
- VSP Provider Directory - Tri-Cities Tennessee (Updated 4/21/23)
- TruHearing Provider Directory (5-5-23)
- Pharmacy Directory (Updated 3/15/23)
- Comprehensive Formulary - Central Tennessee (Updated 5/1/23)
- Comprehensive Formulary - Central Tennessee - Large Print (Updated 5/1/23)
- Comprehensive Formulary - Knoxville Tennessee (Updated 5/1/23)
- Comprehensive Formulary - Knoxville Tennessee - Large Print (Updated 5/1/23)
- Comprehensive Formulary - Tri-Cities Tennessee(Updated 5/1/23)
- Comprehensive Formulary - Tri-Cities Tennessee - Large Print (Updated 5/1/23)
- Medical - Prior Authorization Procedure Codes (Updated 3/24/23)
- Prescription Drug – Prior Authorization Criteria (Updated 5/1/23)
- Step Therapy Criteria (Updated 5/1/23)
- Quantity Limits Criteria (Updated 5/1/23)
- CMS Star Ratings (Updated 3/7/23)
- Annual Enrollment Period (Updated 9/27/22)
- Pre-enrollment checklist (Updated 9/27/22)
- Individual Enrollment Request Form (Updated 1/26/23)
- Enrollment Form (Updated 1/26/23)
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 3/10/23
2023 Premium Billing/Payment
- Premium Payments FAQ (Updated 10/14/22)
- Bank Withdrawal Form (Updated 9/27/22)