Documents & Forms
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2023 Plan Year Documents for Farm Bureau Select RX
- Summary of Benefits
- Annual Notice of Change (ANOC)
- Annual Notice of Change (ANOC) Errata
- Evidence of Coverage
- Pharmacy Directory
- Comprehensive Formulary
- Comprehensive Formulary - Large Print
- Prior Authorization Criteria
- Step Therapy Criteria
- Quantity Limits Criteria
- 2023 Lis Premium Summary
- CMS Star Ratings
2024 Plan Year Documents for Farm Bureau Select RX
2023 Plan Year Documents for Farm Bureau Essential RX
2024 Plan Year Documents for Farm Bureau Essential RX
2023 Other Forms & Documents
2024 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
- Sales Kits
- Prescription Drug Home Delivery Form and FAQ's
- Safe Disposal Language
- Authorization for Release of Protected Health Information
- Disenrollment Form