Documents & Forms (1) | Part-D | Farm Bureau Health Plans

Documents & Forms

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2021 Plan Year Documents for Farm Bureau Select RX

Summary of Benefits
Annual Notice of Change (ANOC)
Evidence of Coverage
Pharmacy Directory
Comprehensive Formulary
Prior Authorization Criteria
Step Therapy Criteria
2021 LIS Premium Summary
2021 Enrollment Form

2021 Plan Year Documents for Farm Bureau Essential RX

Summary of Benefits
Annual Notice of Change (ANOC)
Evidence of Coverage
Pharmacy Directory
Comprehensive Formulary
Prior Authorization Criteria
Step Therapy Criteria
2021 LIS Premium Summary
2021 Enrollment Form

2021 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

2021 Premium Billing/Payment

Premium Payments FAQ
Bank Withdrawal Form
Credit Card Authorization Form