Documents & Forms
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2024 Plan Year Documents for Farm Bureau Select RX
2024 Plan Year Documents for Farm Bureau Essential RX
- Summary of Benefits
- Annual Notice of Change (ANOC)
- Evidence of Coverage
- Pharmacy Directory
- Comprehensive Formulary
- Comprehensive Formulary - Large Print
- Prior Authorization Criteria
- Step Therapy Criteria
- Quantity Limits Criteria
- 2024 LIS Premium Summary
- CMS Star Ratings
- 2024 Enrollment Form
- 2024 Enrollment Checklist
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