2024 Farm Bureau Advantage HMO

* Services may require Prior Authorization and may require a Primary Care Physician (PCP) Referral.

** Does not count toward your out of pocket maximum.

*** Medicare Covered Benefits only. Routine care and other chiropractic services not covered.

**** Most DMEs require Prior Authorization and a Referral from you PCP.

***** Diabetic supplies are limited to specific manufacturers. Test strips and monitors: One Touch, Accu-Check. Continuous glucose monitors available from Freestyle Libre or Dexcom after completing a prior authorization.

****** Amounts do not roll over to next 3 month period.

Initial Coverage Limit is $5,030.00. During the Initial Coverage state, the plan pays its share of the cost of your covered prescriptions and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription. Please review the Evidence of Coverage online for more information on the phases of the benefit.

You stay in this stage until your out of pocket costs reach a total of $8,000.00. When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs. You pay 25% of the negotiated price and a portion of the dispensing fees for brand name drugs. Please
review the Evidence of Coverage online for more information on the Coverage Gap Stage.

Coverage Gap Stage coinsurance requirements do not apply to Part D covered insulin products and most adult Part D vaccines, including shingles, tetanus, and travel vaccines. You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier.

Catastrophic Coverage Limit is $8,000.00. Catastrophic coverage begins after your total yearly drug cost reaches $8,000.00. During this time, the plan pays all of the cost for your drugs. Please reference the Evidence of Coverage, available online, for complete information regarding the Catastrophic Coverage Stage.

Insulin is covered at no more than $35 per month or 30 day supply regardless of coverage tier. Insulin drugs are covered under Tier 3 and Tier 4.

Summary of Benefits (PDF) (updated 10/1/23)

The Summary of Benefits provides an overview of the plan benefits.

Enrollment Form (PDF) (updated 10/1/23)

If you would like to enroll for one of our plans, you can complete the Enrollment Form and mail it to us.

Annual Wellness Visit - Checklist (PDF) (updated 6/13/24)

CMS covers the cost of an annual wellness visit (also referred to as a “Medicare Wellness Visit”) once every twelve (12) months to develop, or update, a beneficiary’s Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA).

Evidence of Coverage - Central Tennessee (PDF) (updated 4/8/24)

The Evidence of Coverage explains your plan benefits, your rights and responsibilities, and provides you with important contact information.

Evidence of Coverage - Knoxville Tennessee (PDF) (updated 4/8/24)

The Evidence of Coverage explains your plan benefits, your rights and responsibilities, and provides you with important contact information.

Evidence of Coverage - Tri-Cities Tennessee (PDF) (updated 4/8/24)

The Evidence of Coverage explains your plan benefits, your rights and responsibilities, and provides you with important contact information.

Pharmacy Directory (PDF) (updated 10/30/24)

The Pharmacy Directory provides you with a list of network pharmacies and their locations.

Comprehensive Formulary (PDF) (updated 11/1/24)

The Comprehensive Formulary is the list of drugs covered by this plan. The formulary also tells you if a drug is restricted.

Comprehensive Formulary - Large Print (PDF) (updated 11/1/24)

The Comprehensive Formulary is the list of drugs covered by this plan. The formulary also tells you if a drug is restricted.

Prior Authorization Criteria (PDF) (Updated 11/1/24)

The Prior Authorization Criteria explains what is needed to review certain drugs that require prior authorization.

Step Therapy Criteria (PDF) (Updated 11/1/24)

The Step Therapy Criteria explains what is needed to review certain drugs that require step therapy.

Quantity Limits Criteria (PDF) (Updated 11/1/24)

The Quantity Limits Criteria explains what is needed to review certain drugs with quantity limits.

CMS Star Ratings (PDF)

The Medicare program uses a 5 star system to rate all prescription drug plans based on quality and performance.