Documents Library for Medicare Supplement & Large Group Medical Insurance

Listed below are brochures, applications and relevant forms for the PBT Large Group Health, and Medicare Supplement plan options. For additional information or help with the application process, please call 1-800-621-0748 and one of our Customer Service Representatives will be happy to assist you.

Medicare Supplement Insurance for Individuals:

Medicare Supplement Insurance (For ISMS/CMS members and spouses turning 65, or older):

Plan A Outline of Coverage
Plan F Outline of Coverage
Plan N Outline of Coverage
Medicare Supplement Plan Rates

Large Group Health Insurance Program
(51 or more eligible employees):

Insurance Plan Charts:

PBT Preferred Provider Option (PPO)
PBT Preferred Choice Indemnity
PBT Health Savings Account (HSA)-Qualified High Deductible Plans
Group Application and Change Form (for initial application, new employees/hires, and additions and/or changes to current coverage). Please read and follow the instruction on Page 1. Complete only those sections that pertain to the action you wish to take.

Claim Forms:

Medical claim form

Important Notices:

2016 HSA Limits for Contributions


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