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Outline of Benefits
The plan covers prescription charges in excess of the copay amount. The benefits are obtained by the use of an identifications card issued by Caremark, Inc to the employee upon enrollment. To access ben- Real Benefits
efits, the employee presents the identification card along with a valid prescription to the participating pharmacy and pays the applicable Budget Certainty
No Waiting Period or Pre-existing condition exclusions. No
The Value Generic Insured
Generic Drug Maximum Benefit Limitations of Coverage.
GENERAL EXCLUSIONS AND LIMITATIONS:1. Any prescription
Prescription Plans
refilled in excess of the number of refills specified by the physician, or any refill dispensed after 1 year from the Prescriber’s original order.2. Any quantity of medications dispensed for more than a [30-day] supply from a Partici-pating Retail Pharmacy or [90-day] supply through the Pharmacy Benefit Manager.3. Medication for which the cost is recoverable under any Workers’ Compensation or Occupational Disease Law or any State or Governmental Agency, or medication furnished by any other Drug or Medical Service for which no charge is made to the Covered Person.4. Medication that is to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent hospital, nursing home, or similar institu-tion that operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals.5. Federal and Non-Federal Legend Non-Drugs.6. Charges for the administration or injection of any drug.7. Sub-stance abuse treatment.8. Therapeutic devices and appliances.9. Prescriptions for household pets.10. Medications not dispensed by a Participating Retail Pharmacy or the Pharmacy Benefit Manager. 11. The following drugs (both the Brand-name Drugs or Generic Drugs) are only available at the Brand-Name drugs pricing noted in the Plan Benefit Schedule section:Single source generic drugs i.e., those available from only a single manufacturer Impotence and erectile function medications Smoking deterrents (except Zyban®)Anti-obesity medications Drugs whose sole purpose is to promote or stimulate hair growth or for cosmetic purposes only. 12. Isotretinoin products (Brand-name Drugs and Generic Drugs) including Accutane®, Amnesteem®, Sotret® and Claravis™. 13. Over-the-counter drugs and vitamins. 14. Ostomy supplies. 15. Non-systemic contraceptives, devices, implants, and injections. 16. Compound prescription drug products. 17. Topical fluoride products. 18. GlucoWatch®/GlucoWatch® Sensors. 19. Drugs labeled “Caution—limited by Federal law to investigational use”, or experimental drugs, even though a charge is made to the individual. 20. Fertility Agents (except those Specialty Drugs which may Value Generic Insured Prescription Plans
be subject to the Generic Drug Benefits section). 21. Injectable Medications (except Brand-name Insulin & those which are Specialty Drugs subject to the Prescription Drug Benefits Provision). 22. Biologicals, Immunization Agents, Underwritten by: Stonebridge Life Insurance Company
Vaccines, Allergy Sera, Blood or Blood Plasma Products (except those Special-ty Drugs which may be subject to the Prescription Drug Benefits Provision). 23. Other drugs as determined by us and the Pharmacy Benefits Manager. We will provide 60 days notice before adding a drug to this list of exclusions. Dispensing Limits 30 day retail and 90 day mail order Pharmacy Benefit Administered by Caremark, Inc. Gulf Guaranty Employee Benefit Services, Inc. Administered by: Gulf Guaranty Employee
Benefit Services, Inc.
Jackson, MS 39236-4977www.ggebs.com www.ggebs.com
Not Your Same Old Generic or
The Insured Value Generic Plans
Discount Card Program.
Typical Plan Benefits at a Glance
Real Prescription Insurance
• No maximum benefit limitations on Covered . . . Real Benefits Budget Certainty.
• No more than $10 copayment for all other • Deeply discounted Brand drugs or Brand Drug • Accepted at 99% of all retail pharmacies including nationwide chains (Walgreens, CVS, • 90 day mail order through CVS Pharmacy. • Prescription drug screening to check for drug interactions and other medication safety issues.
• The Value Generic Plans improve medication access that improves health care and quality of life.
• No plan maximums or gimmicks that reduce access to needed generic medications.
Some provisions, benefits, exclusions or limitations listed, may vary depending on your state of residence.
• Insured Brand drug coverage available, generic only plans provide aggressive managed care Gulf Guaranty Employee
Benefit Services, Inc.
The Value Generic Plans provide a list of low cost generics for only $3.99 for a 30 day supply. For all Since 1990 Gulf Guaranty has focused on providing in- other generics we provide those at no more than $10 novative solutions that manage the benefit cost for its client’s copayment with no monthly or annual employee coast to coast. By partnering with Stonebridge Life Insurance maximums for covered generic drugs. With more Company and Caremark, a national leader in Pharmacy Benefit and more drugs becoming available in generic form, Services, Gulf Guaranty is excited to be offering the most innova- most all medical conditions can now be treated with tive prescription drug solution available in the market today. The a generic drug. An optional brand drug coverage co- Value Generic Plans offer a solution to the needs of the health payment can be added to our value generic plans if care market for a real prescription drug benefit.

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