Understanding the Medicare Coverage Gap

What is the Medicare Coverage Gap?

The coverage gap in Medicare Part D Prescription Drug Plans and Medicare Advantage Plans with Medicare Part D Prescription Drug Coverage is also known as the "donut hole". The coverage gap is the point where you become responsible for paying the full costs of your prescription medicines.*

The coverage gap is a standard guideline set by Medicare. All Medicare prescription drug plans have a coverage gap, but some plans offer additional coverage to help get your through the gap.

You reach the coverage gap after your total yearly drug costs – paid by you and your plan – have reached $2,830. At that point you become responsible for paying 100% of your prescription costs until you have paid $4,550 in yearly out-of-pocket costs, as this chart below explains. Depending on how many prescription medicines you use a year, you may not reach the coverage cap.

How Medicare Part D Works
1		Deductible & annual premiums (if applicable)
2		Percentages you and Medicare pay before your total drug costs reach $2,830
3		What you pay after your total yearly drug costs have reached $2,830 and until your yearly out-of-pocket costs reach $4,550 (called coverage gap)
4		Only if your yearly out-of-pocket drug costs exceed $4,550
	Your out-of-pocket costs
	Medicare’s contribution to costs

More Questions about the Coverage Gap

How can I avoid reaching the coverage gap?

Using generic medicine is the easiest way. Many of Universal American's plans offer generic drugs at low or no cost, depending on the plan. By using covered generics, you won't reach the coverage gap as quickly, and in some cases, not at all. Check with your doctor about using generics.

My medicine is not available in a generic version. Is there anything else I can do?

Some brand-name drugs cost less than others. If your medicine is not on your plan's list of "preferred" medicines, you may pay more for it. Our plans' customer service representatives are happy to give you a list of similar medicines on our formulary that will be less expensive. Then, ask your doctor if the other medicine is safe and effective for you and if he or she will prescribe it.

You may be able to get Extra Help to pay for your prescription drug premiums and costs.

To see if you qualify for getting Extra Help, call:

• 1-800-MEDICARE (1-800-633-4227)
  (TTY/TDD users call 1-877-486-2048)
  24 hours a day/7 days a week
• Social Security Administration at 1-800-772-1213
  (TTY/TDD users call, 1-800-325-0778)
  between 7:00 a.m. and 7:00 p.m., Monday through Friday
• Your state Medicaid Office

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for seventy-five percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.

For full information on plan benefits, call our Customer Service Department at 1-866-249-8668 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 1-800-777-9083) every day.

*You must continue to pay your Medicare Part B premium