A Healthy CollaborationSM

What is the Medicare Coverage Gap?

The coverage gap in Medicare Part D Prescription Drug Plans and Medicare Advantage Plans with integrated Medicare Part D Prescription Drug Coverage is also known as the "donut hole". The "donut hole" 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 $2,700. At that point you become responsible for paying 100% of your prescription costs until you have paid $4,350 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.

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. Generic medicines are approved by the Federal Drug Administration and are just as effective as brand-name medicines. 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 will pay more for it. Our plans' customer service representatives are happy to give you a list 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.

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