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Medicare Drug Coverage Gap or “Donut Hole”

A gap in coverage where the beneficiary pays 100% of drug costs up to a limit, created by Medicare Part D legislation. Affordable Care Act addresses this by offering rebate checks for participants who reach their coverage gap and by requiring pharmaceutical companies to offer discounts to consumers.

Claim

The process through with a beneficiary (or provider on behalf of a beneficiary) requests payment for a particular service.