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drug coverage gap

drug_cov_gap
pharmacy·Updated Jul 22, 2026

Definition

ISO-11179 Definition

A period in the Medicare Part D prescription drug benefit where beneficiary cost-sharing increases significantly after reaching the initial coverage limit until the catastrophic coverage threshold is reached, historically called the donut hole. The Inflation Reduction Act has phased out the traditional coverage gap beginning in 2025 with Medicare Part D restructured into deductible, initial coverage, and catastrophic phases with improved cost-sharing throughout the benefit year.

Standard Abbreviation

drug_cov_gap

Category

pharmacy

Production DDL — FACT_PHARMACY_CLAIM

FACT_PHARMACY_CLAIM.sql
CREATE OR REPLACE TABLE FACT_PHARMACY_CLAIM (
    rx_clm_key      INTEGER        NOT NULL  -- surrogate key,
    rx_clm_id       VARCHAR(50)    NOT NULL  -- pharmacy claim ID,
    mbr_key         INTEGER        NOT NULL  -- FK to DIM_MEMBER,
    ndc_cd          VARCHAR(11)              -- national drug code,
    drug_nm         VARCHAR(255)             -- drug name,
    drug_gnrc_ind   CHAR(1)                  -- generic indicator,
    days_sply_cnt   SMALLINT                 -- days supply count,
    qty_dspnd       DECIMAL(10,3)            -- quantity dispensed,
    rx_fill_dt      DATE                     -- fill date,
    formulary_tier  SMALLINT                 -- formulary tier,
    rx_cost_amt     DECIMAL(10,2)            -- total drug cost,
    mbr_pay_amt     DECIMAL(10,2)            -- member pay amount,
    plan_pay_amt    DECIMAL(10,2)            -- plan pay amount,
    prior_auth_ind  CHAR(1)                  -- prior auth required,
    load_dt         TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical pharmacy table. Convert to BigQuery or Databricks →

Why This Term Matters

Pharmacy data is among the most regulated and codified data in healthcare, governing controlled substances, PBM adjudication, and Medicare Part D reporting. A data engineer fluent in pharmacy terminology builds pipelines that correctly parse NDC codes, validate DEA numbers, and detect drug utilization anomalies before they reach compliance teams. Errors in pharmacy field definitions frequently trigger PBM contract disputes and CMS audit findings.

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