National Provider Identifier (NPI)

A number that identifies a healthcare professional for the purposes of receiving payment from insurers, specifically Medicare. A ten digit number.

Open Enrollment

The designated time each year when you can purchase, apply for, and make changes to an insurance plan for the upcoming year. It is typically November 15th through December 1st, unless modified by an employer or if you have a qualifying life event that has occurred.

Open Formulary

A formulary of medications where drugs that are not listed might be covered at a higher cost.

Out of Network

Facilities, providers, and suppliers like doctors, hospitals, and pharmacies that your health insurance company does not contract with. Going to an out of network facility is typically associated with a higher rate or is not covered at all by insurance.

Out of Pocket Costs

Healthcare costs not covered by an insurance plan or included in a plan's premium. Generally includes copayments (fixed cost per service), coinsurance (fixed percentage per service), and an annual deductible (cost that patient must pay per year before insurance will pay for services). Total health insurance costs thus include BOTH the premium AND the out-of-pocket costs.

Out of Pocket Maximum

A limit in the amount of money paid for covered health care services in a plan year. If met, your health plan will pay 100% of all covered health care costs for the rest of the year. For example, if your out-of-pocket maximum is $5,000 and you have spend that by October, your insurance plan will pay 100% of covered services in November and December of that year.

Over-the-Counter (OTC) Drug

A medication that can be purchased by a patient without a physician prescription but are usually not covered by insurance. Some plans will cover OTC drugs if they are prescribed by a doctor, and employers can offer a Flexible Spending Arrangement (FSA) or Health Reimbursement Arrangement (HRA), which is an employer-managed account of pre-taxed dollars set aside specifically for OTC drugs or other healthcare purchases.

Panel

A group of patients that regularly see one doctor. For example, if you are established with Dr. Jones for primary care, you are in his panel of patients.

Pay or Play Mandate

A provision of the Affordable Care Act requiring employers with 50 or more full-time employees to offer health insurance ("playing") or paying a penalty ("paying"). Part-time and seasonal employees are excluded from the mandate.

Per Diem

Payments made to a hospital or healthcare facility "by the day" regardless of services provided during that day. For instance, if you stay in the hospital for three days, each day has a flat per diem rate regardless of the treatments you get each day.

Pharmacy Benefit Manager (PBM)

A third party that administers pharmaceutical benefits on behalf of an insurance company. Manages formularies, processes and pays pharmaceutical claims to a patient, and draws up contracts with local pharmacies and drug manufacturers.

Pharmacy and Therapeutics (P&T) Committee

A committee of physicians, pharmacists, and other health professionals that develop and update insurance plan formularies.