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What is an EPO?

Understanding your health plan options is essential when choosing a health plan for you and your family. One type of health plan that is often overlooked is the Exclusive Provider Organization (EPO). Let’s look at what an EPO is and how it works.

Learn about Exclusive Provider Organization (EPO) plans

An EPO is a type of health plan that falls somewhere between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) in terms of cost and flexibility. With an EPO, members have only in-network coverage (except for emergencies), but they do not need to select a primary care physician (PCP) or get referrals to see specialists.

How does EPO health insurance work?

Here are the fundamentals of an EPO plan.

Network coverage. EPO plans contract with doctors and hospitals to provide care to the health plan’s members. These providers are called “network providers” or “in-network providers,” and they include physicians, specialists, and facilities, like labs, hospitals, and urgent care centers. A provider that does not have a contract with the health plan is called an “out-of-network provider.”

  • EPO members are only covered for services received from in-network providers. So, it’s important for EPO members to know which providers are in their network.
  • EPO members are covered for emergency care no matter where they are — in or out of network.

Primary Care Physician. A PCP, or family physician, is a general practitioner who provides routine, everyday health care.

While EPO plan members aren’t required to use a PCP to coordinate their care, a PCP can help them manage their long-term health and save them time and money by helping them understand their options for certain services, including:

  • Retail clinics, urgent care centers, and telemedicine visits (if available to you)
  • Blood work and other laboratory services
  • Outpatient surgery

Costs. In addition to a monthly premium, EPO members may have out-of-pocket costs when they receive care.

  • Copay: A copay is the set amount a member pays for a covered health care service. For example, the copay to see a doctor could be $20, while the copay for an emergency room visit could be $100.
  • Deductible: This is the amount a member pays each year before the health plan starts to share the costs. For example, if the health plan has a $1,000 deductible, the member pays the first $1,000 of the costs for the services received. Once the deductible has been met, the insurance will pay for some or all health care services, depending on the health plan.
  • Coinsurance: This is the percentage you pay for some covered services. If your coinsurance is 20 percent, your health insurance company will pay 80 percent of the cost of covered services, and you will pay the remaining 20 percent. The amount you pay is typically not based on the full retail price of the service. It is based on a discounted rate negotiated by your insurance company with heath care providers like doctors and hospitals.

How does an EPO compare to other types of health insurance plans?

EPO compared to a PPO

PPOs offer members the most freedom to see providers both in- and out-of-network without referrals, whereas EPOs are limited to in-network providers. However, both types of plans provide members access to the BlueCard benefit. PPOs generally have the highest monthly premium of all the health plan types (e.g., HMO, EPO). Want to learn more? Check out What is a PPO?

EPO compared to an HMO

Like an EPO, an HMO plan requires you to use in-network providers (except for urgent and emergency care). But unlike an EPO, it does require you to select a PCP and to get referrals before seeing a specialist. Want to learn more about HMOs? Take an in-depth look: What is an HMO?

Should you get an Exclusive Provider Organization plan?

Independence Blue Cross offers three types of EPO plans, including an HSA-qualified plan option as well as a catastrophic plan option.

Personal Choice® EPO Bronze Basic Personal Choice® EPO Bronze Reserve with an HSA Personal Choice® EPO Catastrophic
Deductible $9,100 $7,450 $9,100
Primary care physician visit Visits 1-3: $20 no deductible
Visits 4+: 0% after deductible
0% after deductible Visits 1-3: $50 no deductible
Visits 4+: 0% after deductible
Specialist visit 0% after deductible 0% after deductible 0% after deductible
Inpatient hospital 0% after deductible 0% after deductible 0% after deductible
Generic prescription drugs $25 no deductible (integrated with medical deductible) 0% after deductible (integrated with medical deductible) 0% after deductible (integrated with medical deductible)

Compare all plans

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