What Is an EPO Health Plan?

An Exclusive Provider Organization (EPO) is a managed care plan where services are covered only if you go to doctors, specialists and hospitals in the plan’s network. The only exception to this rule is in the case of an emergency. The network of providers of an EPO are generally larger than with a Health Maintenance Organization (HMO). And with an EPO, they may or may not require referrals from a primary care physician. So check out this detail before signing up for an EPO plan.

If you can find an EPO plan that doesn’t require referrals from a primary care physician, you’ll have a bit more freedom with your health care choices. How much does an EPO plan cost? Premiums with EPOs are higher than HMOs and lower than with a Preferred Provider Organization (PPO). So the price falls in between those two popular health plans. EPO health plans generally have low co-pays and deductibles as well. So they can be affordable health care choices, as long as you stay in the plan’s network for services.

Shopping for an EPO Plan

Think an EPO plan may be the best choice for you and your family? Study the plan details carefully. How much does it cost to visit an in-network physician? What is the plan’s copay per visit? This is how much you pay out of your own pocket per doctor visit. What is the deductible for the plan? A deductible is the amount you pay for covered health care services before your insurance plans start to pay. What is the premium? A premium is the amount of money charged by your insurance company for the health plan that you’ve chosen. Tally up the co-pays, deductible and premium and you’ve got the key costs of an EPO health plan.

Compare Health Insurance Quotes

Here’s another important cost to consider. Check for an EPO health plan’s out-of-pocket maximum. The out-of-pocket maximum is the most you’ll have to personally for covered medical services in a year. After you reach the out-of-pocket maximum, the insurance company will pay 100 percent of covered services. This is an important number to know. So check it out when you are researching an EPO health plan.

Does your EPO plan require you to have a primary care physician to make referrals to other specialists? Some EPO plans do and some don’t.

And maybe most importantly, take a close look at the plan’s network of doctors, specialists and hospitals. Are your favorite doctors already part of this network? Or will you have to pick new doctors and specialists? Is the hospital near you? You won’t want to travel long distances if a loved one needs hospital care.

An EPO plan works best when you stick to in-network doctors and specialists. Out-of-network health services means you pay out of your own pocket unless it is an emergency. So get familiar with your network of providers and stick with it for your medical care.

Pinpointing Your Medical Needs

Still not sure if an EPO is right for you and your family? Take a moment and assess your medical needs. What is your most pressing medical concern? Have you had surgery in the past year? Were you in the hospital? Do you see specialists regularly? Will an EPO plan’s network of providers cover your needs? Make a list of your medical needs and then compare them to what an EPO plan offers. You’ll have a clearer picture if an EPO plan is a good match for you.

Other Health Plan Options

Still undecided about an EPO plan? Here are some other health plan options for you to consider.


With a HMO plan, you must choose from the plan’s network of doctors, specialists and hospitals and you must see a primary care physician for referrals to specialists. Other than an emergency, all other out-of-network services are paid for out of your own pocket. HMO provider networks tend to be smaller than EPO networks. HMOs come with low premiums and low copays for doctor visits. With a HMO, you also may have a low deductible or even a no deductible health plan. A HMO plan might be right for you if you are comfortable having a primary care physician coordinate your health care and you don’t mind choosing from a smaller network of providers.


PPO plans offer a large provider network so you will have plenty of doctors, specialists and hospitals to choose from. But all that choice comes with a price. You’ll pay a higher premium with a PPO than you would with an EPO plan. There also are no referrals needed with a PPO. So you have the convenience of choosing your own doctors and specialists directly. A PPO plan may be right for you if you like a lot of choices in your medical providers and you don’t mind paying more in price.

Comparing Health Plan Offers

Weigh the pros and cons of each plan carefully. Which one most meets the health care needs and cost constraints of your family? You want the health insurance coverage that you are looking for at a price you can afford.

Are you looking for a private health care plan? To get the best deal on price you’ll need to get insurance quotes from several different insurance providers. SmartFinancial makes this easy to do. With SmartFinancial’s help you’ll be comparing health insurance plans from insurance providers near you in no time. SmartFinancial has access to more than 200 insurance companies so you are bound to find the health insurance coverage and price that you are looking for.

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