Exclusive Provider Organization (EPO)

What Is an Exclusive Provider Organization?

An Exclusive Provider Organization, or EPO, is a hybrid health insurance plan. In most conventional health insurance plans, the involvement of a primary care provider is necessary; however, that is not the case when it comes to an EPO.

How EPO Plans Work

In an EPO plan, you are not required to choose a primary care physician, though it is still recommended.  Instead of a primary care physician, a network of specific healthcare providers can serve as a substitute. However, the plan typically does not cover medical services administered outside of the in-network provider list. 

A typical EPO provider network will have a list that includes speech therapists, X-ray facilities, hospitals and a well-rounded selection of specialty doctors who you do not require a referral to see.  People under the terms of the plan will only be able to get service from those on the specified provider list in most circumstances, with the exception of emergency care.  If you opt to get services from out-of-network health providers, your medical services will not be covered by your EPO plan. 

Pros and Cons of an EPO

Pros of an EPO

In certain cases, a person may desire to see a healthcare specialist but would prefer not to have to get a referral to do so. Under the coverage of an EPO, those who do not want to have to procure a referral can have the time that it takes to see their desired specialist significantly expedited.

In addition to the swifter process of getting the attention of particular specialists without a referral, there is also the easily negotiable cost of the plan to consider.  EPO plans tend to be less expensive than their HMO and PPO counterparts because it limits patient access to specific health providers.  This allows EPO providers to negotiate lower rates with health care providers, and passes the savings on to those covered under the EPO plan.

Cons of an EPO

While an EPO can be an accommodating arrangement for those looking to see specialists without a referral, it may not be the best choice for everyone because it limits your choices when it comes to health providers. What an EPO covers is not extended to any out-of-network services, with the exception of a medical emergency.

How Does It Compare?


Unlike a Health Maintenance Organization, or HMO, an Exclusive Provider Organization compensates doctors for services under the classification of care provided. In an HMO plan, a doctor is compensated under the specifications outlined in a fee-for-service payment model.

When under Health Maintenance Organization coverage, the assistance provided won't extend to any healthcare providers who are not explicitly recognized as components of the plan itself. Unlike the EPO model, an HMO does have a requirement that those under its coverage need to have referrals and a primary care physician. 


In a Preferred Provider Organization, or PPO, the services of healthcare providers who aren't part of an official network can still be covered for a slightly inflated rate.  Under an Exclusive Provider Organization plan, any out-of-network medical services received will not be covered at all, with the exception of medical emergencies.

PPO plans tend to be more expensive than EPO plans because they will still cover out-of-network care, which means they have higher monthly premiums.  EPO plans avoid the higher medical costs by requiring you to stay in-network for medical care, and will in turn pass those savings onto you in the form of lower premiums. 

If your curious if an EPO plan is right for you, give one of our agents a call at 858-771-4087, or enter your zip code here for free health insurance quotes!