How Does Exclusive Provider Organization (EPO) Plan Work?

Getting a New Insurance Plan With Lower Monthly Premiums

If you’ve been looking for a new insurance plan, an Exclusive Provider Organization (EPO) plan might be a great option available through your health insurance brokers. EPO plans provide access to high-quality service providers with lower monthly premiums and no need for referrals before seeing a specialist.

How Does Exclusive Provider Organization (EPO) Plan Work?

What Is an Exclusive Provider Organization Plan?

EPO members receive medical care exclusively from the provider’s network of healthcare professionals. EPO plans offer an extensive network of doctors, hospitals, clinics, and other care providers for a wide variety of options and coverage for all essential services. Other than emergency situations, EPOs do not provide coverage for treatment or services that are received outside of the network. You’ll choose a primary care provider and do not need a referral if you want to seek care from a specialist.

How Do EPO Plans Work?

In order to create a provider network, insurers negotiate terms with healthcare provider agencies. These networks will include access to hospitals, pharmacies, imaging, general and specialty healthcare providers, labs, therapists, surgeries, and other healthcare services.

Patients who choose to seek treatment outside of the established network will not receive coverage, so it’s imperative to verify whether your healthcare provider is part of the EPO. There are three exceptions to the in-network requirement:

  • When your EPO plan does not cover a particular specialty in-network
  • When you are already completing a complex treatment plan and then join the EPO
  • In a true emergency, when you need to visit the nearest emergency room

What are The Primary Features of an EPO Plan?

Your Rapid Valley health insurance agent can help you understand the key features of EPO plans, which include:

  • No coverage for out-of-network visits and treatments
  • Pre-authorization if you want to visit an out-of-network provider
  • A requirement to select a primary healthcare provider
  • No need for a referral in order to receive coverage for specialist visits
  • Low premiums, but healthcare visits will typically carry a deductible and may carry a higher out-of-pocket maximum than other types of plans

What Is The Cost of an EPO Plan?

The terms and conditions of each individual EPO plan will vary, so consult with your health insurance agency to learn more about what specific plans and coverage are available to you.

What Should I Know About an EPO Before I Select One?

Take time to consider all available plans through your Colonial Pine Hills health insurance brokers before you commit to applying for any particular health insurance plans. Ask your agent for details regarding:

  • The cost of premiums and how frequently they must be paid
  • The annual deductible amount and out-of-pocket maximum amount
  • When the EPO plan will cover all remaining costs
  • Whether any co-pays will be applicable for certain healthcare services
  • What pharmacy options will you have through the EPO
  • Whether any coinsurance may be applicable
  • What healthcare facilities, services, and providers are available through the EPO to verify that the EPO will cover all of your healthcare needs
  • What services or visits will require pre-authorization

EPO plans are an excellent choice for many people. Patients frequently opt for an EPO plan because it is one of the least expensive health insurance plans that are available. Additionally, the ability to consult with a specialist without having to wait for a referral can be very helpful for many people.

In order to keep costs low, some EPO providers will require pre-authorization for more expensive treatments and medication. This includes imaging such as MRI and CT scans, expensive surgeries, higher cost prescription medications, and some hospitalizations. Pre-authorization helps ensure that healthcare plans provide only necessary services and then pass on those savings to the EPO plan members who enjoy affordable insurance premiums. If you want to work with an out-of-network provider, are seeking an expensive medication, or are considering a non-essential surgery, your healthcare provider will ask the insurer for pre-authorization. This may take a few hours to a week, depending on the need.

Your healthcare provider will file bills and claims directly to your insurer, keeping your EPO plan convenient and free of hassle.

Find The Right Health Insurance Plan For You

The agents at South Dakota Health Insurance are ready to help you find the perfect health insurance plan for your needs. We have access to a wide variety of plans, including EPO, HMO, PPO, and Medicare plans, and contracts with nationally recognized carriers. Our experienced agents work with individuals, businesses, and institutions to provide affordable and comprehensive healthcare insurance options so you can find the best plan that meets your needs and budget. Contact us today to talk with a professional health insurance broker who can help you understand your options.


South Dakota Health Insurance
5040 Saturn Dr,
Rapid City, SD 57703

Tel: 605-653-3824