EPO vs. PPO: What's the difference?

Publish date: 9/30/2026

EPO and PPO are two types of health plans, and the acronyms alone can be confusing. The real difference between them comes down to one question: what happens when you need care outside the plan's network?

Both plan types are built around a network of contracted doctors, hospitals and other providers. HealthCare.gov describes plan types largely by how each one handles care you receive outside that network, and that's the biggest difference between an EPO and a PPO.

You can use this if you need it: Patient hands in their health insurance paperwork at a doctor's office.

Key facts about EPO and PPO plans

  • EPO stands for Exclusive Provider Organization. It generally covers non-emergency care only when you use providers in the plan's network.
  • PPO stands for Preferred Provider Organization. It generally lets you use providers outside the network, though you'll usually pay more.
  • The main difference between an EPO and a PPO is how each plan handles out-of-network care.
  • Many EPO and PPO plans do not require referrals to see specialists, but requirements vary by plan.
  • Networks, costs and covered services vary by plan. Review the plan's Summary of Benefits and Coverage before enrolling or scheduling care.

What is an EPO health plan?

EPO stands for Exclusive Provider Organization. HealthCare.gov defines it as a managed care plan where services are covered only if you go to doctors, specialists or hospitals in the plan's network. Emergency care is the exception to that rule.

That network rule makes it worth confirming that your preferred doctors and hospitals participate in the exact EPO you're considering. A provider can work with an insurance company without joining every network the company offers, and the CMS Health Insurance Basics guide recommends checking a plan's provider directory before scheduling care.

What is a PPO health plan?

PPO stands for Preferred Provider Organization. HealthCare.gov defines it as a plan that contracts with doctors, hospitals, and other providers to create a network of participating providers. You pay less when you use providers in that network.

You can also use doctors, hospitals, and other providers outside that network. That flexibility usually costs more. The CMS Health Insurance Basics guide notes that a PPO generally doesn't require a referral to see a specialist, whether you stay in network or go outside it.

How do EPO and PPO plans compare?

The clearest difference between the two plans is out-of-network coverage. Referral rules, prior authorization requirements, and member cost share amounts can also vary by plan.

Feature EPO PPO

Provider network

Requires members to use a defined network of providers for services to be covered

Encourages members to use a network of participating providers

In-network care

Covered under the plan's benefits

Usually costs less than out-of-network care

Majority of out-of-network care

Generally not covered

Generally covered at an added cost to the member

Emergency care

Covered as an exception to the in-network-only rule

Covered outside the network at the same cost share amount as in-network

These definitions come from HealthCare.gov and the CMS Health Insurance Basics guide.

Can you go out of network with an EPO or a PPO plan?

With an EPO, out-of-network care generally isn't covered. If you see an out-of-network provider for non-emergency care, you will likely be responsible for the full cost unless your plan identifies another exception.

With a PPO, you can generally use an out-of-network provider for covered services. That flexibility usually comes with higher costs, like a higher deductible or higher coinsurance, depending on the plan.

Emergency care works differently. Under federal protections that apply to many plans, insurers can't charge higher member cost share just because emergency care came from an out-of-network hospital. They also can't require prior approval for that emergency room visit. Grandfathered plans created before March 23, 2010 are exempt, so check your plan materials for the rules that apply to you.

Do EPO and PPO plans require referrals?

Referral rules aren't the defining difference between an EPO and a PPO. HealthCare.gov says PPO members can use out-of-network providers without a referral, and the CMS Health Insurance Basics guide says EPOs generally don't require a primary care referral to see a specialist either.

Individual plan rules can still differ. Referral requirements are also separate from prior authorization requirements, so check both before scheduling specialty care.

Which plan is right for you?

The right plan depends on the providers you want to use, the plan's network and benefits, and how much out-of-network flexibility matters to you.

  • Confirm your doctors and hospitals participate in the specific network, not just with the insurance company in general.
  • Compare total costs, including the premium, deductible, copayments, coinsurance and out-of-pocket limit, rather than judging a plan by one number.
  • Check whether referrals or prior authorization are required for the care you expect to use.
  • Review the full benefit package, including prescription drug coverage, alongside the network. Your plan's Summary of Benefits and Coverage is the best place to compare these details side by side.

Capital Blue Cross resources

Capital Blue Cross offers medical plans in 21 counties across Central Pennsylvania and the Lehigh Valley, with network options that vary by county.

  • MyCare Finder: search for in-network doctors and facilities and compare costs. Members can log in for results based on their plan, and people shopping for a plan can search as a guest.

FAQ

What is the difference between an EPO and a PPO?

An EPO generally covers non-emergency care only within its network. A PPO also covers out-of-network care, usually at a higher cost.

What does EPO stand for?

EPO stands for Exclusive Provider Organization.

What does PPO stand for?

PPO stands for Preferred Provider Organization.

Do EPO plans require referrals to see a specialist?

Generally, no. The CMS Health Insurance Basics guide says EPOs typically don't require a primary care referral to see a specialist, though individual plan rules can differ.

This is not medical advice and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment. The information provided is meant for a general audience. Capital Blue Cross and its affiliated companies believe this health education resource provides useful information but does not assume any liability associated with its use.