EPO vs PPO: Which Health Plan Fits Your Needs?

Choosing between an EPO and a PPO health insurance plan can feel overwhelming. Both offer valuable coverage, but the difference between PPO and EPO plans in network access, costs, and flexibility can significantly impact your healthcare experience and budget. Understanding what sets these plans apart will help you make the right choice for your employees or your business.

What Is an EPO?

An Exclusive Provider Organization, commonly called an EPO, is a managed care health insurance plan that requires you to use doctors and hospitals within its network. Similar to an HMO, an EPO doesn't cover out-of-network care except in medical emergencies. However, unlike an HMO, you don't need referrals to see specialists as long as they're in-network.

So what is EPO coverage best suited for? EPO plans typically offer lower monthly premiums because they work with a narrower network of providers. The trade-off is less flexibility. If you need to see a doctor outside the network for non-emergency care, you'll likely pay the full cost out of pocket.

EPO and HMO plans have become increasingly common in the individual insurance market, making up a significant portion of Marketplace plans nationwide.

What Is a PPO?

A Preferred Provider Organization, or PPO, offers greater flexibility when choosing healthcare providers. You can visit both in-network and out-of-network doctors and hospitals, though out-of-network services will cost more. According to the 2025 KFF Employer Health Benefits Survey, 46% of covered workers are enrolled in a PPO, making it the most popular plan type in employer-sponsored coverage.

What is PPO coverage best suited for? PPO plans don't require referrals to see specialists, giving you direct access to the care you need. The extra flexibility comes at a price. PPOs generally have higher monthly premiums and higher out-of-pocket costs compared to EPOs or HMOs.

For employees who travel frequently, live between multiple locations, or want the freedom to choose their own specialists without network restrictions, a PPO can be worth the additional cost.

EPO vs PPO: Key Differences

Here's how EPO and PPO plans compare across the most important factors:

Network Coverage and Provider Access

The biggest difference between PPO and EPO plans is network coverage. EPOs restrict coverage to in-network providers only. If you see an out-of-network doctor for anything other than an emergency, you'll pay the entire bill yourself.

PPOs cover both in-network and out-of-network care. You'll pay less when you stay in-network, but you still have coverage if you need to go outside the network. The plan might cover 60-80% of out-of-network costs after you meet a higher deductible.

Cost Differences

EPO plans typically have lower monthly premiums and lower deductibles. Because the network is smaller and more controlled, insurance companies can negotiate better rates and pass savings on to members.

PPO plans come with higher monthly premiums. The average annual premium for employer-sponsored family coverage in 2025 is $26,993, with PPO plans averaging $28,272 for family coverage. PPOs also have higher deductibles and out-of-pocket maximums, especially for out-of-network care.

Referrals and Administrative Requirements

Good news: neither EPOs nor PPOs require referrals to see specialists. Once you're enrolled, you can schedule appointments with specialists directly without going through a primary care physician first.

The catch with EPOs is that your specialist must be in-network. PPOs give you the freedom to see any specialist you choose, whether they're in-network or not.

Which Plan Is Best for Your Needs?

Choose an EPO if:

• You want lower monthly premiums and are comfortable with a smaller network
• Your preferred doctors and hospitals are in the EPO network
• You don't anticipate needing specialized care outside your local area
• You're generally healthy and don't expect frequent medical visits
• Budget predictability is your top priority

Choose a PPO if:

• You need flexibility to see out-of-network providers
• You travel frequently or split time between different locations
• You have ongoing relationships with specialists who might not be in-network
• You're willing to pay higher premiums for more choices
• You have chronic conditions requiring care from multiple specialists

Consider Your Workforce Demographics

For employers, the right choice often depends on your workforce. Companies with younger, healthier employees might find that EPO plans offer the cost savings employees appreciate. Organizations with older employees or those with chronic conditions might see better satisfaction with PPO flexibility.

Geographic distribution matters too. If your team is spread across multiple states or regions, PPO plans can make it easier for everyone to access care. Concentrated workforces in a single metro area might do well with an EPO's robust local network.

For enterprise companies, offering multiple plan types can address diverse employee needs while managing costs. Small and mid-sized businesses often benefit from understanding their workforce demographics before selecting a single plan type.

How ICHRA Gives You More Options

An Individual Coverage Health Reimbursement Arrangement, or ICHRA, lets employers reimburse employees for individual health insurance premiums, including both EPO and PPO plans. Instead of choosing a single group plan, each employee can select the coverage that fits their needs and budget.

With ICHRA, you can set a defined contribution for health benefits while employees choose between EPO and PPO plans based on their preferences. Some might prioritize lower premiums with an EPO, while others value PPO flexibility. This approach works especially well for startups building their first benefits package and brokers looking to offer clients more personalized solutions.

How We Can Help

At Venteur, we make it simple for employers to offer flexible health benefits without the administrative headache. Our ICHRA platform provides a personalized plan-buying experience that helps employees compare EPO and PPO options side by side. The employer experience is fully compliant and integrates with your payroll provider, so you can focus on running your business.

Whether your employees prefer the cost savings of an EPO or the flexibility of a PPO, our platform supports nationwide coverage across all 50 states. You set the contribution amount, and your team gets to choose the plan that works best for them.