Exclusive Provider Organization (EPO) Overview
Exclusive Provider Organization (EPO) Overview
At CDPHP, we take care to make sure the providers you interact with are providing the best care they can. Imagine in-network care with no paperwork, no referrals, and no surprises.
The EPO plan includes:
- Affordable copayments or coinsurance per visit after meeting your deductible (if any)
- No claim forms or referrals
- No charge for certain preventive care, including routine annual exams and screenings
- Freedom to select your own providers of care within our national network
- Worldwide coverage for emergency care
How it Works
With an EPO you simply select a primary care physician (PCP) from our national network of doctors and that doctor coordinates your care and refers you to network specialists as needed. You are responsible for paying a small fee called a copayment when you visit a doctor, fill a prescription, or visit a hospital.
FAQs
Q. Do I have access to out-of-network benefits?
A. Members of the EPO do not have coverage outside the CDPHP network. Please refer to the benefit materials provided to you at the time of enrollment for specifics on your out-of-pocket costs. These vary according to the plan purchased by your employer group.
This summary offers highlights but does not detail all benefits, limitations, or exclusions. It is not a contract and may be subject to change. For more detailed information, a Membership Certificate is available upon request.
Note: The EPO Plan is underwritten by CDPHP Universal Benefits, Inc. (CDPHP UBI). You must comply with CDPHP UBI’s managed benefits program as set forth in the contract to receive the maximum benefits for all services. Failure to do so will result in you being responsible for an additional payment of 50% of the allowed amount up to a maximum of $500 for each service otherwise payable, in addition to the applicable copayment, deductible, and/or coinsurance, unless penalty is waived by rider.
No Paperwork. No Referrals. And No Surprises.
How it Works
At CDPHP, we believe our most important job is to provide you access to care that helps keep you healthy. That’s why our EPO plan provides full coverage with no out-of-pocket costs for routine physicals, immunizations, well-baby/well-child care, worldwide emergency care, and more. Convenient and cost-effective, our EPO plan provides coverage with the most choices. And, unlike other managed care plans, you don’t have to select a primary care physician (PCP).
Getting great care is easy with our EPO.
Just keep these tips in mind:
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Generally, you should see or call a CDPHP participating practitioner or provider when you need medical care.
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If you need to see a specialist, go to a doctor who is in the CDPHP network.
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Always carry your CDPHP ID card and use it for ALL medical care.
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Always use CDPHP participating practitioners and providers unless it is an emergency or you have prior written authorization from CDPHP.
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You pay only your deductible (if any), copayment, and/or coinsurance for each visit to a participating practitioner and provider.
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This plan does not require that a primary care physician (PCP) direct your care. But, in order for the care to be covered, it must be delivered by a network practitioner or provider.
EPO Plan Tools
EPO Plan Tools
Here are some tools that might be helpful to you if you have an EPO plan.
EPO Member Tip Sheet
Find tips to help you understand everything in your plan from pharmacy benefits, to what to do at the time of care.
EPO Member Handbook
Download this complete guide to your EPO coverage and all of the services available to you in this comprehensive plan.
Secure Online Site Access for Members
Find answers to many of your questions, check your claims, change your primary care provider, update your address, order new ID cards, and more – all online, 24/7.
Find-A-Doc
Search the most current listing of providers in our network.
Wellness Workshops
Sign up for a free wellness and fitness classes! See the line-up of classes and register online.
Forms
Find any forms you may need to complete as you use your EPO plan.
Is Your Prescription Covered?
Use a helpful drug search tool to find information on coverage, pricing, and prescription details.
EPO FAQs
EPO FAQs
Get answers to the most common questions about EPO plans.
Q. What should I do if I have an emergency when I’m out of the area?
A. A medical emergency is defined as a sudden illness or injury so severe that the average person would believe that immediate medical attention is needed to avoid serious health damage or bodily harm.
If you have an emergency outside the CDPHP service area, go to the nearest hospital emergency room. CDPHP will cover the hospital emergency room bill in full — minus your copayment. If the situation is urgent but not an emergency, such as a sore throat, sprain, or infection, contact the CDPHP Resource Coordination Department at 1-800-274-2332 for advice in obtaining the care you need. CDPHP has a national network and can frequently locate a participating provider.
Q. How do I access my out-of-network benefits?
A. Members of the EPO do not have coverage outside the CDPHP network. Please refer to the benefit materials provided to you at the time of enrollment for specifics on your out-of-pocket costs. These vary according to the plan purchased by your employer group.
Q. Do I have to choose a PCP to direct my care?
If you have EPO coverage you do not need to select a PCP. However, we still recommend that you establish yourself with a doctor who will deliver your routine services and coordinate your care with specialists. Please use Find-A-Doc to view the range of doctors available within the CDPHP network.
Q. How do I submit a claim?
A. If you’ve received a covered service and the provider of medical services requested that you pay the charge at the time of service, send a completely itemized bill to our office so that you receive the maximum available benefits. That bill should include:
- Provider’s name, address, telephone number, and tax ID number
- Date of service
- Name of each procedure/procedure code, including the name of any drugs
- Charge for each procedure
- Diagnosis
- Receipt for any payment made
- Member’s name and ID number
Please send claim to: Capital District Physicians’ Health Plan, Inc., P.O. Box 66602, Albany, NY 12206-6602.
Note: This same process applies to claims for care you received out of the country.
Q. Can I order my prescription drugs by mail?
A. Yes. The CDPHP Mail Order Prescription service is available to members who have a prescription drug rider and who take maintenance medication.