| Network | Restricted network of healthcare providers, often requiring referrals for specialists. | Broader network of healthcare providers, allowing access to specialists without referrals. |
| Primary Care Physician | Requires the selection of a primary care physician (PCP) to coordinate care and provide referrals. | Usually does not require a PCP, allowing members to see specialists directly if desired. |
| Out-of-Network Coverage | Typically offers little to no coverage for out-of-network care, except for emergencies. | Provides some coverage for out-of-network care, although at a higher cost to the member. |
| Referrals | Requires referrals from the PCP to see specialists or receive certain medical services. | Generally, no referrals are needed to see specialists or receive specialized care. |
| Cost Sharing | Generally has lower premiums and out-of-pocket costs, making it cost-effective for routine care. | Typically has higher premiums and out-of-pocket costs but offers greater flexibility in provider choice. |
| Deductibles | May have lower deductibles or no deductibles for in-network care. | Often has higher deductibles, both for in-network and out-of-network care. |
| Copayments/Coinsurance | Typically involves fixed copayments for office visits and services. | Often includes a combination of copayments and coinsurance, with a percentage of costs shared by the member. |
| Coverage Area | Primarily suitable for individuals who reside or work within the plan's service area. | Appeals to individuals who desire more flexibility to access healthcare providers nationwide. |
| Pre-Authorization | May require pre-authorization for certain medical procedures or treatments. | May also require pre-authorization but often with more flexibility in choice. |
| Wellness Programs | May offer wellness programs and preventive care services with little to no cost-sharing. | May offer wellness programs but may involve some cost-sharing for preventive care. |
| Emergency Care Coverage | Provides coverage for emergency care both in-network and out-of-network. | Provides coverage for emergency care, with potentially higher costs for out-of-network emergencies. |
