Key Takeaways

• Your PSHB plan involves multiple types of cost sharing, including premiums, copays, coinsurance, and deductibles. These add up significantly beyond what you see on your paycheck.

• Understanding the timelines and thresholds tied to deductibles and out-of-pocket limits in 2025 can help you better manage your healthcare spending throughout the year.

What Shared Costs Actually Mean Under PSHB

If you’re enrolled in the Postal Service Health Benefits (PSHB) program, you’ve probably seen the term “cost sharing” mentioned frequently. But what does it really mean? Cost sharing refers to how you and your plan split the cost of your healthcare. While it may sound simple, the details can get complicated, especially when you break down the different types of payments you’re responsible for.

PSHB is designed to provide postal workers and retirees with strong health coverage, but it’s not free. You contribute not just through premiums, but also every time you visit a doctor, get a prescription, or require specialized treatment. That’s why understanding the full scope of your financial responsibilities is essential.

Premiums: Just the Starting Point

Every PSHB enrollee pays a monthly premium, and this amount is often visible on your pay stub or annuity statement. However, that number doesn’t reflect the total cost. The government covers about 72% of your premium, which means you are responsible for the remaining 28%.

For 2025, the average monthly enrollee share of premiums is:

• Self Only: Around $241

• Self Plus One: Around $521

• Self and Family: Around $567

These are just average figures and can vary based on the plan you choose. But even if you choose a plan with a lower premium, that doesn’t necessarily mean you’ll spend less overall. That’s where copayments, coinsurance, and deductibles come in.

Copayments: Flat Fees That Add Up

Copayments (copays) are fixed amounts you pay for specific services. For example, a primary care visit might require a $20–$40 copay, while a specialist visit could cost you $30–$60. Urgent care and emergency room visits can run even higher, sometimes exceeding $100 per visit.

Even if each individual copay seems manageable, the total can become significant if you or your dependents need frequent care. A couple of specialist visits, one urgent care trip, and routine lab work in a single month can easily cost over $200 in copays alone.

Coinsurance: The Percentage That Surprises You

Unlike copays, which are flat fees, coinsurance is a percentage of the service cost that you’re required to pay after meeting your deductible. For example:

• In-network coinsurance: Often ranges from 10% to 30%

• Out-of-network coinsurance: Can range from 40% to 50%

Let’s say you undergo a medical procedure that costs $2,000 in-network. If your coinsurance is 20%, you’ll pay $400. And that’s on top of any deductible you still owe.

In 2025, this cost-sharing model becomes particularly relevant if you experience hospitalization, physical therapy, or outpatient surgery. These services carry high base costs, and your coinsurance obligation can quickly become one of the largest expenses in your plan.

Deductibles: The Upfront Threshold Before Coverage Kicks In

Your deductible is the amount you must pay out-of-pocket for covered services before your PSHB plan begins to share the cost. The 2025 in-network deductible typically falls between:

• Low-deductible plans: $350–$500

• High-deductible plans: $1,500–$2,000

If you haven’t met your deductible, you’ll pay the full cost of services until you do. For families, this amount can be even more substantial. It’s important to track your deductible progress early in the year so you know when your coverage begins to shift.

Out-of-Pocket Maximums: The Safety Net (With a Catch)

Your plan does provide a backstop in the form of an out-of-pocket maximum. Once your combined spending on deductibles, copays, and coinsurance reaches this limit, your PSHB plan pays 100% of the covered expenses for the rest of the year.

In 2025, these limits are:

• Self Only: $7,500

• Self Plus One or Family: $15,000

However, this safety net only applies to in-network services. If you receive care outside your plan’s network, you may face additional limits or no protection at all.

Pharmacy Costs: Layered Cost Sharing Through Part D Integration

For medicare-eligible enrollees, the PSHB program includes Medicare Part D drug coverage through an Employer Group Waiver Plan (EGWP). This adds another dimension to your cost-sharing responsibilities. In 2025, Part D includes:

• $590 deductible

• $2,000 out-of-pocket cap for prescription drugs

• $35 insulin copay cap

Even before reaching these caps, you’ll often pay coinsurance or tiered copays based on the medication’s formulary status. These costs can build up quickly, especially if you take multiple maintenance drugs.

Preventive Care: The One Area Often Covered Fully

Preventive services like annual physicals, screenings, and immunizations are typically covered at 100% when performed by an in-network provider. This is the one area where cost sharing generally does not apply. However, if your visit goes beyond preventive services into diagnostic territory, copays and coinsurance can kick in unexpectedly.

Specialty Care and Complex Treatment: High-Stakes Cost Sharing

Services like specialist consultations, diagnostic imaging (e.g., MRIs), outpatient procedures, and mental health visits can carry layered costs. You might face:

• A copay to see the specialist

• A percentage coinsurance for the service

• Full costs if the deductible hasn’t been met

If your plan doesn’t offer reduced cost-sharing for those enrolled in Medicare Part B, the financial impact of these services can be even greater.

Emergency and Out-of-Network Services: Cost Spike Territory

Emergency care typically has a higher copay, ranging from $100 to $150. If your emergency visit results in admission, you may also trigger inpatient coinsurance.

Out-of-network care, even if it’s emergency-related, can result in significantly higher out-of-pocket costs. Some plans may cover it, but often at lower reimbursement rates or with a separate deductible.

Family vs. Individual Costs: Shared Coverage, Multiplied Burden

If you’re enrolled in a Self Plus One or Self and Family plan, remember that cost sharing is cumulative. Every family member contributes toward meeting the deductible and out-of-pocket maximums. If one member experiences a major medical event early in the year, your total household costs can surge.

While the premium is higher for family coverage, the real financial impact shows up when two or more people need care within the same benefit period.

Timing Matters: Front-Loaded Expenses Early in the Year

Because deductibles reset every January, many enrollees face the bulk of their out-of-pocket expenses in the first quarter. That’s when routine visits, specialist consultations, or even planned procedures hit harder since you’re likely paying full price until the deductible is met.

If you know you’ll have recurring healthcare needs, you might consider timing them later in the year once your deductible has been satisfied. But emergencies, of course, are never so neatly scheduled.

Medicare Integration Can Shift the Cost Burden

If you’re Medicare-eligible and enrolled in both Part B and your PSHB plan, some of your costs may be significantly lower. Many PSHB plans reduce or eliminate deductibles and coinsurance for those with Medicare Part B.

However, not every enrollee is required to sign up for Part B. For 2025, those who retired before January 1, 2025 or meet specific exemption criteria are not subject to mandatory enrollment. For these individuals, the cost-sharing burden remains higher unless they voluntarily enroll.

Why Cost Sharing Often Feels Higher Than Expected

Even when you believe you’ve chosen a plan with manageable premiums, the combined effect of all the other out-of-pocket costs can feel overwhelming. That’s because the structure is intentionally layered:

• Premiums are paid monthly

• Copays are charged per visit

• Coinsurance applies to percentages of high-cost services

• Deductibles reset annually

Unless you calculate and track these elements proactively, you may underestimate your actual healthcare spending.

What You Can Do to Prepare

Understanding your PSHB plan’s Summary of Benefits and Coverage (SBC) is key. Pay attention to:

• The annual deductible amount

• Coinsurance percentages for in-network and out-of-network care

• Out-of-pocket maximums

• Tiered prescription drug costs

• Medicare coordination rules (if applicable)

You can also use available online tools from OPM and the PSHB Navigator to model different scenarios and estimate your costs based on usage.

How Shared Costs Shape Your Healthcare Decisions

The structure of PSHB cost sharing affects more than your wallet. It also influences how you:

• Choose providers (in-network vs. out-of-network)

• Schedule care (early in the year vs. after deductible)

• Manage prescriptions (generics vs. brand-name)

• Decide on Medicare enrollment (especially Part B)

Being informed helps you avoid surprise bills and allows you to allocate funds accordingly—whether through savings, flexible spending accounts, or adjusting usage patterns.

Be Proactive in Managing Healthcare Spending

PSHB provides robust coverage, but your personal cost burden depends on your plan choice, family size, service usage, and whether you coordinate with Medicare. Cost sharing is not just about paying your part—it’s about understanding how and when those costs arise.

Speak With Someone Who Can Help You Plan

Choosing the right plan and budgeting for healthcare requires more than just glancing at premiums. If you want to better understand how cost sharing will impact your finances, speak with a licensed agent listed on this website. They can help you break down your specific costs and guide you through your available options.