Key Takeaways

• Copayments under the Postal Service Health Benefits (PSHB) program can appear in service areas you may not expect, especially when combined with coinsurance or deductible-based care.

• Understanding where copayments occur in 2025 helps you avoid surprise charges and make better choices about where and how to seek care.

Copayments Aren’t Just for Office Visits Anymore

When you think of a copayment, you might picture a $30 charge for a routine primary care visit. While that still exists, PSHB copayments in 2025 have expanded into areas where they may not have been as common in the past. With new cost-sharing models and Medicare integration for retirees, these fees can now show up in places you might not immediately associate with a copay.

Here’s where you’ll want to pay attention.

Urgent Care Facilities

Urgent care is often viewed as a middle-ground alternative to the emergency room. However, in PSHB plans, copayments for urgent care visits can rival or even exceed those of a standard office visit, especially after hours or on weekends. What complicates this is that some facilities charge a separate facility fee in addition to your flat copayment.

• Copayments typically range from $50 to $75

• May be layered with coinsurance for tests or procedures done during the visit

• Non-preferred urgent care centers may trigger higher copayments

Telehealth Services

While telehealth grew in popularity after 2020, it continues to evolve in 2025. Under PSHB, telehealth is not always free. Many plans impose modest copayments for general consultation, behavioral health sessions, and specialty appointments.

• Charges usually range between $15 and $40 per session

• Some plans waive copayments if tied to wellness initiatives, but that’s not universal

Outpatient Diagnostic Testing

This is where copayments can sneak up on you. A visit for a diagnostic test—X-ray, MRI, or lab work—may appear straightforward, but if it’s conducted at a hospital-based outpatient department, a separate copayment may apply for both the visit and the test itself.

• Common services with hidden copays: EKGs, ultrasounds, and imaging

• Your PSHB plan may split charges into multiple billing events

Physical Therapy and Rehabilitation

If you’ve had surgery or a musculoskeletal injury, physical therapy may become part of your treatment. Many PSHB plans assign a copayment for each visit, even if your therapy sessions occur multiple times per week.

• Copayments may apply per session, not per week or per condition

• Some plans cap the number of covered visits, triggering out-of-pocket costs if exceeded

Even Preventive Care Has Fine Print

Preventive services are supposed to be covered without cost-sharing under federal rules, and that remains true for many services in PSHB plans. But when preventive visits lead to diagnostic or follow-up procedures, copayments can suddenly appear.

For instance:

• A routine colonoscopy may turn into a diagnostic procedure mid-way through if a polyp is removed

• A wellness visit that uncovers a condition might shift the billing to a problem-oriented visit

It’s a subtle shift, but it can result in you owing a copayment that you didn’t expect.

Where Medicare Integration Changes the Math

If you’re a Medicare-eligible Postal Service retiree, you may have lower copayments—or none at all—for many services. But this depends entirely on two key factors:

1. Whether you are enrolled in Medicare Part B

2. Whether your PSHB plan coordinates benefits and waives cost-sharing

In 2025, many PSHB plans offer reduced or zero-dollar copayments for members who are fully enrolled in Medicare Parts A and B. However, some plans require Medicare enrollment to avoid copays on:

• Primary care and specialist visits

• Diagnostic and lab services

• Hospital outpatient procedures

If you haven’t enrolled in Medicare Part B, your PSHB plan may still charge standard copayments—even if you’re over 65.

Emergency Room Visits: Not One-Size-Fits-All

Emergency rooms come with some of the highest copayments in any PSHB plan. But these copays vary depending on the nature of your visit and what services are performed.

In 2025, many plans charge:

• A flat ER copayment of $100 to $150

• Additional cost-sharing for labs, scans, or specialist consultations

• Coinsurance after deductible in certain high-deductible plans

And here’s the key detail: if you are admitted to the hospital directly from the ER, that ER copayment may be waived or rolled into your inpatient admission cost. Always ask your provider how your visit is classified.

Mental Health Services: Pay Attention to the Setting

Behavioral health care is more accessible now, but the setting where you receive services influences how much you pay. For example:

• Outpatient counseling at a clinic may have a small copayment

• Seeing a psychiatrist at a hospital outpatient department may include both a physician fee and a facility fee

• Intensive outpatient programs (IOPs) or partial hospitalization may come with multiple layers of copayments and coinsurance

PSHB plans generally provide strong mental health benefits, but they differ in how services are tiered. Always confirm in advance.

The Pharmacy Window Isn’t Always Transparent

Prescription drugs come with a tiered copayment structure in most PSHB plans. But the surprise happens when:

• A medication is reclassified into a higher tier mid-year

• A pharmacy is out-of-network, resulting in non-preferred copayments

• A drug is administered in a doctor’s office, which may result in a facility copayment instead of a pharmacy benefit charge

While most generics are relatively low-cost, brand-name and specialty drugs are where copayment levels spike. This makes knowing your plan’s formulary essential.

When Copayments Turn Into Coinsurance

The transition from a fixed copayment to a percentage-based coinsurance typically occurs when you hit a service threshold—like entering outpatient surgery, infusion therapy, or durable medical equipment (DME). What began as a known fee becomes an open-ended cost.

Here’s what to track:

• Your deductible status: Have you met it?

• Your plan tier: Are you in a standard or high-deductible PSHB plan?

• Whether Medicare is primary: This can limit your coinsurance exposure

2025 Trends You Should Keep in Mind

Some patterns are emerging in 2025 that affect how and where copayments show up:

• Bundled Services: Certain services are now bundled into a single copayment—for instance, maternity care or joint replacement preparation. But if any part of the bundled care is performed outside the standard timeline or network, separate copays may appear.

• Virtual Behavioral Health: As demand for online counseling grows, copayments for virtual mental health services are stabilizing rather than disappearing. Expect a fixed charge per virtual session.

• Out-of-Network Providers: Even if your facility is in-network, one out-of-network provider (e.g., anesthesiologist) can trigger an additional copayment or full billing charge.

• Medicare Part D Cap: For Medicare-eligible PSHB members, the new $2,000 out-of-pocket drug cap helps manage costs, but copayments still apply until that threshold is met.

How to Stay Ahead of Copayment Surprises

To avoid unexpected out-of-pocket expenses, consider the following:

• Review your plan brochure thoroughly—especially the sections on outpatient care, emergency services, and prescription drugs

• Keep records of your Medicare enrollment and how your PSHB plan coordinates with Parts A and B

• Use preferred providers and in-network facilities whenever possible

• Confirm costs before non-urgent appointments or tests

• Track your deductible progress throughout the year

• Call customer service or speak to a licensed agent listed on the website if anything is unclear

Smart Planning Means Fewer Surprises

Even small copayments add up—especially when they appear in unexpected places. The PSHB program in 2025 offers strong benefits, but only if you understand how its cost-sharing works across different types of care.

Staying informed is your best financial defense. Use your plan documents, Medicare coordination details, and provider networks to your advantage. And if you’re ever unsure, it’s worth getting in touch with a licensed agent listed on this website to walk through your options and help clarify the true cost of care.