Key Takeaways

• Even when you think you understand copays, your PSHB plan can include nuances that impact how much you pay out of pocket for common healthcare services.

• Copayments can vary by service type, provider network status, and Medicare coordination, making it critical to review your plan documents annually.

What You Think a Copay Is… And What It Really Means Under PSHB

Most people assume a copayment is a fixed, predictable fee you pay when visiting a doctor or filling a prescription. And in theory, that’s true. But under the Postal Service Health Benefits (PSHB) Program in 2025, copays can vary more than you might expect depending on how, where, and when you access care.

Copays can apply to a range of services:

• Primary and specialist office visits

• Urgent care and emergency room treatment

• Prescription drugs (tiered by formulary)

• Mental health services

• Physical therapy, chiropractic care, and other rehabilitative treatments

You’re not alone if you assumed these amounts were the same no matter what. The truth is, PSHB copays are structured in ways that reward specific usage behaviors and penalize others. Let’s break that down.

In-Network vs. Out-of-Network Matters More Than You Think

In 2025, PSHB plans distinguish sharply between in-network and out-of-network providers. Using in-network services often results in lower copays, while going out-of-network can shift your cost responsibility dramatically.

For instance:

• In-network urgent care might involve a modest copay.

• The same service out-of-network could result in coinsurance or even full billing, especially if the provider doesn’t accept assignment.

The difference in out-of-pocket costs can easily multiply, especially if you’re managing multiple conditions or need repeated specialist care. It’s essential to double-check the provider directory of your plan before every visit. Just because your doctor accepted your old FEHB plan doesn’t mean they’re part of your 2025 PSHB plan’s network.

Copays by Tier: Prescription Drugs Add Another Layer

Your PSHB drug benefits divide prescriptions into tiers, with each tier corresponding to different copayment levels. In 2025, this generally includes:

• Tier 1: Preferred generics (lowest copay)

• Tier 2: Non-preferred generics and some brand-name drugs

• Tier 3: Preferred brand-name drugs

• Tier 4 and higher: Specialty or non-preferred drugs (highest copay or coinsurance)

Even within the same plan, switching from a Tier 1 generic to a Tier 3 brand-name could triple or quadruple your copay. Additionally, some plans require step therapy, meaning you must try lower-tier medications before higher-tier drugs will be covered.

Review your drug formulary closely. Your prescription might be moved between tiers year to year, so a previously affordable refill could become surprisingly costly.

Medicare Changes the Copay Picture Entirely

If you’re enrolled in Medicare and a PSHB plan simultaneously, the coordination of benefits changes how copays are handled.

In 2025:

• Many PSHB plans waive or significantly reduce copays if you are also enrolled in Medicare Part B.

• Some plans offer enhanced benefits such as reduced specialist copays or no cost-sharing for lab services.

However, if you’re Medicare-eligible and decline to enroll in Part B (and you’re not exempt under the rules for postal annuitants), you might face higher cost-sharing or even loss of certain drug benefits under PSHB.

Understanding how your plan coordinates with Medicare is key to managing your expected copay amounts. This coordination isn’t always automatic, so notify your plan when you enroll in Medicare.

Urgent Care Isn’t Always Simple

Many postal employees and annuitants rely on urgent care centers for quick, convenient treatment. But copays for urgent care visits can be deceptive if you don’t know how your plan categorizes the facility.

• Standalone urgent care clinics may have a designated copay.

• If the clinic is part of a hospital system, it may be billed as outpatient hospital care, triggering a higher copay or even coinsurance.

Always ask how the provider bills the service. What looks like a $50 copay visit might turn into a $300 bill if the location is classified differently.

Specialist Copays Can Stack Quickly

You may only think about copays in isolation: one visit, one fee. But health conditions often require multiple follow-ups across various specialists.

Here’s how that adds up:

• Cardiologist copay: $40

• Neurologist copay: $60

• Physical therapy: $30 per session, 2 sessions per week

• Imaging referral: $100 copay

Even with capped copays, you could spend several hundred dollars each month just on appointments. If you’re also paying for prescriptions or labs, your total monthly outlay climbs further.

This highlights the need to budget for copays as recurring—not one-time—expenses.

Preventive Services Might Be Free… Or Not

Under PSHB, many preventive services like annual check-ups, certain screenings, and immunizations are covered without copays if they are performed by in-network providers and coded properly.

But a few scenarios can unexpectedly trigger copays:

• Your preventive visit turns into a diagnostic evaluation.

• You request additional services not considered part of the preventive bundle.

• The provider miscoded the visit or lab.

This billing nuance means a routine screening can unexpectedly cost you. Review your Explanation of Benefits (EOB) statements closely and don’t hesitate to request reprocessing if coding errors are suspected.

Behavioral Health Copays Are Not One-Size-Fits-All

Mental health services in 2025 have improved coverage under most PSHB plans, especially with growing demand for virtual care. But copays can differ for:

• In-person therapy

• Telehealth visits

• Psychiatry evaluations

• Group therapy sessions

Virtual care may have reduced copays or none at all, but only if you use your plan’s preferred vendor. Using a therapist outside the approved platform or network could result in higher out-of-pocket costs. Always verify provider participation before scheduling.

The Annual Reset: Why January Matters

Copays are flat fees, but they work in tandem with deductibles and out-of-pocket maximums. These reset every calendar year, meaning that in January:

• You start fresh with meeting your deductible.

• Your out-of-pocket spending returns to $0.

• Certain services may cost more until thresholds are met.

This can catch you off guard. A specialist visit in December might involve just a copay. The same visit in January could require full cost-sharing until the deductible is met. Planning your care around this reset can minimize early-year expenses.

Watch for Copay Changes in Your Annual Notice

Every fall, PSHB enrollees receive an Annual Notice of Changes. This outlines modifications in premiums, benefits, and cost-sharing—especially copays.

In 2025, these notices have become even more important as:

• New tiers or service categories may be introduced.

• Copays for specialty services may increase.

• Some routine services may transition from copay to coinsurance.

Don’t ignore this document. Compare it with your previous year’s plan and make sure it still aligns with your healthcare usage. If it doesn’t, Open Season (held each year from November to December) is your chance to make a change.

Copay vs. Coinsurance: Know the Cutoff

In PSHB, not all services involve a simple copay. Some involve coinsurance—a percentage of the allowed cost—which usually comes into play after the deductible is met. But the two can blur, especially with high-cost procedures.

For example:

• A simple lab test may have a copay.

• A complex imaging procedure may require 20% coinsurance.

That means you could go from paying $30 one week to $600 the next depending on how the service is categorized. Review your summary of benefits to know which services are covered by copay and which switch to percentage-based sharing.

It Pays to Stay Informed About PSHB Copays

Copays are often misunderstood as static, predictable costs. But under the 2025 PSHB structure, they’re dynamic, layered, and closely tied to how and where you access care. Whether it’s the tier of your prescription, the network status of your provider, or your Medicare enrollment, many variables influence what you’ll actually pay.

Staying informed can help you:

• Budget monthly medical expenses more accurately

• Avoid unexpected bills

• Make better use of in-network and preventive care

• Time high-cost services strategically

If you haven’t reviewed your PSHB Summary of Benefits yet this year, now is the time. Even small misassumptions can turn into big costs.

For a Smarter Copay Experience, Don’t Rely on Assumptions

Copays are just one part of your larger PSHB cost picture—but they’re the part that hits you most frequently and personally. Understanding them fully can protect your finances over the course of the year.

To get a clearer understanding of your 2025 PSHB options and how your current plan handles copays across different services, reach out to a licensed agent listed on this website. They can help you compare details, assess how your medical usage aligns with the plan, and guide you toward more cost-efficient decisions.