Key Takeaways

• PSHB plans may appear similar on the surface, but their differences can drastically impact your coverage and out-of-pocket costs.

• Don’t overlook factors like network access, coordination with Medicare, and restrictions on supplemental services—they could define your healthcare experience in retirement.

What You Might Be Missing When Reviewing PSHB Plans

With the Postal Service Health Benefits (PSHB) Program fully replacing FEHB for USPS employees and annuitants in 2025, your choice of a plan isn’t just about picking a familiar name. The new structure brings fresh variables that deserve your full attention—especially if you’re approaching retirement or already enrolled in Medicare.

While you might be tempted to compare plans based on premiums or broad benefit categories, some of the most impactful elements are found in the fine print. Here are the specific areas you should be focusing on before finalizing your selection.

1. Network Breadth and Provider Access

Most PSHB plans divide their benefits based on whether services are delivered in-network or out-of-network. While this is not a new concept, the variation between networks in 2025 is substantial.

• In-network care typically costs less. You might see lower copayments, reduced deductibles, and capped out-of-pocket maximums.

• Out-of-network charges can be significant. Some plans require coinsurance of 40%-50% for out-of-network services, which adds up quickly.

• Check provider directories carefully. A plan may cover your region but not your preferred hospital or physician.

If you travel often or live in a rural area, a narrow network could limit your access to timely care.

2. Deductibles and Out-of-Pocket Maximums

You might think a plan with a slightly lower premium is saving you money, but that assumption can backfire.

• Deductibles in 2025 range widely. Some PSHB options feature high-deductible thresholds up to $2,000 for Self Only coverage, while others stay closer to $350.

• The out-of-pocket maximum is capped at $7,500 (Self Only) and $15,000 (Self Plus One or Family) for in-network care. However, these ceilings only apply once deductibles, copayments, and coinsurance accumulate.

Make sure to factor in your typical healthcare usage when weighing the true cost of a plan. If you expect multiple specialist visits, ongoing prescriptions, or potential procedures, a plan with a lower deductible may actually save you more in the long run.

3. Coordination With Medicare Part B

Starting in 2025, PSHB requires Medicare-eligible annuitants and family members to enroll in Medicare Part B, unless exempt. This change has important consequences:

• Some PSHB plans reduce or eliminate deductibles and cost-sharing for those enrolled in Medicare Part B.

• Plans often integrate drug coverage through a Medicare Part D Employer Group Waiver Plan (EGWP).

These benefits can result in lower out-of-pocket costs, but only if you are enrolled in Medicare Part B. If you aren’t, you may face higher medical expenses.

4. Prescription Drug Formularies

Every PSHB plan includes prescription drug coverage, but they don’t all use the same formulary—the list of drugs they cover and how they classify them.

• Tier placement determines your cost. A drug placed in Tier 1 (preferred generics) is far less expensive than a Tier 4 (non-preferred brand).

• 2025 changes to Medicare Part D eliminate the coverage gap, but that only matters if your plan integrates Part D.

You should review the formulary closely, especially if you rely on specific medications. Costs can escalate quickly if your drug is not favored by the plan.

5. Prior Authorization and Service Restrictions

Even if a service is technically covered, you may still need prior authorization. These usage controls are often buried in the fine print, but they can impact:

• Imaging services (MRIs, CT scans)

• Specialist referrals

• Certain prescription drugs

• Physical therapy or rehabilitation

Prior authorization slows down access and may delay treatment. If you have ongoing care needs, find out how strict a plan is with these controls.

6. Telehealth Availability and Rules

In 2025, many PSHB plans highlight telehealth as a convenient option, but the scope and quality differ:

• Some plans limit telehealth to general consultations only.

• Others allow behavioral health, dermatology, and urgent care via virtual visits.

• Copayments vary widely across plans and types of virtual care.

If you rely on telehealth, check whether your plan offers robust virtual care and if it counts toward your deductible and out-of-pocket maximum.

7. Family Coverage Tiers

PSHB includes Self Only, Self Plus One, and Self and Family tiers. You might assume Self Plus One is always cheaper than full-family coverage, but that’s not necessarily the case in 2025.

• Some plans price Self Plus One nearly equal to or even higher than Self and Family.

• If you have a dependent aging into Medicare, this can impact pricing structure.

Review tier pricing closely based on your household’s current and upcoming needs. Misjudging the best tier could result in avoidable costs.

8. Dental and Vision Benefits

PSHB does not bundle dental and vision benefits the same way as some private plans. Instead:

• Dental and vision are typically offered through FEDVIP, not the core PSHB medical plan.

• Some PSHB plans do include limited dental or vision allowances, but they’re not comprehensive.

If you’re retiring soon, this could impact how you coordinate care, especially if you assumed dental or vision would continue without separate enrollment.

9. Special Enrollment Exceptions

Not everyone is required to enroll in Medicare Part B to stay in PSHB, but the exceptions are narrow and specific:

• If you retired on or before January 1, 2025, and aren’t already enrolled in Part B, you are exempt.

• Certain exemptions apply for international residents, VA care recipients, or members of Indian Health Services.

If you incorrectly assume you qualify for an exception, your PSHB coverage could be terminated or downgraded. Always verify your eligibility.

10. Changes From Year to Year

Even though 2025 marks the first year of PSHB implementation, you can still expect updates every Open Season.

• Premiums, deductibles, and out-of-pocket limits may adjust annually.

• Networks can expand or shrink.

• Formularies and copayments may be restructured.

Don’t assume that your 2025 plan will work as well in 2026. Each year requires a full review during Open Season (November to December).

You Deserve a Closer Look at What “Coverage” Really Means

Choosing a PSHB plan in 2025 is not a one-and-done decision. The wrong assumptions about drug tiers, Medicare coordination, or even prior authorizations could lead to higher costs and surprise denials. That’s why you need to look beyond the surface of plan brochures and into how the details align with your health needs and budget.

If you’re uncertain or want professional input tailored to your situation, speak with a licensed agent listed on this website. They can help ensure that the PSHB plan you choose in 2025 truly matches your expectations and protects your retirement.