Key Takeaways

• Your out-of-pocket costs under a PSHB plan can vary significantly based on the type and frequency of care you use, even when flat copays appear predictable.

• Copayments in PSHB plans may increase with specialist visits, brand-name prescriptions, and urgent care trips, especially if you exceed a certain number of visits or rely on out-of-network providers.

Understanding What a Copayment Actually Covers

At first glance, a flat copayment under your Postal Service Health Benefits (PSHB) plan may seem like a straightforward way to budget your medical expenses. You might see $20 for a primary care visit or $40 for a specialist and assume those amounts will always apply. But the reality is more nuanced. Copayments shift depending on the type of care you receive, the provider’s network status, and even how frequently you use certain services.

In 2025, PSHB plans continue to offer a range of flat-rate copays, but the real cost to you depends heavily on the details. Knowing how and why those copays shift is key to avoiding surprises on your medical bills.

Why Copays Aren’t Always Flat Across All Services

The structure of copayments under PSHB is based on service categories. Here are the main types of services that use a copay system:

• Primary care visits

• Specialist visits

• Urgent care

• Emergency room (ER) visits

• Prescription drugs

• Mental health services

• Preventive screenings

Even if your plan lists a flat copay, the rate typically varies depending on the setting (clinic vs hospital), service frequency, and tier of medication. For example, an in-network urgent care visit might cost you $50, while an ER visit could run $150 or more. Mental health sessions may start at $30, but increase if you exceed a certain number within a year.

How Network Choices Affect Your Copay Amounts

Choosing an in-network provider usually means paying the listed copayment. However, once you go out-of-network, those flat amounts may no longer apply. Instead, you’re often subject to coinsurance (a percentage of the service cost) and higher deductibles.

PSHB plans in 2025 define network tiers clearly, and it’s critical to use in-network care whenever possible. While in-network specialist visits might carry a $40 copay, out-of-network visits can result in significantly higher costs that aren’t capped by the same plan protections.

Frequency of Use and Tiered Copays

Many PSHB plans include tiered copayments, especially for services like urgent care or specialist visits. That means the first few visits per calendar year may have a lower copay, with rates increasing after a certain threshold. For example:

• First three urgent care visits: $50 each

• Fourth and subsequent visits: $75 each

This cost structure discourages overuse and encourages scheduling routine care with your primary provider. But if your health condition requires frequent specialist visits, your budget could take a hit in the second half of the year.

Prescription Drugs: Where Copays Really Vary

Prescription medications under PSHB are grouped into tiers:

• Tier 1: Generic drugs

• Tier 2: Preferred brand-name drugs

• Tier 3: Non-preferred brand-name drugs

• Tier 4: Specialty medications

Each tier has its own copayment level. For instance, a Tier 1 drug might cost you $10 per fill, while Tier 3 or Tier 4 medications could cost $70 or more. Some plans implement a coinsurance rate instead of a flat copay for specialty drugs, meaning you’ll pay a percentage of the drug’s cost, which can be significantly higher.

If you rely on ongoing medications, the cost of refills can snowball. In some PSHB plans, you may pay less by using a mail-order pharmacy or 90-day supply, but these options depend on your plan’s pharmacy network and rules.

Preventive Services Often Avoid Copays, But Not Always

Under PSHB in 2025, most preventive care services are fully covered without a copayment, as long as they’re delivered by an in-network provider. These include:

• Annual physical exams

• Vaccinations

• Mammograms and colonoscopies

• Screenings for high blood pressure, diabetes, and cholesterol

However, the moment preventive visits lead to diagnostic testing or follow-up care, copays can apply. For example, if your routine mammogram leads to a diagnostic ultrasound, you might owe a copayment or even coinsurance.

Mental Health and Substance Use Copays

Mental health care under PSHB typically follows a different copay structure than physical health services. Some plans offer reduced rates for telehealth visits or initial counseling sessions. But:

• You may face higher copays for in-person psychiatric services.

• Group therapy sessions might be lower-cost than individual visits.

• Frequency of sessions could trigger higher cost-sharing once a limit is crossed.

This structure can make it harder to predict your total yearly cost if you’re seeing a provider weekly.

Emergency vs Urgent Care: A Big Copay Difference

Emergency room visits generally have the highest copayments in PSHB plans. You might expect to pay $100 to $150 per visit, even if it turns out not to be an emergency. In contrast, urgent care copays usually range from $50 to $75.

Making the right choice for your care setting isn’t just about convenience. It’s about cost. If the situation isn’t life-threatening, consider:

• Telehealth

• Walk-in clinics

• Urgent care centers

These options can offer the same care for a lower copayment, and still be covered within your PSHB network.

Telehealth: A Lower-Cost Copayment Alternative

PSHB plans in 2025 increasingly support telehealth as a cost-saving alternative to in-person care. Common advantages include:

• Lower copays for virtual primary and mental health visits

• No travel or wait time

• Access to care during off-hours or from remote areas

If you only need a prescription refill, quick medical advice, or routine check-ins, choosing telehealth can significantly reduce your annual out-of-pocket spending.

Seasonal or Short-Term Needs Can Increase Total Copays

If you or your dependents experience seasonal illnesses like the flu or allergies, short bursts of care can add up:

• Two urgent care visits in one week = $100 to $150

• Follow-up specialist visit = another $40 to $60

• Prescription medications = additional $30 to $100

Even if each copay seems small, concentrated use over a month or two can make a real dent in your budget. It’s important to plan for short-term spikes in care, not just long-term conditions.

Tracking and Managing Your Copayments Year-Round

Your plan may not alert you every time you cross a visit threshold or when a service switches from preventive to diagnostic. That’s why it’s important to:

• Review your Explanation of Benefits (EOB) statements regularly

• Track how many visits you’ve used by category

• Ask your provider whether services will result in additional charges

Some PSHB plans offer online dashboards or mobile apps where you can monitor copays and service history.

Annual Caps and Out-of-Pocket Maximums Still Apply

In 2025, PSHB plans set an annual out-of-pocket maximum for in-network services. Once your total copays, deductibles, and coinsurance reach this amount, the plan covers all further eligible expenses at 100%. These limits protect you from runaway medical costs, but only after you’ve spent a substantial amount.

Depending on your plan type:

• Self Only maximums are often around $7,500

• Self Plus One or Family maximums may reach $15,000

Make sure you understand how copayments contribute to this cap. Some services may not count, especially those that are out-of-network or not considered medically necessary.

When to Reevaluate Your PSHB Plan Based on Copay Trends

If you find yourself paying higher copays than expected throughout the year, consider whether your current plan fits your usage pattern. During Open Season from November to December, you can:

• Compare plans with lower copayments for the services you use most

• Consider higher-premium plans if they reduce your regular out-of-pocket costs

• Check for plans that waive deductibles or copays when paired with Medicare Part B

Understanding your healthcare habits is key. If you routinely use urgent care, need mental health services, or take multiple prescriptions, your copayment structure becomes one of the most important aspects of your coverage.

Why Every Visit Matters When It Comes to Copays

Every trip to a provider, pharmacy, or urgent care clinic contributes to your total health spending. With PSHB, copayments aren’t static; they change based on usage patterns, the setting of care, network participation, and plan design.

Your best strategy is to stay informed, track your usage, and use available tools like telehealth or mail-order pharmacies to control costs. And when Open Season arrives, reevaluate your plan to make sure your copayment structure matches how you actually use care.

For personalized guidance, reach out to a licensed agent listed on this website who can help you evaluate PSHB plan options and understand how each structure affects your costs.