Key Takeaways

• Medicare Advantage (Part C) plans may advertise extensive extra benefits, but many of those features come with restrictions, conditions, or trade-offs in network access and out-of-pocket costs.

• As a Postal Service Health Benefits (PSHB) enrollee, you must understand what Medicare Part C includes, excludes, and how it compares to your PSHB coverage—especially if you are also enrolled in Medicare Parts A and B.

Understanding Medicare Advantage in the Context of PSHB

Medicare Advantage plans, also called Medicare Part C, often seem appealing due to their broad advertising and long list of extra benefits. Many plans claim to offer vision, hearing, dental, wellness perks, and transportation services. But for those of you enrolled in the Postal Service Health Benefits (PSHB) Program, these surface-level features should not be the only focus. The deeper issue is what these plans often leave out, restrict, or condition—especially when coordinated with Medicare Parts A and B.

Medicare Advantage is not a supplemental plan. It replaces your Original Medicare coverage, and it operates under a different structure. It’s administered by private companies, not the federal government. This introduces variability, which can conflict with the reliability and predictability many of you expect from PSHB benefits.

What You Trade for Extras

Medicare Advantage plans may look more generous at first glance, but they tend to include limits that don’t always get advertised upfront.

1. Network Restrictions

Unlike Original Medicare, which allows you to see any provider that accepts Medicare nationwide, most Part C plans require you to stay within a specific provider network. Out-of-network services often come with higher costs or are not covered at all.

For PSHB participants used to wide provider access, this limitation can be a significant change. If you travel, live in different states throughout the year, or rely on a particular specialist, a Medicare Advantage plan could introduce access hurdles.

2. Prior Authorization Requirements

Many Part C plans require prior authorization for services that are automatically covered under Original Medicare. This means you must receive approval before the plan agrees to cover certain procedures, tests, or even hospital stays. That can delay care or lead to denials.

In contrast, your PSHB plan (especially when paired with Medicare Parts A and B) may allow more direct access to care without as many gatekeeping steps.

3. Higher Maximum Out-of-Pocket Limits

In 2025, Medicare Advantage plans can have a maximum out-of-pocket (MOOP) limit as high as $9,350 for in-network services alone. If your plan includes out-of-network benefits, the combined in-network and out-of-network limit can be as high as $14,000.

By comparison, PSHB plans offer more manageable cost-sharing arrangements. And if you’re enrolled in Medicare Part B as well, many PSHB plans reduce or waive deductibles and coinsurance, resulting in significantly lower out-of-pocket expenses.

4. Prescription Drug Coverage Differences

Medicare Advantage plans usually include Part D drug coverage. While that sounds convenient, it also means:

• Limited formularies (the list of covered drugs)

• Tiered pricing that may not reflect your medication needs

• Pharmacy restrictions or preferred networks

In contrast, if you’re a Medicare-eligible PSHB enrollee, you automatically get prescription drug coverage through a Medicare Part D Employer Group Waiver Plan (EGWP). This structure typically offers broader coverage, a $2,000 annual cap on out-of-pocket drug costs in 2025, and no need to shop for a separate Part D plan.

How PSHB Works Alongside Medicare in 2025

The PSHB Program is specifically designed to coordinate benefits with Medicare for eligible annuitants and their families. When you enroll in Medicare Parts A and B, many PSHB plans offer significant cost-sharing reductions, such as:

• Waived deductibles

• Lower copayments

• Reduced coinsurance

• Reimbursement of all or part of your Medicare Part B premium

This seamless coordination can significantly reduce your total healthcare expenses—without sacrificing provider access or introducing restrictive authorizations. It’s worth noting that this level of integration is unique to PSHB plans, not available with most standalone Medicare Advantage plans.

Why the “Extras” Shouldn’t Be the Only Focus

Medicare Advantage plans often highlight their supplemental benefits, including:

• Routine dental care

• Vision checkups and glasses

• Hearing aids

• Fitness memberships

• Transportation to appointments

• Over-the-counter allowances

However, these benefits often come with limitations. You may be restricted to specific networks, capped annual allowances, or service areas. Many of these features are offered as add-ons, not guaranteed core benefits.

By contrast, some PSHB plans already include comparable supplemental benefits, especially when integrated with Medicare. These benefits are generally more predictable and less prone to abrupt changes in coverage.

Enrollment Timing Matters

PSHB participants must pay close attention to enrollment timelines and eligibility requirements. Here’s how it works in 2025:

• If you retired on or before January 1, 2025, you are not required to enroll in Medicare Part B to remain in your PSHB plan.

• If you retired after January 1, 2025, and you’re eligible for Medicare, you must enroll in Part B to keep your PSHB coverage.

• If you fail to enroll in Medicare Part B when first eligible (usually at age 65), you may face lifelong penalties and risk losing access to certain PSHB benefits.

Choosing a Medicare Advantage plan instead of Original Medicare with PSHB may seem like a good deal based on marketing, but it can result in losing the unique cost-sharing reductions and coordination available through PSHB.

Consider Long-Term Stability, Not Just Short-Term Perks

While the idea of getting extra perks through a Part C plan may sound attractive, it’s vital to consider the long-term implications:

• Networks and coverage rules can change yearly.

• Benefits can be added or removed based on the insurer’s discretion.

• Copayments and coinsurance amounts can fluctuate.

In contrast, PSHB plans are structured around long-term consistency. They align with the federal government’s contribution toward premiums and aim to provide stability across retirement years.

Ask the Right Questions Before Switching

If you’re considering a Medicare Advantage plan instead of using your PSHB benefits with Medicare Parts A and B, make sure you ask yourself:

• Will this plan restrict which doctors I can see?

• Are there prior authorization rules for key services?

• How much will I pay out-of-pocket annually?

• Does this plan coordinate with my PSHB benefits?

• What happens if I move or travel?

• What is covered for prescriptions—and what isn’t?

Getting answers to these questions can help you avoid surprises and protect the benefits you’ve earned through your postal service career.

Comparing Plan Structures: PSHB vs. Medicare Advantage

Here’s a brief overview of structural differences to guide your evaluation:

Stronger with PSHB and Medicare Together

If you’re eligible for Medicare in 2025 and already enrolled in a PSHB plan, combining both can provide you with more consistent, lower-cost coverage than relying on a Part C plan alone.

Instead of being drawn in by ads promoting extra benefits, look closely at what might be missing: provider access, stability, and lower overall costs. That’s where PSHB coverage shines—particularly when Medicare Part B is part of the picture.

Stay Focused on What Matters Most

When it comes to your healthcare coverage in retirement, it’s not just about what a plan says it includes—it’s about how well it works for your life. PSHB offers coordination, financial protection, and wide access that many Medicare Advantage plans simply don’t match.

Before making any coverage changes, talk to a licensed agent listed on this website to ensure your healthcare choices reflect both your needs and your earned benefits.