Key Takeaways

• Copayments under PSHB may appear modest, but if you receive frequent care, these fixed amounts accumulate rapidly and can significantly impact your monthly expenses.

• Understanding how copays interact with other out-of-pocket costs like deductibles and coinsurance is essential to estimating your actual healthcare spending.

The Real Cost Behind “Just” a Copay

You might assume a $20 copay means a simple, affordable visit. But if you’re seeing a provider multiple times a month, that flat fee isn’t so small. Whether it’s for physical therapy, specialist appointments, or mental health support, frequent visits mean repeated payments. Multiply those visits across a few months and you may find your wallet thinning faster than expected.

Postal Service Health Benefits (PSHB) plans generally use copayments for routine services like:

• Primary care visits

• Specialist consultations

• Urgent care trips

• Prescription drugs (depending on tier)

In 2025, these copays may range from $20 to $60 for in-network visits, with urgent care often higher. That structure helps contain costs per visit, but doesn’t protect you from volume. If you attend 8 to 10 appointments in a month due to a short-term condition, or if you manage a chronic illness that requires monthly check-ins, your cumulative costs may rival a high-deductible health plan.

Copays Add Up Fast for Ongoing Conditions

Let’s say you attend physical therapy twice a week for eight weeks. That’s 16 sessions. Even with a $25 copay, you’re paying $400 out of pocket. And that doesn’t include any imaging, specialist visits, or medications you may also need.

Frequent care situations that drive up copay costs include:

• Post-surgical rehabilitation

• Chronic illness management (diabetes, asthma, arthritis)

• Mental health therapy sessions

• Frequent pediatric visits for dependents

These aren’t rare situations. Many PSHB enrollees, especially retirees or families with children, fall into one or more of these categories.

Prescription Copays Multiply Even Faster

Copayments for medications often vary by drug tier. Even if your plan charges only $10 to $25 for Tier 1 or preferred generic medications, multiple prescriptions taken monthly or bi-weekly can result in triple-digit monthly expenses.

In 2025, drug costs may be capped annually at $2,000 under Part D for those with Medicare, but if you’re not yet Medicare-eligible, your PSHB plan alone may not have such protections. You could be paying $100–$200 monthly just on medications depending on your needs.

Common use cases where drug copays accumulate:

• Managing high blood pressure, cholesterol, or thyroid conditions

• Combination therapy for depression or anxiety

• Asthma inhalers and allergy treatments

Reviewing your PSHB drug formulary is critical. Preferred brands often have significantly lower copays than non-preferred options. But even among generics, quantity and refill frequency impact your total cost.

Don’t Forget the Copayments for Urgent and Specialty Services

Primary care visits might feel manageable. But costs often spike when you need:

• Urgent care ($50–$75 copays)

• Emergency room visits ($100–$150 copays)

• Outpatient surgery ($150–$300 or coinsurance)

• Advanced diagnostic tests (MRI, CT scans)

While these events might be infrequent, just one ER visit can throw off your budget. In 2025, coinsurance can still apply after a copayment depending on the service and provider. Some services may require you to meet your deductible first.

Before assuming it’s just a one-time charge, examine the fine print. Is it a flat copay? Is it a copay plus 20% coinsurance? Is it subject to your annual deductible? These layers affect your financial exposure significantly.

Copays Still Count Toward Out-of-Pocket Maximums

Here’s a silver lining: your copays contribute toward your annual out-of-pocket (OOP) maximum.

In 2025, PSHB in-network OOP maximums for most plans are around:

• $7,500 for Self Only

• $15,000 for Self Plus One or Family

That means once you reach this threshold, the plan pays 100% for covered services for the remainder of the calendar year. However, reaching that limit means you’ve already paid a substantial amount.

Most people don’t hit the out-of-pocket cap unless they experience a major health event, surgery, or require extensive ongoing care. Copays chip away at this maximum slowly—but steadily.

Medicare Changes Copay Dynamics

If you’re a Medicare-eligible PSHB enrollee, you may be enrolled in both Medicare Part B and a PSHB plan that coordinates with it. In that case, copayments may be waived or reduced significantly depending on how the plan integrates with Medicare.

Many PSHB plans in 2025 offer these benefits:

• Reduced or eliminated copays for office visits if Medicare Part B is primary

• Waived deductibles for certain in-network services

• Lower prescription costs through the Medicare Part D Employer Group Waiver Plan (EGWP)

But these benefits only apply if you’re enrolled in both Medicare and the corresponding PSHB plan. If you’ve opted out of Medicare Part B (when required), you may pay more in copays and coinsurance.

Family Coverage Increases Copay Frequency

If you’re enrolled under Self Plus One or Self and Family, copays can multiply quickly, especially if:

• A child requires routine pediatric visits

• A spouse needs ongoing specialist care

• Family members use urgent care or behavioral health services

Even one family member requiring weekly therapy or monthly checkups adds up. With 2–3 dependents using services regularly, monthly copays may quietly climb into the $300–$500 range.

Planning ahead for your family’s typical care usage can help you estimate:

• Monthly copay totals

• When you’re likely to hit your deductible

• Whether the plan’s out-of-pocket maximum may eventually offer cost protection

Hidden Triggers That Lead to More Frequent Copays

Several common scenarios can unexpectedly push your copay totals higher:

• Care fragmentation: Different providers for overlapping conditions means more visits.

• Referrals and follow-ups: Some specialist visits require separate copays.

• Lack of virtual care: Not all plans offer telehealth at reduced or no cost.

• Mental health parity gaps: You may be charged the same copay for mental health as for physical health visits—but you need more frequent sessions.

While the individual copay amount may not be shocking, the frequency and diversity of care add up behind the scenes.

Strategies to Minimize Copay Drain

To avoid unpleasant financial surprises, consider these options to manage your copay-related spending:

• Choose providers who bundle services: Some clinics may offer lab work, imaging, or follow-ups under a single visit copay.

• Use preventive services: Many preventive screenings and annual checkups are fully covered without a copay.

• Ask about telehealth: Some plans offer reduced-cost or copay-free virtual visits.

• Review your plan each November: During Open Season, compare the projected cost of copays under different PSHB plans. Some may offer lower copays for high-frequency services.

• Track your spending monthly: Use your plan’s online portal or a budgeting app to tally how much you’re paying in copays, especially if you have a condition that requires ongoing care.

Out-of-Network Care Makes It Worse

One of the fastest ways copays escalate is by using out-of-network providers. Some PSHB plans charge higher copays or deny copay rates entirely if you step outside the provider network.

For example:

• In-network specialist visit: $35

• Out-of-network specialist: 40% coinsurance after deductible

That difference could turn a $35 visit into a $200+ bill. Always confirm provider network participation before scheduling care, especially for:

• Mental health therapists

• Urgent care centers

• Diagnostic facilities

In 2025, PSHB plans continue to enforce network usage more strictly. Higher coinsurance and fewer cost protections apply when you go out-of-network.

High Copays Can Skew Your Perception of Plan Value

If you selected your plan based primarily on premiums, it’s easy to underestimate the true cost of using care. Premiums are just one part of the picture. If your plan has high or frequent copays, the total yearly cost of coverage may be far higher than expected.

Ask yourself:

• Am I or my dependents using care 5+ times a month?

• Are my prescription copays more than $100 per month?

• Do I use urgent care 3–4 times a year?

If yes, then comparing plans based on total expected cost (premiums + average monthly copays) may lead you to choose a better fit in the next Open Season.

Understanding Copays Helps You Take Control

Copayments under PSHB are predictable—but only if you understand how often you’ll need care. Even small amounts snowball when used frequently, especially across family members or multiple prescriptions.

In 2025, evaluating your plan based solely on the advertised copay values is no longer enough. You need to estimate usage frequency, review provider networks, and explore Medicare coordination (if eligible). Every dollar counts, and copays can silently erode your financial plans unless you pay close attention.

If you’re uncertain whether your current plan is still the right match for your healthcare usage, speak with a licensed agent listed on this website to walk through your options before the next enrollment period.