Key Takeaways

• While Medicare Advantage plans can appear attractive in advertisements, many enrollees discover complex cost structures and access limitations once they need care.

• As a Postal Service Health Benefits (PSHB) enrollee, it’s essential to weigh the tradeoffs of Medicare Advantage before opting out of Original Medicare or relying solely on one plan type.

Medicare Advantage Plans: What You Need to Know in 2025

Medicare Advantage (Part C) plans are marketed as all-in-one alternatives to Original Medicare, combining hospital, medical, and often prescription drug coverage. In 2025, they remain a popular option for many Americans, including Postal Service annuitants who are now transitioning into the PSHB system. But these plans aren’t as straightforward as they seem.

If you’re eligible for Medicare and enrolled in a PSHB plan, understanding the fine print of Medicare Advantage is critical. These plans come with limitations that may not be evident in ads or summary brochures. Let’s break down the realities you need to consider.

The Appeal: Why Medicare Advantage Plans Look So Good

Medicare Advantage plans are widely advertised with appealing features such as:

• Lower upfront monthly premiums compared to certain supplemental plans

• Added perks like dental, vision, or fitness memberships

• One ID card for all services

• Simplified coordination of care under one insurance provider

These features make them seem like a streamlined solution for your Medicare coverage. However, they come with tradeoffs that often reveal themselves when you actually seek care.

Network Restrictions You Might Not Expect

One of the biggest surprises with Medicare Advantage plans is the limited provider network. Unlike Original Medicare, which allows you to see nearly any doctor or hospital nationwide that accepts Medicare, Medicare Advantage plans often require you to stay within a specific network of providers.

Some key considerations:

• You may need prior authorization for many services, even routine procedures.

• If you travel or live in multiple states seasonally, you might lose access to in-network care.

• Out-of-network care can be very costly, or not covered at all, unless it’s an emergency.

In contrast, PSHB plans integrated with Medicare typically retain broader provider flexibility, especially for annuitants who maintain Medicare Parts A and B.

Cost-Sharing That Adds Up Quickly

While Medicare Advantage plans often promote low premiums, the real costs come through deductibles, copayments, and coinsurance.

In 2025:

• You may pay $30 to $60 for a specialist visit.

• Emergency room visits can result in $100 to $150 copays.

• Many plans have out-of-pocket maximums as high as $9,350 for in-network services.

PSHB plans combined with Original Medicare generally offer lower cost-sharing, especially if the plan waives or reduces costs for Medicare enrollees. For example, PSHB plans may lower deductibles or copays when you show proof of Medicare Part B enrollment.

Prior Authorizations: Delays and Denials

Another frustrating element of Medicare Advantage is prior authorization. Even if your doctor recommends a test or treatment, the insurance company can delay or deny it.

According to government reviews, many Medicare Advantage plans use prior authorization frequently for:

• Imaging (MRIs, CT scans)

• Skilled nursing facility stays

• Home health services

Delays in care can be critical, particularly for older adults with complex or chronic conditions. Under PSHB with Original Medicare, many of these services do not require pre-approval, helping you get care faster.

Geographic Limitations Still Apply

PSHB retirees and annuitants often have unique lifestyles. You may split time between two homes, or frequently travel. With Original Medicare and a PSHB plan, you generally retain national coverage.

But Medicare Advantage plans typically limit you to your regional network. While some offer emergency or urgent coverage outside the service area, routine care is rarely covered out-of-area. This becomes problematic if you spend weeks or months away from your home base.

Prescription Drug Coverage Isn’t Always Comprehensive

Most Medicare Advantage plans include Part D drug coverage. However, they come with their own formulary, which may not cover all medications you need.

Important details:

• Formularies vary by plan and change annually.

• Drugs may fall under higher cost tiers.

• Prior authorization or step therapy might be required.

In contrast, PSHB plans often integrate with Medicare Part D through an Employer Group Waiver Plan (EGWP), which typically provides more stable coverage, broader formularies, and a $2,000 annual cap on out-of-pocket drug costs in 2025.

Changes to Benefits Can Happen Every Year

Medicare Advantage plans reset their benefits annually. Each fall, during Medicare Open Enrollment (October 15 to December 7), plans release new coverage details, premiums, provider networks, and drug formularies.

If you don’t review these changes and make necessary adjustments, you may end up with:

• Higher costs

• Fewer benefits

• Narrower networks

This volatility contrasts with PSHB plans, which also go through annual updates but may offer more consistency due to federal oversight and integration with Medicare.

Maximum Out-of-Pocket Limits Can Be Misleading

While Medicare Advantage plans must cap your annual out-of-pocket spending for in-network services (in 2025, up to $9,350), this does not include premiums or out-of-network costs. If you use out-of-network providers or have frequent specialist visits, your actual costs can exceed expectations.

PSHB plans often have separate but sometimes lower out-of-pocket maximums, particularly when coordinated with Medicare. For example, you may see:

• $7,500 for Self Only

• $15,000 for Self Plus One or Family

When combined with Medicare, your cost-sharing responsibilities can be further reduced, making the out-of-pocket burden more manageable.

Why PSHB + Original Medicare Offers More Control

For Postal Service annuitants, there’s a strong case for combining Original Medicare (Parts A and B) with a PSHB plan rather than switching to a standalone Medicare Advantage plan.

This combo allows:

• National provider access without network limitations

• Reduced or waived cost-sharing by the PSHB plan

• Automatic drug coverage through the plan’s EGWP

• Streamlined integration without replacing Original Medicare

You maintain control and consistency across different states or healthcare systems. That stability can be especially valuable during emergencies or chronic illness management.

Be Aware of Enrollment Lock-In Rules

If you join a Medicare Advantage plan, you’re usually locked into that plan for the calendar year. While there is a Medicare Advantage Open Enrollment Period from January 1 to March 31 each year, you can only make a one-time change.

Missing that window means you’re stuck with:

• Your current plan’s costs

• Its network restrictions

• Any coverage gaps until the next Open Enrollment in the fall

By contrast, with PSHB and Original Medicare, you can adjust supplemental benefits during the November to December PSHB Open Season, giving you more flexibility.

Key 2025 Updates You Should Know

Medicare rules evolve annually, and 2025 is no exception. This year:

• The Medicare Part B premium is $185, and the deductible is $257.

• Medicare Part D now includes a $2,000 out-of-pocket cap.

• Most PSHB plans continue integrating drug coverage through Part D EGWP.

You should always review your Annual Notice of Change (ANOC) and PSHB plan materials to understand how these updates affect your benefits.

Think Beyond the Ads: Medicare Advantage Isn’t One-Size-Fits-All

Despite the glossy marketing campaigns, Medicare Advantage plans come with strict rules and potential limitations. For Postal Service retirees and annuitants, the PSHB program paired with Original Medicare provides broader provider access, steadier benefits, and fewer surprise bills.

Before enrolling or switching plans, be sure to:

• Review the Summary of Benefits and Evidence of Coverage documents

• Compare plan networks and prescription formularies

• Evaluate travel needs and multiple-residence coverage

• Consider long-term cost protections

A licensed agent listed on this website can help you compare your PSHB plan options and Medicare coordination strategies so you can make an informed choice.

Get Help Evaluating Your PSHB and Medicare Options

Medicare Advantage plans might seem attractive at first glance, but the fine print reveals several tradeoffs. For PSHB enrollees, staying with Original Medicare while coordinating with a strong PSHB plan often leads to better flexibility, cost stability, and access to care.

Make sure your choice matches your long-term needs, not just short-term perks. If you’re unsure which PSHB plan fits best with your Medicare benefits, talk to a licensed agent listed on this website. They can help you make confident, informed decisions based on the latest 2025 plan data.