Key Takeaways

• In 2025, copayments under PSHB plans may seem small at first but can lead to significant out-of-pocket costs if you aren’t tracking them closely.

• Understanding how your PSHB plan structures copayments for primary care, specialists, urgent care, and prescription drugs is critical to avoiding financial surprises.

What You Assume About Copays Might Not Match the Reality

At first glance, a $20 or $40 copayment might not raise any red flags. But when you’re regularly visiting healthcare providers, picking up prescriptions, or managing chronic conditions, those copayments stack up quickly. In 2025, under the Postal Service Health Benefits (PSHB) Program, this concern is more relevant than ever.

With the shift from the Federal Employees Health Benefits (FEHB) program to the PSHB system now complete, you’re dealing with new plan structures. That includes new copayment schedules for everything from office visits to urgent care to emergency room services.

Let’s break down how these seemingly small fixed fees can have a bigger impact than you expect, and what steps you can take to stay in control of your costs.

Understanding the PSHB Copay Structure in 2025

Under PSHB plans, copayments vary by the type of service and whether you use in-network or out-of-network providers. Here are some of the most common areas where copayments apply:

• Primary care visits

• Specialist visits

• Urgent care centers

• Emergency room visits

• Generic and brand-name prescription drugs

• Mental health services

• Outpatient procedures

Each of these has a different copayment tier, and if you use these services often, the cumulative cost can be substantial.

How Copayments Add Up in Real Terms

The reality in 2025 is this: even though copayments offer the comfort of predictable, flat-rate fees, they still represent a direct out-of-pocket cost each time you receive care. Let’s say you have a $30 copayment for specialist visits. If you see a specialist monthly, that’s $360 a year from that one type of service alone.

Now add in:

• Four urgent care visits at $60 each = $240

• Sixteen generic prescription fills at $15 each = $240

• Two ER visits at $150 each = $300

You’re already looking at $1,140 annually, without even including primary care, labs, imaging, or mental health visits. If you’re managing multiple health conditions, this number climbs even faster.

Copays vs. Coinsurance: Know the Difference

In 2025, many PSHB members confuse copayments with coinsurance. While both are forms of cost-sharing, they function very differently:

• Copayment: A fixed dollar amount for a covered service.

• Coinsurance: A percentage of the cost of the service, which can fluctuate depending on the provider’s charges and whether they’re in-network.

While coinsurance can lead to more unpredictable billing, copays seem more manageable. But when services are frequent, copays can exceed coinsurance costs over time, especially in high-utilization scenarios.

You Could Be Paying More Than You Think

One of the most overlooked traps in PSHB plans is assuming you’re saving money by avoiding higher coinsurance. However, depending on your utilization rate, you might actually be spending more on copayments than someone paying coinsurance at 20%.

Here’s what happens:

• You choose a plan with low copays and higher premiums, thinking you’ll save money at the point of care.

• You use services more frequently than you anticipated.

• Your copayments build up steadily, while your premiums are already being deducted biweekly.

The result is that your total annual healthcare spending could be significantly more than you expected.

Are Your Copayments Working Against You?

You may not realize it, but the way your copays are structured could be working against your budget. This is especially true if:

• Your plan charges a separate copay for each part of a bundled service (e.g., office visit + lab work + imaging).

• Mental health care or chronic condition management requires multiple visits per month.

• Prescription refills are frequent or include non-preferred drugs.

In these situations, even moderate copays can snowball into a substantial expense.

PSHB and Medicare: How Copays Change When You’re Medicare-Eligible

If you’re 65 or older and enrolled in both PSHB and Medicare Part B in 2025, your out-of-pocket costs may be lower, depending on how your PSHB plan coordinates with Medicare.

Many PSHB plans offer benefits such as:

• Waived or reduced copays for services covered by Medicare Part B.

• Better prescription coverage via a Medicare Part D integration.

• Lower deductibles and out-of-pocket maximums when both PSHB and Medicare are used together.

But this is not automatic. You need to ensure your Medicare enrollment is active and properly integrated with your PSHB plan. Otherwise, you could miss out on those cost savings.

The Monthly Effect: Tracking Your Out-of-Pocket Copays

One of the smartest moves you can make in 2025 is to track your healthcare expenses monthly. Use a simple spreadsheet or an app to log:

• Date of service

• Type of service

• Copayment paid

• Whether it was in-network or out-of-network

This monthly snapshot can help you:

• Identify patterns of overuse or avoidable visits

• Recognize when switching to a different plan might save money

• Understand when to schedule visits to avoid hitting your annual out-of-pocket maximum too early or too late in the year

Be Cautious During Open Season

Open Season from November to December is your once-a-year opportunity to compare PSHB plans and switch if necessary. Here’s what to review with copayments in mind:

• Are specialist copays higher or lower than your current usage pattern can sustain?

• Does the plan include bundled services for chronic care, or are copays split across multiple visits?

• What do urgent care, ER, and mental health copays look like?

• Does the plan offer enhanced benefits for Medicare-enrolled members?

It may be worth paying slightly more in premiums for a plan that reduces frequent copay burdens, especially if your healthcare usage is consistent.

Don’t Overlook Tiered Copay Structures for Drugs

Prescription drug copays can be particularly tricky. In 2025, most PSHB plans use a multi-tier system:

• Tier 1: Preferred generics

• Tier 2: Non-preferred generics or preferred brands

• Tier 3: Non-preferred brands

• Tier 4: Specialty medications

If your medications move between tiers during the year, your copays will change. A Tier 1 drug might cost $10, while a Tier 4 drug could exceed $100 per fill. Understanding where your medication falls can help you plan your spending or speak with your provider about alternatives.

Small Copays Aren’t Always Small in the Long Run

Psychologically, small copayments feel manageable, but they’re only one piece of the total cost puzzle. If your plan has high copayments but a low premium, you need to actively monitor your spending across the year. Conversely, a plan with slightly higher premiums but fewer or lower copayments could result in a better annual balance.

Think Strategically About Your Healthcare Use

In 2025, smart use of healthcare services goes a long way in managing copayment costs. Consider the following strategies:

• Telehealth: Many PSHB plans offer lower copays for virtual visits.

• Preventive care: Usually covered at no cost when in-network, these services can reduce your need for expensive treatments later.

• Generic medications: When possible, use Tier 1 generics to reduce drug copayments.

• Care coordination: Consolidate services (e.g., labs, imaging, consults) into a single visit to minimize repeat copays.

When It Feels Like You’re Paying Too Much

If your monthly copayments are starting to feel excessive, take time to:

• Recalculate your total out-of-pocket spending for the year so far.

• Revisit your plan brochure to verify the listed copayment structure.

• Check if you’ve approached your out-of-pocket maximum, after which additional services may be covered at no cost.

• Consider contacting your plan’s member services to clarify charges.

Managing the Copay Trap Starts With Awareness

2025 has introduced a new rhythm to how your Postal Service Health Benefits operate. Copayments, while predictable, can become burdensome if you’re not monitoring them. You have the tools to avoid this trap: monthly tracking, smart plan selection, and thoughtful use of services.

If you’re unsure which PSHB plan structure suits your medical needs and budget best, reach out to a licensed agent listed on this website for personalized guidance during the next Open Season.