Key Takeaways

• Some Postal Service Health Benefits (PSHB) plans include deductibles that are not clearly labeled or are embedded within specific benefit categories, making them easy to overlook unless you read the fine print.

• Understanding where these hidden deductibles are located—such as in prescription drug tiers, out-of-network services, or specialist referrals—can prevent unexpected out-of-pocket costs.

Why Deductibles Are Sometimes Hard to Spot

When you review a PSHB brochure or plan summary, you might assume the deductible is clearly listed in one central place. But in reality, some deductibles are embedded in separate sections of the benefits guide and may not be labeled as “deductible” at all. This happens because PSHB plans often split costs across multiple categories:

• Medical services (inpatient and outpatient)

• Prescription drugs

• Out-of-network coverage

• High-deductible health plan (HDHP) structures

Each of these categories may have its own deductible or cost-sharing structure that applies independently from the main medical deductible.

Where Hidden Deductibles Tend to Appear

1. Out-of-Network Benefits

Many PSHB plans promote their in-network benefits up front. However, if you use a provider who is outside the network, you might be subject to an entirely different deductible—and it’s usually higher. Look for this language buried in the plan brochure under sections like:

• “Using Non-Preferred Providers”

• “Out-of-Network Cost-Sharing”

In 2025, the in-network deductible might be $500, but out-of-network deductibles can range from $1,000 to $3,000 depending on the plan. This can dramatically impact your costs if you accidentally use a provider who isn’t in the network.

2. Specialty Drug Tiers

Prescription drug benefits often have tiers that include generic, preferred brand, non-preferred brand, and specialty drugs. What many enrollees miss is that certain specialty drug tiers have separate annual deductibles before the plan even begins to cover a portion of the cost.

You’ll typically find this clause under “Prescription Drug Benefits” or “Specialty Pharmacy Benefits.” These deductibles are often:

• Annual (reset every calendar year)

• Not applied toward your main medical deductible

3. Mental Health and Substance Use Services

Another area where deductibles may appear without obvious labeling is in behavioral health. Even within an in-network setting, some plans apply separate cost-sharing for mental health services. This is especially common for:

• Outpatient therapy

• Intensive outpatient programs

• Substance use rehabilitation

Check the behavioral health benefits section for language like “subject to deductible” or “prior to coinsurance.”

4. Durable Medical Equipment (DME)

If you require durable medical equipment—like CPAP machines, crutches, or wheelchairs—you may find that these benefits apply a separate deductible. This is often mentioned in fine print such as:

• “After annual DME deductible is met”

• “Separate equipment deductible applies”

It’s not uncommon for this deductible to be $150 to $500 annually, depending on the plan structure. In some cases, it doesn’t cross-apply to your primary out-of-pocket max.

5. Preventive vs Diagnostic Screenings

Under PSHB, preventive services are generally covered with no cost-sharing. However, when a screening becomes diagnostic, the billing changes—and so can the deductible status. For example:

• A colonoscopy as a routine check-up may be covered in full

• The same colonoscopy, if ordered for symptoms, may trigger the deductible

This type of language is typically found under preventive care disclaimers: “Services deemed diagnostic are subject to deductible and coinsurance.”

How to Identify These Hidden Deductibles

To locate these cost components before they surprise you, focus on:

• Reviewing every benefit section: Don’t rely solely on the summary chart. Read detailed benefit descriptions, especially for categories like behavioral health and pharmacy.

• Checking footnotes and asterisks: These often lead to explanations about limits, conditions, or secondary deductibles.

• Comparing the Summary of Benefits and Coverage (SBC): This document outlines deductibles for different care types and may highlight inconsistencies not shown in marketing materials.

• Requesting the full plan brochure: Use the Office of Personnel Management (OPM) website or your plan portal to get access to the full, detailed document.

Annual Reset Rules You Should Know

All PSHB deductibles operate on a calendar year basis. That means:

• Deductibles reset every January 1

• Any amount you’ve paid in the prior year does not roll over

• If you change plans during Open Season, you start with a fresh deductible in the new plan, even if your previous plan was nearly met

This reset also applies to those mid-year plan switch scenarios due to qualifying life events (QLEs). If you marry, retire, or move and change plans, your deductible starts from zero under the new policy.

The Difference Between Embedded and Aggregate Deductibles

Understanding the structure of your plan’s deductible can make a big difference:

• Embedded deductible: Each family member has their own individual deductible, and the plan begins covering costs for that person once it is met. Once the family deductible is reached, the plan covers costs for the entire household.

• Aggregate deductible: The family deductible must be met as a whole before anyone in the household receives coverage beyond preventive care.

In 2025, some PSHB plans, particularly high-deductible health plans (HDHPs), continue to use the aggregate model—making it more difficult to reach cost-sharing benefits unless the full amount is paid upfront.

Implications for Budgeting and Health Planning

Missing a hidden deductible can affect your:

• Annual healthcare budgeting: You might believe your only responsibility is the main deductible, but multiple hidden ones can double or even triple your real exposure.

• HSA and FSA planning: If you’re contributing to a Health Savings Account (HSA) or a Flexible Spending Account (FSA), misjudging your actual deductible exposure can result in underfunding.

• Cost comparison across plans: You might opt for a lower premium plan thinking it’s more affordable, only to face higher deductibles buried in service categories.

It’s also important to look at the total out-of-pocket maximum, which includes deductibles, copayments, and coinsurance. But remember—not all deductibles contribute to this cap. Specialty tiers and out-of-network expenses may have their own limits.

Who Is Most Affected by Hidden Deductibles?

While any enrollee can be caught off guard, certain groups tend to feel the effects more strongly:

• Postal retirees living on fixed incomes

• Families with children, especially those needing behavioral health or pediatric specialist care

• Those managing chronic conditions requiring frequent equipment or specialty drugs

• Enrollees without medicare Part B, who typically face higher cost-sharing under PSHB alone

In these cases, taking the time to analyze your plan details pays off significantly.

What You Can Do Right Now

If you’re currently enrolled in a PSHB plan—or planning to switch during Open Season—there are steps you can take immediately:

• Download the full plan brochure and read it in detail

• Call your plan’s member services and ask directly: “Are there separate deductibles for specific benefits like mental health, prescriptions, or DME?”

• Prepare a spreadsheet or checklist of known and hidden deductible amounts across different benefit categories

• Consult a licensed agent listed on this website for plan comparison and personalized support

Spotting the Gaps in PSHB Deductible Clarity

Knowing where these hidden deductibles live and how they function puts you in control. You shouldn’t be blindsided by an extra $1,000 out-of-pocket cost because a benefit wasn’t labeled clearly. Instead, take time now to understand your plan’s fine print—and adjust your health planning accordingly.

For personalized help reviewing your PSHB plan options, contact a licensed agent listed on this website. They can walk you through the specific deductible terms for any plan you’re considering or already enrolled in.