Key Takeaways

• Copayments under the Postal Service Health Benefits (PSHB) Program may appear small individually but can lead to substantial costs over the course of a year.

• Understanding the difference between copays, coinsurance, and deductibles is essential to effectively estimate your actual healthcare spending.

Copayments: What They Really Mean for Your Budget

If you’re enrolled in a Postal Service Health Benefits (PSHB) plan, you’re probably familiar with copayments. These are the flat fees you pay when you receive specific healthcare services, like visiting a primary care doctor or filling a prescription. They may feel predictable and harmless, but over time, they can add up significantly and quietly strain your budget.

In 2025, most PSHB plans still use copayments as the first tier of cost-sharing. That makes it easy to underestimate how much you’re actually spending—especially if you or your family members have frequent visits to doctors, specialists, urgent care clinics, or pharmacies.

Let’s break down how copays work and why ignoring them can be a costly mistake.

What Counts as a Copayment Under PSHB?

A copayment (copay) is a fixed dollar amount you’re responsible for at the time of service. It typically applies to routine services, such as:

• Primary care visits

• Specialist consultations

• Urgent care visits

• Emergency room services

• Prescription medications

• Physical therapy or mental health counseling

Copays vary depending on the plan option you’ve chosen, the type of provider you’re seeing (in-network or out-of-network), and the type of service being provided. For example, seeing a specialist usually carries a higher copay than seeing your primary doctor.

Why Flat Fees Aren’t Always Flat in the Long Run

At first glance, a $25 or $40 copay might not seem like much. But if you’re managing a chronic condition or have a family with regular medical needs, these costs can pile up.

Here’s what adds to the total:

• Multiple appointments per month – A specialist, therapist, and primary care visit could each carry a separate copay.

• Family coverage – If your spouse or children also receive frequent care, those costs multiply quickly.

• Ongoing prescriptions – Even with generic drugs, recurring copays add a monthly cost layer.

• Unexpected illness or injury – An urgent care or emergency room visit introduces new copays that weren’t planned.

Annual Totals Can Surprise You

Because copays are spread across multiple services and times throughout the year, many people don’t realize how much they’ve spent until they look at their annual out-of-pocket statements. What starts as a few dollars here and there can cross into the thousands by year-end—especially when combined with deductibles and coinsurance.

This is particularly important for Postal Service retirees or those managing chronic conditions like diabetes, arthritis, or cardiovascular disease, where care is routine and ongoing.

Copayments vs. Other Cost-Sharing: Know the Difference

It’s common to confuse copayments with coinsurance and deductibles. While they all represent your share of healthcare costs, they function very differently:

• Copayment: A set dollar amount (e.g., $30 for a primary care visit), predictable and due at the time of service.

• Coinsurance: A percentage of the allowed cost after your deductible has been met (e.g., you pay 20%, plan pays 80%).

• Deductible: The amount you must pay before your plan begins covering services beyond preventive care.

Understanding these distinctions can help you make more informed choices when using care.

Copays After You Meet the Deductible

In many PSHB plans, copays apply regardless of whether you’ve met your deductible. For example:

• You may owe a copay for a specialist visit, even if your annual deductible is still unmet.

• In contrast, certain services (like imaging or surgery) might require coinsurance after the deductible is satisfied.

It’s a layered system, and copayments often sit outside the deductible thresholds.

Prescription Drug Copays: Hidden Costs in Plain Sight

Your prescription drug copays might look straightforward at the pharmacy counter, but the total cost over a year tells another story. Even with generics, monthly refills can create a rolling cost that feels small but totals hundreds of dollars annually.

Some drugs are placed on higher tiers with increased copays. That means:

• Tier 1 (generic): Lower copay

• Tier 2 (preferred brand): Moderate copay

• Tier 3 (non-preferred): Higher copay

• Tier 4 or specialty drugs: Highest copays or coinsurance

If you’re managing multiple medications or require drugs from higher tiers, those flat-rate copays build fast.

Why You Shouldn’t Choose a Plan Based Solely on Copays

It’s tempting to choose a plan because it offers lower copays on paper. But this approach can backfire if the plan has:

• Higher deductibles

• Stricter network restrictions

• Limited coverage for specialists or brand-name prescriptions

Always weigh copays alongside:

• Total premium contributions

• Deductible amounts

• Coinsurance responsibilities

• Maximum out-of-pocket limits

The total cost of care is a complex formula. A plan with low copays may not always offer the best overall value.

2025 PSHB Trends: Copayments Still Dominate Routine Care

In 2025, PSHB plans continue to rely on copayments for a broad range of services. These amounts have remained relatively stable compared to the sharp increases in premiums and deductibles over the past year. That’s good news in one way, but it also encourages the belief that copays are harmless.

Here’s what to watch for this year:

• In-network providers usually offer lower copays.

• Emergency room visits carry some of the highest copays.

• Telehealth may still require copays depending on the service.

• Mental health services generally carry a lower copay than specialists.

These trends reflect national health plan structures, but they can vary by PSHB plan option. Reviewing your plan brochure is essential.

Tools to Track Copayment Spending

Keeping a simple record of your copays—either on paper, in a spreadsheet, or with a health app—can help you:

• Identify patterns in your care

• Budget more effectively for medical costs

• Decide whether to switch plan options during Open Season

Some people find they’re better off with a higher-premium plan that has lower copays and broader coverage, especially if they have ongoing medical needs.

The Accumulation Effect: Small Fees Become Large Problems

It’s not the $30 copay once. It’s the $30 copay every week for 52 weeks. That’s the danger of seeing copays as harmless.

Here are the key services where copay buildup is most common:

• Physical therapy (multiple sessions per week)

• Mental health counseling (weekly or biweekly visits)

• Pediatric visits (especially for children under 5)

• Urgent care (seasonal spikes during cold/flu season)

When you begin to view copays over months instead of moments, your healthcare budgeting becomes much more realistic.

How Copays Interact With Out-of-Pocket Maximums

Even though copays feel disconnected from the larger health insurance equation, they still count toward your annual out-of-pocket maximum. In 2025, most PSHB plans set this limit at $7,500 for Self Only and $15,000 for Self Plus One or Self and Family for in-network services.

Once this cap is reached:

• Your plan covers 100% of eligible in-network costs.

• You no longer owe copays or coinsurance for the rest of the year.

This feature provides important financial protection—but only after you’ve already paid a significant amount out of pocket.

Checklist: Managing Copayment Impact

Small Charges With a Big Impact

While copayments might seem minor in isolation, their cumulative effect over months—and across multiple family members—can be surprisingly significant. Don’t let their simplicity distract you from their long-term impact on your wallet.

If you’re unsure how your plan’s copayments align with your healthcare usage, it may be time to speak with a professional. You can get in touch with a licensed agent listed on the website who can help walk you through your options and estimate your total annual costs under different PSHB plans.