Key Takeaways

• Reaching your PSHB deductible is only the first step. Significant out-of-pocket costs can still occur due to coinsurance, copayments, and plan limits.

• Understanding what happens after meeting your deductible helps you avoid unexpected bills and make informed choices about your healthcare for the rest of the year.

Meeting Your Deductible: What It Actually Means

If you’re enrolled in a Postal Service Health Benefits (PSHB) plan in 2025, you likely already know the basics: you pay your premium each month, and when you use medical services, you cover certain costs out of pocket. One of the major benchmarks is your deductible. But reaching that deductible doesn’t mean you’re off the hook financially. It simply marks a new phase in your cost-sharing responsibilities.

Your deductible is the amount you must pay for covered healthcare services before your plan begins to share costs. For most PSHB enrollees, this is an annual figure that resets every calendar year. Once you hit that number, your plan’s cost-sharing kicks in, typically through coinsurance or copayments, depending on the service.

What Happens After You Meet the Deductible?

Meeting your deductible doesn’t mean your plan now pays 100% of all remaining healthcare costs. Instead, your financial role continues in several ways:

Coinsurance Begins

• Coinsurance is your share of the costs of a covered service, calculated as a percentage.

• For example, if your plan has a 20% coinsurance for specialist visits or hospital care, you’re still responsible for 20% of the bill, and your plan covers the remaining 80%.

• The percentage varies depending on whether you’re using in-network or out-of-network providers.

Copayments May Still Apply

• Even after reaching your deductible, flat-rate copays may remain for certain services like urgent care visits or prescription medications.

• These fixed amounts do not go away after hitting the deductible.

Certain Costs Are Always Separate

• Some services, such as dental or vision care (if offered), may operate under separate cost-sharing rules.

• Your prescription drug benefits may have their own tiered copayment structure.

Understanding Coinsurance in the PSHB Framework

After your deductible is met, the bulk of your remaining out-of-pocket costs comes from coinsurance. It is essential to understand how this plays out across different types of care.

Inpatient Hospital Stays

• You may owe a percentage of the total bill for each day you’re hospitalized.

• Some PSHB plans cap the number of days coinsurance applies, while others charge through the entire stay.

Specialist Visits and Outpatient Services

• Coinsurance typically applies here as well, and the percentages may be higher than those for primary care visits.

• Outpatient surgery or advanced imaging (like MRIs or CT scans) may come with significant coinsurance responsibilities.

Emergency Services

• ER visits usually have a combination of a copayment and coinsurance.

• If the visit results in an admission, some plans apply inpatient rules instead.

Reaching the Out-of-Pocket Maximum: The True Cap

The good news is that all PSHB plans include an out-of-pocket maximum (OOPM). This is the most you’ll have to pay for covered in-network services in a calendar year.

• Once your spending reaches this maximum, your plan pays 100% of covered services for the rest of the year.

• It includes deductibles, coinsurance, and copayments, but not premiums.

• For 2025, OOPMs generally fall between $7,500 for Self Only coverage and $15,000 for Self Plus One or Self and Family, although this can vary.

Understanding when and how you’ll reach this threshold is critical for financial planning.

Out-of-Network Services: A Different Set of Rules

If you use a provider outside your plan’s network, everything changes:

• Deductibles and out-of-pocket limits for out-of-network care are often separate and higher.

• Coinsurance rates are typically greater, and there may be no cap on what you could owe, especially if the provider bills above the plan’s allowed amount.

• Some PSHB plans may not cover out-of-network services at all, except in emergencies.

Prescription Drug Costs: A Parallel Track

Prescription drugs under PSHB are subject to their own cost-sharing structures.

• Even after hitting your medical deductible, you may still face copayments or coinsurance for prescriptions.

• Tiered pricing systems mean your cost varies depending on the drug’s classification (generic, preferred brand, non-preferred brand, specialty).

• Fortunately, 2025 introduces a significant change: a $2,000 annual cap on out-of-pocket drug costs under Medicare Part D plans, including those integrated into PSHB for Medicare-eligible enrollees.

Medicare Integration: A Game Changer for Some

If you’re a Medicare-eligible annuitant and enrolled in both PSHB and Medicare Part B, your cost-sharing could be much lower.

• Many PSHB plans waive or reduce deductibles and eliminate coinsurance for members with Medicare Part B.

• Prescription drug coverage for Medicare enrollees is integrated into a Part D EGWP (Employer Group Waiver Plan), which includes the $2,000 annual out-of-pocket cap.

This combination significantly reduces post-deductible spending.

Separate Deductibles by Service Type or Family Member

It’s also important to know that some PSHB plans use different types of deductibles:

• Embedded deductibles apply individually to each family member. Once one person meets their deductible, cost-sharing begins for that individual.

• Aggregate deductibles require the entire family to meet one combined deductible before cost-sharing applies.

Some services, such as mental health care or maternity services, might also have special cost-sharing rules even after the general deductible is met.

Preventive Care: Covered Regardless of Deductible

Preventive services remain fully covered even before your deductible is met. These include:

• Annual checkups

• Routine immunizations

• Screenings like mammograms or colonoscopies

If your provider bills preventive care alongside diagnostic services, however, you may face cost-sharing for the diagnostic portion.

Timing Matters: Watch the Calendar

Because PSHB deductibles and out-of-pocket limits reset every calendar year, when you incur healthcare costs makes a significant difference:

• Meeting your deductible in January allows you to benefit from coinsurance sharing for the rest of the year.

• Reaching it late in the year gives you limited time to take advantage of reduced cost-sharing.

• Timing elective procedures in the same year after meeting your deductible can help you minimize total costs.

Be Proactive: Track Your Spending and Benefits

Many PSHB plans provide tools through their member portals to help you:

• Track your deductible status

• View remaining out-of-pocket liability

• Monitor pharmacy spending

Keeping tabs on this data helps you make timely decisions and avoid surprise bills.

What to Do If You Can’t Afford Post-Deductible Costs

Even with coverage, the financial burden after reaching your deductible can be overwhelming. Here are a few steps to consider:

• Review alternate PSHB plan options during Open Season each November–December to find lower coinsurance or out-of-pocket limits.

• Use in-network providers as much as possible to avoid higher out-of-network charges.

• Explore supplemental programs for Medicare-eligible members that help cover cost-sharing.

• Schedule non-urgent services strategically within your deductible cycle.

Meeting the Deductible Is Just One Milestone

In 2025, managing your healthcare finances under the PSHB Program requires more than just hitting your deductible. The real cost management begins after that milestone. Coinsurance, copayments, and service-specific exclusions can all add to your burden if you’re not careful.

Understanding how your plan handles cost-sharing after the deductible helps you stay prepared. Use your plan’s tools, stay in-network, time your services wisely, and if eligible, consider the advantages of Medicare coordination.

To review your specific options and see what your projected post-deductible costs might look like, connect with a licensed agent listed on this website. Getting personalized help ensures you make the best use of your benefits.