Key Takeaways

• Copayments under the 2025 PSHB plans are no longer as straightforward as they once were. Many variables—including Medicare status, provider networks, and type of service—can dramatically alter what you actually pay.

• The predictability you may have relied on with past FEHB or legacy plans has shifted. Understanding how copayments interact with deductibles, coinsurance, and out-of-pocket caps is now more essential than ever.

Copayments in 2025: Not Just a Fixed Fee Anymore

You may be used to paying a $30 or $40 copayment and assuming that’s the final word. But under the Postal Service Health Benefits (PSHB) Program in 2025, that number often represents just one piece of the puzzle. Copayments still exist, but how they’re applied has evolved, especially for Medicare-eligible enrollees and those using out-of-network providers.

In the current PSHB framework, copayments now depend more heavily on:

• Whether you’ve met your deductible

• The type of provider you see (primary vs. specialist)

• The setting of care (urgent care vs. ER)

• Whether you have Medicare Part B in addition to PSHB

These factors can either lock in a low copay—or expose you to much higher costs under coinsurance or full service rates until other thresholds are met.

How PSHB Has Shifted from FEHB in Terms of Copayments

In past years under the Federal Employees Health Benefits (FEHB) Program, you may have enjoyed a more stable and predictable copayment structure. The PSHB model, while still designed to offer comprehensive coverage, places a stronger emphasis on cost-sharing models that react to plan design.

In 2025, PSHB plans have adopted:

• More defined tiers for service categories

• Greater variation between in-network and out-of-network costs

• Incentives for Medicare enrollment that can significantly alter what you owe at the time of service

This evolution is especially impactful for annuitants who previously counted on flat-fee visits. Now, depending on how your plan is structured and whether you have Medicare, your experience could vary widely from one visit to the next.

The Role of Medicare in Reshaping Copayments

If you’re enrolled in both Medicare Part B and a PSHB plan, you’ll likely notice that some copayments vanish or shrink dramatically. That’s because many PSHB plans are integrating benefits with Medicare, often eliminating cost-sharing in favor of coverage coordination.

However, these reduced copayments often apply only to:

• In-network services

• Services covered by both Medicare and your PSHB plan

• Services not subject to additional plan conditions (like prior authorization or step therapy)

If you haven’t enrolled in Medicare Part B, your PSHB plan still covers services—but you may be responsible for the full copayment or even coinsurance until your deductible is met. That unpredictability is a key reason to review both your PSHB plan materials and your Medicare options each year.

Copayments and Deductibles: The Link You Can’t Ignore

Another change in 2025 is how tightly copayments are linked to deductibles. Some services that once allowed flat copays now require you to meet your deductible first. This is especially true for high-cost services, like:

• Imaging (MRI, CT scans)

• Specialty medications

• Outpatient surgeries

In many plans, once you meet your in-network deductible—which may range from a few hundred dollars to well over a thousand—you then pay only a copayment or coinsurance amount. But until then, the full negotiated cost of the service may fall to you.

This change incentivizes you to understand not just the copayments listed in your plan brochure, but also:

• When the deductible resets (usually January 1)

• What counts toward it (not all copayments do)

• Whether your provider is in-network or out-of-network

When Copayments Disappear—and Why That’s Not Always Good

It might seem like a good thing when you don’t owe a copayment. But that’s not always the case.

Some services in PSHB plans are now shifting from flat-fee copayments to coinsurance. This means instead of paying a predictable $30, you might now be responsible for 20% or more of the service cost.

This can happen with:

• Durable medical equipment (DME)

• Emergency room visits (especially out-of-network)

• Physical therapy or rehabilitation services

So while a plan may advertise fewer copayments, the real question is what’s replacing them. Coinsurance can expose you to far higher costs, especially for big-ticket services.

In-Network vs. Out-of-Network: The Copayment Chasm

Under PSHB in 2025, the gap between in-network and out-of-network copayments has widened significantly. Even routine services may have no copayment limit if performed out-of-network.

In-network providers:

• Have pre-negotiated rates with your plan

• Are more likely to accept reduced or waived copayments (especially with Medicare)

• Count toward your deductible and out-of-pocket maximum

Out-of-network providers:

• May charge you full billed charges

• Often do not apply copayments—just coinsurance or balance billing

• Typically do not coordinate with Medicare coverage in the same way

Choosing in-network care is no longer just a recommendation—it’s financially essential. Before scheduling services, confirm provider status, especially for:

• Radiology

• Specialist visits

• Urgent care clinics near you

Copayment Trends to Watch for the Rest of 2025

As the year progresses, be alert to several ongoing trends in how copayments are structured and applied across PSHB plans:

• Seasonal resets – Your deductible and out-of-pocket maximums restart each calendar year. That can change your costs dramatically if you delay care until later in the year.

• Cost alignment with Medicare – More PSHB plans are adjusting their copayment tiers to reflect Medicare coordination, potentially reducing costs for Medicare-enrolled retirees.

• Plan redesigns in 2026 – Ongoing OPM evaluation may lead to further plan changes in the next Open Season. Reviewing the Annual Notice of Change (ANOC) will be more critical than ever.

Questions You Should Be Asking About Your Copayments

To keep your healthcare predictable—and your costs contained—it’s worth asking these questions now:

• Is my provider in-network under my 2025 PSHB plan?

• Have I met my annual deductible yet?

• Does Medicare coordinate with this service?

• Am I paying a copayment or coinsurance?

• Will this visit count toward my out-of-pocket maximum?

A licensed agent listed on this website can help you answer those questions based on your specific plan and situation.

A Changing Landscape Deserves a Closer Look

In 2025, copayments under PSHB aren’t what they used to be. They’re layered, conditional, and highly sensitive to Medicare status and provider choice. While the program still provides strong protection against catastrophic expenses, the path to affordable care now requires greater awareness on your part.

Take the time to read your plan brochure carefully, track your deductible progress, and verify provider networks before making appointments. The days of assuming a standard copayment are over—your wallet will thank you for adjusting to the new rules.

If you’re still unsure how your PSHB plan handles copayments or want help evaluating your options, reach out to a licensed agent listed on this website for one-on-one guidance.