Key Takeaways

• Overlooking a single clause in your PSHB plan could expose you to unexpected out-of-pocket costs, especially for out-of-network or specialized care.

• Understanding coverage tiers, Medicare integration, and annual limits in 2025 is essential to avoid financial surprises.

The Fine Print You Might Be Missing

The Postal Service Health Benefits (PSHB) program offers a robust suite of health coverage options for USPS employees and annuitants. But even a single overlooked detail in your plan selection could lead to thousands of dollars in medical bills. While most people focus on premiums, deductibles, or whether their doctor is covered, it’s often the subtler clauses—buried in plan brochures or benefit summaries—that carry the biggest long-term financial implications.

In 2025, with the transition from FEHB to PSHB now fully in effect, being attentive to the nuances of your plan is not just helpful—it’s essential.

How Network Access Affects Costs

One common source of financial shock comes from misunderstanding your plan’s network rules. PSHB plans differ in how they treat in-network and out-of-network services. If you inadvertently seek care outside of your plan’s network, even for a routine test or consultation, your costs can spike.

What You Need to Look For:

• Referral requirements for specialists

• Geographic restrictions for preferred providers

• Higher coinsurance or deductible amounts for out-of-network care

In 2025, out-of-network coinsurance can run 40% to 50%, while in-network typically stays between 10% to 30%. Misreading this one detail can mean the difference between a manageable bill and an overwhelming one.

Coordination with Medicare Part B: Mandatory or Optional?

If you’re Medicare-eligible, the rules have changed. Under the PSHB structure, you may be required to enroll in Medicare Part B to keep your coverage—depending on your retirement status and age as of January 1, 2025.

Who Is Required to Enroll in Part B?

• Annuitants who retired after January 1, 2025 and are Medicare-eligible

• Covered family members who are Medicare-eligible

Failing to enroll when required can mean losing significant cost-sharing benefits like waived deductibles or reduced copays. It could even jeopardize your continued PSHB coverage. This small detail is often buried in the transition documentation or only mentioned during Open Season updates.

The Misleading Comfort of Out-of-Pocket Maximums

Many PSHB enrollees take comfort in the annual out-of-pocket maximums. For 2025, these are:

• $7,500 for Self Only

• $15,000 for Self Plus One and Self & Family (in-network only)

However, this only applies to in-network covered services. If you’re hospitalized out-of-network or use a service not considered essential under your plan, the costs may not count toward this limit. In other words, you might assume you’re protected when you’re not.

Common Services That Might Not Count:

• Out-of-network emergency room visits

• Certain durable medical equipment

• Non-formulary drugs under the integrated Part D coverage

Hidden Limits on Prescription Drug Coverage

Starting in 2025, PSHB plans that integrate with Medicare include a Part D Employer Group Waiver Plan (EGWP). These plans cap out-of-pocket prescription costs at $2,000 annually. While this is an improvement over the previous structure, it doesn’t mean every drug is covered.

What to Check in Your Plan’s Drug List:

• Is your current medication on the formulary list?

• What tier is it categorized in? Higher tiers mean higher copays.

• Is there a prior authorization requirement?

Missing these small details could mean your drug isn’t covered, or you pay a high price out-of-pocket until the cap is met.

Enrollment Type Could Affect Your Survivors

Many enrollees don’t realize that their enrollment type—whether Self Only, Self Plus One, or Self and Family—impacts survivor benefits. If you want your spouse or dependent to continue coverage after your death, you must:

• Elect a survivor annuity under retirement

• Be enrolled in Self and Family or Self Plus One at the time of death

If you’re enrolled in Self Only, your surviving spouse will lose PSHB coverage, even if they’re Medicare-eligible. This is a costly mistake that can only be corrected during Open Season while you’re alive and competent to make changes.

Why Open Season Matters More Than Ever in 2025

Open Season (November to December) is your chance to switch plans, change enrollment types, or confirm Medicare integration details. But many PSHB members overlook this window, assuming last year’s plan still fits their needs. Unfortunately, many plans modify their:

• Drug formularies

• Cost-sharing rules

• Provider networks

In 2025, these changes could be more significant due to ongoing transitions from the FEHB system and evolving Medicare alignment. Missing this window could lock you into a financially unfit plan for the entire year.

How Dental and Vision Plans Fit In

Dental and vision benefits under PSHB are not automatically included. You must enroll separately through FEDVIP. Some retirees mistakenly assume these benefits are part of their PSHB plan and only realize the gap when they face a large dental or optical bill.

FEDVIP enrollment also occurs during Open Season. Missing this deadline means waiting another year to add coverage unless you have a Qualifying Life Event.

The Danger of Assuming FEHB Rules Still Apply

If you retired under the FEHB system, it’s easy to assume PSHB will mirror the same policies. That’s a mistake. While many benefits remain similar, the Medicare requirement, drug coverage structure, and provider networks are different.

Not adjusting your expectations—and your paperwork—can lead to denied claims or reduced benefits. Even minor differences in how prior authorizations are handled could delay or deny necessary care.

Take a Closer Look Before It’s Too Late

If there’s one message in 2025 for PSHB members, it’s this: Treat your plan booklet like a legal contract. Because it is. From the smallest cost-sharing clause to mandatory Medicare enrollment, any skipped detail could cost you heavily.

Review every line of your plan brochure and confirm:

• Provider network participation

• Medicare Part B enrollment requirements

• Prescription drug formulary details

• Enrollment type and survivor benefit implications

• What counts toward your out-of-pocket maximum

It’s not just about avoiding paperwork mistakes. It’s about protecting your health and financial future.

Avoiding the Costly Oversights That Trap Many Enrollees

The PSHB transition offers benefits, but it also introduces complexities. And complexities often hide costly surprises. If you haven’t had your plan reviewed in the past year—or haven’t verified how your current health needs align with your plan—it’s time to act.

Speak with a licensed agent listed on this website for a clear breakdown of what your plan does and doesn’t cover. An annual review could mean the difference between coverage you can count on and coverage that quietly fails you.