Key Takeaways

• Copayments under the Postal Service Health Benefits (PSHB) Program may seem like fixed fees, but they often trigger additional out-of-pocket costs depending on the service, provider, and whether Medicare is involved.

• Understanding when copayments end and other charges begin, such as coinsurance or non-covered services, is critical to accurately budgeting your medical expenses in 2025.

What You Assume a Copayment Covers Isn’t Always the Whole Story

If you’re covered under the PSHB program, you might expect your copayment to be the final word on the cost of a doctor visit. A $30 or $40 copay may seem simple enough, but in 2025, healthcare billing is rarely that straightforward. Many plan enrollees overlook how easily a standard visit can generate additional costs once other services are involved.

The Role of Copayments in PSHB Plans

Copayments are flat fees you pay at the time of service for things like:

• Primary care visits

• Specialist visits

• Urgent care visits

• Prescription medications

For example, your PSHB plan might require a $30 copay for a primary care visit or $60 for a specialist. However, that amount often only covers the visit itself—not any procedures, labs, imaging, or follow-up work ordered during that visit.

Where Extra Costs Begin to Sneak In

The copayment typically applies to the office visit fee only. Anything beyond the routine exam may fall under coinsurance or even count toward your deductible. Here are a few common ways that costs can stack up:

• Lab work or blood tests: These may be billed separately, and you’re often responsible for a percentage of the cost if your deductible hasn’t been met.

• Imaging (X-rays, MRIs, CT scans): These services usually carry coinsurance charges or separate copays.

• Special procedures (such as biopsies or minor surgeries): These are not usually included in the standard visit copay.

The result? That $30 doctor visit can balloon into a $200 expense without any warning, especially if you’re not familiar with your plan’s benefits.

Medicare and Copayments: A Complicated Mix

If you’re retired and enrolled in Medicare Part B along with PSHB, the billing dynamics change even further. Many PSHB plans coordinate benefits with Medicare, which can reduce or even eliminate copayments in some cases. But it’s not automatic.

In 2025:

• Medicare generally becomes the primary payer if you’re retired.

• PSHB becomes the secondary payer, which might reduce or waive certain costs.

• However, if you haven’t enrolled in Medicare Part B (and you’re required to), you may end up paying full cost-sharing amounts, including coinsurance and full copays.

The coordination only works properly if you’re meeting all eligibility and enrollment rules. Otherwise, your plan may not apply the Medicare integration benefits.

Differences Between In-Network and Out-of-Network Copays

Another critical factor is whether your provider is in-network. PSHB plans offer wide national networks, but going out-of-network introduces higher copayments and additional cost-sharing.

Here’s what changes when you see an out-of-network provider:

• Copays may be significantly higher or replaced by full coinsurance.

• Balance billing is allowed, meaning the provider can bill you for any amount not paid by the plan.

• Pre-authorization may be required and harder to obtain.

If you’re using a PSHB plan in a new state or traveling, it’s essential to verify network participation before assuming your usual copay applies.

How Deductibles Affect Copayment Expectations

Many PSHB plans in 2025 include both deductibles and copays. The deductible is the amount you must pay out-of-pocket before the plan starts covering certain services. The confusion comes when:

• A service that seems routine (like diagnostic lab work) isn’t covered by the copay and instead applies to the deductible.

• You haven’t met your annual deductible yet, so you’re billed the full allowed amount even though you expected just a copay.

This is particularly common with services like:

• Specialist-ordered tests

• Preventive screenings not coded as such

• Outpatient physical therapy or mental health visits

Copayment vs. Coinsurance: Know the Distinction

In 2025, PSHB plans often include a mix of copayments and coinsurance. Many people assume they’re interchangeable—but they function very differently.

• Copayment: A fixed dollar amount, typically $20 to $75, paid at the time of service.

• Coinsurance: A percentage of the total allowed charge, usually between 10% and 30%, billed after the service.

A primary care visit might carry a $30 copay. But if that same visit includes a covered procedure or diagnostic test, you could be billed 20% of the cost of those services in addition to the copay. This is a common source of surprise bills.

Prescription Drug Copays and the Hidden Cost Layers

Even prescription drugs under PSHB plans can involve more than the standard copay. You may encounter:

• Tiered pricing: Generic drugs may have lower copays, but brand-name or specialty drugs cost much more.

• Quantity limits or step therapy: These may require you to try a lower-cost medication first.

• Non-formulary drugs: These might not be covered at all or may require higher coinsurance instead of a copay.

While many PSHB plans integrate Medicare Part D coverage for retirees, out-of-pocket caps and coordination rules can still leave you with higher-than-expected pharmacy bills.

Preventive Care and Copayment Exceptions

One area where copayments may not apply is preventive care. Under federal rules, many preventive services must be covered at no additional cost to you if received in-network.

These include:

• Annual wellness visits

• Screenings for cancer, diabetes, and hypertension

• Vaccinations (flu, shingles, COVID-19, etc.)

But there’s a catch: coding matters. If your preventive visit turns into a diagnostic discussion or results in a procedure, your provider may code it as a standard visit—triggering copayments and even coinsurance.

To avoid this:

• Confirm that the visit is being scheduled and coded as preventive.

• Ask in advance whether additional charges might apply.

Annual Out-of-Pocket Maximums: The Final Safety Net

All PSHB plans include an annual out-of-pocket maximum for in-network services. In 2025, these maximums are:

• $7,500 for Self Only

• $15,000 for Self Plus One or Self and Family

Once you reach this threshold, your plan covers all further in-network medical costs at 100% for the rest of the calendar year. Copayments, coinsurance, and deductibles all count toward this cap. However:

• Out-of-network charges may have a separate, higher cap or may not count toward the in-network limit.

• Non-covered services don’t count toward the cap at all.

So while the out-of-pocket maximum provides protection, it doesn’t eliminate all financial risk unless you stay within the network and only use covered services.

Tools to Help You Estimate Copay-Related Costs

In 2025, many PSHB plans offer online tools and calculators to help you:

• Estimate your costs for upcoming visits or procedures

• Check copayment and coinsurance responsibilities by service

• Compare in-network vs. out-of-network provider charges

These tools can be accessed through your plan’s member portal and can help avoid surprise bills. But it’s still wise to:

• Request an itemized estimate in advance

• Confirm whether the provider is in-network

• Double-check what services are subject to coinsurance or deductible

Why You Should Review Your Summary of Benefits Each Year

The Summary of Benefits is your blueprint for understanding what you will pay in copays, coinsurance, and deductibles. Since PSHB is relatively new as of 2025, plans may change their cost-sharing structure annually.

During the November to December Open Season period:

• Review your copayment amounts and thresholds

• Compare against your typical medical usage

• Check how Medicare coordination affects your copays if retired

Even a small change in copay structure or coinsurance percentage can significantly impact your annual out-of-pocket costs.

Understanding Copayments Can Save You From Budget Shock

You may think you’re financially prepared for your next doctor visit, but unless you know exactly what your copayment covers and where additional costs may apply, surprises are likely. PSHB plans provide valuable health coverage, but the real cost of care is in the fine print.

Review your plan documents, monitor usage throughout the year, and use all available tools to plan ahead. And when questions arise, don’t guess—get clear, accurate answers.

For help understanding how PSHB copayments work with your specific situation, get in touch with a licensed agent listed on this website. They can help you navigate the complexities and avoid unnecessary costs.