Key Takeaways

• Your PSHB deductible does not cover everything—and knowing exactly what it does can save you from expensive surprises later in the year.

• Even after meeting your deductible, you may still owe coinsurance, copayments, and other out-of-pocket costs depending on the type of care you receive and the provider network.

Understanding the Purpose of a Deductible

Your deductible is the amount you pay out of pocket each calendar year before your health plan begins to share in the cost of covered services. For 2025, this threshold is a core part of how PSHB plans are structured. It applies to in-network services first, and most plans have a separate—and often much higher—deductible for out-of-network care.

What Counts Toward Your Deductible

Your deductible applies to most medical services that are not considered preventive care. Here’s what typically counts:

• Hospital stays and surgeries (non-emergency)

• Lab tests and diagnostic imaging

• Specialist visits (if not part of preventive screenings)

• Outpatient procedures

• Durable medical equipment

It’s important to check your plan brochure for details on exactly which services apply to your deductible. Not everything you pay out of pocket contributes to reaching that limit.

What Doesn’t Count

Some costs are excluded from deductible calculations, even though you may still be paying for them regularly. These may include:

• Premium payments

• Copayments (for many routine visits)

• Certain prescription drug costs, especially if your plan has a separate pharmacy deductible

• Services not covered by your plan or those that exceed allowed charges

Understanding this distinction helps you better forecast how much you’ll actually spend before your plan begins to pay its share.

How Much Are You Expected to Pay in 2025?

In 2025, PSHB in-network deductibles typically range from $350 to $500 for low-deductible options. For high-deductible health plans (HDHPs), they may be as high as $1,500 to $2,000 for Self Only coverage and $3,000 to $4,000 for family options.

These figures do not include:

• Out-of-pocket maximums (which cap your spending for the year)

• Additional out-of-network deductibles

• Prescription deductibles, which may apply separately

So while your deductible might sound manageable, your actual financial exposure is broader—especially if you need care early in the year or outside your plan’s network.

When the Deductible Kicks In

Not every service you receive will require you to meet the deductible first. Preventive care is generally covered in full under PSHB plans. This includes:

• Annual wellness visits

• Screenings for cholesterol, blood pressure, and diabetes

• Routine immunizations

• Certain cancer screenings (mammograms, colonoscopies, etc.)

But once your care moves into diagnostic or treatment territory, the deductible typically comes into play. This is especially true for follow-up tests, referrals to specialists, or treatments for ongoing conditions.

You Met Your Deductible—Now What?

Even after you meet your deductible, you’re not done paying. Your PSHB plan will start sharing the costs, but that doesn’t mean full coverage. You’ll usually move into a coinsurance phase, where you’re responsible for a percentage of the cost.

For example:

• 20% coinsurance means your plan pays 80%, and you pay 20% of the covered charges.

• Some services, like physical therapy or specialist visits, may still include fixed copayments even after the deductible is met.

This cost-sharing continues until you reach your out-of-pocket maximum, which may be between $5,000 and $7,500 for Self Only coverage, and double that for Self Plus One or Self and Family. Once you reach this limit, the plan pays 100% for covered services for the rest of the year.

In-Network vs. Out-of-Network: A Cost Multiplier

One of the most overlooked deductible pitfalls is how quickly costs spiral when you go out of network. If you use a provider not in your plan’s network:

• You may face a separate and higher deductible, often in the $1,000 to $3,000 range.

• Coinsurance rates tend to increase—sometimes from 20% to 40% or more.

• There’s no guarantee the provider will accept your plan’s payment structure, so you may be billed the difference (balance billing).

In-network care gives you cost predictability. Out-of-network care opens the door to much more personal expense.

Pharmacy Deductibles and How They Work

Some PSHB plans treat prescription coverage separately from the medical deductible. In those cases:

• A prescription drug deductible (up to $590 in 2025) may apply.

• Brand-name and specialty drugs often trigger the deductible sooner than generics.

• After you meet the deductible, tiered copayments or coinsurance levels apply.

It’s possible to meet your pharmacy deductible long before your medical deductible—or vice versa. That’s why it’s important to monitor both sides of your benefit usage throughout the year.

You May Still Pay for These, Even With Coverage

Here’s a list of commonly misunderstood items that you could end up paying for, either before or after meeting your deductible:

• Out-of-pocket costs for non-formulary drugs

• Alternative therapies (e.g., acupuncture, chiropractic) unless explicitly covered

• Medical supplies purchased outside of approved vendors

• Services without a referral, depending on your plan rules

• Excess charges beyond plan allowance limits

Carefully reviewing your plan’s summary of benefits can prevent these from becoming unexpected costs.

When Your Deductible Resets

PSHB deductibles reset every calendar year—on January 1st. That means:

• Any deductible amount you paid in 2024 no longer applies in 2025.

• If you delayed a procedure until the new year, you may have to start over paying out of pocket.

• Timing higher-cost treatments for the same year may save you money if you’ve already met the deductible.

Some families choose to schedule major procedures or elective surgeries in the second half of the year to take advantage of having met the deductible already.

Tracking Your Deductible Progress

Many enrollees forget to actively monitor how close they are to meeting their deductible. That’s a mistake that can affect everything from budget planning to care decisions.

Tools you can use:

• Your PSHB plan’s online member portal, which shows real-time deductible status

• Explanation of Benefits (EOBs) that list how much was applied to your deductible

• Annual benefits statements that summarize total spending

Staying informed helps you make smarter financial decisions about when and how to seek care.

Strategies to Minimize Your Out-of-Pocket Burden

You can’t avoid your deductible, but you can minimize the surprise factor and manage costs by being proactive:

• Use in-network providers only whenever possible

• Schedule preventive care early in the year—these don’t count toward the deductible but help detect issues early

• Ask providers for cost estimates in advance

• Bundle care once you’ve met your deductible (e.g., get tests, procedures, and follow-ups in the same year)

• Use HSAs or FSAs if eligible, to offset qualified medical expenses with pre-tax dollars

A bit of planning can go a long way toward keeping your healthcare spending predictable and manageable.

Understanding Your Deductible Is Understanding Your Plan

Your deductible under the PSHB system is not just a number—it’s a financial threshold that determines how and when your plan contributes to your care. If you don’t know what your deductible covers, or how it interacts with other parts of your benefits, you could end up paying far more than expected.

This year, make it a priority to:

• Review your plan brochure and benefits statement

• Understand the services that fall under your deductible

• Keep track of your progress throughout the year

If you’re unsure about how your specific plan handles deductibles or other cost-sharing features, get in touch with a licensed agent listed on this website for personalized advice.