Key Takeaways

• In 2025, if you need insulin, your PSHB plan now offers Medicare-integrated drug coverage with new cost protections you should understand.

• Opting out of this integration may result in losing your prescription drug benefits under PSHB, with limited chances to re-enroll.

Why Insulin Coverage Through PSHB Matters in 2025

If you’re a USPS employee or retiree who uses insulin, 2025 brings a significant shift in how your medication is covered. The new Postal Service Health Benefits (PSHB) Program has taken over from the old FEHB system. With this change comes a key benefit: integrated Medicare Part D coverage through an Employer Group Waiver Plan (EGWP) for Medicare-eligible participants.

This integration isn’t just a formality—it impacts your insulin access, how much you pay, where you can pick up your prescriptions, and whether you’re protected from runaway drug costs. Understanding the 2025 updates is essential for managing your healthcare and avoiding gaps in your medication coverage.

Insulin Cost Protections Are Now Stronger

One of the most important changes you’ll notice is the enhanced cost protection for insulin under PSHB’s new Medicare Part D integration. Here’s what that means for you:

• Monthly insulin costs are capped at $35 per prescription, even if you haven’t met your plan deductible.

• The new $2,000 out-of-pocket cap for Part D in 2025 also limits how much you pay annually for all your covered prescription drugs, including insulin.

• No coverage gap (donut hole) anymore—after hitting the deductible and initial coverage limits, you won’t face higher costs midyear.

These rules apply only if you are Medicare-eligible and enrolled in Medicare Part B, as required by PSHB guidelines.

You Must Enroll in Medicare Part B to Access These Benefits

The PSHB Program requires most Medicare-eligible USPS annuitants and their family members to enroll in Medicare Part B to stay enrolled in a PSHB plan. This affects whether you’re eligible for the Medicare-integrated prescription drug coverage.

Exceptions apply only if:

• You retired on or before January 1, 2025 and are not currently enrolled in Part B.

• You are a USPS employee aged 64 or older as of January 1, 2025.

• You live abroad where Medicare coverage is not available.

• You receive health services from Indian Health Services or the Department of Veterans Affairs.

Failing to enroll in Medicare Part B without meeting one of these exceptions means you will lose your PSHB coverage altogether—including drug benefits.

What Happens If You Opt Out of Medicare Drug Coverage

PSHB integrates prescription drug coverage for Medicare-eligible members using the EGWP model. But if you opt out of this integration, you may lose your drug coverage entirely under PSHB.

Here’s what you risk:

• No access to insulin under PSHB.

• No standalone Medicare drug plan provided.

• No automatic re-enrollment option. You’ll only be allowed to enroll in drug coverage again during certain windows, and re-entry is limited.

If insulin is part of your daily life, opting out is a high-stakes decision with long-term consequences.

Expanded Pharmacy Access Under PSHB

The new PSHB-integrated Medicare Part D coverage also broadens your pharmacy choices. This is particularly useful if you require monthly insulin refills. With the updated 2025 network, you now have access to:

• Nationwide retail pharmacies.

• Mail-order services for home delivery.

• Preferred pharmacies with lower copayments.

These improvements offer greater convenience and potential savings, especially for those managing chronic conditions.

Enrollment Periods That Affected Your Eligibility

Understanding when you should have enrolled can help you avoid penalties or loss of coverage. For insulin users, these timelines mattered in 2024:

• Special Enrollment Period for Medicare Part B ran from April 1 to September 30, 2024.

• Open Season for PSHB ran from November to December 2024.

If you missed these deadlines, your insulin coverage could now be at risk in 2025 unless you qualify for a future Special Enrollment Period.

Your Insulin Is Covered Under Medicare Part D, Not Part B

It’s important to understand where insulin coverage fits in the Medicare structure. Despite needing Part B to access PSHB plans, insulin itself is typically covered under Medicare Part D when used outside of an insulin pump.

• Insulin used with a pump: Covered under Medicare Part B.

• Insulin used with syringes or pens: Covered under Medicare Part D.

Since PSHB integrates with Part D, your insulin falls under this umbrella unless you use a pump.

PSHB Drug Plans Have Better Cost Predictability

PSHB drug coverage through the EGWP eliminates a lot of the unpredictability you may have faced under past plans. For insulin users, this means:

• Flat monthly copays for insulin at $35 or less.

• No midyear cost increases.

• A maximum limit on total annual spending for prescriptions.

These features help you budget effectively without worrying about surprise charges in the latter half of the year.

Don’t Confuse PSHB Drug Coverage with FEHB

If you retired before 2025 and remain in the FEHB system, your drug benefits may differ—especially if you’re not enrolled in Medicare Part B or not eligible for EGWP. USPS retirees who transitioned to PSHB need to understand:

• FEHB drug benefits are not automatically integrated with Medicare.

• PSHB plans use Medicare Part D EGWP to reduce your costs.

• Insulin coverage under PSHB is generally more generous than under standalone FEHB plans, especially after 2025 reforms.

How to Know If You’re Covered

To confirm your insulin is covered under PSHB and you’re not at risk of losing benefits:

• Make sure you’re enrolled in Medicare Part B if required.

• Don’t opt out of the Medicare drug integration.

• Review your PSHB plan’s drug formulary to ensure your brand or type of insulin is included.

• Check your Explanation of Benefits (EOB) to monitor monthly out-of-pocket insulin costs.

Why This Matters for the Long Term

Managing diabetes means long-term planning—and insulin is not optional. The 2025 PSHB drug integration creates a better framework for predictable, affordable access to insulin. But the benefits are only available if you meet the enrollment and eligibility criteria.

Failure to comply with Medicare Part B requirements or opting out of drug integration jeopardizes your ability to get this vital medication. That’s why USPS retirees and employees approaching retirement should treat these new rules as essential reading.

Planning Ahead: What You Should Do Now

If you’re a current USPS employee or retiree who uses insulin:

• Double-check your Medicare enrollment status.

• Understand whether you qualify for any PSHB Part B exceptions.

• Review your PSHB drug plan documents.

• Speak with a licensed agent to evaluate your current and future insulin coverage under PSHB.

Being proactive in 2025 is the best way to avoid coverage interruptions that could impact your health.

Insulin Access Through PSHB Starts With the Right Enrollment

The new PSHB rules in 2025 are reshaping how insulin is covered, especially for Medicare-eligible USPS retirees. With the $35 monthly cap, expanded pharmacy access, and no more donut hole, the program offers real improvements. But these perks come with specific conditions. Make sure you’re enrolled correctly, don’t opt out of Medicare drug coverage, and stay informed.

For personal help reviewing your eligibility and options, speak with a licensed agent listed on this website.