Key Takeaways

• Even if your Postal Service Health Benefits (PSHB) plan includes affordable premiums, you could still face unexpectedly high out-of-pocket costs due to copayments for frequent care—especially for specialists and urgent care visits.

• Understanding the structure of PSHB copayments in 2025 can help you make smarter decisions about where and how often you seek care, potentially reducing avoidable expenses.

Why Copayments Deserve Your Full Attention in 2025

If you’re like many Postal Service employees or retirees, you may think you’ve got your health plan under control because your premiums are manageable and your coverage seems solid. But what often gets overlooked are the small, recurring charges that can quietly drain your wallet—copayments. While they may seem minor at first glance, they quickly add up if you regularly visit specialists or rely on urgent care.

In 2025, with PSHB plans now fully in effect, understanding your copayments isn’t optional. It’s essential.

What Are Copayments in PSHB Plans?

A copayment (or copay) is a fixed amount you pay for a covered healthcare service, typically at the time of the visit. It’s separate from your deductible, coinsurance, and premium.

Common Services That Require Copays:

• Primary care visits

• Specialist consultations

• Urgent care services

• Emergency room visits

• Mental health services

• Prescription drugs

The actual copay amount varies depending on the type of service and your specific PSHB plan option, but there are general patterns to be aware of that can help you anticipate costs.

Copayments vs. Coinsurance: Not the Same Thing

Although both are forms of cost-sharing, copayments are flat fees, while coinsurance is a percentage of the cost of a service. For example:

• Copayment: You pay a fixed $30 for each urgent care visit.

• Coinsurance: You pay 20% of the total cost of the service.

Both may apply in a single visit. For example, you could have a copay for the visit itself and then owe coinsurance for any additional services received during that visit.

Specialist Visits: A Hidden Cost Driver

Seeing a specialist often comes with a higher copay than visiting your primary care provider. If you have multiple conditions or need follow-ups with more than one specialist—such as cardiology, dermatology, or orthopedics—your costs can spiral faster than you expect.

In 2025, many PSHB plans assign higher copayments to specialists than to primary care. While it might only be $40 or $60 per visit, these costs multiply over time, especially if you see specialists monthly or even biweekly.

What to Do:

• Review your Explanation of Benefits (EOB) and PSHB plan brochure to see how specialist copays compare.

• Ask your primary care provider whether coordination with a specialist can be done virtually (which may reduce copays).

Urgent Care: Convenient but Expensive If Overused

Urgent care clinics offer faster access than a doctor’s office and are less intense than the ER, but that convenience comes with a price. Copayments for urgent care tend to be higher than for primary care.

For example, if you visit urgent care instead of waiting for a same-week primary appointment, that convenience might cost an extra $20 or $30 per visit. Do that just twice a month, and you’re looking at an extra $500–$700 annually in copays alone.

Alternative Strategies:

• Telehealth appointments often come with lower copays and faster access.

• Schedule ahead for chronic issues rather than relying on urgent care.

• Know when urgent care is appropriate vs. when a primary care visit would suffice.

Emergency Room Copays: The Steepest of All

Emergency room visits typically carry the highest copayments of any care setting. In 2025 PSHB plans, these can range significantly depending on whether the visit is truly an emergency and whether you are admitted.

Key Points:

• If you’re not admitted, you’ll still owe the full ER copay.

• Some plans reduce or waive the ER copay if you’re admitted afterward, but not all do.

• Using urgent care for non-emergencies can reduce your total out-of-pocket costs substantially.

Prescription Drug Copays: Another Layer of Cost

Even if you don’t see doctors frequently, your medication needs can become a recurring expense. Prescription drug copayments under PSHB plans are tiered, typically by generic, preferred brand, and non-preferred brand.

What This Means in Practice:

• Generic drugs often have the lowest copays.

• Brand-name or specialty drugs come with higher charges.

• Mail-order prescriptions for a 90-day supply can sometimes reduce per-pill costs.

Always check whether your drug is on the plan’s preferred formulary to avoid paying the higher non-preferred copay.

Mental Health and Behavioral Care Copays

More enrollees are using mental health and behavioral care services, and rightly so. However, if you’re seeing a therapist, counselor, or psychiatrist weekly or biweekly, copays can compound quickly.

Tips for Reducing the Impact:

• Look for virtual mental health services, which may have lower copays.

• Check your PSHB plan for visit limits or referral requirements.

• Ask if group therapy sessions are covered at a lower copay.

Children and Family Members Multiply the Cost

If you’re enrolled in a Self Plus One or Self and Family PSHB plan, don’t overlook how copayments multiply. Every family member who visits a provider contributes to the overall cost.

A few specialist visits for one child, plus a couple of urgent care trips for a spouse, and you’ve easily added hundreds of dollars per month.

Be sure to:

• Track all family members’ usage.

• Set a monthly budget for expected copayments.

• Use in-network providers to avoid additional charges.

Know When You Reach the Out-of-Pocket Maximum

Every PSHB plan has an annual out-of-pocket maximum. Once you hit it, the plan pays 100% of covered services. But until you reach it, copayments are on you.

In 2025, these maximums can be as high as $7,500 for Self Only or $15,000 for family coverage, depending on the plan.

Tracking your out-of-pocket spending helps you:

• Know when further care becomes fully covered.

• Assess whether a higher-premium, lower-copay plan might make more sense in future Open Seasons.

Don’t Just Focus on Premiums

Many people choose a plan with lower monthly premiums, assuming that will save money overall. But lower premiums often come with higher copayments. If you or a family member has chronic conditions, sees multiple specialists, or uses urgent care frequently, the cheaper premium can cost you more in the long run.

Instead:

• Estimate your expected number of visits across care types.

• Add projected copayments to your premium to calculate a more realistic annual cost.

• Evaluate different plan options every Open Season—not just the premium.

2025 Is the Year to Stay Alert

With PSHB now fully implemented, the structure of copayments across plan types has shifted for many enrollees. New networks, formularies, and tiered copayments may not align with what you were used to in 2024. What felt affordable last year may be significantly more expensive now, even if your plan name is the same.

Stay proactive:

• Read your plan brochure each Open Season.

• Review your Explanation of Benefits after each visit.

• Keep a log of your out-of-pocket medical expenses.

Reviewing Your Real Costs—Not Just Your Benefits

Even when you have solid PSHB coverage, the true financial picture emerges only when you evaluate your usage. Copayments may seem small per visit, but in aggregate, they often become your largest out-of-pocket expense category—especially if you or your dependents are high utilizers of care.

Review your plan documents, assess your healthcare usage pattern, and speak with a professional if you’re unsure what you’re really paying. A few small changes in how or where you seek care can yield significant savings by the end of the year.

For a clearer understanding of your copayment exposure and help in choosing the most cost-effective PSHB option, consider reaching out to a licensed agent listed on this website for personalized assistance.