Key Takeaways

• PSHB copayments are not as fixed as they appear—adjustments in plan design, Medicare integration, or classification of services can alter them year to year.

• Understanding how PSHB reviews, reclassifies, and realigns benefits annually is essential to avoid surprise costs and ensure proper budgeting.

What You Thought Was a Fixed Copayment Might Not Be

Many Postal Service employees and annuitants assume that once they select a PSHB plan, their copayment amounts for common services—like primary care visits, specialist appointments, and urgent care—are locked in. However, that isn’t always true. PSHB copayments can change from year to year, even if you don’t switch plans. These changes often occur due to annual updates in plan structures, new benefit classifications, or shifts in how your plan integrates with Medicare.

These variations can be subtle. One year, your plan may classify a telehealth visit under general outpatient services with a $20 copay. The next year, that same visit may fall under a new virtual care benefit with a higher copayment or coinsurance rate. These shifts can catch you off guard if you’re not paying close attention.

Why PSHB Copayments Can Change Annually

The PSHB program is designed with annual flexibility so that participating plans can adapt to medical inflation, legislative mandates, and patient care trends. Here are the core reasons your copayments might increase unexpectedly:

1. Annual Plan Redesigns

Every fall, during the PSHB Open Season (which typically runs from November to December), carriers submit updated plan brochures outlining new benefits, cost-sharing structures, and service classifications for the following year. While many enrollees focus on premium changes, small shifts in copayment amounts often go unnoticed.

For instance, a plan may introduce a new behavioral health program that changes how mental health visits are categorized—altering your previous $30 copayment to a tiered copay or even a percentage-based coinsurance.

2. Medicare Coordination Adjustments

If you’re eligible for Medicare Part B and enrolled in it, your PSHB plan may offer enhanced benefits such as reduced copayments or waived deductibles. However, the level of integration varies by plan, and each year brings potential modifications. In 2025, many PSHB plans continue to evolve their Medicare coordination strategies.

This could result in a copayment for an outpatient procedure being waived in 2024 but reinstated in 2025—or vice versa—depending on how your plan accounts for Medicare coverage. If you’re not enrolled in Medicare Part B, your copayment schedule may be entirely different from someone who is, even under the same PSHB plan.

3. Service Reclassification

Plans routinely reclassify services based on how they are delivered, regulated, or bundled with other treatments. For example:

• A lab test previously categorized as part of a preventive visit may be recategorized as diagnostic.

• Urgent care visits might be split into two tiers—basic and advanced—each with a different copayment.

• A brand-name medication may be moved into a different formulary tier, impacting your cost-sharing.

These internal reclassifications don’t require legislative approval and are instead outlined in the updated Summary of Benefits for each plan year.

You Can’t Assume All Copayments Are Protected

Unlike premiums, which draw widespread attention due to their visibility and direct monthly impact, copayments are typically buried in the middle pages of your plan brochure. Yet they often affect you more frequently throughout the year.

If you regularly visit physical therapists, specialists, or use certain urgent care services, even a $10 increase in a copayment can add up significantly over time. Especially in retirement, when you’re budgeting tightly, these changes matter.

Understanding Your 2025 Plan Brochure Is More Crucial Than Ever

In 2025, the transition from FEHB to PSHB continues to generate changes. Plan brochures published each fall now carry more weight than ever because they reflect the updated PSHB structure rather than the FEHB legacy system.

When reviewing your plan materials this year, focus on the following:

• Copayment Tables: These outline specific dollar amounts for services like primary care, specialist visits, emergency room, and urgent care.

• Tiered Service Models: Many plans are shifting to multi-tiered models, which apply different copayments depending on the provider type or service complexity.

• Medicare Integration Details: If you’re enrolled in Medicare Part B, look at how your PSHB plan modifies copayments accordingly.

Remember, brochures are often over 100 pages long. Don’t assume your plan’s copayments are unchanged just because your premium stayed relatively flat.

Mid-Year Plan Modifications Can Also Occur

Although rare, certain changes can also happen mid-year—especially in response to federal regulations or public health emergencies. While PSHB plans are contractually obligated to maintain their benefits throughout the year, some modifications to cost-sharing structures may still occur if mandated by the Office of Personnel Management (OPM).

This could include things like:

• New copayment structures for COVID-19 treatment or preventive care

• Emergency declarations that alter access to mental health or telehealth services

• Updates to prescription drug copayment caps under Medicare Part D integration

Always read official PSHB bulletins or announcements distributed through LiteBlue or KeepingPosted.org to stay informed.

How Medicare Part B Enrollment Affects Your Copayment Structure

If you’re Medicare-eligible but not enrolled in Part B, your PSHB plan may not reduce your copayments the way it would for someone who is enrolled. For 2025, several plans continue offering waived or reduced copayments for Medicare-enrolled members. But if you’re not enrolled, expect to pay standard copayment amounts—which may have increased since 2024.

This dual-structure system means:

• Two enrollees in the same household could pay different copayments for the same service.

• You might miss out on cost-saving adjustments unless you’re actively enrolled in Part B.

If you’re considering enrolling in Medicare Part B now, be sure to check for any enrollment exceptions or penalties if you missed your Initial or Special Enrollment Periods in 2024.

What to Watch for During Open Season

Open Season is your once-a-year opportunity to reassess your plan and lock in your preferred benefits for the upcoming year. To avoid surprises in 2026, pay attention to the following during the 2025 Open Season:

• Compare Plans: Don’t assume your 2025 plan is still the best fit just because it worked well in 2024.

• Use OPM’s Plan Comparison Tools: These can show you side-by-side breakdowns of copayments for the most-used services.

• Review the ANOC (Annual Notice of Change): This outlines every change your current plan made from the previous year, including updates to copayments.

Even a small change buried in the fine print can impact your out-of-pocket costs for the entire year ahead.

Staying Ahead of Copayment Surprises in 2025

To avoid budget disruptions and unexpected charges:

• Check your plan’s updated Summary of Benefits every year.

• Save digital or printed copies for reference.

• Speak with a licensed agent listed on this website before making any changes.

• If you use certain services frequently—like urgent care or physical therapy—pay particular attention to those copayment sections.

• Consider Medicare Part B enrollment if you’re eligible and want to reduce PSHB copayment exposure.

Why It’s Not Just About the Premium

It’s common for PSHB members to focus mainly on monthly premiums when choosing a plan, but that’s only part of the picture. Copayments and coinsurance affect your wallet every time you access care. Choosing a plan with a slightly higher premium but lower copayments for services you use often might save you more over the year.

Premiums are predictable. Copayments can be sneaky. That’s why they deserve just as much attention.

Staying Informed Empowers Better Choices

In the ever-evolving PSHB landscape, your awareness is your greatest tool. Each year brings changes, and those who review their plans carefully, understand what to expect, and make informed choices tend to avoid the surprise bills that frustrate so many retirees and employees.

Take the time to review all materials during Open Season. Ask questions, compare documents, and don’t hesitate to reach out for help. There’s no substitute for informed action when it comes to your health coverage.

Review Your Copayment Structure With Expert Help

Copayment shifts can seem minor—but over the course of a year, they can substantially affect your total healthcare spending. To ensure your PSHB plan still aligns with your care needs and budget, speak with a licensed agent listed on this website before making changes. They can explain how your copayment responsibilities may change and help you compare alternative options for 2026.