Key Takeaways

• Your PSHB premium is only one piece of the puzzle. Out-of-pocket limits, coinsurance, and government contributions all affect how much you actually spend each year.

• Understanding your total financial exposure under PSHB helps you make smarter choices, especially if you expect regular or high-cost medical needs.

Why PSHB Costs Go Beyond the Monthly Premium

If you’re a Postal Service employee or retiree enrolled in the Postal Service Health Benefits (PSHB) program, it’s easy to focus solely on your premium. After all, it’s a predictable deduction from your paycheck or annuity. But in 2025, your true healthcare cost under PSHB is shaped by more than just the monthly premium.

What you pay depends on several other variables: how much the government contributes, what your annual out-of-pocket limit is, how cost-sharing works, and how services like prescriptions or hospital stays are priced within your plan.

Let’s break this down to help you see the full picture.

Government Contributions and Their Role in Your Costs

In 2025, the federal government continues to contribute an average of about 72% of the total PSHB premium. That’s a significant offset, but it also means you’re still responsible for the remaining 28%.

These contributions vary depending on the type of enrollment you select:

• Self Only

• Self Plus One

• Self and Family

The government’s share is based on a weighted average of all plan premiums, not on the most expensive or least expensive plans. So if you choose a high-premium plan, your out-of-pocket share can grow well beyond what others might pay.

Out-of-Pocket Maximums: The Cap That Really Matters

Every PSHB plan comes with an out-of-pocket maximum (OOPM). This is the ceiling on what you’ll spend in a calendar year for covered services—assuming you stay in-network.

For 2025, these limits are:

• Self Only: $7,500

• Self Plus One / Self and Family: $15,000

Why is this important? Because once you hit this threshold, the plan pays 100% for covered in-network services for the rest of the year. That means your financial risk has a cap—but only if you understand and track your spending across deductibles, copays, and coinsurance.

Remember, out-of-pocket limits do not include premiums. They cover:

• Deductibles

• Copayments

• Coinsurance

But they exclude:

• Monthly premiums

• Services not covered by your plan

• Out-of-network charges (unless the plan explicitly includes them)

Deductibles and Coinsurance: The Upfront Hurdles

Your deductible is what you must pay out-of-pocket before your plan begins to cover a share of your costs. In-network deductibles in 2025 generally fall within these ranges:

• Low-deductible plans: $350 to $500

• High-deductible plans: $1,500 to $2,000

Once you’ve met your deductible, you’ll start paying coinsurance. This is typically a percentage of the cost of services, such as 10% to 30% for in-network care. For out-of-network services, the coinsurance can rise to 40% or even 50%.

What makes coinsurance tricky is that it varies by service:

• Primary care: May have a flat copay or lower coinsurance

• Specialist visits: Often have higher coinsurance or a tiered copay

• Emergency care and hospitalization: Usually subject to the highest cost-sharing

So even if your plan advertises low coinsurance, it doesn’t mean every service will be priced that way.

Copayments: Predictable, But Still Cumulative

Copays are flat fees you pay for certain services, such as doctor visits or prescriptions. In 2025 PSHB plans, these commonly include:

• $20 to $40 for primary care

• $30 to $60 for specialists

• $50 to $75 for urgent care

• $100 to $150 for emergency room visits

While these may seem affordable individually, they add up quickly with repeated visits. If you’re managing a chronic condition or frequently visiting multiple specialists, copays can become a major part of your yearly healthcare budget.

The Prescription Drug Cost Factor

One of the biggest contributors to total healthcare costs is prescription medication. PSHB plans in 2025 continue to offer tiered prescription benefits, typically splitting drugs into categories:

• Tier 1: Generic (lowest copay)

• Tier 2: Preferred brand

• Tier 3: Non-preferred brand

• Tier 4 or Specialty Tier: Highest-cost medications

Your cost-sharing might be a flat copay or a percentage (coinsurance), depending on the drug tier. Additionally, if you’re medicare-eligible and enrolled in Part B, your PSHB prescription coverage is integrated with a Medicare Part D Employer Group Waiver Plan (EGWP), which has:

• $2,000 cap on out-of-pocket drug costs in 2025

• Monthly spread payment option for expensive prescriptions

Even with these protections, those using specialty or high-tier medications could hit cost-sharing limits faster than expected.

In-Network vs. Out-of-Network: What You Choose Matters

All PSHB plans have network rules. In-network services are negotiated at lower rates, and your cost-sharing is lower. Out-of-network services, however, can cost significantly more, and not all of that spending will apply to your out-of-pocket maximum.

In 2025, many PSHB plans feature out-of-network deductibles in the range of $1,000 to $3,000. Coinsurance for these services may jump to 50%.

Always verify whether:

• Your provider is in-network

• A service needs prior authorization

• Your out-of-pocket limit includes out-of-network care (most do not)

Family Plans: Costs Multiply in More Ways Than One

If you’re enrolled in Self Plus One or Self and Family coverage, your costs don’t simply double—they compound. While your out-of-pocket maximum is capped at $15,000 in-network, individual deductibles and coinsurance still apply per family member until that combined maximum is met.

A family with multiple children, or one with an aging spouse requiring specialist care, may find they reach these thresholds quickly. Understanding the structure of individual vs. family caps within the same plan is essential to planning for medical expenses.

Medicare Integration Can Shift Your Cost Burden

If you’re a retiree enrolled in Medicare Part B, PSHB plans in 2025 often lower your out-of-pocket burden in several ways:

• Reduced or waived deductibles

• Lower copayments for doctor visits

• Enhanced prescription drug coverage

Some plans even offer premium reimbursements or expanded networks for Medicare-enrolled members. However, participation in Part B is required for many of these benefits. Not enrolling in Part B (when required) can limit your PSHB drug and cost-sharing benefits.

Lifetime Healthcare Planning: Why It’s Not Just About This Year

Looking at your PSHB plan as a one-year decision is a mistake. Your health needs—and your budget—change over time. While a low-premium, high-deductible plan may look attractive now, it can become unsustainable if your care needs increase.

On the other hand, a higher-premium plan with lower coinsurance and a robust drug formulary may save you thousands if you anticipate frequent use of services.

Ask yourself:

• Do you expect to meet your deductible every year?

• Will your prescriptions change or become more complex?

• Are you planning surgeries or specialist care this year?

Enrollment Timing and Review Periods Matter

You can make changes to your PSHB plan only during specific times:

• Open Season: Runs from November to December annually

• Qualifying Life Events (QLEs): Such as marriage, birth, or loss of other coverage

If you don’t review your plan during Open Season, you could be locked into a plan that no longer matches your needs or budget until the next window.

Review your:

• Premium share

• Cost-sharing structure

• Provider network

• Drug coverage tiering

• Out-of-pocket maximums

It’s important to compare all elements side-by-side—not just premiums.

What You Should Focus on Going Forward

Choosing the right PSHB plan in 2025 means weighing every financial factor:

• Your share of premiums

• In-network vs. out-of-network costs

• Deductibles and coinsurance levels

• Prescription coverage and drug tiering

• Whether Medicare integration applies

• Annual out-of-pocket caps

Understanding these variables helps you better forecast your actual expenses throughout the year, rather than being surprised by unexpected bills.

Know the Full Financial Picture Before You Choose

Looking only at the monthly premium can leave you underestimating your total healthcare spending. To make the best use of your PSHB coverage, it’s essential to assess what you might spend in a typical year—based on how you actually use care.

Your costs come in many forms: fixed premiums, copays, coinsurance, deductibles, and prescription costs. And they’re shaped by how your plan integrates with Medicare, what network you choose, and whether you hit your out-of-pocket maximum.

If you’re unsure how these factors affect you personally, it’s worth taking a moment to speak with a licensed agent listed on this website. They can help you align your health needs and budget with the right PSHB plan.