Key Takeaways

• A step-by-step method ensures you accurately check Medicare Part B immunotherapy coverage after PSHB integration.
• Gathering the right documents and asking key questions will clarify your post-2025 coverage and next steps if changes occur.

Many retirees report confusion when checking their Medicare immunotherapy coverage after the 2025 PSHB transition. This guide simplifies the process, helping you clarify what is covered, which steps to follow, and what to do if you notice changes in your benefits.

What Is the PSHB Transition?

Background on PSHB program launch

In 2025, the Postal Service Health Benefits (PSHB) program replaced the Federal Employees Health Benefits (FEHB) program for eligible USPS retirees and employees. The PSHB program was established by federal law as part of broader changes to improve benefits integration and streamline coverage for postal retirees, particularly regarding Medicare coordination. The Office of Personnel Management (OPM) oversees the PSHB program, ensuring it aligns with federal retiree needs and Medicare requirements.

Timeline of major changes in 2025

The official launch of the PSHB program was January 1, 2025. Leading up to this, eligible USPS retirees and their families received information on how their new PSHB plans would work, what changes to expect, and guidance on the required transition steps. After January 1, 2025, most eligible individuals were automatically transitioned from FEHB to PSHB, with Medicare integration becoming a primary focus for those enrolled or eligible for Medicare Part B.

How Does PSHB Affect Medicare Choices?

Relationship between PSHB and Medicare

The PSHB program is designed to work alongside Medicare, especially for retirees aged 65 and older. If you have both Medicare and a PSHB plan, Medicare typically pays first for covered medical services, with PSHB providing secondary coverage. Understanding how these two programs coordinate is essential, particularly for specific treatments like immunotherapy often used to treat cancer and other chronic conditions.

Why coverage review is important

Transitioning from FEHB to PSHB in 2025 may alter how and where certain treatments—like immunotherapy—are covered. Even if you had a seamless experience under FEHB, it is important to verify your immunotherapy coverage now, as plan details, networks, or cost-sharing requirements may have changed during the transition.

What Counts as Immunotherapy in Medicare?

Immunotherapy treatments overview

Immunotherapy is a type of treatment that uses your body’s immune system to help fight diseases such as cancer, autoimmune disorders, and certain infections. Under Medicare Part B, this may include approved injectable drugs, infusions administered in a doctor’s office or outpatient center, and other therapies prescribed by your physician.

Where services are typically covered

Medicare Part B generally covers medically necessary immunotherapy drugs when administered in outpatient settings like hospitals, clinics, or doctor’s offices. The PSHB coverage often coordinates with Part B, paying remaining eligible costs if the medication and service are included under the plan. Always check whether your specific immunotherapy treatment is recognized and covered.

Step 1: Gather Your Plan Information

Locating your PSHB and Medicare details

Start by collecting all documents related to your PSHB plan, including your welcome kit, member ID card, and summary of benefits. You will also need your Medicare card to confirm your Part B enrollment and your Medicare Beneficiary Identifier (MBI) number for reference.

Documents and info you’ll need

Prepare the following for a smooth review:

• PSHB plan summary of benefits (2025 or newer)
• Medicare card (showing Part A and Part B)
• Recent Explanation of Benefits (EOBs) for prior immunotherapy treatments
• Contact information for both PSHB and Medicare helplines

Storing these in an accessible folder eases the process each time you need to verify a treatment or contact a representative.

Step 2: Review Current Coverage Online

Accessing Medicare’s online tools

To check the latest details about your immunotherapy benefits:

• Log in to your account at Medicare.gov
• Use the “What Medicare Covers” tool to search for your immunotherapy medications by name or code
• Download your Medicare Summary Notice (MSN) or log in to your PSHB plan portal for recent claims activity

Finding your immunotherapy benefit details

Look specifically for:

• Whether the immunotherapy medication is listed (including drug name, CPT or HCPCS code)
• Coverage rules about administration location and pre-approvals
• What portion Medicare pays versus PSHB pays

Take screenshots or print relevant coverage pages for your records.

Step 3: Confirm PSHB Plan Integration

Understanding plan coordination

After January 1, 2025, PSHB plans must coordinate with Medicare for eligible retirees. Typically, Medicare is the primary payer, and your PSHB plan acts as secondary insurance, covering eligible costs not paid by Medicare, such as copayments or deductibles, for qualified treatments like immunotherapy.

Checking coverage after January 1, 2025

Make sure:

• The PSHB plan recognizes your Medicare enrollment and applies secondary coverage
• No new restrictions or pre-authorizations have been added for your immunotherapy
• Your preferred providers are still in-network
• You understand any changes in your out-of-pocket responsibility

If information online is unclear, move to the next step for direct confirmation.

Step 4: Contact Plan Representatives

Questions to ask about immunotherapy

Reach out to both your PSHB and Medicare Part B representatives. Key questions include:

• Is my current immunotherapy treatment covered under both Medicare and my PSHB plan?
• Are there any new requirements or authorizations since January 1, 2025?
• Have there been changes to provider networks, drug formularies, or copay/coinsurance for these therapies?

How to document your conversation

Always note specific details:

• The date of your call or email
• The name and department of the representative
• Summary of explanations given
• Any official confirmation numbers or follow-up steps suggested

This documentation will support you if discrepancies arise, or if you need to appeal a denied claim.

What If Coverage Has Changed?

Next steps if treatment coverage differs

If you discover your immunotherapy coverage has changed or a claim is denied,

• Ask for a written explanation of the denial or change
• Review the specific provisions in your PSHB plan summary of benefits
• Contact your treating provider’s office for advice about alternative options or next steps

How to appeal or request clarification

You have the right to request an appeal through both your PSHB plan and Medicare, depending on which payer made the determination. Follow the steps provided on your denial notice, submit any required forms promptly, and include supporting documentation from your doctor. Stay in close contact with your plan for updates, and consider seeking assistance if the process is unclear.

What You’ll Need to Check Coverage

Required documents for verification

To check your immunotherapy coverage effectively, you need:

• Current PSHB and Medicare cards
• Summary of Benefits from your PSHB plan
• Records of immunotherapy prescriptions and prior authorizations

Where to get help if needed

If you need help, contact:

• Your retiring agency’s benefits office
• OPM’s PSHB information hotline
• Medicare at 1-800-MEDICARE, or use your secure Medicare.gov account for more assistance

These resources can help resolve difficult cases or clarify your benefit questions as you navigate Medicare Part B and PSHB integration.