Key Takeaways

• The PSHB out-of-pocket maximum may sound like a safety net, but for 2025, it could still expose you to thousands in unreimbursed medical costs if you’re not prepared.

• Knowing how each cost-sharing element (deductibles, copays, coinsurance) interacts with your plan’s out-of-pocket ceiling is essential to budgeting for your healthcare.

What the PSHB Out-of-Pocket Maximum Actually Means

In the Postal Service Health Benefits (PSHB) Program, the out-of-pocket maximum is the ceiling on how much you must pay for covered services in a calendar year. Once you reach this limit, your plan pays 100% of covered in-network expenses for the remainder of the year.

For 2025, this limit is set at:

• $7,500 for Self Only coverage

• $15,000 for Self Plus One and Self & Family coverage

These figures apply to in-network services only. If you receive care outside your plan’s network, a separate and often higher limit may apply—or worse, the expenses may not count toward your out-of-pocket cap at all.

Understanding What Counts Toward Your Maximum

Not every dollar you spend on healthcare will count toward your out-of-pocket maximum. Only eligible expenses for covered, in-network services contribute to it.

Costs that count:

• Deductibles

• Copayments for medical visits and prescriptions

• Coinsurance for services like hospital stays and specialist visits

Costs that don’t count:

• Premiums

• Out-of-network costs

• Services not covered by the plan

• Balance billing by out-of-network providers

• Non-prescription drug purchases

If you’re not careful, you could end up paying thousands more than expected simply because a service wasn’t covered or was out of network.

Deductibles and Copays Can Add Up Quickly

Even if your plan has a lower deductible or moderate copays, they can accumulate rapidly—especially if you or a family member develops a serious health issue or needs ongoing care.

For example:

• A single urgent care visit may have a copay of $50–$75

• A specialist consultation could be $30–$60 each visit

• Hospital admissions could involve coinsurance ranging from 10% to 30%, depending on your plan

Once you factor in regular prescriptions, physical therapy, or diagnostic imaging, you might hit the out-of-pocket maximum sooner than anticipated. But getting there means you’ve already paid thousands out of your own pocket.

Out-of-Network Costs Still Pose a Major Risk

Many PSHB enrollees assume all services will be covered equally, but out-of-network care often comes with steep penalties. In 2025, out-of-network deductibles and coinsurance levels are significantly higher—and worse, those expenses may not count toward your plan’s stated out-of-pocket maximum.

This means:

• Out-of-network care can have a separate, much higher ceiling

• Balance billing is more likely, which is when providers charge the difference between their rate and what the plan pays

• You could pay thousands more without getting closer to meeting your in-network limit

Make sure to double-check your provider directory or call your plan before receiving non-emergency care.

The Prescription Drug Cap Offers Limited Relief

In 2025, medicare-eligible enrollees have access to a $2,000 annual out-of-pocket cap for prescription drugs under Part D through PSHB. While this is a welcomed improvement, it only applies to drug costs—and only for those who are enrolled in Medicare.

If you’re not Medicare-eligible or not enrolled in Part B, your prescription drug costs may continue to be subject to the regular cost-sharing provisions of your PSHB plan. That could mean continuing to pay high copays or coinsurance for non-preferred or specialty drugs.

Family Coverage? Your Risk Is Doubled

The $15,000 out-of-pocket maximum for Self Plus One and Self & Family plans applies collectively—not per individual. This means that you and your covered family members must together meet this amount before full coverage kicks in.

Here’s what that implies:

• One family member with a chronic condition can edge the household closer to the ceiling on their own

• If multiple members use services regularly, expenses can add up even faster

• The financial exposure is greater, and so is the need for strategic planning

If you’re covering more than yourself, you should calculate healthcare costs across the entire family, not just your personal expenses.

Comparing Plan Types: Not All PSHB Plans Are Created Equal

In 2025, PSHB offers multiple plan types, each with its own deductible, coinsurance, and copay structure. These plans can fall under categories like:

• High-deductible health plans (HDHPs)

• Standard PPO-style plans

• Plans integrated with Medicare for eligible enrollees

While all must adhere to the $7,500 and $15,000 out-of-pocket limits, some may offer more generous cost-sharing arrangements or better coordination with Medicare.

Plans that work closely with Medicare Part B may:

• Waive or reduce deductibles

• Lower copays for Medicare-covered services

• Reduce prescription drug costs via Part D EGWP integration

Before selecting or changing plans during Open Season, you’ll want to compare how close each plan could bring you to the out-of-pocket limit based on your actual healthcare usage.

Strategies to Avoid Financial Surprises

Even with these high limits, you have options to soften the impact:

• Stay in-network: It’s the simplest way to ensure your expenses count toward your plan’s cap

• Track expenses: Keep tabs on how much you’ve paid year-to-date

• Check billing accuracy: Always review your Explanation of Benefits (EOBs) and medical bills

• Use preventive care: Most PSHB plans offer preventive services with no cost-sharing

• Plan during Open Season: Reassess your plan every year, especially if your medical needs have changed

Timing Matters: The Calendar Year Reset

Remember that your out-of-pocket maximum resets every January 1. That means:

• If you hit your maximum in December, it starts over the next month

• Healthcare expenses in early 2025 could require full out-of-pocket contributions again

• Consider scheduling elective procedures in the same calendar year to consolidate costs

Emergency Scenarios Can Wipe Out Your Budget

Emergencies are unpredictable—and expensive. Even with a plan that offers strong cost-sharing, a sudden hospital visit or surgery can catapult your expenses up to the out-of-pocket ceiling almost instantly.

In these scenarios:

• Out-of-network providers may be involved

• Ambulance transport could cost more

• Follow-up care can extend for weeks or months

Always keep some financial buffer available, especially if your health or age increases the likelihood of acute care needs.

Medicare Makes a Difference—But Only If You Enroll

For Medicare-eligible Postal retirees, the integration of Medicare Part B with PSHB can dramatically reduce your healthcare costs. However, this advantage only applies if you’re actively enrolled in Part B.

Failing to enroll—or opting out—could mean:

• Losing access to lower deductibles and waived copays

• Paying higher drug costs

• Facing reduced provider access and less coordination between your plan and Medicare

This coordination is built into many PSHB plans in 2025, but it’s not automatic unless you’re enrolled in both parts of Medicare.

Make Your PSHB Plan Work For You in 2025

If you’re like most Postal employees or retirees, you enrolled in PSHB for peace of mind. But peace of mind only comes with a full understanding of what you’re actually protected against.

Take time to review your plan’s brochure and cost-sharing tables. Evaluate your in-network providers. Track your spending, and use the Medicare coordination benefits if you’re eligible.

If you have any questions or uncertainties about what your plan covers—or how much you may be responsible for—reach out today to a licensed agent listed on this website.