Key Takeaways

• Even when two PSHB plans appear nearly identical in summaries, small hidden differences in how they manage care, reimburse services, or coordinate with Medicare can result in major out-of-pocket cost differences.

• To choose the best plan for your needs in 2025, you must go beyond summary brochures and understand how each plan handles networks, referrals, cost-sharing tiers, and integration with Medicare Part B.

Why Plan Summaries Don’t Tell the Whole Story

You’ve likely read through the Postal Service Health Benefits (PSHB) summaries while preparing for Open Season or reviewing your annuitant options. While these overviews help you compare basic details such as monthly premiums and deductibles, they leave out nuanced differences that can heavily influence what you actually pay and how you access care.

In 2025, with the PSHB program fully replacing FEHB for Postal Service members, understanding these subtleties is more important than ever. Some plans offer lower deductibles but have narrower networks. Others may offer generous prescription benefits only under specific conditions. These are the details that don’t show up unless you dig.

Differences in Provider Networks

One of the most significant hidden variables between plans is the provider network. Two plans might both claim to offer national coverage, but how they define that can vary:

• Some plans use exclusive provider organizations (EPOs), which may cover only in-network care.

• Others offer point-of-service (POS) options, where out-of-network care is possible but comes with higher costs.

• A plan might list a broad network but rely on third-party contractors in rural areas, potentially reducing service quality or access.

Make sure to verify whether your preferred providers are truly in-network under each specific plan. Relying solely on a national label can lead to surprise bills.

How Referrals and Preapprovals Are Managed

Many summaries gloss over referral requirements, even though they can dramatically affect how quickly and easily you access care:

• Some plans require a primary care physician (PCP) to approve specialist visits.

• Others allow direct access to specialists, which may be especially helpful if you manage chronic conditions.

• Preauthorization policies may differ for imaging, surgeries, or high-cost medications.

These rules can delay care and create administrative hassle if not properly understood before enrollment.

Prescription Drug Tier Structures Can Differ

Every PSHB plan includes prescription drug coverage, but drug tiering systems differ, even among plans that look alike:

• One plan may classify a specific brand-name medication as Tier 2 (moderate copay), while another labels it Tier 3 (high copay).

• Some plans cover a wider range of generics at lower cost, while others have more limited formularies.

• A plan may exclude certain maintenance drugs altogether unless you use mail-order delivery or specific preferred pharmacies.

These differences don’t appear in the summary but can affect thousands in out-of-pocket costs annually—especially if you rely on specialty medications.

Integration with Medicare Part B Is Not Always the Same

In 2025, Medicare-eligible annuitants must understand how PSHB plans coordinate with Medicare Part B. While summaries may note that a plan “works with Medicare,” that phrasing oversimplifies things:

• Some plans waive deductibles, copays, and coinsurance if you’re enrolled in Medicare Part B.

• Others only reduce those amounts slightly.

• Certain plans reimburse a portion of your Part B premium, while others offer no financial coordination at all.

Unless you investigate the exact cost-sharing reductions and reimbursement rules in detail, you may assume Medicare offers you more savings than it actually does.

Out-of-Pocket Maximums Hide Key Differences

All PSHB plans must include annual out-of-pocket (OOP) limits for in-network services. However, what counts toward that limit can vary subtly:

• One plan may include prescription drug costs in the OOP max; another might not.

• Some plans exclude certain copayments or apply only a percentage of your spending.

• If you go out of network, separate OOP limits may apply—often double or more the in-network cap.

These variations change your actual risk exposure, particularly if you have significant ongoing medical needs.

Behavioral Health and Specialty Services Access

Mental health, substance use disorder treatments, and other specialty care are areas where coverage nuances often differ behind the scenes:

• Some plans offer telehealth access to behavioral health providers with no referral.

• Others might require preauthorization or deny coverage unless services are rendered by plan-approved facilities.

• Certain therapies like ABA (applied behavior analysis) or psychiatric evaluations may be capped in sessions annually in one plan but unlimited in another.

These services may not be needed by everyone, but if they are part of your care plan, these hidden differences matter.

Customer Service Quality Isn’t Measurable in Brochures

The quality of a plan’s customer service—including call center support, ease of claims processing, and help with appeals—can make or break your experience:

• Some plans offer 24/7 live support; others only during business hours.

• You may face long delays getting prior authorization, processing claims, or resolving denied services.

• If you manage care for a dependent or need frequent clarification on benefits, poor service can be a daily burden.

This isn’t reflected in cost or benefit tables but can significantly impact how supported you feel.

Telehealth and Virtual Care Have Different Limitations

Many PSHB summaries simply note that telehealth is included, but that doesn’t mean all plans treat it equally:

• One plan may limit telehealth to general medical consults, while another includes behavioral health, dermatology, and chronic disease management.

• Certain services might be free under one plan, but require coinsurance under another.

• Platform compatibility (e.g., app vs. browser vs. phone) can vary, affecting ease of access.

With the continued rise of virtual care in 2025, these distinctions can affect how accessible your benefits truly are.

Preventive Services: Coverage vs. Compliance

While all PSHB plans meet ACA minimums for preventive care, some go above and beyond—but this isn’t always in the summary:

• One plan may cover additional screenings for at-risk groups without a copay.

• Another may offer wellness incentives, like premium reductions or gift cards for completing checkups.

• Some plans integrate preventive tracking tools that remind you of missed services, improving long-term health outcomes.

If you prioritize staying ahead of chronic disease risks, these extras can be surprisingly valuable.

Limited Language Access and Cultural Support

While the core benefits may be the same, language support and cultural sensitivity vary widely:

• Some plans provide multilingual support, culturally aligned care coordination, and translated documents.

• Others rely on minimal translation services and don’t offer culturally competent providers.

This difference can impact care quality, especially for bilingual households or those with cultural considerations in care preferences.

Enrollment Support and Plan Education Vary Greatly

Finally, don’t underestimate how different PSHB plans are when it comes to helping you understand and use your benefits:

• Some offer personalized onboarding calls or virtual benefits orientations.

• Others provide a static PDF and expect you to self-navigate.

• Plan websites can range from modern and mobile-friendly to difficult-to-navigate portals.

Your ability to use your coverage effectively may depend on how much support your plan offers beyond enrollment.

Your Plan Might Be Technically “Good Enough”—But That’s Not the Point

Every PSHB plan meets basic federal requirements. But if you stop at the summary, you might end up with a plan that’s technically sufficient but poorly aligned to your life. You deserve better.

Before the next Open Season or Qualifying Life Event window, consider taking these steps:

• Compare full plan brochures, not just summaries

• Call the plan’s customer support to ask about referrals, telehealth, and Medicare coordination

• Use the official plan comparison tool to filter by your needs

• Review past year claims if you’re already enrolled, to identify service gaps

To make the right decision, get in touch with a licensed agent listed on this website who can walk you through the hidden elements that matter most to your situation.