Key Takeaways

• Copayments under PSHB can seem low individually, but frequent use of services like primary care, specialists, urgent care, or prescriptions can quickly add up to significant monthly costs.

• Understanding the true impact of copayments means looking beyond a single visit or prescription and planning for the volume of use you might realistically have in a year.

What Is a Copayment in the PSHB Context?

When you’re enrolled in a Postal Service Health Benefits (PSHB) plan, your total cost for care is typically divided among premiums, deductibles, copayments, and coinsurance. A copayment is a fixed dollar amount you pay for a specific service, like a $30 charge when visiting a specialist. Unlike coinsurance, which is a percentage of the service cost, copayments are predetermined amounts listed in your plan brochure.

Copayments are common for:

• Primary care visits

• Specialist consultations

• Urgent care visits

• Emergency room visits

• Prescription medications

You might think that knowing your copayment is $20 or $40 per visit means you have a predictable, manageable cost. But here’s the truth: while each copay looks small, over time and with multiple services, those seemingly low fees can accumulate into hundreds or even thousands of dollars annually.

Why Copayments Add Up Faster Than Expected

The simplicity of a flat fee can be deceptive. If you only go to the doctor once or twice a year, you might barely feel the impact. But PSHB plans are used by thousands of annuitants and employees managing chronic conditions, undergoing routine testing, or needing frequent follow-ups.

Here are ways costs add up:

• Primary Care: Even two visits per quarter at $30 each means $240 annually.

• Specialists: Ongoing care with a cardiologist, dermatologist, or rheumatologist could involve monthly visits. At $60 each, that’s $720 per year.

• Urgent Care: An unexpected illness could mean a $75 copay, even for something as simple as strep throat.

• Prescriptions: A $15 copay per generic medication might seem trivial until you’re taking five prescriptions monthly. That’s $75 a month, $900 a year.

Add those together and you’re easily spending over $1,800 a year in copays, and that’s before considering any emergency visits or imaging services with separate charges.

2025 PSHB Copayment Ranges: General Overview

In 2025, PSHB copayment amounts generally fall into these ranges:

• Primary Care Visits: $20 to $40

• Specialist Visits: $30 to $60

• Urgent Care: $50 to $75

• Emergency Room: $100 to $150

• Prescription Drugs (30-day supply):

  • Tier 1 (Generics): $10 to $20

  • Tier 2 (Preferred Brands): $35 to $75

  • Tier 3 (Non-Preferred): $75 to $125

Some plans also have separate tiers for specialty medications or preferred vs. non-preferred pharmacies.

These figures reflect in-network usage. Using out-of-network providers can result in much higher costs or no coverage at all, depending on your plan.

What Drives Frequent Copayment Use

Even if your health is relatively stable, several factors can dramatically increase how often you face copayments:

1. Chronic Illness Management

Diabetes, hypertension, arthritis, COPD, or high cholesterol often require routine checkups, lab work, and prescription refills.

2. Specialist-Driven Treatment

Care for complex or age-related conditions can mean regular visits to multiple specialists each quarter.

3. Diagnostic Imaging and Lab Work

Lab tests or imaging like X-rays, MRIs, or CT scans often carry separate copays, especially when done in hospital settings.

4. Physical or Mental Health Therapy

Weekly sessions with a physical therapist or licensed mental health provider may each carry a separate copay.

5. Multiple Family Members

If your PSHB plan covers a spouse or dependents, the number of visits and prescriptions across your household can double or triple the out-of-pocket cost.

Strategies to Manage High Copayment Volume

You don’t need to avoid necessary care, but you do need to be proactive in managing costs under your PSHB plan. Here are several practical steps:

Review Your Plan’s Summary of Benefits

Carefully examine your plan’s copayment levels, especially for services you use most frequently. Don’t just focus on premiums.

Consolidate Appointments

Ask your providers if it’s possible to combine checkups, labs, or multiple services into a single visit to reduce repeated charges.

Use Telehealth Options

Some PSHB plans offer lower copayments or even no copayments for virtual visits. It’s an efficient way to access care at a reduced cost.

Choose Preferred Providers and Pharmacies

Your plan may offer reduced copayments for using in-network or preferred pharmacies and providers. Always check first.

Reevaluate Medication Options

Ask your doctor whether a lower-tier drug or 90-day mail-order supply could reduce your monthly copayments.

Copayments vs. Deductibles and Coinsurance: Know the Differences

In 2025, most PSHB plans still use a combination of cost-sharing structures:

• Deductible: The amount you must pay before your plan begins to cover certain services. PSHB deductibles range from $350 to $500 for low-deductible plans.

• Coinsurance: A percentage of the cost of care that you pay after meeting the deductible, such as 10% to 30% for imaging or surgery.

• Copayment: A fixed dollar amount per service, often due whether or not you’ve met your deductible.

It’s important to note: copayments typically do not count toward your deductible, but they do count toward your annual out-of-pocket maximum.

Annual Out-of-Pocket Limits Still Leave Room for Surprises

In 2025, the PSHB in-network out-of-pocket maximums are:

• Self Only: $7,500

• Self Plus One: $15,000

• Self and Family: $15,000

Once you reach your plan’s maximum, the PSHB plan covers 100% of your in-network care for the rest of the year. But many members don’t hit these thresholds unless they experience major health events like surgery, hospitalization, or cancer treatment.

If you’re paying $1,800 or more a year in copayments, but never meet your deductible or out-of-pocket max, you could be bearing a large portion of health costs silently and steadily.

The Psychological Effect of Copayments

There’s another angle to consider: copayments can influence your decisions about seeking care. Research shows that people often delay or skip appointments and medications due to cost concerns, even when the copayment is relatively modest.

For those managing chronic conditions, skipping care can backfire into higher long-term costs and more serious health risks.

Planning for copayments ahead of time, using budgeting tools or FSAs, can help reduce financial stress and support smarter decision-making throughout the year.

Planning Ahead in the PSHB System

You likely already receive your Open Season notice each fall, but too many enrollees focus only on premiums. In 2025, PSHB plans differ widely in:

• Copayment amounts

• Number of prescription drug tiers

• Copayment vs. coinsurance structures

• Coverage for out-of-network providers

Don’t assume your current plan is the most cost-effective just because your premium stayed stable. Reviewing all cost-sharing details could reveal a better fit based on your healthcare usage.

Start by asking:

• How often did I visit the doctor or fill prescriptions last year?

• How much did I pay in total copayments?

• Would another PSHB plan offer lower out-of-pocket costs for the same care?

Use OPM’s plan comparison tools or consult a licensed agent to get a clearer picture.

Small Copays, Big Impact: What You Can Do Now

While PSHB copayments are just one piece of your health cost puzzle, they are often underestimated because of their small size. But their frequency and cumulative effect can seriously affect your budget if you don’t plan ahead.

Review your plan in full detail. Understand not just what your copayments are, but how often you’ll realistically be using them. And if your needs or your family’s health situation changes mid-year, be ready to assess the potential impact.

If you’re unsure how to evaluate the copayment structure within your PSHB plan, or you want to see if switching plans might help reduce your out-of-pocket costs, get in touch with a licensed agent listed on this website for help reviewing your options.