Key Takeaways

• Even small details buried in your Postal Service Health Benefits (PSHB) plan brochure can lead to unexpected out-of-pocket costs if overlooked.

• Understanding your PSHB plan’s cost-sharing structure, coordination with Medicare, and limitations on provider networks is essential to avoid unpleasant financial surprises.

It Looks Clear—Until You Actually Use Your Plan

When you first glance through a PSHB brochure, the numbers and terms might seem familiar or even reassuring. However, the real clarity only comes when you apply those terms in a real-life medical scenario. A misunderstanding—especially around deductibles, coinsurance, or plan exclusions—can result in hundreds or even thousands in surprise costs.

What you don’t catch in print can catch you in your wallet. And while PSHB is built on a solid foundation with robust government contributions, not paying close attention to the details may undercut the security you’re counting on.

Digging Into the Fine Print of Cost Sharing

Most PSHB plans include a combination of the following cost-sharing components:

• Deductibles: The amount you must pay before your plan starts covering services.

• Copayments: Fixed fees you pay for certain services, like office visits or prescriptions.

• Coinsurance: A percentage of the costs you pay after meeting your deductible.

• Out-of-pocket maximums: The most you’ll pay in a plan year before your plan covers 100% of in-network services.

In 2025, most PSHB plans have in-network deductibles ranging between $350 and $500 for low-deductible plans, or $1,500 to $2,000 for high-deductible options. But the trick lies in the exclusions. Some services, like certain specialty drugs or out-of-network care, might not count toward your out-of-pocket maximum, leaving you vulnerable to extra costs you hadn’t anticipated.

Medicare Integration Isn’t Always Automatic

If you’re a Medicare-eligible Postal Service annuitant in 2025, most PSHB plans expect you to be enrolled in Medicare Part B. And that’s not just a suggestion. For those who aren’t exempt under current policy (like individuals who retired on or before January 1, 2025), declining to enroll in Part B can mean higher out-of-pocket costs and even the loss of coordinated benefits.

When you do enroll in Part B, many PSHB plans lower your cost-sharing, including reduced deductibles and waived copayments. However, if you misunderstand the enrollment timelines or assume you’re covered without enrolling, the costs stack up quickly. Medicare coordination is a huge cost-saving opportunity—but only if you play by the rules.

Pharmacy Benefits: Not All Drug Lists Are Equal

Your PSHB drug coverage in 2025 is typically integrated with Medicare Part D through an Employer Group Waiver Plan (EGWP). While that brings protections like the new $2,000 annual out-of-pocket cap for prescriptions, there’s a catch: the formulary.

Every plan uses a drug list to determine what’s covered and at what cost tier. If your prescribed medication isn’t on that list or is placed in a high-cost tier, you may be on the hook for higher coinsurance, or you may have to switch medications altogether. And remember: your prescription costs may not count toward your medical out-of-pocket maximum.

Provider Networks Can Be Limiting

Another area where surprises happen is with provider access. In-network care is essential for cost control. Yet not all plans have broad networks, and some only offer strong coverage regionally. You may assume a facility is in-network based on location or brand familiarity, but if it’s not part of your plan’s network, the bill can be staggering.

Also, emergency and urgent care coverage might differ when you’re out of state or traveling. While emergencies are generally covered anywhere, follow-up care after a hospitalization may not be. A simple misstep in assuming your network extends nationwide could result in big bills.

Prior Authorizations and Service Limitations

Some of the most overlooked limitations in PSHB plans come from authorization requirements and visit caps. These include:

• Pre-approval requirements for surgeries, MRIs, or mental health services

• Caps on physical therapy or occupational therapy visits per year

• Limits on skilled nursing facility stays

If you fail to obtain prior authorization, your claim may be denied or only partially reimbursed. Even with coverage, exceeding caps can lead to steep charges that must be paid entirely out of pocket.

Understanding the rules ahead of time is critical. If your physician refers you for services without checking your plan’s limitations, you could end up liable for 100% of the costs.

Preventive Care Isn’t Always Free

PSHB plans cover many preventive services in full—if you meet certain conditions. That includes being in-network, using the correct procedure codes, and ensuring your provider labels the service as preventive.

For instance, if a screening becomes diagnostic mid-procedure (like a polyp removal during a colonoscopy), you might owe coinsurance. It’s the kind of technicality that can turn a “no-cost” service into a costly one unless you know what to ask about beforehand.

Out-of-Network and Balance Billing Pitfalls

If you receive care outside of your plan’s network, you may face two layers of cost:

• Higher cost-sharing: Most plans require more from you when using non-network providers.

• Balance billing: Out-of-network providers may bill you for the difference between what they charge and what your plan pays.

In 2025, balance billing protections exist under federal law in emergency situations, but these do not extend to all non-emergency services. That means if you see a specialist not in your plan’s network, you could receive a bill well above what you expected.

Also, some PSHB plans offer partial reimbursement for out-of-network care, but these amounts are capped and unpredictable. Relying on out-of-network services should be a last resort, not a routine choice.

Telehealth Isn’t a One-Size-Fits-All Benefit

You may assume all PSHB plans cover telehealth the same way. In reality, there’s wide variation in how and when these services are covered. Some plans offer virtual primary care with no copay, while others only cover telehealth through specific platforms.

And if you use a telehealth provider not contracted with your plan, you could be charged the full visit cost. It’s easy to assume that a virtual visit equals convenience and savings, but unless your plan confirms the coverage, those assumptions could lead to surprise bills.

Cost Changes Every Year

In 2025, average PSHB premiums have increased for enrollees, especially those in Self Plus One and Self and Family tiers. Even if you stay in the same plan, deductibles, copayments, and drug tiers can shift. Not reviewing the annual changes—typically released during Open Season from November to December—means you could miss a critical update that affects your costs.

Each plan releases a summary of benefits and coverage changes every fall. Ignoring that notice can be costly. What was covered in 2024 may have changed by 2025, especially for high-cost medications or specialist visits.

The $2,000 Part D Cap Doesn’t Apply to Everything

The newly implemented $2,000 cap on Part D drug spending is a major improvement. But it’s important to know what’s not included:

• Over-the-counter medications

• Non-formulary drugs

• Brand-name medications without prior authorization

If your doctor prescribes a drug outside your plan’s list, or if you decline to use the lower-cost alternative offered, the full cost may fall on you. The $2,000 cap is helpful, but only if you follow the plan’s pharmacy protocols.

Annual Enrollment is Your Only Real Window

From November to December each year, PSHB Open Season allows you to:

• Change your plan

• Adjust your enrollment type (Self Only, Self Plus One, or Self and Family)

• Add or remove eligible dependents

Outside of this window, changes are only allowed during a Qualifying Life Event (QLE), such as marriage, divorce, or retirement. Missing Open Season could mean staying locked into a plan that no longer fits your health or financial needs.

Many plan members miss the fine print changes revealed during Open Season. As a result, they enter the new year unaware that their previous prescriptions, providers, or benefits may have shifted.

Your PSHB Plan Is a Contract—Read It Like One

Too often, PSHB enrollees treat the plan brochure like promotional material instead of a contract. Yet that brochure, and the details within, govern your care and financial responsibility. If it mentions that preauthorization is required, or that only network providers are covered in full, that isn’t a suggestion. It’s enforceable.

In 2025, with evolving costs and stricter coordination with Medicare, your PSHB plan should be treated with the same scrutiny you’d give any legal or financial agreement.

Read Before You Pay the Price

What you don’t know can cost you when it comes to PSHB. Plan documents are not meant to be skimmed. They’re meant to be studied, compared, and understood—especially before Open Season or a major medical event.

If you’re uncertain whether your current PSHB plan suits your needs or whether you’re paying more than necessary due to overlooked details, now is the time to act. Contact a licensed agent listed on this website for a full review of your plan and personal health situation.