Key Takeaways

• While you may have planned for your monthly PSHB premiums in 2025, copayments for common services like primary care, specialist visits, and urgent care can gradually add up—and often aren’t fully accounted for in annual budgets.

• Medicare coordination can reduce some out-of-pocket costs under PSHB, but only if you meet specific enrollment requirements and understand how these copayments interact with deductibles and coinsurance.

The Reality of Copayments in the PSHB System

When you transition to the Postal Service Health Benefits (PSHB) Program, especially in retirement, your attention often gravitates toward your monthly premium. That makes sense—it’s a predictable cost. But focusing solely on premiums can lull you into a false sense of financial preparedness. In 2025, copayments are playing a bigger role in your total healthcare spending than you might think.

Copayments are the fixed amounts you pay for specific healthcare services. They’re not based on the cost of the service itself, like coinsurance. Instead, you pay a flat fee each time you visit a doctor, pick up a prescription, or use urgent care. These small payments might seem minor—$20 here, $50 there—but they can quietly erode your retirement income over time if you aren’t budgeting for them properly.

Understanding Where Copayments Hit Most Often

Under the PSHB Program in 2025, copayments typically apply in the following areas:

• Primary care visits: These range from $20 to $40 per visit, depending on your plan.

• Specialist visits: Expect to pay $30 to $60 per appointment.

• Urgent care visits: Often between $50 and $75.

• Emergency room visits: These can run $100 to $150 per use.

• Prescription drugs: Tiered copays based on generic, preferred, or specialty drugs.

Even if each category feels affordable in isolation, frequent usage—especially for those managing chronic conditions—can push these costs into the thousands annually.

How Copayments and Deductibles Interact

In most PSHB plans, copayments are due before you meet your deductible. This means you’re paying these amounts out-of-pocket on top of whatever you may owe toward the deductible. For instance:

• If your in-network deductible is $600 and you make a $40 copayment for a specialist visit, that copayment doesn’t count toward the deductible.

• This creates a dual burden—paying the copayment upfront and still working toward meeting your deductible.

Copayments also don’t usually apply toward coinsurance limits or out-of-network deductibles. This is a key budgeting detail that’s frequently overlooked.

Medicare Changes the Copay Equation—But Not Always

If you’re enrolled in Medicare Part B and pair it with a PSHB plan, your plan may waive or reduce some copayments, especially for physician services and outpatient care. However, this isn’t automatic. You must:

• Be fully enrolled in Medicare Part B.

• Choose a PSHB plan that coordinates with Medicare to provide additional cost relief.

Even then, not all copayments disappear. For instance, some plans may still charge copays for prescriptions or for services outside the Medicare coverage scope.

And remember: retirees who aren’t required to enroll in Part B—such as those who retired on or before January 1, 2025—may see higher copayments than peers who do enroll.

Hidden Copayments You Might Not Expect

Beyond routine visits and prescriptions, other services come with their own unexpected copayments:

• Physical therapy sessions – Often have their own tiered copayment system.

• Mental health counseling – Each session can carry its own charge.

• Special diagnostic services – MRIs, CT scans, and similar tests sometimes come with fixed copayments even if you meet your deductible.

• Out-of-network visits – Some plans assign a separate (and higher) copayment for services outside the network, in addition to higher coinsurance or deductibles.

These charges may not be frequent, but when they do arise, they’re costly—and often omitted from routine financial planning.

Annual Copayment Impact on Retiree Budgets

To understand the scale, consider a retiree who visits a primary care doctor once per month, sees a specialist quarterly, fills three prescriptions monthly, and uses urgent care twice per year:

• 12 Primary care visits x $30 = $360

• 4 Specialist visits x $50 = $200

• 36 Prescriptions x $15 = $540

• 2 Urgent care visits x $60 = $120

That’s $1,220 annually in copayments—before touching deductibles, coinsurance, or premiums. And this is a moderate use case. Many retirees with chronic health needs could easily double that figure.

Tips for Accounting for Copayments in Your 2025 Budget

Rather than treating copayments as incidental, include them in your core health budget using these approaches:

• Estimate annual usage: Review last year’s medical service usage to project copayment totals for this year.

• Track prescription tiers: Tier 3 or specialty drugs carry significantly higher copayments. Knowing your medications helps anticipate costs.

• Choose a plan that coordinates well with Medicare: If you’re Medicare-eligible, consider selecting a PSHB plan known for reducing or eliminating copayments for Medicare-enrolled members.

• Consider cost vs. convenience: Lower copayments may be tied to limited provider networks. Weigh the savings against potential access limitations.

• Use a Health Savings Account (HSA) or Flexible Spending Account (FSA): These pre-tax funds can be used to cover copayments, helping stretch your retirement income.

What to Expect When You Hit the Out-of-Pocket Maximum

PSHB plans have out-of-pocket limits—usually $7,500 for Self Only and $15,000 for Self Plus One or Self & Family in-network in 2025. Once you reach this cap, your plan covers 100% of eligible expenses.

However, not all costs count toward this cap:

• Premiums and some copayments don’t apply to the out-of-pocket max.

• Out-of-network costs may have a separate, higher cap or may not apply at all.

This means even if you hit the cap for other expenses like coinsurance, your copayments may continue unless your plan explicitly includes them.

Comparing Copayments vs. Coinsurance for Budget Planning

It’s easy to confuse copayments and coinsurance, but the budgeting impact is different:

• Copayments offer predictability. You always know what you owe.

• Coinsurance is a percentage, so your cost varies based on the price of the service.

For high-cost services, coinsurance can lead to large bills, while copayments offer smaller but more frequent hits to your finances. Effective retirement planning needs to accommodate both.

Reviewing Your PSHB Plan During Open Season

From November to December each year, you get a window to re-evaluate your PSHB plan. Here’s why it matters:

• Copayment amounts can change annually.

• New plans may offer lower copayments for services you use most.

• Plans with higher premiums may reduce copayment obligations, potentially saving you money overall.

Don’t rely on past assumptions—copay structures evolve. Review your plan’s 2025 brochure carefully or speak to a licensed agent listed on this website to compare options.

Budgeting for Copayments Is No Longer Optional

As PSHB continues in 2025, retirees face higher out-of-pocket responsibility than in years past. With average healthcare usage increasing with age, and more services now requiring fixed payments, it’s no longer sustainable to treat copayments as afterthoughts.

Even those who coordinate with Medicare still face potential charges for drugs, specialists, or out-of-network care. By planning for these costs now, you protect your income, avoid financial strain during the year, and make smarter choices during Open Season.

Speak with a licensed agent listed on this website if you need help identifying which PSHB plan offers the best value for your health and budget profile.