Key Takeaways

  • Copayments under PSHB plans might seem minor individually, but they can add up significantly across the year—especially if you have ongoing care needs or frequently visit specialists.

  • Understanding how and when copayments apply can help you better plan your healthcare expenses and avoid unexpected financial pressure.

Copayments Aren’t Just a One-Time Cost

When you enroll in a Postal Service Health Benefits (PSHB) plan, you probably focus first on your monthly premium. That’s understandable—it’s a fixed number and feels easy to compare across plans. But what often surprises enrollees is how quickly the smaller, recurring charges called copayments can pile up.

Copayments are the fixed fees you pay at the time of receiving medical care. For example:

  • A flat fee to see a primary care doctor.

  • A separate, usually higher fee for specialists.

  • Different copayments for urgent care or emergency room visits.

Unlike deductibles or coinsurance, copayments apply right away. And while they seem affordable per visit, they often accumulate in the background.

Why Copayments Accumulate So Easily

You likely assume that copayments are predictable and manageable. But several factors influence how much you’ll actually pay over a year:

  • Frequency of visits: A biweekly or monthly check-up adds up quickly.

  • Types of providers you see: Primary care may have a modest copayment, but specialists typically cost more.

  • Services that trigger copayments: Lab work, imaging, mental health sessions, or physical therapy can all come with their own charges.

  • Urgent vs. scheduled care: Visits to urgent care or ER often come with higher copayments.

Over the course of 12 months, even modest copayments—multiplied by the number of visits—can turn into a substantial part of your total healthcare spending.

Common Situations That Lead to High Annual Copayments

Some healthcare patterns are more likely to lead to higher cumulative copayments:

  • Chronic condition management: If you’re managing diabetes, heart disease, asthma, or another long-term illness, frequent monitoring and check-ins can push copayment totals higher.

  • Post-hospital follow-ups: Even after hospital stays are covered, follow-up visits with multiple providers each come with their own copayments.

  • Therapy sessions: Weekly mental health or physical therapy sessions can mean 50+ copayments per year.

  • Specialist referrals: If your primary care provider refers you to specialists, you may owe copayments to both.

How PSHB Plans Structure Copayments

In 2025, most PSHB plans follow a tiered copayment system:

  • Lower copayments for primary care visits and generic prescriptions.

  • Mid-range copayments for specialists and preferred brand-name drugs.

  • Higher copayments for urgent care and ER visits.

This structure encourages using lower-cost care when possible. But if your health situation requires higher-tier services, your costs grow proportionately.

While each PSHB plan has a different exact structure, most follow this general logic. You can find specific copayment details in your plan brochure—but even with that information, estimating your total yearly cost can still be difficult.

When Copayments Catch You Off Guard

Even if you read your plan brochure, copayments may still surprise you for reasons such as:

  • Multiple services in one visit: A routine visit that includes lab work or imaging may result in more than one copayment.

  • In-network vs. out-of-network care: Some plans charge higher or additional copayments for out-of-network providers.

  • Preventive vs. diagnostic care: Many PSHB plans waive copayments for preventive services. But if your visit shifts into diagnosis, a copayment may apply.

  • Newly added services or providers: Changes to your health needs may introduce services that weren’t part of your routine before, increasing your exposure to copayments.

Budgeting for Copayments Throughout the Year

To avoid being surprised by these costs, consider building a simple plan:

  • Track visits and costs: Keep a log of each healthcare visit and the associated copayment.

  • Review plan documents annually: Every November to December, PSHB Open Season allows you to review changes to copayments and cost structures for the coming year.

  • Estimate based on past usage: Look at last year’s visits and multiply by the current year’s copayment amounts.

  • Anticipate new services: If you’re starting new therapies or have been referred to a specialist, add those copayments into your plan.

Even a rough estimate can help you avoid underestimating your true out-of-pocket costs.

Coordination with Medicare Part B

If you’re a Medicare-eligible annuitant enrolled in both Medicare Part B and a PSHB plan, your out-of-pocket exposure for copayments may be reduced. Many PSHB plans offer:

  • Lower copayments for enrollees with Medicare Part B.

  • Waived copayments for specific services like lab tests or specialist visits.

However, this isn’t automatic across all plans. Some PSHB plans require you to use preferred networks or meet other criteria to access reduced cost-sharing. That’s why reviewing your Evidence of Coverage matters—especially in a dual-coverage situation.

The Importance of Knowing Copayment Limits

Most PSHB plans don’t include copayments in your deductible—but they do count toward your annual out-of-pocket maximum.

For 2025, the PSHB out-of-pocket limits for in-network care are:

  • $7,500 for Self Only

  • $15,000 for Self Plus One or Self and Family

While these maximums include copayments, deductibles, and coinsurance, it’s important to know that:

  • Only in-network charges count toward the limit.

  • Once you hit the maximum, covered in-network services become fully paid by the plan for the rest of the year.

Keeping a running total of your out-of-pocket spending can help you know when you’re close to that threshold—especially if you have high copayment volume.

PSHB Plan Comparisons and Copayment Patterns

When comparing PSHB plans, don’t just look at premiums. Ask the following:

  • What are the copayments for primary care vs. specialists?

  • How are urgent care and emergency room visits charged?

  • Are there any services that are exempt from copayments?

  • Are copayments different with Medicare Part B?

These details are often buried in your plan brochures, but they make a big difference over time. A plan with a slightly higher premium might actually save you money if its copayments are consistently lower.

Avoiding Costly Surprises During the Year

Here are some practical ways to minimize unpleasant surprises:

  • Ask upfront: Always confirm copayments with your provider’s billing office before your visit.

  • Stay in-network: Out-of-network providers often charge more, and copayments may not be capped.

  • Know what’s covered: Preventive services like annual wellness exams often don’t require copayments. Take advantage of them.

  • Utilize telehealth: Many PSHB plans offer reduced or waived copayments for virtual visits.

Being proactive can significantly reduce the overall amount you spend through copayments in 2025.

What to Watch for in the Coming Year

During the annual Open Season from November to December, you’ll have the opportunity to:

  • Compare copayment changes across available PSHB plans.

  • Switch to a plan that better fits your healthcare usage.

  • Review your provider network to ensure continuity of care without unexpected copayment increases.

Even if you’re happy with your current plan, don’t assume it will stay the same. Plans update cost-sharing structures each year. Small increases in copayments can translate to large annual increases for frequent users.

Don’t Let Small Numbers Fool You

The term “copayment” sounds like a minor expense—and that’s part of the problem. It’s easy to dismiss it when budgeting. But when you experience a year filled with provider visits, specialist care, or therapy sessions, these seemingly small fees add up.

Ignoring them can throw off your healthcare budget significantly, particularly when you’re focused only on monthly premiums or deductibles. Think of copayments as the slow leak in your healthcare spending—not dramatic, but steady.

Being informed and proactive allows you to treat copayments as part of your overall financial planning, not just as an afterthought.

Make Your Copayment Strategy Work for You

Understanding your PSHB plan’s copayment structure puts you in a stronger financial position. You’re not just a patient—you’re also a planner. By forecasting your care needs and accounting for recurring costs like copayments, you create a more accurate and sustainable healthcare budget.

For help choosing a plan that balances premium costs with reasonable copayments, speak with a licensed agent listed on this website. They can provide professional insight tailored to your healthcare patterns and preferences.