Key Takeaways

  • Even predictable copayments under the Postal Service Health Benefits (PSHB) Program can become unexpectedly expensive when services are used frequently or layered with other cost-sharing requirements.

  • Understanding when and how copayments apply, and how they differ from coinsurance and deductibles, is key to avoiding unpleasant financial surprises throughout the year.

Why Copayments Appear Simple—But Often Aren’t

Copayments in your PSHB plan may look like the most straightforward part of your coverage: a fixed amount for a specific service. A $30 copay for a specialist visit, for example, seems manageable. But what you may not realize is how quickly these costs can escalate—especially when you require repeated care, multiple types of services, or ongoing prescriptions.

While PSHB copayments are meant to give you predictable costs, the moment your usage rises even slightly above the average, those numbers stop feeling predictable and start feeling punishing.

Copayments Aren’t Capped—But Your Out-of-Pocket Maximum Is

The most important point many enrollees miss is that copayments themselves are not individually capped. You could pay a $40 copay every week of the year for therapy, and unless you hit your out-of-pocket maximum, there’s no limit to how much you’ll spend.

In 2025, PSHB plans typically cap annual in-network out-of-pocket costs at around:

  • $7,500 for Self Only

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

These totals include copayments, deductibles, and coinsurance—but until you reach them, copayments can accumulate without warning.

Where Copayments Add Up the Fastest

Certain services are more likely to rack up frequent copayment charges. Here are some to keep a closer eye on:

Office Visits

  • Primary care visits might require a $20 to $40 copayment.

  • Specialists often range higher, from $30 to $60.

If you see multiple providers each month, your costs multiply quickly.

Urgent and Emergency Care

  • Urgent care visits may come with $50 to $75 copays.

  • Emergency room services typically require $100 to $150 per visit.

Multiple ER visits in a year—especially for families—can create unexpected budget pressures.

Prescription Medications

  • Brand-name and non-preferred medications usually carry higher copayments.

  • You may face a separate copayment for each prescription, filled every 30 days.

Add chronic conditions or multiple family members, and the monthly totals grow substantially.

The Copayment vs. Coinsurance vs. Deductible Confusion

Many PSHB enrollees underestimate total costs because they confuse copayments with other forms of cost-sharing. Here’s how they differ:

  • Copayment: Fixed amount per service (e.g., $40 per specialist visit)

  • Coinsurance: Percentage of the cost you pay after the deductible (e.g., 20% of a $1,000 scan)

  • Deductible: The amount you must pay before insurance begins covering most services

Even with a copay, coinsurance may still apply for more extensive treatments, and the deductible may still need to be met for certain procedures.

PSHB Copayments: In-Network vs. Out-of-Network

If you choose out-of-network providers, you may pay much more than the listed copay. In many PSHB plans:

  • In-network providers offer fixed, predictable copayments.

  • Out-of-network services often involve both higher copays and additional coinsurance charges.

Stick with network providers whenever possible to maintain budget control.

The Role of Medicare in Reducing Copayments

For Medicare-eligible retirees under PSHB, enrolling in Medicare Part B can substantially reduce your overall cost-sharing. Many PSHB plans coordinate with Medicare to:

  • Waive or reduce certain copayments.

  • Limit coinsurance for common services.

  • Eliminate some deductibles altogether.

However, this benefit only applies if you are enrolled in both Medicare Part B and your PSHB plan.

When Copayments Collide with High Utilization

You may start the year with a reasonable estimate of how often you’ll need care. But health issues don’t follow a calendar. Here’s how things can change:

  • You sprain your ankle, requiring several follow-ups, imaging, and physical therapy.

  • A family member needs mental health services with weekly visits.

  • You’re prescribed several brand-name drugs that each carry separate copayments.

Even a brief medical episode can mean dozens of copayments within a few months. Without careful tracking, you can quickly exceed your health budget for the year.

What You Can Do Now to Prepare

Rather than reacting to unexpected totals at year-end, you can take proactive steps to reduce the burden copayments place on your wallet.

Review the Summary of Benefits

Your PSHB plan provides a clear breakdown of copayments in the plan brochure. Review the sections on:

  • Primary and specialty care

  • Emergency and urgent care

  • Prescription tiers (generic, preferred, non-preferred)

  • Mental health and therapy sessions

This will help you calculate realistic monthly and annual expectations.

Estimate Annual Usage

Try mapping out your household’s typical health services:

  • How many visits to each type of provider do you expect?

  • How many prescriptions will need filling monthly?

  • Are there any anticipated procedures or treatments?

This estimate gives you a clearer picture of how quickly copayments can accumulate.

Use Preventive Services

Many preventive services are covered without copayments under PSHB when using in-network providers. These include:

  • Annual wellness visits

  • Vaccinations

  • Screening tests

Taking advantage of preventive care can help you avoid more expensive services—and copayments—later on.

Leverage Your FSA or HSA

If you’re enrolled in a plan that allows it, consider contributing to a Flexible Spending Account (FSA) or Health Savings Account (HSA):

  • FSA maximum in 2025: $3,300

  • HSA maximum in 2025: $4,300 for individuals; $8,550 for families

These accounts let you set aside pre-tax funds for eligible health expenses, including copayments.

Consider Plan Changes During Open Season

From November to December each year, you have the opportunity to compare and change your PSHB plan. If your current plan’s copayments are adding up, review options with:

  • Lower copayment amounts

  • Better prescription drug tiers

  • Stronger coordination with Medicare

Making a switch could lead to significant savings for the next calendar year.

Why Families Feel the Pinch Even More

Copayments scale with each member of your family. If you’re covering a spouse and children, consider the multiplying effect:

  • Two children seeing pediatricians regularly

  • A spouse on multiple prescriptions

  • ER visits for accidents or unexpected illnesses

While the Self & Family plan offers broad coverage, the out-of-pocket maximum is also higher. That means you’ll be paying copayments longer before hitting any cap.

What Happens If You Miss a Payment

If you’re not paying attention to your copayments and miss a provider bill:

  • You may incur late fees.

  • Unpaid amounts can be sent to collections.

  • Future access to care could be limited if your provider requires payment up front.

It’s important to track and pay copayments promptly—even the small ones.

Don’t Let Copayments Catch You Off Guard

Copayments may seem like a minor aspect of your PSHB plan, but over the course of a year, they can quietly become one of your largest expenses. This is especially true if you or a family member has a chronic condition, multiple prescriptions, or an unplanned health event.

Being proactive—reviewing your plan, tracking your usage, using preventive care, and budgeting accordingly—can keep you from being blindsided. And if you’re unsure about what your specific copayment responsibilities are under your plan, that’s a perfect time to reach out.

Understand Your Options Before the Costs Mount

Copayments under PSHB are a fixed cost per service—but when services multiply, so do your expenses. Take time to understand where, when, and how these charges apply. The real surprise isn’t the amount you owe at any one time—it’s how quickly those fixed amounts pile up over the course of the year.

If you need help understanding your specific copayment responsibilities or want to explore plans with lower overall out-of-pocket costs, get in touch with a licensed agent listed on this website.