You Might Be Paying Extra Copays in PSHB Without Realizing the Reason Why

Key Takeaways

• Your PSHB copayment amounts may change based on provider network, service type, and plan structure—without any change in your monthly premium.

• Understanding plan rules around referrals, authorizations, and benefit tiers is essential to avoid higher-than-expected out-of-pocket costs.

What Triggers Unexpected Copays in PSHB Plans?

In 2025, the Postal Service Health Benefits (PSHB) program replaces FEHB for USPS employees and retirees. While it promises familiar structure, many enrollees are discovering that their out-of-pocket expenses—especially copayments—can vary in subtle ways. If you’re paying more than expected at the doctor’s office or pharmacy, you’re not alone. Copay amounts might appear fixed, but the reality is more complex.

Let’s break down what might be increasing your copayments—often without you realizing it.

1. Using Out-of-Network Providers Without Knowing It

Just because a provider accepts your insurance card doesn’t mean they’re in-network for your PSHB plan.

• In-network providers have pre-negotiated rates and lower copays.

• Out-of-network providers often come with higher copays or full out-of-pocket charges.

• Some PSHB plans include partial coverage for out-of-network services, while others cover none at all unless it’s an emergency.

Always confirm provider network status, especially when referred to specialists or seeking urgent care outside your regular clinic.

2. Skipping Referrals or Pre-Authorizations

Many enrollees mistakenly assume that because they have insurance, they can see any doctor or receive any test without prior steps.

• Certain services (e.g., MRIs, surgeries, or specialty consultations) often require pre-authorization.

• Skipping this step can lead to denial of coverage, converting your planned copay into the full bill.

• Some plans require a referral from a primary care physician (PCP) to see a specialist. Without it, a higher copay or full charge may apply.

Verify your plan’s requirements in the plan brochure and confirm steps with your provider before receiving care.

3. Misunderstanding the Tier System for Services

PSHB plans often categorize healthcare services into tiers, especially for prescription drugs, specialists, and facilities.

• Generic prescriptions usually have the lowest copay, while non-preferred brand-name drugs carry higher costs.

• Some specialists may be considered Tier 2 or Tier 3 based on your plan’s preferred provider listing.

• Facilities like imaging centers or urgent care clinics can be placed in different tiers, impacting your copay.

Failing to use a lower-tier provider can increase your costs, even when services are in-network.

4. Receiving Care at Hospital-Based Clinics

You may visit what appears to be a regular doctor’s office only to be charged a hospital facility fee.

• Many hospitals have acquired clinics and outpatient facilities.

• These locations may be billed as hospital outpatient departments.

• Even routine services may be subject to additional copays or coinsurance.

Ask your provider if the office is considered hospital-affiliated under your PSHB plan.

5. Confusing Urgent Care with Emergency Room Visits

Emergency rooms and urgent care centers offer different levels of care—and come with different copays.

• In 2025, typical urgent care copays range from $50 to $75.

• Emergency room copays are often $100 to $150, and that doesn’t include possible coinsurance or deductibles.

• Choosing the ER for non-emergency conditions can dramatically increase your costs.

Understand your plan’s definitions of emergency care versus urgent care and use 24/7 nurse advice lines when uncertain.

6. Using Retail Clinics or Telehealth Without Checking Plan Alignment

Many PSHB plans now support retail clinics and telehealth. However, using a non-participating provider may affect your costs.

• Retail clinics in pharmacies or supermarkets might not be covered under your specific plan.

• Telehealth platforms not integrated with your PSHB plan may result in full charges instead of flat copays.

Check which services and vendors are approved before scheduling virtual or walk-in visits.

7. Receiving Services During a Deductible Period

If your PSHB plan includes a deductible, you may pay more than the standard copay until that deductible is met.

• Deductibles apply to certain services, such as hospitalization, outpatient procedures, or high-cost imaging.

• Until your deductible is satisfied, you may pay the full negotiated rate instead of just a copay.

• Not all services are subject to the deductible, but understanding which ones are is critical.

Review your plan’s Summary of Benefits to identify when deductibles apply.

8. Coverage Differences Between Family Members

If you’re enrolled in a Self Plus One or Self and Family plan, your dependents may have different provider usage patterns.

• A dependent seeing an out-of-network specialist could result in a higher copay than expected.

• Pediatric services, mental health care, and specialty prescriptions may have distinct cost-sharing rules.

• Family deductibles and out-of-pocket maximums can complicate how costs are split across multiple users.

Monitor each covered member’s usage to avoid overlapping charges or mistaken assumptions.

9. Lab Work Sent to Non-Preferred Vendors

Routine lab tests, while often low cost, can become expensive if sent to a non-preferred lab.

• Your doctor may automatically route samples to a lab outside your plan’s network.

• Some PSHB plans designate specific national labs as preferred partners.

• Using a different lab can lead to higher copays or full out-of-pocket bills.

Ask your provider where the lab work is being sent and if it aligns with your PSHB plan’s lab network.

10. Receiving Preventive Care That Isn’t Classified as Preventive

Not all screenings or annual exams are coded as preventive—even if they feel routine.

• Preventive care is often covered at no copay, but only if certain criteria are met.

• If your provider includes diagnostic testing, symptom evaluation, or follow-up treatment during the visit, it may be billed differently.

• This change in billing classification can trigger a copay, deductible, or coinsurance.

Ask your provider in advance how the service will be billed under your PSHB plan.

Take Time to Recheck Your Plan Documents Each Year

The transition to PSHB means every year could bring changes in cost-sharing, even if your premium remains stable.

• Plan brochures are updated annually.

• Your 2025 plan may have introduced new tiers, altered referral requirements, or adjusted copay structures.

• If you rely on the same assumptions from prior years, you might pay more without realizing why.

Review the 2025 PSHB brochures carefully during Open Season from November to December.

What to Do If Your Copays Seem Too High

You’re not stuck with unexplained charges. There are steps you can take:

• Contact your PSHB plan’s customer service for itemized explanations.

• Appeal a charge if you believe it was coded incorrectly.

• Review your Explanation of Benefits (EOB) for any discrepancies.

• Confirm network status and billing codes with your provider.

• If needed, file a grievance through your plan’s formal process.

Staying proactive can prevent future overcharges and help you use your benefits more strategically.

You Deserve Predictability in Your Health Costs

Copayments under PSHB should feel transparent—but in reality, they often reflect layers of policy, coding, and provider contracts. What looks like a simple charge may be the result of provider tiering, coding misclassifications, or network gaps. The more you understand your plan’s moving parts, the more likely you are to avoid unnecessary costs.

If you’re unsure about a recent charge or want to review your plan’s cost-sharing structure, speak with a licensed agent listed on this website. They can walk you through your 2025 PSHB options and help ensure your health coverage works the way you expect.