Key Takeaways

  • Even when PSHB plans appear similar on the surface, their copay structures can vary widely and significantly impact your out-of-pocket costs in 2025.

  • Comparing the fine details of copayment levels for primary care, specialists, urgent care, emergency visits, and prescriptions is essential to avoid overspending throughout the year.

The Copay Question: What You Might Miss by Looking Only at Premiums

When you browse PSHB options, the premium usually grabs your attention first. It’s a predictable monthly figure that feels like a good baseline to compare plans. However, in 2025, looking only at the premium gives you an incomplete picture. Copayments can quietly become the cost drivers that derail your annual budget if you don’t assess them carefully.

Two plans with similar premiums can have completely different copayment requirements. One might charge you $20 for a primary care visit, while another could set it at $40. Multiply that over a year—especially if you manage a chronic condition or need frequent care—and the difference becomes more than just a minor inconvenience.

Understanding Copayment Categories in PSHB Plans

In PSHB, copays typically fall into the following categories:

  • Primary care visits

  • Specialist visits

  • Urgent care services

  • Emergency room services

  • Prescription drugs (tiered)

  • Mental health and substance use services

  • Telehealth visits

Each of these categories can carry vastly different copayment structures from plan to plan. Knowing how they are structured can help you identify hidden costs that might not show up until you need care.

1. Primary and Specialist Visits: A Common Point of Variation

Primary care copays might look small individually, but they add up quickly. In 2025, PSHB plans generally charge between $20 and $40 for each primary care visit. The difference in specialist copays can be even wider, ranging from $30 to $60 per visit.

If you require frequent specialist consultations—such as cardiology, endocrinology, or dermatology—you could be paying hundreds of dollars more annually under a higher-copay plan, even if it has a slightly lower monthly premium.

2. Urgent Care vs. Emergency Room: Watch the Gap

Urgent care centers provide a valuable middle ground between primary care and the ER. But in many PSHB plans, urgent care copays can range from $50 to $75, while ER visits may cost between $100 and $150.

Some enrollees choose plans assuming they’ll rarely visit the ER, but forget that urgent care trips are far more common—especially during flu season or for minor injuries. A plan that charges more for urgent care can leave you spending more out of pocket than you anticipate.

3. Prescription Drug Tiers: Where the Fine Print Matters Most

In 2025, all PSHB plans integrate Medicare Part D benefits for Medicare-eligible enrollees. Even if you’re not Medicare-eligible, your prescription drug costs will be governed by a tiered system. These tiers often include:

  • Tier 1: Generic drugs (lowest copay)

  • Tier 2: Preferred brand-name drugs

  • Tier 3: Non-preferred brand-name drugs

  • Tier 4: Specialty or high-cost medications

A generic drug might cost you $10 under one plan and $20 under another. For brand-name or specialty drugs, the disparity can be much higher. Plans with seemingly identical premiums can differ significantly in drug copays, especially when you need regular medication.

Some PSHB plans also have separate rules for mail-order drugs or 90-day supplies. Others offer reduced or waived deductibles if you’re also enrolled in Medicare Part B. Make sure to read each plan’s drug cost-sharing rules in detail.

4. Mental Health and Behavioral Services: Growing Access, But Different Costs

PSHB plans in 2025 continue to expand access to mental health care, aligning with federal priorities. However, coverage doesn’t mean cost equality.

Some plans charge the same copay for therapy sessions as they do for primary care. Others treat them as specialist visits, triggering higher copays. If mental health services are a priority for you or your family, this is a detail worth investigating before enrollment.

5. Telehealth: Not Always Free or Equal

Telehealth visits surged in popularity and necessity in recent years. In 2025, many PSHB plans offer telehealth coverage, but the copay structures vary. Some treat it like a standard office visit; others offer reduced rates or waive the copay altogether.

However, plans may have separate rules depending on the provider—for example, using the plan’s partnered telehealth provider versus your regular doctor offering remote visits. Don’t assume all telehealth is low-cost unless the plan says so explicitly.

6. Family Coverage: Copay Impact Is Multiplied

If you’re enrolled in a Self Plus One or Self and Family option, every copay applies to multiple people. A $15 difference in urgent care copays might not seem large until your child needs care five times in a year. Multiply that across a family, and it could easily surpass any premium savings you hoped to secure.

In 2025, PSHB Self Plus One and Self and Family plans typically have the same copay structures as Self Only, but the financial impact of each copay is multiplied due to the number of users. This makes it even more critical to evaluate copays closely.

7. Plan Summaries Can Be Misleading Without Full Detail

Plan brochures often emphasize what they cover, not what you pay. A common mistake is skimming these documents for general benefits and assuming the costs are roughly equal.

In reality, PSHB plans often bury the specifics of cost-sharing within multiple tables and footnotes. Take time to compare side-by-side tables of:

  • Primary care visit costs

  • Tiered drug costs

  • ER and urgent care costs

  • Deductible thresholds

Look beyond the marketing claims and review the Summary of Benefits and Coverage (SBC) document, which standardizes copay details across plans.

8. Medicare Enrollment Alters Your Copay Math

If you’re enrolled in Medicare Part B, many PSHB plans offer enhanced cost-sharing benefits. This can include:

  • Lower deductibles

  • Reduced or waived copays

  • Coordinated prescription coverage under an integrated Medicare Part D EGWP

In 2025, some PSHB plans offer financial incentives for Medicare enrollees, like reimbursements or premium adjustments. More importantly, the reduced out-of-pocket costs can significantly shift the value equation between plans that otherwise appear similar.

If you’re eligible but not enrolled in Medicare Part B, you could lose out on these savings and find yourself paying more than expected. Your PSHB copays will be higher in many cases, and prescription costs will not be offset by Medicare integration.

9. High-Deductible Plans and Copay Waivers

Some PSHB plans are classified as High-Deductible Health Plans (HDHPs). In these plans, copays don’t kick in until you meet the deductible—which could be $1,500 or more for Self Only and higher for families.

These plans often appeal to enrollees who are eligible to contribute to a Health Savings Account (HSA). But you must factor in how many services will be subject to full cost until the deductible is met. This includes:

  • Specialist visits

  • Lab tests

  • Imaging

  • Hospital outpatient procedures

Be sure you’re comfortable with paying out-of-pocket upfront in exchange for potentially lower premiums and HSA tax advantages.

10. Annual Out-of-Pocket Maximums Add Context, But Don’t Prevent Surprises

PSHB plans include annual out-of-pocket maximums, which cap your total spending for covered in-network services. In 2025, these range from around $7,500 for Self Only to $15,000 for family coverage.

While this cap provides peace of mind, many enrollees never hit it. That means you’re more likely to feel the impact of individual copays throughout the year. Don’t rely on the maximum as your primary form of protection—look at what you’ll likely pay on a monthly basis based on your health habits.

Small Copay Differences Add Up Faster Than You Think

PSHB coverage might look uniform at a glance, especially when monthly premiums are close. But when you add up copays for common services, the true cost of each plan begins to emerge.

A plan with slightly higher premiums and much lower copays may cost you less over the course of a year—especially if you manage health conditions, take medications regularly, or have a family using the same plan.

This is why reviewing the full cost-sharing summary is crucial. Don’t settle for surface-level comparisons. Instead, compare actual service costs, ask questions about how Medicare affects cost-sharing, and factor in your expected healthcare needs.

If you’re unsure, get in touch with a licensed agent listed on this website for one-on-one assistance in evaluating the cost structure that best suits your situation.