These PSHB Copayment Triggers Are Easy to Overlook—and Hard to Budget For Later

Key Takeaways

• Certain PSHB copayment triggers aren’t immediately obvious but can significantly affect your annual healthcare spending.

• Understanding when and why higher copays apply allows you to plan better and avoid unexpected costs.

Copayments in PSHB: What You Think You Know

Under the Postal Service Health Benefits (PSHB) Program in 2025, most enrollees expect routine copayments—predictable, fixed amounts for services like primary care visits or prescriptions. However, many enrollees don’t realize that several triggers can shift your copayment responsibility without warning. These triggers don’t always show up in plan summaries and often get buried in plan brochures.

Your monthly budget could take a hit if you’re not aware of how these triggers work. You might assume your copay will remain consistent throughout the year, but that isn’t always the case.

1. Service Location Changes Can Alter Your Copay

Where you receive care matters. PSHB plans often distinguish between:

• In-network vs. out-of-network facilities

• Retail clinics vs. urgent care centers vs. hospitals

If you walk into an urgent care center thinking it’s in-network and it turns out not to be, your copay could double or even triple. Some plans categorize walk-in clinics, telehealth platforms, and standalone facilities differently than you’d expect.

Key Tip:

Always confirm provider and facility network status beforehand—even if you’ve visited them before under FEHB.

2. Specialist Referrals That Aren’t Pre-Authorized

Certain PSHB plans in 2025 require pre-authorization for specialty services. If you go directly to a dermatologist, cardiologist, or neurologist without a referral or prior approval, you could be charged an out-of-network copay—even if the specialist is technically in-network.

This often happens with mental health services, physical therapy, and advanced imaging.

What You Can Do:

• Review your plan’s prior authorization list each year.

• Ask your primary care provider if the referral has been submitted and approved.

3. Using a Provider Who Recently Left the Network

Networks change. Just because a doctor was in-network last year doesn’t guarantee they still are.

In 2025, some PSHB plans update provider networks quarterly. If you don’t check before your visit, you may end up paying a higher copayment, especially for specialists and outpatient procedures.

Check the plan’s directory close to your appointment date or call the provider’s office directly.

4. Services Billed Separately From the Main Visit

Even when you visit an in-network facility, not all services you receive there may be billed as part of the standard visit. Common examples include:

• Lab tests

• Radiology services

• Anesthesia

• Durable medical equipment (DME)

These are often billed by third-party providers. If the lab or DME supplier is out-of-network, your plan may require a higher copayment or even apply coinsurance.

Financial Impact:

Copays for these services can vary from $40 to $150, depending on your plan tier and network rules.

5. Extended Visits and Multiple Diagnoses

Some plans apply different copayment levels for longer visits or appointments involving multiple diagnoses. For example, an extended mental health therapy session or a visit that combines diabetes management with a cardiovascular evaluation may push the encounter into a higher copay tier.

Also, behavioral health services—especially when combined with medication management—may have tiered cost structures that differ from general medical services.

Planning Ahead:

Ask in advance about how long your visit is scheduled for and how many services will be billed.

6. Telehealth Doesn’t Always Mean Cheaper

While telehealth has gained popularity, especially after 2020, not all telehealth services come with lower copays under PSHB in 2025. Some plans still apply regular in-office visit copays to virtual consultations, especially if the provider is not within the plan’s preferred telehealth platform.

Also, if you use a telehealth provider who’s out-of-network or whose platform isn’t listed as an official partner, your copay could be the same—or even higher—than an in-person visit.

7. Care Received During Travel

If you travel and need care outside your residential area, your PSHB plan may cover it differently. Routine or non-emergency care received out-of-state or outside your local plan region may trigger out-of-network copays.

Even if a facility accepts your PSHB plan, it might not be part of your plan’s network in that state.

Avoid This Trap:

• Use your plan’s mobile app or call their helpline when planning travel.

• For longer stays away from home, inquire about temporary care arrangements or guest member programs.

8. Late or Missed Paperwork for Authorization

Some plans require timely submission of authorization or verification forms for procedures, recurring services, or second opinions. Missing these deadlines—even by a few days—can shift your responsibility to a higher copayment category.

This often affects:

• Home health care

• Physical therapy

• Outpatient surgery

Best Practice:

Stay in touch with your provider’s billing staff and ask them to verify all required paperwork has been submitted.

9. Hospital-Based Physicians Charging Separately

A common budget surprise occurs when you receive treatment at an in-network hospital, but individual providers—such as the radiologist, anesthesiologist, or pathologist—bill separately and are not in-network.

This could result in you being billed for additional copays outside your standard hospital visit.

Strategy:

Before planned hospital visits, request a list of all providers who will be involved in your care and verify their network status.

10. Mid-Year Plan Changes or Benefit Adjustments

Although your PSHB plan for 2025 starts January 1, some aspects can still change during the year—especially following updates to federal healthcare guidelines or contracts with provider networks.

Changes to:

• Drug formularies

• Copayment tiers

• Covered providers

…may occur mid-year and affect what you owe.

How to Prepare:

• Read any notices from your plan carefully.

• Check for emails or mail regarding updates to your Summary of Benefits.

Being Proactive Helps You Avoid Surprise Costs

PSHB enrollees who stay informed are less likely to be surprised by rising copayments. Every plan includes a detailed brochure that’s updated annually, and many offer digital tools to verify provider networks, review copay tiers, and submit authorizations.

You also have the right to request a pre-treatment estimate to find out how much you’ll owe before receiving care.

Take advantage of:

• Plan directories

• Mobile apps

• Secure messaging with care coordinators

These tools exist to help you control your healthcare spending, but only if you use them consistently.

Why These Triggers Matter More in Retirement

If you’re retired or approaching retirement, your healthcare budget is likely more fixed. Unexpected copayment increases can throw off your financial planning. Some PSHB plans offer reduced cost-sharing for Medicare-eligible retirees, but only if you’re properly enrolled in both Medicare Part A and Part B.

If you delay Medicare Part B enrollment or don’t notify your PSHB plan of your Medicare status, your copayment schedule may not adjust accordingly. This makes copayment triggers even more significant.

Take the time to coordinate your benefits and ensure all paperwork is properly submitted. Don’t rely on assumptions from your FEHB experience—PSHB rules have changed.

Take Charge of Your PSHB Copayment Schedule

You have more control than you might think. The difference between an affordable year and one filled with surprise costs often comes down to awareness and preparation. Review your plan documents thoroughly, ask your provider questions before receiving care, and stay current with all plan updates.

If you need help interpreting your plan’s copayment rules, get in touch with a licensed agent listed on this website. A brief conversation now could save you hundreds—or more—over the course of the year.