Supreme Court Clears the Path: Lower Medicare Drug Prices are Officially Coming

Ed MacConnell

The landscape of healthcare in America just took a significant turn toward affordability. In a landmark moment for seniors across the country, the Supreme Court has declined to hear a major challenge to the Medicare Drug Price Negotiation Program. This decision marks the end of a long legal battle initiated by some of the world's largest pharmaceutical companies. By refusing to take up the case, the highest court in the land has effectively cleared the path for the federal government to negotiate prices directly with drug manufacturers, a move that was once prohibited by law. At Total Benefit Solutions Inc, we’ve been watching this case closely. Our mission is to… Read More

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Infographic: Navigating the 2027 Medicare Part D Overhaul

Ed MacConnell

Buckle up, because the world of medicare drugs is getting a total makeover. If you’ve spent any time navigating the maze of Medicare Part D over the last decade, you probably remember the dreaded "Donut Hole", that confusing gap in coverage that felt like falling into a financial pit just when you needed help the most. Well, by 2027, the Donut Hole isn't just closed; it’s ancient history. At Total Benefit Solutions Inc, we spend our days (and sometimes our nights) digging through federal regulations so you don't have to. We are health insurance advocates who never accept "no" for an answer, especially when it comes to your benefits. Our… Read More

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Medicare Client Consultation

The May 2026 Medicare Updates Everything You Need to Know Now

Ed MacConnell

Welcome to your essential update for May 2026. If you’ve been feeling like the world of health insurance is moving faster than you can keep up with, you aren’t alone. Between shifting pharmaceutical programs and complex federal regulations, staying informed is a full-time job. Luckily, it’s our full-time job. At Total Benefit Solutions Inc, we don’t just watch the changes; we navigate them for you. This month, we have three major updates that will impact how you access care, how much you pay for prescriptions, and how your business stays compliant with Medicare rules. The July 2026 Ozempic/GLP-1 “Bridge Program” One of the most frequent questions we’ve received lately is:… Read More

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Medicare Secondary Payer Rules

Medicare Secondary Payer Rules: 15 Things You Need to Know to Avoid Penalties.

Ed MacConnell

So, your business is growing, your team is aging like a fine wine, and suddenly, you’ve got employees hitting that magical number: 65. Congratulations! You’ve reached the level of the “Medicare Secondary Payer” (MSP) boss fight. If that sounds intimidating, it’s because it can be. Medicare Secondary Payer rules are essentially the government’s way of saying, “We aren’t paying for this if someone else can.” At Total Benefit Solutions Inc, we spend our days navigating these regulatory minefields so you don’t have to step on a $1,000-per-claim landmine. Whether you’re offering group health insurance for employers or looking into affordable group health insurance options, understanding MSP is non-negotiable. Here are… Read More

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The Ozempic Odyssey: Navigating Medicare Coverage Without the Headache

Ed MacConnell

If you’ve turned on a television or scrolled through social media lately, you’ve heard the names: Ozempic, Wegovy, Zepbound. These GLP-1 medications have completely transformed the conversation around weight management and chronic disease. But for those of us on Medicare, the conversation has often been a short one: "No, Medicare doesn't cover weight loss drugs." For years, that 2003 federal law (the Medicare Modernization Act) has acted like a brick wall, explicitly banning coverage for medications used solely for weight loss. At Total Benefit Solutions Inc, we don't like the word "no." Neither does our resident expert, Dr. Ben E. Fitz. Today, we’re breaking down the complex odyssey of Medicare… Read More

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Big News: We’ve Joined the American Association for Medicare Supplement Insurance (AAMSI)!

Ed MacConnell

If you’ve been hanging around Total Benefit Solutions Inc for more than five minutes, you know we don’t do things halfway. Whether we’re fighting a denied claim until the insurance company basically begs us to stop calling (we won’t) or navigating the labyrinth of federal regulations, we’re all in. That’s why I’m beyond excited to share some major news. I’ve officially joined the American Association for Medicare Supplement Insurance (AAMSI). You can even check out my shiny new profile right here. Now, I know what you’re thinking: "Ed, another acronym? Really?" But hang with me for a second, because this isn’t just a badge for my email signature. It’s a… Read More

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Member of American Association of Medicare Supplements

Total Benefit Solutions is Now an Official Member of the American Association for Medicare Supplement Insurance

Lily Dalton

We’re proud to announce that Total Benefit Solutions is now an official member of the American Association for Medicare Supplement Insurance (AAMSI)! AAMSI is a nationally recognized organization dedicated to supporting professionals who specialize in Medicare and Medicare Supplement insurance. Their mission is to promote education, ethical standards, and consumer awareness within the Medicare industry. Becoming a member of AAMSI reflects our ongoing commitment to providing trusted guidance, reliable information, and personalized support to every client we serve. As part of this respected organization, Total Benefit Solutions gains access to valuable industry resources, continued education, and up-to-date Medicare insights — helping us better serve our clients with confidence and care.… Read More

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Member of American Association of Medicare #medicare Supplements #medicaresupplements

Why Everyone Is Talking About the New Medicare GLP-1 Bridge (And You Should Too)

Ed MacConnell

If you’ve turned on a television, scrolled through social media, or even just sat in a doctor’s waiting room lately, you’ve heard the names. Ozempic. Wegovy. Zepbound. These GLP-1 medications (Glucagon-like peptide-1 receptor agonists) have basically become the “iPhone” of the medical world, everybody wants one, but the price tag can make your eyes water. For years, if you were on Medicare, the conversation usually ended with a polite but firm “No.” Federal law literally forbade Medicare from covering drugs specifically for weight loss. It was a frustrating “Catch-22” (a situation where you can’t win because of contradictory rules): you were encouraged to get healthy, but the most effective tools… Read More

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Member of American Association of Medicare #medicare Supplements #medicaresupplements

Medicare Secondary Payer Rules: 15 Things You Need to Know to Avoid Penalties

Ed MacConnell

Let’s be honest: talking about Medicare Secondary Payer (MSP) rules is about as exciting as watching paint dry in a room full of accountants. But here’s the kicker, if you’re a small business owner, ignoring these rules is a great way to watch your hard-earned profits vanish into a black hole of federal fines. At Total Benefit Solutions Inc, we spend our days navigating the labyrinth of group health insurance for employers, and we’ve seen it all. We know that you’re just trying to provide affordable group health insurance without getting slapped by Uncle Sam. CMS (the Centers for Medicare & Medicaid Services) has a very specific sense of humor,… Read More

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Medicare Secondary Payer Rules: A Quick-Start Guide for Employers with 65+ Staff

Ed MacConnell

As we move further into 2026, the landscape of the American workforce continues to shift. More than ever, we are seeing valued team members choose to work well past the traditional retirement age of 65. While having that experience and institutional knowledge on your team is a massive win for your business, it does introduce a specific layer of complexity regarding your employee benefits strategy. The biggest question we get here at Total Benefit Solutions Inc is often some variation of: "My top salesperson just turned 65. Do they have to go on Medicare, and who pays their medical bills first?" The answer lies within the Medicare Secondary Payer (MSP)… Read More

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Total Benefit Solutions #healthinsurance, #healthinsuranceNJ, #horizonbluecross, #IndividualMandate #healthinsurance, #medical #medicare #medicalplans #Medicaid #healplans #totalbenefitsolutions #employee benefits #healthinsurance, #aca, #aca, #obamacarealternatives, #cobra, #pennie, #getcoveredNJ, #medicareadvantage, #medicaresupplements, #totalbenefits #independence #bluecross, #aetna, #unitedhealthcare, #amerihealth, #nippon, #unitedconcordia, #horizon, #AmericanHealthInsurance, #aflac, #aetna, #ICHRA, #HRA, #healthreimbursement, #buckscounty, #healthinsurancenearme, #healthinusrancebuckscounty, #healthinsurancebuckscounty, #healthinsurancenearby, #healthonsurancephiladelphia, #healthinsuranceinPA, #healthinsuranceNJ, #PENNIE, #PENNIEHEALTHINSURANCE, #cobraalternatives, #turning26, #turning65, #adultinghealthinsurance, #healthinsurancenearme, #healthinsurancenearby, #healthinsurancefeasterville, #healthinsurancephilly, #bluecardppo, #minimumessentialplans, #minimumvalueplans, #shorttermhealthplan, #bluecross

A new Special Enrollment Period has been created allowing select beneficiaries in Pennsylvania to shop for coverage until April 30

Lily Dalton

A new Special Enrollment Period (SEP) has been opened for certain Pennsylvania UnitedHealthcare Medicare Advantage beneficiaries, allowing them to shop for new coverage through April 30 due to a contract dispute with Lehigh Valley Health Network that eliminated in-network access for affected members as of January 26, 2026. This SEP is separate from the standard Medicare Advantage Open Enrollment Period, which ends March 31. Last week, the Shapiro Administration announced an SEP for UnitedHealthcare Medicare Advantage beneficiaries using Lehigh Valley Health Network Providers. This SEP is a result of contract disputes between Lehigh Valley Health Network and UnitedHealthcare. As of January 26, 2026, over 5,400 UnitedHealthcare Medicare Advantage members lost in-network access… Read More

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Kroger pharmacy is back in MA and PDP network

Loramei Romeo

Kroger and affiliated pharmacies have rejoined Medicare Advantage (MA) and Prescription Drug Plan (PDP) network which are effective on February 5, 2025. Kroger is included in the network for all our PDP plans, such as Saver Rx, Extra Rx, and Assurance Rx. Starting February 5, 2025, all claims from Kroger pharmacies will be processed as in-network. Claims made before this date will not be reimbursed. Below is a list of Kroger and its affiliated pharmacies that are now in our MA and PDP network. Bakers Pharmacy Dillon Pharmacy Gene Maddy Kroger Owen’s Pharmacy QFC Pharmacy City Market Fred Meyer Pharmacy Gerbes Pharmacy Mariano’s Pharmacy Payless Pharmacy Ralphs Pharmacy Copps Food… Read More

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Reminder for Medicare Part D CMS

Loramei Romeo

Employers who sponsoring a group health plan, whether they are self-insured or insured, are required to notify the Centers for Medicare and Medicaid Services (CMS) of the creditable (or non-creditable) status of the plan’s prescription drug coverage. Employers must go to CMS’s online reporting system at https://www.cms.gov/Medicare/Prescription-Drug-Coverage/CreditableCoverage/CCDisclosureForm.html. to provide this information. Just a friendly reminder that notice needs to be given by the following dates: • Within 30 days following the prescription drug plan’s termination. • Within 60 days following the start of each plan year. • Within 30 days following any modification to the prescription drug plan’s creditable coverage status. If an employer-sponsored prescription drug plan’s creditable coverage status changes… Read More

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Horizon and Braven Health Prescription Drug Benefits

Loramei Romeo

IMPORTANT NOTICE: Horizon and Braven Health Prescription Drug Benefits GLP-1 medications like Ozempic and Mounjaro are covered by the prescription drug benefits of Horizon Medicare Blue Rx (PDP) and Braven Health Medicare Advantage plans. GLP-1 medications are used to treat obesity and type 2 diabetes. Medicare, however, only covers these medications for diabetes. Prior authorization is also required for GLP-1 medications. This implies that before we agree to cover the medication, the member or their practitioner must obtain plan approval. To guarantee pharmaceutical safety and assist in directing the proper use of specific medications, prior permission is implemented. The medication may not be covered by the plan if the member DOES… Read More

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Guide to more savings and benefits & Letters to MA customers

Loramei Romeo

Guide to more savings and benefits The discounts for the Medicare supplements insurance provides savings that can be used by customers to reinvest in additional coverage. The discount is up to 20% with combined household discounts which are, discount for more than one member of the household holds a policy is 14% and discount when a customer lives with one or more people is 6%. The supplemental benefits are fit for client’s needs in cancer treatment, choice accident, dental, vision, hearing, hospital indemnity, lump sum cancer, lump sum heart attack, and stroke. Letters mailed to Medicare Advantage customers There are different versions of Benefits at a Glance (BAAG), letters regarding… Read More

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New Medicare Part-D Changes Affecting Employers for 2024-25

Mirasol Bandong

Dear Valued Client:  We wanted to alert you to an upcoming change that could have a significant impact on Medicare-eligible employees and dependents who currently have group health coverage. Starting in 2025, Medicare Part D plans will have a $2,000 out-of-pocket limit. As CMS explains, this change, which is part of the Inflation Reduction Act, also includes measures like a $35 cap on insulin and new authority for Medicare to negotiate prices for certain high-cost drugs.  The new $2,000 cap for Part D is particularly important because it could alter the status of many employer group health plans that currently provide drug coverage. Each year, employers must determine whether their prescription drug… Read More

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2025 Part D Changes and Employer Sponsored Group Health Plans

Mirasol Bandong

Employers must inform the Centers for Medicare and Medicaid Services (“CMS”) and participants and beneficiaries who qualify for Medicare Part D of the creditable or non-creditable status of the group health plan prescription drug plan(s). When prescription medication coverage meets or exceeds Medicare Part D, it is considered creditable. Any coverage that falls short of Medicare Part D’s quality standards is deemed non-creditable As previously reported, the Inflation Reduction Act of 2022 (“IRA”) changed aspects of the Medicare Part D program to enhance and improve Medicare Part D coverage. The changes include: As a result of these changes, some employer sponsored prescription drug coverage may no longer qualify as creditable… Read More

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Individual Health Insurance help is available for employer groups!

Ed MacConnell

Why do group clients need help with an Individual health insurance expert? Here are some scenarios when groups need individual solutions:

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IBC Medicare Members Save money with your IBX Care Card

Ed MacConnell

Your IBX Care Card comes preloaded with a quarterly balance. Your card will be automatically reloaded every quarter (every three months). Be sure to spend your allowance each quarter, as any unused balance will not roll over to the next quarter. Please keep your card in a safe location, as you may use the same card for as long as you remain a member of a participating plan. Click here for more information about the IBX Care card for Medicare members or contact us today at (215)355-2121

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Cigna Changes to MA ID cards

Mirasol Bandong

As with the 2025 plan year, our Medicare Advantage ID cards will be altered. By utilizing our digital portals to obtain a member’s current PCP, treating providers will be encouraged to use them more efficiently, which will prevent needless treatment delays brought on by the referral process. See what’s changing below, so you’re ready to answer any customer questions this upcoming AEP. What’s changing? 2024 2025 What is staying the same? When are these changes occurring? Members in HMO plans are still required to maintain a PCP New enrollees with a 1/1/2025 effective date will start receiving ID cards without PCP information as soon as 10/15/2024. The PCP network name… Read More

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Wellcare PDP Plans: Contract Termination: Important Change!!

Ed MacConnell

Total Benefit Solutions, Inc has been notified by Wellcare PDP plans that our contract is being terminated without cause beginning immediately. Due to the changes in coverage mandated by the Inflation Reduction Act, Wellcare is terminating our agreement for the purposes of not paying bew or renewal business commissions. What does that mean for our clients?Beginning immediately, we will no longer be able to enroll new customers onto Wellcare PDP plans. Further moving forward, we will be unable to provide service to our existing clients already on Wellcare or who choose to renew with a Wellcare PDP plan for 2025. Our experts are standing by to answer your questions or… Read More

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Important Changes to Medicare Drug Coverage for 2025

Ed MacConnell

The Inflation Reduction Act (IRA) has resulted in significant changes to Part D including: Elimination of the Coverage Gap or “donut hole”A new $2,000 out-of-pocket spending capA shift in cost sharing responsibility in the catastrophic coverage phaseA new cost sharing smoothing option called the Medicare Prescription Payment Plan These changes have an enormous impact on your Medicare coverage in 2025 for nearly all those on Medicare including Medicare beneficiaries who are still choosing their employer plans. Please review your ANOC carefully for your 2025 coverage and contact your Total Benefit Solutions Inc health insurance experts if you have any questions or concerns about how these changes impact you and your… Read More

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Tower Health is back!

Mirasol Bandong

Tower Health is back in Cigna Medicare Advantage network in Pennsylvania! After productive negotiations with Tower Health in Pennsylvania, Cigna is happy to announce that they are back in their Medicare Advantage network effective June 1, 2024. This includes Phoenixville and Pottstown Hospital, all Primary Care Physicians (PCPs), specialists, ancillary providers, and other hospitals that were previously in-network. We are dedicated to providing exceptional service, so please do not hesitate to contact our dedicated Total Benefit Solutions health insurance specialists at (215)-355-2121 or fill out the contact form below. We are available to answer any questions or address any concerns you may have.

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