CRC COMPLIANCE
By Misty Baker, Director of Compliance and Government Affairs, CRC Benefits
It’s no secret GLP-1 medications are reshaping the conversation around employee benefits. A few short years ago, these drugs were mainly prescribed for type 2 diabetes. Today, they’ve become household names, often associated with weight loss and, more recently, with heart health. That shift brings opportunity and plenty of compliance considerations for employer-sponsored health plans.
As you go into your 2026 renewal conversations, here’s what you need to know about where GLP-1s stand, how they may affect employer plans, and the compliance questions you should help your clients think through.
WHY THE GLP-1 CONVERSATION CHANGED
The FDA’s 2024 approval of semaglutide (Wegovy) for reducing cardiovascular risk was a game changer. Until then, GLP-1s were mainly considered weight-loss drugs outside of diabetes treatment. Now, they’re also tied to preventing heart attacks and strokes in certain high-risk patients. That approval gave these medications clinical credibility beyond weight management, which means employers are hearing more requests from employees and physicians for coverage.
At the same time, more Americans know what GLP-1s are, thanks to media coverage and direct-to-consumer ads. Demand isn’t slowing down, and supply has improved compared to the shortages we saw just a year or two ago. Add in pipeline developments, including oral versions, and we can expect even more attention in 2026.
WHAT THIS MEANS FOR EMPLOYER PLANS
Here’s the hard truth: GLP-1s aren’t going away, and they aren’t cheap. Pharmacy spend is already one of the biggest drivers of medical trend. Employers that offer coverage without clear rules may face significant cost increases. On the other hand, employers that exclude coverage entirely may face pushback from employees, retention challenges, and potential compliance concerns if the exclusion has unintended impacts.
That’s where you come in. Agents should be ready to guide clients through balanced, compliance-minded options that manage cost while addressing employee health needs.
THE COMPLIANCE ANGLE
When we talk about GLP-1 coverage, several compliance touchpoints come into play:
IRS Rules: Weight-loss programs and medications can qualify as eligible medical expenses under HSAs, FSAs, and HRAs but only if used to treat a diagnosed disease such as obesity, diabetes, or heart disease. Documentation matters.
ADA and Nondiscrimination: Obesity can be considered a disability under the Americans with Disabilities Act. Blanket exclusions could raise legal risks if they disproportionately impact employees with qualifying conditions.
Wellness Program Design: If an employer ties GLP-1 use to participation in a wellness program, the incentives and requirements must fit within federal wellness program rules.
Medicare Perspective: While Medicare still does not cover weight-loss drugs, it has begun covering GLP-1s for cardiovascular risk in certain situations. That development doesn’t automatically change employer obligations, but it does set expectations among older employees and retirees.
Your role is to bring clarity, help clients avoid compliance missteps, and position coverage decisions as thoughtful, evidence-based, and fair.
COVERAGE STRATEGIES EMPLOYERS ARE CONSIDERING
Most employers fall into one of three buckets:
- Open Access: Covering GLP-1s broadly for weight management and diabetes without strict controls. This may improve employee satisfaction but can drive costs sharply higher.
- Targeted Access: Covering GLP-1s for specific conditions such as cardiovascular disease plus obesity, or diabetes, with prior authorization and ongoing review.
- Exclusion with Exceptions: Not covering GLP-1s for general weight management, but allowing coverage for FDA-approved indications such as cardiovascular risk reduction.
Of these, the second approach is the most common and arguably the most sustainable for 2026. It balances clinical evidence with financial reality and gives employers a documented, defensible policy.
PRACTICAL GUARDRAILS
If your clients are weighing GLP-1 coverage, here are some of the strategies worth discussing:
Prior Authorization: Require a diagnosis and physician documentation that aligns with FDA-approved indications.
Program Pairing: Make coverage contingent on participation in a structured program (nutrition, activity, behavioral support). This improves outcomes and helps satisfy IRS guidance on eligible expenses.
Continuation Criteria: Set check-ins at three and six months to confirm the medication is working. If not, coverage ends.
Preferred Drug Lists: Work with PBMs to identify a preferred GLP-1 and use formulary management to control cost.
Fraud and Safety Checks: Avoid coverage of compounded versions, which the FDA has cautioned against.
CONVERSATIONS TO HAVE WITH CLIENTS RIGHT NOW
Here’s how to frame the discussion with HR and finance leaders:
Define the Goal: Is the employer’s main objective weight management, cardiovascular risk reduction, or both?
Budget Realistically: Costs will rise if coverage expands. Employers need to understand the financial trade-offs before making a decision.
Plan for Fairness: Apply the same rules consistently to all employees who meet the criteria. Document the policy clearly to avoid confusion.
Communicate Clearly: Employees will ask about GLP-1s. Employers should prepare FAQs and consistent messaging to explain what’s covered, what’s not, and why.
Policy Changes: Keep an eye on Congress and CMS. A shift in Medicare policy could ripple into employer expectations.
Manufacturing Expansions: Additional supply may ease access issues, but it won’t eliminate cost concerns in the near term.
BOTTOM LINE
GLP-1s are no longer a side note in benefits discussions. They’re front and center. Employers need guidance that blends compliance with cost control, and employees need clear communication about what coverage looks like in 2026. Your role is to bring clarity, help clients avoid compliance missteps, and position coverage decisions as thoughtful, evidence-based, and fair.
The sooner you start these conversations, the better prepared your clients will be as renewals hit.
Misty Baker, Director of Compliance & Government Affairs at CRC Benefits Misty Baker is a nationally recognized expert in ACA, ERISA, COBRA, and FMLA. With over 20 years in benefits regulation and agent advocacy, she educates brokers, employers, and policymakers, bridging policy and practice. Her leadership and dedication have earned prestigious awards and shaped legislation at state and federal levels.