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Employers Experiment with Direct-to-Consumer Access for GLP-1s

by Inoventive Solutions
January 27, 2026

Employers grappling with the cost and complexity of GLP-1 drugs are increasingly testing a workaround: steering certain employees to direct-to-consumer (DTC) arrangements that operate outside the company’s health plan.

The shift reflects a growing tension for benefits executives: how to manage soaring GLP-1 demand while preserving affordability, plan sustainability and clinical oversight.

How direct-to-consumer works

Under a DTC model, employees purchase GLP-1 drugs outside the pharmacy benefit on a manufacturer or designated website. Deductibles, out-of-pocket maximums, prior authorization and PBM utilization management requirements do not apply.

While this removes plan-level clinical guardrails, it can materially lower employees’ monthly costs. In many cases, cash-pay prices offered by manufacturers or online platforms are lower than what employees would pay through insurance even after discounts and coinsurance.

Instead of covering GLP-1s as a plan benefit, some employers provide fixed monthly stipends — often $100 to $200 — to offset the cost of direct purchases. This allows employers to cap financial exposure while still offering employees access to treatment.

Drug manufacturers are accelerating this shift. Eli Lilly and Novo Nordisk have expanded DTC programs that allow patients to purchase GLP-1 drugs without using insurance, with monthly cash prices below historical list prices.

Beyond consumer programs, both Lilly and Novo Nordisk are piloting direct-to-employer (DTE) models that bypass traditional PBM structures. In these arrangements, self-insured employers negotiate pricing directly with manufacturers, while third-party administrators handle eligibility screening, prescribing coordination and fulfillment. The goal is to move pricing closer to net cost and reduce employee cost-sharing.

According to the Peterson Health Technology Institute, some employers are evaluating DTC and DTE arrangements because these may offer lower prices than those through traditional pharmacy benefits. They also provide employers with more predictable spending. 

However, benefits leaders should view these arrangements as complementary tools rather than replacements for a structured GLP-1 strategy.

Pros and cons

Pros:

  • Lower out-of-pocket costs for certain employees.
  • Second-chance access for employees who do not qualify under plan rules.
  • Predictable employer cost exposure when using fixed stipends or subsidies.
  • DTC models typically bypass prior authorization and PBM requirements, reducing friction and administrative delays for employees.

Cons:

  • Loss of clinical oversight and utilization controls. Off-benefit purchases bypass prior authorization, step therapy and ongoing clinical management built into the plan.
  • Employers lose access to claims data needed to track adherence, safety, effectiveness and long-term cost trends.
  • Employees may underestimate their total financial exposure, particularly if they later transition back to plan-based coverage.
  • Cash-pay prices can make plan coverage appear inefficient or overpriced, even when the pricing structures are not directly comparable.
  • Manufacturer DTC pricing reflects market strategy, not negotiated benefit contracts, and can change or be withdrawn with little notice.
  • Once established for GLP-1s, employees may expect similar pathways for other high-cost medications.

What employers can do

For many employers, the most pragmatic use of DTC access is as a secondary pathway. Employees who do not meet plan eligibility criteria can still pursue treatment without forcing employers to broaden coverage in ways that may be financially unsustainable.

As manufacturers continue to refine pricing strategies and employer pilots mature, benefits executives may find that selective use of DTC models offers flexibility in an increasingly complex GLP-1 landscape — provided these pathways are integrated thoughtfully into an overall benefits strategy rather than used as a blunt cost-cutting tool.

"gavel
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Model Law Could Spur States to Rein in Prior Authorization

by Inoventive Solutions
January 20, 2026

A new model law adopted by the executive committee of the National Council of Insurance Legislators (NCOIL) could spur more states to adopt legislation to regulate health insurers’ use of prior authorization.

While prior authorization remains an important tool for managing utilization and costs, insurers’ rules are often opaque, which leads to confusion and frustration among patients who have been denied or experienced delayed care. As a result, lawmakers in many states are looking for guardrails that improve transparency and predictability without dismantling the process altogether.

NCOIL’s model act draws heavily from reforms enacted in Mississippi and influenced by similar efforts in Minnesota. The organization does not regulate insurance itself, but its model laws often serve as starting points for state legislation, particularly on complex insurance issues.

What the model act does

If adopted by states, the model law would establish several baseline requirements for health insurers and health plans, including:

  • Publicly posting a complete list of services subject to prior authorization, along with applicable requirements and clinical review criteria.
  • Publishing prior authorization approval and denial statistics in an accessible format.
  • Completing expedited prior authorization reviews within 24 hours after all necessary information is received.
  • Ensuring that appeals are reviewed by physicians with appropriate training or experience relevant to the service under review.
  • Reporting aggregated annual data on prior authorization activity to state insurance regulators.

These steps are designed to reduce administrative friction and make the process more predictable for providers and patients, while still allowing insurers to manage care.

The model preserves insurers’ ability to require prior authorization for certain services — such as advanced imaging or surgical procedures — while setting clearer expectations for how those programs operate. This is important for employers since prior authorization can help rein in unnecessary spending, while unpredictable delays can disrupt employees’ care and productivity.

Minnesota’s experience

NCOIL leaders have pointed to Minnesota as an example of how structured prior authorization rules can work in practice. Reforms there emphasized transparency, timeliness and accountability, and are widely viewed by policymakers as having improved the process without driving up costs or undermining insurers’ role in utilization management.

That track record gives the model act additional credibility as states consider whether and how to intervene. For employers operating in multiple states, it also raises the prospect of more consistent rules across jurisdictions over time, rather than a patchwork of sharply different requirements.

What employers should watch

For now, the model act does not change any existing laws. Each state would need to introduce and pass its own legislation, and lawmakers may adopt the model in full or only in part. Still, prior authorization has become a bipartisan priority at the state level, particularly as concerns grow about access to care and administrative burden.

Employers that purchase fully insured health plans should pay attention to legislative activity in the states where they operate, as new requirements could affect plan administration, reporting and vendor relationships. Even employers with self-funded plans may see indirect effects as insurers and third-party administrators adjust processes to align with emerging state standards.

"stethoscope
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‘Stealth’ Health Plan Cost Drivers Employers Can’t Ignore

by Inoventive Solutions
January 13, 2026

As employers face rapidly rising health insurance costs for their employees, industry pundits are increasingly urging benefit leaders to confront “stealth” cost drivers that quietly inflate spending year after year.

While headline issues like premium increases draw the most attention, some of the most meaningful opportunities to control costs lie in areas that are often underinvested or poorly integrated into benefit strategies.

Addiction support services

Behavioral health, and particularly substance use disorders, remains one of the most expensive and least efficiently managed areas of employer-sponsored health care.

Untreated mental health and addiction issues contribute to higher medical claims, absenteeism and lost productivity. According to the Center for Prevention and Health Services, untreated mental health concerns can cost a single organization tens of thousands of dollars annually and amount to more than $100 billion nationwide.

Despite those figures, addiction and recovery services have historically received less attention than other wellness initiatives. Inpatient treatment models can be disruptive for employees and expensive for employers, while high relapse rates have made some organizations hesitant to invest more heavily in this space.

Employer actions: As a result, employers are increasingly looking at more structured, accountable recovery programs that focus on ongoing support, medication-assisted treatment and measurable outcomes.

Improving access to specialty care

Employees may technically have coverage, but long wait times for specialists can delay treatment and worsen underlying conditions. Nationally, more than 100 million specialty referrals are issued each year, yet patients in many metropolitan areas wait more than a month to see specialists such as gastroenterologists, dermatologists or cardiologists.

When employees cannot access specialty care in a timely manner, they are more likely to rely on emergency rooms or urgent care, which drives up costs.

Employer actions: Some employers are responding by supplementing traditional plans with specialty telehealth solutions or third-party platforms that shorten wait times and improve care coordination.

Consider surveying employees to identify gaps in access and understand whether additional solutions are warranted.

Accessing plan analytics to tailor benefits

Because many organizations still design benefits based on assumptions rather than real utilization patterns, only a small share of workers report being truly satisfied with their benefits — suggesting a disconnect between what is offered and what is needed.

Employer actions: Use carrier-provided tools, if available, such as reporting dashboards, health risk assessments or plan modeling software. Review claims data at least quarterly to identify cost trends, any under- or overutilization, emerging risks or cost anomalies.

Understanding which programs are being used, where employees are falling through the cracks and which interventions are producing results allows organizations to refine benefits with greater precision and financial discipline.

The takeaway

Rising health care costs are unlikely to ease in the near term, but employers are not without options. While there are many areas that can be addressed, focusing on emerging cost-containment efforts could be a winning strategy for employers.

"medical
Uncategorized

Seven Tips for Avoiding High Medical Bills

by Inoventive Solutions
January 6, 2026

When people sign up for a new health insurance plan, be that an employer-sponsored plan or one purchased on the Affordable Care Act (ACA) exchange, they can often be confused about when coverage starts, what is covered and whether they have to share in the medical bills.

The Kaiser Family Foundation recently compiled a list of seven takeaways from stories about people who ended up paying large out-of-pocket expenses for medical care. Health plan enrollees should read the following to learn how they can better use their plan and avoid financial blowback.

1. Most insurance coverage doesn’t start immediately

Many new plans come with waiting periods, so it’s important to maintain continuous coverage until a new plan kicks in.

One exception: An employee can opt into a COBRA policy or purchase a plan on the ACA marketplace (healthcare.gov or a state-run plan in certain states) within 60 days of losing their job-based coverage. With COBRA, once you pay, the coverage applies retroactively, even for care received while you were temporarily uninsured.

They will also qualify for a special enrollment period on the ACA marketplace to get coverage for the rest of the year. Coverage can start the first day of the month after someone loses their employer-sponsored coverage.

2. Check coverage before checking in

Some plans come with unexpected restrictions, potentially affecting coverage for care ranging from contraception to immunizations and cancer screenings.

Enrollees should call their insurer — or, for job-based insurance, their human resources department or retiree benefits office — and ask whether there are exclusions for the care they need, including per-day or per-policy-period caps, and what they can expect to pay out-of-pocket.

3. ‘Covered’ does not mean insurance will pay

Carefully read the fine print on network gap exceptions, prior authorizations and other insurance approvals. The terms may be limited to certain doctors, services and dates.

Also, while the service may be covered, sometimes it won’t be until the deductible or out-of-pocket maximum is met.

4. Get estimates for nonemergency procedures

Before scheduling a nonemergency procedure, an enrollee may be able to shop around among different providers that offer the procedure. Request estimates in writing and if an enrollee objects to the price, they should negotiate before undergoing care.

5. Location matters

Prices can vary depending on where a patient receives care and where tests are performed. If a patient needs blood work, they should ask their doctor to send the requisition to an in-network lab.

A doctor’s office connected to a health system, for instance, may send samples to a hospital lab, which can mean higher charges if it’s not in-network.

6. When admitted, contact the billing office early

When an enrollee or a loved one has been hospitalized, it can help to speak to a billing representative if possible. Questions to ask:

  • Has the patient been fully admitted or are they being kept under observation status?
  • Has the care been determined to be “medically necessary?”
  • If a transfer to another facility is recommended, is the ambulance service in-network or is it possible to choose one that is?

7. Ask for a discount

Medical charges are almost always higher than what insurers would pay, and providers expect them to negotiate lower rates. Health plan enrollees can also negotiate.

Uninsured or underinsured patients may be eligible for self-pay or charity care discounts.

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