A year ago, most employers covering GLP-1s for weight loss relied on prior authorization alone. That's changed fast.
Peterson-KFF reported that 34% of employers covering GLP-1s for weight loss now require participation in a lifestyle program — up from 10% the year before. Brown & Brown's employer survey found that 38% require lifestyle program participation, with additional employers considering step therapy requirements for 2026. Mercer's survey found that PBMs are increasingly pairing GLP-1 authorizations with lifestyle management programs.
The trend is clear: employers are moving from "do we cover GLP-1s?" to "how do we structure coverage to produce durable outcomes?" Step therapy — requiring engagement with a behavioral intervention before or alongside medication authorization — is emerging as the design framework for that shift.
But step therapy programs vary enormously in quality and structure. This post is a practical guide for benefits leaders designing one.
What Step Therapy Actually Means in This Context
Traditional pharmaceutical step therapy requires trying a lower-cost medication before a more expensive one. GLP-1 step therapy for weight management is different — it requires engagement with a behavioral or lifestyle intervention, either before medication authorization or as a concurrent requirement.
The models employers are using fall into three categories:
Pre-authorization behavioral requirement. The employee must demonstrate meaningful engagement with a lifestyle program before GLP-1 coverage is approved. This is the most restrictive model. It reduces initial utilization but creates a longer path to medication for employees who may need it urgently.
Concurrent enrollment requirement. GLP-1 coverage is approved, but the employee must simultaneously participate in a behavioral support program to maintain coverage. This is the model gaining the most traction — it doesn't delay medication access but ensures the behavioral foundation is being built alongside pharmacotherapy.
Recommended but not required. The employer offers a lifestyle program alongside GLP-1 coverage and encourages participation but doesn't mandate it. This is the least restrictive model. It avoids the compliance complexity of mandatory programs but produces lower participation rates.
Each model has tradeoffs. The right choice depends on your population, your legal environment, and how aggressively you want to manage utilization versus access.
Designing the Behavioral Component
The step therapy program is only as good as the behavioral intervention it requires. An employer who mandates "lifestyle program participation" but pairs it with a generic wellness app or a monthly coaching call hasn't solved the durability problem — they've added an administrative step.
Based on the evidence for what produces durable weight management outcomes, the behavioral component should meet a few criteria:
Evidence-based dietary framework. The ADA, AHA, and 2025-2030 U.S. Dietary Guidelines all point toward flexible, nutrient-dense dietary patterns. Programs built on extreme restriction produce initial compliance but poor long-term adherence — which defeats the purpose of a step therapy requirement designed to build lasting habits.
Objective feedback mechanism. Programs that rely entirely on self-reported food logging face the same dropout problem regardless of whether participation is mandated. A step therapy behavioral component that uses objective measurement — biomarker feedback, metabolic data — maintains its engagement loop even when the employee's initial motivation fades.
Scalable delivery. If the behavioral requirement applies to every employee seeking GLP-1 authorization, the program needs to serve that population without bottlenecks. Programs requiring scheduled coaching calls or in-person visits create wait times and access barriers that undermine the step therapy timeline. Fully remote, digitally delivered programs can enroll employees immediately and scale without degrading quality.
Pharmacotherapy compatibility. The behavioral component must be designed to work alongside GLP-1s, not as a replacement for them. The goal is to build the dietary patterns and metabolic awareness that make pharmacotherapy more effective and provide a foundation for when medication is eventually discontinued.
Our own program, Key to Health, was designed for this context — a fully automated intervention with a published RCT (Falkenhain et al., Obesity, 2021) and real-world data (preprint, N=2,296) showing complementary effects alongside GLP-1 medications. But regardless of which program an employer selects, the criteria above — evidence-based dietary framework, objective feedback, scalable delivery, pharmacotherapy compatibility — are what make a step therapy behavioral component credible.
What CMS BALANCE Suggests About Design
The CMS BALANCE Model, launching in Medicaid as early as May 2026 and Medicare Part D in January 2027, pairs GLP-1 coverage with evidence-based lifestyle support offerings. While the model applies to Medicare and Medicaid — not employer plans directly — its design principles are instructive.
CMS negotiates with manufacturers on three dimensions: pricing, coverage criteria, and lifestyle support. The lifestyle component isn't an afterthought — it's a negotiated element of the coverage package. The CMS Innovation Center will evaluate whether the combination of medication and lifestyle support produces better outcomes and cost sustainability than medication access alone.
For employers designing step therapy, the BALANCE Model offers a reference point: the largest payer in the country has concluded that drug access paired with behavioral support is a design worth testing. Employer plans can apply the same logic — designing for durability, not just access.
The Compliance Landscape
Step therapy requirements for GLP-1s raise legal and compliance questions that benefits leaders should address proactively:
ADA considerations. Obesity may qualify as a disability under the ADA in certain circumstances. Morgan Lewis has noted that while the ADA doesn't require employers to cover any specific treatment, plan designs that limit coverage based on disability status require careful evaluation. Step therapy requirements should be applied consistently across the covered population and documented with clinical rationale.
HIPAA nondiscrimination. Step therapy requirements must apply equally to all similarly situated plan participants. Mid-year changes to coverage terms require particular care.
ERISA fiduciary obligations. Self-funded employers have fiduciary responsibilities in plan design. Documenting the clinical and financial rationale for step therapy — including the evidence base for the behavioral component — strengthens the plan's defensibility.
This is not legal advice, and employers should work with benefits counsel on specific plan design questions. The point is that step therapy is legally navigable — employers across the country are implementing it — but the design needs to be thoughtful and consistently applied.
Implementation Timeline
If your open enrollment is in Q4 2026, the step therapy design timeline is already underway:
Q2 2026 (now). Evaluate behavioral intervention vendors. Define your step therapy model (pre-authorization, concurrent, or recommended). Review compliance considerations with benefits counsel. Model the cost impact — both the behavioral program cost and the projected utilization changes.
Q3 2026. Finalize plan design language with your PBM and TPA. Build the authorization workflow — how does an employee demonstrate program participation? What triggers medication approval? Develop employee communications explaining the new requirement.
Q4 2026 (open enrollment). Launch the updated plan design. Communicate clearly: this isn't a barrier to coverage, it's a program designed to make coverage more effective. Employees starting the behavioral program during open enrollment should have access to medication authorization on a defined timeline.
Q1 2027. Measure early engagement and authorization patterns. Are employees participating in the behavioral program? What's the GLP-1 authorization rate compared to the prior year? Adjust the program based on early data.
The employers who implement step therapy well in 2027 will be the ones who started the design work in spring 2026. The window for Q4 open enrollment changes is narrowing.
The Strategic Case
Step therapy isn't just a cost management tool — though it is that. It's a clinical design choice that reflects what the evidence says about durable weight management: medication works better when paired with behavioral support, and behavioral support provides a foundation that persists after pharmacotherapy ends.
The employers moving in this direction aren't restricting access to GLP-1s. They're designing coverage that makes the investment in GLP-1s more likely to produce lasting outcomes. That's a fundamentally different framing — and it's the one that holds up in conversations with employees, CFOs, and legal counsel alike.
