CPA here specializing in healthcare tax issues. Your breakdown is mostly right, but let me add some important details:

HSA vs FSA key differences for GLP-1 users:

• HSA: Funds roll over indefinitely. You need a High Deductible Health Plan (HDHP). 2026 contribution limits: $4,300 individual, $8,550 family. Triple tax advantage (deduction, tax-free growth, tax-free withdrawal for medical expenses).
• FSA: Use it or lose it (some plans allow $640 rollover). Available with any employer plan. 2026 contribution limit: $3,200. Only tax-free on contribution and withdrawal — no investment growth.

For the compounded medication gray area — the IRS requires that the expense be "primarily for the prevention or alleviation of a physical defect or illness." Obesity IS recognized as a disease (ICD-10 E66.01). If your prescription is for obesity treatment, it qualifies.

My recommendation: Get a Letter of Medical Necessity from your prescribing physician that specifically states the GLP-1 is prescribed for treatment of obesity (a medical condition). Keep this on file. If the IRS ever questions your HSA/FSA withdrawals, this letter is your protection.

I've been using my HSA for compounded semaglutide for 8 months now with no issues. Here's my setup:

• HDHP through my employer (Aetna) — no GLP-1 coverage
• Max out HSA contribution every year ($4,300 in 2026)
• Compounded semaglutide: $159/month × 12 = $1,908/year
• Telehealth visits: $49/month × 12 = $588/year
• Labs (2x/year): ~$150
• Supplies: ~$96/year
• Total GLP-1 expenses: ~$2,742/year

All paid from HSA. Tax savings at my marginal rate (32% federal + 6% state): ~$1,042/year. That effectively makes my GLP-1 therapy cost $1,700/year net.

I keep every receipt and my Letter of Medical Necessity on file. Haven't been audited but I'm ready if I am.

This is really helpful. I just switched to an HDHP this year specifically to get access to an HSA for my GLP-1 costs. Two questions:

1. My employer contributes $750/year to my HSA. Does that count toward the $4,300 limit?
2. I'm paying for brand Wegovy out of pocket ($1,349/month — I know, it's brutal, but my doctor wants me on brand). Can I pay this from HSA even though it's not going through insurance?

1. Yes, the employer contribution counts toward your annual limit. So if they contribute $750, you can contribute up to $3,550 in 2026.

2. Yes, as long as you have a valid prescription, the medication is eligible regardless of whether insurance is involved. Keep the pharmacy receipt showing the drug name, your name, and the date. If you're ordering directly from a pharmacy (not through insurance), the receipt from the pharmacy is your documentation.

At $1,349/month, you'll burn through your entire HSA balance in about 3 months though. You may want to use HSA strategically — pay the first few months from HSA to get the tax benefit, then switch to regular cash/credit for the rest. Or consider whether compounded is an option for you — $159/month from HSA would last you the whole year and then some.