Insurance & Cost

503A compounding pharmacy is a state-licensed pharmacy where a pharmacist or physician prepares a drug for a specific, identified patient based on a valid prescription.

503B outsourcing facility is a drug compounder registered with FDA that operates under manufacturing-quality rules, without needing a prescription for each named patient before compounding.

Appeal refers to a request to your health insurer or the Health Insurance Marketplace to review a decision that denied a benefit or payment.

Cash pay is paying the full price of a medication yourself, without using insurance to cover any part of the cost.

Cash price of GLP-1s refers to what Zepbound and Wegovy cost when paid out of pocket through the manufacturer's own self-pay channel, rather than through insurance.

Coinsurance is the percentage of a covered service's cost you pay, such as 20%, after you've met your deductible.

Copay is a fixed dollar amount, such as $20, that you pay for a covered service or prescription after you've met your deductible.

Coverage exclusion is a service or drug your health plan's terms say it will not pay for or cover.

Deductible is the amount you pay for covered health care services before your insurance plan starts to pay.

Formulary is the list of prescription drugs a health plan covers, also called a drug list.

FSA is an arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars.

GLP-1 cost refers to what a patient or payer spends on drugs like Ozempic, Wegovy, Mounjaro, and Zepbound, which varies by list price, Medicare-negotiated price, self-pay offer, and insurance coverage.

HSA is a savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses.

Letter of medical necessity is a statement from your prescriber explaining why a specific drug is medically necessary for you.

LillyDirect is Eli Lilly's direct-to-consumer healthcare platform, offering home delivery and telehealth options for Lilly medications.

Manufacturer savings card is a discount offered directly by a drug maker to lower the out-of-pocket cost for patients with commercial insurance or who pay without insurance.

Medicaid coverage is the extent to which a state Medicaid program pays for GLP-1 medications, which varies because weight-loss drugs are optional while diabetes drugs are mandatory.

Medicare Part D is the Medicare prescription drug benefit that has historically excluded GLP-1 medications used only for weight loss.

Membership fee is the recurring charge a telehealth program bills for provider consultations, messaging, and platform access, separate from any medication cost.

Most-favored-nation pricing refers to a policy aiming to bring American drug prices in line with those paid by similar nations.

NovoCare Pharmacy is the pharmacy service Novo Nordisk operates to deliver GLP-1 medications directly to patients, with self-pay pricing that does not require insurance.

Out-of-pocket maximum is the most you have to pay for covered services in a plan year before your health plan starts covering 100% of the costs of covered benefits.

Patient assistance program is a program, usually run by a drug's manufacturer, that provides medicine at no cost to patients who meet its eligibility rules, typically insurance status and income.

Pharmacy benefit manager is a company that negotiates drug rebates with manufacturers, builds the formulary and its rules, and reimburses pharmacies for a health plan's prescription claims.

Prior authorization is approval your health plan requires before it will cover a specific service or prescription, such as a GLP-1 medication.

Step therapy is a type of prior authorization that requires trying a lower-cost drug proven effective for most people with your condition before the plan covers a costlier one.

TrumpRx is a federal website listing self-pay prices for certain brand-name medications, including Wegovy, Ozempic, and Zepbound, under agreements the White House announced with drugmakers.

Wegovy at Costco / CVS refers to the retail pharmacy channels Novo Nordisk names as partners for its Wegovy self-pay pricing, not a separate discounted price at those stores.

Wegovy cost is the price a patient pays for Wegovy, which depends on insurance coverage and dosage form.

Wegovy coupon is Novo Nordisk's manufacturer savings offer that lowers the monthly cost of Wegovy for patients with commercial insurance or who pay without insurance.