50 terms, each defined as a mechanism rather than a slogan. Every entry says what the thing is, and what it changes about a price, a pharmacy, or an insurance decision.
Drugs and Forms
GLP-1 receptor agonist
A medication that imitates GLP-1, a gut hormone released after eating, to slow stomach emptying and reduce appetite signaling.
Glucagon-like peptide-1 is a hormone the gut releases after a meal. A receptor agonist is a drug built to activate the same receptor that hormone activates. The effects usually described are slower stomach emptying, insulin release when blood sugar is high, and reduced appetite signaling in the brain.
The label covers a family of medications, not one product. Semaglutide is a GLP-1 receptor agonist. Tirzepatide activates that receptor and a second one, so it is usually called a dual agonist instead. Compare the specific compound rather than the category.
See also: Semaglutide, Tirzepatide, GIP
Used on: Semaglutide vs Tirzepatide: What Actually Differs, What a GLP-1 Telehealth Intake Actually Asks, and Why
GIP
A second gut hormone alongside GLP-1, whose receptor tirzepatide activates and semaglutide does not.
GIP stands for glucose-dependent insulinotropic polypeptide. Like GLP-1, it is an incretin, meaning a hormone the gut releases in response to food. Tirzepatide activates the GIP receptor in addition to the GLP-1 receptor, which is why it is described as a dual agonist.
Two receptors instead of one is not automatically better for a given person. What it does mean is that these are different compounds, with different labeling and different approved uses. That single structural difference sits underneath most of the semaglutide-versus-tirzepatide comparison.
See also: GLP-1 receptor agonist, Tirzepatide, Semaglutide
Used on: Semaglutide vs Tirzepatide: What Actually Differs, Switching Between GLP-1 Medications: What the Change Actually Involves
Semaglutide
The active ingredient in several GLP-1 medications, sold under brand names and also prepared as a compounded product.
Semaglutide is an ingredient name, not a brand. It is a GLP-1 receptor agonist, marketed under more than one brand name, with a different approved use attached to each. Brands are not interchangeable on paper even where the ingredient is identical.
It is also the compound most often prepared by compounding pharmacies and sold through telehealth programs. Read the active ingredient exactly as printed on what you receive. Some products sold under this name have used salt forms, which are different active ingredients.
See also: GLP-1 receptor agonist, Brand-name drug, Compounded drug, Salt form
Used on: Providers Offering an Oral GLP-1, Best Semaglutide Providers, Compared, Best Tirzepatide Providers, Compared
Tirzepatide
The active ingredient in a dual agonist, acting on both the GLP-1 receptor and the GIP receptor.
Tirzepatide is an ingredient name. It activates the GLP-1 receptor and the GIP receptor, so it is usually described as a dual agonist rather than a GLP-1 drug. It is sold under more than one brand name, each carrying its own approved use.
On the cash-pay side of this market, tirzepatide generally costs more than semaglutide at the same provider. A few programs charge one rate for either compound. That is worth checking before comparing two providers on a single compound.
See also: GIP, Semaglutide, Flat-rate pricing, Cash-pay
Used on: Providers Offering an Oral GLP-1, Best Semaglutide Providers, Compared, Best Tirzepatide Providers, Compared
Liraglutide
An earlier GLP-1 receptor agonist, from the generation of these medications that came before semaglutide and tirzepatide.
Liraglutide reached the market before the compounds most of this site compares. It works on the same receptor as semaglutide, and it is sold under brand names with different approved uses attached to different brands, in the familiar pattern.
It comes up most often for readers who have taken it already. That history can matter when a plan asks what else was tried, because a step is judged on what is documented rather than on what is remembered.
See also: GLP-1 receptor agonist, Step therapy, Brand-name drug
Compounded drug
A medication prepared by a pharmacy or an outsourcing facility rather than manufactured under an FDA-approved application.
A compounded preparation is made to fill a need the approved product is not filling. Compounded drugs are not FDA-approved. The agency does not review them for safety, effectiveness, or quality before they reach a patient, and it says so directly.
That describes the category, not any one pharmacy. Quality rests on the practices of the facility that prepared it, so ask which pharmacy fills an order and under which section it operates. What compounders may prepare has shifted before and can shift again, so check the current position rather than any general description.
See also: 503A compounding pharmacy, 503B outsourcing facility, Brand-name drug, Drug shortage list, Active pharmaceutical ingredient
Used on: Compounded vs Brand GLP-1s: What the Difference Actually Means for You, 503A and 503B Pharmacies: What the Two Categories Actually Are, Belle Health Review
Brand-name drug
An FDA-approved product sold under a manufacturer's brand, reviewed by the agency for safety, effectiveness, and manufacturing.
For a brand-name GLP-1 the FDA has reviewed the manufacturing, the evidence for the labeled use, and the labeling itself. Every unit is made under the conditions set out in that approved application, and a manufacturer stands behind it.
The practical differences show up in the box. There is a published label, an established path for reporting an adverse event, and manufacturer support programs. A brand is also the version an insurance plan is set up to pay for, on the occasions it pays at all.
See also: Compounded drug, Generic drug, Formulary, Pen vs vial
Generic drug
A copy of an approved drug, itself approved by the FDA as equivalent to the original and sold without the brand name.
A generic is approved on the basis that it carries the same active ingredient and performs the same way as the product it copies. It is a fully approved medication reviewed before it can be sold, not a compounded preparation.
The word gets used loosely in GLP-1 marketing. An ingredient name such as semaglutide is not itself a generic version of anything. A compounded preparation containing that ingredient is not a generic either, because it has not been through an approval.
See also: Brand-name drug, Compounded drug, Biosimilar, Active pharmaceutical ingredient
Biosimilar
A follow-on version of a biologic medicine, approved after review as highly similar to the original product.
Biologic medicines are large, complex molecules made in living systems, and they cannot be copied exactly the way a simple chemical can. A biosimilar is approved on evidence that it is highly similar to an already approved biologic, with no clinically meaningful differences.
The word turns up in GLP-1 marketing where it does not apply. A product is a biosimilar only if it was reviewed and approved as one. A compounded preparation is not a biosimilar, and neither is an ingredient sold under its chemical name.
See also: Generic drug, Brand-name drug, Compounded drug
Active pharmaceutical ingredient
The substance in a medication that produces the effect, as opposed to the liquid, preservatives, or packaging around it.
Often shortened to API. On a GLP-1 product it is the line that says semaglutide or tirzepatide, and it is the single most useful thing to read on the label of what arrives.
Two products can look alike and carry different active ingredients. A salt form is a different ingredient. A combination preparation adds something else to the vial. If the ingredient printed on the label is not what you believe you are taking, that is worth stopping over.
See also: Salt form, Compounded drug, Generic drug, Pen vs vial
Used on: What FDA's Shortage Decisions Changed for GLP-1 Compounders
A chemical variant of an ingredient, such as a sodium or acetate version, which is a different active ingredient.
The FDA has warned specifically about salt forms of semaglutide, such as semaglutide sodium and semaglutide acetate. These are not the semaglutide in the approved products. They are different active ingredients wearing a familiar name.
This turned into a real problem in the market rather than a theoretical one. The check is dull and effective. Read the ingredient exactly as printed on what arrives, and ask what else is in the vial before accepting it.
See also: Active pharmaceutical ingredient, Compounded drug, Semaglutide
Used on: Compounded vs Brand GLP-1s: What the Difference Actually Means for You, What FDA's Shortage Decisions Changed for GLP-1 Compounders
Oral vs injectable
The two ways these medications are supplied: a tablet taken by mouth, or a solution injected under the skin.
Most GLP-1 products in this market are injectable, and some programs also sell an oral form. The route changes several practical things at once: how the medication is stored and carried, what arrives in the package, and what a patient has to do with it.
It is not a case of one route being a milder version of the other. The forms carry different labeling and different approved uses, and which is appropriate is a question for a prescriber. Compare the specific product rather than the route.
See also: Pen vs vial, Titration, GLP-1 receptor agonist
Used on: Oral vs Injectable GLP-1s: What Actually Differs
Titration
Adjusting a medication's dose in steps over time, rather than starting at the level a patient will settle on.
Titration is a concept rather than a schedule. A prescriber sets the steps and the timing, and the product's labeling describes the increments the approved version was designed around. No comparison page can tell you what yours should be.
It matters for shopping because pricing can move with dose. Some programs charge more as the dose climbs, and some hold one rate at every dose. A figure quoted at the lowest dose describes a moment, not a whole course.
See also: Maintenance dose, Flat-rate pricing, Price qualifier
Used on: Amble Review, Belle Health Review, Ivím Health Review
Maintenance dose
The level a patient stays on once dose adjustment is finished, as distinct from where treatment began.
The distinction is between the opening of treatment and the steady state that follows it. What a maintenance level should be, and whether one is reached at all, are clinical questions belonging to a prescriber.
For a shopper the useful question is what a program charges once the dose stops moving. A rate advertised against the starting point can be a different number from the one a patient lives with later. Ask for both before committing.
See also: Titration, Starting-at price, Flat-rate pricing
Pen vs vial
How the medication arrives: a prefilled pen with marked increments, or a vial the patient draws from with a syringe.
Brand-name products are generally supplied as pens, with the manufacturer's Instructions for Use and labeled increments. Compounded preparations typically arrive as a vial and syringe, where the person injecting measures a volume from a concentration the pharmacy chose.
That moves a measuring responsibility onto the patient which the pen's design removes, and it is a well-recognized source of error. There is also usually no manufacturer leaflet with a compounded vial, so find out in advance who answers a question about the product itself.
See also: Compounded drug, Brand-name drug, Oral vs injectable, Active pharmaceutical ingredient
Supply and Pharmacy
503A compounding pharmacy
A traditional compounding pharmacy that prepares medications for an individual patient against a prescription.
The name comes from section 503A of the federal law governing compounding. A pharmacy operating this way compounds for an individual patient pursuant to a prescription, and it is licensed and inspected primarily by its state board of pharmacy.
It is a different category from an outsourcing facility, and the difference is a fair and answerable question to put to a program. A company that will not say which category its pharmacy falls into, or will not name the pharmacy at all, has told you something useful.
See also: 503B outsourcing facility, Compounded drug, Rubric check, Mail-order pharmacy
503B outsourcing facility
A compounding facility registered with the FDA that can produce batches without a prescription for a named patient.
Named for section 503B. An outsourcing facility registers with the FDA, is subject to federal inspection, and has to meet current good manufacturing practice requirements. That is a meaningfully higher bar for manufacturing oversight than the traditional pharmacy category.
It still does not make the product FDA-approved. A preparation from an outsourcing facility has not been reviewed for safety or effectiveness before it reaches a patient. The category describes oversight of the facility, not approval of the medicine.
See also: 503A compounding pharmacy, Compounded drug, Brand-name drug
Used on: Compounded vs Brand GLP-1s: What the Difference Actually Means for You, 503A and 503B Pharmacies: What the Two Categories Actually Are
Drug shortage list
The FDA's published record of drugs in short supply, which shapes what compounders are permitted to prepare.
When an approved drug is listed as in shortage, compounders have latitude they do not otherwise have to prepare a version of it. Demand for these medications outran supply for an extended period, and a large compounded market formed in that gap.
Listings change, and so does everything that follows from them. No status is printed here for a reader to rely on months from now. Check the FDA's own shortage database directly, and ask any program on what basis it is compounding today.
See also: Compounded drug, 503A compounding pharmacy, 503B outsourcing facility
Used on: Compounded vs Brand GLP-1s: What the Difference Actually Means for You, What FDA's Shortage Decisions Changed for GLP-1 Compounders
FDA warning letter
A notice from the FDA that it considers a company in violation of its rules, most commonly over marketing and labeling claims.
A warning letter tells a company the agency has identified violations and expects them corrected. The large majority concern marketing and labeling, meaning how a product was promoted or presented. A letter is not a finding that a medication is unsafe, ineffective, or contaminated.
That distinction decides how a letter is used here. It is disclosed on a provider's review along with what it actually concerned, and it never moves a score or a ranking position. A letter discloses; it does not disqualify. The agency publishes its own copy, and the weighing belongs to the reader.
See also: LegitScript, Disclosure score, Compounded drug
Used on: Best Semaglutide Providers, Compared, Best Tirzepatide Providers, Compared, Amble Review
LegitScript
A private certification a healthcare company can apply for and then display as a seal on its own site.
LegitScript runs a commercial certification program for healthcare and pharmacy businesses. A company that holds one can display a seal. Seals like this get read as verdicts constantly, which is why it is worth being exact about what one shows.
A seal loading on a page establishes that a seal is published. It does not establish who holds the underlying certificate, because a displayed image or identifier shows only that one exists, never who is entitled to display it. If a seal matters to your decision, verify it at the source.
See also: FDA warning letter, NPI, Disclosure score
Used on: Found Review, REMEVi Review, YourHealthRx Review
NPI
A National Provider Identifier, the standard identification number issued to healthcare providers in the United States.
An NPI is a unique number assigned to a healthcare provider or organization and used across billing and administrative systems. Numbers are searchable, so an NPI offers a way to confirm that an entity is registered as the kind of provider it claims to be.
Some programs say a dispensing pharmacy is verified by NPI without naming it. That is a step past saying nothing, and it still stops short of what a reader needs. A number you are not given cannot be looked up. A name can.
See also: Rubric check, Telehealth platform vs prescriber, Mail-order pharmacy, LegitScript
Used on: REMEVi Review, Belle Health vs REMEVi, REMEVi vs YourHealthRx
The difference between the company that takes your payment and the clinician or clinic that actually writes the prescription.
Many programs in this market are a platform layer. The brand runs the website, the intake, and the billing, while an affiliated medical group employs the clinicians and a separate pharmacy dispenses. Three parties can sit behind one checkout.
It matters when something goes wrong. Ask during intake who reviews eligibility, who signs the prescription, who to contact about a side effect, and who to contact about a shipment. On a platform model those are frequently different answers.
See also: Mail-order pharmacy, NPI, Rubric check
Mail-order pharmacy
A pharmacy that dispenses by shipping to a patient's address rather than handing medication across a counter.
Telehealth GLP-1 programs generally dispense this way, so medication arrives in the mail. That changes the practical questions: shipping times, temperature-controlled packaging, what happens to a delayed or damaged shipment, and who to call about it.
It is also the point where a program's disclosure gets tested. Knowing which pharmacy ships an order lets a reader look that pharmacy up. A phrase such as 'a licensed US pharmacy' is a description, not a name.
See also: 503A compounding pharmacy, Telehealth platform vs prescriber, Rubric check
Money
Cash-pay
Paying for a medication or a program directly, without running it through an insurance benefit.
Most telehealth GLP-1 programs are cash-pay. The reader pays the program and the program supplies the medication, with no plan involved and usually no claim filed. It is the reason these prices can be compared at all, because they are published.
Cash-pay carries a downstream effect worth knowing. A plan can generally see only what it paid for, so treatment bought this way leaves no trace in its claims history. That can matter later, if a plan asks what has already been tried.
See also: Out-of-pocket cost, Step therapy, Subscription pricing
Used on: Compounded vs Brand GLP-1s: What the Difference Actually Means for You, GLP-1 Prior Authorization: How the Process Actually Works, Step Therapy, and What It Means for You
Subscription pricing
A recurring charge that continues on a cycle until it is canceled, rather than a one-time payment per order.
These programs generally bill on a repeating cycle. The parts that decide what it costs a reader are the cycle length, what each charge includes, when it renews, and how it is stopped.
Read the cancellation terms before the first charge rather than after it. A subscription that is easy to start and awkward to leave is a different product from one that is easy to leave, whatever the two of them charge.
See also: Membership fee, Plan-length commitment, Flat-rate pricing
Membership fee
A charge for access to a program, separate from what the medication itself costs.
Some programs split the bill: one charge for membership or access to the clinical service, another for the medication. Others fold everything into a single figure. Neither structure is better on its own, and they cannot be compared as though they were the same thing.
The questions that settle it are plain. Is medication included in the advertised figure or added to it? Is the fee refundable, and under what conditions? A program that publishes a specific refund policy has committed to more than most of this field.
See also: Subscription pricing, Out-of-pocket cost, Price qualifier
Used on: What a Required Membership Fee Changes About Your Monthly Cost, Starting At: What a GLP-1 Price Page Is Actually Telling You, Found Review
Starting-at price
An advertised figure representing the lowest a program can cost, not what a typical patient ends up paying.
A starting-at figure is a floor. It usually attaches to the lowest dose, the longest prepaid commitment, a discounted first month, or some combination of those. Each of those conditions is a reason the number may not describe your purchase.
This is why a qualifier is printed beside every figure on this site. A starting-at rate set against another program's ongoing rate is not a comparison. Find out which conditions produce the advertised number before treating it as the price.
See also: Price qualifier, Introductory rate, Plan-length commitment, Titration
Used on: Starting At: What a GLP-1 Price Page Is Actually Telling You, Amble vs Belle Health, Amble vs Found
Flat-rate pricing
One price that does not change as the dose changes, and which sometimes covers either compound.
Across much of this market the monthly charge rises as the dose does. A flat rate holds where it is. A few programs go further and charge the same for semaglutide and tirzepatide, which is unusual, because tirzepatide generally costs more.
A flat rate is genuinely useful for predictability, and it also skews comparisons. A program with one rate for either compound looks strong on the more expensive one and weaker on the cheaper one. Check which compound a table is comparing before reading a verdict into it.
See also: Titration, Maintenance dose, Subscription pricing, Tirzepatide
Plan-length commitment
A requirement to buy or prepay several months at once in order to get an advertised rate.
The lowest advertised rate in this market is frequently gated behind a multi-month or full-year commitment. Billing month to month costs more, sometimes by a large step rather than a rounding difference.
A long prepayment is a real decision. It is a bet that the treatment suits you, that you will want to continue, and that the program will serve you well for the whole term. Where any of that is uncertain, the month-to-month rate is the number that applies.
See also: Starting-at price, Subscription pricing, Price qualifier, Membership fee
Used on: Cheapest GLP-1 Providers, Compared, Apex MD Review, Apex MD vs bmiMD
Introductory rate
A discounted price for a first period only, after which the ongoing rate takes over.
An introductory month is a promotion rather than a price. What matters for a decision is the ongoing rate, meaning what a patient pays from the second cycle onward, because that is the figure most of a course gets bought at.
Comparing one program's introductory month against another's ongoing rate produces a false result. Where a figure on this site is an introductory rate, the qualifier beside it says so.
See also: Starting-at price, Price qualifier, Subscription pricing
Used on: Starting At: What a GLP-1 Price Page Is Actually Telling You, OrderlyMeds Review, YourHealthRx Review
Out-of-pocket cost
What a patient actually pays for a medication, rather than its list price or what a plan is billed.
There are two very different versions of this. On a cash-pay program the out-of-pocket cost is the whole cost, and it is generally published. Under an insurance benefit it is whatever share the plan leaves to the member, which the plan's own documents define.
The two do not compare cleanly. A benefit that covers a medication can still leave a substantial amount to the member, and a plan that does not cover it leaves all of it. Which situation you are in is answered by your plan documents.
See also: Cash-pay, Formulary, Tier, Explanation of benefits
Insurance
Prior authorization
A plan's requirement that a prescription be approved against its own written criteria before the plan will pay for it.
The prescription stays valid whatever the plan decides. What prior authorization controls is payment. A request goes in against the plan's published criteria for that drug, and the answer turns on whether the submitted documentation matches those criteria.
That is why outcomes can feel arbitrary. Most requests are decided on what is in the chart and on the form, not on a full history. A denial is not the end of the process, and it generally names both the reason and the route to challenge it.
See also: Step therapy, Denial, Medical necessity, Formulary
Used on: Providers for Readers Weighing Insurance Against Cash Pay, Compounded vs Brand GLP-1s: What the Difference Actually Means for You, GLP-1 Prior Authorization: How the Process Actually Works
Step therapy
A plan's requirement that one or more other treatments be tried before it will pay for the one prescribed.
Step therapy sequences payment, not treatment. The steps are set out in the plan's own criteria, and a request has to show they were climbed. It frequently sits inside a prior authorization rather than beside it, so a denial can rest on it without naming it.
The mechanism that decides most of these is visibility. A plan can see a step automatically only where its own claims history shows it paid for that treatment. Anything paid out of pocket, supplied as samples, or filled under different coverage leaves no trace, so the answer is documentation from the chart.
See also: Prior authorization, Denial, Cash-pay, Formulary
Used on: GLP-1 Prior Authorization: How the Process Actually Works, How to Read Your Plan's Drug List, Self-Funded vs Fully Insured: Why Your Coverage Differs
The list of medications a plan covers, together with the conditions attached to each one.
A formulary is where a plan states what it pays for. Beside each drug it can carry a tier, and it can flag requirements such as prior authorization, step therapy, or quantity limits. It is the document that answers whether a medication is covered at all.
Formularies are revised, usually on a plan-year cycle, and they differ from plan to plan. A drug's position on one list says nothing about its position on another. Your own plan's formulary is the only one that describes your coverage.
See also: Tier, Prior authorization, Step therapy, Pharmacy benefit manager
Used on: GLP-1 Prior Authorization: How the Process Actually Works, Formulary Exceptions and Tiering Exceptions, How a GLP-1 Appeal Works
Tier
A cost band on a plan's formulary that determines what share of a medication's cost falls to the member.
Plans group covered drugs into tiers, and each tier carries its own member cost. A lower tier generally means a smaller share for the member and a higher tier a larger one. The bands, and what each one costs, are set by the individual plan.
A tier is a placement rather than a judgment about a medication, and placements move between plan years. Some plans also operate an exception process for asking that a drug be treated at a different tier, described in the plan's own documents.
See also: Formulary, Out-of-pocket cost, Prior authorization
Used on: GLP-1 Prior Authorization: How the Process Actually Works, Switching Between GLP-1 Medications: What the Change Actually Involves, Formulary Exceptions and Tiering Exceptions
Denial
A plan's decision not to pay for something as requested, issued in a letter that states a reason and a route to challenge it.
A denial letter is a document to read closely rather than a verdict to accept. It generally names the policy that was applied, the reason the request failed, and the routes available next. Those three things decide what to do.
Reasons fall into rough groups. Something was missing from the submission. A criterion was judged unmet. Or the benefit does not include the drug at all. Reading a denial as one flat refusal hides which happened, and each calls for a different response.
See also: Prior authorization, Internal appeal, External review, Medical necessity
Used on: GLP-1 Prior Authorization: How the Process Actually Works, How a GLP-1 Appeal Works, Self-Funded vs Fully Insured: Why Your Coverage Differs
Internal appeal
A request that a plan reconsider its own denial, decided inside the plan rather than by an outside party.
The first level of appeal generally goes back to the plan that issued the denial. Deadlines apply on both sides, and they are stated in the denial letter and the plan documents. Missing yours is the most avoidable way an appeal fails.
What tends to change an outcome is new material rather than a stronger tone. The specific criterion that was not satisfied is the thing to answer, and a plan can generally be asked for the criteria it applied and the material behind the decision.
See also: Denial, External review, Medical necessity, Prior authorization
Used on: GLP-1 Prior Authorization: How the Process Actually Works, How a GLP-1 Appeal Works, Self-Funded vs Fully Insured: Why Your Coverage Differs
External review
A review of a plan's denial by an independent party outside the plan, generally available once internal appeals are exhausted.
External review moves the decision to a reviewer who does not work for the plan. It generally becomes available after the plan's own appeal levels are finished, and the denial letter is where its availability and its deadline are stated.
Whether it is available, who runs it, and what deadlines apply depend on how a plan is regulated. That is one practical consequence of the split between self-funded and fully insured coverage, and it is a reason the distinction is worth knowing.
See also: Internal appeal, Denial, Self-funded plan, Fully insured plan
Used on: GLP-1 Prior Authorization: How the Process Actually Works, How a GLP-1 Appeal Works, Self-Funded vs Fully Insured: Why Your Coverage Differs
Self-funded plan
Employer coverage where the employer pays claims from its own funds, even when an insurance company administers it.
In a self-funded arrangement the employer carries the financial risk. An insurance company is often hired to administer the plan, so the card and the paperwork can look identical to fully insured coverage from the member's side.
The difference shows up in which rules reach the plan. Self-funded employer plans are regulated along different lines from insured products, so a state law addressing coverage or appeals may not apply. Plan documents state which arrangement you are in.
See also: Fully insured plan, External review, Formulary, Pharmacy benefit manager
Used on: Self-Funded vs Fully Insured: Why Your Coverage Differs
Fully insured plan
Employer coverage where an insurance company is paid premiums and bears the risk of paying claims.
In a fully insured arrangement the employer buys a product from an insurer, and the insurer pays the claims. That product is regulated as insurance in the state where it is issued.
This is the arrangement most state insurance laws are written to reach. It is how two people at different employers, holding cards with the same logo, can have different routes open on the same denial. The card does not tell you which one you have.
See also: Self-funded plan, External review, Denial
Used on: Self-Funded vs Fully Insured: Why Your Coverage Differs
Pharmacy benefit manager
A company hired to run the prescription side of a health plan, including its drug list and its coverage reviews.
A pharmacy benefit manager sits between a plan and a pharmacy. It typically administers the formulary, processes prescription claims, runs pharmacy networks, and applies the plan's coverage requirements such as prior authorization.
This is why a coverage answer can arrive from a company whose name is not on your insurance card. It also means the criteria applied to a request may be published by that administrator rather than by the plan itself.
See also: Formulary, Prior authorization, Self-funded plan, Explanation of benefits
Used on: GLP-1 Prior Authorization: How the Process Actually Works, How a GLP-1 Appeal Works, Self-Funded vs Fully Insured: Why Your Coverage Differs
Explanation of benefits
A statement, not a bill, showing how a plan processed a claim and what it left to the member.
An EOB arrives after a claim is handled. It sets out what was charged, what the plan allowed, what it paid, and what remains the member's responsibility. The line saying this is not a bill is accurate, and it is the line people skip.
It is useful as evidence. An EOB records what a plan paid for and when, which is exactly what claims-history questions turn on later. Keeping them is easier than reconstructing a treatment history from memory.
See also: Out-of-pocket cost, Denial, Step therapy, Pharmacy benefit manager
Medical necessity
A plan's standard for whether a treatment is appropriate and payable in a specific case, defined in the plan's own documents.
Medical necessity sounds like a clinical judgment and functions as a contractual one. Each plan defines the term, and its criteria for a given drug spell out what has to be documented before the standard counts as met.
So a denial on medical necessity is not a statement that a treatment is wrong for you. It is a statement that the submitted record did not meet a written definition. The response is usually documentary, and it belongs with the prescriber.
See also: Prior authorization, Denial, Internal appeal, Formulary
Used on: How a GLP-1 Appeal Works
How This Site Works
Disclosure score
The score out of ten shown beside each provider here, built from four equally weighted checks on what a company discloses.
Four checks, each worth the same, expressed out of ten. A company meeting all four scores ten, and a company meeting two scores five. Every check is recorded as a plain yes or no taken from what the company publishes.
It measures disclosure, not care. The number says how much a company shows you before you pay, and nothing about whether its clinicians are good, whether shipping arrives, or whether a medication will work for you. A high score can still be a poor fit.
See also: Rubric check, Comparison board, FDA warning letter, Price qualifier
Rubric check
One of the four yes-or-no questions behind a provider's score here: pharmacy named, price published, all fifty states, brand available.
Pharmacy named asks whether a company says in public which compounding pharmacy or outsourcing facility fills its orders. A phrase like 'a licensed US pharmacy' is not a name and does not pass. Price published asks whether a monthly figure appears before an email address or an intake form is required.
All fifty states asks whether a company's own coverage list reaches every state. Brand available asks whether an FDA-approved GLP-1 can be obtained through the company, or only a compounded preparation. None of the four is inferred from marketing copy.
See also: Disclosure score, 503A compounding pharmacy, Brand-name drug, Mail-order pharmacy
Price qualifier
The condition printed beside every price here: the plan term, the dose, or the billing basis that figure depends on.
A starting rate, a first-month rate, a prepaid-commitment rate, and a bundled rate are four different things. Dropping the condition turns a true figure into a false one, so no price appears on this site without one attached.
It is the most useful thing to carry away from a comparison table. Two figures with different qualifiers are not comparable, however alike they look sitting side by side.
See also: Starting-at price, Introductory rate, Plan-length commitment, Verification date
Used on: Providers Offering Brand-Name GLP-1s, MangoRx Review, REMEVi Review
Verification date
The date a price was read from a company's own page, stored alongside every figure shown here.
Every price on this site comes from the provider's published page and is stored with the date it was read and the address it came from. Dates are shown to readers as a month and a year.
Prices in this market move quickly, so the date is how staleness gets judged. It is there so a reader can weigh how much a figure still carries and check the source before acting on it.
See also: Price qualifier, Disclosure score, Comparison board
Used on: Providers Offering Brand-Name GLP-1s, Best Semaglutide Providers, Compared, Best Tirzepatide Providers, Compared
Comparison board
A ranked table of providers for one category, ordered by score, showing the single published price that earned each its place.
Each board covers one category, whether a compound, a form, or a way of buying. A provider appears on a board only where it actually offers what that board is about, and the figure shown is one real published price rather than a blended average.
Order comes from the score. No company can pay to be added to a board, moved up one, or taken off, and there is no sponsored review or paid placement anywhere on the comparison.
See also: Disclosure score, Paid partner, Price qualifier, Rubric check
Paid partner
A provider whose affiliate program pays this site a commission when a reader signs up after clicking through.
Some links here can pay us, and a reader pays nothing extra for arriving that way. How many providers are paid partners is counted from the roster rather than typed into a sentence, so it stays true as arrangements begin and end.
A provider that pays nothing is still linked, still scored, and still written up the same way. A commission does not buy a higher score, a softened criticism, a removed disclosure, or a different verdict, and no provider sees a page before it is published.
See also: Outbound hop, Comparison board, Disclosure score
Outbound hop
The intermediate address every provider link on this site passes through before it reaches the company.
Every outbound provider link routes through the same step, for paid partners and unpaid providers alike. That places every company behind an identical exit, so none gets a shorter or cleaner path to a reader than another.
It is also where a paid program's tracking is attached. An unpaid provider's link carries no tracking at all, and resolves to that company's own address with nothing appended to it.
See also: Paid partner, Comparison board