HealthRX.com · Printable cost worksheet
Compounded semaglutide cost and access worksheet
Use this sheet before starting compounded semaglutide or Wegovy or Ozempic. Fill in quotes, plan charges and hidden costs so you can budget for the long term and take the answers to your clinician, pharmacist or insurer.
Price quotes to compare
Write the amount and the date each quote was given.
Branded Wegovy or Ozempic pharmacy quoteAmount and pharmacy name
Plan copay or specialty tier chargeInclude any deductible still owed
Compounded telehealth monthly priceStarting price and dose it covers
Price after the first monthAsk whether it changes and when
Injection supplies included in the price?Yes, no, or cost if billed separately
Gather before you call or visit
Having these in hand keeps the conversation short.
- Bring your insurance plan summary and member card
- Write down your deductible and out-of-pocket maximum for this year
- Check with your pharmacy whether your plan covers the branded product
- Note whether your state Medicaid program covers the medicine you are considering
- Confirm whether your HSA or FSA administrator accepts this prescription
- Bring itemized receipts for every payment so far
- List your current medicines and any lab results your clinician requested
- Check whether your telehealth provider holds a LegitScript certification
Hidden costs tracker
Record every extra charge as it happens, including labs, sharps containers and urgent care.
| Date | Item | Amount | Paid by |
|---|---|---|---|
Questions for your prescriber, pharmacist or insurer
- Does my plan cover Wegovy or Ozempic for my condition?
- What will I pay each month after my deductible is met?
- Will the monthly price change after the first month?
- Are needles, swabs and sharps containers included in the price?
- Which follow-up labs will I need, and what will each one cost?
- If my budget covers only a short course, how should the plan be designed?
- Can my HSA or FSA pay for this prescription, and what paperwork do I need?
- What happens to my dose and cost if I have to pause treatment?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.