A first year and a second year on the same prescription are not the same purchase, and the difference is not inflation. Year one contains the climb. The approved semaglutide schedule spends its first sixteen weeks below 2.4 mg and reaches that dose in week seventeen; the approved tirzepatide schedule spends its first twenty weeks below 15 mg and reaches it in week twenty-one. That is 30.8% and 38.5% of a fifty-two-week year spent somewhere other than the destination. Year two contains none of it, which is set out step by step in the schedule article.
Where the price follows the milligram
Across the 477 sellers recorded here, 148 state that one price covers every dose, 36 state that the price rises with the dose, and 293 state nothing either way. For the middle group, the climb described above is a billing event repeated four or five times before the first anniversary, and then never again.
Eight rows across five of those sellers publish an actual ladder — a milligram strength with a dollar figure beside it, three rungs or more. Comparing the top rung against the bottom on each of the eight gives a median multiple of 1.71, with a range from 1.50 to 2.34. A ladder is therefore worth roughly as much as the gap between two different sellers, applied to one buyer who never changed sellers.
The cheaper headline belongs to the policy that re-prices
This is the part that runs backwards. Sorting the compounded injection prices by what each seller says about dose, the sellers who hold one rate publish a median of $174.50 for semaglutide across 142 rows, while the sellers who re-price by dose publish a median of $164.50 across 26. On tirzepatide it is $239 across 134 rows against $218 across 26. Sellers who say nothing sit above both, at $179 and $249.
So a comparison page sorted on the advertised number places the re-pricing sellers ahead of the holding ones by about six percent on one molecule and nine percent on the other. Nothing dishonest is happening: the figure is the first rung, the first rung is genuinely cheaper, and the page is quoting it accurately. It is simply the rung that applies to the fewest weeks of the purchase, which is why a board built around a held rate looks more expensive than it is.
Silence is the most common answer, and it is not free
The largest group is the one that says nothing. Those 293 sellers publish a median of $179 for compounded semaglutide injection across 266 rows and $249 for tirzepatide across 235 — above both the flat group and the dose-indexed group on both molecules. A buyer choosing from that group is paying a higher advertised figure and carrying the dose question unanswered as well.
Nothing about that spread proves those sellers re-price. It means the question has not been settled on their pages, and an unsettled question is a variable a second-year budget cannot close. The difference between a stated policy and an absent one is a sentence of copy, and it is worth the gap between two comparison rows.
Walking one published ladder across two years
One of the eight ladders steps in the same milligrams as the approved weekly schedule, which makes it possible to price a real year instead of a hypothetical one. Its rungs are $145 at 2.5 mg, $295 at 5 mg, $345 at 7.5 mg, $395 at 10 mg, $445 at 12.5 mg and $545 at 15 mg, billed as four-week fills — and thirteen four-week fills land inside a calendar year, which is the calendar arithmetic worked through in the annual-cost article.
Walked across the schedule, the first thirteen fills are one at $145, one at $295, one at $345, one at $395, one at $445 and eight at $545. Year one totals $5,985. Year two is thirteen fills at $545 and totals $7,085. The second year costs $1,100 more than the first, an increase of 18.4% against a price list that did not change.
Measured against the entry rung, the gap is wider still. Thirteen fills at $145 is $1,885, which is the annual figure an advertised price implies. The second year is 3.76 times that. A ladder with fewer rungs behaves very differently: walking a three-rung ladder the same way produces $6,345 in year one and $6,545 in year two, a rise of 3.2%. The number of steps matters more than the size of any one of them.
Most people never reach the rung that projection assumes
The arithmetic above prices a patient who climbs to the top dose and stays. A retrospective cohort of 2,306 patients treated in a multidisciplinary academic obesity clinic between 2022 and 2024 measured how often that happens. Of the semaglutide users, 81% escalated to at least 1 mg but only 23% reached 2.4 mg. Of the tirzepatide users, 75% received at least 10 mg and 28% received 15 mg.[1]
A UK primary-care cohort of 8,200 initiators in type 2 diabetes found the same shape earlier in the ladder: only 58% of semaglutide initiators reached a recommended maintenance dose after four weeks and 21% were still on a starting dose, with the most common subcutaneous doses at the tenth prescription being 0.5 mg (44.0%) and 1 mg (48.6%).[2] That cohort was treated for diabetes rather than for weight, on a product whose ceiling is lower, so it bounds the question rather than answering it.
The correction to the projection is not good news
The reason fewer people reach the top rung is the reason the second year is a smaller market than the first. In that academic clinic, median persistence was 10.7 months, with an interquartile range of 5.4 to 16.3 — so the median patient stopped before the first year was out.[1] The drug was supplied at no cost to the patient under a program bundle, which removes price as the explanation.
The UK cohort put one-year discontinuation at 41.1% (95% CI, 40.1 to 42.2), and the subgroup split is the part worth keeping: discontinuation was higher among people without obesity, at 49.2% for a body-mass index under 30, than among those at 35 or above, at 37.2%.[2] Discontinuation also ran higher on oral semaglutide (55.8%) than on the injection (46.4%).
So the honest reading of a dose ladder is double-edged. The worst case rarely arrives, because most people stop or stall below the top dose — and stalling below the top dose is the same event as not receiving the exposure the trials measured. Where persistence did reach twelve months in that clinic, median weight loss was 14.4% (IQR 9.5% to 20.5%).[1] What happens to the weight after the prescription ends is a separate literature, set out in the withdrawal article.
Four things the second year changes that the first hides
An opening discount is gone. A first-fill rate, a two-month introductory order, a waived start fee: each of those is a year-one line that has no year-two equivalent, so a plan whose first year looked competitive can rank differently on its renewal. A prepay term renews at whatever the rate is then, not at the rate that was signed.
The ladder is above the buyer, not below. In year one, every unpriced rung is a future charge; in year two, the only remaining movement is downward, because the dose has either settled or been reduced. That turns a dose-indexed plan from an open-ended liability into a fixed one, and it is the single respect in which the second year is the easier of the two to budget.
The dose is settled, which cuts the same way. A buyer who knows the dose they are on can price it exactly rather than from a range, and a seller that publishes a rung for that milligram can be compared against another seller at the same milligram for the first time. Running both figures through the titration planner turns a schedule into a bill.
And the plan itself has to survive. A prescription that has run a year is a prescription that has outlived at least one price revision, one pharmacy assignment and, on the sellers that publish a state list, any change to where the service operates. None of those three is visible in a monthly figure, and each is a reason a second year can end at a different seller than the one the first year was bought from.
What this does not establish
Coverage is not census. Of the 477 sellers here, 293 state no dose-pricing policy at all, and most have not been individually adjudicated on the question. A row carrying no ladder and no correction has not been examined and found clean; it has not been examined. The eight published ladders are the sellers who disclosed, which is a self-selected group and probably a better-behaved one.
Nor does any of this describe the product. Compounded drugs are not FDA-approved, which means the agency does not verify their safety, effectiveness or quality before they are marketed.[3] A seller that holds one rate across every dose has told you about its billing and nothing about its pharmacy. What each company states, and how a figure gets established before it is published here, is recorded in the methodology.
The question that settles a second year is short and has a written answer: what does this cost at the dose expected in month eighteen, and is that figure on the page or behind the intake? A seller that answers has priced two years. One that answers only for the opening rung has priced four weeks.