Cost Per Pound Lost on GLP-1 in 2026 — Real Dollar Math by Access Path

Why cost-per-pound is the honest apples-to-apples metric

Monthly sticker price is misleading because a cheaper drug that delivers less weight loss isn’t actually cheaper. A $1,349/mo Wegovy pen producing 35 lb of loss over 12 months costs $462/lb. A $299/mo compounded semaglutide producing 22 lb (real-world is often lower than trial mean) costs $163/lb. The ranking can invert when you weight for efficacy.

Cost-per-pound at 12 months (assume 35 lb lost)

• Wegovy insured + savings card ($50/mo): $600 / 35 lb = $17/lb.
• Zepbound insured + card ($50/mo): $17/lb.
• LillyDirect Zepbound vial ($499/mo): $171/lb.
• NovoCare Wegovy vial ($499/mo): $171/lb.
• Compounded telehealth ($299/mo): $103/lb — if response matches branded.
• Wegovy cash list ($1,349/mo): $463/lb. Unreasonable for most.

How GLP-1 compares to alternatives

• Bariatric sleeve gastrectomy: $15–25K cash; 70 lb over 2 years: $215–$360/lb. Regain-resistant.
• WW / Noom: $25–$55/mo; ~11 lb at 12 months: $27–$60/lb but response bimodal.
• DPP lifestyle: free to low-cost; ~16 lb at 12 months. Best per-pound, adherence-limited.
• Phentermine-topiramate (Qsymia): ~$100–$150/mo, 9–10% TBWL = ~$120/lb.

Tirzepatide vs semaglutide at equal price

SURMOUNT-5 head-to-head: tirzepatide 15 mg = 20.2% TBWL vs semaglutide 2.4 mg = 13.7% at 72 weeks. At 225 lb baseline, that’s 45 lb vs 31 lb — 14 lb absolute gap. At equal monthly pricing ($499 LillyDirect vs $499 NovoCare), tirzepatide is unambiguously better cost-per-pound: $199/lb vs $290/lb. Only reasons to choose semaglutide on cost: your insurance covers Wegovy but not Zepbound, or you tolerate semaglutide meaningfully better.

The durable-pound caveat

The metric above is cost per pound during treatment. GLP-1 weight loss is durable while on the drug, reversible when stopped (STEP 4: ~two-thirds regain within 12 months). If you stop after 12 months, effective cost-per-pound-maintained-at-year-3 is much higher. Bariatric surgery’s one-time cost amortizes over decades. ICER estimated semaglutide at ~$237,000/QALY at list price in 2022 — above the $150K willingness-to-pay threshold. Tirzepatide is more cost-effective per SURMOUNT-1 efficacy.

Levers you control

1. Prior authorization: $50 copay vs $499 cash is the single largest variable.
2. Drug choice: tirzepatide produces ~50% more TBWL than semaglutide.
3. Dose optimization: 5 mg tirz or 1 mg sema if you plateau early.
4. Duration: cost-per-pound improves between months 3 and 12 as denominator grows.
5. HSA/FSA: ~25–30% effective discount for most households.