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5-Amino-1MQ Vials (10 mg each): 1 week (5 mg/day = 35 mg total) 4 vials 2 weeks (5 mg/day = 70 mg total) 7 vials 4 weeks (5 mg/day = 140 mg total) 14 vials Insulin Syringes (U-100, 1 mL): 1 week (once daily): 7 syringes 2 weeks (once daily): 14 syringes 4 weeks (once daily): 28 syringes Bacteriostatic Water (10 mL bottles): Use 2.0 mL per vial for reconstitution

Your provider confirms the final recommendation after reviewing your medical history and goals

Example Scenario: A provider administers a corticosteroid injection for a condition not listed as covered in the payers medical necessity guidelines

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