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Accepted reasons for clinical necessity include: Intolerance to GI side effects requires a low-dose titration schedule not available commercially Need for split dosing across two or three weekly injections at doses not available commercially Allergy or sensitivity to an inactive ingredient in the commercial formulation, such as benzyl alcohol, excipients, or preservatives Requirement for a preservative-free formulation Therapeutic-additive requirements, such as leucine, methylcobalamin (B12), pyridoxine (B6), or L-carnitine A specific dose strength or concentration not available in any commercial format An alternative delivery method or dosage form not available commercially The clinical necessity must be explicitly documented on the prescription by the ordering prescriber