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It is an autoimmune disease which makes it impossible to absorb B12 via the gut
Pearson SD, Whaley CM, Emond SK
However, they do accept HSA and FSA payments, which provide tax-advantaged savings that can reduce your effective cost by 20 to 37 percent depending on your tax bracket
International Journal for Vitamin and Nutrition Research 71 (1): 6065
Those two situations reliably cause the worst outcomes I see in practice
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