Human Growth Hormone (HGH): Benefits, Risks, and Uses

Human growth hormone (HGH) is a naturally occurring peptide hormone that plays a central role in growth, metabolism, tissue repair, and body composition. Understanding how HGH works begins with its production and function in the body, followed by the prescription brands and formulations available and its classification as a peptide hormone rather than a steroid. It is also important to understand how HGH affects height, muscle mass, body weight, testosterone levels, and hair health while distinguishing medically proven effects from common misconceptions.

Beyond its biological role, HGH therapy provides well-established benefits for people with diagnosed growth hormone deficiency, including supporting normal childhood growth, preserving muscle and bone health, improving body composition, promoting tissue repair, enhancing metabolism, increasing exercise capacity, and improving recovery and quality of life. At the same time, treatment requires careful consideration of its potential side effects, legal status, appropriate medical use, safe purchasing options, and overall treatment costs. Together, these insights provide a balanced understanding of when HGH therapy is medically appropriate, what outcomes to expect, the risks involved, and the legal and financial considerations associated with treatment.

What Is Human Growth Hormone?

Human Growth Hormone (HGH), also known as somatotropin, is a naturally occurring, pea-sized peptide hormone produced and secreted by the anterior pituitary gland, located at the base of the brain. As a key hormone of the endocrine system, HGH regulates normal growth, metabolism, and body composition throughout life. It is essential for healthy bone, muscle, and tissue development during childhood and adolescence and continues to support normal tissue maintenance and metabolic function in adults. 

Beyond its role in growth and development, HGH helps maintain overall physical development and physiological balance by supporting the body’s normal growth and repair processes. Clinically, HGH is an important biomarker because abnormal hormone levels may indicate growth disorders, pituitary dysfunction, or other endocrine conditions, making it a valuable component of medical evaluation and diagnosis.

How Does Human Growth Hormone (HGH) Work?

Human Growth Hormone (HGH) works by being released in pulses by the pituitary gland into the bloodstream, where it binds directly to growth hormone receptors (GHR) on target cells. It regulates physical growth, metabolism, tissue repair, and overall development through two complementary pathways, direct cellular signaling and the stimulated production of Insulin-like Growth Factor 1 (IGF-1). To keep these processes in harmony, HGH activity is tightly governed by a hormonal feedback loop that maintains optimal body balance.

HGH works through the following mechanisms:

• Direct Action on Target Cells: By binding directly to growth hormone receptors (GHR) throughout the body, HGH actively controls energy metabolism and tissue maintenance. In this direct role, it stimulates fat breakdown (lipolysis) to free up energy, inhibits excess glucose uptake to maintain balanced blood sugar levels, and accelerates protein synthesis to preserve lean mass.
• Indirect Action via IGF-1: Once HGH reaches the liver, it stimulates the production and release of Insulin-like Growth Factor 1 (IGF-1). This downstream hormone acts as the primary engine for structural growth, driving cartilage and long bone lengthening in developing bodies, building skeletal muscle, and stimulating cell proliferation for lifelong tissue repair.
• Hormonal Feedback Regulation: To prevent overproduction and maintain overall endocrine balance, the body relies on a tight negative feedback loop. As circulating levels of HGH and IGF-1 rise, they signal both the pituitary gland and the hypothalamus to decrease further hormone release until levels naturally drop and the cycle resets.

What Brand Names and Forms Does Human Growth Hormone Come In?

Human Growth Hormone (HGH) is available in FDA-approved brand-name formulations, including Genotropin, Norditropin, Omnitrope, and Serostim, as well as compounded HGH products. Although all formulations contain recombinant human growth hormone (somatropin), they differ in their approved indications, delivery devices, dosing options, and regulatory status.

FDA-Approved HGH Products:

• Genotropin (Pfizer)

Genotropin is a prescription-only recombinant somatropin manufactured by Pfizer to treat pediatric and adult growth hormone deficiencies (GHD), as well as genetic and growth conditions such as Prader-Willi syndrome, Turner syndrome, and small for gestational age (SGA). Supplied as a lyophilized powder requiring reconstitution, it uses a two-chamber cartridge system, multi-dose pre-filled pens, or two-chamber single-use devices (Genotropin MiniQuick) where the powder and diluent are mixed inside the device before daily subcutaneous injection. Depending on the specific product format, Genotropin can be stored at room temperature for up to one month (30 days) after first use or reconstitution.

• Norditropin (Novo Nordisk)
  Norditropin is a once-daily recombinant somatropin manufactured by Novo Nordisk, indicated for pediatric growth disorders and adult growth hormone deficiency. It is supplied as a pre-mixed, ready-to-use liquid solution in Norditropin FlexPro pre-filled injection pens, completely eliminating the need for manual reconstitution prior to daily subcutaneous injection. After first use, the pen offers convenient handling and may be stored at room temperature below 25°C (77°F) for up to 3 weeks (21 days).
  
• Omnitrope (Sandoz)
  Approved as a biosimilar somatropin product, Omnitrope provides the same clinical efficacy and FDA indications for growth failure and GHD as original reference products at a lower cost structure. It is available in multiple delivery formats, including ready-to-use liquid cartridges for Omnitrope Pen 5 / Pen 10 injection devices, as well as lyophilized powder in glass vials requiring manual reconstitution before injection. Most formulations require strict, continuous refrigeration, with only limited room-temperature stability after first use.
  
• Serostim (EMD Serono)
  Unlike most somatropin brands targeting general GHD, Serostim is a specialized recombinant human growth hormone explicitly FDA-approved for treating HIV-associated muscle wasting, cachexia, and other catabolic conditions to increase and maintain lean body mass, body weight, and physical endurance. Formulated as a lyophilized powder in single-use or multi-dose glass vials provided with a separate diluent, it requires manual reconstitution prior to subcutaneous injection, after which unused portions must be refrigerated immediately and administered within the manufacturer-recommended time frame.

Compounded or Unregulated HGH Products:

• Compounded HGH
  Prepared by specialized compounding pharmacies using custom formulations, concentrations, or delivery methods, compounded biological products do not undergo the same rigorous FDA clinical safety, purity, and efficacy trials as brand-name biologics.
  
• Unregulated / Black Market HGH
  llicit products distributed online, in gyms, or through non-medical channels without a prescription frequently lack quality control standards, carrying high risks of bacterial contamination, improper dosage concentrations, or complete absence of active somatropin.
  
• Over-the-Counter “HGH Releasers” & Supplements
  Dietary pills, sprays, or powders sold online or in retail stores claiming to naturally boost pituitary growth hormone production do not contain actual human growth hormone, which is a protein molecule that can only be biologically active when administered via subcutaneous injection, and are regulated merely as dietary supplements rather than clinical medications.

Is Human Growth Hormone a Steroid, Peptide, or Controlled Substance?

Human Growth Hormone (HGH) is a peptide hormone, a prescription medication, and is legally classified as a prescription legend drug in some jurisdictions rather than a steroid or controlled substance. Its classification varies depending on the biological, medical, legal, and sports-regulation context, with each category describing a different aspect of its structure, approved use, regulatory status, or restrictions.

• Steroid classification: HGH is not a steroid. Steroids are lipid-based compounds derived from cholesterol (such as testosterone or cortisol) that freely cross cell membranes to interact with internal nuclear receptors. In contrast, HGH contains no steroid ring structure and acts through entirely different biochemical pathways.
• Peptide hormone classification: As a peptide hormone, HGH is biochemically classified as a peptide hormone (specifically, a single-chain protein or polypeptide composed of 191 amino acids). Because it is a protein, it cannot be taken orally, stomach acids would digest it, and it must be administered via subcutaneous injection to bind to growth hormone receptors on target cell surfaces.
• Controlled substance status: In the United States, HGH is classified as a Schedule III controlled substance under the Controlled Substances Act (and tightly restricted under the Anabolic Steroids Control Act). Federal law strictly regulates its distribution, making it illegal to prescribe or possess HGH for off-label uses such as anti-aging, body-building, or general athletic enhancement without a valid medical indication (such as documented adult GHD or muscle wasting).
• Performance-enhancing drug classification: HGH is universally banned as a performance-enhancing drug (PED) by major athletic bodies, including the World Anti-Doping Agency (WADA), the International Olympic Committee (IOC), and professional sports leagues. It falls under the category of “Peptide Hormones, Growth Factors, Related Substances, and Mimetics” due to its ability to increase lean tissue mass, accelerate recovery, and enhance lipolysis.

What Does Human Growth Hormone Do to the Body?

Human Growth Hormone can increase height only in children with open growth plates and approved growth disorders, but it does not make adults taller, directly increase testosterone, treat common hair loss, or significantly increase muscle growth or weight loss in healthy individuals. Its medically approved benefits are primarily limited to treating diagnosed HGH deficiency and certain growth disorders under healthcare supervision.

Does Human Growth Hormone Make You Taller?

Yes, Human Growth Hormone can make you taller, but only in children and adolescents whose growth plates are still open and who have a diagnosed growth hormone deficiency or another approved growth disorder. In these cases, HGH stimulates bone growth, supports normal skeletal development, and can help children achieve a taller adult height when prescribed and monitored by a healthcare professional. Once the growth plates have fused, which typically occurs after puberty, HGH can no longer increase height. In adults, HGH supports functions such as metabolism, body composition, muscle mass, and tissue repair, but it does not increase bone length or make a person taller.

Does Human Growth Hormone Build Muscle Mass?

Yes, but primarily in people with a diagnosed Human Growth Hormone deficiency, however, in individuals with normal HGH levels, additional HGH does not meaningfully increase muscle size, strength, power, or athletic performance. While HGH can increase lean body mass by promoting protein synthesis and reducing body fat, this increase does not necessarily reflect greater muscle hypertrophy or improved physical performance, particularly in healthy adults. A 2024 systematic review and meta-analysis of 11 randomized controlled trials found that growth hormone administration increased lean body mass by 2.72 kg but did not improve muscle protein synthesis or muscle strength, indicating that increases in lean body mass largely reflect fluid retention rather than true muscle growth (Smolensky et al., 2024).

Does Human Growth Hormone Cause Weight Gain or Weight Loss?

No, Human Growth Hormone is not an effective treatment for significant weight loss, and some individuals may initially experience weight gain because of fluid retention. However, it can reduce body fat while increasing lean body mass, especially in people with a diagnosed HGH deficiency. A 2025 Phase 3 randomized clinical trial involving 259 adults with growth hormone deficiency found that growth hormone therapy increased total lean body mass by 1.60 kg while reducing trunk fat percentage by 1.68% and trunk fat mass by 0.48 kg compared with placebo, demonstrating improvements in body composition rather than meaningful weight loss (Hoffman et al., 2025).

Does Human Growth Hormone Increase Testosterone?

No, Human Growth Hormone does not directly increase testosterone and should not be considered a testosterone-raising treatment. Although HGH and testosterone are both regulated by the endocrine system, treating a diagnosed HGH deficiency may indirectly support overall hormonal function in some individuals. These indirect effects vary by person and do not mean that HGH consistently raises testosterone levels or replaces testosterone replacement therapy (TRT) when testosterone deficiency is present.

Does Human Growth Hormone Help With Hair Loss?

No, Human Growth Hormone (HGH) does not help treat common hair-loss conditions and is not an established therapy for disorders such as androgenetic alopecia or alopecia areata. In people with a diagnosed HGH deficiency, treatment may indirectly improve hair quality or thickness by restoring normal hormone levels. Current evidence remains limited and does not show that HGH consistently promotes hair regrowth or reverses common forms of hair loss in individuals with normal HGH levels.

What Are the Benefits of Human Growth Hormone?

The key benefits of Human Growth Hormone (HGH) include supporting normal growth in children with growth hormone deficiency, preserving muscle mass and bone density, improving body composition, and strengthening bones. It also promotes tissue repair, enhances exercise capacity, supports healthy metabolism, improves quality of life, and aids physical recovery in people with diagnosed HGH deficiency. These advantages are primarily seen when HGH is prescribed to treat a diagnosed growth hormone deficiency or another approved medical condition.

9 key benefits of human growth hormone are:

1. Supports Growth in Children with Deficiency
   Human growth hormone (HGH) therapy is the standard treatment for children diagnosed with growth hormone deficiency (GHD), a condition where the pituitary gland doesn’t produce enough natural hormone. Without treatment, these children grow at a significantly slower rate than their peers and may end up notably shorter as adults. Supplemental HGH, given as injections, helps normalize growth velocity, allowing children to catch up toward a height closer to their genetic potential. Treatment is monitored closely by pediatric endocrinologists and continued until growth plates close or target height is reached.
   
2. Preserves Muscle Mass and Bone Density in Adults
   In adults with clinically confirmed growth hormone deficiency, HGH replacement therapy helps preserve lean muscle mass and maintain bone density by restoring hormone levels needed for normal muscle protein synthesis and bone remodeling. Reduced HGH production can contribute to sarcopenia, lower bone mineral density, and a higher risk of fractures. The benefits are well documented in medically diagnosed patients rather than healthy adults seeking anti-aging treatment.
   
3. Improves Body Composition (Fat vs. Lean Mass)
   HGH plays a role in regulating how the body stores and uses fat versus lean tissue. In deficient adults, therapy has been associated with reductions in visceral (abdominal) fat and increases in lean body mass, shifting overall body composition in a healthier direction. This effect is one of the more consistently observed outcomes in clinical trials of HGH replacement, though results vary by individual, dose, and duration of treatment, and are not a substitute for diet and exercise.
   
4. Strengthens bones
   Through its role in stimulating osteoblast activity and regulating calcium metabolism, HGH supports stronger bones by improving bone mineral density in people with diagnosed growth hormone deficiency over the course of long-term treatment. Because bone remodeling occurs gradually, measurable improvements often require several months or even years of therapy. An 18-month clinical study of adults with growth hormone deficiency found that lumbar spine bone mineral density increased by 0.011 g/cm² after growth hormone replacement (P = 0.045), demonstrating gradual improvements in bone health with continued treatment (Lin et al., 2023).
   
5. Promotes tissue repair
   HGH stimulates the production of insulin-like growth factor 1 (IGF-1), which supports cell regeneration and protein synthesis, both important for healing tissue such as skin, muscle, and connective tissue. This is part of why HGH deficiency can be associated with slower wound healing and reduced recovery capacity. Replacement therapy in deficient individuals may support the body’s normal repair processes, though this is distinct from claims about HGH accelerating healing in people with normal hormone levels.
   
6. Improves exercise capacity
   For adults with growth hormone deficiency, HGH therapy can improve exercise capacity by supporting muscle strength, cardiovascular function, and energy metabolism required for sustained physical activity. Treatment has been associated with better exercise tolerance, including improvements in VO2 max and overall stamina. These benefits have been observed in people receiving HGH replacement for a diagnosed deficiency and do not apply to using HGH as a performance enhancer in healthy athletes.
   
7. Supports healthy metabolism
   Because HGH regulates the metabolism of fats, proteins, and carbohydrates, replacement therapy helps restore healthier metabolic function in adults with growth hormone deficiency while supporting more balanced energy production and nutrient utilization. A 2025 clinical study found that 12 months of growth hormone replacement significantly reduced total fat mass (P = 0.023), trunk fat (P = 0.020), total cholesterol, and LDL cholesterol while increasing HDL cholesterol in adults with isolated growth hormone deficiency, demonstrating improvements in metabolic health and body composition (Schiavo et al., 2025).
   
8. Enhances quality of life in people with HGH deficiency
   For adults experiencing the physical and emotional effects of growth hormone deficiency, HGH replacement therapy can improve overall quality of life by restoring hormone levels that support normal energy, mood, stamina, and daily functioning. People receiving treatment often report improvements in fatigue, emotional well-being, social functioning, and day-to-day activities after hormone levels are restored. These outcomes are specific to correcting a medically confirmed deficiency.
   
9. Supports recovery and physical function
   By supporting tissue repair, maintaining muscle mass, and regulating energy metabolism, HGH replacement therapy helps improve physical recovery and everyday function in adults with clinically diagnosed growth hormone deficiency. These combined effects can contribute to better strength, mobility, and recovery following illness or physical stress, improving overall functional capacity. The documented benefits apply to medically supervised treatment, while HGH use outside approved clinical indications carries significant health risks.

What Are the Side Effects and Risks of Human Growth Hormone?

Human growth hormone (HGH) may cause common side effects, serious or age-specific complications, long-term risks and contraindications, and product-quality concerns. Most side effects are dose-related and improve with medical supervision, but regular monitoring is essential to detect complications early and ensure safe treatment.

Below are the side effects and risks of human growth hormone:

• Common side effects and dose-related effects

Injection-site reactions, fluid retention (edema), joint pain, muscle pain, headache, carpal tunnel syndrome, insulin resistance, hyperglycemia, and an increased risk of diabetes, particularly with higher doses or in susceptible individuals. Most side effects are dose-related and often improve with dose adjustment or appropriate medical management.

• Serious adverse effects and age-specific risks

Rare complications include intracranial hypertension, pancreatitis, severe allergic reactions, and worsening sleep-related breathing disorders. Children should also be monitored for slipped capital femoral epiphysis (hip complications), scoliosis progression, and glucose abnormalities, while adults are more likely to develop edema, joint stiffness, and carpal tunnel syndrome.

• Long-term risks, contraindications, and precautions: 

Excessive or prolonged HGH use may cause acromegaly-like changes, persistent insulin resistance, type 2 diabetes, and cardiovascular complications associated with hormone excess. HGH should not be used in patients with active cancer, active tumor growth, critical illness after major surgery or trauma, severe diabetic retinopathy, or closed growth plates for height treatment. It may require thyroid or adrenal hormone dose adjustments, and people with a history of cancer should be monitored during treatment.

• Product quality, monitoring, and warning signs

Counterfeit or contaminated HGH products may contain incorrect hormone concentrations or harmful impurities, making prescription products from licensed pharmacies the safest option. Monitor IGF-1, blood glucose, HbA1c, thyroid and adrenal function, growth response, blood pressure, edema, and vision during treatment. Seek immediate medical attention for severe headache, vision changes, persistent vomiting, severe abdominal pain, hip pain or limping in children, breathing difficulty, chest pain, or signs of high blood sugar.

Why Do Athletes and Bodybuilders Use Human Growth Hormone?

Athletes and bodybuilders use human growth hormone (HGH) to improve body composition, recovery, and physical appearance, hoping it will support better training outcomes and performance. While some of these goals reflect HGH’s biological functions, many claimed benefits in healthy individuals are not strongly supported by scientific evidence, and non-medical use carries significant health and professional risks.

6 key benefits of HGH for Athletes and bodybuilders are:

1. Increase Lean Muscle Mass

One of the main reasons athletes and bodybuilders use HGH is to increase lean muscle mass by supporting protein synthesis and muscle tissue development, although greater lean mass does not consistently translate into increased strength or power.

2. Reduce Body Fat and Change Physique

Many users turn to HGH to reduce body fat, particularly visceral fat, and achieve a leaner, more muscular appearance, though some visible changes may result from fluid retention rather than actual muscle growth.

3. Support Recovery and Tissue Repair

 Faster recovery from intense training sessions and sports injuries is another common reason for HGH use because it supports tissue repair and cell regeneration, even though evidence for accelerated healing in healthy individuals remains limited.

4. Improve Athletic Performance

The expectation of improving strength, endurance, speed, or overall athletic performance motivates some athletes to use HGH, but current evidence does not consistently demonstrate meaningful improvements in competitive performance among healthy individuals.

5. Combine With Other Performance-Enhancing Drugs

Some individuals misuse HGH alongside other performance-enhancing drugs to pursue greater physique or performance changes, a practice that increases health risks without providing predictable or proven athletic benefits.

6. Accept Health and Professional Risks

 Despite its perceived benefits, non-medical HGH use can cause side effects such as joint pain, fluid retention, insulin resistance, and abnormal tissue growth, while unauthorized use violates World Anti-Doping Agency (WADA) rules unless a Therapeutic Use Exemption (TUE) is granted, potentially resulting in suspensions, disqualification, loss of titles, and reputational damage.

How Can You Increase Human Growth Hormone Naturally?

You can increase human growth hormone (HGH) naturally by improving sleep quality, performing high-intensity exercise, maintaining a healthy body weight and balanced diet, practicing intermittent fasting when appropriate, and considering targeted amino acids or supplements under medical guidance. While these strategies support your body’s normal HGH production, they optimize natural hormone release rather than raise HGH beyond healthy physiological levels.

5 key ways to increase HGH naturally are:

1. Optimize Your Sleep

Prioritize 7 to 9 hours of uninterrupted, high-quality sleep each night because the largest release of HGH occurs during deep sleep. Maintaining a consistent sleep schedule, limiting screen exposure before bedtime, and creating a cool, dark sleeping environment can support the body’s natural nighttime HGH production.

2. Perform High-Intensity Exercise

Include high-intensity interval training (HIIT) or resistance training in your weekly routine to stimulate short-term increases in HGH release. Compound exercises, such as squats and deadlifts, performed at moderate to high intensity with adequate recovery, can encourage your body’s natural hormonal response while improving overall fitness.

3. Manage Body Fat and Diet

Maintain a healthy body weight through a balanced diet rich in lean protein, whole grains, fruits, vegetables, and healthy fats, as excess body fat is associated with lower HGH secretion. Limiting added sugars and refined carbohydrates may also help support healthy insulin levels, which play a role in normal HGH regulation.

4. Practice Intermittent Fasting

Consider intermittent fasting under medical guidance if it aligns with your health needs, as periods without food may temporarily increase natural HGH secretion by lowering insulin levels. This approach is not suitable for everyone, including children, pregnant women, and people with certain medical conditions, so professional advice is recommended.

5. Consider Targeted Amino Acids and Supplements

Discuss specific amino acids, such as arginine or ornithine, and evidence-based supplements with a healthcare professional before use. These nutrients may modestly influence HGH release under certain conditions, but they should complement healthy lifestyle habits rather than replace proper nutrition, exercise, or medical treatment.

Is Human Growth Hormone Safe and Legal?

Human growth hormone (HGH) is safe and legal only when it is prescribed and injected under a doctor’s supervision for approved medical conditions. In many countries, HGH is a prescription-only medication approved by the U.S. Food and Drug Administration (FDA) to treat specific growth disorders in children and conditions such as HIV-associated muscle wasting in adults. Using or purchasing HGH for bodybuilding, weight loss, anti-aging, or athletic performance enhancement is generally illegal in many jurisdictions and carries significant health risks. In addition, over-the-counter pills or sprays marketed to boost HGH are not FDA-approved and lack reliable evidence of safety or effectiveness. 

Where Can You Get Human Growth Hormone (HGH )Safely and Legally?

You can get human growth hormone (HGH) safely and legally only with a valid prescription from a licensed endocrinologist or qualified healthcare provider. If you plan to buy human growth hormone, obtain it only through licensed hospitals, specialty pharmacies, retail pharmacies, or verified mail-order pharmacies that require a valid prescription, maintain proper cold-chain storage, and provide authentic products with identifiable lot numbers. Avoid sources that do not require a prescription, lack pharmacy licensing, have unclear product origins, or make unrealistic bodybuilding or anti-aging claims.

How Do You Buy Human Growth Hormone Legally Online?

You can buy HGH hormone legally online only with a valid prescription from a licensed healthcare provider and through a licensed online pharmacy. Choose a pharmacy that verifies prescriptions, offers pharmacist access, dispenses approved products, and uses temperature-controlled shipping. Avoid sellers that offer HGH without a prescription, promote oral HGH, hide business details, or advertise unrealistically low prices.

Follow these steps to buy human growth hormone (HGH) legally online:

• Obtain a medical diagnosis from a licensed healthcare provider and receive a valid prescription if HGH is medically indicated.
• Choose a licensed online pharmacy that verifies prescriptions, provides pharmacist access, and dispenses FDA-approved or locally authorized HGH from approved manufacturers.
• Verify safe delivery practices by confirming temperature-controlled shipping, intact packaging, identifiable lot numbers, recall policies, and any required insurance or prior authorization.
• Follow local customs and import regulations if ordering across borders, as prescription and import rules vary by country.
• Watch for warning signs, including pharmacies that sell HGH without a prescription, accept only cryptocurrency, hide business or licensing details, claim oral HGH works like injections, omit lot information, or offer prices far below those charged by regulated pharmacies.

How Much Does Human Growth Hormone Cost?

HGH therapy costs about $1,200 to $5,000 per month for the medication alone, with brand-name products such as Norditropin and Genotropin often costing $2,400 to $4,800 per month, while biosimilar options range from $1,000 to $2,500 per month. Total treatment costs increase with endocrinology consultations, IGF-1 testing, growth hormone stimulation tests, injection supplies, and ongoing monitoring, bringing annual expenses to approximately $15,000 to $60,000. 

Insurance commonly covers pediatric growth hormone deficiency, while adult coverage usually requires documented deficiency, prior authorization, deductibles, and coinsurance. Eligible patients also qualify for manufacturer patient-assistance programs that help reduce out-of-pocket costs.