It is a separate one-time $20 dermatologist review fee for each new product purchase or new subscription start, whether you are a new patient or a returning patient. It is listed before you submit the order.
The fee does not apply to recurring subscription renewals. Your checkout summary also shows your treatment price, amount due today, shipping, and renewal cadence. Review the displayed total before confirming your order.
If you stop a subscription and start it again later, review the checkout summary for any applicable charge before submitting the new order.