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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications Compound Exclusion List of Bulk Chemicals TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION 1 10-1 CLEANSER (GRAM) 1-DAY OINTMENT WITH PREFILLED APPLICATOR 1ST BASE CREAM (GRAM) 1ST MEDX-PATCH ADHESIVE PATCH, MEDICATED 1ST RELIEF SPRAY, NON-AEROSOL (ML) 2 IN 1 DANDRUFF SHAMPOO SHAMPOO 2,3-DIMERCAPTOSUCCINIC ACID POWDER (GRAM) 2,4-DINITROCHLOROBENZENE CRYSTALS 24 HOUR ALLERGY TABLET 24HOUR ALLERGY TABLET 2-DEOXY-D-GLUCOSE POWDER (GRAM) 2-METHOXYESTRADIOL POWDER (GRAM) 3M NEXCARE DURAPORE TAPE, NON-MEDICATED 4-AMINOBENZOIC ACID POTASSIUM POWDER (GRAM) 4-AMINOPYRIDINE POWDER (GRAM) 7-KETO DHEA POWDER (GRAM) A & D CREAM (GRAM) A.E.R TRAVELER TOWELETTE (EA) ABREVA CREAM (GRAM)

Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

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Page 1: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

1

10-1 CLEANSER (GRAM)

1-DAY OINTMENT WITH PREFILLED APPLICATOR

1ST BASE CREAM (GRAM)

1ST MEDX-PATCH ADHESIVE PATCH, MEDICATED

1ST RELIEF SPRAY, NON-AEROSOL (ML)

2 IN 1 DANDRUFF SHAMPOO SHAMPOO

2,3-DIMERCAPTOSUCCINIC ACID POWDER (GRAM)

2,4-DINITROCHLOROBENZENE CRYSTALS

24 HOUR ALLERGY TABLET

24HOUR ALLERGY TABLET

2-DEOXY-D-GLUCOSE POWDER (GRAM)

2-METHOXYESTRADIOL POWDER (GRAM)

3M NEXCARE DURAPORE TAPE, NON-MEDICATED

4-AMINOBENZOIC ACID POTASSIUM POWDER (GRAM)

4-AMINOPYRIDINE POWDER (GRAM)

7-KETO DHEA POWDER (GRAM)

A & D CREAM (GRAM)

A.E.R TRAVELER TOWELETTE (EA)

ABREVA CREAM (GRAM)

Page 2: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

2

ABSORBINE PAIN RELIEVING GEL (GRAM)

ABSTRAL TABLET, SUBLINGUAL

ACACIA POWDER (GRAM)

ACANYA GEL WITH PUMP (GRAM)

ACCOLATE TABLET

ACEBUTOLOL HCL POWDER (GRAM)

ACEPHEN SUPPOSITORY, RECTAL

ACEPROMAZINE MALEATE POWDER (GRAM)

ACESULFAME POTASSIUM POWDER (GRAM)

ACETAMINOPHEN POWDER (GRAM)

ACETAMINOPHEN SUPPOSITORY, RECTAL

ACETAMINOPHEN W/BUTALBITAL TABLET

ACETARSONE POWDER (GRAM)

ACETAZOLAMIDE POWDER (GRAM)

ACETIC ACID LIQUID (ML)

ACETYL HEXAPEPTIDE-8 POWDER (GRAM)

ACETYL HEXAPEPTIDE-8 SOLUTION, NON-ORAL

ACETYL SALICYLIC ACID POWDER (GRAM)

ACETYLCHOLINE CHLORIDE POWDER (GRAM)

Page 3: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

3

ACETYLCYSTEINE POWDER (GRAM)

ACETYL-D-GLUCOSAMINE POWDER (GRAM)

ACETYL-L-CARNITINE HCL POWDER (GRAM)

ACID REDUCER CAPSULE,DELAYED RELEASE (ENTERIC COATED)

ACIDOPHILUS LACTOBACILLUS POWDER (GRAM)

ACIPHEX TABLET, ENTERIC COATED

ACIPHEX SPRINKLE CAPSULE, DELAYED RELEASE SPRINKLE

ACNE CARE BAR

ACNE CLEANSER CLEANSER (GRAM)

ACNE CLEANSING BAR BAR

ACNE CONTROL CLEANSER CLEANSER (GRAM)

ACNE CONTROL CLEANSER CREAM (GRAM)

ACNE CREAM CREAM (GRAM)

ACNE FOAMING FACE WASH CLEANSER (GRAM)

ACNE MEDICATION GEL (GRAM)

ACNE MEDICATION LOTION (ML)

ACNE PAD PADS, MEDICATED (EA)

ACNE SPOT TREATMENT CREAM (GRAM)

ACNE TREATMENT GEL (GRAM)

Page 4: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

4

ACNE TREATMENT CLEANSING BAR BAR

ACNECLEAR GEL (GRAM)

ACNEFREE COMBINATION PACKAGE (ML)

ACNEFREE SEVERE KIT

ACNOMEL CREAM (GRAM)

ACTICARNITINE SF SOLUTION, ORAL

ACTICOAT BANDAGE

ACTICOAT FLEX 3 BANDAGE

ACTICOAT FLEX 7 BANDAGE

ACTICOAT MOISTURE CONTROL BANDAGE

ACTICOAT SITE BANDAGE

ACTIMARIS WOUND GEL GEL (GRAM)

ACTIQ LOZENGE ON A HANDLE

ACTIVATED CHARCOAL POWDER (GRAM)

ACUICYN SPRAY, NON-AEROSOL (ML)

ACULAR DROPS

ACULAR LS DROPS

ACUWASH CLEANSER (ML)

ACYCLOVIR CREAM (GRAM)

Page 5: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

5

ACYCLOVIR OINTMENT (GRAM)

ACYCLOVIR POWDER (GRAM)

ACZONE GEL (GRAM)

ACZONE GEL WITH PUMP (GRAM)

ADALAT CC TABLET, EXTENDED RELEASE

ADAPALENE CREAM (GRAM)

ADAPALENE GEL (GRAM)

ADAPALENE GEL WITH PUMP (GRAM)

ADAPALENE LOTION (ML)

ADAPALENE SOLUTION, NON-ORAL

ADAPALENE SWAB, MEDICATED

ADAPALENE-BENZOYL PEROXIDE GEL WITH PUMP (GRAM)

ADAZIN CREAM (GRAM)

ADDAPRIN TABLET

ADEMETIONINE DISULFATE TOSYLAT POWDER (GRAM)

ADENOSINE POWDER (GRAM)

ADENOSINE-5-TRIPHOSPHATE POWDER (GRAM)

ADENOSYLCOBALAMIN POWDER (GRAM)

ADHESIVE BANDAGE BANDAGE

Page 6: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

6

ADHESIVE PADS BANDAGE

ADHESIVE TAPE TAPE, NON-MEDICATED

ADRENOCORTICOTROPHIC HORMONE POWDER (GRAM)

ADVANCED ACNE SPOT TREATMENT GEL (ML)

ADVANCED ACNE SPOT TREATMENT OINTMENT(ML)

ADVANCED ACNE WASH CLEANSER, EXTENDED RELEASE

ADVANCED ANTIBACTERIAL BANDAGE ADHESIVE PATCH, MEDICATED

ADVANCED EXFOLIATING CLEANSER CLEANSER (GRAM)

ADVANCED HEALING BANDAGE BANDAGE

ADVANCED HEALING PAD BANDAGE

ADVANCED WOUND CLEANSER (ML)

ADVIL CAPSULE

ADVIL TABLET

ADVIL TABLET,CHEWABLE

ADVIL COLD & SINUS CAPSULE

ADVIL COLD & SINUS TABLET

ADVIL LIQUI-GELS CAPSULE

ADVIL MIGRAINE CAPSULE

ADVIL PM CAPSULE

Page 7: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

7

ADVIL PM TABLET

ADVOCATE PAIN RELIEF LIQUID (ML)

AER PADS, MEDICATED (EA)

AFEDITAB CR TABLET, EXTENDED RELEASE

AFLEXERYL-LC ADHESIVE PATCH, MEDICATED

AFLEXERYL-MC ADHESIVE PATCH, MEDICATED

AGONEAZE KIT

AKTEN GEL (ML)

AKTIPAK GEL (EA)

ALANINE POWDER (GRAM)

ALA-QUIN CREAM (GRAM)

ALA-SEB SHAMPOO

ALA-SEB-T SHAMPOO

ALAVERT TABLET, EXTENDED RELEASE 12 HR

ALAVERT TABLET, DISINTEGRATING

ALBA-DERM CREAM (GRAM)

ALBENDAZOLE POWDER (GRAM)

ALBUTEROL SULFATE POWDER (GRAM)

ALCLOMETASONE DIPROPIONATE CREAM (GRAM)

Page 8: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

8

ALCLOMETASONE DIPROPIONATE OINTMENT (GRAM)

ALCOHOL SOLUTION, NON-ORAL

ALCOHOL PREP PADS, MEDICATED (EA)

ALCOHOL PREP PAD PADS, MEDICATED (EA)

ALCOHOL SWABS WITH BENZOCAINE PADS, MEDICATED (EA)

ALCOHOL WIPES PADS, MEDICATED (EA)

ALCORTIN A GEL (GRAM)

ALCORTIN A GEL IN PACKET (GRAM)

ALDOSTERONE POWDER (GRAM)

ALEVE CAPSULE

ALEVE TABLET

ALEVICYN GEL (GRAM)

ALEVICYN SPRAY, NON-AEROSOL (ML)

ALEVICYN ANTIPRURITIC SG SPRAY GEL

ALFENTA AMPUL (ML)

ALFENTANIL HYDROCHLORIDE AMPUL (ML)

ALGICELL AG BANDAGE

ALGINIC ACID POWDER (GRAM)

ALGISITE M BANDAGE

Page 9: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

9

ALIVIO ADHESIVE PATCH, MEDICATED

ALKYL (C12-15) BENZOATE LIQUID (ML)

ALKYL ACRYLATE CROSSPOLYMER POWDER (GRAM)

ALL DAY ALLERGY SOLUTION, ORAL

ALL DAY ALLERGY TABLET

ALL DAY RELIEF TABLET

ALL DAY RELIEF PAIN TABLET

ALL PURPOSE CLOTH TAPE TAPE, NON-MEDICATED

ALLANTOIN POWDER (GRAM)

ALLEGRA ALLERGY TABLET

ALLERCLEAR TABLET

ALLERCLEAR D-12HR TABLET, EXTENDED RELEASE 12 HR

ALLERCLEAR D-24HR TABLET, EXTENDED RELEASE 24 HR

ALLER-EASE SUSPENSION, ORAL (FINAL DOSE FORM)

ALLER-EASE TABLET

ALLER-FEX TABLET

ALLERGY TABLET

ALLERGY & CONGEST RELIEF TABLET, EXTENDED RELEASE 24 HR

ALLERGY & CONGESTION RELIEF TABLET, EXTENDED RELEASE 12 HR

Page 10: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

10

ALLERGY & CONGESTION RELIEF TABLET, EXTENDED RELEASE 24 HR

ALLERGY CREAM CREAM (GRAM)

ALLERGY RELIEF CAPSULE

ALLERGY RELIEF SOLUTION, ORAL

ALLERGY RELIEF TABLET

ALLERGY RELIEF TABLET, DISINTEGRATING

ALLERGY RELIEF & NASAL DECONGE TABLET, EXTENDED RELEASE 24 HR

ALLERGY RELIEF D TABLET, EXTENDED RELEASE 12 HR

ALLERGY RELIEF D TABLET, EXTENDED RELEASE 24 HR

ALLERGY RELIEF-D TABLET, EXTENDED RELEASE 12 HR

ALLERGY-CONGESTION RELIEF-D TABLET, EXTENDED RELEASE 24 HR

ALLER-TEC TABLET

ALLEVESS PATCH ADHESIVE PATCH, MEDICATED

ALLEVYN BANDAGE

ALLEVYN ADHESIVE BANDAGE

ALLEVYN AG ADHESIVE BANDAGE

ALLEVYN GENTLE BORDER BANDAGE

ALLEVYN GENTLE BORDER LITE BANDAGE

ALLEVYN GENTLE BORDER SACRUM BANDAGE

Page 11: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

11

ALLEVYN LIFE BANDAGE

ALLEVYN SACRUM BANDAGE

ALLOPURINOL POWDER (GRAM)

ALLZITAL TABLET

ALMOND OIL OIL (ML)

ALMOTRIPTAN MALATE TABLET

ALOCANE EMERGENCY BURN GEL (ML)

ALOE BURN GEL AEROSOL, SPRAY (GRAM)

ALOE GRANDE CREAM (GRAM)

ALOE VERA GEL (GRAM)

ALOE VERA GEL (ML)

ALOE VERA OIL (ML)

ALOE VERA POWDER (GRAM)

ALOE VERA PAIN RELIEVING GEL (GRAM)

ALOE VERA W/LIDOCAINE GEL (GRAM)

ALOE VESTA FOAM (ML)

ALOE VESTA SOAP, LIQUID

ALOE VESTA SOLUTION, NON-ORAL

ALOQUIN GEL (GRAM)

Page 12: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

12

ALOXI VIAL (ML)

ALPAWASH OINTMENT (GRAM)

ALPHA KERI OIL OIL (ML)

ALPHA LIPOIC ACID POWDER (GRAM)

ALPHA PINENE LIQUID (GRAM)

ALPHA TOCOPHEROL LIQUID (ML)

ALPHA-KETOGLUTARIC ACID CRYSTALS

ALPHA-LIPOIC ACID POWDER (GRAM)

ALPHASOFT OIL (ML)

ALPRAZOLAM POWDER (GRAM)

ALPROSTADIL POWDER (GRAM)

ALTABAX OINTMENT (GRAM)

ALTADERM CREAM BASE CREAM (GRAM)

ALUM POWDER POWDER (GRAM)

ALUMINUM ACETATE POWDER (GRAM)

ALUMINUM CHLORIDE POWDER (GRAM)

ALUMINUM CHLORIDE SOLUTION, NON-ORAL

ALUMINUM CHLOROHYDRATE POWDER (GRAM)

ALUMINUM HYDROXIDE GRANULES (GRAM)

Page 13: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

13

ALUMINUM HYDROXIDE POWDER (GRAM)

ALUMINUM POTASSIUM SULFATE CRYSTALS

ALUMINUM POTASSIUM SULFATE GRANULES (GRAM)

ALUMINUM SULFATE POWDER (GRAM)

AMANTADINE HCL POWDER (GRAM)

AMCINONIDE CREAM (GRAM)

AMCINONIDE LOTION (ML)

AMCINONIDE OINTMENT (GRAM)

AMELUZ GEL (GRAM)

AMERGE TABLET

AMERICAINE AEROSOL (GRAM)

AMERICAN GINSENG ROOT POWDER (GRAM)

AMERIGEL GEL (GRAM)

AMERIGEL WOUND WASH SOLUTION (GRAM)

AMERIWASH LOTION (ML)

AMIKACIN SULFATE POWDER (GRAM)

AMILORIDE HCL POWDER (GRAM)

AMINOBENZOATE POTASSIUM POWDER (GRAM)

AMINOBENZOIC ACID POWDER (GRAM)

Page 14: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

14

AMINOBUTYRIC ACID POWDER (GRAM)

AMINOCAPROIC ACID POWDER (GRAM)

AMINOLEVULINIC ACID HCL POWDER (GRAM)

AMINOPHYLLINE POWDER (GRAM)

AMINOSALICYLIC ACID POWDER (GRAM)

AMITIZA CAPSULE

AMITRIPTYLINE HCL POWDER (GRAM)

AMLODIPINE BESYLATE POWDER (GRAM)

AMLODIPINE BESYLATE TABLET

AMLODIPINE BESYLATE-BENAZEPRIL CAPSULE

AMMONIUM ALUM POWDER (GRAM)

AMMONIUM BROMIDE GRANULES (GRAM)

AMMONIUM CHLORIDE GRANULES (GRAM)

AMMONIUM LACTATE CREAM (GRAM)

AMMONIUM LACTATE LOTION (GRAM)

AMMONIUM LACTATE SOLUTION, NON-ORAL

AMMONIUM LAURYL SULFATE LIQUID (ML)

AMMONIUM SULFATE GRANULES (GRAM)

AMMONIUM TETRATHIOMOLYBDATE POWDER (GRAM)

Page 15: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

15

AMOXAPINE TABLET

AMOXICILLIN POWDER (GRAM)

AMPHOTERICIN B POWDER (GRAM)

AMRIX CAPSULE, EXT RELEASE 24 HR

ANACAINE OINTMENT (GRAM)

ANAFRANIL CAPSULE

ANA-LEX KIT

ANALGESIC BALM OINTMENT (GRAM)

ANALGESIC CREAM RUB CREAM (GRAM)

ANALGESIC CREME RUB CREAM (GRAM)

ANALPRAM-HC CREAM WITH APPLICATOR

ANALPRAM-HC LOTION (ML)

ANAPROX DS TABLET

ANASEPT GEL (GRAM)

ANASTIA LOTION (GRAM)

ANASTROZOLE POWDER (GRAM)

ANDROSTENEDIONE POWDER (GRAM)

ANECREAM CREAM (GRAM)

ANECREAM KIT

Page 16: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

16

ANHYDROUS BASE CREAM (GRAM)

ANHYDROUS GEL GEL (GRAM)

ANHYDROUS OINTMENT OINTMENT (GRAM)

ANISINDIONE POWDER (GRAM)

ANJESO VIAL (ML)

ANODYNE LPT KIT

ANTHRALIN POWDER (GRAM)

ANTI MONKEY BUTT POWDER (GRAM)

ANTIBACTERIAL BANDAGES ADHESIVE PATCH, MEDICATED

ANTIBACTERIAL PAD ADHESIVE PATCH, MEDICATED

ANTIBACTERIAL SOAP LIQUID (ML)

ANTIBACTERIAL WIPES TOWELETTE (EA)

ANTIBIOTIC OINTMENT (GRAM)

ANTIBIOTIC + PAIN RELIEF CREAM (GRAM)

ANTIBIOTIC + PAIN RELIEF OINTMENT (GRAM)

ANTIBIOTIC PLUS CREAM (GRAM)

ANTI-DANDRUFF WITH MENTHOL SHAMPOO

ANTIFUNGAL LIQUID (ML)

ANTIFUNGAL SOLUTION, NON-ORAL

Page 17: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

17

ANTIFUNGAL NAIL PEN SOLUTION, NON-ORAL

ANTI-ITCH AEROSOL, SPRAY (ML)

ANTI-ITCH CREAM (GRAM)

ANTI-ITCH GEL (ML)

ANTI-ITCH LOTION (ML)

ANTI-ITCH PLUS CREAM (GRAM)

ANTI-ITCH VAGINAL CREAM (GRAM)

ANTI-ITCH VAGINAL MAX STRENGTH CREAM (GRAM)

ANTIMONY SULFIDE POWDER (GRAM)

ANTIMONY TRICHLORIDE CRYSTALS

ANTIPYRINE POWDER (GRAM)

ANTISEPTIC SOLUTION, NON-ORAL

ANTISEPTIC BIO-HAND GEL IN PACKET (ML)

ANTISEPTIC GEL GEL (ML)

ANTISEPTIC PERINEAL WASH II CLEANSER (ML)

ANTISEPTIC SKIN CLEANSER LIQUID (ML)

ANTISEPTIC WOUND-SKIN CLEANSER (ML)

ANU-MED SUPPOSITORY, RECTAL

ANZEMET TABLET

Page 18: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

18

APEXICON E CREAM (GRAM)

APLIGRAF DISK

APOMORPHINE HCL POWDER (GRAM)

APOTHEDERM TRANSDERMAL CREAM (GRAM)

APOTHESAR 2 CREAM (GRAM)

APOTHESAR PLUS CREAM (GRAM)

APOTHESIL BASE CREAM (GRAM)

APRIZIO PAK KIT

APRIZIO PAK II KIT

AQUA GLYCOLIC LOTION (ML)

AQUA GLYCOLIC HC COMBINATION PACKAGE (ML)

AQUA LACTEN LOTION (ML)

AQUACEL BANDAGE

AQUACEL AG FOAM BANDAGE

AQUACEL EXTRA BANDAGE

AQUACEL FOAM BANDAGE

AQUACEL-AG BANDAGE

AQUAFLO BANDAGE

AQUAMED LOTION (ML)

Page 19: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

19

AQUANIL CLEANSER (ML)

AQUAPHILIC WITH CARBAMIDE OINTMENT (GRAM)

ARAZLO LOTION (GRAM)

ARBEM H-COSMETIC CREAM (GRAM)

ARBEM LIPOPEN CREAM (GRAM)

ARCH BANDAGE BANDAGE

ARCTIC RELIEF GEL (GRAM)

ARGININE CRYSTALS

ARGININE POWDER (GRAM)

ARGININE HCL POWDER (GRAM)

ARGLAES POWDER (GRAM)

ARGLAES FILM BANDAGE

ARIDA GEL (GRAM)

ARLACEL 165 FLAKES (GRAM)

ARNICA FLOWER TINCTURE

ARNICA LG LIQUID (GRAM)

ARROW ROOT POWDER (GRAM)

ARSENIC TRIOXIDE POWDER (GRAM)

ARTHRICREAM CREAM (GRAM)

Page 20: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

20

ARTHRITIS CREAM (GRAM)

ARTHRITIS PAIN RELIEF CREAM (GRAM)

ARTHRITIS RELIEF AEROSOL, SPRAY (ML)

ARTHRITIS WONDER CREAM (GRAM)

ARTHRITIS WONDER CREAM ROLL-ON (GRAM)

ARTHROTEC TABLET,IMMEDIATE,DELAY RELEASE,BIPHASE

ARTISS SYRINGE (ML)

ARYMO ER TABLET, ORAL ONLY, EXTENDED RELEASE

ASA-BUTALB-CAFF-COD CAPSULE

ASC LOTIONIZED CLEANSER CLEANSER (ML)

ASCOMP WITH CODEINE CAPSULE

ASCORBIC ACID POWDER (GRAM)

ASCORBYL PALMITATE POWDER POWDER (GRAM)

ASPARAGINE MONOHYDRATE CRYSTALS

ASPARAGINE MONOHYDRATE POWDER (GRAM)

ASPARTAME POWDER (GRAM)

ASPARTIC ACID POWDER (GRAM)

ASPARTIC ACID MAGNESIUM SALT POWDER (GRAM)

ASPARTIC ACID POTASSIUM SALT POWDER (GRAM)

Page 21: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

21

ASPERCREME ADHESIVE PATCH, MEDICATED

ASPERCREME CREAM (GRAM)

ASPERCREME LIQUID ROLL-ON (ML)

ASPERCREME LOTION (ML)

ASPERCREME HEAT GEL (GRAM)

ASPERCREME MAX LIQUID (ML)

ASPER-FLEX CREAM (GRAM)

ASPIRIN POWDER (GRAM)

ASPIRIN SUPPOSITORY, RECTAL

ASTERO GEL WITH PUMP (ML)

ASTRAGALUS ROOT POWDER (GRAM)

ASTRINGENT SOLUTION POWDER IN PACKET (EA)

ASTRINGYN SOLUTION (GRAM)

ATENOLOL POWDER (GRAM)

ATHLETE'S FOOT CREAM (GRAM)

ATHLETIC TAPE TAPE, NON-MEDICATED

ATOPADERM CREAM (GRAM)

ATOPAVO EMULSION (GRAM)

ATOPICLAIR CREAM (GRAM)

Page 22: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

22

ATRAC-TAIN CREAM (GRAM)

ATRAPRO CP COMBINATION PACKAGE, CREAM AND GEL

ATRAPRO DERMAL SPRAY SPRAY, NON-AEROSOL (ML)

ATRAPRO HYDROGEL GEL (GRAM)

ATREVIS HYDROGEL CREAM (GRAM)

ATROPINE SULFATE POWDER (GRAM)

ATTAPULGITE POWDER (GRAM)

AUSTRALIAN TEA TREE OIL OIL (ML)

AUXIPRO VANISHING CREAM CREAM (GRAM)

AVADERM CREAM (GRAM)

AVAGE CREAM (GRAM)

AVAR CLEANSER (GRAM)

AVAR FOAM (GRAM)

AVAR PADS, MEDICATED (EA)

AVAR LS CLEANSER (GRAM)

AVAR LS FOAM (GRAM)

AVAR LS PADS, MEDICATED (EA)

AVAR-E CREAM (GRAM)

AVAR-E LS CREAM CREAM (GRAM)

Page 23: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

23

AVC CREAM WITH APPLICATOR

AVEENO CREAM (GRAM)

AVEENO LOTION (ML)

AVEENO BABY BATH PACKET (EACH)

AVEENO BABY CLEANSER (ML)

AVEENO BABY CREAM (GRAM)

AVEENO BATH PACKET (EA)

AVEENO DAILY MOISTURIZING LOTION (GRAM)

AVEENO DAILY MOISTURIZING LOTION (ML)

AVEENO MOISTURIZING CREAM CREAM (GRAM)

AVENOVA SPRAY, NON-AEROSOL (ML)

AVITENE POWDER (GRAM)

AVITENE POWDER IN PACKET (EA)

AVITENE SHEET (EA)

AVO EMULSION (GRAM)

AVOCADO OIL OIL (ML)

AVOGEL BANDAGE

AVOSIL OINTMENT (GRAM)

AXERT TABLET

Page 24: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

24

AZ CREAM (GRAM)

AZATHIOPRINE POWDER (GRAM)

AZELAIC ACID FLAKES (GRAM)

AZELAIC ACID GEL (GRAM)

AZELAIC ACID POWDER (GRAM)

AZELASTINE HCL POWDER (GRAM)

AZELEX CREAM (GRAM)

AZITHROMYCIN POWDER (GRAM)

B.F.I. POWDER (GRAM)

BABY ANTI MONKEY BUTT CREAM (GRAM)

BABY ANTI MONKEY BUTT POWDER (GRAM)

BABY CHEST RUB OINTMENT (GRAM)

BABY WASH CLEANSER (GRAM)

BACITRACIN OINTMENT (GRAM)

BACITRACIN OINTMENT IN PACKET (EA)

BACITRACIN OINTMENT IN PACKET (GRAM)

BACITRACIN PACKET (EA)

BACITRACIN POWDER (EA)

BACITRACIN POWDER (GRAM)

Page 25: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

25

BACITRACIN/POLYMYXIN OINTMENT (GRAM)

BACITRACIN/POLYMYXIN PACKET (EA)

BACITRAYCIN PLUS OINTMENT (GRAM)

BACLOFEN POWDER (GRAM)

BACLOFEN TABLET

BACLOFEN VIAL (ML)

BACTINE AEROSOL, SPRAY WITH PUMP (ML)

BACTINE SOLUTION, NON-ORAL

BACTINE SPRAY, NON-AEROSOL (ML)

BALMEX CREAM (GRAM)

BALMEX ADULT CARE CREAM (GRAM)

BALMEX COMPLETE PROTECTION CREAM (GRAM)

BALNEOL LOTION (ML)

BALNEOL LOTION IN PACKET

BALSAM PERU-CASTOR OIL OINTMENT (GRAM)

BANDAGE BANDAGE

BANDAGE ROLL BANDAGE

BANDAGES BANDAGE

BAND-AID BANDAGE

Page 26: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

26

BAND-AID ACTIV FLEX BANDAGE

BAND-AID CLOTH TAPE TAPE, NON-MEDICATED

BAND-AID FLEXIBLE FABRIC BANDAGE

BAND-AID GAUZE PADS BANDAGE

BAND-AID HURT-FREE BANDAGE

BAND-AID MIRASORB GAUZE SPONGE SPONGE

BAND-AID NON-STICK PADS BANDAGE

BAND-AID PAPER TAPE TAPE, NON-MEDICATED

BAND-AID PLUS ANTIBIOTIC BANDAGE

BAND-AID ROLLED GAUZE BANDAGE

BAND-AID SECURE-FLEX BANDAGE

BAND-AID SURGIPAD DRESSING BANDAGE

BAND-AID WATERPROOF PAD BANDAGE

BAND-AID WATERPROOF TAPE TAPE, NON-MEDICATED

BANOPHEN ANTI-ITCH CREAM (GRAM)

BARIUM SULFATE POWDER (GRAM)

BASADROX GEL IN PACKET (ML)

BASE 7542 CREAM (GRAM)

BASE C POLYETHYLENE GLYCOL 300 LIQUID (ML)

Page 27: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

27

BASE CREAM CREAM (GRAM)

BASE G ALMOND OIL OIL (ML)

BASE GELATIN GUMMY TROCHE GEL (GRAM)

BASE H-CARBOXYMETHYLCELLULOSE POWDER (GRAM)

BASE HORMONE CREAM CREAM (GRAM)

BASE W301 CREAM (GRAM)

BASE X FLAKES (GRAM)

BASE, NATATROCHE WAX (GRAM)

BASE, PCCA ACACIA SYRUP

BASE, PCCA COBASE #1 WAX (GRAM)

BASE, PCCA DMAE COMPLEX LIQUID (ML)

BASE, PCCA EMULSIFIX-205 EMULSION (GRAM)

BASE, PCCA FIXED OIL SUSP SUSPENSION, ORAL (FINAL DOSE FORM)

BASE, PCCA LOXASPERSE POWDER (GRAM)

BASE, PCCA LOXORAL POWDER (GRAM)

BASE, PCCA MUCOLOX LIQUID (GRAM)

BASE, PCCA OCCLUSADERM GEL (GRAM)

BASE, PCCA PLASTICIZED GEL (GRAM)

BASE, PCCA POLYPEG WAX (GRAM)

Page 28: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

28

BASE, PCCA PRACAMAC OIL OIL (ML)

BASE, PCCA RAPID DISSOLVE POWDER (GRAM)

BASE, PCCA RDT-PLUS POWDER (GRAM)

BASE, PCCA RHEOSPRAY GEL (GRAM)

BASE, PCCA SORBITOL LOLLIPOP FLAKES (GRAM)

BASE, PCCA SPIRA-WASH GEL (GRAM)

BASE, PCCA SUSPENDALL GEL (GRAM)

BASE, PCCA VANISHING CRM-LOT CREAM (GRAM)

BASE, PCCA VANPEN CREAM (GRAM)

BASE, PCCA VERSABASE FOAM (ML)

BASE, PCCA XEMATOP CREAM (GRAM)

BASE, PCCA XYLIFOS POWDER (GRAM)

BASE-I SORBITAN MONOPALMITATE CREAM (GRAM)

BASIC FUCHSIN HYDROCHLORIDE POWDER (GRAM)

BAY RUM LOTION (ML)

BAZA CLEAR OINTMENT (GRAM)

BAZA CREAM COMBINATION PACKAGE (EA)

BAZA PROTECT CREAM (GRAM)

BEAU RX GEL (GRAM)

Page 29: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

29

BECLOMETHASONE DIPROPIONATE POWDER (GRAM)

BEDSIDE-CARE SOLUTION, NON-ORAL

BEDSIDE-CARE PERINEAL CLEANSER (ML)

BELLADONNA LIQUID (ML)

BELLADONNA POWDER (GRAM)

BELLADONNA & OPIUM SUPPOSITORY, RECTAL

BENACTYZINE HCL POWDER (GRAM)

BENADRYL AEROSOL, SPRAY (ML)

BENADRYL ITCH RELIEF SOLUTION, NON-ORAL

BENADRYL ITCH STOPPING CREAM (GRAM)

BENADRYL ITCH STOPPING GEL (ML)

BENAZEPRIL HCL POWDER (GRAM)

BENGAY GEL (GRAM)

BENGAY GREASELESS CREAM (GRAM)

BENGAY ULTRA STRENGTH ADHESIVE PATCH, MEDICATED

BENGAY ULTRA STRENGTH CREAM (GRAM)

BENGAY VANISHING SCENT GEL (GRAM)

BENSAL HP OINTMENT (GRAM)

BENZACLIN GEL (GRAM)

Page 30: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

30

BENZACLIN GEL WITH PUMP (GRAM)

BENZALKONIUM CHLORIDE SOLUTION, NON-ORAL

BENZAMYCIN GEL (GRAM)

BENZEFOAM FOAM (GRAM)

BENZEFOAM ULTRA FOAM (GRAM)

BENZEPRO CLEANSER (GRAM)

BENZEPRO FOAM (GRAM)

BENZEPRO TOWELETTE (EA)

BENZETHONIUM CHLORIDE POWDER (GRAM)

BENZOCAINE POWDER (GRAM)

BENZOIC ACID CRYSTALS

BENZOIC ACID POWDER (GRAM)

BENZOIN TINCTURE

BENZOIN COMPOUND TINCTURE

BENZOIN GUM POWDER (GRAM)

BENZOQUINONE CRYSTALS

BENZOYL PEROXIDE CLEANSER (GRAM)

BENZOYL PEROXIDE CLEANSER (ML)

BENZOYL PEROXIDE FOAM (GRAM)

Page 31: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

31

BENZOYL PEROXIDE GEL (GRAM)

BENZOYL PEROXIDE POWDER (GRAM)

BENZ-PROTECT SWAB, MEDICATED

BENZYL ALCOHOL LIQUID (ML)

BENZYL BENZOATE LIQUID (ML)

BERRI-FREEZ GEL (GRAM)

BERRI-FREEZ GEL (ML)

BERRI-FREEZ SPRAY, NON-AEROSOL (ML)

BETA CARE LOTION (ML)

BETA GLUCAN POWDER (GRAM)

BETA GLUCAN (1-3) NQ POWDER (GRAM)

BETA MED SHAMPOO

BETA XMA CREAM (GRAM)

BETA-CAROTENE BEADS (GRAM)

BETADINE CLEANSER (ML)

BETADINE SOLUTION, NON-ORAL

BETADINE SPRAY, NON-AEROSOL (ML)

BETADINE SWAB, MEDICATED

BETAHISTINE DIHYDROCHLORIDE POWDER (GRAM)

Page 32: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

32

BETAINE POWDER (GRAM)

BETAINE HYDROCHLORIDE POWDER (GRAM)

BETAMETHASONE ACETATE POWDER (GRAM)

BETAMETHASONE DIPROPIONATE POWDER (GRAM)

BETAMETHASONE SODIUM PHOSPHATE POWDER (GRAM)

BETAMETHASONE VALERATE POWDER (GRAM)

BETAMIDE LOTION (ML)

BETASAL SHAMPOO

BETASEPT LIQUID (ML)

BETHANECHOL CHLORIDE POWDER (GRAM)

BHRT BASE CREAM (GRAM)

BIAFINE EMULSION (GRAM)

BIATAIN BANDAGE

BIMATOPROST DROPS, WITH APPLICATOR (ML)

BIMATOPROST POWDER (GRAM)

BIOBRANE BANDAGE

BIOBRANE GLOVES BANDAGE

BIOBRANE-L BANDAGE

BIOFLAVONOID LEMON POWDER (GRAM)

Page 33: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

33

BIOFLAVONOIDS CITRUS POWDER (GRAM)

BIOFREEZE GEL (ML)

BIOGUARD GAUZE BANDAGE

BIOGUARD ISLAND BANDAGE

BIOGUARD NON-ADHERENT BANDAGE

BIONECT CREAM (GRAM)

BIONECT FOAM (GRAM)

BIONECT GEL (GRAM)

BIOPEPTIDE BIOCOSMETIC BASE CREAM (GRAM)

BIOSTEP BANDAGE

BIOSTEP AG BANDAGE

BIO-THERM LOTION (GRAM)

BIOTIN POWDER (GRAM)

BISABOLOL LIQUID (ML)

BISAC-EVAC SUPPOSITORY, RECTAL

BISACODYL ENEMA (ML)

BISACODYL POWDER (GRAM)

BISACODYL SUPPOSITORY, RECTAL

BISCOLAX SUPPOSITORY, RECTAL

Page 34: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

34

BISMUTH CITRATE POWDER (GRAM)

BISMUTH SUBCARBONATE POWDER (GRAM)

BISMUTH SUBGALLATE POWDER (GRAM)

BISMUTH SUBNITRATE POWDER (GRAM)

BISMUTH SUBSALICYLATE POWDER (GRAM)

BLANCHE CREAM (GRAM)

BLENDERM TAPE, NON-MEDICATED

BLISTER RELIEF BANDAGE

BLISTEX OINTMENT (GRAM)

BLOOD CLOTTING AEROSOL (GRAM)

BLUE AGAVE LIQUID (ML)

BLUE GEL GEL (GRAM)

BLUE TUBE CREAM (GRAM)

BLUE-EMU LIDOCAINE PATCH ADHESIVE PATCH, MEDICATED

BOIL EASE OINTMENT (GRAM)

BOIL RELIEF OINTMENT (GRAM)

BORAX GRANULES (GRAM)

BORDERED GAUZE BANDAGE

BORIC ACID GRANULES (GRAM)

Page 35: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

35

BORIC ACID POWDER (GRAM)

BORON POWDER (GRAM)

BORON CITRATE POWDER (GRAM)

BORO-PACKS POWDER IN PACKET (EA)

BOSWELLIA SERRATA EXTRACT POWDER (GRAM)

BP GEL (GRAM)

BP FOAM FOAM (GRAM)

BP GEL GEL (GRAM)

BP WASH CLEANSER (GRAM)

BP WASH CLEANSER (ML)

BP WASH ACNE TREATMENT KIT

BPCO OINTMENT (GRAM)

BPCO OINTMENT IN PACKET (GRAM)

BPO GEL (GRAM)

BPO TOWELETTE (EA)

BPO-10 CLEANSER (GRAM)

BPO-5 CLEANSER (GRAM)

BREATHE RIGHT STRIP

BRIJ LIQUID (GRAM)

Page 36: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

36

BRIJ LIQUID (ML)

BRIJ WAX (GRAM)

BRILLIANT BLUE G POWDER (GRAM)

BRILLIANT GREEN CRYSTALS

BRILLIANT GREEN POWDER (GRAM)

BRIMONIDINE TARTRATE POWDER (GRAM)

BROMELAIN POWDER (GRAM)

BROMFENAC SODIUM POWDER (GRAM)

BROMHEXINE HYDROCHLORIDE POWDER (GRAM)

BROMI-LOTION LOTION (ML)

BROMI-TALC POWDER (GRAM)

BROMI-TALC PLUS POWDER (GRAM)

BROMOCRIPTINE MESYLATE POWDER (GRAM)

BROMPHENIRAMINE MALEATE POWDER (GRAM)

BUDESONIDE POWDER (GRAM)

BUFFER CREAM POWDER (GRAM)

BUFLOMEDIL HCL POWDER (GRAM)

BULKEE II BANDAGE

BUPAP TABLET

Page 37: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

37

BUPIVACAINE HCL POWDER (GRAM)

BUPRENORPHINE HYDROCHLORIDE POWDER (GRAM)

BUPROPION HCL POWDER (GRAM)

BURN RELIEF AEROSOL, SPRAY (GRAM)

BURN RELIEF GEL (GRAM)

BURN RELIEF WITH ALOE AEROSOL, SPRAY (GRAM)

BUSPIRONE HCL POWDER (GRAM)

BUSPIRONE HCL TABLET

BUTALBITAL POWDER (GRAM)

BUTALBITAL COMPOUND CAPSULE

BUTALBITAL COMPOUND W/CODEINE CAPSULE

BUTALBITAL W/ACETAMINOPHEN CAPSULE

BUTALBITAL W/ACETAMINOPHEN TABLET

BUTALBITAL/APAP/CAFFEINE CAPSULE

BUTALBITAL/APAP/CAFFEINE TABLET

BUTALBITAL/CAFF/APAP/CODEINE CAPSULE

BUTALBITAL-ASP-CAFFEINE CAPSULE

BUTALBITAL-ASP-CAFFEINE TABLET

BUTENAFINE HCL CREAM (GRAM)

Page 38: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

38

BUTORPHANOL TARTRATE POWDER (GRAM)

BUTTERFLY CLOSURES TAPE, NON-MEDICATED

BUTYL ALCOHOL LIQUID (ML)

BUTYLATED HYDROXYANISOLE WAX (GRAM)

BUTYLENE GLYCOL LIQUID (ML)

BUTYLPARABEN POWDER (GRAM)

CAFFEINE POWDER (GRAM)

CAFFEINE CITRATED POWDER (GRAM)

CALACLEAR LOTION (ML)

CALADROX OINTMENT (GRAM)

CALADRYL LOTION (ML)

CALADRYL CLEAR LOTION (ML)

CALAGEL GEL (ML)

CALAGESIC LOTION (ML)

CALAHIST LOTION (ML)

CALAHIST CLEAR LOTION (ML)

CALAMINE LOTION (ML)

CALAMINE POWDER (GRAM)

CALAMINE SUSPENSION, TOPICAL (ML)

Page 39: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

39

CALAMINE CLEAR LOTION (ML)

CALAMINE MEDICATED LOTION (ML)

CALAMINE PHENOLATED LOTION (ML)

CALAMINE PLUS LOTION (ML)

CALAN TABLET

CALAN SR TABLET, EXTENDED RELEASE

CALCIPOTRIENE CREAM (GRAM)

CALCIPOTRIENE FOAM (GRAM)

CALCIPOTRIENE OINTMENT (GRAM)

CALCIPOTRIENE POWDER (GRAM)

CALCIPOTRIENE SOLUTION, NON-ORAL

CALCIPOTRIENE-BETAMETHASONE SUSPENSION, TOPICAL (GRAM)

CALCIPOTRIENE-BETAMETHASONE DP OINTMENT (GRAM)

CALCIPOTRIOL POWDER (GRAM)

CALCITRENE OINTMENT (GRAM)

CALCITRIOL CRYSTALS

CALCITRIOL OINTMENT (GRAM)

CALCITRIOL POWDER (GRAM)

CALCITRIOL IN ALMOND OIL LIQUID (ML)

Page 40: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

40

CALCIUM ACETATE POWDER (GRAM)

CALCIUM ALGINATE POWDER (GRAM)

CALCIUM AMINO ACID CHELATE GRANULES (GRAM)

CALCIUM ASCORBATE POWDER (GRAM)

CALCIUM CARBONATE POWDER (GRAM)

CALCIUM CHLORIDE GRANULES (GRAM)

CALCIUM CHLORIDE POWDER (GRAM)

CALCIUM CITRATE POWDER (GRAM)

CALCIUM FOLINATE POWDER (GRAM)

CALCIUM GLUBIONATE POWDER (GRAM)

CALCIUM GLUCONATE POWDER (GRAM)

CALCIUM GLYCEROPHOSPHATE POWDER (GRAM)

CALCIUM HYDROXIDE POWDER (GRAM)

CALCIUM LACTATE POWDER (GRAM)

CALCIUM LEVULINATE DIHYDRATE POWDER (GRAM)

CALCIUM OXIDE POWDER (GRAM)

CALCIUM PANTOTHENATE POWDER (GRAM)

CALCIUM PHOSPHATE POWDER (GRAM)

CALCIUM PHOSPHATE TRIBASIC POWDER (GRAM)

Page 41: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

41

CALCIUM PYRUVATE POWDER (GRAM)

CALCIUM SACCHARATE POWDER (GRAM)

CALCIUM SILICATE POWDER (GRAM)

CALCIUM SULFATE POWDER (GRAM)

CALCIUM THIOGLYCOLATE TRIHYDR POWDER (GRAM)

CALDESENE POWDER (GRAM)

CALDOLOR INTRAVENOUS SOLUTION, PIGGYBACK (ML)

CALDOLOR VIAL (ML)

CALDYPHEN LOTION (ML)

CALDYPHEN CLEAR LOTION (ML)

CALICYLIC CREAM (GRAM)

CALLERGY CLEAR LOTION (ML)

CALLUS CUSHION EACH

CALLUS REMOVER ADHESIVE PATCH, MEDICATED

CALMOL-4 SUPPOSITORY, RECTAL

CALMOSEPTINE OINTMENT (GRAM)

CALMOSEPTINE OINTMENT IN PACKET (GRAM)

CALYPXO CREAM (GRAM)

CAM LOTION (ML)

Page 42: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

42

CAMBIA POWDER IN PACKET (EA)

CAMPHO-PHENIQUE SOLUTION, NON-ORAL

CAMPHOR CRYSTALS

CAMPHOR SPIRIT

CAMPHOTREX GEL WITH APPLICATOR (GRAM)

CANADA BALSAM LIQUID (ML)

CANASA SUPPOSITORY, RECTAL

CANTHARIDIN CRYSTALS

CANTHARIDIN POWDER (GRAM)

CAPRYLIC ACID LIQUID (ML)

CAPRYLIC-CAPRIC TRIGLYCERIDE LIQUID (ML)

CAPSAICIN ADHESIVE PATCH, MEDICATED

CAPSAICIN CREAM (GRAM)

CAPSAICIN LIQUID (ML)

CAPSAICIN POWDER (GRAM)

CAPSAICIN HOT PATCH ADHESIVE PATCH, MEDICATED

CAPSAICIN PALMITATE POWDER (GRAM)

CAPSFENAC PAK KIT, CREAM AND SOLUTION

CAPSICUM HOT PATCH ADHESIVE PATCH, MEDICATED

Page 43: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

43

CAPSICUM OLEORESIN LIQUID (ML)

CAPTOPRIL POWDER (GRAM)

CAPZASIN GEL WITH APPLICATOR (GRAM)

CAPZASIN LIQUID (ML)

CAPZASIN-HP CREAM (GRAM)

CARBACHOL POWDER (GRAM)

CARBAMAZEPINE POWDER (GRAM)

CARBAMAZEPINE ER TABLET, EXTENDED RELEASE 12 HR

CARBAMIDE PEROXIDE POWDER (GRAM)

CARBATROL CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR

CARBAZOCHROME REAGENT POWDER (GRAM)

CARBIDOPA POWDER (GRAM)

CARBIMAZOLE POWDER (GRAM)

CARBOFLEX BANDAGE

CARBOGEL GEL (GRAM)

CARBOHOL GEL (GRAM)

CARBOMER 934P POWDER (GRAM)

CARBOMER 940 POWDER (GRAM)

CARBOMER GEL-AQUEOUS GEL (GRAM)

Page 44: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

44

CARBOMER GEL-HYDROALCOHOLIC GEL (GRAM)

CARBOMER HOMOPOLYMER TYPE C POWDER (GRAM)

CARBOXYMETHYLCELLULOSE SODIUM GRANULES (GRAM)

CARDENE AMPUL (ML)

CARDENE INTRAVENOUS SOLUTION, PIGGYBACK (ML)

CARDIZEM TABLET

CARDIZEM CD CAPSULE, EXT RELEASE 24 HR

CARDIZEM LA TABLET, EXTENDED RELEASE 24 HR

CARETOUCH ALCOHOL PREP PAD PADS, MEDICATED (EA)

CA-REZZ CREAM (GRAM)

CA-REZZ SOAP, LIQUID

CA-REZZ NORISC CREAM (GRAM)

CA-REZZ NORISC SPRAY, NON-AEROSOL (ML)

CARISOPRODOL POWDER (GRAM)

CARISOPRODOL TABLET

CARISOPRODOL COMPOUND TABLET

CARISOPRODOL COMPOUND/CODEINE TABLET

CARISOPRODOL-ASPIRIN TABLET

CARISOPRODOL-ASPIRIN-CODEINE TABLET

Page 45: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

45

CARNAUBA WAX FLAKES (GRAM)

CARNITOR SOLUTION, ORAL

CARNITOR TABLET

CARNITOR VIAL (ML)

CARNITOR SF SOLUTION, ORAL

CARRAGEENAN POWDER (GRAM)

CARRASYN GEL GEL (GRAM)

CARRASYN HYDROGEL WOUND GEL (GRAM)

CARRINGTON MOISTURE BARRIER CREAM (GRAM)

CARTIA XT CAPSULE, EXT RELEASE 24 HR

CASCARA SAGRADA FLUID EXTRACT

CASTELLANI PAINT LIQUID (ML)

CASTELLANI PAINT MODIFIED LIQUID (ML)

CASTIVA COOLING LIQUID (GRAM)

CASTIVA WARMING LIQUID (GRAM)

CAVILON CREAM (ML)

CAVILON LOTION (ML)

CAVILON SPRAY, NON-AEROSOL (ML)

CAVILON MOISTURIZING BODY CREAM (ML)

Page 46: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

46

CAYA CONTOURED DIAPHRAGM

CEDAR LEAF OIL OIL (ML)

CEFTAZIDIME POWDER (GRAM)

CEFTAZIDIME-SODIUM CARBONATE POWDER (GRAM)

CEFTRIAXONE SODIUM POWDER (GRAM)

CELA CREAM BASE CREAM (GRAM)

CELACYN GEL WITH PUMP (GRAM)

CELACYN POST PROCEDURE COMBINATION PACKAGE, GEL AND SPRAY

CELEBREX CAPSULE

CELECOXIB CAPSULE

CELECOXIB POWDER (GRAM)

CELLULASE POWDER (GRAM)

CEO-TWO SUPPOSITORY, RECTAL

CERACADE EMULSION (GRAM)

CERAMAX CREAM (GRAM)

CERAMAX LOTION (GRAM)

CERAVE CLEANSER (ML)

CERAVE LOTION, EXTENDED RELEASE (ML)

CERESIN WAX (GRAM)

Page 47: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

47

CERTAIN LIQUID (ML)

CERVIDIL INSERT, EXTENDED RELEASE

CESIUM CHLORIDE CRYSTALS

CETACAINE AEROSOL, SPRAY (GRAM)

CETACAINE ANESTHETIC LIQUID (GRAM)

CETAKLENZ CLEANSER (ML)

CETAPHIL BAR

CETAPHIL CLEANSER (ML)

CETAPHIL CREAM (GRAM)

CETAPHIL LOTION (GRAM)

CETAPHIL LOTION (ML)

CETAPHIL DERMACONTROL LOTION (ML)

CETAPHIL RESTORADERM CLEANSER (ML)

CETAPHIL RESTORADERM LOTION (ML)

CETEARYL ALCOHOL-CETEARETH-20 FLAKES (GRAM)

CETIRIZINE HCL SOLUTION, ORAL

CETIRIZINE HCL TABLET

CETIRIZINE HCL TABLET,CHEWABLE

CETYL ALCOHOL FLAKES (GRAM)

Page 48: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

48

CETYL ALCOHOL GRANULES (GRAM)

CETYL ESTERS FLAKES (GRAM)

CETYL MYRISTOLEATE OIL (GRAM)

CETYL MYRISTOLEATE POWDER (GRAM)

CETYL MYRISTOLEATE WAX (GRAM)

CETYLPYRIDINIUM CHLORIDE CRYSTALS

CHAMOMILE FLOWER POWDER (GRAM)

CHAMOSYN OINTMENT (GRAM)

CHEST RUB OINTMENT (GRAM)

CHEST RUB STICK (GRAM)

CHEW-HESIVE GEL (GRAM)

CHILD ALL DAY ALLERGY SOLUTION, ORAL

CHILD PAIN REL-FEVER REDUCER SUPPOSITORY, RECTAL

CHILDREN'S ADVIL SUSPENSION, ORAL (FINAL DOSE FORM)

CHILDREN'S ALL DAY ALLERGY SOLUTION, ORAL

CHILDREN'S ALLEGRA ALLERGY SUSPENSION, ORAL (FINAL DOSE FORM)

CHILDREN'S ALLEGRA ALLERGY TABLET, DISINTEGRATING

CHILDREN'S ALLERGY COMPLETE SOLUTION, ORAL

CHILDRENS ALLERGY MEDICINE SOLUTION, ORAL

Page 49: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

49

CHILDREN'S ALLERGY MEDICINE SOLUTION, ORAL

CHILDREN'S ALLERGY RELIEF SOLUTION, ORAL

CHILDREN'S ALLERGY RELIEF SUSPENSION, ORAL (FINAL DOSE FORM)

CHILDREN'S ALLERGY RELIEF TABLET,CHEWABLE

CHILDREN'S ALLER-TEC SOLUTION, ORAL

CHILDREN'S CETIRIZINE HCL SOLUTION, ORAL

CHILDREN'S CETIRIZINE HCL TABLET,CHEWABLE

CHILDREN'S CLARITIN SOLUTION, ORAL

CHILDREN'S CLARITIN TABLET,CHEWABLE

CHILDREN'S FEVER REDUCING SUPPOSITORY, RECTAL

CHILDREN'S IBUPROFEN SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)

CHILDREN'S IBUPROFEN SUSPENSION, ORAL (FINAL DOSE FORM)

CHILDREN'S LORATADINE SOLUTION, ORAL

CHILDREN'S LORATADINE TABLET,CHEWABLE

CHILDREN'S MOTRIN SUSPENSION, ORAL (FINAL DOSE FORM)

CHILDREN'S PROFEN IB SUSPENSION, ORAL (FINAL DOSE FORM)

CHILDREN'S WAL-FEX SUSPENSION, ORAL (FINAL DOSE FORM)

CHILDREN'S WAL-ZYR SOLUTION, ORAL

CHILDREN'S WAL-ZYR TABLET,CHEWABLE

Page 50: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

50

CHILDREN'S ZYRTEC SOLUTION, ORAL

CHILDREN'S ZYRTEC ALLERGY TABLET, DISINTEGRATING

CHILD'S BENADRYL ITCH COOLING GEL (GRAM)

CHLORAL HYDRATE CRYSTALS

CHLORAMBUCIL POWDER (GRAM)

CHLORAMPHENICOL POWDER (GRAM)

CHLORAMPHENICOL PALMITATE POWDER (GRAM)

CHLORHEXIDINE DIACETATE POWDER (GRAM)

CHLORHEXIDINE GLUCONATE LIQUID (ML)

CHLORHEXIDINE GLUCONATE SOLUTION, NON-ORAL

CHLORHEXIDINE GLUCONATE TOWELETTE (EA)

CHLOROACETIC ACID POWDER (GRAM)

CHLOROBUTANOL CRYSTALS

CHLOROPHYLLIN SODIUM COPPER POWDER (GRAM)

CHLOROQUINE PHOSPHATE POWDER (GRAM)

CHLOROXINE POWDER (GRAM)

CHLOROXYLENOL POWDER (GRAM)

CHLORPHENIRAMINE MALEATE POWDER (GRAM)

CHLORPROMAZINE HCL POWDER (GRAM)

Page 51: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

51

CHLORZOXAZONE TABLET

CHOLECALCIFEROL CRYSTALS

CHOLESTEROL POWDER (GRAM)

CHOLESTYRAMINE POWDER (GRAM)

CHOLINE CRYSTALS

CHOLINE POWDER (GRAM)

CHOLINE BITARTRATE POWDER (GRAM)

CHOLINE MAG TRISALICYLATE POWDER (GRAM)

CHONDROITIN SULFATE POWDER (GRAM)

CHORIONIC GONADOTROPIN POWDER (EA)

CHROMIUM PICOLINATE POWDER (GRAM)

CHROMIUM POLYNICOTINATE POWDER (GRAM)

CHROMIUM POT SULF DODECAHYDR POWDER (GRAM)

CHRYSADERM DAY CREAM CREAM (GRAM)

CHRYSADERM NIGHT CREAM CREAM (GRAM)

CHRYSIN POWDER (GRAM)

CHYMOTRYPSIN POWDER (GRAM)

CICA-CARE SHEET (EA)

CICLODAN COMBINATION PACKAGE (GRAM)

Page 52: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

52

CICLODAN SOLUTION, NON-ORAL

CICLOPIROX SOLUTION, NON-ORAL

CICLOPIROX OLAMINE POWDER (GRAM)

CIDALEAZE CREAM (GRAM)

CIDOFOVIR POWDER (GRAM)

CIMETIDINE POWDER (GRAM)

CINNAMON BARK POWDER (GRAM)

CIPROFLOXACIN HCL CRYSTALS

CIPROFLOXACIN HCL POWDER (GRAM)

CISPLATIN POWDER (GRAM)

CITRIC ACID GRANULES (GRAM)

CITRIC ACID POWDER (GRAM)

CITRUS BERGAMOT POWDER (GRAM)

CLARINEX SYRUP

CLARINEX TABLET

CLARITHROMYCIN POWDER (GRAM)

CLARITIN CAPSULE

CLARITIN SOLUTION, ORAL

CLARITIN TABLET

Page 53: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

53

CLARITIN TABLET, DISINTEGRATING

CLARITIN-D TABLET, EXTENDED RELEASE 12 HR

CLARITIN-D TABLET, EXTENDED RELEASE 24 HR

CLEAN & CLEAR ADVANTAGE LOTION (ML)

CLEANSING EYELID WIPES PADS, MEDICATED (EA)

CLEANSING SKIN CREAM CREAM (GRAM)

CLEANSING WASH CLEANSER (ML)

CLEANSING WASH SOLUTION, NON-ORAL

CLEAR ANTI-ITCH LOTION (ML)

CLEAR AWAY ADHESIVE PATCH, MEDICATED

CLEAR BANDAGES BANDAGE

CLEAR PORE CLEANSER (ML)

CLEAR TAPE TAPE, NON-MEDICATED

CLEAR WATERPROOF STRIPS BANDAGE

CLEARASIL DAILY CLEAR CLEANSER (ML)

CLEARASIL DAILY CLEAR CREAM (GRAM)

CLEMASTINE FUMARATE POWDER (GRAM)

CLEMIZOLE HCL POWDER (GRAM)

CLEVIPREX VIAL (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

54

CLIDINIUM BROMIDE POWDER (GRAM)

CLINDACIN ETZ KIT

CLINDACIN PAC KIT

CLINDAMYCIN HCL POWDER (GRAM)

CLINDAMYCIN PHOSPHATE CRYSTALS

CLINDAMYCIN PHOSPHATE POWDER (GRAM)

CLINDAMYCIN PHOS-TRETINOIN GEL (GRAM)

CLINDAMYCIN-BENZOYL PEROXIDE GEL (GRAM)

CLINDAMYCIN-BENZOYL PEROXIDE GEL WITH PUMP (GRAM)

CLIOQUINOL POWDER (GRAM)

CLM PATCH ADHESIVE PATCH, MEDICATED

CLOBETASOL E CREAM (GRAM)

CLOBETASOL EMULSION FOAM (GRAM)

CLOBETASOL PROPIONATE CREAM (GRAM)

CLOBETASOL PROPIONATE FOAM (GRAM)

CLOBETASOL PROPIONATE POWDER (GRAM)

CLOCORTOLONE PIVALATE CREAM (GRAM)

CLODAN KIT, SHAMPOO AND CLEANSER

CLODERM CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

55

CLOFAZIMINE POWDER (GRAM)

CLOMIPHENE CITRATE POWDER (GRAM)

CLOMIPRAMINE HCL POWDER (GRAM)

CLONAZEPAM POWDER (GRAM)

CLONIDINE HCL POWDER (GRAM)

CLOPIDOGREL POWDER (GRAM)

CLORPACTIN WCS-90 SOLUTION, RECONSTITUTED, NON-ORAL

CLOTH FIRST AID TAPE TAPE, NON-MEDICATED

CLOTH TAPE TAPE, NON-MEDICATED

CLOTRIMAZOLE POWDER (GRAM)

CLOVE OIL OIL (ML)

CMX ADHESIVE PATCH, MEDICATED

COAL TAR SOLUTION, NON-ORAL

COAL TAR TAR (GRAM)

COATS ALOE CREAM (GRAM)

COATS ALOE JELLY (ML)

COATS ALOE LIQUID (ML)

COATS ALOE ANALGESIC LINIMENT

COATS ALOE MOISTURIZING LOTION (ML)

Page 56: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

56

COBAMAMIDE POWDER (GRAM)

COBAN BANDAGE

COCAINE HCL CRYSTALS

COCAINE HCL SOLUTION, NON-ORAL

COCAMIDE DEA LIQUID (ML)

COCOA BUTTER CREAM (GRAM)

COCOA BUTTER LOTION (ML)

COCOA BUTTER OINTMENT (GRAM)

COCONUT OIL (GRAM)

COCONUT OIL (ML)

COCONUT OIL CREAM CREAM (GRAM)

COD LIVER OIL OIL (ML)

CODEINE PHOSPHATE POWDER (GRAM)

CODEINE SULFATE TABLET

COENZYME Q10 POWDER (GRAM)

COLCHICINE POWDER (GRAM)

COLD & HOT ADHESIVE PATCH, MEDICATED

COLD & HOT CREAM (GRAM)

COLD & HOT LIQUID (ML)

Page 57: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

57

COLD & HOT OINTMENT (GRAM)

COLD & HOT EXTRA STR ADHESIVE PATCH, MEDICATED

COLD & HOT PAIN RELIEF ADHESIVE PATCH, MEDICATED

COLD & HOT PAIN RELIEF CREAM (GRAM)

COLD & HOT PAIN RELIEF OINTMENT (GRAM)

COLD & SINUS PAIN RELIEF TABLET

COLD SORE TREATMENT CREAM (GRAM)

COLD SORE TREATMENT GEL (GRAM)

COLD-SINUS RELIEF TABLET

COLEMAN 100 MAX SPRAY, NON-AEROSOL (ML)

COLEMAN 100 MAX INSECT REPEL AEROSOL, SPRAY (GRAM)

COLEMAN BOTANICALS INSECT REP SPRAY, NON-AEROSOL (ML)

COLEMAN HIGH-DRY INSECT REPEL AEROSOL, POWDER (GRAM)

COLEMAN SKINSMART INSECT REP AEROSOL, SPRAY (GRAM)

COLEMAN SKINSMART INSECT REP SPRAY, NON-AEROSOL (ML)

COLEMAN SPORTSMEN INSECT REPEL AEROSOL, SPRAY (GRAM)

COLISTIMETHATE SODIUM POWDER (GRAM)

COLISTIN SULFATE POWDER (EA)

COLLAGEN HYDROLYSATE POWDER (GRAM)

Page 58: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

58

COLLAGENASE POWDER (EA)

COLLODION LIQUID (ML)

COLLODION FLEXIBLE LIQUID (ML)

COLLOIDAL SILICON DIOXIDE POWDER (GRAM)

COMBINE ABD BANDAGE

COMFEEL BANDAGE

COMFEEL PLUS BANDAGE

COMFEEL PURILON GEL (GRAM)

COMFEEL SEASORB BANDAGE

COMFORT PAC-CYCLOBENZAPRINE KIT

COMFORT PAC-IBUPROFEN KIT

COMFORT PAC-MELOXICAM KIT

COMFORT PAC-NAPROXEN KIT

COMFORT SHIELD TOWELETTE (EA)

COMPAZINE SUPPOSITORY, RECTAL

COMPLEX 15 CREAM (GRAM)

COMPLEX 15 LOTION (ML)

COMPOUND W ADHESIVE PATCH, MEDICATED

COMPOUND W GEL (GRAM)

Page 59: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

59

COMPOUND W LIQUID (ML)

COMPRO SUPPOSITORY, RECTAL

CONCEPTROL GEL WITH PREFILLED APPLICATOR (GRAM)

CONDYLOX GEL (GRAM)

CONFORM BANDAGE

CONFORMANT 2 BANDAGE

CONFORMANT 2 SHEET (EA)

CONTI BAR

CONZIP CAPSULE,EXT.RELEASE 24 HR BIPHASIC 17-83

CONZIP CAPSULE,EXT.RELEASE 24 HR BIPHASIC 25-75

COOL HEAT CREAM CREAM (GRAM)

COOL 'N HEAT CREAM (GRAM)

COOL 'N HEAT STICK (GRAM)

COOL THERAPY GEL (ML)

COOLING BURN AEROSOL, SPRAY (GRAM)

COOLMAGIC BANDAGE

COPA HYDROPHILIC FOAM BANDAGE

COPASIL GEL (GRAM)

COPPER GLUCONATE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

60

COPPER GLYCINATE POWDER (GRAM)

COPPER PEPTIDE GHK-CU POWDER (GRAM)

COPPER SULFATE CRYSTALS

CORAL CALCIUM POWDER (GRAM)

CORDRAN CREAM (GRAM)

CORDRAN LOTION (ML)

CORDRAN OINTMENT (GRAM)

CORDRAN TAPE, MEDICATED

CORN CUSHION EACH

CORN OIL OIL (ML)

CORN REMOVER ADHESIVE PATCH, MEDICATED

CORN STARCH POWDER (GRAM)

CORN-CALLUS REMOVER KIT

CORTANE-B LOTION (ML)

CORTICOTROPIN POWDER (GRAM)

CORTISONE CREAM (GRAM)

CORTISONE ACETATE POWDER (GRAM)

CORTISPORIN CREAM (GRAM)

CORTISPORIN OINTMENT (GRAM)

Page 61: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

61

CORTIZONE CREAM (GRAM)

COTTONSEED OIL (ML)

COUMARIN POWDER (GRAM)

CRANBERRY POWDER (GRAM)

CREAM CONCENTRATE CREAM (GRAM)

CREAMY ACNE FACE CLEANSER (GRAM)

CREATINE POWDER (GRAM)

CREATININE POWDER (GRAM)

CRESEMBA CAPSULE

CRESEMBA VIAL (EA)

CRESOL (M) ACETATE LIQUID (ML)

CRINONE GEL WITH PREFILLED APPLICATOR (GRAM)

CRITIC-AID PASTE (GRAM)

CRITIC-AID CLEAR OINTMENT (GRAM)

CROMOLYN SODIUM POWDER (GRAM)

CROTAMITON LIQUID (ML)

CROTON OIL OIL (GRAM)

CUPRIC CHLORIDE CRYSTALS

CUPRIC SULFATE POWDER (GRAM)

Page 62: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

62

CURAD BANDAGE

CURAFIL GEL (GRAM)

CURCUMIN POWDER (GRAM)

CURE CHROME SOLUTION, NON-ORAL

CURI-STRIP STRIP

CURITY BANDAGE

CURITY SPONGE

CURITY ABDOMINAL BANDAGE

CURITY ALCOHOL PREPS PADS, MEDICATED (EA)

CURITY AMD BANDAGE

CURITY AMD SPONGE

CURITY AMD STRIP

CURITY DETECTABLE LAP SPONGE

CURITY IODOFORM BANDAGE

CUSTOM BASE PCCA LIPODERM CREAM (GRAM)

CUTEMOL EMOLLIENT CREAM (GRAM)

CUTICERIN BANDAGE

CUTINOVA HYDRO BANDAGE

CUTIS PLUS CREAM (GRAM)

Page 63: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

63

CUTTER BACKWOODS AEROSOL, SPRAY (GRAM)

CUTTER BACKWOODS SPRAY, NON-AEROSOL (ML)

CUTTER BACKWOODS DRY AEROSOL, SPRAY (GRAM)

CUTTER LEMON EUCALYPTUS SPRAY, NON-AEROSOL (ML)

CUTTER NATURAL REPELLENT AEROSOL, SPRAY (GRAM)

CUTTER NATURAL REPELLENT SPRAY, NON-AEROSOL (ML)

CUTTER SKINSATIONS SPRAY, NON-AEROSOL (ML)

CYANOCOBALAMIN POWDER (GRAM)

CYCLANDELATE POWDER (GRAM)

CYCLOBENZAPRINE HCL CAPSULE, EXT RELEASE 24 HR

CYCLOBENZAPRINE HCL POWDER (GRAM)

CYCLOBENZAPRINE HCL TABLET

CYCLODEXTRIN REAGENT POWDER (GRAM)

CYCLODEXTRIN-BETA POWDER (GRAM)

CYCLOMETHICONE LIQUID (ML)

CYCLOPENTOLATE HCL POWDER (GRAM)

CYCLOPHOSPHAMIDE POWDER (GRAM)

CYCLOSERINE POWDER (GRAM)

CYCLOSPORINE POWDER (GRAM)

Page 64: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

64

CYMBALTA CAPSULE,DELAYED RELEASE (ENTERIC COATED)

CYPROHEPTADINE HCL POWDER (GRAM)

CYSTEAMINE HYDROCHLORIDE POWDER (GRAM)

CYSTEINE POWDER (GRAM)

D & C GREEN #6 POWDER (GRAM)

DAILY ACNE WASH CLEANSER (ML)

DAILY FACE WASH CLEANSER (GRAM)

DAILY MOISTURIZING LOTION LOTION (ML)

DALFAMPRIDINE POWDER (GRAM)

DANAZOL POWDER (GRAM)

DANDRUFF SHAMPOO SHAMPOO

DANDRUFF SHAMPOO-MENTHOL SHAMPOO

DANTROLENE SODIUM POWDER (GRAM)

DAPIPRAZOLE HCL POWDER (GRAM)

DAPSONE GEL (GRAM)

DAPSONE GEL WITH PUMP (GRAM)

DAPSONE POWDER (GRAM)

DAYLOGIC ACNE FOAMING WASH CLEANSER (GRAM)

DAYLOGIC MINOXIDIL FOAM (GRAM)

Page 65: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

65

DAYPRO TABLET

D-BIOTIN POWDER (GRAM)

D-CARE 100X KIT

DEEP BLUE GEL (GRAM)

DEGLYCYRRHIZINATED LICORICE POWDER (GRAM)

DEHYDROEPIANDROSTERONE POWDER (GRAM)

DELUO SPRAY, NON-AEROSOL (ML)

DEMECARIUM BROMIDE POWDER (GRAM)

DEMEROL AMPUL (ML)

DEMEROL CARTRIDGE (ML)

DEMEROL SYRINGE (ML)

DEMEROL TABLET

DEMEROL VIAL (ML)

DENAVIR CREAM (GRAM)

DENDRACIN LOTION (ML)

DENDRACIN NEURODENDRAXCIN LOTION (ML)

DEOXYCHOLIC ACID POWDER (GRAM)

DERMACEA BANDAGE

DERMACEA SPONGE

Page 66: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

66

DERMACEA NON-WOVEN SPONGE

DERMACEA STRETCH BANDAGE

DERMACINRX CLORHEXACIN KIT

DERMACINRX EMPRICAINE KIT

DERMACINRX LEXITRAL COMBINATION PACKAGE, SOLUTION AND CREAM

DERMACINRX PHN PAK KIT, PATCH, MEDICATED AND CREAM

DERMACINRX PRIZOPAK KIT

DERMACINRX SILAPAK KIT

DERMACINRX SILAZONE KIT

DERMACINRX SURGICAL PHARMAPAK KIT

DERMACINRX THERAZOLE PAK COMBINATION PACKAGE (GRAM)

DERMACINRX TSS SOLUTION, NON-ORAL

DERMACINRX ZRM PAK KIT, PATCH, MEDICATED AND CREAM

DERMACLOUD OINTMENT (GRAM)

DERMADAILY LOTION (ML)

DERMADRESS BANDAGE

DERMADROX OINTMENT (GRAM)

DERMADROX SPRAY, NON-AEROSOL (ML)

DERMAFIX AEROSOL, SPRAY (ML)

Page 67: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

67

DERMAGAUZE BANDAGE

DERMAGESIC CREAM (GRAM)

DERMAGESIC LOTION (ML)

DERMAGINATE BANDAGE

DERMAGRAFT SHEET (EA)

DERMAGRAN GEL (GRAM)

DERMAGRAN OINTMENT (GRAM)

DERMAGRAN HYDROPHILIC WOUND BANDAGE

DERMAL WOUND CLEANSER CLEANSER (ML)

DERMALEVIN BANDAGE

DERMAMED AEROSOL, SPRAY (ML)

DERMAMED OINTMENT (GRAM)

DERMANAIL LIQUID (ML)

DERMAPLEX GEL (GRAM)

DERMAREST PSORIASIS GEL (ML)

DERMAREST PSORIASIS LOTION (ML)

DERMAREST PSORIASIS SHAMPOO

DERMASARRA LOTION (ML)

DERMA-SMOOTHE-FS OIL (ML)

Page 68: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

68

DERMASORB HC COMBINATION PACKAGE, CLEANSER AND LOTION

DERMASORB TA CREAM (GRAM)

DERMASYN GEL (GRAM)

DERMASYN SPRAY, NON-AEROSOL (GRAM)

DERMAVIEW BANDAGE

DERMAVIEW II BANDAGE

DERMAWERX SDS KIT

DERMAWERX SURGICAL PLUS PAK KIT

DERMAZENE CREAM CREAM (GRAM)

DERMAZENE CREAM CREAM IN PACKET (GRAM)

DERMAZINC BAR

DERMAZINC CREAM (GRAM)

DERMAZINC SHAMPOO

DERMAZINC SPRAY, NON-AEROSOL (ML)

DERMAZONE KIT

DERMAZYL KIT, PATCH, MEDICATED AND CREAM

DERMOPLAST AEROSOL (GRAM)

DERMULCERA OINTMENT (GRAM)

DESIPRAMINE HCL POWDER (GRAM)

Page 69: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

69

DESIPRAMINE HCL TABLET

DESLORATADINE TABLET

DESLORATADINE TABLET, DISINTEGRATING

DESMOPRESSIN ACETATE POWDER (GRAM)

DESONIDE POWDER (GRAM)

DESOXIMETASONE POWDER (GRAM)

DESOXYCORTICOSTERONE ACETATE POWDER (GRAM)

DEVIL'S CLAW POWDER (GRAM)

DEXAMETHASONE POWDER (GRAM)

DEXAMETHASONE ACETATE POWDER (GRAM)

DEXAMETHASONE MICRONIZED POWDER (GRAM)

DEXAMETHASONE SODIUM PHOSPHATE POWDER (GRAM)

DEXILANT CAPSULE, DELAYED RELEASE, BIPHASIC

DEXPANTHENOL LIQUID (GRAM)

DEXPANTHENOL POWDER (GRAM)

DEXTRAN POWDER (GRAM)

DEXTROMETHORPHAN HBR POWDER (GRAM)

DEXTROSE GRANULES (GRAM)

DEXTROSE POWDER (GRAM)

Page 70: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

70

D-GALACTOSE POWDER (GRAM)

D-GLUCONOLACTONE POWDER (GRAM)

DHEA POWDER (GRAM)

DHS SHAMPOO

DHS CONDITIONING RINSE SOLUTION, NON-ORAL

DHS SAL SHAMPOO

DHS ZINC SHAMPOO

DIAMINOPYRIDINE POWDER (GRAM)

DIAPER CREAM CREAM (GRAM)

DIASTAT KIT

DIASTAT ACUDIAL KIT

DIAZEPAM KIT

DIAZEPAM POWDER (GRAM)

DIAZOXIDE POWDER (GRAM)

DIBUCAINE OINTMENT (GRAM)

DIBUCAINE HCL POWDER (GRAM)

DIBUTYL SQUARATE LIQUID (GRAM)

DICHLORALPHENAZONE POWDER (GRAM)

DICHLOROACETIC ACID LIQUID (ML)

Page 71: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

71

DICKINSON'S WITCH HAZEL LIQUID (ML)

DICLO GEL KIT

DICLO GEL-XRYLIX SHEET KIT

DICLOFENAC POTASSIUM TABLET

DICLOFENAC SODIUM DROPS

DICLOFENAC SODIUM GEL (GRAM)

DICLOFENAC SODIUM POWDER (GRAM)

DICLOFENAC SODIUM TABLET, ENTERIC COATED

DICLOFENAC SODIUM TABLET, EXTENDED RELEASE 24 HR

DICLOFENAC SODIUM MICRONIZED POWDER (GRAM)

DICLOFENAC SODIUM-MISOPROSTOL TABLET,IMMEDIATE,DELAY RELEASE,BIPHASE

DICLOFEX DC COMBINATION PACKAGE, SOLUTION AND CREAM

DICLOFONO GEL IN PACKET (GRAM)

DICLOPAK KIT, CREAM AND SOLUTION

DICLOSAICIN COMBINATION PACKAGE, SOLUTION AND CREAM

DICLOTRAL COMBINATION PACKAGE, SOLUTION AND CREAM

DICLOZOR KIT

DICUMAROL POWDER (GRAM)

DICYCLOMINE HCL POWDER (GRAM)

Page 72: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

72

DI-DAK-SOL SOLUTION, NON-ORAL

DIETHANOLAMINE LIQUID (ML)

DIETHYLCARBAMAZINE CITRATE POWDER (GRAM)

DIETHYLEN GLYCOL M-ETHYL ETHER LIQUID (ML)

DIETHYL-M-TOLUAMIDE LIQUID (ML)

DIETHYLPROPION HCL POWDER (GRAM)

DIETHYLSTILBESTROL POWDER (GRAM)

DIFFERIN CREAM (GRAM)

DIFFERIN GEL (GRAM)

DIFFERIN GEL WITH PUMP (GRAM)

DIFFERIN LOTION (ML)

DIFLORASONE DIACETATE CREAM (GRAM)

DIFLORASONE DIACETATE OINTMENT (GRAM)

DIFLUCAN SUSPENSION, RECONSTITUTED, ORAL (ML)

DIFLUCAN TABLET

DIFLUNISAL POWDER (GRAM)

DIGOXIN POWDER (GRAM)

DIHYDROCODEINE BITARTRATE POWDER (GRAM)

DIHYDROERGOTAMINE MESYLATE POWDER (GRAM)

Page 73: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

73

DIHYDROXYACETONE POWDER (GRAM)

DIINDOLYLMETHANE POWDER (GRAM)

DIIODO-L-THYRONINE POWDER (GRAM)

DILAUDID LIQUID (ML)

DILAUDID SYRINGE (ML)

DILAUDID TABLET

DILTIAZEM 24HR ER (CD) CAPSULE, EXT RELEASE 24 HR

DILTIAZEM 24HR ER (LA) TABLET, EXTENDED RELEASE 24 HR

DILTIAZEM 24HR ER (XR) CAPSULE,EXTENDED-RELEASE 24HR DEGRADABLE

DILTIAZEM CD CAPSULE, EXTENDED RELEASE 24HR

DILTIAZEM ER CAPSULE, EXTENDED RELEASE 12 HR

DILTIAZEM ER CAPSULE, EXTENDED RELEASE 24HR

DILTIAZEM HCL POWDER (GRAM)

DILTIAZEM HCL TABLET

DILTIAZEM HCL VIAL (ML)

DILTIAZEM HCL VIAL WITH THREADED PORT (EA)

DILT-XR CAPSULE,EXTENDED-RELEASE 24HR DEGRADABLE

DIMENHYDRINATE POWDER (GRAM)

DIMERCAPTOPROPANESULFONATE SOD CRYSTALS

Page 74: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

74

DIMERCAPTOPROPANESULFONATE SOD POWDER (GRAM)

DIMETHIPAC GEL (GRAM)

DIMETHYL FUMARATE CRYSTALS

DIMETHYL SULFONE POWDER (GRAM)

DIMETHYL SULFOXIDE LIQUID (ML)

DIMETHYLACETAMIDE LIQUID (ML)

DIMETHYLAMINOETHANOL BITART POWDER (GRAM)

DIMETHYLGLYCINE HYDROCHLORIDE CRYSTALS

DIOSGENIN POWDER (GRAM)

DIOSMIN POWDER (GRAM)

DIOXYBENZONE POWDER (GRAM)

DIPHENHYDRAMINE HCL CREAM (GRAM)

DIPHENHYDRAMINE HCL POWDER (GRAM)

DIPHENIDOL HCL POWDER (GRAM)

DIPHENYLCYCLOPROPENONE POWDER (GRAM)

DIPYRIDAMOLE POWDER (GRAM)

DISKETS TABLET, SOLUBLE

DISP DOUCHE EXTRA CLNS V&W SOLUTION, NON-ORAL

DISPOSABLE ENEMA ENEMA (ML)

Page 75: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

75

DISTILLED WATER LIQUID (ML)

DISULFIRAM POWDER (GRAM)

DIVALPROEX SODIUM POWDER (GRAM)

DL-3-HYDROXYBUTYRIC ACID SOD POWDER (GRAM)

DL-LEUCINE POWDER (GRAM)

DL-MALIC ACID POWDER (GRAM)

DL-PHENYLALANINE POWDER (GRAM)

DMAE LIQUID (ML)

D-MANNOSE POWDER (GRAM)

DML FACIAL MOISTURIZER CREAM (GRAM)

DML FORTE CREAM (GRAM)

DMSA POWDER (GRAM)

DNA MEDICATED COLLECTION KIT

DOCOSANOL CREAM (GRAM)

DOCOSANOL POWDER (GRAM)

DOCUSATE SODIUM ENEMA (ML)

DOCUSATE SODIUM POWDER (GRAM)

DOCUSOL ENEMA (EA)

DOCUSOL KIDS ENEMA (EA)

Page 76: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

76

DOCUSOL PLUS ENEMA (EA)

DOLOPHINE HCL TABLET

DOLOTRANZ KIT, CREAM AND GEL

DOMEBORO POWDER IN PACKET (EA)

DOPAMINE HCL POWDER (GRAM)

DOUBLE ANTIBIOTIC OINTMENT (GRAM)

DOUBLE ANTIBIOTIC OINTMENT IN PACKET (EA)

DOULEURIN LOTION (ML)

DOVONEX CREAM (GRAM)

DOXAZOSIN MESYLATE POWDER (GRAM)

DOXEPIN HCL CAPSULE

DOXEPIN HCL CONCENTRATE, ORAL

DOXEPIN HCL POWDER (GRAM)

DOXEPIN HCL TABLET

DOXYCYCLINE HYCLATE POWDER (GRAM)

DOXYCYCLINE MONOHYDRATE POWDER (GRAM)

DOXYLAMINE SUCCINATE POWDER (GRAM)

DR SCHOLL'S CLEAR AWAY ADHESIVE PATCH, MEDICATED

DR. SCHOLL'S FOOT POWDER POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

77

DRAW OUT SALVE OINTMENT (GRAM)

DRITHOCREME HP CREAM (GRAM)

DROPERIDOL AMPUL (ML)

DROPERIDOL POWDER (GRAM)

DROPERIDOL VIAL (ML)

DRY SKIN LOTION (ML)

DRY SKIN LOTION LOTION (ML)

DRYMAX EXTRA BANDAGE

DRYSOL SOLUTION, NON-ORAL

DS PREP PAK KIT, GEL AND TOWELETTE

DSUVIA TABLET IN APPLICATOR

DUAC GEL (GRAM)

DULCOLAX SUPPOSITORY, RECTAL

DULOXETINE HCL CAPSULE,DELAYED RELEASE (ENTERIC COATED)

DULOXETINE HCL POWDER (GRAM)

DUODERM BANDAGE

DUODERM CGF BANDAGE

DUODERM HYDROACTIVE BANDAGE

DUODERM HYDROACTIVE GEL (GRAM)

Page 78: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

78

DUODERM HYDROACTIVE PASTE (GRAM)

DUOFILM LIQUID (ML)

DURABASE CREAM (GRAM)

DURABASE ADVANCED CREAM (GRAM)

DURAFIBER BANDAGE

DURAFLEX GEL (ML)

DURAGESIC PATCH, TRANSDERMAL 72 HOURS

DURAMORPH AMPUL (ML)

DURAPORE TAPE, NON-MEDICATED

DUTASTERIDE POWDER (GRAM)

D-XYLOSE POWDER (GRAM)

DYCLONINE HCL POWDER (GRAM)

DYLOJECT VIAL (ML)

DYNAHEX LIQUID (ML)

DYNAMIC KIT

DYNAMIC PLUS PAK KIT

DYPHYLLINE POWDER (GRAM)

EASY COMFORT ALCOHOL PAD PADS, MEDICATED (EA)

EASY TOUCH ALCOHOL PREP PADS PADS, MEDICATED (EA)

Page 79: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

79

EC-NAPROSYN TABLET, ENTERIC COATED

ECONAZOLE NITRATE POWDER (GRAM)

E-CREAM CREAM (GRAM)

ECZEMA CREAM (ML)

ECZEMA LOTION (GRAM)

ECZEMA RELIEF CREAM (GRAM)

EDETATE ACID POWDER (GRAM)

EDETATE CALCIUM DISODIUM POWDER (GRAM)

EDETATE DISODIUM POWDER (GRAM)

EDETATE TETRASODIUM POWDER (GRAM)

EDROPHONIUM CHLORIDE POWDER (GRAM)

EFFERVESCENT POWDER (GRAM)

EGCG POWDER (GRAM)

EGME LIQUID (ML)

EHA LOTION (ML)

ELASTIC BANDAGE BANDAGE

ELASTO-GEL BANDAGE

ELASTO-GEL CAST-SPLINT PADDING BANDAGE

ELASTO-GEL CIRCLE DRESSING BANDAGE

Page 80: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

80

ELETONE CREAM (GRAM)

ELETRIPTAN HBR TABLET

ELEUTHEROCOCCUS SENTICOSUS POWDER (GRAM)

ELIDEL CREAM (GRAM)

ELIMITE CREAM (GRAM)

ELON OINTMENT (GRAM)

ELON DUAL DEFENSE SOLUTION, NON-ORAL

ELURYNG RING, VAGINAL

EMBEDA CAPSULE,ORAL ONLY, EXT. RELEASE PELLETS

EMOLIVAN CREAM (GRAM)

EMOLLIA CREAM (GRAM)

EMOLLIA LIQUID (ML)

EMOLLIENT CREAM (GRAM)

EMPRICAINE-II KIT

EMU OIL LIQUID (ML)

EMU OIL OIL (ML)

EMU-LAC CREAM (ML)

EMULSIFYING WAX WAX (GRAM)

EMULSION CONCENTRATE EMULSION

Page 81: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

81

EMULSION SB EMULSION (GRAM)

ENALAPRIL MALEATE POWDER (GRAM)

ENDO-AVITENE SHEET (EA)

ENDOCET TABLET

ENDOFORM SHEET (EA)

ENDOMETRIN INSERT

ENDOXCIN ADHESIVE PATCH, MEDICATED

ENEMA ENEMA (ML)

ENEMA BAG EACH

ENEMEEZ ENEMA (ML)

ENOVATIZER GEL (ML)

ENSTILAR FOAM (GRAM)

ENTTY SPRAY, NON-AEROSOL (ML)

ENZOCLEAR FOAM (GRAM)

EPHEDRINE HCL POWDER (GRAM)

EPHEDRINE SULFATE POWDER (GRAM)

EPICERAM EMULSION, EXTENDED RELEASE

EPIDUO GEL WITH PUMP (GRAM)

EPIDUO FORTE GEL WITH PUMP (GRAM)

Page 82: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

82

EPIFIX AMNIOTIC MEMBRANE SHEET (EA)

EPIFOAM FOAM (GRAM)

EPINEPHRINE POWDER (GRAM)

EPINEPHRINE BITARTRATE POWDER (GRAM)

EPITOL TABLET

EPSOM SALT CRYSTALS

EQUETRO CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR

ERGOCALCIFEROL POWDER (GRAM)

ERGOLOID MESYLATES POWDER (GRAM)

ERGOTAMINE TARTRATE POWDER (GRAM)

ERTACZO CREAM (GRAM)

ERY SWAB, MEDICATED

ERYGEL GEL (GRAM)

ERYTHROMYCIN GEL (GRAM)

ERYTHROMYCIN POWDER (GRAM)

ERYTHROMYCIN SOLUTION, NON-ORAL

ERYTHROMYCIN SWAB, MEDICATED

ERYTHROMYCIN ESTOLATE POWDER (GRAM)

ERYTHROMYCIN ETHYLSUCCINATE POWDER (GRAM)

Page 83: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

83

ERYTHROMYCIN-BENZOYL PEROXIDE GEL (GRAM)

ESGIC CAPSULE

ESGIC TABLET

ESOMEP-EZS KIT, CAPSULE, DELAYED RELEASE AND SPRAY

ESOMEPRAZOLE MAGNESIUM CAPSULE,DELAYED RELEASE (ENTERIC COATED)

ESOMEPRAZOLE MAGNESIUM SUSP FOR RECON,DELAYED REL. IN A PACKET

ESOMEPRAZOLE SODIUM VIAL (EA)

ESOMEPRAZOLE STRONTIUM CAPSULE,DELAYED RELEASE (ENTERIC COATED)

ESOTERICA FADE CREAM CREAM (GRAM)

ESPUMIL FOAM (ML)

ESTRADIOL POWDER (GRAM)

ESTRADIOL BENZOATE POWDER (GRAM)

ESTRADIOL CYPIONATE POWDER (GRAM)

ESTRADIOL HEMIHYDRATE POWDER (GRAM)

ESTRADIOL VALERATE POWDER (GRAM)

ESTRIOL POWDER (GRAM)

ESTRONE CRYSTALS

ESTRONE POWDER (GRAM)

ETHANOLAMINE LIQUID (ML)

Page 84: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

84

ETHER LIQUID (GRAM)

ETHINYL ESTRADIOL POWDER (GRAM)

ETHOSUXIMIDE POWDER (GRAM)

ETHOXY DIGLYCOL LIQUID (ML)

ETHYL ALCOHOL LIQUID (ML)

ETHYL ALCOHOL SOLUTION, NON-ORAL

ETHYL CHLORIDE AEROSOL, SPRAY (ML)

ETHYL OLEATE LIQUID (ML)

ETHYLENEDIAMINE LIQUID (ML)

ETODOLAC CAPSULE

ETODOLAC TABLET

ETODOLAC ER TABLET, EXTENDED RELEASE 24 HR

ETOMIDATE POWDER (GRAM)

ETONOGESTREL-ETHINYL ESTRADIOL RING, VAGINAL

ETOPOSIDE POWDER (GRAM)

EUCALYPTUS OIL (ML)

EUCERIN LOTION (ML)

EUCERIN DAILY PROTECTION LOTION (ML)

EUCERIN ECZEMA RELIEF CREAM (GRAM)

Page 85: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

85

EVANS BLUE POWDER (GRAM)

EVICEL VIAL (ML)

EXALGO TABLET, EXTENDED RELEASE 24 HR

EXCEL AP SWAB, MEDICATED

EXCEL-GEL GEL (GRAM)

EXCILON SPONGE

EXELDERM CREAM (GRAM)

EXELDERM SOLUTION, NON-ORAL

EXODERM LOTION (ML)

EXOTEN-C LOTION (GRAM)

EXTRA LONG FABRIC BANDAGE BANDAGE

EXUDERM RCD BANDAGE

EXUDERM SACRUM BANDAGE

EXUDERM SATIN BANDAGE

EXUDERM ULTRA BANDAGE

EXU-DRY BANDAGE

EXU-DRY SLIT TUBE BANDAGE

EYELID WIPES TOWELETTE (EA)

EYESCRUB PAD

Page 86: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

86

FABIOR FOAM (GRAM)

FABRIC BANDAGES BANDAGE

FAGRON CAPFILL PRO POWDER (GRAM)

FAGRON DISPERSAPRO POWDER (GRAM)

FAGRON LS PLUS CREAM (GRAM)

FAGRON LS ULTRA CREAM (GRAM)

FAGRON NATURAL CREAM CREAM (GRAM)

FAGRON SUPREME CREAM CREAM (GRAM)

FAGRON VERSIFIX LIQUID (ML)

FAMOTIDINE POWDER (GRAM)

FAST CLEARING SPOT GEL (ML)

FAST RELIEF LAXATIVE SUPPOSITORY, RECTAL

FATTIBASE WAX (GRAM)

FATTY ACID BASE WAX (GRAM)

FD&C BLUE #1 POWDER (GRAM)

FD&C BLUE #2 POWDER (GRAM)

FD&C GREEN #3 POWDER (GRAM)

FD&C RED #3 POWDER (GRAM)

FD&C RED #40 POWDER (GRAM)

Page 87: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

87

FD&C YELLOW #5 POWDER (GRAM)

FD&C YELLOW #6 POWDER (GRAM)

FELDENE CAPSULE

FELODIPINE ER TABLET, EXTENDED RELEASE 24 HR

FEM PH JELLY WITH APPLICATOR (GRAM)

FEMCAP EACH

FEMININE CARE DOUCHE SOLUTION, NON-ORAL

FEMININE MOIST & LUBRICATING JELLY (GRAM)

FEMININE MOISTURIZER GEL WITH APPLICATOR (GRAM)

FEMRING RING, VAGINAL

FENOPROFEN CALCIUM CAPSULE

FENOPROFEN CALCIUM POWDER (GRAM)

FENOPROFEN CALCIUM TABLET

FENORTHO CAPSULE

FENTANYL PATCH, TRANSDERMAL 72 HOURS

FENTANYL BASE POWDER (GRAM)

FENTANYL CITRATE AMPUL (ML)

FENTANYL CITRATE CARTRIDGE (ML)

FENTANYL CITRATE LOZENGE ON A HANDLE

Page 88: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

88

FENTANYL CITRATE PATIENT CONTROLLED ANALGESIA SYRINGE

FENTANYL CITRATE PLASTIC BAG, INJECTION (ML)

FENTANYL CITRATE POWDER (GRAM)

FENTANYL CITRATE SYRINGE (ML)

FENTANYL CITRATE TABLET, EFFERVESCENT

FENTANYL CITRATE VIAL (ML)

FENTANYL CITRATE/NS PATIENT CONTROLLED ANALGESIA SYRINGE

FENTANYL CITRATE/NS PLASTIC BAG, INJECTION (ML)

FENTANYL CITRATE/NS SYRINGE (ML)

FENTANYL CITRATE-STERILE WATER PLASTIC BAG, INJECTION (ML)

FENTANYL/BUPIVACAINE/NS PLASTIC BAG, INJECTION (ML)

FENTANYL/BUPIVACAINE/NS PREFILLED PUMP RESERVOIR

FENTANYL/BUPIVACAINE/NS SYRINGE (ML)

FENTANYL-ROPIVACAINE PLASTIC BAG, INJECTION (ML)

FENTANYL-ROPIVACAINE PREFILLED PUMP RESERVOIR

FENTORA TABLET, EFFERVESCENT

FERRIC AMMONIUM CITRATE POWDER (GRAM)

FERRIC CHLORIDE POWDER (GRAM)

FERRIC SUBSULFATE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

89

FERRIC SUBSULFATE SOLUTION, NON-ORAL

FERRIC SULFATE GRANULES (GRAM)

FERROUS BISGLYCINATE CHELATE POWDER (GRAM)

FERROUS FUMARATE POWDER (GRAM)

FERROUS GLUCONATE POWDER (GRAM)

FERROUS SULFATE GRANULES (GRAM)

FERROUS SULFATE POWDER (GRAM)

FERULIC ACID POWDER (GRAM)

FEVERALL SUPPOSITORY, RECTAL

FEVERFEW POWDER (GRAM)

FEXMID TABLET

FEXOFENADINE HCL POWDER (GRAM)

FEXOFENADINE HCL SUSPENSION, ORAL (FINAL DOSE FORM)

FEXOFENADINE HCL TABLET

FINACEA FOAM (GRAM)

FINACEA GEL (GRAM)

FINASTERIDE POWDER (GRAM)

FIORICET CAPSULE

FIORICET WITH CODEINE CAPSULE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

90

FIORINAL CAPSULE

FIORINAL W/CODEINE CAPSULE

FIRST AID AEROSOL, SPRAY (GRAM)

FIRST AID SPRAY, NON-AEROSOL (ML)

FIRST AID ABX PAIN RELIEF CREAM (GRAM)

FIRST AID ABX PAIN RELIEF OINTMENT (GRAM)

FIRST AID ANTIBIOTIC OINTMENT (GRAM)

FIRST AID ANTISEPTIC AEROSOL, SPRAY (ML)

FIRST AID ANTISEPTIC SOLUTION, NON-ORAL

FIRST AID TAPE BANDAGE

FIRST-AID SPRAY, NON-AEROSOL (ML)

FIRST-LANSOPRAZOLE SUSPENSION, RECONSTITUTED, ORAL (ML)

FIRST-OMEPRAZOLE SUSPENSION, RECONSTITUTED, ORAL (ML)

FIRST-PROGESTERONE VGS SUPPOSITORY, VAGINAL

FITALITE CREAM (GRAM)

FIXED OIL SUSPENSION SUSPENSION, ORAL (FINAL DOSE FORM)

FLANAX LINIMENT

FLANAX TABLET

FLANDERS BUTTOCKS OINTMENT OINTMENT (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

91

FLEX FABRIC BANDAGE BANDAGE

FLEXALL GEL (GRAM)

FLEXIBLE FABRIC BANDAGE ADHESIVE PATCH, MEDICATED

FLEXIBLE FABRIC BANDAGES BANDAGE

FLEXIBLE FOAM STRIPS BANDAGE

FLEXI-SEAL SIGNAL FMS MISCELLANEOUS

FLEXITOL CREAM (GRAM)

FLEXZAN ADHESIVE DRESSING BANDAGE

FLIBANSERIN POWDER (GRAM)

FLOXURIDINE POWDER (GRAM)

FLUCONAZOLE POWDER (GRAM)

FLUCONAZOLE SUSPENSION, RECONSTITUTED, ORAL (ML)

FLUCONAZOLE TABLET

FLUCONAZOLE IN DEXTROSE INTRAVENOUS SOLUTION, PIGGYBACK (ML)

FLUCONAZOLE IN SALINE INTRAVENOUS SOLUTION, PIGGYBACK (ML)

FLUCONAZOLE IN SALINE IV SOLUTION, PIGGYBACK, BOTTLE (ML)

FLUCYTOSINE POWDER (GRAM)

FLUDROCORTISONE ACETATE POWDER (GRAM)

FLUMAZENIL POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

92

FLUNISOLIDE POWDER (GRAM)

FLUOCINOLONE ACETONIDE OIL (ML)

FLUOCINOLONE ACETONIDE POWDER (GRAM)

FLUOCINONIDE POWDER (GRAM)

FLUORESCEIN SODIUM POWDER (GRAM)

FLUOROURACIL POWDER (GRAM)

FLUOXETINE HCL POWDER (GRAM)

FLUPHENAZINE DECANOATE LIQUID (GRAM)

FLUPHENAZINE DECANOATE OIL (GRAM)

FLURANDRENOLIDE CREAM (GRAM)

FLURANDRENOLIDE LOTION (ML)

FLURANDRENOLIDE OINTMENT (GRAM)

FLURBIPROFEN POWDER (GRAM)

FLURBIPROFEN TABLET

FLURBIPROFEN SODIUM DROPS

FLUTICASONE PROPIONATE POWDER (GRAM)

FLUTICASONE PROPIONATE MICRO POWDER (GRAM)

FOAM BANDAGES BANDAGE

FOAM DRESSING BANDAGE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

93

FOAMING ACNE FACE WASH CLEANSER (GRAM)

FOLIC ACID POWDER (GRAM)

FOOD COLOR BLACK POWDER (GRAM)

FOOD COLOR BLUE LIQUID (ML)

FOOD COLOR BLUE POWDER (GRAM)

FOOD COLOR BLUE ROYAL POWDER (GRAM)

FOOD COLOR BROWN POWDER (GRAM)

FOOD COLOR GREEN LIQUID (ML)

FOOD COLOR GREEN POWDER (GRAM)

FOOD COLOR LIME GREEN POWDER (GRAM)

FOOD COLOR ORANGE POWDER (GRAM)

FOOD COLOR PINK LIQUID (ML)

FOOD COLOR RED LIQUID (ML)

FOOD COLOR RED POWDER (GRAM)

FOOD COLOR VIOLET POWDER (GRAM)

FOOD COLOR WHITE LIQUID (ML)

FOOD COLOR YELLOW LIQUID (ML)

FOOD COLOR YELLOW POWDER (GRAM)

FOOT POWDER POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

94

FORDUSTIN POWDER (GRAM)

FOREHEAD THERMOMETER EACH

FORMADON SOLUTION WITH APPLICATOR (ML)

FORMADON SOLUTION, NON-ORAL

FORMALDEHYDE SOLUTION WITH APPLICATOR (ML)

FORMALDEHYDE SOLUTION, NON-ORAL

FORMOTEROL FUMARATE POWDER (GRAM)

FREE & CLEAR SHAMPOO

FREEDOM ADAPTADERM GEL (GRAM)

FREEDOM PEG TROCHE BASE POWDER (GRAM)

FREEZE IT GEL (GRAM)

FREEZONE LIQUID (ML)

FROTEK CREAM IN METERED-DOSE APPLICATOR (GRAM)

FROTEK CREAM IN PACKET (GRAM)

FROVA TABLET

FROVATRIPTAN SUCCINATE TABLET

FRUCTOSE GRANULES (GRAM)

FULLER'S EARTH POWDER (GRAM)

FUNGI-NAIL OINTMENT (GRAM)

Page 95: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

95

FUNGI-NAIL SOLUTION, NON-ORAL

FURAZOLIDONE POWDER (GRAM)

FUROSEMIDE POWDER (GRAM)

GABAPENTIN POWDER (GRAM)

GABLOFEN SYRINGE (ML)

GABLOFEN VIAL (ML)

GAMMA-AMINOBUTYRIC ACID POWDER (GRAM)

GARDENIA FRAGRANCE OIL OIL (ML)

GATIFLOXACIN SESQUIHYDRATE POWDER (GRAM)

GAUZE BANDAGE

GAUZE BANDAGE BANDAGE

GAUZE DRESSING BANDAGE

GAUZE PADS BANDAGE

GEL CORN PROTECTORS EACH

GEL PAD BANDAGE

GEL TOE PROTECTOR EACH

GEL TOE SPACERS EACH

GELFILM EACH

GEL-FLOW SYRINGE (EA)

Page 96: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

96

GEL-FLOW SYRINGE KIT (EA)

GELFOAM SPONGE

GELFOAM JMI COMBINATION PACKAGE (EA)

GELFOAM JMI KIT

GELRITE GEL (ML)

GEMFIBROZIL POWDER (GRAM)

GEN7T ADHESIVE PATCH, MEDICATED

GEN7T LOTION (GRAM)

GEN7T PLUS ADHESIVE PATCH, MEDICATED

GEN7T PLUS LOTION (GRAM)

GENADUR LIQUID (ML)

GENISTEIN POWDER (GRAM)

GENTAMICIN SULFATE POWDER (GRAM)

GENTIAN VIOLET CRYSTALS

GENTIAN VIOLET SOLUTION, NON-ORAL

GENTLE LAXATIVE SUPPOSITORY, RECTAL

GENTLE RAIN SOAP, LIQUID

GENTLE SKIN CLEANSER CLEANSER (ML)

GENTLE TAPE BANDAGE

Page 97: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

97

GERANIUM OIL OIL (ML)

GERI-HYDROLAC CREAM (GRAM)

GERI-HYDROLAC LOTION (ML)

GERM BLOC FOAM (ML)

GERM BLOC LOTION (ML)

GERMALL PLUS LIQUID (ML)

GERMPHOBIC SOLUTION, NON-ORAL

GINGER ROOT POWDER (GRAM)

GINSENG ROOT POWDER (GRAM)

GLACIAL ACETIC ACID LIQUID (ML)

G-LEVOCARNITINE SOLUTION, ORAL

GLIPIZIDE POWDER (GRAM)

GLUCONOLACTONE POWDER (GRAM)

GLUCOSAMINE POWDER (GRAM)

GLUCOSAMINE HCL POWDER (GRAM)

GLUTAMINE POWDER (GRAM)

GLUTARALDEHYDE SOLUTION, NON-ORAL

GLUTATHIONE POWDER (GRAM)

GLUTATHIONE-L POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

98

GLYBURIDE POWDER (GRAM)

GLYCERIN LIQUID (ML)

GLYCEROL FORMAL LIQUID (ML)

GLYCEROL MONOOLEATE PASTE (GRAM)

GLYCINE POWDER (GRAM)

GLYCINE SOYA PROTEIN LIQUID (ML)

GLYCOFUROL LIQUID (ML)

GLYCOLIC ACID CRYSTALS

GLYCOLIC ACID SOLUTION, NON-ORAL

GLYCOPYRROLATE POWDER (GRAM)

GLYCOSAMINOGLYCANS LIQUID (ML)

GLYCYRRHIZIC ACID POWDER (GRAM)

GLYDO JELLY WITH PREFILLED APPLICATOR (ML)

GOLD BOND CREAM (GRAM)

GOLD BOND LOTION (GRAM)

GOLD BOND POWDER (GRAM)

GOLD BOND MEDICATED FOOT POWDER (GRAM)

GOLD BOND ULTIMATE LIQUID (GRAM)

GOLD BOND ULTIMATE DIABETIC CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

99

GOLD BOND ULTIMATE ECZEMA RLF CREAM (GRAM)

GOLD BOND ULTIMATE PSORIASIS CREAM (GRAM)

GOLD SODIUM THIOMALATE POWDER (GRAM)

GORDOBALM LOTION (ML)

GORDOCHOM SOLUTION, NON-ORAL

GORDOFILM SOLUTION WITH APPLICATOR (ML)

GORDOGESIC CREAM (GRAM)

GORDOMATIC CRYSTALS

GORDOMATIC LOTION (ML)

GORDOMATIC POWDER (GRAM)

GORDON'S NO. FIVE AEROSOL, POWDER (GRAM)

GORDO-VITE A CREAM (GRAM)

GORDO-VITE A LOTION (ML)

GORDO-VITE E CREAM (GRAM)

GOWEY TINCTURE TINCTURE

GRAFIX CORE SHEET (EA)

GRAFIX PRIME SHEET (EA)

GRAMICIDIN D POWDER (GRAM)

GRANISETRON HCL TABLET

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

100

GRANISETRON HCL VIAL (ML)

GRAPESEED OIL (ML)

GREEN SOAP POWDER (GRAM)

GREEN SOAP TINCTURE

GREEN TEA POWDER (GRAM)

GREEN TEA FRAGRANCE OIL LIQUID (GRAM)

GRISEOFULVIN POWDER (GRAM)

GRX FOAM DRESSING BANDAGE

GRX HEMORRHOIDAL OINTMENT WITH APPLICATOR

GRX VITAMIN E CREAM (GRAM)

GRX VITAMIN E LOTION (ML)

GRX WOUND GEL GEL (GRAM)

GUAIFENESIN POWDER (GRAM)

GUANABENZ ACETATE POWDER (GRAM)

GUANETHIDINE HEMISULFATE POWDER (GRAM)

GUANIDINEACETIC ACID POWDER (GRAM)

GUARANA SEED EXTRACT POWDER (GRAM)

GUM BASE GEL (GRAM)

GYMNEMA SYLVESTRIS LEAF POWDER (GRAM)

Page 101: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

101

GYNAZOLE-1 CREAM WITH PREFILLED APPLICATOR

GYNOL II JELLY WITH APPLICATOR (GRAM)

H2O GEL BASE GEL (GRAM)

HAIR REGROWTH FOAM (GRAM)

HAIR REGROWTH SOLUTION, NON-ORAL

HALCINONIDE CREAM (GRAM)

HALOG CREAM (GRAM)

HALOG OINTMENT (GRAM)

HALOG SOLUTION, NON-ORAL

HALOPERIDOL POWDER (GRAM)

HALOPERIDOL DECANOATE POWDER (GRAM)

HALUCORT GEL (GRAM)

HAND SANITIZER GEL (ML)

HAND SOAP LIQUID (ML)

HAND WASH LIQUID (ML)

HAWTHORNE BERRY POWDER (GRAM)

HC PRAMOXINE CREAM (GRAM)

HC PRAMOXINE CREAM WITH APPLICATOR

H-CHLOR GEL (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

102

H-CHLOR 6 SOLUTION, NON-ORAL

HEARTBURN TREATMENT 24 HOUR CAPSULE,DELAYED RELEASE (ENTERIC COATED)

HEAT THERAPY PATCHES BANDAGE

HEATWRAPS BANDAGE

HEAVY DUTY FABRIC ANTIBAC BNDG ADHESIVE PATCH, MEDICATED

HEMATOXYLIN, C.I. 75290 POWDER (GRAM)

HEMORRHOID RELIEF CREAM (GRAM)

HEMORRHOIDAL SUPPOSITORY, RECTAL

HEMORRHOIDAL COOLING GEL (GRAM)

HEMORRHOIDAL CREAM CREAM (GRAM)

HEMORRHOIDAL H SUPPOSITORY, RECTAL

HEMORRHOIDAL HYGIENE PADS, MEDICATED (EA)

HEMORRHOIDAL MEDICATED PADS, MEDICATED (EA)

HEMORRHOIDAL MEDICATED WIPES PADS, MEDICATED (EA)

HEMORRHOIDAL OINTMENT OINTMENT (GRAM)

HEMORRHOIDAL OINTMENT OINTMENT WITH APPLICATOR

HEMORRHOIDAL PADS PADS, MEDICATED (EA)

HEMORRHOIDAL SUPPOSITORIES SUPPOSITORY, RECTAL

HEMORRHOIDAL SUPPOSITORY SUPPOSITORY, RECTAL

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

103

HEMORRHOIDAL-ANALGESIC OINTMENT (GRAM)

HEPARIN SODIUM POWDER (GRAM)

HEPES POWDER (GRAM)

HEPTAMINOL LIQUID (GRAM)

HERPECIN L STICK (GRAM)

HIBICLENS LIQUID (ML)

HISTAMINE PHOSPHATE CRYSTALS

HISTIDINE HCL POWDER (GRAM)

HOMATROPINE METHYLBROMIDE POWDER (GRAM)

HONEY ALMOND FRAGRANCE LIQUID (ML)

HONGO CURA OINTMENT (GRAM)

HONGO CURA SPRAY, NON-AEROSOL (ML)

HPR FOAM (GRAM)

HPR PLUS CREAM (GRAM)

HPR PLUS FOAM (GRAM)

HPR PLUS HYDROGEL KIT, CREAM AND GEL

HPR PLUS-MB HYDROGEL COMBINATION PACKAGE, GEL AND FOAM

HRT BASE CREAM (GRAM)

HRT BASE BOTANICAL CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

104

HRT BASE HEAVY OINTMENT (GRAM)

HRT BOTANICAL BASE CREAM (GRAM)

HRT CREAM CREAM (GRAM)

HRT CREAM BASE WOMEN CREAM (GRAM)

HRT ESSENTIAL CREAM CREAM (GRAM)

HRT GEL BASE MEN GEL (GRAM)

HRT HEAVY CREAM BASE CREAM (GRAM)

HUMCO BASE, PAIN MGMT CREAM (GRAM)

HUPERZINE SERRATE A POWDER (GRAM)

HYALURONIC ACID POWDER (GRAM)

HYALURONIDASE POWDER (EA)

HYCLODEX SPRAY, NON-AEROSOL (ML)

HYDRALAZINE HCL POWDER (GRAM)

HYDRASYN25 CREAM (GRAM)

HYDRAZINE SULFATE CRYSTALS

HYDROCERIN LOTION (ML)

HYDROCHLORIC ACID LIQUID (ML)

HYDROCHLOROTHIAZIDE POWDER (GRAM)

HYDROCODONE BITARTRATE CAPSULE,ORAL ONLY, EXTENDED RELEASE 12HR

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

105

HYDROCODONE BITARTRATE CRYSTALS

HYDROCODONE BITARTRATE POWDER (GRAM)

HYDROCOL II BANDAGE

HYDROCORTISONE CREAM (GRAM)

HYDROCORTISONE OINTMENT (GRAM)

HYDROCORTISONE POWDER (GRAM)

HYDROCORTISONE ACETATE POWDER (GRAM)

HYDROCORTISONE BUTYRATE CREAM (GRAM)

HYDROCORTISONE BUTYRATE LOTION (ML)

HYDROCORTISONE BUTYRATE OINTMENT (GRAM)

HYDROCORTISONE BUTYRATE SOLUTION, NON-ORAL

HYDROCORTISONE PLUS CREAM (GRAM)

HYDROCORTISONE W/ ALOE CREAM (GRAM)

HYDROCORTISONE W/ALOE CREAM (GRAM)

HYDROCORTISONE W/IODOQUINOL CREAM (GRAM)

HYDROCORTISONE-IODOQUINOL-ALOE CREAM IN PACKET (GRAM)

HYDROFERA BLUE BANDAGE

HYDROFLUORIC ACID LIQUID (ML)

HYDROGEL GEL (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

106

HYDROGEN PEROXIDE SOLUTION, NON-ORAL

HYDROGEN PEROXIDE SPRAY, NON-AEROSOL (ML)

HYDROGEN PEROXIDE TOWELETTE (EA)

HYDRO-LAN CREAM (GRAM)

HYDROLYZED HYALURONIC ACID POWDER (GRAM)

HYDROMORPHONE ER TABLET, EXTENDED RELEASE 24 HR

HYDROMORPHONE HCL AMPUL (ML)

HYDROMORPHONE HCL CARTRIDGE (ML)

HYDROMORPHONE HCL LIQUID (ML)

HYDROMORPHONE HCL PATIENT CONTROLLED ANALGESIA SYRINGE

HYDROMORPHONE HCL PATIENT CONTROLLED ANALGESIA VIAL

HYDROMORPHONE HCL POWDER (GRAM)

HYDROMORPHONE HCL SUPPOSITORY, RECTAL

HYDROMORPHONE HCL SYRINGE (ML)

HYDROMORPHONE HCL TABLET

HYDROMORPHONE HCL VIAL (ML)

HYDROMORPHONE HCL/NS PATIENT CONTROLLED ANALGESIA SYRINGE

HYDROMORPHONE HCL/NS PATIENT CONTROLLED ANALGESIA VIAL

HYDROMORPHONE HCL/NS PLASTIC BAG, INJECTION (ML)

Page 107: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

107

HYDROMORPHONE HCL/NS PREFILLED PUMP RESERVOIR

HYDROMORPHONE HCL/NS SYRINGE (ML)

HYDROPHILIC OINTMENT OINTMENT (GRAM)

HYDROPHILIC PETROLATUM OINTMENT (GRAM)

HYDROQUINONE CREAM (GRAM)

HYDROQUINONE CREAM, EXTENDED RELEASE (GRAM)

HYDROQUINONE CRYSTALS

HYDROQUINONE EMULSION (GRAM)

HYDROQUINONE POWDER (GRAM)

HYDROSKIN CREAM (GRAM)

HYDROUS EMULSIFIED BASE CREAM (GRAM)

HYDROXOCOBALAMIN POWDER (GRAM)

HYDROXYAMPHETAMINE HBR POWDER (GRAM)

HYDROXYAPATITE POWDER (GRAM)

HYDROXYCHLOROQUINE SULFATE POWDER (GRAM)

HYDROXYETHYL CELLULOSE POWDER (GRAM)

HYDROXYETHYL METHACRYLATE LIQUID (GRAM)

HYDROXYPROGESTERONE CAPROATE POWDER (GRAM)

HYDROXYPROPY-BETA-CYCLODEXTRIN POWDER (GRAM)

Page 108: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

108

HYDROXYQUINOLINE SULFATE POWDER (GRAM)

HYDROXYTRYPTOPHAN POWDER (GRAM)

HYDROXYUREA POWDER (GRAM)

HYDROXYZINE HCL POWDER (GRAM)

HYDROXYZINE HCL SOLUTION, ORAL

HYDROXYZINE HCL TABLET

HYDROXYZINE HCL VIAL (ML)

HYDROXYZINE PAMOATE CAPSULE

HYDROXYZINE PAMOATE POWDER (GRAM)

HYGEL GEL (GRAM)

HYGIENIC CLEANSING PADS PADS, MEDICATED (EA)

HYLAGUARD CREAM (GRAM)

HYLATOPICPLUS CREAM (GRAM)

HYLATOPICPLUS FOAM (GRAM)

HYLATOPICPLUS LOTION (ML)

HYOSCYAMINE SULFATE POWDER (GRAM)

HYPERCARE LIQUID (ML)

HYPER-HEAL CREAM (GRAM)

HYPO-ALLERGENIC BANDAGES BANDAGE

Page 109: Compound Exclusion List of Bulk Chemicals TRADE NAME ......all day relief pain tablet all purpose cloth tape tape, non-medicated allantoin powder (gram) allegra allergy tablet allerclear

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

109

HYPOCYN SPRAY, NON-AEROSOL (ML)

HYPROMELLOSE(METHOCEL K 100 M) POWDER (GRAM)

HYSINGLA ER TABLET,ORAL ONLY,EXTENDED RELEASE 24 HR

IBU TABLET

IBUPROFEN CAPSULE

IBUPROFEN POWDER (GRAM)

IBUPROFEN SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)

IBUPROFEN SUSPENSION, ORAL (FINAL DOSE FORM)

IBUPROFEN TABLET

IBUPROFEN TABLET,CHEWABLE

IBU-PROFEN COLD & SINUS TABLET

IBUPROFEN COLD-SINUS TABLET

IBUPROFEN IB TABLET

IBUPROFEN IB TABLET,CHEWABLE

IBUPROFEN LYSINE VIAL (ML)

IBUPROFEN PM CAPSULE

IBUPROFEN PM TABLET

ICE BLUE GEL GEL (GRAM)

ICHTHAMMOL LIQUID (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

110

ICHTHAMMOL POWDER (GRAM)

ICY HOT ADHESIVE PATCH, MEDICATED

ICY HOT AEROSOL, SPRAY (ML)

ICY HOT BANDAGE

ICY HOT CREAM (GRAM)

ICY HOT GEL (GRAM)

ICY HOT LIQUID (ML)

ICY HOT OINTMENT (GRAM)

ICY HOT STICK (GRAM)

ICY HOT ADVANCED RELIEF CREAM (GRAM)

IDEALBASE CREAM (GRAM)

IDEBENONE POWDER (GRAM)

IDOXURIDINE POWDER (GRAM)

IMIDUREA POWDER (GRAM)

IMIPRAMINE HCL POWDER (GRAM)

IMIPRAMINE HCL TABLET

IMIQUIMOD POWDER (GRAM)

IMITREX CARTRIDGE (ML)

IMITREX PEN INJECTOR (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

111

IMITREX SPRAY, NON-AEROSOL (EA)

IMITREX TABLET

IMITREX VIAL (ML)

IMVEXXY INSERT

IMVEXXY INSERT, DOSE PACK

INCONTROL ALCOHOL PADS PADS, MEDICATED (EA)

INDOCIN SUPPOSITORY, RECTAL

INDOCIN SUSPENSION, ORAL (FINAL DOSE FORM)

INDOCYANINE GREEN POWDER (GRAM)

INDOLE-3-CARBINOL POWDER (GRAM)

INDOMETHACIN CAPSULE

INDOMETHACIN CAPSULE, EXTENDED RELEASE

INDOMETHACIN POWDER (GRAM)

INDOMETHACIN VIAL (EA)

INFANT IBUPROFEN SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)

INFANT'S ADVIL SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)

INFANTS' IBUPROFEN SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)

INFANT'S MOTRIN SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)

INFANTS PROFENIB SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

112

INFLAMMA-K KIT, PATCH, MEDICATED AND SOLUTION DROPS

INFUMORPH AMPUL (ML)

INOSITOL POWDER (GRAM)

INOVA COMBINATION PACKAGE (EA)

INOVA 4-1 COMBINATION PACKAGE (EA)

INOVA 8-2 COMBINATION PACKAGE (EA)

INSECT REPELLENT AEROSOL, SPRAY (GRAM)

INSECT REPELLENT AEROSOL, SPRAY WITH PUMP (ML)

INSTANT PAIN RELIEF SOLUTION, NON-ORAL

INTERSORB BANDAGE

INTRASITE GEL (GRAM)

IODIDES TINCTURE

IODINE CRYSTALS

IODINE GRANULES (GRAM)

IODINE SOLUTION, NON-ORAL

IODINE TINCTURE

IODINE STRONG TINCTURE

IODOFLEX PADS, MEDICATED (EA)

IODOFORM POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

113

IODOQUINOL POWDER (GRAM)

IODOQUINOL-HYDROCORTISONE-ALOE GEL (GRAM)

IODOSORB GEL (GRAM)

IOPANOIC ACID POWDER (GRAM)

IPRATROPIUM BROMIDE POWDER (GRAM)

I-PRIN TABLET

IRENKA CAPSULE,DELAYED RELEASE (ENTERIC COATED)

ISAGEL GEL (GRAM)

ISAGEL NO RINSE GEL (ML)

ISOLEUCINE POWDER (GRAM)

ISOMETHEPTENE MUCATE POWDER (GRAM)

ISONIAZID POWDER (GRAM)

ISOPROPAMIDE IODIDE POWDER (GRAM)

ISOPROPYL ALCOHOL PADS, MEDICATED (EA)

ISOPROPYL ALCOHOL SPRAY, NON-AEROSOL (ML)

ISOPROPYL MYRISTATE LIQUID (ML)

ISOPROPYL PALMITATE LIQUID (ML)

ISOPROPYL W/WINTERGREEN LIQUID (ML)

ISOPROTERENOL HCL POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

114

ISOSORBIDE POWDER (GRAM)

ISOTRETINOIN POWDER (GRAM)

ISOXSUPRINE HCL POWDER (GRAM)

ISRADIPINE CAPSULE

ITCH RELIEF AEROSOL, SPRAY (GRAM)

ITCH RELIEF AEROSOL, SPRAY (ML)

ITCH RELIEF CREAM (GRAM)

ITCH RELIEF GEL (ML)

ITCH RELIEF LOTION (ML)

ITCH-X GEL (GRAM)

ITCH-X SPRAY, NON-AEROSOL (ML)

ITRACONAZOLE CAPSULE

ITRACONAZOLE POWDER (GRAM)

ITRACONAZOLE SOLUTION, ORAL

IV 3000 BANDAGE

IV PREP WIPES PADS, MEDICATED (EA)

IV3000 FRAME DELIVERY BANDAGE

IVERMECTIN CREAM (GRAM)

IVERMECTIN POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

115

JASMINE FRAGRANCE LIQUID (ML)

JESSNER'S SOLUTION, NON-ORAL

JOCK ITCH CREAM (GRAM)

JOHNSON'S FOOT POWDER IN PACKET (EA)

JOJOBA OIL OIL (ML)

JUBLIA SOLUTION WITH APPLICATOR (ML)

JUNIPER TAR OIL (ML)

K50 EMULSION (GRAM)

KADIAN CAPSULE, EXTENDED RELEASE PELLETS

KALTOSTAT BANDAGE

KALTOSTAT FORTEX BANDAGE

KANAMYCIN SULFATE POWDER (GRAM)

KAOLIN POWDER (GRAM)

KARAYA POWDER (GRAM)

KARAYA GUM POWDER (GRAM)

KELO-COTE GEL (GRAM)

KELOCOTE SCAR GEL GEL (GRAM)

KENDALL BANDAGE

KENDALL GEL (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

116

KENDALL CLOTH BANDAGE

KENDALL PAPER TAPE TAPE, NON-MEDICATED

KEPPRA TABLET

KERA TEK GEL (GRAM)

KERADAN CREAM (GRAM)

KERAGEL GEL (GRAM)

KERAGELT GEL (GRAM)

KERALYT GEL (GRAM)

KERALYT SCALP KIT, SHAMPOO AND GEL

KERAMATRIX SHEET (EA)

KERI ORIGINAL MOISTURE THERAPY SUSPENSION, TOPICAL (GRAM)

KERLIX BANDAGE

KERLIX SPONGE

KERLIX AMD SPONGE

KERLIX AMD BANDAGE BANDAGE

KERODEX CREAM (GRAM)

KERYDIN SOLUTION WITH APPLICATOR (ML)

KETAMINE HCL POWDER (GRAM)

KETOCONAZOLE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

117

KETOGLUTARIC ACID CRYSTALS

KETOPROFEN CAPSULE

KETOPROFEN CAPSULE, EXTENDED RELEASE PELLETS 24 HR

KETOPROFEN POWDER (GRAM)

KETOROLAC TROMETHAMINE CARTRIDGE (ML)

KETOROLAC TROMETHAMINE DROPS

KETOROLAC TROMETHAMINE POWDER (GRAM)

KETOROLAC TROMETHAMINE SPRAY, NON-AEROSOL (EA)

KETOROLAC TROMETHAMINE SYRINGE (ML)

KETOROLAC TROMETHAMINE TABLET

KETOROLAC TROMETHAMINE VIAL (ML)

KETOTIFEN FUMARATE POWDER (GRAM)

KIDNEY BEAN EXTRACT POWDER (GRAM)

KIDS MINI ENEMA ENEMA (ML)

KINETIN POWDER (GRAM)

KIWI FRAGRANCE LIQUID (ML)

KLOFENSAID II DROPS

KOJIC ACID POWDER (GRAM)

KRISGEL 100 LIQUID (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

118

KRYSTAL SF CANDY BASE POWDER (GRAM)

KUDZU ROOT POWDER (GRAM)

K-Y LUBRICATING JELLY JELLY (GRAM)

L.M.X.4 CREAM (GRAM)

L.M.X.4 PLUS KIT

L.M.X.5 CREAM (GRAM)

L-5 METHYLTETRAHYDROFOLATE CAL POWDER (GRAM)

LABETALOL HCL POWDER (GRAM)

LAC-HYDRIN 5 LOTION (GRAM)

LACTASE POWDER (GRAM)

LACTIC ACID LIQUID (ML)

LACTINOL HX CREAM (GRAM)

LADY ANTI MONKEY BUTT POWDER (GRAM)

L-ALANINE POWDER (GRAM)

LAMB'S WOOL EACH

LAMISIL AEROSOL, SPRAY (ML)

LAMISIL AT CREAM (GRAM)

LAMISIL AT GEL (GRAM)

LAMOTRIGINE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

119

LANACANE FIRST AID AEROSOL (GRAM)

LANAPHILIC OINTMENT (GRAM)

LANAPHILIC WITH UREA OINTMENT (GRAM)

LANOLIN CREAM (GRAM)

LANOLIN WAX (GRAM)

LANOLIN ALCOHOL WAX (GRAM)

LANOLIN OIL OIL (ML)

LANSOPRAZOLE CAPSULE,DELAYED RELEASE (ENTERIC COATED)

LANSOPRAZOLE POWDER (GRAM)

LANSOPRAZOLE TABLET, DISINTEGRATING, DELAYED RELEASE

LANTISEPTIC OINTMENT (GRAM)

L-ARGININE BASE POWDER (GRAM)

L-ARGININE HCL POWDER (GRAM)

L-ARGININE MONOHYDROCHLORIDE POWDER (GRAM)

L-ASPARTIC ACID POWDER (GRAM)

LATANOPROST OIL (GRAM)

LATISSE DROPS, WITH APPLICATOR (ML)

LAURETH-9 LIQUID (ML)

LAURIC ACID POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

120

LAVARE WOUND WASH GEL (GRAM)

LAXATIVE SUPPOSITORY SUPPOSITORY, RECTAL

LAZANDA AEROSOL, SPRAY WITH PUMP (EA)

LC-4 CREAM (GRAM)

LC-5 CREAM (GRAM)

L-CARNITINE POWDER (GRAM)

L-CARNITINE TABLET

L-CARNOSINE POWDER (GRAM)

L-CITRULLINE POWDER (GRAM)

L-CYSTEINE CRYSTALS

L-CYSTEINE POWDER (GRAM)

L-CYSTINE POWDER (GRAM)

LDO PLUS GEL WITH PUMP (ML)

LEAD (II) ACETATE TRIHYDRATE CRYSTALS

LEAD TETROXIDE POWDER (GRAM)

LECITHIN GRANULES (GRAM)

LECITHIN ISOPROPYL PALMITATE LIQUID (ML)

LECITHIN ORGANOGEL LIQUID (ML)

LECITHIN SOYA POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

121

LENZAGEL GEL (GRAM)

LENZAPATCH ADHESIVE PATCH, MEDICATED

LENZAPRO ADHESIVE PATCH, MEDICATED

LETROZOLE POWDER (GRAM)

LEUCINE CRYSTALS

LEUCOVORIN CALCIUM POWDER (GRAM)

LEUPROLIDE ACETATE POWDER (GRAM)

LEVA SET KIT

LEVAMISOLE HCL POWDER (GRAM)

LEVETIRACETAM POWDER (GRAM)

LEVETIRACETAM TABLET

LEVETIRACETAM TABLET, EXTENDED RELEASE 24 HR

LEVICYN GEL (GRAM)

LEVICYN SPRAY, NON-AEROSOL (ML)

LEVICYN ANTIPRURITIC SG SPRAY GEL

LEVIGOLT CREAM (GRAM)

LEVIGOSP SPRAY, NON-AEROSOL (ML)

LEVOCARNITINE POWDER (GRAM)

LEVOCARNITINE SOLUTION, ORAL

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

122

LEVOCARNITINE TABLET

LEVOCARNITINE SF SOLUTION, ORAL

LEVOCETIRIZINE DIHYDROCHLORIDE POWDER (GRAM)

LEVOCETIRIZINE DIHYDROCHLORIDE SOLUTION, ORAL

LEVOCETIRIZINE DIHYDROCHLORIDE TABLET

LEVODOPA POWDER (GRAM)

LEVOFLOXACIN HEMIHYDRATE POWDER (GRAM)

LEVOMEFOLATE CALCIUM POWDER (GRAM)

LEVORPHANOL TARTRATE POWDER (GRAM)

LEVORPHANOL TARTRATE TABLET

LEVOTHYROXINE SODIUM POWDER (GRAM)

LEVULAN SOLUTION WITH APPLICATOR (EA)

LEXIXRYL KIT

L-GLUTAMIC ACID POWDER (GRAM)

L-GLUTAMINE POWDER (GRAM)

L-HISTIDINE POWDER (GRAM)

L-HISTIDINE MONOHYDROCHLORIDE POWDER (GRAM)

LICE COMPLETE KIT 1-2-3 KIT

LICE KILLING LIQUID (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

123

LICE KILLING SHAMPOO

LICE PYRINYL SHAMPOO SHAMPOO

LICE SOLUTION KIT

LICE TREAMENT KIT

LICE TREATMENT KIT

LICE TREATMENT LIQUID (ML)

LICE TREATMENT SHAMPOO

LICORICE ROOT POWDER (GRAM)

LIDO KING ADHESIVE PATCH, MEDICATED

LIDOCAINE ADHESIVE PATCH, MEDICATED

LIDOCAINE CARTRIDGE (ML)

LIDOCAINE CREAM (GRAM)

LIDOCAINE KIT

LIDOCAINE OINTMENT (GRAM)

LIDOCAINE POWDER (GRAM)

LIDOCAINE HCL AMPUL (ML)

LIDOCAINE HCL CREAM (GRAM)

LIDOCAINE HCL JELLY (ML)

LIDOCAINE HCL JELLY WITH PREFILLED APPLICATOR (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

124

LIDOCAINE HCL LOTION (ML)

LIDOCAINE HCL PEN INJECTOR (EA)

LIDOCAINE HCL POWDER (GRAM)

LIDOCAINE HCL SOLUTION, NON-ORAL

LIDOCAINE HCL SOLUTION, ORAL

LIDOCAINE HCL SYRINGE (ML)

LIDOCAINE HCL VIAL (ML)

LIDOCAINE HCL IN 7.5% DEXTROSE AMPUL (ML)

LIDOCAINE HCL IN DEXTROSE INTRAVENOUS SOLUTION

LIDOCAINE HCL W/EPINEPHRINE AMPUL (ML)

LIDOCAINE HCL W/EPINEPHRINE CARTRIDGE (ML)

LIDOCAINE HCL W/EPINEPHRINE VIAL (ML)

LIDOCAINE HCL-MENTHOL SPRAY, NON-AEROSOL (ML)

LIDOCAINE PAIN RELIEF ADHESIVE PATCH, MEDICATED

LIDOCAINE PAIN RELIEF AEROSOL, SPRAY (GRAM)

LIDOCAINE PLUS CREAM (GRAM)

LIDOCAINE-HC CREAM (GRAM)

LIDOCAINE-HC CREAM WITH APPLICATOR

LIDOCAINE-HC GEL WITH APPLICATOR (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

125

LIDOCAINE-HC KIT

LIDOCAINE-PRILOCAINE CREAM (GRAM)

LIDOCAINE-PRILOCAINE KIT

LIDOCAINE-TETRACAINE CREAM (GRAM)

LIDOCARE ADHESIVE PATCH, MEDICATED

LIDODERM ADHESIVE PATCH, MEDICATED

LIDODOSE SWAB, MEDICATED (ML)

LIDO-K LOTION (ML)

LIDOPAC KIT

LIDOPATCH ADHESIVE PATCH, MEDICATED

LIDOPIN CREAM (GRAM)

LIDOPRIL KIT

LIDOPRIL XR KIT

LIDO-PRILO CAINE PACK KIT

LIDOPRO ADHESIVE PATCH, MEDICATED

LIDOPRO OINTMENT (GRAM)

LIDOPRO OINTMENT WITH APPLICATOR

LIDORX GEL WITH PUMP (ML)

LIDO-SORB LOTION (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

126

LIDOTRAL CREAM (GRAM)

LIDOTRANS 5 PAK KIT

LIDOTREX GEL (GRAM)

LIDOVEX CREAM (GRAM)

LIDOZENGEL GEL (ML)

LIDOZENPATCH ADHESIVE PATCH, MEDICATED

LIDOZION LOTION (ML)

LIDTOPIC MAX CREAM IN METERED-DOSE APPLICATOR (ML)

LIME OIL OIL (ML)

LIMENCIN ADHESIVE PATCH, MEDICATED

LIMENCIN LOTION (ML)

LINCOMYCIN HCL POWDER (GRAM)

LINDANE SHAMPOO

LINOLEIC ACID LIQUID (GRAM)

LIORESAL AMPUL (ML)

LIOTHYRONINE SODIUM POWDER (GRAM)

LIP BALM OINTMENT (GRAM)

LIP-GUARD OINTMENT(EA)

LIPMAX LIQUID (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

127

LIPO CREAM BASE CREAM (GRAM)

LIPOBASE CREAM (GRAM)

LIPOBASE HEAVY CREAM (GRAM)

LIPOBASE REGULAR CREAM (GRAM)

LIPOCREAM BASE CREAM (GRAM)

LIPOIC ACID POWDER (GRAM)

LIPOIL LIQUID (ML)

LIPOPEN ABSORPTN ENHANCE BASE CREAM (GRAM)

LIPOPEN ANHYDROUS CREAM (GRAM)

LIPOPEN ULTRA CREAM (GRAM)

LIPOSOMAL HEAVY CREAM (GRAM)

LIPOVAN CREAM (GRAM)

LIPOZYME BASE CREAM (GRAM)

LIPROZONEPAK KIT

LIQUA-GEL GEL (ML)

LIQUID BANDAGE SOLUTION, NON-ORAL

LIQUID CORN & CALLUS REMOVER LIQUID (ML)

LIQUIGEL COMPLEX LIQUID (GRAM)

LIQUIMAT LOTION (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

128

LISCO SPONGE

LISINOPRIL POWDER (GRAM)

L-ISOLEUCINE CRYSTALS

L-ISOLEUCINE POWDER (GRAM)

LISSAMINE GREEN B POWDER (GRAM)

LITHIUM CARBONATE POWDER (GRAM)

LITHIUM CITRATE POWDER (GRAM)

LIVIXIL PAK KIT

L-LEUCINE POWDER (GRAM)

L-LYSINE OINTMENT (GRAM)

L-LYSINE POWDER (GRAM)

LMC ADHESIVE PATCH, MEDICATED

L-MENTHOL CRYSTALS

L-METHIONINE POWDER (GRAM)

L-METHYLFOLATE CALCIUM POWDER (GRAM)

LMR PLUS KIT

LMX 4 KIT

LOCOID CREAM (GRAM)

LOCOID LOTION (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

129

LOCOID OINTMENT (GRAM)

LOCOID SOLUTION, NON-ORAL

LOCOID LIPOCREAM CREAM (GRAM)

LOCUST BEAN GUM POWDER (GRAM)

LODINE TABLET

LOLLIBASE POWDER (GRAM)

LONG LASTING VAGINAL GEL WITH PREFILLED APPLICATOR (GRAM)

LOPERAMIDE HCL POWDER (GRAM)

LOPROX COMBINATION PACKAGE (GRAM)

LOPROX KIT, SUSPENSION AND CLEANSER

LORADAMED TABLET

LORATA-D TABLET, EXTENDED RELEASE 24 HR

LORATADINE CAPSULE

LORATADINE POWDER (GRAM)

LORATADINE SOLUTION, ORAL

LORATADINE TABLET

LORATADINE TABLET, DISINTEGRATING

LORATADINE ALLERGY SOLUTION, ORAL

LORATADINE HIVES RELIEF SOLUTION, ORAL

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

130

LORATADINE MICRONIZED POWDER (GRAM)

LORATADINE-D TABLET, EXTENDED RELEASE 12 HR

LORATADINE-D TABLET, EXTENDED RELEASE 24 HR

LORAZEPAM POWDER (GRAM)

L-ORNITHINE MONOHYDROCHLORIDE POWDER (GRAM)

LORZONE TABLET

LOTREL CAPSULE

LOTRIMIN ULTRA CREAM (GRAM)

LOUTREX CREAM (GRAM)

LOZIBASE GEL (GRAM)

LOZIBASE S FLAKES (GRAM)

LP LITE PAK KIT

L-PROLINE CRYSTALS

L-SERINE CRYSTALS

L-THREONINE CRYSTALS

LUBRICATING JELLY JELLY (GRAM)

LUBRIDERM ADVANCED THERAPY LOTION (ML)

LUBRIDERM SENSITIVE SKIN LOTION (ML)

LUBRIDERM SKIN NOURISHING LOTION (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

131

LUBRIN INSERT

LUBRISILK LOTION (ML)

LUGOL'S SOLUTION, NON-ORAL

LULICONAZOLE CREAM (GRAM)

LUTEIN BEADS (GRAM)

LUTEIN POWDER (GRAM)

LUXAMEND CREAM (GRAM)

LUZU CREAM (GRAM)

L-VALINE POWDER (GRAM)

LYCELLE GEL (ML)

LYSINE POWDER (GRAM)

MAC ADHESIVE PATCH, MEDICATED

MACA ROOT POWDER (GRAM)

MAFENIDE ACETATE PACKET (EA)

MAGIC BULLET SUPPOSITORY, RECTAL

MAGNESIUM ALUMINUM SILICATE POWDER (GRAM)

MAGNESIUM AMINO ACID CHELATE POWDER (GRAM)

MAGNESIUM ASCORBATE POWDER (GRAM)

MAGNESIUM BISGLYCINATE CHELATE POWDER (GRAM)

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TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

132

MAGNESIUM CARBONATE POWDER (GRAM)

MAGNESIUM CHLORIDE CRYSTALS

MAGNESIUM CITRATE POWDER (GRAM)

MAGNESIUM GLUCONATE POWDER (GRAM)

MAGNESIUM GLYCINATE POWDER (GRAM)

MAGNESIUM HYDROXIDE POWDER (GRAM)

MAGNESIUM MALATE POWDER (GRAM)

MAGNESIUM OXIDE POWDER (GRAM)

MAGNESIUM PHOSPHATE POWDER (GRAM)

MAGNESIUM SULFATE CRYSTALS

MAGNESIUM SULFATE POWDER (GRAM)

MAJOR-PREP HEMORRHOIDAL OINTMENT WITH APPLICATOR

MALATHION LOTION (ML)

MALEIC ACID CRYSTALS

MALIC ACID POWDER (GRAM)

MALTODEXTRIN POWDER (GRAM)

MANDELIC ACID POWDER (GRAM)

MANGANESE CHLORIDE POWDER (GRAM)

MANGANESE GLUCONATE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

133

MANGANESE SULFATE POWDER (GRAM)

MANNITOL POWDER (GRAM)

MANUKA HONEY GEL (ML)

MAPROTILINE HCL TABLET

MARTEN-TAB TABLET

MATZIM LA TABLET, EXTENDED RELEASE 24 HR

MAXALT TABLET

MAXALT MLT TABLET, DISINTEGRATING

MAXILUBE JELLY (GRAM)

MAXORB BANDAGE

MAXORB EXTRA BANDAGE

MAXORB EXTRA AG BANDAGE

MB HYDROGEL KIT, CREAM AND GEL

MCL ADHESIVE PATCH, MEDICATED

MEBENDAZOLE POWDER (GRAM)

MECAMYLAMINE HCL POWDER (GRAM)

MECHLORETHAMINE HCL POWDER (GRAM)

MECHOLYL OINTMENT (GRAM)

MECLIZINE HCL POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

134

MECLOFENAMATE SODIUM CAPSULE

MECLOFENAMATE SODIUM POWDER (GRAM)

MECLOFENOXATE HCL POWDER (GRAM)

MEDERMA CLEANSER (ML)

MEDERMA CREAM (GRAM)

MEDERMA GEL (GRAM)

MEDERMA FOR KIDS GEL (GRAM)

MEDFIX TAPE, NON-MEDICATED

MEDFIX EZ TAPE, NON-MEDICATED

MEDI PADS PADS, MEDICATED (EA)

MEDIBASE C LIQUID (ML)

MEDICATED BODY POWDER POWDER (GRAM)

MEDICATED CHEST RUB OINTMENT (GRAM)

MEDICATED CORN REMOVERS ADHESIVE PATCH, MEDICATED

MEDICATED DOUCHE SOLUTION, NON-ORAL

MEDICATED FOOT POWDER (GRAM)

MEDICATED HEAT PATCH ADHESIVE PATCH, MEDICATED

MEDICATED PADS PADS, MEDICATED (EA)

MEDICATED WIPES PADS, MEDICATED (EA)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

135

MEDIDERM CREAM (GRAM)

MEDI-DERM CREAM (GRAM)

MEDI-DERM-L CREAM (ML)

MEDI-DERM-L-RX CREAM (ML)

MEDI-FIRST BURN CREAM IN PACKET (EA)

MEDIGRIP BANDAGE

MEDIHOL GEL BASE ALCOHOL GEL (GRAM)

MEDIHONEY BANDAGE

MEDIHONEY GEL (ML)

MEDIHONEY PASTE (ML)

MEDI-PATCH ADHESIVE PATCH, MEDICATED

MEDIPLAST CORN-CALLUS-WART ADHESIVE PATCH, MEDICATED

MEDIPORE TAPE, NON-MEDICATED

MEDIPORE DRESS-IT BANDAGE

MEDIPORE H TAPE, NON-MEDICATED

MEDIPROXEN TABLET

MEDI-RDT BASE POWDER (GRAM)

MEDIUM CHAIN TRIGLYCERIDES LIQUID (GRAM)

MEDIUM CREAM CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

136

MEDOLOR PAK KIT

MEDROX ADHESIVE PATCH, MEDICATED

MEDROX OINTMENT (GRAM)

MEDROXYPROGESTERONE AC MICRO POWDER (GRAM)

MEFENAMIC ACID CAPSULE

MEFENAMIC ACID POWDER (GRAM)

MEGESTROL ACETATE POWDER (GRAM)

MELATONIN POWDER (GRAM)

MELOXICAM POWDER (GRAM)

MELOXICAM TABLET

MEMANTINE HCL POWDER (GRAM)

MENADIONE POWDER (GRAM)

MENADIONE SODIUM BISULFITE CRYSTALS

MENCAPS ADHESIVE PATCH, MEDICATED

MEN-PHOR LOTION (ML)

MENTAX CREAM (GRAM)

MENTHO-CAINE KIT, OINTMENT AND SPRAY

MENTHODERM OINTMENT (GRAM)

MENTHOL CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

137

MENTHOL CRYSTALS

MENTHOL GEL (GRAM)

MENTHOL-CAMPHOR CREAM (GRAM)

MENTHOL-ZINC OXIDE OINTMENT (GRAM)

MENTHOZEN ADHESIVE PATCH, MEDICATED

MENTHOZEN CREAM (ML)

MEPERIDINE HCL CARTRIDGE (ML)

MEPERIDINE HCL POWDER (GRAM)

MEPERIDINE HCL SOLUTION, ORAL

MEPERIDINE HCL TABLET

MEPERIDINE HCL VIAL (ML)

MEPERIDINE HCL/NS PLASTIC BAG, INJECTION (ML)

MEPROBAMATE TABLET

MEQUINOL CRYSTALS

MERCAPTOPURINE POWDER (GRAM)

MERTHIOLATE SOLUTION, NON-ORAL

MESALAMINE ENEMA (ML)

MESALAMINE ENEMA KIT

MESALAMINE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

138

MESALAMINE SUPPOSITORY, RECTAL

METAPROTERENOL SULFATE POWDER (GRAM)

METAXALL TABLET

METAXALONE TABLET

METFORMIN HCL POWDER (GRAM)

METHACHOLINE CHLORIDE POWDER (GRAM)

METHACRYLIC ACID COPOLYMER POWDER (GRAM)

METHADONE HCL CONCENTRATE, ORAL

METHADONE HCL POWDER (GRAM)

METHADONE HCL SOLUTION, ORAL

METHADONE HCL TABLET

METHADONE HCL TABLET, SOLUBLE

METHADONE HCL VIAL (ML)

METHADOSE CONCENTRATE, ORAL

METHADOSE TABLET, SOLUBLE

METHAGUAL GEL (GRAM)

METHANESULFONIC ACID LIQUID (GRAM)

METHAZOLAMIDE POWDER (GRAM)

METHENAMINE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

139

METHENAMINE MANDELATE POWDER (GRAM)

METHIMAZOLE POWDER (GRAM)

METHIONINE POWDER (GRAM)

METHOCARBAMOL POWDER (GRAM)

METHOCARBAMOL TABLET

METHOCARBAMOL VIAL (ML)

METHOCEL K 100 M POWDER (GRAM)

METHOTREXATE POWDER (GRAM)

METHOXSALEN CRYSTALS

METHOXSALEN POWDER (GRAM)

METHSCOPOLAMINE BROMIDE POWDER (GRAM)

METHYL 5-AMINOLEVULINATE HCL POWDER (GRAM)

METHYL SALICYLATE CREAM (GRAM)

METHYL SALICYLATE LIQUID (ML)

METHYL SULFONE CRYSTALS

METHYLCELLULOSE GEL (ML)

METHYLCELLULOSE POWDER (GRAM)

METHYLCOBALAMIN POWDER (GRAM)

METHYLPARABEN POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

140

METHYLPHENIDATE HCL POWDER (GRAM)

METHYLPREDNISOLONE POWDER (GRAM)

METHYLPREDNISOLONE AC MICRO POWDER (GRAM)

METHYLPYRAZOLE LIQUID (ML)

METHYLTESTOSTERONE POWDER (GRAM)

METHYLTESTOSTERONE MICRONIZED POWDER (GRAM)

METHYLTETRAHYDROFOLIC ACID POWDER (GRAM)

METHYSERGIDE MALEATE POWDER (GRAM)

METOCLOPRAMIDE HCL POWDER (GRAM)

METOPROLOL TARTRATE POWDER (GRAM)

METRONIDAZOLE POWDER (GRAM)

METRONIDAZOLE BENZOATE POWDER (GRAM)

MEXILETINE HCL POWDER (GRAM)

MEZPAROX-HC CREAM (GRAM)

MG217 PSORIASIS CREAM (ML)

MIADERM LOTION (ML)

MICONAZOLE POWDER (GRAM)

MICONAZOLE 3 KIT

MICONAZOLE NITRATE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

141

MICONAZOLE-ZINC OXIDE-PETROLTM OINTMENT (GRAM)

MICROCRYS-CELLULOSE-CMC NA POWDER (GRAM)

MICROCRYSTALLINE CELLULOSE POWDER (GRAM)

MICROCYN SPRAY, NON-AEROSOL (ML)

MICROCYN HYDROGEL GEL (GRAM)

MICRODERM BASE CREAM CREAM (GRAM)

MICROFOAM TAPE, NON-MEDICATED

MICROPORE TAPE, NON-MEDICATED

MICROSOME BASE CREAM CREAM (GRAM)

MICROSPONGE SPONGE

MIDAZOLAM HCL POWDER (GRAM)

MIDOL TABLET

MIGERGOT SUPPOSITORY, RECTAL

MILK THISTLE POWDER (GRAM)

MIMYX CREAM (GRAM)

MINERAL OIL ENEMA (ML)

MINERAL OIL OIL (ML)

MINERAL OIL ENEMA ENEMA (ML)

MINERAL OIL HEAVY OIL (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

142

MINERAL OIL LIGHT OIL (ML)

MINERIN LOTION LOTION (ML)

MINITRAN PATCH, TRANSDERMAL 24 HOURS

MINOCYCLINE HCL POWDER (GRAM)

MINOXIDIL POWDER (GRAM)

MINOXIDIL SOLUTION, NON-ORAL

MINOXIDIL FOR MEN FOAM (GRAM)

MIRVASO GEL (GRAM)

MIRVASO GEL WITH PUMP (GRAM)

MISOPROSTOL POWDER (GRAM)

MISOPROSTOL HPMC POWDER (GRAM)

MITIGO VIAL (ML)

MITOMYCIN POWDER (GRAM)

MITOTANE POWDER (GRAM)

MLC ADHESIVE PATCH, MEDICATED

MOBIC TABLET

MOBISYL CREAM (GRAM)

MOISTURE BARRIER OINTMENT OINTMENT (GRAM)

MOISTURE RECOVERY LOTION (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

143

MOISTURIZING LOTION LOTION (ML)

MOLYBDENUM POWDER (GRAM)

MOMETASONE FUROATE POWDER (GRAM)

MONISTAT 3 KIT

MONISTAT 7 KIT

MONOBENZONE POWDER (GRAM)

MONOSODIUM GLUTAMATE POWDER (GRAM)

MONSEL'S SOLUTION WITH APPLICATOR (ML)

MONSEL'S SOLUTION, NON-ORAL

MONTELUKAST SODIUM GRANULES IN PACKET (EA)

MONTELUKAST SODIUM POWDER (GRAM)

MONTELUKAST SODIUM TABLET

MONTELUKAST SODIUM TABLET,CHEWABLE

MORPHABOND ER TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR

MORPHINE SULFATE CARTRIDGE (ML)

MORPHINE SULFATE PATIENT CONTROLLED ANALGESIA SYRINGE

MORPHINE SULFATE PATIENT CONTROLLED ANALGESIA VIAL

MORPHINE SULFATE PEN INJECTOR (ML)

MORPHINE SULFATE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

144

MORPHINE SULFATE SOLUTION, ORAL

MORPHINE SULFATE SUPPOSITORY, RECTAL

MORPHINE SULFATE SYRINGE (EA)

MORPHINE SULFATE SYRINGE (ML)

MORPHINE SULFATE TABLET

MORPHINE SULFATE VIAL (ML)

MORPHINE SULFATE CR TABLET, EXTENDED RELEASE

MORPHINE SULFATE ER CAPSULE, EXTENDED RELEASE PELLETS

MORPHINE SULFATE ER CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR

MORPHINE SULFATE ER TABLET, EXTENDED RELEASE

MORPHINE SULFATE IN DEXTROSE PATIENT CONTROLLED ANALGESIA SYRINGE

MORPHINE SULFATE IN DEXTROSE PLASTIC BAG, INJECTION (ML)

MORPHINE SULFATE/NS PATIENT CONTROLLED ANALGESIA SYRINGE

MORPHINE SULFATE/NS PLASTIC BAG, INJECTION (ML)

MORPHINE SULFATE/NS PREFILLED PUMP RESERVOIR

MOSCO CORN REMOVER ADHESIVE PATCH, MEDICATED

MOSCO LIQ CALLUS-CORN REMOVER LIQUID (ML)

MOTRIN IB CAPSULE

MOTRIN IB TABLET

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

145

MOTRIN PM TABLET

MOXIFLOXACIN HCL POWDER (GRAM)

MOXISYLYTE HCL POWDER (GRAM)

MS CONTIN TABLET, EXTENDED RELEASE

MSM WITH GLUCOSAMINE CREAM (GRAM)

MTX ADHESIVE PATCH, MEDICATED

MULTI ANTIBIOTIC PLUS CREAM (GRAM)

MULTIBASE CREAM (GRAM)

MULTIUSE BASE CREAM (GRAM)

MUPIROCIN POWDER (GRAM)

MUSCLE RUB CREAM (GRAM)

MUSCLE RUB ULTRA STRENGTH CREAM (GRAM)

MYCO NAIL LIQUID (ML)

MYCO NAIL A SOLUTION, NON-ORAL

MYCOCIDE NS LIQUID (ML)

MYOFLEX CREAM (GRAM)

NABUMETONE POWDER (GRAM)

NABUMETONE TABLET

NABUMETONE MICRONIZED POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

146

NADOLOL POWDER (GRAM)

NAIL SCRUB LOTION (ML)

NALBUPHINE HCL POWDER (GRAM)

NALFON CAPSULE

NALFON TABLET

NALIDIXIC ACID POWDER (GRAM)

NALOCET TABLET

NALOXONE HCL POWDER (GRAM)

NALTREXONE BASE MONOHYDRATE POWDER (GRAM)

NALTREXONE HYDROCHLORIDE POWDER (GRAM)

NANDROLONE DECANOATE POWDER (GRAM)

NAPHTHOL POWDER (GRAM)

NAPRELAN TABLET,EXTENDED RELEASE MULTIPHASE 24 HR

NAPROSYN SUSPENSION, ORAL (FINAL DOSE FORM)

NAPROSYN TABLET

NAPROXEN POWDER (GRAM)

NAPROXEN SUSPENSION, ORAL (FINAL DOSE FORM)

NAPROXEN TABLET

NAPROXEN TABLET, ENTERIC COATED

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

147

NAPROXEN SODIUM CAPSULE

NAPROXEN SODIUM POWDER (GRAM)

NAPROXEN SODIUM TABLET

NAPROXEN SODIUM DS TABLET

NAPROXEN SODIUM ER TABLET,EXTENDED RELEASE MULTIPHASE 24 HR

NARATRIPTAN HCL TABLET

NASAL ANTISEPTIC SWABS SWAB, MEDICATED

NASAL STRIPS STRIP

NATRAPEL AEROSOL, SPRAY (ML)

NATROBA SUSPENSION, TOPICAL (ML)

NATURAL MIXED TOCOPHEROLS POWDER (GRAM)

NATURAL OATMEAL BATH TREATMENT PACKET (EA)

NATURAL PAIN RELIEVING GEL (GRAM)

NEOMYCIN SULFATE POWDER (GRAM)

NEOPROFEN VIAL (ML)

NEOSALUS CREAM (GRAM)

NEOSALUS FOAM (GRAM)

NEOSALUS LOTION (ML)

NEOSALUS CP CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

148

NEOSPORIN FOAM (ML)

NEOSPORIN OINTMENT (GRAM)

NEOSPORIN OINTMENT IN PACKET (EA)

NEOSPORIN + PAIN RELIEF CREAM (GRAM)

NEOSPORIN + PAIN RELIEF OINTMENT (GRAM)

NEOSPORIN MOISTURIZING CREAM CREAM (GRAM)

NEOSPORIN NEO TO GO SPRAY, NON-AEROSOL (ML)

NEOSPORIN-PAIN ITCH SCAR OINTMENT (GRAM)

NEOSTIGMINE METHYLSULFATE POWDER (GRAM)

NEO-SYNALAR CREAM (GRAM)

NETTLE LEAF POWDER (GRAM)

NEUAC COMBINATION PACKAGE, CREAM AND GEL

NEUAC GEL (GRAM)

NEURCAINE KIT, PATCH, MEDICATED AND CREAM

NEURO MAX GEL (GRAM)

NEUTROGENA STICK (EA)

NEUTROGENA MOISTURE LOTION (ML)

NEW GENERATION BANDAGE

NEW SKIN AEROSOL, SPRAY (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

149

NEW SKIN FILM-FORMING LIQUID WITH APPLICATOR

NEW TEROCIN LOTION (ML)

NEXCARE GENTLE PAPER TAPE TAPE, NON-MEDICATED

NEXCARE TEGADERM BANDAGE

NEXIUM 24HR CAPSULE,DELAYED RELEASE (ENTERIC COATED)

NEXIUM 24HR TABLET, ENTERIC COATED

NEXIUM OTC CAPSULE,DELAYED RELEASE (ENTERIC COATED)

NEXIUM RX CAPSULE,DELAYED RELEASE (ENTERIC COATED)

NEXIUM RX SUSP FOR RECON,DELAYED REL. IN A PACKET

NEXIUM RX VIAL (EA)

NEXTOL SF CANDY BASE POWDER (GRAM)

NIACIN POWDER (GRAM)

NIACINAMIDE CRYSTALS

NIACINAMIDE POWDER (GRAM)

NIAOULI OIL OIL (GRAM)

NICARDIPINE HCL AMPUL (ML)

NICARDIPINE HCL CAPSULE

NICARDIPINE HCL VIAL (ML)

NICARDIPINE HCL-0.9% NACL INTRAVENOUS SOLUTION, PIGGYBACK (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

150

NICLOSAMIDE POWDER (GRAM)

NICOTINAMIDE ADENINE POWDER (GRAM)

NICOTINE POLACRILEX POWDER (GRAM)

NICOTINE TARTRATE POWDER (GRAM)

NICOTINIC ACID POWDER (GRAM)

NIFEDIPINE CAPSULE

NIFEDIPINE POWDER (GRAM)

NIFEDIPINE ER TABLET, EXTENDED RELEASE

NIFEDIPINE ER TABLET, EXTENDED RELEASE 24 HR

NIFEDIPINE MICRONIZED POWDER (GRAM)

NIMODIPINE CAPSULE

NISOLDIPINE TABLET, EXTENDED RELEASE 24 HR

NITRIC ACID LIQUID (ML)

NITRO-DUR PATCH, TRANSDERMAL 24 HOURS

NITROFURANTOIN POWDER (GRAM)

NITROFURAZONE POWDER (GRAM)

NITROGLYCERIN PATCH, TRANSDERMAL 24 HOURS

NIVATOPIC PLUS CREAM (GRAM)

NIVEA CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

151

NIVEA ORIGINAL LOTION (ML)

NIVEA SOFT CREAM (GRAM)

NIX LIQUID (ML)

NO STING BARRIER FILM AEROSOL, SPRAY (ML)

NO STING BARRIER FILM PADS, MEDICATED (EA)

NO STING BARRIER FILM SWAB, MEDICATED

NO STING SKIN PREP TOWELETTE (EA)

NOBLE FORMULA BAR

NOBLE FORMULA CREAM (ML)

NOBLE FORMULA SHAMPOO

NOBLE FORMULA SPRAY, NON-AEROSOL (ML)

NOBLE FORMULA S SPRAY, NON-AEROSOL (ML)

NOLIX CREAM (GRAM)

NOLIX LOTION (ML)

NON-DROWSY ALLERGY TABLET

NON-STICK PAD BANDAGE

NON-STICK PADS BANDAGE

NOREPINEPHRINE BITARTRATE POWDER (GRAM)

NORETHINDRONE ACETATE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

152

NORFORMS SUPPOSITORY, VAGINAL

NORPRAMIN TABLET

NORTRIPTYLINE HCL CAPSULE

NORTRIPTYLINE HCL POWDER (GRAM)

NORVASC TABLET

NOURILITE EMULSION (GRAM)

NOURISIL GEL (GRAM)

NOURIVAN ANTIOX CREAM (GRAM)

NOVACORT GEL WITH PERINEAL APPLICATOR

NOXAFIL SUSPENSION, ORAL (FINAL DOSE FORM)

NOXAFIL TABLET, ENTERIC COATED

NOXAFIL VIAL (ML)

NOXI-K CREAM (GRAM)

NOXIPAK KIT

NUCYNTA TABLET

NUCYNTA ER TABLET, EXTENDED RELEASE 12 HR

NUDICLO KIT, CREAM AND SOLUTION

NUDROXICIN V2 LIQUID (ML)

NULIDO ADHESIVE PATCH, MEDICATED

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

153

NULIDO GEL (ML)

NUMBONEX LOTION (GRAM)

NUPERCAINAL OINTMENT (GRAM)

NUSURGEPAK KIT

NUTRIARX KIT

NUVAIL NAIL FILM SOLUTION (ML)

NUVARING RING, VAGINAL

NUVAZIL SHEET (EA)

NYLIDRIN HCL POWDER (GRAM)

NYMALIZE SOLUTION, ORAL

NYMALIZE SYRINGE (ML)

NYSTATIN POWDER (EA)

NYSTATIN W/TRIAMCINOLONE CREAM (GRAM)

NYSTATIN W/TRIAMCINOLONE OINTMENT (GRAM)

NYSTATIN/TRIAMCINOLONE CREAM (GRAM)

OASIS SHEET (EA)

OATMEAL BATH PACKET (EA)

OC8 GEL (GRAM)

O-CAL-ETTE EACH

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

154

OCCLUVAN OINTMENT (GRAM)

OCEAN GEL (GRAM)

OCTINOXATE LIQUID (ML)

OCUSOFT HYPOCHLOR SPRAY GEL (ML)

OCUSOFT HYPOCHLOR SPRAY, NON-AEROSOL (ML)

OCUSOFT LID SCRUB FOAM (ML)

OCUSOFT LID SCRUB KIT

OFF ACTIVE AEROSOL, SPRAY (GRAM)

OFF DEEP WOODS AEROSOL, SPRAY (GRAM)

OFF DEEP WOODS SPRAY, NON-AEROSOL (ML)

OFF DEEP WOODS DRY AEROSOL, POWDER (GRAM)

OFF DEEP WOODS SPORTSMEN AEROSOL, SPRAY (GRAM)

OFF DEEP WOODS SPORTSMEN SPRAY, NON-AEROSOL (ML)

OFF FAMILYCARE AEROSOL, POWDER (GRAM)

OFF FAMILYCARE SPRAY, NON-AEROSOL (ML)

OIL FREE ACNE WASH CLEANSER (ML)

OINTMENT BASE OINTMENT (GRAM)

OLEABASE PLASTICIZED OINTMENT (GRAM)

OLUX-E FOAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

155

OMEPPI CAPSULE

OMEPRAZOLE CAPSULE,DELAYED RELEASE (ENTERIC COATED)

OMEPRAZOLE POWDER (GRAM)

OMEPRAZOLE TABLET, ENTERIC COATED

OMEPRAZOLE TABLET, DISINTEGRATING, DELAYED RELEASE

OMEPRAZOLE-SODIUM BICARBONATE CAPSULE

OMEPRAZOLE-SODIUM BICARBONATE PACKET (EA)

OMNIBASE CREAM (GRAM)

ON THE SPOT CREAM (GRAM)

ONDANSETRON HCL AMPUL (ML)

ONDANSETRON HCL POWDER (GRAM)

ONDANSETRON HCL SOLUTION, ORAL

ONDANSETRON HCL SYRINGE (ML)

ONDANSETRON HCL TABLET

ONDANSETRON HCL VIAL (ML)

ONDANSETRON HCL-NS INTRAVENOUS SOLUTION, PIGGYBACK (ML)

ONDANSETRON ODT TABLET, DISINTEGRATING

ONEXTON GEL WITH PUMP (GRAM)

ONMEL TABLET

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

156

ONZETRA XSAIL AEROSOL POWDER, BREATH ACTIVATED (EA)

OPANA AMPUL (ML)

OPANA TABLET

OPANA ER TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR

OPSITE BANDAGE

OPSITE IV BANDAGE

OPTIFOAM BANDAGE

ORA-HESIVE BASE OINTMENT (GRAM)

ORIGANUM OIL OIL (ML)

ORIGINAL ABSORBINE JR. LINIMENT

ORIGINAL FORMULA BAR

ORNITHINE POWDER (GRAM)

ORPHENADRINE CITRATE AMPUL (ML)

ORPHENADRINE CITRATE POWDER (GRAM)

ORPHENADRINE CITRATE TABLET, EXTENDED RELEASE

ORPHENADRINE CITRATE VIAL (ML)

ORTHO-NESIC GEL (ML)

OSELTAMIVIR PHOSPHATE POWDER (GRAM)

OUTGRO LIQUID (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

157

OVIDE LOTION (ML)

OXALIC ACID CRYSTALS

OXANDROLONE POWDER (GRAM)

OXAPROZIN TABLET

OXAYDO TABLET, ORAL ONLY

OXICONAZOLE NITRATE CREAM (GRAM)

OXISTAT CREAM (GRAM)

OXISTAT LOTION (ML)

OXYBENZONE POWDER (GRAM)

OXYBUTYNIN CHLORIDE POWDER (GRAM)

OXYCODONE HCL CAPSULE

OXYCODONE HCL CONCENTRATE, ORAL

OXYCODONE HCL POWDER (GRAM)

OXYCODONE HCL SOLUTION, ORAL

OXYCODONE HCL SYRINGE (EA)

OXYCODONE HCL TABLET

OXYCODONE HCL ER TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR

OXYCODONE HCL-IBUPROFEN TABLET

OXYCODONE W/ACETAMINOPHEN SOLUTION, ORAL

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

158

OXYCODONE W/ACETAMINOPHEN TABLET

OXYCODONE W/ASPIRIN TABLET

OXYCONTIN TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR

OXYMETAZOLINE HCL POWDER (GRAM)

OXYMORPHONE HCL TABLET

OXYMORPHONE HCL TABLET, EXTENDED RELEASE 12 HR

OXYMORPHONE HCL ER TABLET, EXTENDED RELEASE 12 HR

OXYTETRACYCLINE HCL POWDER (GRAM)

OXYTOCIN POWDER (GRAM)

OXYZAL WET DRESSING SOLUTION, NON-ORAL

OZOBAX SOLUTION, ORAL

P & S LIQUID (ML)

P & S SHAMPOO

PACNEX CLEANSER (ML)

PACNEX HP PADS, MEDICATED (EA)

PACNEX LP PADS, MEDICATED (EA)

PAIN EASE AEROSOL, SPRAY (ML)

PAIN FREE TAPE TAPE, NON-MEDICATED

PAIN FREE WRAP BANDAGE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

159

PAIN RELIEF ADHESIVE PATCH, MEDICATED

PAIN RELIEF CREAM (GRAM)

PAIN RELIEF CREAM (ML)

PAIN RELIEF GEL (GRAM)

PAIN RELIEVING ADHESIVE PATCH, MEDICATED

PAIN RELIEVING CREAM (GRAM)

PAIN RELIEVING GEL (GRAM)

PAIN RELIEVING OINTMENT (GRAM)

PAIN RELIEVING PATCH ADHESIVE PATCH, MEDICATED

PAIN RELIEVING RUB CREAM (GRAM)

PALMAROSA OIL OIL (GRAM)

PALMITOYL PENTAPEPTIDE-4 GEL (GRAM)

PALONOSETRON HCL SYRINGE (ML)

PALONOSETRON HCL VIAL (ML)

PAMELOR CAPSULE

PANCREATIN POWDER (GRAM)

PANDEL CREAM (GRAM)

PANOXYL BAR

PANOXYL CLEANSER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

160

PANRETIN GEL (GRAM)

PANTHENOL POWDER (GRAM)

PANTOPRAZOLE SODIUM GRANULES DELAYED RELEASE FOR SUSP PACKET

PANTOPRAZOLE SODIUM TABLET, ENTERIC COATED

PANTOPRAZOLE SODIUM VIAL (EA)

PAPAIN POWDER (GRAM)

PAPAVERINE HCL POWDER (GRAM)

PAPER TAPE TAPE, NON-MEDICATED

PAPER TAPE AND DISPENSER TAPE, NON-MEDICATED

PARACHLOROPHENOL POWDER (GRAM)

PARAFON FORTE DSC TABLET

PAROMOMYCIN SULFATE POWDER (GRAM)

P-CARE X KIT

PCCA ALADERM BASE OINTMENT (GRAM)

PCCA ANHYDROUS LIPODERMA CREAM (GRAM)

PCCA BASE ANHYDROUS OINTMENT (GRAM)

PCCA COSMETIC HRT BASE CREAM (GRAM)

PCCA CUSTOM LIPO-MAX CREAM CREAM (GRAM)

PCCA EFFERVESCENT POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

161

PCCA LIPODERM BASE CREAM (GRAM)

PCCA LIPODERM HMW GEL (GRAM)

PCCA MBK BASE WAX (GRAM)

PCCA MVC CREAM CREAM (GRAM)

PCCA NATACREAM CREAM (GRAM)

PCCA POLOXAMER 407 NF GEL (ML)

PCCA POLYGLYCOL TROCHE BASE POWDER (GRAM)

PCCA STEVIOSIDE LIQUID (ML)

PCCA T3 SODIUM DILUTION POWDER (GRAM)

PCCA T4 SODIUM DILUTION POWDER (GRAM)

PCCA VANISHING BASE CREAM (GRAM)

PECTIN POWDER (GRAM)

PEDIA-LAX ENEMA ENEMA (ML)

PEDIATRIC ENEMA ENEMA (ML)

PEDI-BORO SOAK POWDER IN PACKET (EA)

PEG 400 MONOSTEARATE WAX (GRAM)

PEG OINTMENT OINTMENT (GRAM)

PEG TROCHE BASE POWDER (GRAM)

PEG-40 CASTOR OIL OIL (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

162

PEGBLEND WAX (GRAM)

PENCREAM CREAM (GRAM)

PENDERM CREAM (GRAM)

PENETRAN + PLUS LOTION (ML)

PENICILLAMINE POWDER (GRAM)

PENICILLAMINE(D-) POWDER (GRAM)

PEN-KERA CREAM (ML)

PENLEN SPRAY, NON-AEROSOL (ML)

PENNSAID SOLUTION IN METERED-DOSE PUMP (GRAM)

PENNYROYAL OIL OIL (ML)

PENSOMAL CREAM (GRAM)

PENTOBARBITAL SODIUM POWDER (GRAM)

PENTOSAN POLYSULFATE SODIUM POWDER (GRAM)

PENTOXIFYLLINE POWDER (GRAM)

PENTOXIFYLLINE TABLET, EXTENDED RELEASE

PENTRAVAN CREAM (GRAM)

PENTRAVAN PLUS CREAM (GRAM)

PENTYLENE GLYCOL LIQUID (ML)

PENTYLENETETRAZOLE CRYSTALS

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

163

PEPSIN 3,000 DIGESTION POWDER (GRAM)

PERCOCET TABLET

PERFLUORODECALIN LIQUID (GRAM)

PERFORM PAIN RELIEVING GEL (ML)

PERIANAL CLEANSING CLEANSER (ML)

PERICLEAN CLEANSER (ML)

PERIFRESH CLEANSER (ML)

PERIGIENE CLEANSER (ML)

PERIGUARD OINTMENT (GRAM)

PERINEAL SKIN CLEANSER CLEANSER (ML)

PERISCENT SOLUTION, NON-ORAL

PERISHIELD OINTMENT (GRAM)

PERMETHRIN CREAM (GRAM)

PERMETHRIN LIQUID (GRAM)

PERMETHRIN LIQUID (ML)

PERPHENAZINE POWDER (GRAM)

PERSA-GEL GEL (GRAM)

PERSONAL LUBRICANT JELLY (GRAM)

PERSONAL LUBRICANT SOLUTION (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

164

PERSONAL LUBRICATING JELLY JELLY (GRAM)

PERUVIAN BALSAM LIQUID (GRAM)

PEUCEDANUM OSTRUTHIUM EXTRACT SOLUTION (GRAM)

PFCB CREAM (GRAM)

PHARMABASE CREAM (GRAM)

PHARMABASE HEAVY CREAM (GRAM)

PHARMABASE LIGHT CREAM (GRAM)

PHENADOZ SUPPOSITORY, RECTAL

PHENAZOPYRIDINE HCL POWDER (GRAM)

PHENELZINE SULFATE POWDER (GRAM)

PHENERGAN SUPPOSITORY, RECTAL

PHENINDIONE POWDER (GRAM)

PHENIRAMINE MALEATE POWDER (GRAM)

PHENOBARBITAL POWDER (GRAM)

PHENOBARBITAL SODIUM POWDER (GRAM)

PHENOL CRYSTALS

PHENOL LIQUID (ML)

PHENOL EZ SWAB, MEDICATED

PHENOLSULFONIC ACID LIQUID (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

165

PHENOXYBENZAMINE HCL POWDER (GRAM)

PHENOXYETHANOL LIQUID (ML)

PHENTERMINE HCL POWDER (GRAM)

PHENTOLAMINE MESYLATE POWDER (GRAM)

PHENYL SALICYLATE POWDER (GRAM)

PHENYLALANINE POWDER (GRAM)

PHENYLALANINE (DL) CRYSTALS

PHENYLBUTAZONE POWDER (GRAM)

PHENYLEPHRINE HCL POWDER (GRAM)

PHENYLETHYLAMINE HCL CRYSTALS

PHENYLMERCURIC ACETATE POWDER (GRAM)

PHENYLMERCURIC NITRATE CRYSTALS

PHENYLTOLOXAMINE DIHYD CIT POWDER (GRAM)

PHENYTOIN POWDER (GRAM)

PHENYTOIN SODIUM POWDER (GRAM)

PHLAG SPRAY SPRAY, NON-AEROSOL (ML)

PHOSPHATIDYLCHOLINE POWDER (GRAM)

PHOSPHATIDYLSERINE POWDER (GRAM)

PHOSPHORIC ACID LIQUID (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

166

PHRENILIN FORTE CAPSULE

PHYTIC ACID SOLUTION (GRAM)

PHYTOBASE CREAM (GRAM)

PHYTONADIONE LIQUID (GRAM)

PHYTONADIONE LIQUID (ML)

PICATO GEL (EA)

PICODERM CREAM (GRAM)

PILOCARPINE HCL POWDER (GRAM)

PILOCARPINE NITRATE CRYSTALS

PILOCARPINE NITRATE POWDER (GRAM)

PIMECROLIMUS CREAM (GRAM)

PINE OIL OIL (ML)

PIPERINE POWDER (GRAM)

PIROXICAM CAPSULE

PIROXICAM POWDER (GRAM)

PLACEBO #00 CAPSULE

PLANTAR WART REMOVER ADHESIVE PATCH, MEDICATED

PLASTIC ADHESIVE BANDAGES BANDAGE

PLASTIC STRIP BANDAGE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

167

PLASTICIZED BASE GEL (GRAM)

PLEXION CLEANSER (GRAM)

PLEXION CREAM (GRAM)

PLEXION LOTION (GRAM)

PLEXION PADS, MEDICATED (EA)

PLIAGLIS CREAM (GRAM)

PLIXDA SWAB, MEDICATED

PLO GEL MEDIFLO COMBINATION PACKAGE, GEL AND LIQUID

PLO GEL MEDIFLO GEL (ML)

PLO GEL MEDIFLO PRE-MIXED GEL (GRAM)

PLO GEL PREMIUM LECITHIN GEL (GRAM)

PLO TRANSDERMA CREAM (GRAM)

PLO20 GEL (GRAM)

PLURONIC GEL (GRAM)

PLURONIC GEL (ML)

PLURONIC LIQUID (ML)

PLURONIC F-127 POWDER (GRAM)

PNA-HRT BASE CREAM CREAM (GRAM)

PODOCON-25 LIQUID (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

168

PODOFILOX POWDER (GRAM)

PODOFILOX SOLUTION, NON-ORAL

PODOPHYLLUM RESIN POWDER (GRAM)

POISON IVY CLEANSER (GRAM)

POISON IVY TREATMENT AEROSOL, SPRAY (ML)

POLAR FREEZE GEL (GRAM)

POLAR FROST GEL (ML)

POLIBAR ACB ENEMA (GRAM)

POLOX GEL (ML)

POLOXAMER 188 BEADS (GRAM)

POLOXAMER 188 POWDER (GRAM)

POLOXAMER 407 POWDER (GRAM)

POLY BACITRACIN OINTMENT (GRAM)

POLYBASE WAX (GRAM)

POLYETHYLENE GLYCOL GRANULES (GRAM)

POLYETHYLENE GLYCOL LIQUID (GRAM)

POLYETHYLENE GLYCOL LIQUID (ML)

POLYETHYLENE GLYCOL POWDER (GRAM)

POLYETHYLENE GLYCOL WAX (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

169

POLYHEXAMETHYLENE BIGUANIDE SOLUTION, NON-ORAL

POLYMYXIN B SULFATE POWDER (EA)

POLYOX WSR-301 POWDER (GRAM)

POLYOXYL 40 STEARATE PELLET (GRAM)

POLYOXYL 40 STEARATE WAX (GRAM)

POLYOXYL LAURYL ETHER 9 LIQUID (ML)

POLYPEG SUPPOSITORY WAX (GRAM)

POLYSKIN II BANDAGE

POLYSORBATE LIQUID (ML)

POLYSORBATE SOLUTION, NON-ORAL

POLYSPORIN OINTMENT (GRAM)

POLYSPORIN PACKET (EA)

POLYTOZA SHEET (EA)

POLYVINYL ALCOHOL POWDER (GRAM)

PONSTEL CAPSULE

PONTOCAINE SOLUTION, NON-ORAL

POSACONAZOLE SUSPENSION, ORAL (FINAL DOSE FORM)

POSACONAZOLE TABLET, ENTERIC COATED

POTASSIUM ACETATE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

170

POTASSIUM ACID TARTRATE POWDER (GRAM)

POTASSIUM AZELAOYL DIGLYCINATE LIQUID (ML)

POTASSIUM BICARBONATE GRANULES (GRAM)

POTASSIUM BICARBONATE POWDER (GRAM)

POTASSIUM BROMIDE CRYSTALS

POTASSIUM BROMIDE PELLET (GRAM)

POTASSIUM BROMIDE POWDER (GRAM)

POTASSIUM CHLORIDE GRANULES (GRAM)

POTASSIUM CHLORIDE POWDER (GRAM)

POTASSIUM CITRATE GRANULES (GRAM)

POTASSIUM CITRATE POWDER (GRAM)

POTASSIUM GLUCONATE POWDER (GRAM)

POTASSIUM HYDROXIDE PELLET (GRAM)

POTASSIUM HYDROXIDE SOLUTION, NON-ORAL

POTASSIUM IODIDE CRYSTALS

POTASSIUM IODIDE GRANULES (GRAM)

POTASSIUM IODIDE POWDER (GRAM)

POTASSIUM METABISULFITE POWDER (GRAM)

POTASSIUM NITRATE GRANULES (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

171

POTASSIUM NITRATE POWDER (GRAM)

POTASSIUM PERCHLORATE CRYSTALS

POTASSIUM PERMANGANATE CRYSTALS

POTASSIUM PERMANGANATE GRANULES (GRAM)

POTASSIUM PHOSPHATE CRYSTALS

POTASSIUM SORBATE CRYSTALS

POTASSIUM SORBATE POWDER (GRAM)

POTASSIUM SULFATE CRYSTALS

POVIDONE K-30 POWDER (GRAM)

POVIDONE-IODINE GEL (ML)

POVIDONE-IODINE LIQUID IN PACKET (ML)

POVIDONE-IODINE OINTMENT (GRAM)

POVIDONE-IODINE PADS, MEDICATED (EA)

POVIDONE-IODINE POWDER (GRAM)

POVIDONE-IODINE SOLUTION, NON-ORAL

POVIDONE-IODINE SPRAY, NON-AEROSOL (ML)

POVIDONE-IODINE SWAB, MEDICATED

POWDER SCENT FRAGRANCE LIQUID (ML)

PR BENZOYL PEROXIDE CLEANSER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

172

PR CREAM CREAM (GRAM)

PRACASIL TM-PLUS GEL (GRAM)

PRAMOSONE CREAM (GRAM)

PRAMOSONE LOTION (ML)

PRAMOSONE OINTMENT (GRAM)

PRAMOSONE E CREAM (GRAM)

PRAMOXINE HCL POWDER (GRAM)

PRAMOXINE HCL W/HYDROCORTISONE CREAM WITH APPLICATOR

PRAMOXINE-HC CREAM (GRAM)

PRAZIQUANTEL POWDER (GRAM)

PRAZOSIN HCL POWDER (GRAM)

PRE-ATTACHED LTA KIT SOLUTION, ORAL

PREDNISOLONE POWDER (GRAM)

PREDNISOLONE ACETATE MICRONIZE POWDER (GRAM)

PREDNISOLONE SODIUM PHOSPHATE POWDER (GRAM)

PREDNISONE POWDER (GRAM)

PREGNENOLONE POWDER (GRAM)

PREGNENOLONE MICRONIZED POWDER (GRAM)

PREMARIN CREAM WITH APPLICATOR

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

173

PRE-MOISTENED HEMORRHOIDAL PADS, MEDICATED (EA)

PRE-MOISTENED MEDICATED WIPES PAD

PREPARATION H CREAM (GRAM)

PREPARATION H GEL (GRAM)

PREPARATION H OINTMENT WITH APPLICATOR

PREPARATION H PADS, MEDICATED (EA)

PREPARATION H SUPPOSITORY, RECTAL

PREPARATION H TOTABLES PADS, MEDICATED (EA)

PREPIDIL GEL WITH PREFILLED APPLICATOR (GRAM)

PREPPIES EACH

PRESERA FOAM (GRAM)

PREVACID OTC CAPSULE,DELAYED RELEASE (ENTERIC COATED)

PREVACID RX CAPSULE,DELAYED RELEASE (ENTERIC COATED)

PREVACID RX TABLET, DISINTEGRATING, DELAYED RELEASE

PRIKAAN KIT

PRIKAAN LITE KIT

PRILO PATCH KIT, PATCH, MEDICATED AND CREAM

PRILOCAINE HCL POWDER (GRAM)

PRILOLID KIT

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

174

PRILOSEC OTC TABLET, ENTERIC COATED

PRILOSEC RX SUSP FOR RECON,DELAYED REL. IN A PACKET

PRILOVIX KIT

PRILOVIX LITE KIT

PRILOVIX LITE PLUS KIT

PRILOVIX ULTRALITE KIT

PRILOVIX ULTRALITE PLUS KIT

PRILOVIXIL KIT

PRIMER MODIFIED UNNA BOOT BANDAGE

PRIMIDONE POWDER (GRAM)

PRIMLEV TABLET

PRIZOPAK II KIT

PRO COMFORT ALCOHOL PADS PADS, MEDICATED (EA)

PRO DNA COLLECTION KIT

PRO DNA MEDICATED COLLECTION KIT

PRO SPORTS TAPE TAPE, NON-MEDICATED

PROCAINAMIDE HCL POWDER (GRAM)

PROCAINE HCL CRYSTALS

PROCARBAZINE HCL POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

175

PROCARDIA CAPSULE

PROCARDIA XL TABLET, EXTENDED RELEASE 24 HR

PRO-CEPTION FERTILITY PAK EACH

PROCHLORPERAZINE EDISYLATE POWDER (GRAM)

PROCHLORPERAZINE MALEATE POWDER (GRAM)

PROCHLORPERAZINE MALEATE SUPPOSITORY, RECTAL

PROCOMYCIN CREAM (GRAM)

PROCORT CREAM WITH APPLICATOR

PROCTOFOAM-HC FOAM (GRAM)

PROFENO TABLET

PROGESTERONE POWDER (GRAM)

PROLATE TABLET

PROMETHAZINE HCL POWDER (GRAM)

PROMETHAZINE HCL SUPPOSITORY, RECTAL

PROMETHEGAN SUPPOSITORY, RECTAL

PROMISEB CREAM (GRAM)

PROMISEB COMPLETE KIT, CLEANSER AND CREAM

PROPANTHELINE BROMIDE POWDER (GRAM)

PROPARACAINE HCL POWDER (GRAM)

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Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

176

PROPRANOLOL HCL POWDER (GRAM)

PROPYL GALLATE POWDER (GRAM)

PROPYLENE GLYCOL M-STEARATE WAX (GRAM)

PROPYLPARABEN CRYSTALS

PROPYLPARABEN POWDER (GRAM)

PROPYLTHIOURACIL POWDER (GRAM)

PROSHIELD FOAM & SPRAY CLEANSER (ML)

PROSTAGLANDIN E1 POWDER (GRAM)

PROSTIN E2 VAGINAL SUPPOSITORY SUPPOSITORY, VAGINAL

PROTAMINE SULFATE POWDER (GRAM)

PROTECTIVE POWDER (GRAM)

PROTIRELIN POWDER (GRAM)

PROTONIX GRANULES DELAYED RELEASE FOR SUSP PACKET

PROTONIX TABLET, ENTERIC COATED

PROTONIX IV VIAL (EA)

PROTOPIC OINTMENT (GRAM)

PROTRIPTYLINE HCL TABLET

PROVIL TABLET

PRUCLAIR CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

177

PRUMYX CREAM (GRAM)

PRUTECT EMULSION (GRAM)

PSEUDOEPHEDRINE HCL POWDER (GRAM)

PSORCON CREAM (GRAM)

PSORIASIS MEDICATED SHAMPOO

PSYLLIUM POWDER (GRAM)

PSYLLIUM HUSK POWDER (GRAM)

PUMICE POWDER (GRAM)

PURE AND GENTLE SALINE ENEMA ENEMA (ML)

PURE COMFORT ALCOHOL PAD PADS, MEDICATED (EA)

PUROXCIN ADHESIVE PATCH, MEDICATED

PYRANTEL PAMOATE POWDER (GRAM)

PYRAZINAMIDE POWDER (GRAM)

PYRIDOSTIGMINE BROMIDE POWDER (GRAM)

PYRIDOXAL-5-PHOSPHATE POWDER (GRAM)

PYRIDOXINE HCL CRYSTALS

PYRIDOXINE HCL POWDER (GRAM)

PYRILAMINE MALEATE POWDER (GRAM)

PYRIMETHAMINE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

178

PYROGALLIC ACID OINTMENT (GRAM)

PYROGALLOL CRYSTALS

PYRUVIC ACID LIQUID (GRAM)

PYRUVIC ACID LIQUID (ML)

PYRUVIC ACID SODIUM SALT POWDER (GRAM)

Q-DERM CREAM (GRAM)

QMIIZ ODT TABLET, DISINTEGRATING

QUATERNIUM-15 POWDER (GRAM)

QUERCETIN DIHYDRATE POWDER (GRAM)

QUINACRINE HCL POWDER (GRAM)

QUINIDINE SULFATE CRYSTALS

QUINIDINE SULFATE POWDER (GRAM)

QUININE HCL POWDER (GRAM)

QUININE SULFATE POWDER (GRAM)

QUINJA GEL (GRAM)

QUTENZA KIT

QUZYTTIR VIAL (ML)

RA LOTION (ML)

RABEPRAZOLE SODIUM CAPSULE, DELAYED RELEASE SPRINKLE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

179

RABEPRAZOLE SODIUM TABLET, ENTERIC COATED

RACEPINEPHRINE HCL POWDER (GRAM)

RADIADERM R1-R2 COMBINATION PACKAGE, GEL AND LOTION

RADIADERM R1-R2 COMBINATION PACKETS, GEL AND LOTION

RADIADERM R2 LOTION (ML)

RADIADERM R2 LOTION IN PACKET

RADIAGUARD LOTION (GRAM)

RADIAPLEXRX GEL (GRAM)

RANGER READY REPELLENT AEROSOL, SPRAY WITH PUMP (ML)

RANITIDINE HCL POWDER (GRAM)

RAPESEED OIL LIQUID (ML)

RAPID CLEAR PADS, MEDICATED (EA)

RAPID DISSOLVE TABLET POWDER (GRAM)

RAPLIXA VIAL (GRAM)

RASAGILINE MESYLATE POWDER (GRAM)

RASH RELIEF-ZINC OXIDE SPRAY, NON-AEROSOL (GRAM)

RAUWOLFIA SERPENTINA POWDER (GRAM)

READY TO USE ENEMA ENEMA (ML)

READYSHARP KETOROLAC KIT

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

180

READYSHARP LIDOCAINE KIT

RECEDO GEL (GRAM)

RECOTHROM VIAL (EA)

RECTASMOOTHE CREAM (GRAM)

RECTICARE CREAM (GRAM)

RECTICARE TOWELETTE (EA)

RECTIV OINTMENT (GRAM)

RECURA CREAM (GRAM)

RED ALGAE POWDER (GRAM)

RED YEAST RICE POWDER (GRAM)

RED YEAST RICE EXTRACT POWDER (GRAM)

REFISSA CREAM (GRAM)

REGENECARE GEL (GRAM)

REGENECARE GEL (ML)

REGENECARE HA GEL (GRAM)

REGENECARE HA GEL (ML)

REGENECARE HA SPRAY GEL (ML)

REGRANEX GEL (GRAM)

REHYLA CLEANSER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

181

REHYLA CLEANSER (ML)

REJUVACARE PLUS CREAM (GRAM)

RELADOR PAK KIT

RELADOR PAK PLUS KIT

RELAFEN TABLET

RELAFEN DS TABLET

RELAGARD JELLY WITH APPLICATOR (GRAM)

RELIADERM CREAM ROLL-ON (GRAM)

RELIEVER PATCH ADHESIVE PATCH, MEDICATED

RELPAX TABLET

REMEDY LIQUID (ML)

REMEDY CALAZIME PASTE (GRAM)

REMEDY PHYTOPLEX Z-GUARD PASTE (GRAM)

REMIFENTANIL HCL VIAL (EA)

RENEWAL PACKET (EA)

RENEWCREAM HRT CREAM (GRAM)

RENOVA CREAM (GRAM)

REPEL 100 SPRAY, NON-AEROSOL (ML)

REPEL FAMILY AEROSOL, POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

182

REPEL FAMILY AEROSOL, SPRAY (GRAM)

REPEL HUNTER'S AEROSOL, SPRAY (GRAM)

REPEL LEMON EUCALYPTUS SPRAY, NON-AEROSOL (ML)

REPEL SPORTSMEN AEROSOL, SPRAY (GRAM)

REPEL SPORTSMEN MAX AEROSOL, SPRAY (GRAM)

REPEL SPORTSMEN MAX LOTION (GRAM)

REPEL SPORTSMEN MAX SPRAY, NON-AEROSOL (ML)

REPEL TICK DEFENSE AEROSOL, SPRAY (GRAM)

REPHRESH GEL WITH PREFILLED APPLICATOR (GRAM)

REPLENS GEL WITH APPLICATOR (GRAM)

REPLICARE BANDAGE

REPLICARE THIN BANDAGE

REPLICARE ULTRA BANDAGE

REPLICARE ULTRA SACRUM BANDAGE

RESERPINE POWDER (GRAM)

RESINOL OINTMENT (GRAM)

RESORCINOL CRYSTALS

RESORCINOL POWDER (GRAM)

RESTIZAN GEL WITH PUMP (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

183

RESTORE BANDAGE

RESTORE CALCIUM ALGINATE BANDAGE

RESTORE CONTACT LAYER SILVER BANDAGE

RESTORE EX THIN HYDROCOLLOID BANDAGE

RESTORE FOAM HEEL DRESSING BANDAGE

RESTORE HYDROCOLLOID DRESSING BANDAGE

RESTORE HYDROGEL BANDAGE

RESTORE HYDROGEL GEL (ML)

RESTORE SKIN CLEANSER CLEANSER (ML)

RESTORE SKIN CONDITIONING CREAM (ML)

RESTORE TRIO BANDAGE

RESTORE WOUND CLEANSER CLEANSER (ML)

RESVERATROL POWDER (GRAM)

RETIN-A MICRO GEL (GRAM)

RETIN-A MICRO PUMP GEL WITH PUMP (GRAM)

RETINOIC ACID POWDER (GRAM)

REVITADERM GEL (ML)

REZAMID LOTION (GRAM)

RHOFADE CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

184

RIAX FOAM (GRAM)

RIBOFLAVIN POWDER (GRAM)

RIBOFLAVIN-5-PHOSPHATE SODIUM POWDER (GRAM)

RIBOSE POWDER (GRAM)

RICE STARCH POWDER (GRAM)

RID KIT

RID SHAMPOO

RIFAMPIN POWDER (GRAM)

RIFAXIMIN POWDER (GRAM)

RISAMINE OINTMENT (GRAM)

RIZATRIPTAN TABLET

RIZATRIPTAN TABLET, DISINTEGRATING

ROBATHOL OIL (ML)

ROBAXIN TABLET

ROBAXIN VIAL (ML)

ROCURONIUM BROMIDE POWDER (GRAM)

ROGAINE FOAM (GRAM)

ROGAINE SOLUTION, NON-ORAL

ROLLED GAUZE BANDAGE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

185

RONDIC SPONGE

ROPIVACAINE HCL/PF POWDER (GRAM)

ROPIVACAINE HCL-NS POWDER (GRAM)

ROSADAN KIT, CLEANSER AND CREAM

ROSADAN KIT, CLEANSER AND GEL

ROSANIL CLEANSER (GRAM)

ROSE BENGAL POWDER (GRAM)

ROSIN LUMP (GRAM)

ROSULA CLEANSER (GRAM)

ROSULA PADS, MEDICATED (EA)

ROTEX CREAM (GRAM)

ROWASA ENEMA KIT

ROWEEPRA TABLET

ROWEEPRA XR TABLET, EXTENDED RELEASE 24 HR

ROXICODONE TABLET

ROXYBOND TABLET, ORAL ONLY

RUBIDIUM CHLORIDE POWDER (GRAM)

RUTIN POWDER (GRAM)

SA3DERM CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

186

SACCHARIN CRYSTALS

SAF-CLENS AF CLEANSER (ML)

SAFFLOWER OIL OIL (ML)

SAF-GEL GEL (GRAM)

SALACTIC FILM LIQUID (ML)

SALEX COMBINATION PACKAGE (ML)

SALEX KIT, CLEANSER AND CREAM ER

SALEX SHAMPOO

SALICYLIC ACID COMBINATION PACKAGE (ML)

SALICYLIC ACID CREAM (GRAM)

SALICYLIC ACID CREAM, EXTENDED RELEASE (GRAM)

SALICYLIC ACID CRYSTALS

SALICYLIC ACID FILM-FORMING LIQUID WITH APPLICATOR

SALICYLIC ACID FOAM (GRAM)

SALICYLIC ACID GEL (GRAM)

SALICYLIC ACID KIT, CLEANSER AND CREAM ER

SALICYLIC ACID LIQUID (ML)

SALICYLIC ACID LOTION (ML)

SALICYLIC ACID LOTION, EXTENDED RELEASE (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

187

SALICYLIC ACID POWDER (GRAM)

SALICYLIC ACID SHAMPOO

SALICYLIC ACID ER FILM-FORMING SOLUTION ER WITH APPLICATOR

SALIMEZ CREAM (GRAM)

SALIMEZ FORTE CREAM (GRAM)

SALINE ENEMA ENEMA (ML)

SALINE WOUND WASH AEROSOL, SPRAY (ML)

SALINE WOUND WASH CLEANSER (ML)

SALJET SALINE RINSE VIAL (ML)

SALKERA FOAM (GRAM)

SALONPAS ADHESIVE PATCH, MEDICATED

SALONPAS AEROSOL, SPRAY (ML)

SALONPAS FOAM (ML)

SALONPAS DEEP RELIEVING GEL (GRAM)

SALONPAS-HOT ADHESIVE PATCH, MEDICATED

SAL-PLANT GEL (GRAM)

SALSALATE POWDER (GRAM)

SALT DURABLE CREAM (GRAM)

SALTSTABLE LO CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

188

SALTSTABLE LS CREAM (GRAM)

SALVAX FOAM (GRAM)

SALVAX DUO PLUS FOAM (GRAM)

SANADERMRX KIT

SANARE ADV SCAR THERAPY BASE GEL (GRAM)

SANCUSO PATCH, TRANSDERMAL WEEKLY

SANIZEN GEL (ML)

SANTYL OINTMENT (GRAM)

SARNA LOTION (ML)

SAUGELLA CLEANSER (ML)

SAVELLA TABLET

SAVELLA TABLET, DOSE PACK

SAW PALMETTO BERRY POWDER (GRAM)

SCALACORT DK COMBINATION PACKAGE (ML)

SCALP RELIEF LIQUID (ML)

SCANPOR TAPE REFILL TAPE, NON-MEDICATED

SCANPOR TAPE W/DISPENSER TAPE, NON-MEDICATED

SCAR GEL (GRAM)

SCAR GEL WITH PUMP (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

189

SCAR SHEET (EA)

SCAR CARE BASE ENHANCED GEL (GRAM)

SCARLET RED POWDER (GRAM)

SCOPOLAMINE HYDROBROMIDE POWDER (GRAM)

SCOPOLAMINE METHYL NITRATE POWDER (GRAM)

SEBEX SHAMPOO

SEBUDERM GEL (GRAM)

SECRETIN-MANNITOL POWDER (GRAM)

SECURA CLEANSER (ML)

SECURA COMBINATION PACKAGE (EA)

SECURA FOAM (ML)

SECURA MOISTURIZING CLEANSER (ML)

SEDANARE CREAM (GRAM)

SELEGILINE HCL POWDER (GRAM)

SELENIUM SULFIDE POWDER (GRAM)

SELENIUM W-YEAST POWDER (GRAM)

SELENOMETHIONINE POWDER (GRAM)

SELF ADHERENT WRAP BANDAGE

SELF-ADHERENT GENTLE WRAP BANDAGE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

190

SELF-ADHERING BANDAGE

SELFGRIP BANDAGE

SELSUN BLUE SHAMPOO

SELSUN BLUE MOISTURIZING SHAMPOO

SENSI-CARE OINTMENT (GRAM)

SENSI-CARE SOLUTION, NON-ORAL

SENSI-CARE MOISTURIZING 2 CREAM (GRAM)

SEPINEO P 600 LIQUID (ML)

SERAQUA LIQUID (ML)

SERMORELIN ACETATE POWDER (GRAM)

SEROTONIN HCL POWDER (GRAM)

SERTRALINE HCL POWDER (GRAM)

SFROWASA ENEMA (ML)

SHARK CARTILAGE POWDER (GRAM)

SHEA BUTTER WAX (GRAM)

SHEER BANDAGE BANDAGE

SHEER SPOT BANDAGES BANDAGE

SHEER STRIPS BANDAGE

SHOWER FRESH FRAGRANCE LIQUID (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

191

SILALITE PAK KIT, OINTMENT AND SHEET

SILAZONE-II KIT

SILDENAFIL CITRATE POWDER (GRAM)

SILICA GEL POWDER (GRAM)

SILICON DIOXIDE POWDER (GRAM)

SILICONE DISC COMBINATION PACKAGE (EA)

SILICONE ROLL COMBINATION PACKAGE (EA)

SILICONE SCAR KIT

SILICONE SCAR THERAPY GEL STRP STRIP

SILICONE SHEET COMBINATION PACKAGE (EA)

SILICONE TAPE COMBINATION PACKAGE (EA)

SILKY LUBRICATING GEL (GRAM)

SILOSOME CREAM (GRAM)

SILVASORB BANDAGE

SILVASORB GEL, EXTENDED RELEASE (ML)

SILVASORB CAVITY BANDAGE

SILVER GEL GEL (GRAM)

SILVER NITRATE CRYSTALS

SILVER NITRATE OINTMENT (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

192

SILVER NITRATE SOLUTION, NON-ORAL

SILVER NITRATE APPLICATOR STICK (EA)

SILVER PROTEIN POWDER (GRAM)

SILVER SULFADIAZINE POWDER (GRAM)

SILVERMED CLEANSER (ML)

SILVERMED GEL, EXTENDED RELEASE (ML)

SILVERSEAL HYDROGEL BANDAGE

SILVRSTAT GEL (GRAM)

SIMETHICONE LIQUID (ML)

SIMPLGEL 30 GEL (GRAM)

SIMVASTATIN POWDER (GRAM)

SINGLE USE SWAB PADS, MEDICATED (EA)

SINGULAIR GRANULES IN PACKET (EA)

SINGULAIR TABLET

SINGULAIR TABLET,CHEWABLE

SIROLIMUS POWDER (GRAM)

SKARJEL GEL (ML)

SKELAXIN TABLET

SKIN CLEANSER CLEANSER (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

193

SKIN CLOSURE STRIPS STRIP

SKIN RELIEF MOISTURE LOTION (ML)

SKIN REPAIR LOTION (ML)

SKIN TREATMENT LOTION (GRAM)

SKINTASTIC SPRAY, NON-AEROSOL (ML)

SKINTEGRITY BANDAGE

SKINTEGRITY GEL (GRAM)

SKINTEGRITY SPRAY, NON-AEROSOL (ML)

SKLICE LOTION (GRAM)

SKYYDERM CREAM BASE CREAM (GRAM)

SODIUM 4-AMINOSALICYLATE POWDER (GRAM)

SODIUM ACETATE POWDER (GRAM)

SODIUM ACETATE TRIHYDRATE CRYSTALS

SODIUM ACETATE TRIHYDRATE GRANULES (GRAM)

SODIUM ALGINATE POWDER (GRAM)

SODIUM ASCORBATE POWDER (GRAM)

SODIUM BENZOATE POWDER (GRAM)

SODIUM BORATE POWDER (GRAM)

SODIUM BROMIDE GRANULES (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

194

SODIUM BUTYRATE POWDER (GRAM)

SODIUM CACODYLATE POWDER (GRAM)

SODIUM CAPRATE POWDER (GRAM)

SODIUM CARBONATE POWDER (GRAM)

SODIUM CHLORITE FLAKES (GRAM)

SODIUM CITRATE GRANULES (GRAM)

SODIUM CITRATE POWDER (GRAM)

SODIUM DEOXYCHOLATE POWDER (GRAM)

SODIUM DICHLOROACETATE POWDER (GRAM)

SODIUM FLUORIDE POWDER (GRAM)

SODIUM FLUOROPHOSPHATE POWDER (GRAM)

SODIUM GLUCONATE POWDER (GRAM)

SODIUM HYALURONATE POWDER (GRAM)

SODIUM HYALURONIC ACID POWDER (GRAM)

SODIUM HYDROXIDE FLAKES (GRAM)

SODIUM HYDROXIDE GRANULES (GRAM)

SODIUM HYDROXIDE PELLET (GRAM)

SODIUM HYDROXIDE POWDER (GRAM)

SODIUM HYDROXIDE SOLUTION, NON-ORAL

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

195

SODIUM IODIDE CRYSTALS

SODIUM LACTATE SOLUTION, NON-ORAL

SODIUM L-ASPARTATE MONOHYDRATE POWDER (GRAM)

SODIUM LAURETH SULFATE LIQUID (ML)

SODIUM LAURYL SULFATE POWDER (GRAM)

SODIUM METABISULFITE GRANULES (GRAM)

SODIUM METABISULFITE POWDER (GRAM)

SODIUM NITRATE POWDER (GRAM)

SODIUM NITRITE GRANULES (GRAM)

SODIUM OLEATE POWDER (GRAM)

SODIUM PERBORATE CRYSTALS

SODIUM PERBORATE POWDER (GRAM)

SODIUM PHENYLBUTYRATE POWDER (GRAM)

SODIUM PHOSPHATE GRANULES (GRAM)

SODIUM PHOSPHATE POWDER (GRAM)

SODIUM POLYSTYRENE SULFONATE ENEMA (ML)

SODIUM PROPIONATE POWDER (GRAM)

SODIUM PYRROLIDONE CARBOXYLATE LIQUID (ML)

SODIUM SACCHARIN GRANULES (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

196

SODIUM SACCHARIN POWDER (GRAM)

SODIUM SALICYLATE POWDER (GRAM)

SODIUM SELENITE POWDER (GRAM)

SODIUM STEARATE POWDER (GRAM)

SODIUM STEARYL FUMARATE POWDER (GRAM)

SODIUM SULFACETAMIDE/SULFUR CLEANSER (GRAM)

SODIUM SULFACETAMIDE/SULFUR CLEANSER (ML)

SODIUM SULFACETAMIDE/SULFUR COMBINATION PACKAGE, CLEANSER AND CREAM

SODIUM SULFACETAMIDE/SULFUR CREAM (GRAM)

SODIUM SULFACETAMIDE/SULFUR KIT

SODIUM SULFACETAMIDE/SULFUR LOTION (GRAM)

SODIUM SULFACETAMIDE/SULFUR PADS, MEDICATED (EA)

SODIUM SULFACETAMIDE/SULFUR SUSPENSION, TOPICAL (GRAM)

SODIUM SULFACETAMIDE/SULFUR SUSPENSION, TOPICAL (ML)

SODIUM SULFATE POWDER (GRAM)

SODIUM SULFITE POWDER (GRAM)

SODIUM TARTRATE DIHYDRATE CRYSTALS

SODIUM TETRADECYL SULFATE POWDER (GRAM)

SODIUM TETRADECYL SULFATE SOLUTION, NON-ORAL

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

197

SODIUM THIOSALICYLATE POWDER (GRAM)

SODIUM THIOSULFATE CRYSTALS

SODIUM THIOSULFATE POWDER (GRAM)

SODIUM-L-ASCORBYL-2-PHOSPHATE POWDER (GRAM)

SOF-SET BANDAGE

SOFT CLOTH BANDAGE

SOLARAZE GEL (GRAM)

SOLARCAINE AEROSOL, SPRAY (GRAM)

SOLARCAINE ALOE EXTRA GEL (GRAM)

SOLARCAINE COOL ALOE AEROSOL, SPRAY (GRAM)

SOLOSITE GEL (GRAM)

SOLOX GEL GEL (ML)

SOLU-K GEL (GRAM)

SOLUPAK KIT, OINTMENT AND SPRAY

SOLYDRA OIL (ML)

SOMA TABLET

SOMBRA COOL THERAPY GEL (GRAM)

SONAFINE EMULSION (GRAM)

SOOLANTRA CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

198

SOOTHE & COOL BODY LOTION LOTION (ML)

SOOTHE & COOL MOIST BARRIER OINTMENT (GRAM)

SOOTHE & COOL PERINEAL WASH SOAP, LIQUID

SOOTHE & COOL SKIN CREAM CREAM (GRAM)

SOOTHE & COOL SKIN PASTE OINTMENT (GRAM)

SOOTHING BATH TREATMENT PACKET (EA)

SORBIC ACID POWDER (GRAM)

SORBITAN MONOLAURATE LIQUID (ML)

SORBITAN MONOOLEATE LIQUID (ML)

SORBITOL CANDY BASE PELLET (GRAM)

SORBOLENE CREAM (GRAM)

SORBSAN BANDAGE

SORE MUSCLE RUB GEL (GRAM)

SORESPOT BANDAGE

SORILUX FOAM (GRAM)

SOYBEAN CASEIN DIGEST MEDIUM POWDER (GRAM)

SOYBEAN OIL OIL (ML)

SP ANTIPRURITIC GEL (GRAM)

SPECIAL CARE LOTION (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

199

SPECTRAGEL GEL (GRAM)

SPERMACETI FLAKES (GRAM)

SPG SUPPOSI-BASE WAX (GRAM)

SPINOSAD SUSPENSION, TOPICAL (ML)

SPIRONOLACTONE POWDER (GRAM)

SPIRULINA POWDER (GRAM)

SPONIX ANTI-FUNGAL SOLUTION, NON-ORAL

SPORANOX CAPSULE

SPORANOX SOLUTION, ORAL

SPORTS PAIN RELIEF CREAM (GRAM)

SPORTS TAPE TAPE, NON-MEDICATED

SPORTSCREME CREAM (GRAM)

SPRAY AND STRETCH AEROSOL, SPRAY (ML)

SPRAYZOIN SPRAY, NON-AEROSOL (ML)

SPRITAM TABLET FOR SUSPENSION

SPRIX SPRAY, NON-AEROSOL (EA)

SPS ENEMA (ML)

SQUALANE OIL (ML)

SQUARIC ACID POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

200

SQUARIC ACID DIBUTYLESTER POWDER (GRAM)

SQUARIC ACID IN BUTANOL LIQUID (GRAM)

SS 10-2 CLEANSER (GRAM)

SSS 10-5 CREAM (GRAM)

SSS 10-5 FOAM (GRAM)

ST. JOHN'S WORT POWDER (GRAM)

ST-37 SOLUTION, NON-ORAL

STANNOUS CHLORIDE DIHYDRATE CRYSTALS

STANOZOLOL POWDER (GRAM)

STEARIC ACID FLAKES (GRAM)

STERA BASE CREAM (GRAM)

STERILE PADS BANDAGE

STERILID FOAM (ML)

STERI-STRIP STRIP

STERI-STRIP WOUND CLOSURE SYST BANDAGE

STEVIA GLYCERITE LIQUID (ML)

STEVIOL GLYCOSIDES POWDER (GRAM)

STIK IT AMPUL (EA)

STOPAIN SPRAY, NON-AEROSOL (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

201

STRATACTX GEL (GRAM)

STRATASORB BANDAGE

STRATAXRT GEL (GRAM)

STRAVIX SHEET (EA)

STREPTOMYCIN SULFATE POWDER (GRAM)

STRETCH GAUZE BANDAGE BANDAGE

STRONG AMMONIA SOLUTION, NON-ORAL

STRONG IODINE TINCTURE

STRONG STRIPS BANDAGE

STRONTIUM CHLORIDE HEXAHYDRATE CRYSTALS

STRONTIUM NITRATE CRYSTALS

SUBSYS SPRAY, NON-AEROSOL (EA)

SUCCIMER DMSA POWDER (GRAM)

SUCCINIC ACID CRYSTALS

SUCCINYLCHOLINE CHLORIDE POWDER (GRAM)

SUCRALFATE POWDER (GRAM)

SUCROSE CRYSTALS

SUCROSE POWDER (GRAM)

SUCROSE OCTAACETATE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

202

SUFENTANIL CITRATE AMPUL (ML)

SUFENTANIL CITRATE POWDER (GRAM)

SUFENTANIL CITRATE VIAL (ML)

SULAR TABLET, EXTENDED RELEASE 24 HR

SULCONAZOLE NITRATE CREAM (GRAM)

SULCONAZOLE NITRATE SOLUTION, NON-ORAL

SULFACETAMIDE POWDER (GRAM)

SULFACETAMIDE SODIUM POWDER (GRAM)

SULFACETAMIDE SODIUM-SULFUR CLEANSER (GRAM)

SULFACLEANSE 8/4 SUSPENSION, TOPICAL (ML)

SULFADIAZINE POWDER (GRAM)

SULFAMERAZINE CRYSTALS

SULFAMETHOXAZOLE POWDER (GRAM)

SULFAMYLON CREAM (GRAM)

SULFAMYLON PACKET (EA)

SULFANILAMIDE POWDER (GRAM)

SULFAPYRIDINE POWDER (GRAM)

SULFASALAZINE POWDER (GRAM)

SULFATHIAZOLE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

203

SULFISOXAZOLE CRYSTALS

SULFO-LO BAR

SULFOSALICYLIC ACID DIHYDRATE CREAM (GRAM)

SULFUR POWDER (GRAM)

SULFURATED POTASH LUMP (GRAM)

SULFURIC ACID LIQUID (ML)

SULINDAC POWDER (GRAM)

SULINDAC TABLET

SULPHAN BLUE POWDER (GRAM)

SUMADAN CLEANSER (GRAM)

SUMADAN KIT

SUMADAN XLT COMBINATION PACKAGE, CLEANSER AND CREAM

SUMATRIPTAN SPRAY, NON-AEROSOL (EA)

SUMATRIPTAN SUCCINATE CARTRIDGE (ML)

SUMATRIPTAN SUCCINATE PEN INJECTOR (ML)

SUMATRIPTAN SUCCINATE POWDER (GRAM)

SUMATRIPTAN SUCCINATE SYRINGE (ML)

SUMATRIPTAN SUCCINATE TABLET

SUMATRIPTAN SUCCINATE VIAL (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

204

SUMAVEL DOSEPRO NEEDLE-FREE INJECTOR (ML)

SUMAXIN CLEANSER (GRAM)

SUMAXIN PADS, MEDICATED (EA)

SUMAXIN CP KIT

SUMAXIN TS SUSPENSION, TOPICAL (ML)

SUMMER'S EVE DISPOSABLE DOUCHE SOLUTION, NON-ORAL

SUMMER'S EVE DOUCHE SOLUTION, NON-ORAL

SUMMER'S EVE FEMININE WASH SOLUTION, NON-ORAL

SUMMER'S EVE INTIM CLN CLOTH MISCELLANEOUS

SUPER STRIP BANDAGES BANDAGE

SUPEROXIDE DISMUTASE POWDER (EA)

SUPPOSIBASE F POWDER (GRAM)

SUPPOSIBLEND WAX (GRAM)

SUPPOSI-PLEX R36 PELLET (GRAM)

SUPPOSI-PLEX V33 PELLET (GRAM)

SURE COMFORT ALCOHOL PREP PADS PADS, MEDICATED (EA)

SURE RESULT TAC PAK KIT

SURE-PREP ALCOHOL PREP PADS PADS, MEDICATED (EA)

SUREPRESS BANDAGE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

205

SURESITE MATRIX BANDAGE

SURESITE WINDOW BANDAGE

SURGICAL DRESSINGS BANDAGE

SURGICAL PADS BANDAGE

SURGIFOAM SPONGE

SURGILUBE JELLY (GRAM)

SURMONTIL CAPSULE

SUSTOL LIQUID, EXTENDED RELEASE SYRINGE (ML)

SWEEN PREP LIQUID (ML)

SWEEN PREP PADS, MEDICATED (EA)

SYNALAR

COMBINATION PACKAGE, OINTMENT AND

CREAM

SYNALAR CREAM (GRAM)

SYNALAR TS KIT

SYNAPSIN POWDER (GRAM)

SYNERA ADHESIVE PATCH, MEDICATED SELF-HEATING

SYNERDERM SPRAY, NON-AEROSOL (ML)

SYNVEXIA TC CREAM (GRAM)

SYRINGE AVITENE POWDER (GRAM)

SYSTANE TOWELETTE (EA)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

206

TACHOSIL ADHESIVE PATCH, MEDICATED

TACLONEX OINTMENT (GRAM)

TACLONEX SUSPENSION, TOPICAL (GRAM)

TACROLIMUS OINTMENT (GRAM)

TACROLIMUS POWDER (GRAM)

TACROLIMUS MICRONIZED POWDER (GRAM)

TADALAFIL POWDER (GRAM)

TALC POWDER (GRAM)

TAMOXIFEN CITRATE POWDER (GRAM)

TANNIC ACID POWDER (GRAM)

TARGRETIN GEL (GRAM)

TARTARIC ACID CRYSTALS

TARTARIC ACID GRANULES (GRAM)

TAURINE POWDER (GRAM)

TAZAROTENE CREAM (GRAM)

TAZAROTENE POWDER (GRAM)

TAZORAC CREAM (GRAM)

TAZORAC GEL (GRAM)

TAZTIA XT CAPSULE, EXTENDED RELEASE 24HR

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

207

TDC MAX CREAM (GRAM)

TDM SOLUTION, NON-ORAL

TEA TREE OIL OIL (ML)

TEA TREE OIL SPRAY, NON-AEROSOL (ML)

TEARS AGAIN SPRAY, NON-AEROSOL (ML)

TECHNA 20 SF TROCHE BASE POWDER (GRAM)

TEGADERM BANDAGE

TEGADERM + PAD BANDAGE

TEGADERM AG MESH BANDAGE

TEGADERM FOAM BANDAGE

TEGADERM HP BANDAGE

TEGADERM HYDROCOLLOID BANDAGE

TEGADERM HYDROCOLLOID THIN BANDAGE

TEGADERM HYDROGEL GEL (GRAM)

TEGAGEN HG BANDAGE

TEGAGEN HI BANDAGE

TEGASORB THIN BANDAGE

TEGRETOL SUSPENSION, ORAL (FINAL DOSE FORM)

TEGRETOL TABLET

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

208

TEGRETOL XR TABLET, EXTENDED RELEASE 12 HR

TELFA BANDAGE

TELFA AMD BANDAGE

TELFA CLEAR BANDAGE

TENA SOAP, LIQUID

TENCON TABLET

TENDER TAPE BANDAGE

TENDERSORB BANDAGE

TENDERWET KIT

TENDERWET ACTIVE BANDAGE

TENDERWET ACTIVE CAVITY BANDAGE

TENSOR BANDAGE

TERAZOL CREAM WITH APPLICATOR

TERBINAFINE CREAM (GRAM)

TERBINAFINE POWDER (GRAM)

TERBUTALINE SULFATE POWDER (GRAM)

TERCONAZOLE CREAM WITH APPLICATOR

TERCONAZOLE SUPPOSITORY, VAGINAL

TEROCIN ADHESIVE PATCH, MEDICATED

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

209

TEROCIN LOTION (ML)

TERODERM CREAM (GRAM)

TERODERM PLUS CREAM (GRAM)

TERPIN HYDRATE CRYSTALS

TERPIN HYDRATE POWDER (GRAM)

TESTOSTERONE POWDER (GRAM)

TESTOSTERONE CYPIONATE POWDER (GRAM)

TESTOSTERONE ENANTHATE POWDER (GRAM)

TESTOSTERONE MICRONIZED POWDER (GRAM)

TESTOSTERONE PROPIONATE POWDER (GRAM)

TETRACAINE WAX (GRAM)

TETRACAINE HCL POWDER (GRAM)

TETRACYCLINE POWDER (GRAM)

TETRACYCLINE HCL POWDER (GRAM)

TETRAHYDROBIOPTERIN DI-HCL POWDER (GRAM)

TETRAHYDROBIOPTERIN HCL POWDER (GRAM)

TETRAHYDROCURCUMINOIDS POWDER (GRAM)

TETRAHYDROZOLINE HCL POWDER (GRAM)

TETRIX CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

210

THEANINE POWDER (GRAM)

THEOBROMINE POWDER (GRAM)

THEOPHYLLINE ANHYDROUS POWDER (GRAM)

THEOPHYLLINE ETHYLENEDIAMINE POWDER (GRAM)

THERA-GESIC CREAM (GRAM)

THERA-GESIC PLUS CREAM (GRAM)

THERAPEUTIC SHAMPOO

THERAPEUTIC BLUE GEL GEL (GRAM)

THERAPEUTIC DANDRUFF SHAMPOO SHAMPOO

THERAPEUTIC MINERAL ICE GEL (GRAM)

THERAPEUTIC T+PLUS SHAMPOO

THERAPEVO GEL (GRAM)

THERMACARE BANDAGE

THIABENDAZOLE POWDER (GRAM)

THIAMINE HCL POWDER (GRAM)

THIMEROSAL POWDER (GRAM)

THIOGUANINE POWDER (GRAM)

THIORIDAZINE HCL POWDER (GRAM)

THIOTEPA POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

211

THREONINE POWDER (GRAM)

THRITEX ADHESIVE PATCH, MEDICATED

THROMBI-GEL PADS, MEDICATED (EA)

THROMBIN-JMI SPRAY SYRINGE (EA)

THROMBIN-JMI SPRAY, NON-AEROSOL (EA)

THROMBIN-JMI VIAL (EA)

THROMBI-PAD PADS, MEDICATED (EA)

THYMOL CRYSTALS

THYMOL IODIDE POWDER (GRAM)

THYMUS POWDER (GRAM)

THYROID POWDER (GRAM)

TIADYLT ER CAPSULE, EXTENDED RELEASE 24HR

TIAZAC CAPSULE, EXTENDED RELEASE 24HR

TICARCILLIN DISOD-CLAVULANATE POWDER (GRAM)

TIGER BALM ADHESIVE PATCH, MEDICATED

TIGER BALM CREAM (GRAM)

TIGER BALM CREAM (ML)

TIGER BALM LINIMENT

TIGER BALM OINTMENT (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

212

TIMOLOL MALEATE POWDER (GRAM)

TINCTURE IODINE TINCTURE

TINEACIDE CREAM (GRAM)

TINIDAZOLE POWDER (GRAM)

TIOCONAZOLE 1 OINTMENT WITH PREFILLED APPLICATOR

TIOPRONIN POWDER (GRAM)

TISSEEL VHSD KIT

TISSEEL VHSD SYRINGE (ML)

TITANIUM DIOXIDE LIQUID (GRAM)

TITANIUM DIOXIDE POWDER (GRAM)

TIVORBEX CAPSULE

TIZANIDINE HCL CAPSULE

TIZANIDINE HCL POWDER (GRAM)

TIZANIDINE HCL TABLET

TOBRAMYCIN SULFATE POWDER (GRAM)

TOCOPHERYL ACID SUCCINATE POWDER (GRAM)

TODAY CONTRACEPTIVE SPONGE CONTRACEPTIVE SPONGE

TOETAL FRESH SOLUTION, NON-ORAL

TOFRANIL TABLET

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

213

TOLAZOLINE HCL POWDER (GRAM)

TOLMETIN SODIUM CAPSULE

TOLMETIN SODIUM TABLET

TOLNAFTATE POWDER (GRAM)

TOLSURA CAPSULE, SOLID DISPERSION

TOLUIDINE BLUE O POWDER (GRAM)

TOMMY GEL GEL (GRAM)

TOPICAINE GEL (GRAM)

TOPICAINE 5 GEL (GRAM)

TOPIRAMATE POWDER (GRAM)

TOSYMRA SPRAY, NON-AEROSOL (EA)

TOTAL BLOCK LOTION (ML)

TOTAL HOME INSECT REPELLENT AEROSOL, SPRAY (ML)

TOVET EMOLLIENT FOAM (GRAM)

TRAMADOL HCL POWDER (GRAM)

TRAMADOL HCL TABLET

TRAMADOL HCL ER CAPSULE,EXT.RELEASE 24 HR BIPHASIC 17-83

TRAMADOL HCL ER CAPSULE,EXT.RELEASE 24 HR BIPHASIC 25-75

TRAMADOL HCL ER TABLET, EXTENDED RELEASE 24 HR

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

214

TRAMADOL HCL ER TABLET,EXTENDED RELEASE MULTIPHASE 24 HR

TRAMADOL HCL-ACETAMINOPHEN TABLET

TRANEXAMIC ACID POWDER (GRAM)

TRANILAST POWDER (GRAM)

TRANSANOSIL LOTION (ML)

TRANSDERMAL PAIN BASE CREAM (GRAM)

TRANSDERM-IQ OINTMENT ROLL-ON (GRAM)

TRANSPARENT DRESSING BANDAGE

TRANSPARENT FILM DRESSING BANDAGE

TRANSPARENT I.V. SITE DRESSING BANDAGE

TRANSPARENT MEPITEL FILM DRESS BANDAGE

TRANSPARENT THIN FILM DRESSING BANDAGE

TRANSPORE TAPE, NON-MEDICATED

TRANZAREL GEL (ML)

TRAUMEEL OINTMENT (GRAM)

TRAZODONE HCL POWDER (GRAM)

TRETINOIN CREAM (GRAM)

TRETINOIN POWDER (GRAM)

TRETINOIN ACID POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

215

TRETINOIN MICROSPHERE GEL (GRAM)

TRETINOIN MICROSPHERE GEL WITH PUMP (GRAM)

TRETIN-X COMBINATION PACKAGE (EA)

TRIAMCINOLONE POWDER (GRAM)

TRIAMCINOLONE ACETONIDE POWDER (GRAM)

TRIAMCINOLONE DIACETATE POWDER (GRAM)

TRIAMCINOLONE HEXACETONIDE POWDER (GRAM)

TRIAMTERENE POWDER (GRAM)

TRI-CHLOR SOLUTION, NON-ORAL

TRICHLORMETHIAZIDE POWDER (GRAM)

TRICHLOROACETIC ACID CRYSTALS

TRICHLOROACETIC ACID POWDER (GRAM)

TRICHLOROACETIC ACID SOLUTION, RECONSTITUTED, NON-ORAL

TRICLOSAN POWDER (GRAM)

TRIETHANOLAMINE LAURYL SULFATE LIQUID (ML)

TRIETHANOLAMINE SALICYLATE LIQUID (GRAM)

TRIFLURIDINE POWDER (GRAM)

TRILOSTANE POWDER (GRAM)

TRI-LUMA CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

216

TRIMEPRAZINE TARTRATE POWDER (GRAM)

TRIMETHOBENZAMIDE HCL POWDER (GRAM)

TRIMETHOPRIM POWDER (GRAM)

TRIMIPRAMINE MALEATE CAPSULE

TRIMO-SAN JELLY WITH APPLICATOR (GRAM)

TRIOXSALEN CRYSTALS

TRIPELENNAMINE HCL POWDER (GRAM)

TRIPLE ANTIBIOTIC AEROSOL, SPRAY (GRAM)

TRIPLE ANTIBIOTIC OINTMENT (GRAM)

TRIPLE ANTIBIOTIC OINTMENT IN PACKET (EA)

TRIPLE ANTIBIOTIC EXTRA OINTMENT (GRAM)

TRIPLE ANTIBIOTIC PLUS OINTMENT (GRAM)

TRIPLE ANTIBIOTIC-PAIN RELIEF OINTMENT (GRAM)

TRIPLE CREAM CREAM (GRAM)

TRIPLE DYE SWAB, MEDICATED

TRIPLE HELIX COLLAGEN BANDAGE

TRIPLE HELIX COLLAGEN POWDER (GRAM)

TRIPLE HELIX COLLAGEN POWDER IN PACKET (GRAM)

TRIPROLIDINE HCL POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

217

TRI-SILA KIT

TRIVIX KIT

TROCHE BASE PELLET (GRAM)

TROCHE BASE POWDER (GRAM)

TROCHIBASE POWDER (GRAM)

TROCHIBASE S FLAKES (GRAM)

TROLAMINE SOLUTION, NON-ORAL

TROLAMINE SALICYLATE CREAM (GRAM)

TROLAMINE SALICYLATE SOLUTION, NON-ORAL

TROMETHAMINE POWDER (GRAM)

TRONOLANE CREAM (GRAM)

TROPICAMIDE POWDER (GRAM)

TRUE COMFORT ALCOHOL PADS PADS, MEDICATED (EA)

TRU-MICIN LOTION (ML)

TRUSKIN SHEET (EA)

TRYPAN BLUE POWDER (GRAM)

TRYPSIN POWDER (GRAM)

TRYPTOPHAN (L) POWDER (GRAM)

T-SAL SHAMPOO

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

218

TUBULAR GAUZE BANDAGE

TUCKS PADS, MEDICATED (EA)

TURMERIC POWDER (GRAM)

TURMERIC ROOT POWDER (GRAM)

TURPENTINE LIQUID (ML)

TYROSINE POWDER (GRAM)

U-BASE CREAM (GRAM)

UBIDECARENONE POWDER (GRAM)

UBIQUINOL POWDER (GRAM)

UCERIS AEROSOL, FOAM WITH APPLICATOR (GRAM)

ULESFIA LOTION (GRAM)

ULTILET PADS, MEDICATED (EA)

ULTIVA VIAL (EA)

ULTRACET TABLET

ULTRACIN LOTION (ML)

ULTRACIN M GEL (ML)

ULTRACIN T LOTION (ML)

ULTRADERM BASE CREAM (GRAM)

ULTRAFOAM SPONGE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

219

ULTRAM TABLET

ULTRASAL-ER FILM-FORMING SOLUTION ER WITH APPLICATOR

ULTRASONE CREAM (GRAM)

ULTRATHON LOTION (GRAM)

ULTRATHON INSECT REPELLENT 8 AEROSOL, SPRAY (GRAM)

ULTRAVATE X COMBINATION PACKAGE (GRAM)

ULTRAVATE X

COMBINATION PACKAGE, OINTMENT AND

CREAM

UNDECYLENIC ACID LIQUID (ML)

UNDELENIC TINCTURE

UNGUENTINE OINTMENT (GRAM)

UNIBASE CREAM (GRAM)

UNIVERSAL WATER GEL GEL (GRAM)

UNNA-FLEX COMBINATION PACKAGE (EA)

URAMAXIN GT KIT, CREAM AND GEL

UREA BEADS (GRAM)

UREA POWDER (GRAM)

UREA PEROXIDE POWDER (GRAM)

URIDINE POWDER (GRAM)

URSODIOL POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

220

VACUSTIM BLACK KIT

VAGICAINE CREAM (GRAM)

VAGINAL ITCH CREAM CREAM (GRAM)

VAGISIL CREAM (GRAM)

VAGISIL POWDER (GRAM)

VALACYCLOVIR POWDER (GRAM)

VALCHLOR GEL (GRAM)

VALERIAN POWDER (GRAM)

VALINE CRYSTALS

VALINE POWDER (GRAM)

VALPROATE SODIUM POWDER (GRAM)

VALPROIC ACID LIQUID (ML)

VANADIUM GRANULES (GRAM)

VANADOM TABLET

VANADYL SULFATE CRYSTALS

VANALICE GEL (ML)

VANATOL LQ SOLUTION, ORAL

VANATOL S SOLUTION, ORAL

VANCOMYCIN HCL POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

221

VANIBASE CREAM (GRAM)

VANICREAM DIAPER RASH OINTMENT (GRAM)

VANICREAM SUNSCREEN CREAM (GRAM)

VANIQA CREAM (GRAM)

VANISHING CREAM (GRAM)

VANISHING BOTANICAL CREAM (GRAM)

VANISHING CREAM CREAM (GRAM)

VANISH-PEN CREAM BASE CREAM (GRAM)

VANOXIDE-HC SUSPENSION, TOPICAL (GRAM)

VARDENAFIL HCL POWDER (GRAM)

VCF AEROSOL, FOAM WITH APPLICATOR (GRAM)

VCF FILM, MEDICATED (EA)

VCF GEL WITH PREFILLED APPLICATOR (GRAM)

VECTICAL OINTMENT (GRAM)

VECURONIUM BROMIDE POWDER (GRAM)

VEEGUM GRANULES (GRAM)

VELTIN GEL (GRAM)

VELVACHOL CREAM (GRAM)

VENELEX OINTMENT (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

222

VENELEX OINTMENT IN PACKET (GRAM)

VERAPAMIL ER CAPSULE, EXTENDED RELEASE PELLETS 24 HR

VERAPAMIL ER TABLET, EXTENDED RELEASE

VERAPAMIL ER PM CAPSULE,24HR EXTENDED RELEASE PELLET CT

VERAPAMIL HCL AMPUL (ML)

VERAPAMIL HCL CAPSULE, EXTENDED RELEASE PELLETS 24 HR

VERAPAMIL HCL POWDER (GRAM)

VERAPAMIL HCL SYRINGE (ML)

VERAPAMIL HCL TABLET

VERAPAMIL HCL VIAL (ML)

VEREGEN OINTMENT (GRAM)

VERELAN CAPSULE, EXTENDED RELEASE PELLETS 24 HR

VERELAN PM CAPSULE,24HR EXTENDED RELEASE PELLET CT

VERSABASE GEL (GRAM)

VERSABASE LOTION (GRAM)

VERSABASE SHAMPOO (GRAM)

VERSABASE ANHYDROUS HRT GEL (GRAM)

VERSABASEA CREAM (GRAM)

VERSALON SPONGE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

223

VERSAPRO CREAM BASE CREAM (GRAM)

VERSAPRO GEL BASE GEL (GRAM)

VERSAPRO LOTION BASE LOTION (GRAM)

VERSASKIN CREAM (GRAM)

VERSATILE CREAM (GRAM)

VERSATILE RICH CREAM (GRAM)

VERSIGEL CREAM (GRAM)

VFEND SUSPENSION, RECONSTITUTED, ORAL (ML)

VFEND TABLET

VFEND IV VIAL (EA)

VICKS BABYRUB OINTMENT (GRAM)

VICKS VAPORUB OINTMENT (GRAM)

VIDARABINE POWDER (GRAM)

VIDARABINE MONOHYDRATE POWDER (GRAM)

VIGILON WOUND DRESSING BANDAGE

VINPOCETINE POWDER (GRAM)

VIRASAL FILM-FORMING LIQUID WITH APPLICATOR

VISTARIL CAPSULE

VISTEC SPONGE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

224

VITACIN CREAM (GRAM)

VITAMIN A BEADS (GRAM)

VITAMIN A LIQUID (GRAM)

VITAMIN A LIQUID (ML)

VITAMIN D3 CRYSTALS

VITAMIN D3 LIQUID (GRAM)

VITAMIN D3 LIQUID (ML)

VITAMIN D3 POWDER (GRAM)

VITAMIN E CREAM (GRAM)

VITAMIN E LIQUID (GRAM)

VITAMIN E LIQUID (ML)

VITAMIN E OIL (ML)

VITAMIN E OINTMENT (GRAM)

VITAMIN E POWDER (GRAM)

VITAMIN E & A BEAUTY OIL (ML)

VITAMIN E & C BEAUTY LOTION (ML)

VITAMIN E & D BEAUTY OIL (ML)

VITAMIN E & K BEAUTIFUL SKIN OIL (ML)

VITAMIN E PLUS CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

225

VITAMIN E SUCCINATE POWDER (GRAM)

VITAMIN E W/VIT A&D CREAM (GRAM)

VITAMIN K LIQUID (GRAM)

VITAMIN K POWDER (GRAM)

VITA-RAY CREAM (GRAM)

VIVA PATCH ADHESIVE PATCH, MEDICATED

V-MAX CREAM (GRAM)

VOLTAREN GEL (GRAM)

VOLTAREN ARTHRITIS PAIN GEL (GRAM)

VOLTAREN-XR TABLET, EXTENDED RELEASE 24 HR

VORICONAZOLE POWDER (GRAM)

VORICONAZOLE SUSPENSION, RECONSTITUTED, ORAL (ML)

VORICONAZOLE TABLET

VORICONAZOLE VIAL (EA)

VTOL LQ SOLUTION, ORAL

VUSION OINTMENT (GRAM)

VYTONE CREAM IN PACKET (GRAM)

WAL-DRYL AEROSOL, SPRAY (ML)

WAL-DRYL CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

226

WAL-FEX ALLERGY TABLET

WAL-ITIN SOLUTION, ORAL

WAL-ITIN TABLET

WAL-ITIN D TABLET, EXTENDED RELEASE 24 HR

WAL-ITIN D 12 HOUR TABLET, EXTENDED RELEASE 12 HR

WAL-PROFEN CAPSULE

WAL-PROFEN TABLET

WAL-PROFEN D TABLET

WAL-PROXEN TABLET

WAL-SPORIN OINTMENT (GRAM)

WALTZ FREE FOAM (ML)

WALTZ FREE LOTION (ML)

WAL-ZYR CAPSULE

WAL-ZYR SOLUTION, ORAL

WAL-ZYR TABLET

WARFARIN SODIUM POWDER (GRAM)

WART REMOVER ADHESIVE PATCH, MEDICATED

WART REMOVER GEL (GRAM)

WART REMOVER LIQUID (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

227

WART REMOVER PLASTER

WATER LIQUID (ML)

WATER SHIELD BANDAGES BANDAGE

WATERPROOF ADHESIVE TAPE, NON-MEDICATED

WATERPROOF STRONG STRIPS BANDAGE

WAX PARAFFIN BEADS (GRAM)

WEBCOL ALCOHOL PREPS PADS, MEDICATED (EA)

WEBRIL BANDAGE

WEBRIL II BANDAGE

WHEY PROTEIN ISOLATE POWDER (GRAM)

WHITE WILLOW BARK POWDER (GRAM)

WHYTEDERM SURGIPAK KIT

WHYTEDERM TDPAK KIT

WHYTEDERM TRILASIL PAK KIT

WIDE SEAL DIAPHRAGM DIAPHRAGM

WILEY BASIC ELEMENTS BHRT BASE CREAM (GRAM)

WINDOW BANDAGES BANDAGE

WITCH HAZEL AEROSOL, SPRAY (GRAM)

WITCH HAZEL LIQUID (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

228

WITCH HAZEL SOLUTION, NON-ORAL

WITEPSOL PELLET (GRAM)

WOUND & SKIN CLEANSER SPRAY, NON-AEROSOL (ML)

WOUND CARE CREAM CREAM (GRAM)

WOUND GEL GEL (GRAM)

WOUND GEL SPRAY, NON-AEROSOL (GRAM)

WOUND MATRIX SHEET (EA)

WOUND WASH SALINE AEROSOL, SPRAY (ML)

WOUNDGARD GAUZE BANDAGE

WOUN'DRES GEL (GRAM)

XALIX FILM-FORMING SOLUTION ER WITH APPLICATOR

XANTHAN GUM POWDER (GRAM)

XCEL 100 CREAM (GRAM)

XCLAIR CREAM (ML)

XELITRAL COMBINATION PACKAGE, SOLUTION AND CREAM

XERAC AC SOLUTION, NON-ORAL

XERESE CREAM (GRAM)

XEROFLO GAUZE DRESSING BANDAGE

XEROFORM BANDAGE

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

229

XEROFORM NON-OCCLUSIVE DRESSNG BANDAGE

XEROFORM PETROLATUM DRESSING BANDAGE

XILAPAK KIT

XOLIDO CREAM (ML)

XOLIDO XP CREAM (ML)

XOTEN LOTION (ML)

XOTEN-C LOTION (GRAM)

XRYLIX KIT

X-SEB T PEARL SHAMPOO

XTRACARE LOTION (ML)

XYLITOL POWDER (GRAM)

XYLOCAINE AMPUL (ML)

XYLOCAINE AMPUL, LUER TIP

XYLOCAINE VIAL (ML)

XYLOCAINE DENTAL-EPINEPHRINE CARTRIDGE (ML)

XYLOCAINE WITH EPINEPHRINE AMPUL (ML)

XYLOCAINE WITH EPINEPHRINE VIAL (ML)

XYLOMETAZOLINE HCL POWDER (GRAM)

XYLOSE POWDER (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

230

XYZAL SOLUTION, ORAL

XYZAL TABLET

YEAST LIQUID (GRAM)

YLANG-YLANG FRAGRANCE OIL (ML)

YODORA CREAM (GRAM)

YOHIMBINE HCL POWDER (GRAM)

ZAFIRLUKAST TABLET

ZANABIN GEL (GRAM)

ZANAFLEX CAPSULE

ZANAFLEX TABLET

ZANFEL CLEANSER (GRAM)

Z-CLINZ CLEANSER (ML)

ZEASORB POWDER (GRAM)

ZEAXANTHIN POWDER (GRAM)

ZEBUTAL CAPSULE

ZEGERID OTC CAPSULE

ZEGERID RX CAPSULE

ZEGERID RX PACKET (EA)

ZEMBRACE SYMTOUCH PEN INJECTOR (ML)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

231

ZENOPTIQ GEL WITH PUMP (ML)

ZENOPTIQ SPRAY, NON-AEROSOL (ML)

ZERVIATE DROPPERETTE, SINGLE-USE DROP DISPENSER

ZIANA GEL (GRAM)

ZIKS CREAM (GRAM)

ZIM'S MAX-FREEZE GEL (GRAM)

ZINC ACETATE CRYSTALS

ZINC CHLORIDE GRANULES (GRAM)

ZINC CITRATE POWDER (GRAM)

ZINC GLUCONATE POWDER (GRAM)

ZINC MONOMETHIONINE POWDER (GRAM)

ZINC OXIDE CREAM (GRAM)

ZINC OXIDE POWDER (GRAM)

ZINC PICOLINATE POWDER (GRAM)

ZINC PYRITHIONE LIQUID (GRAM)

ZINC PYRITHIONE LIQUID (ML)

ZINC SULFATE POWDER (GRAM)

ZINC UNDECYLENATE POWDER (GRAM)

ZINC-OXYDE PLUS OINTMENT (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

232

ZINGO PEN INJECTOR (EA)

ZIONODIL LOTION (ML)

ZIPSOR CAPSULE

ZITHRANOL SHAMPOO (GRAM)

ZOFRAN SOLUTION, ORAL

ZOFRAN TABLET

ZOFRAN VIAL (ML)

ZOFRAN ODT TABLET, DISINTEGRATING

ZOHYDRO ER CAPSULE,ORAL ONLY, EXTENDED RELEASE 12HR

ZOLMITRIPTAN POWDER (GRAM)

ZOLMITRIPTAN TABLET

ZOLMITRIPTAN ODT TABLET, DISINTEGRATING

ZOMIG SPRAY, NON-AEROSOL (EA)

ZOMIG TABLET

ZOMIG ZMT TABLET, DISINTEGRATING

ZONISAMIDE POWDER (GRAM)

ZORVOLEX CAPSULE

ZOSTRIX CREAM (GRAM)

ZOSTRIX-HP CREAM (GRAM)

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Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

233

ZOVIRAX CREAM (GRAM)

ZOVIRAX OINTMENT (GRAM)

ZTLIDO ADHESIVE PATCH, MEDICATED

ZUPLENZ FILM, MEDICATED (EA)

ZYRTEC OTC CAPSULE

ZYRTEC OTC TABLET

ZYRTEC OTC TABLET, DISINTEGRATING