Compound Exclusion List of Bulk Chemicals TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION ·...
Transcript of Compound Exclusion List of Bulk Chemicals TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION ·...
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)
ABSORBINE PAIN RELIEVING GEL (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
2
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)
ACETYLCYSTEINE POWDER (GRAM)
ACETYL-D-GLUCOSAMINE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
3
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 SPOT TREATMENT CREAM (ML)
ACNE TREATMENT CREAM (GRAM)
ACNE TREATMENT GEL (GRAM)
ACNE TREATMENT CLEANSING BAR BAR
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
4
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)
ACYCLOVIR OINTMENT (GRAM)
ACYCLOVIR POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
5
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)
ADEMETIONINE DISULFATE TOSYLAT POWDER (GRAM)
ADENOSINE POWDER (GRAM)
ADENOSINE-5 MONOPHOSPHATE POWDER (GRAM)
ADENOSINE-5-TRIPHOSPHATE POWDER (GRAM)
ADENOSYLCOBALAMIN POWDER (GRAM)
ADHESIVE BANDAGE BANDAGE
ADHESIVE GAUZE PAD BANDAGE
ADHESIVE PADS BANDAGE
ADHESIVE TAPE TAPE, NON-MEDICATED
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
6
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 RECOVERY LOTION (ML)
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
ADVIL PM TABLET
ADVOCATE PAIN RELIEF LIQUID (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
7
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)
ALCLOMETASONE DIPROPIONATE OINTMENT (GRAM)
ALCOHOL SOLUTION, NON-ORAL
ALCOHOL PREP PADS, MEDICATED (EA)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
8
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
ALIVIO ADHESIVE PATCH, MEDICATED
ALKYL (C12-15) BENZOATE LIQUID (ML)
ALKYL ACRYLATE CROSSPOLYMER POWDER (GRAM)
ALL DAY ALLERGY SOLUTION, ORAL
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
9
ALL DAY ALLERGY TABLET
ALL DAY ALLERGY TABLET,CHEWABLE
ALL DAY RELIEF TABLET
ALL DAY RELIEF PAIN TABLET
ALL PURPOSE CLOTH TAPE TAPE, NON-MEDICATED
ALLANTOIN POWDER (GRAM)
ALLEGRA ALLERGY TABLET
ALLEGRA INTENSIVE RELIEF CREAM (GRAM)
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
ALLERGY & CONGESTION RELIEF TABLET, EXTENDED RELEASE 24 HR
ALLERGY CREAM CREAM (GRAM)
ALLERGY RELIEF CAPSULE
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
10
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
ALLEVYN LIFE BANDAGE
ALLEVYN SACRUM BANDAGE
ALLOPURINOL POWDER (GRAM)
ALLZITAL TABLET
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
11
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)
ALOXI VIAL (ML)
ALPAWASH OINTMENT (GRAM)
ALPHA KERI OIL OIL (ML)
ALPHA LIPOIC ACID POWDER (GRAM)
ALPHA PINENE LIQUID (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
12
ALPHA TOCOPHEROL LIQUID (ML)
ALPHA-KETOGLUTARIC ACID CRYSTALS
ALPHA-LIPOIC ACID POWDER (GRAM)
ALPHAQUIN HP CREAM (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)
ALUMINUM HYDROXIDE POWDER (GRAM)
ALUMINUM POTASSIUM SULFATE CRYSTALS
ALUMINUM POTASSIUM SULFATE GRANULES (GRAM)
ALUMINUM SULFATE POWDER (GRAM)
AMANTADINE HCL POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
13
AMCINONIDE CREAM (GRAM)
AMCINONIDE LOTION (ML)
AMCINONIDE OINTMENT (GRAM)
AMELUZ GEL (GRAM)
AMERGE TABLET
AMERICAINE AEROSOL (GRAM)
AMERICAN GINSENG ROOT POWDER (GRAM)
AMERIGEL BANDAGE
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)
AMINOBUTYRIC ACID POWDER (GRAM)
AMINOCAPROIC ACID POWDER (GRAM)
AMINOLEVULINIC ACID HCL POWDER (GRAM)
AMINOPHYLLINE POWDER (GRAM)
AMINOSALICYLIC ACID POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
14
AMITIZA CAPSULE
AMITRIPTYLINE HCL POWDER (GRAM)
AMLACTIN CREAM (GRAM)
AMLACTIN KIT
AMLACTIN LOTION (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)
AMOXAPINE TABLET
AMOXICILLIN POWDER (GRAM)
AMPHOTERICIN B POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
15
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 E KIT, CREAM AND TOWELETTE
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
ANHYDROUS BASE CREAM (GRAM)
ANHYDROUS GEL GEL (GRAM)
ANHYDROUS OINTMENT OINTMENT (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
16
ANISINDIONE POWDER (GRAM)
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 SOAP SOAP, LIQUID
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
ANTIFUNGAL NAIL PEN SOLUTION, NON-ORAL
ANTI-ITCH AEROSOL, SPRAY (ML)
ANTI-ITCH CREAM (GRAM)
ANTI-ITCH GEL (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
17
ANTI-ITCH LOTION (ML)
ANTI-ITCH PLUS 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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
18
APRIZIO PAK KIT
AQUA GLYCOLIC CLEANSER (ML)
AQUA GLYCOLIC LIQUID (ML)
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)
AQUANIL CLEANSER (ML)
AQUAPHILIC WITH CARBAMIDE OINTMENT (GRAM)
ARBEM H-COSMETIC CREAM (GRAM)
ARBEM LIPOPEN CREAM (GRAM)
ARCH BANDAGE BANDAGE
ARCTIC RELIEF GEL (GRAM)
ARGININE CRYSTALS
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
19
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)
ARTHRITIS CREAM (GRAM)
ARTHRITIS HEATWRAPS BANDAGE
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
20
ASA-BUTALB-CAFF-COD CAPSULE
ASC LOTIONIZED CLEANSER CLEANSER (ML)
ASCOMP WITH CODEINE CAPSULE
ASCORBIC ACID POWDER (GRAM)
ASCORBYL PALMITATE POWDER POWDER (GRAM)
ASHWAGANDHA EXTRACT 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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
21
ASPIRIN SUPPOSITORY, RECTAL
ASTERO GEL WITH PUMP (ML)
ASTRAGALUS POWDER (GRAM)
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)
ATOPICLAIR CREAM (GRAM)
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 EMOLLIENT CREAM (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
22
AUXIPRO PLASTICIZED OINTMENT (GRAM)
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
23
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
24
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 PACKET (EA)
BACITRACIN POWDER (EA)
BACITRACIN POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
25
BALNEOL LOTION (ML)
BALNEOL LOTION IN PACKET
BALSAM PERU-CASTOR OIL OINTMENT (GRAM)
BANDAGE BANDAGE
BANDAGE ROLL BANDAGE
BANDAGES BANDAGE
BANDAGES KIT
BAND-AID BANDAGE
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
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 TOUGH PADS BANDAGE
BAND-AID WATERPROOF PAD BANDAGE
BAND-AID WATERPROOF TAPE TAPE, NON-MEDICATED
BANOPHEN ANTI-ITCH CREAM (GRAM)
BARIUM SULFATE POWDER (GRAM)
BASE 7542 CREAM (GRAM)
BASE C POLYETHYLENE GLYCOL 300 LIQUID (ML)
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, 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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
27
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
28
BAZA CLEAR OINTMENT (GRAM)
BAZA CREAM COMBINATION PACKAGE (EA)
BAZA PROTECT CREAM (GRAM)
BEAU RX GEL (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
29
BENGAY VANISHING SCENT GEL (GRAM)
BENSAL HP OINTMENT (GRAM)
BENZACLIN GEL (GRAM)
BENZACLIN GEL WITH PUMP (GRAM)
BENZALKONIUM CHLORIDE SOLUTION, NON-ORAL
BENZAMYCIN GEL (GRAM)
BENZAMYCINPAK GEL (EA)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
30
BENZOYL PEROXIDE CLEANSER (GRAM)
BENZOYL PEROXIDE CLEANSER (ML)
BENZOYL PEROXIDE FOAM (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
31
BETADINE SWAB, MEDICATED
BETAHISTINE DIHYDROCHLORIDE POWDER (GRAM)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
32
BIOFLAVONOID LEMON POWDER (GRAM)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
33
BISMUTH CITRATE POWDER (GRAM)
BISMUTH SUBCARBONATE POWDER (GRAM)
BISMUTH SUBGALLATE POWDER (GRAM)
BISMUTH SUBNITRATE POWDER (GRAM)
BISMUTH SUBSALICYLATE POWDER (GRAM)
BITTER MELON EXTRACT POWDER (GRAM)
BLANCHE CREAM (GRAM)
BLENDERM TAPE, NON-MEDICATED
BLISTER CARE BANDAGE
BLISTER RELIEF BANDAGE
BLISTEX OINTMENT (GRAM)
BLOOD CLOTTING AEROSOL (GRAM)
BLUE AGAVE LIQUID (ML)
BLUE GEL GEL (GRAM)
BOIL EASE OINTMENT (GRAM)
BOIL RELIEF OINTMENT (GRAM)
BORAX GRANULES (GRAM)
BORDERED GAUZE BANDAGE
BORIC ACID GRANULES (GRAM)
BORIC ACID POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
34
BORON POWDER (GRAM)
BORON CITRATE POWDER (GRAM)
BORO-PACKS POWDER IN PACKET (EA)
BOSWELLIA SERRATA EXTRACT POWDER (GRAM)
BOVINE SERUM ALBUMIN 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)
BPO GEL (GRAM)
BPO KIT
BPO TOWELETTE (EA)
BPO-10 CLEANSER (GRAM)
BPO-5 CLEANSER (GRAM)
BREATHE RIGHT STRIP
BRIJ LIQUID (GRAM)
BRIJ LIQUID (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
35
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
BUPIVACAINE HCL POWDER (GRAM)
BUPRENORPHINE HYDROCHLORIDE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
36
BUPROPION HCL POWDER (GRAM)
BURN RELIEF AEROSOL, SPRAY (GRAM)
BURN RELIEF GEL (GRAM)
BURN RELIEF WITH ALOE AEROSOL, SPRAY (GRAM)
BURNS-SCALDS-ABRASIONS BANDAGE
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)
BUTORPHANOL TARTRATE POWDER (GRAM)
BUTTERFLY CLOSURES TAPE, NON-MEDICATED
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
37
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)
CALAMINE CLEAR LOTION (ML)
CALAMINE MEDICATED LOTION (ML)
CALAMINE PHENOLATED LOTION (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
38
CALAMINE PLUS LOTION (ML)
CALAN TABLET
CALAN SR TABLET, EXTENDED RELEASE
CALCIPOTRIENE CREAM (GRAM)
CALCIPOTRIENE OINTMENT (GRAM)
CALCIPOTRIENE POWDER (GRAM)
CALCIPOTRIENE SOLUTION, NON-ORAL
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
39
CALCIUM CHLORIDE POWDER (GRAM)
CALCIUM CITRATE POWDER (GRAM)
CALCIUM FOLINATE POWDER (GRAM)
CALCIUM GLUBIONATE POWDER (GRAM)
CALCIUM GLUCONATE POWDER (GRAM)
CALCIUM HYDROXIDE POWDER (GRAM)
CALCIUM LACTATE POWDER (GRAM)
CALCIUM LEVULINATE DIHYDRATE POWDER (GRAM)
CALCIUM PANTOTHENATE POWDER (GRAM)
CALCIUM PHOSPHATE POWDER (GRAM)
CALCIUM PHOSPHATE TRIBASIC POWDER (GRAM)
CALCIUM PYRUVATE POWDER (GRAM)
CALCIUM SACCHARATE POWDER (GRAM)
CALCIUM SULFATE POWDER (GRAM)
CALCIUM THIOGLYCOLATE TRIHYDR POWDER (GRAM)
CALDESENE POWDER (GRAM)
CALDOLOR VIAL (ML)
CALDYPHEN LOTION (ML)
CALDYPHEN CLEAR LOTION (ML)
CALICYLIC CREAM (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
40
CALLERGY CLEAR LOTION (ML)
CALLUS CUSHION EACH
CALLUS PADS EACH
CALLUS REMOVER ADHESIVE PATCH, MEDICATED
CALMOL-4 SUPPOSITORY, RECTAL
CALMOSEPTINE OINTMENT (GRAM)
CALMOSEPTINE OINTMENT IN PACKET (GRAM)
CALYPXO CREAM (GRAM)
CAM LOTION (ML)
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)
CAPACET CAPSULE
CAPRYLIC ACID LIQUID (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
41
CAPRYLIC-CAPRIC TRIGLYCERIDE LIQUID (ML)
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
42
CARBIMAZOLE POWDER (GRAM)
CARBOFLEX BANDAGE
CARBOGEL GEL (GRAM)
CARBOHOL GEL (GRAM)
CARBOMER 934P POWDER (GRAM)
CARBOMER 940 POWDER (GRAM)
CARBOMER GEL-AQUEOUS GEL (GRAM)
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 CLEANSER (ML)
CA-REZZ CREAM (GRAM)
CA-REZZ SOAP, LIQUID
CA-REZZ SPRAY, NON-AEROSOL (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
43
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
44
CASTELLANI PAINT MODIFIED LIQUID (ML)
CASTIVA COOLING LIQUID (GRAM)
CASTIVA WARMING LIQUID (GRAM)
CAVILON CREAM (GRAM)
CAVILON CREAM (ML)
CAVILON LOTION (ML)
CAVILON SPRAY, NON-AEROSOL (ML)
CAVILON MOISTURIZING BODY CREAM (ML)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
45
CEO-TWO SUPPOSITORY, RECTAL
CERACADE EMULSION (GRAM)
CERAMAX CREAM (GRAM)
CERAMAX LOTION (GRAM)
CERAVE CLEANSER (ML)
CERAVE LOTION (GRAM)
CERAVE LOTION, EXTENDED RELEASE (ML)
CERESIN WAX (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
46
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)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
47
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
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
48
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
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
CHLOROFORM LIQUID (ML)
CHLOROPHYLLIN SODIUM COPPER POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
49
CHLOROQUINE PHOSPHATE POWDER (GRAM)
CHLOROXINE POWDER (GRAM)
CHLOROXYLENOL POWDER (GRAM)
CHLORPHENIRAMINE MALEATE POWDER (GRAM)
CHLORPROMAZINE HCL POWDER (GRAM)
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)
CHROMELIN COMPLEXION BLENDER SOLUTION, NON-ORAL
CHROMIUM PICOLINATE POWDER (GRAM)
CHROMIUM POLYNICOTINATE POWDER (GRAM)
CHROMIUM POT SULF DODECAHYDR POWDER (GRAM)
CHRYSADERM DAY CREAM CREAM (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
50
CHRYSADERM NIGHT CREAM CREAM (GRAM)
CHRYSIN POWDER (GRAM)
CHYMOTRYPSIN POWDER (GRAM)
CICA-CARE SHEET (EA)
CICLODAN COMBINATION PACKAGE (GRAM)
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)
CITRIC ACID GRANULES (GRAM)
CITRIC ACID POWDER (GRAM)
CITRUS BERGAMOT POWDER (GRAM)
CLARINEX SYRUP
CLARINEX TABLET
CLARITHROMYCIN POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
51
CLARITIN CAPSULE
CLARITIN SOLUTION, ORAL
CLARITIN TABLET
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 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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
52
CLEVIPREX VIAL (ML)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
53
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
CNL 8 KIT
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
54
COBALT GLUCONATE POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
55
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)
COLLAGENASE POWDER (EA)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
56
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)
COMPOUND W LIQUID (ML)
COMPRO SUPPOSITORY, RECTAL
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
57
CONCEPTROL GEL WITH PREFILLED APPLICATOR (GRAM)
CONDYLOX GEL (GRAM)
CONDYLOX SOLUTION, NON-ORAL
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)
COPPER GLYCINATE POWDER (GRAM)
COPPER PEPTIDE GHK-CU POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
58
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 COMBINATION PACKAGE (EA)
CORN-CALLUS REMOVER KIT
CORN-CALLUS REMOVER LIQUID (ML)
CORTANE-B LOTION (ML)
CORTICOTROPIN POWDER (GRAM)
CORTISONE CREAM (GRAM)
CORTISONE ACETATE POWDER (GRAM)
CORTISPORIN CREAM (GRAM)
CORTISPORIN OINTMENT (GRAM)
CORTIZONE CREAM (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
59
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)
CURAD BANDAGE
CURAFIL GEL (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
60
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)
CUTTER BACKWOODS AEROSOL, SPRAY (GRAM)
CUTTER BACKWOODS SPRAY, NON-AEROSOL (ML)
CUTTER BACKWOODS DRY AEROSOL, SPRAY (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
61
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)
CYMBALTA CAPSULE,DELAYED RELEASE (ENTERIC COATED)
CYPROHEPTADINE HCL POWDER (GRAM)
CYSTEAMINE HYDROCHLORIDE POWDER (GRAM)
CYSTEINE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
62
D & C GREEN #6 POWDER (GRAM)
DAILY FACE WASH CLEANSER (GRAM)
DAILY MOISTURIZING LOTION LOTION (ML)
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
63
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)
DERMA CIDOL 2000 LIQUID (ML)
DERMA STAT FOAM (ML)
DERMACEA BANDAGE
DERMACEA SPONGE
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
64
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)
DERMAGAUZE BANDAGE
DERMAGESIC CREAM (GRAM)
DERMAGESIC LOTION (ML)
DERMAGINATE BANDAGE
DERMAGRAFT SHEET (EA)
DERMAGRAN GEL (GRAM)
DERMAGRAN OINTMENT (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
65
DERMAGRAN HYDROPHILIC WOUND BANDAGE
DERMAL WOUND CLEANSER CLEANSER (ML)
DERMALEVIN BANDAGE
DERMAMED AEROSOL, SPRAY (ML)
DERMAMED OINTMENT (GRAM)
DERMA-N CREAM (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)
DERMASORB AF CREAM (GRAM)
DERMASORB HC COMBINATION PACKAGE, CLEANSER AND LOTION
DERMASORB TA CREAM (GRAM)
DERMASORB XM CREAM (GRAM)
DERMASYN GEL (GRAM)
DERMASYN SPRAY, NON-AEROSOL (GRAM)
DERMAVIEW BANDAGE
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
66
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)
DESIPRAMINE HCL TABLET
DESLORATADINE TABLET
DESLORATADINE TABLET,DISINTEGRATING
DESMOPRESSIN ACETATE POWDER (GRAM)
DESONIDE POWDER (GRAM)
DESOXIMETASONE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
67
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)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
68
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)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
69
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
70
DIFFERIN GEL WITH PUMP (GRAM)
DIFFERIN LOTION (ML)
DIFLORASONE DIACETATE CREAM (GRAM)
DIFLORASONE DIACETATE OINTMENT (GRAM)
DIFLUCAN SUSPENSION, RECONSTITUTED, ORAL (ML)
DIFLUCAN TABLET
DIGOXIN POWDER (GRAM)
DIHYDROCODEINE BITARTRATE POWDER (GRAM)
DIHYDROERGOTAMINE MESYLATE POWDER (GRAM)
DIHYDROXYACETONE POWDER (GRAM)
DIINDOLYLMETHANE POWDER (GRAM)
DIIODO-L-THYRONINE POWDER (GRAM)
DILAUDID LIQUID (ML)
DILAUDID SYRINGE (ML)
DILAUDID TABLET
DILAUDID-HP AMPUL (ML)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
71
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
72
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)
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)
DMAE LIQUID (ML)
DMAE POWDER (GRAM)
D-MANNOSE POWDER (GRAM)
DML FACIAL MOISTURIZER CREAM (GRAM)
DML FORTE CREAM (GRAM)
DMSA POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
73
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)
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)
DOULEURIN LOTION (ML)
DOVONEX CREAM (GRAM)
DOXAZOSIN MESYLATE POWDER (GRAM)
DOXEPIN HCL CAPSULE
DOXEPIN HCL CONCENTRATE, ORAL
DOXEPIN HCL POWDER (GRAM)
DOXYCYCLINE HYCLATE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
74
DOXYCYCLINE MONOHYDRATE POWDER (GRAM)
DOXYLAMINE SUCCINATE POWDER (GRAM)
DR SCHOLL'S CLEAR AWAY ADHESIVE PATCH, MEDICATED
DR. SCHOLL'S FOOT POWDER POWDER (GRAM)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
75
DUODERM CGF BANDAGE
DUODERM HYDROACTIVE BANDAGE
DUODERM HYDROACTIVE GEL (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
76
EASY COMFORT ALCOHOL PAD PADS, MEDICATED (EA)
EASY TOUCH ALCOHOL PREP PADS PADS, MEDICATED (EA)
EC-NAPROSYN TABLET, ENTERIC COATED
ECONAZOLE NITRATE POWDER (GRAM)
E-CREAM CREAM (GRAM)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
77
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)
EMU OIL LIQUID (ML)
EMU OIL OIL (ML)
EMU-LAC CREAM (ML)
EMULSIFYING WAX WAX (GRAM)
EMULSION CONCENTRATE EMULSION
EMULSION SB EMULSION (GRAM)
ENALAPRIL MALEATE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
78
ENDO-AVITENE SHEET (EA)
ENDOCET TABLET
ENDOFORM SHEET (EA)
ENDOMETRIN INSERT
ENDOXCIN ADHESIVE PATCH, MEDICATED
ENEMA ENEMA (ML)
ENEMA BAG EACH
ENEMEEZ ENEMA (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)
EPIFIX AMNIOTIC MEMBRANE SHEET (EA)
EPIFOAM FOAM (GRAM)
EPINEPHRINE POWDER (GRAM)
EPINEPHRINE BITARTRATE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
79
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)
ERYTHROMYCIN-BENZOYL PEROXIDE GEL (GRAM)
ESGIC CAPSULE
ESGIC TABLET
ESOMEP-EZS KIT, CAPSULE, DELAYED RELEASE AND SPRAY
ESOMEPRAZOLE MAGNESIUM CAPSULE,DELAYED RELEASE (ENTERIC COATED)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
80
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
81
ETHYL OLEATE LIQUID (GRAM)
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
82
EXELDERM SOLUTION, NON-ORAL
EXODERM LOTION (ML)
EXOTEN-C LOTION (GRAM)
EXTRA LONG FABRIC BANDAGE BANDAGE
EXTRA STRENGTH MUSCLE RUB CREAM (GRAM)
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
83
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
84
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
85
FENTANYL CITRATE-STERILE WATER PLASTIC BAG, INJECTION (ML)
FENTANYL/BUPIVACAINE/NS PLASTIC BAG, INJECTION (ML)
FENTANYL/BUPIVACAINE/NS PREFILLED PUMP RESERVOIR
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)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
86
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
FIORINAL CAPSULE
FIORINAL W/CODEINE CAPSULE
FIRST AID AEROSOL, SPRAY (GRAM)
FIRST AID GEL (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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
87
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
88
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)
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)
FLUOXYMESTERONE POWDER (GRAM)
FLUPHENAZINE DECANOATE LIQUID (GRAM)
FLUPHENAZINE DECANOATE OIL (GRAM)
FLURANDRENOLIDE CREAM (GRAM)
FLURANDRENOLIDE LOTION (ML)
FLURANDRENOLIDE OINTMENT (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
89
FLURBIPROFEN POWDER (GRAM)
FLURBIPROFEN TABLET
FLURBIPROFEN SODIUM DROPS
FLUTICASONE PROPIONATE POWDER (GRAM)
FLUTICASONE PROPIONATE MICRO POWDER (GRAM)
FOAM BANDAGES BANDAGE
FOAM DRESSING BANDAGE
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
90
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)
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)
FP CEPA GEL GEL (GRAM)
FP DERM CREAM CREAM (GRAM)
FP DERM GEL GEL (GRAM)
FP ENHANCING CREAM CREAM (GRAM)
FP NATURAL CREAM CREAM (GRAM)
FP NATURAL LOTION LOTION (GRAM)
FP PLUS CREAM CREAM (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
91
FP SILO GEL GEL (GRAM)
FP SUPREME CREAM CREAM (GRAM)
FP ULTRA CREAM CREAM (GRAM)
FREE & CLEAR SHAMPOO
FREEDOM ADAPTADERM CREAM (GRAM)
FREEDOM ADAPTADERM GEL (GRAM)
FREEDOM ALCOHOL GEL (GRAM)
FREEDOM CEPAPRO GEL (GRAM)
FREEDOM DERMA SERUM LIQUID (ML)
FREEDOM DERMA-D CREAM (GRAM)
FREEDOM ESTERDERM LIQUID (ML)
FREEDOM HRT ULTRA CREAM (GRAM)
FREEDOM LOLLIPOP BASE PELLET (GRAM)
FREEDOM ODT BASE POWDER (GRAM)
FREEDOM PEG TROCHE BASE PELLET (GRAM)
FREEDOM PEG TROCHE BASE POWDER (GRAM)
FREEDOM POLYMATRIX POWDER (GRAM)
FREEDOM SET-GEL LIQUID (ML)
FREEDOM SILOMAC GEL (GRAM)
FREEDOM SILOMAC ULTRA GEL (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
92
FREEDOM SIMPLECAP POWDER (GRAM)
FREEDOM TRIBLEND SUPPOS BASE PELLET (GRAM)
FREEDOM ULTRAPEN CREAM (GRAM)
FREEDOM XYLOX POWDER (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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
93
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)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
94
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 MOISTURIZING LOTION LOTION (ML)
GENTLE RAIN SOAP, LIQUID
GENTLE SKIN CLEANSER CLEANSER (ML)
GENTLE TAPE BANDAGE
GERANIUM OIL OIL (ML)
GERI-HYDROLAC CREAM (GRAM)
GERI-HYDROLAC LOTION (ML)
GERM BLOC FOAM (ML)
GERM BLOC LOTION (ML)
GERMALL PLUS LIQUID (ML)
GERMANIUM SESQUIOXIDE POWDER (GRAM)
GINGER ROOT POWDER (GRAM)
GINKGO BILOBA POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
95
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)
GLYBURIDE POWDER (GRAM)
GLYCERIN LIQUID (ML)
GLYCEROL FORMAL LIQUID (ML)
GLYCEROL MONOOLEATE PASTE (GRAM)
GLYCERYL DISTEARATE POWDER (GRAM)
GLYCINE POWDER (GRAM)
GLYCINE SOYA PROTEIN LIQUID (ML)
GLYCOFUROL LIQUID (ML)
GLYCOLIC ACID CRYSTALS
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
96
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 PAIN RELIEVING CREAM (GRAM)
GOLD BOND ULTIMATE LIQUID (GRAM)
GOLD BOND ULTIMATE DIABETIC CREAM (GRAM)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
97
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
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
98
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)
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)
HALOPERIDOL POWDER (GRAM)
HALOPERIDOL DECANOATE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
99
HAND SANITIZER GEL (ML)
HAND SOAP LIQUID (ML)
HAND SOAP SOAP, LIQUID
HAND WASH LIQUID (ML)
HAWTHORNE BERRY POWDER (GRAM)
HC PRAMOXINE CREAM (GRAM)
HC PRAMOXINE CREAM WITH APPLICATOR
H-CHLOR GEL (GRAM)
H-CHLOR 6 SOLUTION, NON-ORAL
HEARTBURN TREATMENT 24 HOUR CAPSULE,DELAYED RELEASE (ENTERIC COATED)
HEAT THERAPY PATCHES BANDAGE
HEATWRAPS BANDAGE
HEMATOXYLIN, C.I. 75290 POWDER (GRAM)
HEMORRHOID RELIEF SUPPOSITORY, RECTAL
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
100
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
101
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)
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 NATURAL CREAM BASE CREAM (GRAM)
HRT NATURAL LOTION BASE LOTION (GRAM)
HRT SUPREME 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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
102
HYDRASYN25 CREAM (GRAM)
HYDRAZINE SULFATE CRYSTALS
HYDROCERIN LOTION (ML)
HYDROCHLORIC ACID LIQUID (ML)
HYDROCHLOROTHIAZIDE POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
103
HYDROCORTISONE-IODOQUINOL-ALOE CREAM IN PACKET (GRAM)
HYDROFERA BLUE BANDAGE
HYDROFLUORIC ACID LIQUID (ML)
HYDROGEL GEL (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
104
HYDROMORPHONE HCL/NS PATIENT CONTROLLED ANALGESIA SYRINGE
HYDROMORPHONE HCL/NS PATIENT CONTROLLED ANALGESIA VIAL
HYDROMORPHONE HCL/NS PLASTIC BAG, INJECTION (ML)
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 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 GRANULES (GRAM)
HYDROXYETHYL CELLULOSE POWDER (GRAM)
HYDROXYETHYL METHACRYLATE LIQUID (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
105
HYDROXYPROGESTERONE CAPROATE POWDER (GRAM)
HYDROXYPROPY-BETA-CYCLODEXTRIN POWDER (GRAM)
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)
HYLATOPICPLUS CREAM (GRAM)
HYLATOPICPLUS FOAM (GRAM)
HYLATOPICPLUS LOTION (ML)
HYOSCYAMINE SULFATE POWDER (GRAM)
HYPERCARE LIQUID (ML)
HYPER-HEAL CREAM (GRAM)
HYPO-ALLERGENIC BANDAGES BANDAGE
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
106
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)
ICHTHAMMOL POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
107
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)
IMITREX SPRAY, NON-AEROSOL (EA)
IMITREX TABLET
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
108
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)
INFLAMMA-K KIT, PATCH, MEDICATED AND SOLUTION DROPS
INFUMORPH AMPUL (ML)
INOSITOL POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
109
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)
IODOQUINOL POWDER (GRAM)
IODOQUINOL-HYDROCORTISONE-ALOE GEL (GRAM)
IODOSORB GEL (GRAM)
IONSYS SYSTEM, TRANSDERMAL IONTOPHORETIC PCA
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
110
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)
ISOSORBIDE POWDER (GRAM)
ISOTRETINOIN POWDER (GRAM)
ISOXSUPRINE HCL POWDER (GRAM)
ISRADIPINE CAPSULE
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
111
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)
JASMINE FRAGRANCE LIQUID (ML)
JESSNER'S SOLUTION, NON-ORAL
JOCK ITCH CREAM (GRAM)
JOHNSON'S FOOT POWDER IN PACKET (EA)
JOJOBA OIL OIL (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
112
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)
KENDALL CLOTH BANDAGE
KENDALL PAPER TAPE TAPE, NON-MEDICATED
KEPPRA TABLET
KERA TEK GEL (GRAM)
KERADAN CREAM (GRAM)
KERAGEL GEL (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
113
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
114
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
115
LACTASE POWDER (GRAM)
LACTIC ACID CREAM (GRAM)
LACTIC ACID LIQUID (ML)
LACTIC ACID LOTION (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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
116
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)
LATRIX SUSPENSION, TOPICAL (GRAM)
LAURETH-9 LIQUID (ML)
LAURIC ACID POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
117
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
118
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
LEVOCARNITINE TABLET
LEVOCARNITINE VIAL (ML)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
119
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)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
120
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
121
LIDOCAINE HCL W/EPINEPHRINE VIAL (ML)
LIDOCAINE HCL-MENTHOL SPRAY, NON-AEROSOL (ML)
LIDOCAINE PAIN RELIEF ADHESIVE PATCH, MEDICATED
LIDOCAINE PLUS CREAM (GRAM)
LIDOCAINE-HC CREAM (GRAM)
LIDOCAINE-HC CREAM WITH APPLICATOR
LIDOCAINE-HC GEL WITH APPLICATOR (GRAM)
LIDOCAINE-HC KIT
LIDOCAINE-PRILOCAINE CREAM (GRAM)
LIDOCAINE-PRILOCAINE KIT
LIDOCAINE-TETRACAINE CREAM (GRAM)
LIDOCARE ADHESIVE PATCH, MEDICATED
LIDOCREAM CREAM (GRAM)
LIDOCREAM KIT
LIDODERM ADHESIVE PATCH, MEDICATED
LIDODOSE SWAB, MEDICATED (ML)
LIDO-K LOTION (ML)
LIDOMD OINTMENT ROLL-ON (GRAM)
LIDOPAC KIT
LIDOPATCH ADHESIVE PATCH, MEDICATED
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
122
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
123
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)
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 ABSORPTION CREAM (GRAM)
LIPOPEN ABSORPTN ENHANCE BASE CREAM (GRAM)
LIPOPEN ANHYDROUS CREAM (GRAM)
LIPOPEN PLUS CREAM (GRAM)
LIPOPEN ULTRA CREAM (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
124
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
125
L-MENTHOL CRYSTALS
L-METHIONINE POWDER (GRAM)
L-METHYLFOLATE CALCIUM POWDER (GRAM)
LMR PLUS KIT
LMX 4 KIT
LOCOID CREAM (GRAM)
LOCOID LOTION (ML)
LOCOID OINTMENT (GRAM)
LOCOID SOLUTION, NON-ORAL
LOCOID LIPOCREAM CREAM (GRAM)
LOCUST BEAN GUM POWDER (GRAM)
LODINE TABLET
LOLLIBASE POWDER (GRAM)
LOLLIPOP BASE 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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
126
LORATADINE CAPSULE
LORATADINE POWDER (GRAM)
LORATADINE SOLUTION, ORAL
LORATADINE TABLET
LORATADINE TABLET,DISINTEGRATING
LORATADINE ALLERGY SOLUTION, ORAL
LORATADINE HIVES RELIEF SOLUTION, ORAL
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
127
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)
LUBRIN INSERT
LUBRISILK LOTION (ML)
LUBRI-SKIN 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)
LYCOPENE BEADS (GRAM)
LYSINE POWDER (GRAM)
MAC ADHESIVE PATCH, MEDICATED
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
128
MACA ROOT POWDER (GRAM)
MAFENIDE ACETATE PACKET (EA)
MAFENIDE ACETATE POWDER (GRAM)
MAGIC BULLET SUPPOSITORY, RECTAL
MAGNESIUM ALUMINUM SILICATE POWDER (GRAM)
MAGNESIUM AMINO ACID CHELATE POWDER (GRAM)
MAGNESIUM ASCORBATE POWDER (GRAM)
MAGNESIUM BISGLYCINATE CHELATE POWDER (GRAM)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
129
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)
MANGANESE SULFATE POWDER (GRAM)
MANNITOL POWDER (GRAM)
MANUKA HONEY GEL (ML)
MAPROTILINE HCL TABLET
MARGESIC CAPSULE
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
130
MB HYDROGEL KIT, CREAM AND GEL
MEBENDAZOLE POWDER (GRAM)
MECAMYLAMINE HCL POWDER (GRAM)
MECHLORETHAMINE HCL POWDER (GRAM)
MECHOLYL OINTMENT (GRAM)
MECLIZINE HCL POWDER (GRAM)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
131
MEDICATED DOUCHE SOLUTION, NON-ORAL
MEDICATED HEAT PATCH ADHESIVE PATCH, MEDICATED
MEDICATED PADS PADS, MEDICATED (EA)
MEDICATED WIPES PADS, MEDICATED (EA)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
132
MEDI-RDT BASE POWDER (GRAM)
MEDIUM CHAIN TRIGLYCERIDES LIQUID (GRAM)
MEDIUM CREAM CREAM (GRAM)
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
MELPAQUE HP CREAM (GRAM)
MELQUIN-3 SOLUTION, NON-ORAL
MEMANTINE HCL POWDER (GRAM)
MENADIONE POWDER (GRAM)
MENADIONE SODIUM BISULFITE CRYSTALS
MENCAPS ADHESIVE PATCH, MEDICATED
MEN-PHOR LOTION (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
133
MENTAX CREAM (GRAM)
MENTHO-CAINE KIT, OINTMENT AND SPRAY
MENTHODERM OINTMENT (GRAM)
MENTHOL CREAM (GRAM)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
134
MESALAMINE ENEMA (ML)
MESALAMINE ENEMA KIT
MESALAMINE POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
135
METHAZOLAMIDE POWDER (GRAM)
METHENAMINE POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
136
METHYLPARABEN POWDER (GRAM)
METHYLPHENIDATE HCL POWDER (GRAM)
METHYLPREDNISOLONE POWDER (GRAM)
METHYLPREDNISOLONE AC MICRO POWDER (GRAM)
METHYLPYRAZOLE LIQUID (ML)
METHYLTESTOSTERONE POWDER (GRAM)
METHYLTESTOSTERONE MICRONIZED POWDER (GRAM)
METHYLTETRAHYDROFOLATE CALCIUM 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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
137
MICONAZOLE NITRATE POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
138
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)
MOBIC SUSPENSION, ORAL (FINAL DOSE FORM)
MOBIC TABLET
MOBISYL CREAM (GRAM)
MOISTURE BARRIER OINTMENT OINTMENT (GRAM)
MOISTURE RECOVERY LOTION (ML)
MOISTURIZING LOTION LOTION (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
139
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)
MORPHINE SULFATE SOLUTION, ORAL
MORPHINE SULFATE SUPPOSITORY, RECTAL
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
140
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
MOTRIN PM TABLET
MOXIFLOXACIN HCL POWDER (GRAM)
MOXISYLYTE HCL POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
141
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)
NADOLOL POWDER (GRAM)
NAIL SCRUB LOTION (ML)
NALBUPHINE HCL POWDER (GRAM)
NALFON CAPSULE
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
142
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
NAPROXEN SODIUM CAPSULE
NAPROXEN SODIUM POWDER (GRAM)
NAPROXEN SODIUM TABLET
NAPROXEN SODIUM DS TABLET
NAPROXEN SODIUM ER TABLET,EXTENDED RELEASE MULTIPHASE 24 HR
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
143
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
144
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
145
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)
NICLOSAMIDE POWDER (GRAM)
NICOTINAMIDE ADENINE POWDER (GRAM)
NICOTINE POLACRILEX POWDER (GRAM)
NICOTINE TARTRATE POWDER (GRAM)
NICOTINIC ACID POWDER (GRAM)
NIFEDICAL XL TABLET, EXTENDED RELEASE 24 HR
NIFEDIPINE CAPSULE
NIFEDIPINE POWDER (GRAM)
NIFEDIPINE ER TABLET, EXTENDED RELEASE
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
146
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
147
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
148
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
NULIDO GEL (ML)
NUMBONEX LOTION (GRAM)
NUPERCAINAL OINTMENT (GRAM)
NUSURGEPAK KIT
NUTRIARX KIT
NUVAIL NAIL FILM SOLUTION (ML)
NUVARING RING, VAGINAL
NUVAZIL SHEET (EA)
NYATA COMBINATION PACKAGE, GEL AND POWDER
NYLIDRIN HCL POWDER (GRAM)
NYMALIZE SOLUTION, ORAL
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
149
NYSTATIN POWDER (EA)
NYSTATIN W/TRIAMCINOLONE CREAM (GRAM)
NYSTATIN W/TRIAMCINOLONE OINTMENT (GRAM)
NYSTATIN/TRIAMCINOLONE CREAM (GRAM)
OASIS SHEET (EA)
OATMEAL BATH PACKET (EA)
OATMEAL MOISTURIZING LOTION (ML)
OC8 GEL (GRAM)
O-CAL-ETTE EACH
OCCLUVAN OINTMENT (GRAM)
OCEAN GEL (GRAM)
OCTINOXATE LIQUID (ML)
OCUFEN DROPS
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
150
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)
OMEGA-3 DHA POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
151
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
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
152
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)
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)
OXSORALEN LOTION (ML)
OXYBENZONE POWDER (GRAM)
OXYBUTYNIN CHLORIDE POWDER (GRAM)
OXYCODONE HCL CAPSULE
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
153
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
154
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
155
PAMELOR CAPSULE
PANCREATIN POWDER (GRAM)
PANCURONIUM BROMIDE POWDER (GRAM)
PANDEL CREAM (GRAM)
PANOXYL BAR
PANOXYL CLEANSER (GRAM)
PANOXYL CREAM (GRAM)
PANRETIN GEL (GRAM)
PANTHENOL POWDER (GRAM)
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)
PAZOL XS SHAMPOO
P-CARE X KIT
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
156
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)
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)
PEDIADERM AF CREAM (GRAM)
PEDIADERM HC KIT, LOTION AND CREAM, EMOLLIENT
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
157
PEDIADERM TA CREAM (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-40 CASTOR OIL OIL (ML)
PEGBLEND WAX (GRAM)
PENCREAM CREAM (GRAM)
PENDERM CREAM (GRAM)
PENETRAN + PLUS LOTION (ML)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
158
PENTOXIFYLLINE TABLET, EXTENDED RELEASE
PENTRAVAN CREAM (GRAM)
PENTRAVAN PLUS CREAM (GRAM)
PENTYLENE GLYCOL LIQUID (ML)
PENTYLENETETRAZOLE CRYSTALS
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
159
PERPHENAZINE POWDER (GRAM)
PERSA-GEL GEL (GRAM)
PERSONAL LUBRICANT JELLY (GRAM)
PERSONAL LUBRICANT SOLUTION (GRAM)
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)
PHENOBARBITAL POWDER (GRAM)
PHENOBARBITAL SODIUM POWDER (GRAM)
PHENOL CRYSTALS
PHENOL LIQUID (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
160
PHENOL EZ SWAB, MEDICATED
PHENOLSULFONIC ACID LIQUID (ML)
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
PHENYLPROPANOLAMINE HCL POWDER (GRAM)
PHENYLTOLOXAMINE DIHYD CIT POWDER (GRAM)
PHENYTOIN POWDER (GRAM)
PHENYTOIN SODIUM POWDER (GRAM)
PHLAG SPRAY SPRAY, NON-AEROSOL (ML)
PHOSPHATIDYLCHOLINE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
161
PHOSPHATIDYLSERINE POWDER (GRAM)
PHOSPHORIC ACID LIQUID (ML)
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 BARK EXTRACT POWDER (GRAM)
PINE OIL OIL (ML)
PIPERINE POWDER (GRAM)
PIROXICAM CAPSULE
PIROXICAM POWDER (GRAM)
PLACEBO #00 CAPSULE
PLANTAR WART REMOVER ADHESIVE PATCH, MEDICATED
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
162
PLASTIC ADHESIVE BANDAGES BANDAGE
PLASTIC STRIP BANDAGE
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
163
PODOCON-25 LIQUID (ML)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
164
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)
POLYVINYL ALCOHOL POWDER (GRAM)
PONSTEL CAPSULE
PONTOCAINE SOLUTION, NON-ORAL
POSACONAZOLE SUSPENSION, ORAL (FINAL DOSE FORM)
POSACONAZOLE TABLET, ENTERIC COATED
POTASSIUM ACETATE POWDER (GRAM)
POTASSIUM ACID TARTRATE POWDER (GRAM)
POTASSIUM AZELAOYL DIGLYCINATE LIQUID (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
165
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)
POTASSIUM NITRATE POWDER (GRAM)
POTASSIUM PERCHLORATE CRYSTALS
POTASSIUM PERMANGANATE CRYSTALS
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
166
POTASSIUM PERMANGANATE GRANULES (GRAM)
POTASSIUM PHOSPHATE CRYSTALS
POTASSIUM PHOSPHATE POWDER (GRAM)
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 SPONGE
POVIDONE-IODINE SPRAY, NON-AEROSOL (ML)
POVIDONE-IODINE SWAB, MEDICATED
POWDER SCENT FRAGRANCE LIQUID (ML)
PR BENZOYL PEROXIDE CLEANSER (GRAM)
PR CREAM CREAM (GRAM)
PRACASIL TM-PLUS GEL (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
167
PRAMCORT CREAM WITH APPLICATOR
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
PRE-MOISTENED HEMORRHOIDAL PADS, MEDICATED (EA)
PRE-MOISTENED MEDICATED WIPES PAD
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
168
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
PRILOSEC OTC TABLET, ENTERIC COATED
PRILOSEC RX SUSP FOR RECON,DELAYED REL. IN A PACKET
PRILOVIX KIT
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
169
PRILOVIX LITE KIT
PRILOVIX LITE PLUS KIT
PRILOVIX ULTRALITE KIT
PRILOVIX ULTRALITE PLUS KIT
PRIMER MODIFIED UNNA BOOT BANDAGE
PRIMIDONE POWDER (GRAM)
PRIMLEV TABLET
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)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
170
PROCOMYCIN CREAM (GRAM)
PROCORT CREAM WITH APPLICATOR
PROCTOFOAM-HC FOAM (GRAM)
PROFENO TABLET
PROGESTERONE POWDER (GRAM)
PROMETHAZINE HCL POWDER (GRAM)
PROMETHAZINE HCL SUPPOSITORY, RECTAL
PROMETHEGAN SUPPOSITORY, RECTAL
PROMISEB CREAM (GRAM)
PROMISEB COMPLETE KIT, CLEANSER AND CREAM
PROPANEDIOL LIQUID (ML)
PROPANTHELINE BROMIDE POWDER (GRAM)
PROPARACAINE HCL POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
171
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
172
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)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
173
QUINIDINE SULFATE POWDER (GRAM)
QUININE HCL POWDER (GRAM)
QUININE SULFATE POWDER (GRAM)
QUINJA GEL (GRAM)
QUTENZA KIT
RA LOTION (ML)
RABEPRAZOLE SODIUM CAPSULE, DELAYED RELEASE SPRINKLE
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
174
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
175
REGENECARE HA GEL (GRAM)
REGENECARE HA GEL (ML)
REGENECARE HA SPRAY GEL (ML)
REGRANEX GEL (GRAM)
REHYLA CLEANSER (GRAM)
REHYLA CLEANSER (ML)
REJUVACARE PLUS CREAM (GRAM)
RELADOR PAK KIT
RELADOR PAK PLUS KIT
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 FOAM (GRAM)
RENEWAL PACKET (EA)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
176
RENEWAL DAILY MOISTURE LOTION LOTION (ML)
RENEWCREAM HRT CREAM (GRAM)
RENOVA CREAM (GRAM)
REPEL 100 SPRAY, NON-AEROSOL (ML)
REPEL FAMILY AEROSOL, POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
177
RESINOL OINTMENT (GRAM)
RESORCINOL CRYSTALS
RESORCINOL POWDER (GRAM)
RESTIZAN GEL WITH PUMP (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
178
REZAMID LOTION (GRAM)
RHOFADE CREAM (GRAM)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
179
ROLLED GAUZE BANDAGE
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
180
SAF-CLENS AF CLEANSER (ML)
SAFFLOWER OIL OIL (ML)
SAF-GEL GEL (GRAM)
SALACTIC FILM LIQUID (ML)
SALACYN CREAM (GRAM)
SALACYN LOTION (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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
181
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-HOT ADHESIVE PATCH, MEDICATED
SAL-PLANT GEL (GRAM)
SALSALATE POWDER (GRAM)
SALT DURABLE CREAM (GRAM)
SALTSTABLE LO CREAM (GRAM)
SALTSTABLE LS CREAM (GRAM)
SALVAX FOAM (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
182
SALVAX DUO PLUS FOAM (GRAM)
SANADERMRX KIT
SANARE ADV SCAR THERAPY BASE GEL (GRAM)
SANCUSO PATCH, TRANSDERMAL WEEKLY
SANTYL OINTMENT (GRAM)
SARNA LOTION (ML)
SAUGELLA CLEANSER (ML)
SAVELLA TABLET
SAVELLA TABLET, DOSE PACK
SAW PALMETTO POWDER (GRAM)
SAW PALMETTO BERRY POWDER (GRAM)
SCALACORT DK COMBINATION PACKAGE (ML)
SCALP ITCH-DANDRUFF RELIEF LIQUID (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)
SCAR SHEET (EA)
SCAR CARE BASE ENHANCED GEL (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
183
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-ADHERING BANDAGE
SELFGRIP BANDAGE
SELSUN BLUE SHAMPOO
SELSUN BLUE MOISTURIZING SHAMPOO
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
184
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)
SILALITE PAK KIT, OINTMENT AND SHEET
SILAZONE-II KIT
SILDENAFIL CITRATE POWDER (GRAM)
SILICA GEL POWDER (GRAM)
SILICON DIOXIDE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
185
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
186
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)
SKIN CLOSURE STRIPS COMBINATION PACKAGE (EA)
SKIN CLOSURE STRIPS STRIP
SKIN RELIEF MOISTURE LOTION (ML)
SKIN REPAIR LOTION (ML)
SKIN TREATMENT LOTION (GRAM)
SKINTASTIC SPRAY, NON-AEROSOL (ML)
SKINTEGRITY BANDAGE
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
187
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 ACETATE TRIHYDRATE POWDER (GRAM)
SODIUM ALGINATE POWDER (GRAM)
SODIUM ASCORBATE POWDER (GRAM)
SODIUM BENZOATE POWDER (GRAM)
SODIUM BORATE POWDER (GRAM)
SODIUM BROMIDE GRANULES (GRAM)
SODIUM BUTYRATE POWDER (GRAM)
SODIUM CACODYLATE POWDER (GRAM)
SODIUM CAPRATE POWDER (GRAM)
SODIUM CAPRYLATE POWDER (GRAM)
SODIUM CARBONATE POWDER (GRAM)
SODIUM CHLORITE FLAKES (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
188
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
189
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
190
SODIUM SULFACETAMIDE/SULFUR COMBINATION PACKAGE, CLEANSER AND CREAM
SODIUM SULFACETAMIDE/SULFUR CREAM (GRAM)
SODIUM SULFACETAMIDE/SULFUR FOAM (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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
191
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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
192
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)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
193
SPORTS PAIN RELIEF CREAM (GRAM)
SPORTS TAPE TAPE, NON-MEDICATED
SPORTSCREME CREAM (GRAM)
SPRAY AND STRETCH AEROSOL, SPRAY (ML)
SPRAYZOIN 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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
194
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)
STRATASORB BANDAGE
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
195
SUCCIMER DMSA POWDER (GRAM)
SUCCINIC ACID CRYSTALS
SUCCINYLCHOLINE CHLORIDE POWDER (GRAM)
SUCRALFATE POWDER (GRAM)
SUCROSE CRYSTALS
SUCROSE POWDER (GRAM)
SUCROSE OCTAACETATE POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
196
SULFAMYLON CREAM (GRAM)
SULFAMYLON PACKET (EA)
SULFANILAMIDE POWDER (GRAM)
SULFAPYRIDINE POWDER (GRAM)
SULFASALAZINE POWDER (GRAM)
SULFATHIAZOLE POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
197
SUMATRIPTAN SUCCINATE PEN INJECTOR (ML)
SUMATRIPTAN SUCCINATE POWDER (GRAM)
SUMATRIPTAN SUCCINATE SYRINGE (ML)
SUMATRIPTAN SUCCINATE TABLET
SUMATRIPTAN SUCCINATE VIAL (ML)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
198
SURE COMFORT ALCOHOL PREP PADS PADS, MEDICATED (EA)
SURE RESULT TAC PAK KIT
SURE-PREP ALCOHOL PREP PADS PADS, MEDICATED (EA)
SUREPRESS BANDAGE
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
199
SYNVEXIA TC CREAM (GRAM)
SYRINGE AVITENE POWDER (GRAM)
SYSTANE TOWELETTE (EA)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
200
TAZORAC GEL (GRAM)
TAZTIA XT CAPSULE, EXTENDED RELEASE 24HR
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
201
TEGRETOL TABLET
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
202
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)
THEANINE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
203
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)
THREONINE POWDER (GRAM)
THRITEX ADHESIVE PATCH, MEDICATED
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
204
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)
TIMOLOL MALEATE POWDER (GRAM)
TINCTURE IODINE TINCTURE
TINEACIDE CREAM (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
205
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
TOLAZOLINE HCL POWDER (GRAM)
TOLMETIN SODIUM CAPSULE
TOLMETIN SODIUM TABLET
TOLNAFTATE POWDER (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
206
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
TRAMADOL HCL ER TABLET,EXTENDED RELEASE MULTIPHASE 24 HR
TRAMADOL HCL-ACETAMINOPHEN TABLET
TRANEXAMIC ACID POWDER (GRAM)
TRANILAST POWDER (GRAM)
TRANSANOSIL LOTION (ML)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
207
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 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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
208
TRIAMTERENE POWDER (GRAM)
TRI-BIOZENE OINTMENT (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)
TRIFLURIDINE POWDER (GRAM)
TRILOSTANE POWDER (GRAM)
TRI-LUMA CREAM (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
209
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)
TRI-SILA KIT
TRIXAICIN CREAM (GRAM)
TRIXAICIN HP CREAM (GRAM)
TROCHE BASE PELLET (GRAM)
TROCHE BASE POWDER (GRAM)
TROCHIBASE POWDER (GRAM)
TROCHIBASE S FLAKES (GRAM)
TROLAMINE SOLUTION, NON-ORAL
TROLAMINE SALICYLATE CREAM (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
210
TROLAMINE SALICYLATE SOLUTION, NON-ORAL
TROMETHAMINE POWDER (GRAM)
TRONOLANE CREAM (GRAM)
TROPAZONE LOTION (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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
211
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)
ULTRA-FLEX BANDAGE
ULTRAFOAM SPONGE
ULTRAM TABLET
ULTRAM ER TABLET, EXTENDED RELEASE 24 HR
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
212
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 KIT
UREA POWDER (GRAM)
UREA PEROXIDE POWDER (GRAM)
URIDINE POWDER (GRAM)
URSODIOL POWDER (GRAM)
VACUSTIM BLACK KIT
VAGICAINE CREAM (GRAM)
VAGINAL ITCH CREAM CREAM (GRAM)
VAGISIL CREAM (GRAM)
VAGISIL POWDER (GRAM)
VALACYCLOVIR POWDER (GRAM)
VALCHLOR GEL (GRAM)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
213
VALERIAN POWDER (GRAM)
VALINE POWDER (GRAM)
VALPROATE SODIUM POWDER (GRAM)
VALPROIC ACID LIQUID (ML)
VANADIUM GRANULES (GRAM)
VANADYL SULFATE CRYSTALS
VANALICE GEL (ML)
VANATOL LQ SOLUTION, ORAL
VANATOL S SOLUTION, ORAL
VANCOMYCIN HCL POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
214
VASCUDERM HYDROGEL WOUND GEL (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)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
215
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
216
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
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
217
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)
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-XR TABLET, EXTENDED RELEASE 24 HR
VOPAC MDS KIT
VORICONAZOLE POWDER (GRAM)
VORICONAZOLE SUSPENSION, RECONSTITUTED, ORAL (ML)
VORICONAZOLE TABLET
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
218
VORICONAZOLE VIAL (EA)
VUSION OINTMENT (GRAM)
VYTONE CREAM IN PACKET (GRAM)
WAL-DRYL AEROSOL, SPRAY (ML)
WAL-DRYL CREAM (GRAM)
WAL-FEX ALLERGY TABLET
WAL-ITIN SOLUTION, ORAL
WAL-ITIN TABLET
WAL-ITIN TABLET,DISINTEGRATING
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
219
WAL-ZYR TABLET
WARFARIN SODIUM POWDER (GRAM)
WART REMOVER ADHESIVE PATCH, MEDICATED
WART REMOVER GEL (GRAM)
WART REMOVER LIQUID (ML)
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
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
220
WILEY BASIC ELEMENTS BHRT BASE CREAM (GRAM)
WINDOW BANDAGES BANDAGE
WITCH HAZEL LIQUID (ML)
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)
XARTEMIS XR TABLET, ORAL ONLY, IR AND ER, BIPHASIC
XCEL 100 CREAM (GRAM)
XCLAIR CREAM (ML)
XELITRAL COMBINATION PACKAGE, SOLUTION AND CREAM
XERAC AC SOLUTION, NON-ORAL
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
221
XERESE CREAM (GRAM)
XEROFLO GAUZE DRESSING BANDAGE
XEROFORM 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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
222
XYLOSE POWDER (GRAM)
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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
223
ZENCIA CLEANSER (ML)
ZENOPTIQ GEL WITH PUMP (ML)
ZENOPTIQ SPRAY, NON-AEROSOL (ML)
ZIANA GEL (GRAM)
ZIKS CREAM (GRAM)
ZIM'S MAX-FREEZE ADHESIVE PATCH, MEDICATED
ZIM'S MAX-FREEZE GEL (GRAM)
ZINC ACETATE CRYSTALS
ZINC ACETATE POWDER (GRAM)
ZINC CHLORIDE GRANULES (GRAM)
ZINC CHLORIDE POWDER (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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
224
ZINC UNDECYLENATE POWDER (GRAM)
ZINC-OXYDE PLUS OINTMENT (GRAM)
ZINGO PEN INJECTOR (EA)
ZIPSOR CAPSULE
ZITHRANOL SHAMPOO (GRAM)
ZITHRANOL-RR CREAM, RAPID RELEASE (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)
Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Exclusion List of Bulk Chemicals
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
225
ZOSTRIX-HP CREAM (GRAM)
ZOVIRAX CREAM (GRAM)
ZOVIRAX OINTMENT (GRAM)
ZTLIDO ADHESIVE PATCH, MEDICATED
ZUPLENZ FILM, MEDICATED (EA)
ZYRTEC OTC CAPSULE
ZYRTEC OTC TABLET
ZYRTEC OTC TABLET,DISINTEGRATING