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Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
1
ABSORBASE OINTMENT (GRAM)
ACID GONE SUSPENSION, ORAL (FINAL DOSE FORM)
ACID GONE TABLET,CHEWABLE
ADVANCED ANTACID SUSPENSION, ORAL (FINAL DOSE FORM)
ADVANCED ANTACID-ANTIGAS SUSPENSION, ORAL (FINAL DOSE FORM)
ADVANCED HEALING OINTMENT (GRAM)
ALCALAK TABLET,CHEWABLE
ALER-CAP CAPSULE
ALFALFA POWDER (GRAM)
ALKA-SELTZER TABLET, EFFERVESCENT
ALKA-SELTZER HEARTBURN TABLET, EFFERVESCENT
ALKA-SELTZER HEARTBURN+GAS TABLET,CHEWABLE
ALKA-SELTZER PLUS ALLERGY TABLET
ALLER-G-TIME TABLET
ALLERGY CAPSULE
ALLERGY LIQUID (ML)
ALLERGY TABLET
ALLERGY MEDICINE CAPSULE
ALLERGY MEDICINE LIQUID (ML)
ALLERGY MEDICINE TABLET
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
2
ALLERGY RELIEF CAPSULE
ALLERGY RELIEF LIQUID (ML)
ALLERGY RELIEF TABLET
ALMACONE SUSPENSION, ORAL (FINAL DOSE FORM)
ALMACONE TABLET,CHEWABLE
ALMACONE-2 SUSPENSION, ORAL (FINAL DOSE FORM)
ALOE VESTA OINTMENT (GRAM)
ALUM/MAG HYDROXIDE W/SIMETH SUSPENSION, ORAL (FINAL DOSE FORM)
ALUMINUM HYDROXIDE SUSPENSION, ORAL (FINAL DOSE FORM)
AMERICERIN CREAM (GRAM)
AMERIPHOR OINTMENT (GRAM)
ANISE EXTRACT FLAVOR LIQUID (ML)
ANTACID SUSPENSION, ORAL (FINAL DOSE FORM)
ANTACID TABLET,CHEWABLE
ANTACID & GAS RELIEF SUSPENSION, ORAL (FINAL DOSE FORM)
ANTACID ANTI-GAS SUSPENSION, ORAL (FINAL DOSE FORM)
ANTACID ANTI-GAS TABLET,CHEWABLE
ANTACID ANTI-GAS DOUBLE STR SUSPENSION, ORAL (FINAL DOSE FORM)
ANTACID CALCIUM TABLET,CHEWABLE
ANTACID EXTRA STRENGTH TABLET,CHEWABLE
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
3
ANTACID M SUSPENSION, ORAL (FINAL DOSE FORM)
ANTACID MAXIMUM STRENGTH SUSPENSION, ORAL (FINAL DOSE FORM)
ANTACID MULTI-SYMPTOM TABLET,CHEWABLE
ANTACID PLUS ANTI-GAS SUSPENSION, ORAL (FINAL DOSE FORM)
ANTACID SUPREME SUSPENSION, ORAL (FINAL DOSE FORM)
ANTACID ULTRA TABLET,CHEWABLE
ANTACID WITH SIMETHICONE SUSPENSION, ORAL (FINAL DOSE FORM)
ANTACID/ANTIGAS SUSPENSION, ORAL (FINAL DOSE FORM)
ANTI DIARRHEAL LIQUID (ML)
ANTI-DIARRHEA TABLET
ANTI-DIARRHEAL CAPSULE
ANTI-DIARRHEAL LIQUID (ML)
ANTI-DIARRHEAL SUSPENSION, ORAL (FINAL DOSE FORM)
ANTI-DIARRHEAL TABLET
ANTI-GAS CAPSULE
ANTIHISTAMINE ALLERGY LIQUID (ML)
APPLE LIQUID (ML)
APPLE OIL (ML)
APPLE POWDER (GRAM)
APPLE FLAVOR LIQUID (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
4
APPLE-ADE FLAVOR LIQUID (ML)
APRICOT FLAVOR LIQUID (ML)
APRICOT FLAVOR POWDER (GRAM)
AQUA CARE SODIUM CHLORIDE SOLUTION, IRRIGATION
AQUA CARE STERILE WATER IRRIG SOLUTION, IRRIGATION
AQUAPHOR OINTMENT (GRAM)
AQUAPHOR WITH NATURAL HEALING OINTMENT (GRAM)
AR CAPS CAPSULE
ASCORBIC ACID GRANULES (GRAM)
BALMEX OINTMENT (GRAM)
BANANA LIQUID (ML)
BANANA CREME LIQUID (ML)
BANATROL PLUS POWDER IN PACKET (EA)
BANOPHEN CAPSULE
BANOPHEN LIQUID (ML)
BANOPHEN TABLET
BASE, CUSTOM POLYGLYCOL PELLET (GRAM)
BASE, PCCA BITTER DRUG POWDER (GRAM)
BENADRYL CAPSULE
BENADRYL ALLERGY LIQUID (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
5
BENADRYL ALLERGY TABLET
BICARSIM TABLET
BICARSIM FORTE TABLET
BISMATROL SUSPENSION, ORAL (FINAL DOSE FORM)
BISMATROL TABLET,CHEWABLE
BISMUTH SUSPENSION, ORAL (FINAL DOSE FORM)
BISMUTH TABLET
BISMUTH TABLET,CHEWABLE
BISMUTH MAXIMUM STRENGTH SUSPENSION, ORAL (FINAL DOSE FORM)
BISMUTH SUBSALICYLATE SUSPENSION, ORAL (FINAL DOSE FORM)
BITTER ALMOND OIL OIL (ML)
BITTER STOP FLAVOR LIQUID (ML)
BITTERNESS MASK FLAVOR LIQUID (ML)
BITTERNESS REDUCING AGENT POWDER (GRAM)
BITTERNESS SUPPRESSOR LIQUID (ML)
BLACKBERRY FLAVOR LIQUID (ML)
BLENDED SUSPENDING COMPOUND SUSPENSION, ORAL (FINAL DOSE FORM)
BLUEBERRY FLAVOR LIQUID (ML)
BUBBLE GUM FLAVOR LIQUID (ML)
BUTTER FLAVOR LIQUID (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
6
BUTTER RUM LIQUID (ML)
BUTTER RUM OIL (ML)
BUTTERSCOTCH FLAVOR LIQUID (ML)
CALCIUM ANTACID TABLET,CHEWABLE
CALCIUM CARBONATE TABLET
CALCIUM CARBONATE TABLET,CHEWABLE
CAL-GEST TABLET,CHEWABLE
CAPSUBLEND-H POWDER (GRAM)
CAPSUBLEND-P POWDER (GRAM)
CAPSUBLEND-S POWDER (GRAM)
CAPSULE #0 CAPSULE
CAPSULE #0 DRCAPS CAPSULE,DELAYED RELEASE (ENTERIC COATED)
CAPSULE #00 CAPSULE
CAPSULE #000 CAPSULE
CAPSULE #1 CAPSULE
CAPSULE #1 DRCAPS CAPSULE,DELAYED RELEASE (ENTERIC COATED)
CAPSULE #10 CAPSULE
CAPSULE #11 CAPSULE
CAPSULE #13 CAPSULE
CAPSULE #2 CAPSULE
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
7
CAPSULE #3 CAPSULE
CAPSULE #4 CAPSULE
CAPSULE #5 CAPSULE
CAPSULE #7 CAPSULE
CAPSULE CONI-SNAP CAPSULE
CARAMEL LIQUID (ML)
CARRINGTON MOISTURE BARRIER CREAM (GRAM)
CHEESECAKE FLAVOR LIQUID (ML)
CHERRY SYRUP
CHERRY CONCENTRATE SYRUP
CHERRY FLAVOR SYRUP
CHERRY-ADE FLAVOR POWDER (GRAM)
CHILDREN'S ALLERGY MEDICINE ELIXIR
CHILDREN'S ALLERGY MEDICINE LIQUID (ML)
CHILDREN'S ALLERGY MEDICINE TABLET,DISINTEGRATING
CHILDREN'S ALLERGY RELIEF LIQUID (ML)
CHILDREN'S ALLERGY RELIEF TABLET,DISINTEGRATING
CHILDREN'S ANTACID SUSPENSION, ORAL (FINAL DOSE FORM)
CHILDREN'S AURODRYL ALLERGY LIQUID (ML)
CHILDREN'S BENADRYL ALLERGY LIQUID (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
8
CHILDREN'S BENADRYL ALLERGY TABLET,CHEWABLE
CHILDREN'S COLD & ALLERGY LIQUID (ML)
CHILDREN'S DIPHENHYDRAMINE LIQUID (ML)
CHILDREN'S PEPTO TABLET,CHEWABLE
CHILDREN'S SOOTHE TABLET,CHEWABLE
CHILDREN'S WAL-DRYL ALLERGY LIQUID (ML)
CHILDREN'S WAL-DRYL ALLERGY PREFILLED SPOON
CHILDREN'S WAL-DRYL ALLERGY TABLET,DISINTEGRATING
CHILD'S BENADRYL ALLERGY LIQUID (ML)
CHLORHEXIDINE FLAVOR LIQUID (ML)
CHOCOLATE FLAVOR LIQUID (ML)
CHOCOLATE FLAVOR POWDER (GRAM)
CHOCOLATE HAZELNUT FLAVOR LIQUID (ML)
CINNAMON OIL (ML)
CLOVE OIL (ML)
COCOA BUTTER CREAM (GRAM)
COCOA BUTTER OINTMENT (GRAM)
COCONUT LIQUID (ML)
COFFEE FLAVOR LIQUID (ML)
COLA FLAVOR LIQUID (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
9
COMFORT GEL SUSPENSION, ORAL (FINAL DOSE FORM)
COMPLETE ALLERGY CAPSULE
COMPLETE ALLERGY LIQUID (ML)
COMPLETE ALLERGY TABLET
COMPOZ TABLET
COTTON CANDY FLAVOR LIQUID (ML)
CRAN-RASPBERRY FLAVOR LIQUID (ML)
CREME DE MENTHE LIQUID (ML)
CURITY SOLUTION, IRRIGATION
DAYLOGIC ADVANCED HEALING OINTMENT (GRAM)
DERMACERIN CREAM (GRAM)
DERMAPHOR OINTMENT (GRAM)
DESITIN OINTMENT (GRAM)
DEWEE'S CARMINATIVE SUSPENSION, ORAL (FINAL DOSE FORM)
DIAMODE TABLET
DIARRHEA RELIEF SUSPENSION, ORAL (FINAL DOSE FORM)
DIGESTIVE RELIEF TABLET
DIOTAME TABLET,CHEWABLE
DIPHEDRYL CAPSULE
DIPHEDRYL LIQUID (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
10
DIPHEDRYL TABLET
DIPHEDRYL ALLERGY LIQUID (ML)
DIPHEN TABLET
DIPHENHIST CAPSULE
DIPHENHIST LIQUID (ML)
DIPHENHIST TABLET
DIPHENHYDRAMINE HCL CAPSULE
DIPHENHYDRAMINE HCL CARTRIDGE (ML)
DIPHENHYDRAMINE HCL DROPS
DIPHENHYDRAMINE HCL ELIXIR
DIPHENHYDRAMINE HCL LIQUID (ML)
DIPHENHYDRAMINE HCL SYRINGE (ML)
DIPHENHYDRAMINE HCL SYRUP
DIPHENHYDRAMINE HCL TABLET
DIPHENHYDRAMINE HCL VIAL (ML)
DIPHENOXYLATE W/ATROPINE LIQUID (ML)
DIPHENOXYLATE W/ATROPINE TABLET
DRY SKIN THERAPY CREAM (GRAM)
DRY SKIN TREATMENT OINTMENT (GRAM)
ENGLISH TOFFEE FLAVOR LIQUID (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
11
EUCERIN CREAM (GRAM)
EUCERIN INTENSIVE REPAIR CREAM (GRAM)
EUCERIN SKIN CALMING CREAM (GRAM)
EUGENOL LIQUID (ML)
E-Z-GAS II GRANULES, EFFERVESCENT IN PACKET (EA)
FLANAX SUSPENSION, ORAL (FINAL DOSE FORM)
FLAVOR BLEND 2 IN 1 SUSPENSION, ORAL (FINAL DOSE FORM)
FLAVOR CHEWS ANTACID TABLET,CHEWABLE
FLAVOR PLUS SUSPENSION, ORAL (FINAL DOSE FORM)
FLAVOR SWEET LIQUID (ML)
FLAVOR SWEET-SF LIQUID (ML)
FLAVORX LIQUID (ML)
FOAMING ANTACID SUSPENSION, ORAL (FINAL DOSE FORM)
FOAMING ANTACID TABLET,CHEWABLE
GAS RELIEF CAPSULE
GAS RELIEF SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
GAS RELIEF TABLET,CHEWABLE
GAS-X CAPSULE
GAS-X STRIP
GAS-X TABLET,CHEWABLE
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
12
GAVISCON SUSPENSION, ORAL (FINAL DOSE FORM)
GAVISCON TABLET,CHEWABLE
GELUSIL TABLET,CHEWABLE
GERI-DRYL LIQUID (ML)
GERI-DRYL TABLET
GERI-LANTA SUSPENSION, ORAL (FINAL DOSE FORM)
GERI-MOX SUSPENSION, ORAL (FINAL DOSE FORM)
GERI-PECTATE SUSPENSION, ORAL (FINAL DOSE FORM)
GLYCERIN LIQUID (ML)
GLYCERIN SOLUTION, NON-ORAL
GLYCERIN AND ROSE WATER LIQUID (ML)
GLYCERIN LAXATIVE SOLUTION WITH PREFILLED APPLICATOR (ML)
GLYCERIN W/ROSEWATER LIQUID (ML)
GRAPE LIQUID (ML)
GRAPE FLAVOR LIQUID (ML)
GRAPEFRUIT OIL (ML)
GREEN APPLE FLAVOR LIQUID (ML)
GUAVA FLAVOR LIQUID (ML)
HEARTBURN ANTACID TABLET,CHEWABLE
HEARTBURN RELIEF SUSPENSION, ORAL (FINAL DOSE FORM)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
13
HEARTBURN RELIEF TABLET,CHEWABLE
HONEY FLAVOR LIQUID (ML)
HYDRATING HEALING OINTMENT (GRAM)
HYDROCERIN CREAM (GRAM)
HYDROLATUM OINTMENT (GRAM)
HYDROPHOR OINTMENT (GRAM)
IMODIUM A-D LIQUID (ML)
IMODIUM A-D TABLET
IMODIUM MULTI-SYMPTOM RELIEF TABLET
INFANT GAS RELIEF SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
INFANTS GAS RELIEF SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
INFANTS' MYLICON SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
KAHLUA FLAVOR LIQUID (ML)
KAOPECTATE SUSPENSION, ORAL (FINAL DOSE FORM)
KAOPECTATE TABLET
KAO-TIN SUSPENSION, ORAL (FINAL DOSE FORM)
KENDALL 0.9% NACL WITH CAP SYRINGE, WITH SWAB CAP (ML)
K-PEC SUSPENSION, ORAL (FINAL DOSE FORM)
LACTOSE POWDER (GRAM)
LEMON OIL (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
14
LEMON OIL OIL (ML)
LEMONADE FLAVOR LIQUID (ML)
LICORICE FLAVOR LIQUID (ML)
LIDOCAINE SOLUTION, ORAL
LIDOCAINE HCL SOLUTION, ORAL
LIME FLAVOR OIL (ML)
LIMONENE FLAVOR LIQUID (ML)
LIQUID ANTACID SUSPENSION, ORAL (FINAL DOSE FORM)
LIQUIVIDA HYDRATION KIT KIT
LITTLE REMEDIES GAS RELIEF SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
LOMOTIL TABLET
LOPERAMIDE HCL CAPSULE
LOPERAMIDE HCL LIQUID (ML)
LOPERAMIDE HCL TABLET
MAALOX ADVANCED SUSPENSION, ORAL (FINAL DOSE FORM)
MAALOX ADVANCED TABLET,CHEWABLE
MAALOX MS SUSPENSION, ORAL (FINAL DOSE FORM)
MAG-AL SUSPENSION, ORAL (FINAL DOSE FORM)
MAG-AL PLUS SUSPENSION, ORAL (FINAL DOSE FORM)
MAG-AL PLUS XS SUSPENSION, ORAL (FINAL DOSE FORM)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
15
MAGNASWEET 110 LIQUID (ML)
MAGNASWEET 135 POWDER (GRAM)
MAGNESIUM OXIDE TABLET
MAGNESIUM STEARATE POWDER (GRAM)
MANGO FLAVOR LIQUID (ML)
MANGO FLAVOR POWDER (GRAM)
MAPLE FLAVOR LIQUID (ML)
MARSHMALLOW FLAVOR LIQUID (ML)
MARSHMALLOW OIL FLAVOR LIQUID (ML)
MASANTI SUSPENSION, ORAL (FINAL DOSE FORM)
M-DRYL LIQUID (ML)
METHOCEL E 4 M GRANULES (GRAM)
METHOCEL E 4 M POWDER (GRAM)
MI-ACID SUSPENSION, ORAL (FINAL DOSE FORM)
MI-ACID TABLET,CHEWABLE
MI-ACID DS TABLET,CHEWABLE
MICROCRYSTALLINE CELLULOSE POWDER (GRAM)
MILK OF MAGNESIA SUSPENSION, ORAL (FINAL DOSE FORM)
MINERIN CREAM (GRAM)
MINT CHOCOLATE CHIP FLAVOR LIQUID (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
16
MINTOX SUSPENSION, ORAL (FINAL DOSE FORM)
MINTOX MAXIMUM STRENGTH SUSPENSION, ORAL (FINAL DOSE FORM)
MINTOX PLUS TABLET,CHEWABLE
MONOJECT 0.9% NACL SYRINGE (ML)
MONOJECT PREFILL SYRINGE (ML)
MONOJECT PREFILL ADVANCED SYRINGE (ML)
MOTOFEN TABLET
MULTI-PURPOSE OINTMENT OINTMENT (GRAM)
MX-SOL LIQUID (ML)
MX-SOL BLEND SUSPENSION, ORAL (FINAL DOSE FORM)
MX-SOL SF LIQUID (ML)
MX-SOL SF SUSPENSION, ORAL (FINAL DOSE FORM)
MX-SOL SUSPEND SUSPENSION, ORAL (FINAL DOSE FORM)
MYLANTA GAS MINIS TABLET,CHEWABLE
MYLANTA MAXIMUM STRENGTH SUSPENSION, ORAL (FINAL DOSE FORM)
MYLANTA TONIGHT SUSPENSION, ORAL (FINAL DOSE FORM)
MYTAB GAS TABLET,CHEWABLE
MYTAB GAS MAXIMUM STRENGTH TABLET,CHEWABLE
NARAMIN LIQUID IN PACKET (ML)
NATURAL BITTERNESS MASKING POWDER (GRAM)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
17
NAUZENE UPSET STOMACH-NAUSEA TABLET,CHEWABLE
NEUTROGENA NORWEGIAN FORMULA CREAM (GRAM)
NIGHT TIME SLEEP AID TABLET
NIGHTTIME ALLERGY RELIEF TABLET
NIGHTTIME SLEEP AID CAPSULE
NIGHTTIME SLEEP AID TABLET
NIGHTTIME SLEEP GEL CAPSULE
NORMAL SALINE SYRINGE (ML)
OPIUM TINCTURE
ORA PLUS SUSPENSION, ORAL (FINAL DOSE FORM)
ORA-BLEND SUSPENSION, ORAL (FINAL DOSE FORM)
ORA-BLEND SF SUSPENSION, ORAL (FINAL DOSE FORM)
ORAL MIX SUSPENSION, ORAL (FINAL DOSE FORM)
ORAL MIX SUSPENSION, RECONSTITUTED, ORAL (GRAM)
ORAL SUSPEND SUSPENSION, ORAL (FINAL DOSE FORM)
ORAL SUSPENDING COMPOUND PLUS SUSPENSION, ORAL (FINAL DOSE FORM)
ORAL SYRUP LIQUID (ML)
ORAL SYRUP SF LIQUID (ML)
ORANGE CONCENTRATE LIQUID (ML)
ORANGE CREAM FLAVOR LIQUID (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
18
ORANGE FLAVOR LIQUID (ML)
ORANGE FLAVOR POWDER (GRAM)
ORA-SWEET LIQUID (ML)
ORA-SWEET-SF LIQUID (ML)
ORMIR CAPSULE
PAREGORIC LIQUID (ML)
PASSION FRUIT FLAVOR POWDER (GRAM)
PCCA NATAPRES LIQUID (ML)
PEACH FLAVOR LIQUID (ML)
PEANUT BUTTER FLAVOR LIQUID (ML)
PEDIACLEAR COUGH DROPS
PEDIA-LAX SOLUTION WITH PREFILLED APPLICATOR (ML)
PEDIA-LAX TABLET,CHEWABLE
PEPPERMINT OIL (ML)
PEPTIC RELIEF SUSPENSION, ORAL (FINAL DOSE FORM)
PEPTIC RELIEF TABLET,CHEWABLE
PEPTO-BISMOL SUSPENSION, ORAL (FINAL DOSE FORM)
PEPTO-BISMOL TABLET
PEPTO-BISMOL TABLET,CHEWABLE
PETROLATUM JELLY (GRAM)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
19
PETROLATUM OINTMENT (GRAM)
PETROLEUM JELLY (GRAM)
PETROLEUM JELLY LIP TREATMENT JELLY (GRAM)
PHARBEDRYL CAPSULE
PHAZYME CAPSULE
PHILLIPS' MILK OF MAGNESIA SUSPENSION, ORAL (FINAL DOSE FORM)
PHILLIPS' MILK OF MAGNESIA TABLET,CHEWABLE
PINA COLADA FLAVOR LIQUID (ML)
PINEAPPLE EXTRACT LIQUID (ML)
PINEAPPLE FLAVOR LIQUID (ML)
PINK BISMUTH SUSPENSION, ORAL (FINAL DOSE FORM)
PINK BISMUTH TABLET
PINK BISMUTH TABLET,CHEWABLE
PRALINES AND CREAM FLAVOR LIQUID (ML)
PROPYLENE GLYCOL LIQUID (ML)
PROTECTIVE OINTMENT OINTMENT (GRAM)
PUMPKIN FLAVOR LIQUID (ML)
PURIFIED WATER LIQUID (ML)
Q-DRYL CAPSULE
Q-DRYL LIQUID (ML)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
20
QUENALIN SYRUP
RASPBERRY OIL (ML)
RASPBERRY CONCENTRATE LIQUID (ML)
RASPBERRY FLAVOR LIQUID (ML)
RASPBERRY FLAVOR POWDER (GRAM)
RASPBERRY SYRUP SYRUP
REMEDY CLEAR-AID OINTMENT (GRAM)
RENEWAL HEALING OINTMENT (GRAM)
REST SIMPLY TABLET
RI MAG PLUS SUSPENSION, ORAL (FINAL DOSE FORM)
RI-GEL SUSPENSION, ORAL (FINAL DOSE FORM)
RI-GEL II SUSPENSION, ORAL (FINAL DOSE FORM)
RIGINIC SUSPENSION, ORAL (FINAL DOSE FORM)
RI-MAG SUSPENSION, ORAL (FINAL DOSE FORM)
RI-MOX SUSPENSION, ORAL (FINAL DOSE FORM)
RI-MOX PLUS SUSPENSION, ORAL (FINAL DOSE FORM)
ROLAIDS TABLET,CHEWABLE
ROOT BEER FLAVOR LIQUID (ML)
RULOX SUSPENSION, ORAL (FINAL DOSE FORM)
SAFE WASH SOLUTION, NON-ORAL
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
21
SALINE FLUSH SYRINGE (ML)
SALINE WOUND WASH SOLUTION, NON-ORAL
SECURA PROTECTIVE OINTMENT (GRAM)
SESAME OIL OIL (ML)
SILADRYL LIQUID (ML)
SILPHEN SYRUP
SIMETHICONE CAPSULE
SIMETHICONE SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML)
SIMETHICONE TABLET,CHEWABLE
SIMPLE SYRUP SYRUP
SIMPLY SLEEP TABLET
SLEEP TABLET
SLEEP AID CAPSULE
SLEEP AID LIQUID (ML)
SLEEP AID TABLET
SLEEP TIME CAPSULE
SLEEP TIME LIQUID (ML)
SMOOTH ANTACID TABLET,CHEWABLE
SODIUM BICARBONATE POWDER (GRAM)
SODIUM BICARBONATE TABLET
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
22
SODIUM CHLORIDE CARTRIDGE (ML)
SODIUM CHLORIDE GRANULES (GRAM)
SODIUM CHLORIDE INTRAVENOUS SOLUTION
SODIUM CHLORIDE PIGGYBACK WITH THREADED PORT (ML)
SODIUM CHLORIDE PIGGYBACK WITH VIAL PORT (NON-THREADED)
SODIUM CHLORIDE POWDER (GRAM)
SODIUM CHLORIDE SOLUTION, IRRIGATION
SODIUM CHLORIDE SYRINGE (ML)
SODIUM CHLORIDE TABLET
SODIUM CHLORIDE TABLET, SOLUBLE
SODIUM CHLORIDE VIAL (ML)
SODIUM CHLORIDE-WATER INTRAVENOUS SOLUTION
SOOTHE SUSPENSION, ORAL (FINAL DOSE FORM)
SOOTHE TABLET
SOOTHE TABLET,CHEWABLE
SORBITOL SOLUTION, ORAL
SPEARMINT OIL (ML)
STEARIC ACID POWDER (GRAM)
STEVIA POWDER (GRAM)
STEVIA EXTRACT POWDER (GRAM)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
23
STEVIOSIDE POWDER (GRAM)
STOMACH RELIEF SUSPENSION, ORAL (FINAL DOSE FORM)
STOMACH RELIEF TABLET
STOMACH RELIEF TABLET,CHEWABLE
STRAWBERRY LIQUID (ML)
STRAWBERRY OIL (ML)
STRAWBERRY CREAM FLAVOR LIQUID (ML)
SUPER SYNERSWEET FLAVOR POWDER (GRAM)
SUSPENSION VEHICLE NATURAL SUSPENSION, ORAL (FINAL DOSE FORM)
SWABFLUSH SYRINGE, WITH SWAB CAP (ML)
SWEETNESS ENHANCER FLAVOR LIQUID (ML)
SWEET-SF LIQUID (ML)
SYREX SYRINGE (ML)
SYRPALTA SYRUP
SYRSPEND SF SUSPENSION, ORAL (FINAL DOSE FORM)
SYRSPEND SF SUSPENSION, RECONSTITUTED, ORAL (GRAM)
SYRSPEND SF ALKA SUSPENSION, RECONSTITUTED, ORAL (GRAM)
SYRSPEND SF PH4 SUSPENSION, RECONSTITUTED, ORAL (GRAM)
SYRUP VEHICLE SYRUP
SYRUP VEHICLE SF SOLUTION, ORAL
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
24
TAME THE FLAME TABLET,CHEWABLE
TANGERINE FLAVOR POWDER (GRAM)
TANGERINE OIL OIL (ML)
TANGERINE SWEETENED FLAVOR POWDER (GRAM)
TEABERRY OIL FLAVOR LIQUID (ML)
THERAPEUTIC MOISTURIZING CREAM (GRAM)
TOTAL ALLERGY TABLET
TOXIN CONTROL TABLET
TROPICAL PUNCH FLAVOR LIQUID (ML)
TUMS TABLET,CHEWABLE
TUMS FRESHERS TABLET,CHEWABLE
TUMS SMOOTHIES TABLET,CHEWABLE
TUMS ULTRA TABLET,CHEWABLE
TUMS ULTRA STRENGTH TABLET,CHEWABLE
TUMS X-STR TABLET,CHEWABLE
TUTTI FRUTTI FLAVOR LIQUID (ML)
UNISOM CAPSULE
UNISOM SLEEPMELTS TABLET,DISINTEGRATING
VANAMINE PD DROPS
VANICREAM CREAM (GRAM)
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
25
VANICREAM LITE LOTION (ML)
VANILLA BUTTERNUT FLAVOR LIQUID (ML)
VANILLA EXTRACT FLAVOR LIQUID (ML)
VANILLA FLAVOR LIQUID (ML)
VANILLIN POWDER (GRAM)
VANILLIN FLAVOR POWDER (GRAM)
VASELINE JELLY (ML)
VASELINE WHITE PETROLEUM JELLY (GRAM)
VASELINE WHITE PETROLEUM OINTMENT IN PACKET (GRAM)
VERSA FREE SOLUTION, ORAL
VERSA PLUS SUSPENSION, ORAL (FINAL DOSE FORM)
VITAMIN A AND D OINTMENT (GRAM)
WAL-DRYL CAPSULE
WAL-DRYL LIQUID (ML)
WAL-DRYL TABLET
WAL-SLEEP Z CAPSULE
WAL-SLEEP Z LIQUID (ML)
WAL-SLEEP Z TABLET,DISINTEGRATING
WAL-SOM CAPSULE
WATER INTRAVENOUS SOLUTION
Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications
Compound Inclusion List
TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION
26
WATER SOLUTION, IRRIGATION
WATERMELON LIQUID (ML)
WATERMELON OIL (ML)
WHITE PETROLATUM JELLY (GRAM)
WHITE PETROLATUM OINTMENT (GRAM)
WHITE PETROLATUM OINTMENT IN PACKET (GRAM)
WHITE PETROLEUM JELLY (GRAM)
WIBI LOTION (ML)
WILD CHERRY FLAVOR LIQUID (ML)
WINTERGREEN OIL (ML)
Z-SLEEP CAPSULE
Z-SLEEP LIQUID (ML)
ZZZQUIL CAPSULE
ZZZQUIL LIQUID (ML)