PDF Compound Exclusion List of Bulk Chemicals TRADE NAME ...

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION

DOSAGE FORM DESCRIPTION

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)

1

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION

DOSAGE FORM DESCRIPTION

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)

2

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION

DOSAGE FORM DESCRIPTION

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

3

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION

DOSAGE FORM DESCRIPTION

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)

4

Compound Exclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Exclusion List of Bulk Chemicals

TRADE NAME DESCRIPTION

DOSAGE FORM DESCRIPTION

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

5

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