Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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

1

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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

2

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

3

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

4

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

BENADRYL ALLERGY 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)

BUTTER RUM LIQUID (ML)

5

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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

CAPSULE #3 CAPSULE

6

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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, CHEWABLE

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)

7

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

8

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

9

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

EUCERIN CREAM (GRAM)

10

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

EUCERIN INTENSIVE REPAIR CREAM (GRAM)

EUCERIN SKIN CALMING CREAM (GRAM)

EUGENOL LIQUID (ML)

E-Z-GAS II GRANULES, EFFERVESCENT IN PACKET (EA)

FLAVOR BLEND 2 IN 1 SUSPENSION, ORAL (FINAL DOSE FORM)

FLAVOR CHEWS ANTACID TABLET, CHEWABLE

FLAVOR PLUS SUSPENSION, ORAL (FINAL DOSE FORM)

FLAVOR SWEET-SF LIQUID (ML)

FLAVORX LIQUID (ML)

FLAVORX GRAPE FLAVOR LIQUID (ML)

FLAVORX LEMON FLAVOR 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

GAVISCON SUSPENSION, ORAL (FINAL DOSE FORM)

11

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

HEARTBURN RELIEF TABLET, CHEWABLE

12

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

HONEY FLAVOR LIQUID (ML)

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)

LEMON OIL OIL (ML)

LEMONADE FLAVOR LIQUID (ML)

13

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

MAGNASWEET 110 LIQUID (ML)

MAGNASWEET 135 POWDER (GRAM)

14

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

MINTOX SUSPENSION, ORAL (FINAL DOSE FORM)

MINTOX MAXIMUM STRENGTH SUSPENSION, ORAL (FINAL DOSE FORM)

15

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

MINTOX PLUS TABLET, CHEWABLE

MONOJECT 0.9% NACL SYRINGE (ML)

MONOJECT PREFILL ADVANCED SYRINGE (ML)

MOTOFEN TABLET

MULTI-PURPOSE OINTMENT OINTMENT (GRAM)

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)

NAUZENE UPSET STOMACH-NAUSEA TABLET, CHEWABLE

NEUTROGENA NORWEGIAN FORMULA CREAM (GRAM)

NIGHT TIME SLEEP AID TABLET

NIGHTTIME ALLERGY RELIEF TABLET

16

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

ORANGE FLAVOR LIQUID (ML)

ORANGE FLAVOR POWDER (GRAM)

ORA-SWEET-SF LIQUID (ML)

PAREGORIC LIQUID (ML)

17

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

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)

18

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

RASPBERRY OIL (ML)

RASPBERRY CONCENTRATE LIQUID (ML)

RASPBERRY FLAVOR LIQUID (ML)

RASPBERRY FLAVOR POWDER (GRAM)

RASPBERRY SYRUP SYRUP

REMEDY CLEAR-AID OINTMENT (GRAM)

REST SIMPLY TABLET

RI MAG PLUS SUSPENSION, ORAL (FINAL DOSE FORM)

19

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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

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

20

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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

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

21

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

SODIUM CHLORIDE VIAL (ML)

SODIUM CHLORIDE-WATER INTRAVENOUS SOLUTION

SOOTHE SUSPENSION, ORAL (FINAL DOSE FORM)

SOOTHE TABLET

SOOTHE TABLET, CHEWABLE

SORBITOL SOLUTION, ORAL

STEARIC ACID POWDER (GRAM)

STEVIA POWDER (GRAM)

STEVIA EXTRACT 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)

22

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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

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

23

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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)

VANICREAM LOTION (GRAM)

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

24

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

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

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)

ZINC STEARATE POWDER (GRAM)

Z-SLEEP CAPSULE

Z-SLEEP LIQUID (ML)

ZZZQUIL CAPSULE

25

Compound Inclusion List for Pharmacy Medical Policy 579, Compounded Medications

Compound Inclusion List TRADE NAME DESCRIPTION DOSAGE FORM DESCRIPTION

ZZZQUIL LIQUID (ML)

26