Compounded Drug Products

Coverage decision

All compounded drug products require prior authorization from the department or self-insured employer (see the Outpatient Drug Formulary). Compounded drug products include, but are not limited to, antibiotics for intravenous therapy, pain cocktails for weaning, total parenteral nutrition and non-commercially available preparations. Failure to seek authorization before compounding will risk non-payment of compounded products.

PLEASE NOTE: Compounded topical preparations containing multiple active ingredients are not covered due to a lack of good quality scientific evidence of effectiveness or safety for these specific ingredient combinations and/or mode of administration. There are many commercially available, FDA-approved alternatives, such as oral generic nonsteroidal anti-inflammatory drugs, muscle relaxants, tricyclic antidepressants, gabapentin and topical salicylate and capsaicin creams on the Outpatient Drug Formulary.

Examples of non-covered compounded topical preparations: 

• Diclofenac + baclofen + cyclobenzaprine + tetracaine preparation promoted for tendonitis, arthritis or epicondylitis.
• Ketamine + cyclobenzaprine + diclofenac + gabapentin + orphenadrine + tetracaine preparation promoted for failed back syndrome, myofascial pain syndrome, radiculopathy or fibromyalgia.
• Ibuprofen + ketoprofen + cyclobenzaprine preparation promoted for musculoskeletal pain.
• Ketoprofen + ketamine + gabapentin + lidocaine preparation for chronic pain.