Compounded Drug Products

Coverage decision

Compounded drug products require prior authorization except for compounded multiple ingredient topical preparations, which are not covered. If you do not get authorization before compounding, you may not be paid.

Examples of non-covered compounded topical preparations:

  • Diclofenac + baclofen + cyclobenzaprine + tetracaine preparation
  • Ketamine + cyclobenzaprine + diclofenac + gabapentin + orphenadrine + tetracaine preparation
  • Ibuprofen + ketoprofen + cyclobenzaprine preparation
  • Ketoprofen + ketamine + gabapentin + lidocaine preparation

There are many available 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.

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.