Appendix E - Extemporaneous Mixtures

To be eligible under the NIHB Program, extemporaneous mixtures (compounds) must have at least one ingredient listed on the DBL and must not duplicate the formulation of commercially manufactured drug products. Mixtures that contain exception or limited use drugs must receive prior approval by the DEC. Mixtures that contain ingredients excluded from the Program will not be eligible for coverage.

All extemporaneous mixtures must be submitted with the corresponding pseudo-DIN to be reimbursed appropriately. Pharmaceutical powders of eligible ingredients may be used in lieu of tablets/capsules. These powders must be billed at AAC and must not exceed the maximum allowable AAC which is based on the price of the DIN of the comparable listed tablet or capsule.

Back Order Items and Compounding:
Providers who are preparing a compound to replace a commercially available product which is on back-order do not require a PA. The claim must be submitted using the corresponding miscellaneous pseudo-DIN. Providers are required to maintain documentation demonstrating that the commercially available product was on back-order at the time of dispense.
Compounds with Diclofenac:
Compounds with diclofenac as an ingredient require a PA and will be reviewed on a case-by-case basis.

COMPOUNDED INJECTION OR INFUSION

Table: COMPOUNDED INJECTION OR INFUSION
DIN Brand name
99506004 GENTAMYCIN STERILE INFUSION
99506000 CEFAZOLIN STERILE INFUSION
99506001 CEFTRIAXONE STERILE INFUSION
99506005 AMPICILLIN STERILE INFUSION
99506003 PENICILLIN G STERILE INFUSION
99506008 CLINDAMYCIN STERILE INFUSION

COMPOUNDED INTERNAL USE LIQUID

Table: COMPOUNDED INTERNAL USE LIQUID
DIN Brand name
99503031 ISONIAZID ORAL LIQUID
99503022 RIFAMPIN ORAL LIQUID
99503012 METRONIDAZOLE ORAL LIQUID
99503004 NITRO-FURANTOIN ORAL LIQUID
99503017 TRIMETHOPRIM ORAL LIQUID
99503011 BACLOFEN ORAL LIQUID

COMPOUNDED INJECTION OR INFUSION

Table: COMPOUNDED INJECTION OR INFUSION
DIN Brand name
99506015 IRON SUCROSE STERILE INFUSION

COMPOUNDED INTERNAL USE LIQUID

Table: COMPOUNDED INTERNAL USE LIQUID
DIN Brand name
99503006 TRANEXAMIC DENTAL MOUTHWASH
99503016 AMIODARONE ORAL LIQUID
99503021 CLONIDINE ORAL LIQUID
99503015 METOPROLOL ORAL LIQUID
99503014 PROPRANOLOL ORAL LIQUID
99503023 SOTALOL ORAL LIQUID
99503003 AMLODIPINE ORAL LIQUID
99503013 ENALAPRIL ORAL LIQUID
99503009 ALDACTAZIDE ORAL LIQUID
99503001 SPIRONOLACTONE ORAL LIQUID
99503020 BENZODIAZEPINE ORAL LIQUID
99503026 LEVETIRACETAM ORAL LIQUID
99503027 TOPIRAMATE ORAL LIQUID
99503000 HYDROCHLOROTHIAZIDE ORAL LIQUID
99503024 UROSODIOL ORAL LIQUID
99503010 LANSOPRAZOLE ORAL LIQUID
99503002 OMEPRAZOLE ORAL LIQUID
99503005 DOMPERIDONE ORAL LIQUID
99503007 DEXAMETHASONE ORAL LIQUID
99503008 PREDNISONE ORAL LIQUID

COMPOUNDED TOPICAL OINTMENT

Table: COMPOUNDED TOPICAL OINTMENT
DIN Brand name
99502000 CLINDAMYCIN IN DILUSOL OR DUONALC

COMPOUNDED TOPICAL CREAM

Table: COMPOUNDED TOPICAL CREAM
DIN Brand name
99500003 SALICYLIC ACID IN CORTICOSTEROID CREAM

COMPOUNDED TOPICAL OINTMENT

Table: COMPOUNDED TOPICAL OINTMENT
DIN Brand name
99501001 SALICYLIC ACID IN NON-MEDICATED OINTMENT

COMPOUNDED TOPICAL CREAM

Table: COMPOUNDED TOPICAL CREAM
DIN Brand name
99500008 MOMETASONE CREAM

COMPOUNDED INTERNAL POWDER

Table: COMPOUNDED INTERNAL POWDER
DIN Brand name
99505003 PHENAZOPYRIDINE COMPOUNDED

COMPOUNDED TOPICAL CREAM

Table: COMPOUNDED TOPICAL CREAM
DIN Brand name
99500000 HYDROCORTISONE POWDER AND CLOTRIMAZOLE CREAM
99500010 LCD IN CORTICOSTEROID CREAM
99500009 LCD IN NON-MEDICATED CREAM
99500002 MENTHOL &/OR CAMPHOR IN STEROID
99500004 MISCELLANEOUS COMPOUNDED TOPICAL CREAM
99500001 STEROID AND ANTIFUNGAL CREAM
99500006 SULFUR IN NON-MEDICATED CREAM

COMPOUNDED EXTERNAL LOTION

Table: COMPOUNDED EXTERNAL LOTION
DIN Brand name
99502001 MENTHOL & CAMPHOR IN CORTICOSTEROID LOTION
99502002 MISCELLANEOUS COMPOUNDED EXTERNAL LOTION

EXTEMPORANEOUS MIXTURE (H2 BLOCKERS)

Table: EXTEMPORANEOUS MIXTURE (H2 BLOCKERS)
DIN Brand name
99505005 H2RA SOLID

STERILE EXTEMPORANEOUS MIXTURE

Table: STERILE EXTEMPORANEOUS MIXTURE
DIN Brand name
00915000 STERILE EXTEMPORANEOUS MIXTURE (QC)

COMPOUNDED TOPICAL OINTMENT

Table: COMPOUNDED TOPICAL OINTMENT
DIN Brand name
99501006 ALL PURPOSE NIPPLE OINTMENT
99501003 CALCIUM CHANNEL BLOCKER IN OINTMENT
99501008 DILTIAZEM IN OINTMENT
99501000 LCD IN CORTICOSTEROID OINTMENT
99501005 LCD IN NON-MEDICATED OINTMENT
99501004 MISCELLANEOUS COMPOUNDED TOPICAL OINTMENT
99501002 SULFUR IN NON-MEDICATED OINTMENT

COMPOUNDED EYE/EAR DROP

Table: COMPOUNDED EYE/EAR DROP
DIN Brand name
99507002 ANTIBIOTIC DROPS
99507001 ANTIFUNGAL DROPS
99507003 ANTIVIRAL DROPS

COMPOUNDED INTERNAL USE LIQUID

Table: COMPOUNDED INTERNAL USE LIQUID
DIN Brand name
99503028 ANTACID AND LIDOCAINE ORAL LIQUID
99503029 MAGIC MOUTHWASH
99503025 MISCELLANEOUS COMPOUNDED INTERNAL LIQUID

COMPOUNDED INTERNAL POWDER

Table: COMPOUNDED INTERNAL POWDER
DIN Brand name
99505004 BACKORDER INTERNAL POWDER
99505000 MISCELLANEOUS COMPOUNDED INTERNAL POWDER

GENDER AFFIRMING THERAPY

Table: GENDER AFFIRMING THERAPY
DIN Brand name
00915312 GENDER AFFIRMING HORMONES
00915311 GENDER AFFIRMING TOPICAL HORMONES

COMPOUNDED INJECTION OR INFUSION

Table: COMPOUNDED INJECTION OR INFUSION
DIN Brand name
99506021 MISCELLANEOUS COMPOUNDED INJECTION/INFUSION

COMPOUNDED TOPICAL CREAM

Table: COMPOUNDED TOPICAL CREAM
DIN Brand name
99504001 MISC LIMITED USE EXTERNAL COMPOUND MIXTURE

COMPOUNDED EYE/EAR DROP

Table: COMPOUNDED EYE/EAR DROP
DIN Brand name
99507000 MISCELLANEOUS COMPOUNDED EYE/EAR DROP

COMPOUNDED INTERNAL USE LIQUID

Table: COMPOUNDED INTERNAL USE LIQUID
DIN Brand name
99503033 MISC LIMITED USE COMPOUND INTERNAL
99503032 OPIOID COMPOUNDED

COMPOUNDED EXTERNAL POWDER

Table: COMPOUNDED EXTERNAL POWDER
DIN Brand name
99504000 MISCELLANEOUS COMPOUNDED EXTERNAL POWDER

COMPOUNDED SUPPOSITORY

Table: COMPOUNDED SUPPOSITORY
DIN Brand name
99508000 MISCELLANEOUS COMPOUNDED SUPPOSITORY

EXTEMPORANEOUS MIXTURE (NSAID)

Table: EXTEMPORANEOUS MIXTURE (NSAID)
DIN Brand name
99501007 NSAID IN TRANSDERMAL BASE
99501009 TRANSDERMAL LIDOCAINE W/NSAID

COMPOUNDED INTERNAL USE LIQUID

Table: COMPOUNDED INTERNAL USE LIQUID
DIN Brand name
99503018 ALLOPURINOL ORAL LIQUID
99503019 AZATHIOPRINE ORAL LIQUID
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