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.

For additional information regarding extemporaneous mixtures, please refer to NIHB's Guide for Pharmacy Benefits.

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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Date modified:: 2021-04-01