Compounded Prescription PINs

For more information on PharmaCare coverage of compounded prescriptions, see the PharmaCare Policy Manual, Section 5.13 (PDF, 425KB).


Non-benefit PINs

Product

PIN

Alcoholic Medicinal (Non Benefit)

66123239

Compounded Preparations (Non Benefit)

66123252

Controlled Compound (Non Benefit)

66124162

Narcotic Compound (Non Benefit)

66123367

Topical Antifungal Compounded Preps (Non Benefit)

66124164

 

Benefit PINs

Please note that a breakdown of PINs and their maximum fee (CSV, 6KB) is available in an Excel csv file.

  • All compounds listed in the tables below are covered without Special Authority approval if the eligibility criteria specified in the PharmaCare Policy Manual Section 5.13 are met.
  • Certain active ingredients still require Special Authority for coverage as noted.

Important: If you are unsure whether PharmaCare will cover a specific compound, please contact the PharmaNet Help Desk for clarification before submitting the claim on PharmaNet.

Types of compounds listed below:

 

Oral Solutions

Product

Ingredient Requires Special Authority

PIN

Saturated potassium iodide solution

 

999113

 

Oral Suspensions 

Product

Ingredient Requires Special Authority

PIN

Acetazolamide compounded suspension

 

22123223

Allopurinol compounded suspension

 

22123307

Alprazolam compounded suspension

 

22123308

Amiloride compounded suspension

 

22123309

Amiodarone compounded suspension

 

22123310

Amitriptyline compounded suspension

 

22123224

Amlodipine compounded suspension

Yes

22123311

Aripiprazole compounded suspension

Yes

22123272

Atenolol compounded suspension

 

22123225

Azathioprine compounded suspension

 

22123236

Baclofen compounded suspension

 

22123226

Bisoprolol compounded suspension

 

22123227

Captopril compounded suspension

 

22123228

Carvedilol compounded suspension

Yes, except for Plan P

22123265

Cisapride compounded suspension

Yes

22123195

Citalopram compounded suspension

 

22123229

Clobazam compounded suspension

 

22123230

Clonazepam compounded suspension

 

22123231

Clonidine compounded suspension

 

22123232

Clozapine compounded suspension

 

22123233

Corticosteroid + nystatin + diphenhydramine + tetracycline mouthrinse

Yes, except for Plan P

22123332

Corticosteroid + nystatin + diphenhydramine + tetracycline + lidocaine mouthrinse

Yes, except for Plan P

22123333

Corticosteroid + nystatin + diphenhydramine mouthrinse

Yes, except for Plan P

22123334

Corticosteroid + nystatin + lidocaine +/- glycerin

Yes, except for Plan P

22123335

Cyclobenzaprine compounded suspension

 

22123234

Dantrolene compounded suspension

 

22123235

Diazepam compounded suspension

 

22123237

Domperidone compounded suspension

 

22123238

Enalapril compounded suspension

 

22123239

Escitalopram compounded suspension

 

22123240

Esomeprazole compounded suspension

Yes

22123271

Felodipine compounded suspension

 

22123241

Folic acid compounded suspension

 

22123242

Gabapentin compounded suspension

SA required only for Plan G

22123243

Glycopyrrolate compounded suspension

 

22123302

Griseofulvin compounded suspension

 

22123244

Hydrochlorothiazide compounded suspension

 

22123245

Hydroxyurea compounded suspension

Yes

22123270

Hyoscine compound suspension

 

22123298

Labetalol compounded suspension

 

22123312

Lamotrigine compounded suspension

SA required only for Plan G

22123246

Lansoprazole compounded suspension

Yes

22123269

Leflunomide compounded suspension

Yes

22123273

Levetiracetam compounded suspension

Yes

22123267

Levo-thyroxine compounded suspension

 

22123247

Lisinopril compounded suspension

 

22123313

Lorazepam compounded suspension

 

22123248

Methylphenidate compounded suspension

 

22123249

Metoprolol compounded suspension

 

22123250

Metronidazole compounded suspension

 

22123251

Nitrazepam compounded suspension

 

22123314

Nitrofurantoin compounded suspension

 

22123252

Nortriptyline compounded suspension

 

22123253

Omeprazole compounded suspension

Yes

22123268

Oxazepam compounded suspension

 

22123254

Pantoprazole sod compounded suspension

Yes

22123315

Paroxetine compounded suspension

 

22123255

Propranolol compounded suspension

 

22123316

Quetiapine compounded suspension

 

22123257

Ramipril compounded suspension

 

22123256

Rifampin compounded suspension

 

22123317

Sertraline compounded suspension

 

22123258

Sildenafil compounded suspension

Yes

22123318

Sotalol compounded suspension

 

22123259

Spironolactone compounded suspension

 

22123260

Sulfasalazine compounded suspension

 

22123261

Tacrolimus compounded suspension

Yes

22123266

Temazepam compounded suspension

 

22123262

Topiramate compounded suspension

 

22123319

Trazodone compounded suspension

 

22123263

Ursodiol compounded suspension

 

22123264

Vancomycin compounded suspension

Yes

22123320

Zopiclone compounded suspension

Yes

22123274

 

Dermatologicals

Product

Ingredient Requires Special Authority

PIN

Anthralin + salicyclic acid ointment (psoriasis/eczema)

 

22123277

Clindamycin in medicated/non-medicated benefit base

 

22123280

Coal tar/LCD in medicated/non-medicated benefit base

 

22123305

Corticosteroid in non-medicated benefit base

 

22123283

Corticosteroid in medicated benefit base

 

22123303

Corticosteroid + antifungal in benefit base

Yes, except for Plan P

22123286

Corticosteroid +/- menthol, camphor +/- urea topical compound

 

22123278

Erythromycin in medicated/non-medicated benefit base

 

22123279

Metronidazole in medicated/non-medicated benefit base

 

22123281

Retinoic acid in medicated/non-medicated benefit base

Yes

22123304

Salicyclic acid ointment/cream (psoriasis/eczema)

 

22123284

Salicyclic acid + Corticosteroid ointment/cream (psoriasis/eczema)

 

22123285

Sulfur/sulfacetamide in medicated benefit base

 

22123282

Urea (only in combination with at least one prescription benefit ingredient)

 

22123337

 

Intrathecal Compound Injections: Palliative

Product

Ingredient Requires Special Authority

PIN

Narcotic intrathecal compound: palliative

 

22123299

Non-narcotic intrathecal compound: palliative

 

22123300

Narcotic + non-narcotic intrathecal compound: palliative

 

22123301

 

CADD Injections: Palliative

Product

Ingredient Requires Special Authority

PIN

Non-narcotic CADD pump compound: palliative

 

22123287

Narcotic CADD pump compound: palliative

 

22123288

Medical Assistance in Dying (MAiD)

Product                                          

Ingredient Requires Special Authority

PIN    

Oral Drug Regimen Coma-Inducing Agent: 
PB+CHLORHYD+MS ORAL CPD SUSP (MAID)

Yes

88000002

 

 

 

Preservative-Free Eyedrops

Product

Ingredient Requires Special Authority

PIN

Acetylcysteine PF compound eyedrop

 

22123289

Amphotericin PF compound eyedrop

 

22123290

Cefazolin PF compound eyedrop

 

22123291

Ceftazidime PF compound eyedrop

 

22123292

Gentamicin PF compound eyedrop

 

22123293

Pilocarpine PF compound eyedrop

 

22123294

Timolol PF compound eyedrop

 

22123295

Tobramycin PF compound eyedrop

 

22123296

Vancomycin PF compound eyedrop

 

22123297

 

Miscellaneous Compounds

PharmaCare compound pricing policies apply; see the PharmaCare Policy Manual Section 5.13 (PDF, 422KB).

Product

Ingredient Requires Special Authority

PIN

Disulfiram caps 125mg compounded

 

66124089

Disulfiram caps 250mg compounded

 

66124085

Disulfiram caps 500mg compounded

 

66124087

Bimix (Prostaglandin compound injection)

Yes

66123495

Trimix (Prostaglandin compound injection)

Yes

66123483