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What compound medications are covered?

Updated

Compounds are medications that are not available commercially that must be prepared by a pharmacist (could be oral, topical or injectable). Compounds must contain an active eligible ingredient in a therapeutic concentration in an eligible base in order for it to be a benefit of your drug plan.

Eligible compounds

Claims for compounded products are eligible for coverage if:

  • It does not duplicate the formulation, specifically the strength and route of administration, of a commercially manufactured product marketed in Canada nor can the desired dose be obtained using commercially manufactured products; and

  • The main therapeutic ingredient aligns with any frequency restrictions or requirements on the plan; and

  • The compound is not listed as ineligible in the Section A: Ineligible Compounds section of this article; and

  • For topical compounds (creams, ointments and lotions), the base is listed as an eligible base under Section B and all dinned* ingredients are a benefit of the plan. Non-dinned raw materials are considered eligible ingredients; or

  • For all other compounds containing dinned* ingredients, at least one of the dinned* ingredients must be a benefit of the plan. If there are no dinned ingredients, the compound is eligible.

Compounding of two or more creams or ointments that are already benefits of the plan are eligible.

For Quebec plan members only, any compounded product is eligible for coverage if it is an eligible benefit of the Régie de l’assurance maladie du Québec (RAMQ).

Considerations for duplicates of commercially manufactured products will be made in the event of a backorder if there are no therapeutic alternatives available within the same therapeutic class.

* Products containing a drug identification number (DIN), natural product number (NPN), or a homeopathicmedicine number (DIN-HM)

Section A: Ineligible Compounds

  • Compounds for cosmetic purposes

  • Compounds for gummies, lollipops, lozenges or troches

  • Compounds for slow, sustained, or timed-release products

  • Compounds with active pharmaceutical ingredients that are not available as a dinned* product in Canada

  • Topical pain compounds, defined as any topical compound containing any of the following ingredients: Anticonvulsants, baclofen, clonidine, ketamine, and non-steroidal anti-inflammatory drugs

  • Bioidentical hormone replacement therapy, defined as any compound containing any of the following ingredients: Estrogens, progestins and dehydroepiandrosterone (DHEA)

Section B : Eligible Bases

  • Aquafor Ointment (02009609)

  • Dermabase (00067350)

  • Glaxal Base (00295604)

  • Anhydrous Lanolin (50725)

  • Petrolatum Jelly (00094854)

  • Eucerin Ointment (00900907)

  • Rougier Base (00964956)

  • Mediderm Cream Base (00961582)

  • Transal Base (00962511)

  • Schering Base (985554)

  • Taro Base (960063)

Reimbursement

The eligible drug cost is the combined cost of all ingredients used within the compound, including the therapeutically inactive components such as diluents, solvents, fillers, preservatives, sweeteners, stabilizers, etc. Costs for units beyond those used in the compound (e.g. remainder of vials or bottles) will not be considered for reimbursement. We require a breakdown of all the ingredients used in the compound via computer generated pharmacy software to process the claim.

Any compounds being submitted to the insurer may be subject to post-adjudication validation to ensure alignment to clinical and pricing policy requirements. Claims will be reversed should audit determine it ineligible based on our Compound Drug Policy.

Claims pay to rendered subject to post-adjudication validation with allowed amounts as follows:

We reimburse at $1.10/min when calculating the eligible compounding fee. The following list details the allowable charges we will reimburse for eligible compounds. Please refer to the following list when submitting claims for compound mixtures:

  • Compound Code: 0, Type of Compound: Compounded Topical Cream, Maximum allowed time for billing purposes: 20 minutes

  • Compound Code: 1, Type of Compound: Compounded Topical Ointment, Maximum allowed time for billing purposes: 20 minutes

  • Compound Code: 2, Type of Compound: Compounded external lotion, Maximum allowed time for billing purposes: 20 minutes

  • Compound Code: 3, Type of Compound: Compounded internal use liquid, Maximum allowed time for billing purposes: 20 minutes

  • Compound Code: 4, Type of Compound: Compounded external powder, Maximum allowed time for billing purposes: 20 minutes

  • Compound Code: 5, Type of Compound: Compounded internal powder, Maximum allowed time for billing purposes: 30 minutes

  • Compound Code: 6, Type of Compound: Compounded injection or infusion, Maximum allowed time for billing purposes: 20 minutes

  • Compound Code: 7, Type of Compound: Compounded eye or ear drop, Maximum allowed time for billing purposes: 30 minutes

  • Compound Code: 8, Type of Compound: Compounded suppository, Maximum allowed time for billing purposes: 30 minutes

  • Compound Code: 9, Type of Compound: Compounded other, Maximum allowed time for billing purposes: 20 minutes

Some plan designs may have a fee cap for dispensing fees. In this case, the compounding fee will be calculated up to the allowed amount set by the plan design and the remaining compounding fee can be charged to the member.

As per our National Pricing Policy, a pharmacy cannot balance bill the member the differential between our allowed compounding fee and the pharmacy’s compounding fee except for in the Province of Ontario.

Please note that the above fee structure is not applicable in Quebec.

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