Question of the Day January 6, 2013 How many insurance companies require this for compounded prescriptions? How many compounding pharmacies fill it out? How many fill it out correctly

COMPOUND PRESCRIPTIONS

The pharmacy or dispensing facility must complete the remaining portion of

this form and return it to the member/patient or provide the member/patient

with a Universal Claim Form for a Compounded Medication.*

• Provide an 11 digit NDC number for each of the ingredient(s) in the medication

• Indicate the drug ingredient(s) and quantity.

• Indicate the metric quantity dispensed in number of tablets, grams or milliliters for liquids,

creams, ointments or injectables.

• Indicate the amount paid for the prescription by the patient.

The original pharmacy prescription label or cash receipt should accompany this claim form or the

Universal Claim Form for a compounded medication. Prescription labels and receipts will not be

returned; you may wish to make copies for your records.

C O M P O U N D P R E S C R I P T I O N S

For pharmacy use only*

NDC# Drug/Ingredient Quantity Charge

Total Charge: $

Note: If the medication/drug was purchased in a foreign country,

the currency must be converted into US dollars.

see actual form here