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