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Coverage criteria policies

Compounded medications

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Compounded medications billed at costs over $200 require prior authorization from HealthPartners Pharmacy Administration. Compound products prescribed for self-administration must be billed on the pharmacy claims system.


Compound medications must contain at least one ingredient that is a federal legend (prescription-only) drug to be considered a covered benefit by the health plan.

High cost compounded prescriptions (>$200) will be reviewed for medical necessity. Required information includes the diagnosis, products previously tried, evidence or efficacy, and medical necessity.

Prior authorization is required for the following compounding ingredients

  • diclofenac
  • flurbiprofen
  • ketoprofen
  • meloxicam
  • fluticasone
  • gabapentin
  • ketamine
  • cyclobenzaprine
  • Resveratrol powder
  • Freedom Derma-D cream
  • Lipoic acid powder
  • Magnesium chloride powder
  • L-glutamine powder
  • Salicylic acid powder
  • methyltetrahydrofolate
  • Coenzyme Q10

All claims for compound medications will be paid based on a reasonable market price.


Compounded medications are created when two or more ingredients are combined into a new product.

Compounding is a practice in which a licensed pharmacist, a licensed physician, or in the case of an outsourcing facility, a person under the supervision of a licensed pharmacist, combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.





Compounded drug, not otherwise classified

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 12/22/2014 - Date of origin
  • 07/12/2017 - Effective date
Review date
  • 05/2018
Revision date
  • 11/07/2016

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