Compound preparations are covered provided they contain at least one federal legend drug that is not a vitamin or mineral, in therapeutic amounts. A federal legend drug is defined as a medication product that by federal law bears the statement "Caution - Federal (U.S.A.) law prohibits dispensing without a prescription" or equivalent.
Compounds drug claims should be submitted via the on-line claims adjudication system for all HMSA plans. Instructions for all lines of business are described below.
Every claim must include an indicator of 0, 1 or 2. The indicators are defined as:
0 = Not specified
1 = Not a compound
2 = Compound
When filing a claim it is very important to enter accurate indicators. For example, if an indicator of “2” (compound) is entered for a noncompound claim, the claim will not pay correctly and may return an incorrect copayment.
A compounded prescription is considered to be a "Brand" if it contains one or more brand drugs as an ingredient. For "Brand" compounds, submit the NDC of the highest-priced brand drug. The claims processor will return the appropriate brand co-payment amount that should be charged to the member.
A compounded prescription is considered to be a "Generic" if it consists of generic drugs only. For "Generic" compounds, submit the NDC of the highest-priced generic drug. The claims processor will return the appropriate generic co-payment amount that should that should be charged to the member.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |