Compounded clobetasol propionate: 0.1% and 0.2% ointments, 0.05% foam and topical/vaginal gel, three scalp combinations, a dental gel/paste and lidocaine oral gel, 0.05% and 0.025% oral rinses, and a 0.5 mg vaginal suppository. Hair-loss combinations are on the hair-loss form.
Cholestyramine 400 mg oral capsules and topical preparations: 5%, 6.5% and 10% ointments, a zinc oxide 20% / cholestyramine 5% ointment, a cholestyramine / nystatin / zinc oxide ointment and a 5% / zinc oxide gel, in 60 to 240 g with container selection.
Ondansetron for patients who cannot keep oral medication down or need a form no manufacturer makes: 4, 5 and 8 mg rectal suppositories, a 4 mg / prochlorperazine 25 mg suppository, a gluten-free 0.8 mg/mL oral suspension, 4 and 8 mg slow-release capsules, and four topical creams and gels.
Ichthammol (drawing salve) compounded as a topical ointment at 10%, 12%, 20%, or a prescriber's strength and base, in 30 or 60 g. No ichthammol product is FDA-approved.
Ciclopirox olamine compounded as 6% cream and gel, 7.77% and 8% nail lacquer (the 8% only when a vehicle the manufactured lacquer does not offer is needed), 1.5% topical solution, and 1.5% shampoo, for prescriber-directed use in tinea pedis, cruris, and corporis, cutaneous candidiasis, tinea versicolor, seborrheic dermatitis of the scalp, and confirmed mild to moderate onychomycosis. Manufactured 0.77% cream, gel, and suspension, 1% shampoo, and 8% nail lacquer are FDA-approved and dispensed as such when they fit. Single-agent ciclopirox only; combinations with terbinafine, azoles, urea, ibuprofen, DMSO, salicylic acid, or corticosteroids have their own forms.
Triamcinolone acetonide compounded as 0.025%, 0.1%, and 0.5% cream or ointment in a preservative-free or simplified base, 0.5% gel, 0.05% lotion, 0.1% topical solution, 0.04% spray, 0.025% and 0.1% shampoo, 0.1% oral adhesive paste, and 0.1%, 0.2%, and 0.4% swish-and-spit oral rinse (the 0.4% preservative-free), for prescriber-directed use in eczema, psoriasis, dermatitis, lichen planus, seborrheic dermatitis, oral lichen planus, aphthous ulcers, and other inflammatory oral lesions. Manufactured 0.025%, 0.1%, and 0.5% cream and ointment, lotion, spray, and 0.1% dental paste are FDA-approved and dispensed as such when they fit. Single-agent triamcinolone only; nystatin, antibiotic, coal tar, urea, and anesthetic combinations, the otic solutions, capsules, oral suspensions, and nasal spray have their own forms.
Cyclobenzaprine hydrochloride compounded as 0.5%, 1%, 2%, and 5% topical gel in an anhydrous base with a metered pump (30 to 100 g), a cream base on request, 1 and 2 mg/mL oral liquid, 10 mg troches, and custom-strength capsules, for prescriber-directed off-label use in localized muscle spasm, neck and back pain, myofascial pain, and temporomandibular joint disorders. Single-agent cyclobenzaprine only; combination gels with ketoprofen, diclofenac, baclofen, gabapentin, lidocaine, or amitriptyline and the rectal suppositories have their own forms.
Scopolamine hydrobromide compounded as 0.25 mg/0.1 mL and 0.4 mg/0.1 mL transdermal gel in a measured applicator, 0.25 and 2.5 mg/mL topical cream, 0.2, 0.4, and 1.2 mg oral capsules, 0.5 and 1 mg slow-release capsules, 0.4 mg troches, 0.1 mg/mL oral suspension, and 0.2% nasal spray, for prescriber-directed off-label use in motion sickness, nausea, vertigo, and sialorrhea when the fixed-dose patch does not fit. Single-agent scopolamine only; the caffeine and chlorpheniramine combination capsules and the methscopolamine preparations have their own forms.
Dimethyl sulfoxide (DMSO) 10% topical gel and 50% topical cream in metered pumps, 30 g and 60 g, for prescriber-directed off-label use in localized musculoskeletal pain and inflammation or as a penetration-enhancing base. Single-agent DMSO only; the diclofenac, ketoprofen, lidocaine, antifungal nail, and povidone-iodine combinations that use DMSO as a base are separate preparations with their own forms.
Apomorphine HCl 2 mg and 3 mg sublingual troches (polyglycol base) in 15 and 30 counts, and 3 mg/mL sublingual solution in 25 and 30 mL, for prescriber-directed off-label use in erectile dysfunction. Single-agent sublingual preparations only; combination troches with tadalafil or sildenafil are separate preparations.
Povidone-iodine 0.5%, 1%, and 1.25% nasal spray in 15 mL and 30 mL metered bottles for prescriber-directed nasal antisepsis and pre-surgical decolonization courses. The nasal spray only; oral rinse, topical gels and solutions, troches, suppositories, and the DMSO combinations are separate preparations.
Single-agent fluocinonide for the skin (0.01-0.1% cream, ointment, gel, solution, and lotion, 15-60 g or 30-60 mL) plus the 0.05% oral adhesive paste and 0.05% oral rinse for lichen planus and other inflammatory conditions inside the mouth. Combinations with coal tar, kojic acid, hydroquinone, tretinoin, or ketoconazole are on their own forms.
Single-agent lidocaine for the skin: 5-30% cream, gel, ointment and 10% spray, 30-60 g, with container selection and an office-use routing row for the provider-applied 30% plasticized preparation. Combinations and nasal spray are on their own forms.
Compounded diclofenac on one sheet: single-agent topical and transdermal gels from 1.3% to 20%, twelve combination gels with gabapentin, lidocaine, amitriptyline, cyclobenzaprine, baclofen, menthol, DMSO or verapamil, oral liquids and acid-resistant capsules, and a 50 mg suppository. Container selection on both topical pages.
Non-controlled baclofen vaginal or rectal suppositories for pelvic floor spasm: baclofen 10 mg, baclofen 10 mg / lidocaine 5%, and custom baclofen strengths. May be faxed. Diazepam- or ketamine-containing versions must be e-prescribed (see the Diazepam / Baclofen E-Prescribing Guide).
Not a fax form. Schedule III e-prescribing guide for women's testosterone: Atrevis hydrogel, cream and vaginal strengths with the exact wording to enter in your EPCS system.
Not a fax form. Schedule III e-prescribing guide for men's testosterone: injection, cream and gel strengths with the exact wording to enter in your EPCS system.
Not a fax form. Schedule IV e-prescribing guide for diazepam / baclofen vaginal or rectal suppositories: EPCS drug-entry guidance, the Bayview DB- codes, route and refill rules, and an example prescription line. Baclofen-only suppositories are not controlled and have their own fax form.
Budesonide nasal irrigation capsules (0.5, 0.6 and 1 mg, with optional mupirocin or other antibiotic) dissolved in a 240 mL saline sinus rinse for chronic rhinosinusitis and nasal polyps.
Flavored oral suspensions, capsules and transdermal ear gels for dogs and cats: methimazole, cisapride, pimobendan, trilostane, ursodiol and other veterinary compounds. Includes a pet patient block.
Not a fax form. Schedule III e-prescribing guide for compounded ketamine: how to pick a drug entry that validates for EPCS, the Bayview KET- codes for nasal spray, troches and rapid-dissolve tablets, quantity and refill limits, and an example prescription line.
Preservative-free methylcobalamin 1, 5 and 10 mg/mL and hydroxocobalamin 1 and 25 mg/mL injections, plus the hydroxocobalamin 5 mg/mL nasal spray. Vials, single-dose vials and prefilled syringes.
All TXA preparations on one sheet - 250 mg capsules, 2% paste, 3% solution, 7% and 10% creams, 5% nasal spray and the 4.8% oral rinse. Carries the thromboembolic and contraception screening note.
All compounded tacrolimus on one sheet - 0.1% and 0.2% otic solution, 4 mg/60 mL rectal enema, 0.1% anhydrous gel, ketotifen cream, 0.1% shampoo and the minoxidil / tacrolimus / clobetasol foam.
Sodium thiosulfate 20% and 25% creams, gels and solutions, with or without zinc oxide, fragrance-free and metered-pump options. Oral 300 mg capsules ordered separately.
All nystatin preparations on one sheet - vaginal suppositories, 2% nasal spray in aqueous or Mucolox, 500,000 unit capsules, Stomahesive powder and hydrocortisone cream.
Sildenafil, tadalafil and vardenafil on one sheet - tablets, rapid dissolve tablets and troches, each strength with its own quantity row and quick-reference code.
Cantharidin 1% solution and the cantharidin / podophyllin / salicylic acid combination, 5 mL each. Provider-applied in office, compounded to a patient-specific prescription under 503A.
Diltiazem 2% ointment or gel, nifedipine 0.3% ointment, and nitroglycerin 0.125% / 0.2% ointment including a lidocaine combination, with per-row quantities. Carries the PDE5 contraindication warning.
Twelve acne cream formulas and six rosacea formulas on one sheet, with per-row quantities. Azelaic acid, clindamycin, benzoyl peroxide, tretinoin, spironolactone, metronidazole, ivermectin, brimonidine and niacinamide.
Combined dermatology prescribing form — the five brightening tiers (HQ Free, Control, Vanish, Clear, Ultra Plus) and the four tretinoin wrinkle tiers (Mild, Moderate, Plus, Max) on one sheet, with base, duration and quantity selections.
Short-chain fatty acid enema (sodium acetate / propionate / butyrate 60-30-40 mM, or butyrate alone) in single-use 60 mL doses. Includes site selection for the rectum, the diverted distal bowel, or an ostomy, plus a course-length field.
Prescribing form for compounded magic mouthwash — diphenhydramine / antacid / lidocaine 1:1:1, expectorate or swallow, with fields for the 24-hour maximum and the interval before eating or drinking.
Lidocaine 2-8% nasal spray, plain or isotonic, 5-20 mL. Includes nostril selection and a required maximum-sprays-per-day and per-week field. Off-label for headache.
Tacrolimus 4 mg per 60 mL rectal enema for refractory ulcerative proctitis or distal colitis, dispensed as a multi-dose supply. Includes a blood-level and renal-function monitoring field.
Nystatin 2% nasal spray in an aqueous or Mucolox base, 6-15 mL, with a two-phase duration and taper line. Off-label; evidence in chronic sinus disease is limited.
Nystatin 100,000 unit vaginal suppositories, 14-30 count, with an induction-then-maintenance course line. No FDA-approved nystatin vaginal product is marketed in the US.
Preservative-free sterile B12 injection - methylcobalamin 1, 5 or 10 mg/mL and hydroxocobalamin 1 or 25 mg/mL, as a vial or prefilled 1 mL syringe. IM or SubQ, with loading-then-maintenance scheduling.
Any medication compounded as an oral suspension - anhydrous or aqueous, dye-free, sugar-free, alcohol-free, flavored, feeding-tube friendly. Includes guanfacine, leucovorin and omeprazole concentration menus.
Order form for compounded non-controlled female hormone therapy: progesterone capsules and cream, Bi-Est cream, estradiol cream and DHEA cream. Testosterone-containing preparations must be e-prescribed.
Order form for compounded intravesical bladder instillations dispensed in single-patient syringes: gentamicin, tobramycin, and heparin / lidocaine / sodium bicarbonate.
Order form for compounded fortified anti-infective ophthalmic solutions used for infectious keratitis and corneal ulcer: vancomycin, tobramycin and gentamicin. For antifungal eye drops see the Amphotericin B form.
Order form for compounded low-dose atropine ophthalmic solution used for myopia progression control. Strengths 0.01%, 0.02% and 0.05% in 5 mL and 10 mL.
Not a fax form. Testosterone is a Schedule III controlled substance and must be e-prescribed (EPCS). This opens the men's e-prescribing guide; a separate women's guide is listed under Testosterone (Women).
