2. Multi-Ingredient Compound Submission Procedures Place Client Logo here

3. Submitting Multi-Ingredient Compounds  All compounds must be submitted using the Multi-Ingredient compound template  Contact your software provider if unsure how to submit a Multi- Ingredient compound template  SC Medicaid Bulletin SC Medicaid Bulletin Magellan Medicaid Administration | 2

4. Submission Procedure for Compound Claims  There are three areas to complete when filing a compound claim 1. Claim Segment 2. Compound Segment 3. Each line item Magellan Medicaid Administration | 3

5. On Claim Segment  SUBMISSION CLARIFICATION CODE (NCPDP field # 42Ø-DK) = 8.  PRODUCT/SERVICE ID QUALIFIER (NCPDP field # 436-E1) = 03.  PRODUCT CODE/NDC (NCPDP field # 4Ø7-D7) Enter as 00000000000  COMPOUND CODE (NCPDP field # 4Ø6-D6) = 2.  QUANTITY DISPENSED (NCPDP field # 442-E7) for entire product.  GROSS AMOUNT DUE (NCPDP field # 43Ø-DU) for entire product. Magellan Medicaid Administration | 4

6. On Compound Segment  COMPOUND DOSAGE FORM DESCRIPTION CODE (NCPDP field # 45Ø-EF)  COMPOUND DISPENSING UNIT FORM INDICATOR (NCPDP field # 451-EG)  COMPOUND ROUTE OF ADMINISTRATION (NCPDP field # 452-EH)  COMPOUND INGREDIENT COMPONENT COUNT (NCPDP field # 447-EC) (Maximum of 25 ingredients)  (See next slide for valid entries for compound segments) Magellan Medicaid Administration | 5

7. Valid Entries for Dosage, Unit, and Route Magellan Medicaid Administration | 6 Compound Dosage FormCompound Dispensing Unit FormCompound Route of Administration 01-Capsule 02-Ointment 03-Cream 04-Suppository 05-Powder 06-Emulsion 07-Liquid 10-Tablet 11-Solution 12-Suspension 13-Lotion 14-Shampoo 15-Elixir 16-Syrup 17-Lozenge 18-Enema 1- Each 2- Grams 3- Milliliter 1- Buccal 2- Dental 3- Inhalation 4- Injection 5- Intraperitoneal 6- Irrigation 7- Mouth/ Throat 8- Mucous Membrane 9- Nasal 10- Ophthalmic 11- Oral 12- Other/ Misc 13- Otic 14- Perfusion 15- Rectal 16- Sublingual 17- Topical 18- Transdermal 19- Translingual 20- Urethral 21- Vaginal 22- Enteral

8. For Each Line Item  COMPOUND PRODUCT ID QUALIFIER (NCPDP field # 488-RE)  COMPOUND PRODUCT ID (NCPDP field # 489-TE); (i.e., NDC of each ingredient)  COMPOUND INGREDIENT QUANTITY (NCPDP field # 448-ED); (i.e., quantity of each ingredient)  COMPOUND INGREDIENT DRUG COST (NCPDP field # 449-EE); (i.e., ingredient cost of each ingredient) Magellan Medicaid Administration | 7

9. Reminder  Contact your Software Provider if you are unsure where fields are located Magellan Medicaid Administration | 8

10. Important Notes  The claim segment product ID (i.e., NDC) is a mandatory field when submitting multi- ingredient compound claims  A multi-ingredient compound claim must be submitted with eleven zeroes (00000000000)  A claim will reject if all zeroes are not submitted as the product ID Magellan Medicaid Administration | 9

11. Magellan Medicaid Administration | 10 CLAIM SEGMENT Field NameNCPDP Field #Comments SUBMISSION CLARIFICATION CODE420-DKEnter a value of “8” PRODUCT CODE/NDC407-D7Enter a value of “00000000000” COMPOUND CODE406-D6N/A QUANTITY DISPENSED442-E7Enter quantity of entire product GROSS AMOUNT DUE430-DUEnter amount due for entire product COMPOUND SEGMENT Field NameNCPDP field #Comments COMPOUND DOSAGE FORM DESCRIPTION CODE450-EFN/A COMPOUND DISPENSING UNIT FORM INDICATOR451-EGN/A COMPOUND ROUTE OF ADMINISTRATION452-EHN/A COMPOUND INGREDIENT COMPONENT COUNT447-ECMaximum of 25 ingredients LINE ITEM FOR EACH DRUG Field NameNCPDP field #Comments COMPOUND PRODUCT ID QUALIFIER488-REN/A COMPOUND PRODUCT ID489-TEEnter the NDC of each ingredient COMPOUND INGREDIENT QUANTITY448-EDEnter the quantity of each ingredient COMPOUND INGREDIENT DRUG COST449-EEEnter ingredient cost of each ingredient

12. Contacts  Magellan Medicaid Administration  SCProvidersupport@magellanhealth.com SCProvidersupport@magellanhealth.com  SCDHHS  Janet Giles  Gilesje@scdhhs.gov Gilesje@scdhhs.gov  Brandie Crider  CRIDERB@scdhhs.gov CRIDERB@scdhhs.gov  Phone: 803-898-2876 Magellan Medicaid Administration | 11 SC