UW HEALTH CLINICAL POLICY 1
Policy Title: UW Health Formulary Restricted Clinic Administered Medication
Pharmacy Department Review and Use of Non-UW Health Supplied Medications
Administered in Clinics
Policy Number: 6.1.5
Category: UW Health
Effective Date: August 25, 2016
To maximize the quality, safety, financial and patient experience outcomes of the organization’s medications
typically administered in a clinic setting using an internal prior authorization system. To outline the
requirements to administer a non-UW Health supplied medication in a clinic.
A. Brown bagging – A circumstance where a medication that is procured outside of the UW Health supply chain
(e.g. from the patient’s local independent pharmacy) and brought to the clinic by the patient for
B. White bagging – A circumstance where an insurer requires a non-UW Health pharmacy (e.g. national
specialty pharmacy) to send a supply of medication directly to a UW Health clinic or pharmacy from the non-
UW Health pharmacy for clinic administration.
III. POLICY ELEMENTS
A. UW Health formulary restrictions for clinic administered medications will be approved by the Pharmacy and
Therapeutics Committee and Medical Board. UW Health formulary restrictions will be developed using the
best available evidence, expert opinion, and when possible patient/family advisors.
B. Brown bagging and white bagging of injected or infused medications is strongly discouraged and should
occur only when it is not possible for the medication to be obtained through an established UW Health
supply chain (e.g. direct purchase from manufacturer or wholesaler).
C. All requests for brown or white bagging for injected or infused medications must be reviewed by The Chair of
the Pharmacy and Therapeutics Committee or their delegate. Approval on brown or white bagging will be
made on a patient-by-patient basis only when the clinical benefit to the patient outweighs the risk of
compromised medication integrity and pedigree.
D. Patients should sign a patient agreement (refer to Appendix A) when administered and injected or infused
medication that is obtained through brown or white bagging.
A. UW Health Formulary Restricted Medication Pharmacy Department Review
i. Patients should not be scheduled for medication administration for restricted medications until
approved by the UW Health Pharmacy Department.
ii. A pharmacist will review all orders for formulary restricted medications to determine if criteria for
use are met prior to dispensing.
iii. When the order for a formulary restricted medication order is approved, the pharmacist will
communicate the approval with the prescriber and/or agent of the prescriber.
iv. If an order for a formulary restricted medication is denied, the pharmacist will communicate the
denial with rationale to the prescriber and/or agent of the prescriber and the process to appeal the
decision. An appeal of a formulary medication restriction denial can be made of the Chair,
Pharmacy and Therapeutics Committee by contacting the Manager, Drug Policy Program.
B. Requests for brown or white bagging
i. A request for a patient-specific exemption should be submitted via In-Basket to the UW Health
Medication Prior Authorization staff at “UWRX Medication Prior Authorization Request” and
complete the fields contained in the dot phrase “.rxrwhitebaggingrequest”.
ii. The UW Health Medication Prior Authorization Staff will work with the patient’s insurer and vendor
to try to find an alternative to white bagging.
UW HEALTH CLINICAL POLICY 2
Policy Title: UW Health Formulary Restricted Clinic Administered Medication Pharmacy Department
Review and Use of Non-UW Health Supplied Medications Administered in Clinics
Policy Number: 6.1.5
iii. If no alternative can be found to white bagging, the request will be sent to the Manager, Drug
Policy Program who will work with the Chair, Pharmacy and Therapeutics Committee or their
delegate to approve the request.
iv. The final approval decision and logistics for shipping will be communicated to clinic staff in a
Health Link Referral and documented as a Clinical Info Note in the patient’s electronic record.
v. The clinic should not charge the patient for the cost of the drug.
vi. Should an exception be granted, an attempt should be made to verify the integrity of the
medication (e.g. prior to clinic storage conditions, potential for contamination or compromise, etc.)
when it arrives to the clinic or pharmacy by a licensed practitioner, preferably a pharmacist.
Author: Manager, Drug Policy Program
Senior Management Sponsor: Chief Ambulatory Operating Officer
Reviewers: Chief Medical Officer, VP Specialty Clinics, VP Primary Care
Approval committees: P & T Committee, UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: July 18, 2016
UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospital and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.
Peter Newcomer, MD
UW Health Chief Medical Officer
J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee
Appendix A: Patient Agreement for the Use of Non-UW Health Supplied Medications
VIII. REVIEW DETAILS
Next Revision Due: December 2018
Formerly Known as: UWHC Ambulatory departmental policy #8.30, Management of Clinic Administered
Medications with Internal Pharmacy Prior Authorization