UW HEALTH CLINICAL POLICY 1
Policy Title: Restricted Primarily Ambulatory Administered Medications in Hospitalized
Policy Number: 6.1.9
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 16, 2016
To encourage the appropriate cost-effective use of medications typically administered in a clinic, home, or
infusion care setting in hospitalized patients.
A. Self-administered: medication is administered by the patient or their caregiver.
B. Clinic-administered: medication is administered by a healthcare professional at a clinic or other outpatient
healthcare facility (e.g. infusion center).
C. Pharmacy benefit: the insurance coverage that typically covers home/self-administered prescription
D. Medical benefit: the insurance coverage that typically covers clinic-administered medications, office visits,
clinic visits, labs, and hospitalizations.
III. POLICY ELEMENTS
A. As part of the addition to formulary, the UW Health Pharmacy and Therapeutics Committee will determine if
a medication is governed by this policy according to the following criteria:
i. Risks of adverse events when given to hospitalized patients (e.g. infection, delayed wound healing)
ii. Delaying initiation or continuation of therapy until after discharge usually poses minimal clinical risk
to the patient
iii. Patient access to the medication is restricted or limited by their pharmacy and/or medical benefit
B. An attending physician must provide the clinical rationale why the initiation or continuation of a medication
restricted under this policy cannot be delayed until after discharge to the pharmacist and should document
this rationale in the medical record. Patient convenience alone is not sufficient clinical rationale.
C. The pharmacist should coordinate fiscal screening and prior authorization for the inpatient administration
and subsequent self-administration or clinic-administration when required by the patient’s pharmacy or
A. When an order is received for any of the medications included in Appendix A, a pharmacist will review the
order for clinical appropriateness including but not limited to:
i. Risks of adverse events (e.g. infection, delayed wound healing, contraindications, warnings)
ii. Indication for acute or chronic condition
iii. Anticipated length of stay
iv. Dosing interval and pharmacodynamic/pharmacokinetic properties of the medication
v. Clinical rationale provided by the patient’s attending physician
B. The pharmacist should coordinate fiscal screening with the inpatient Medication Assess Specialist prior to
i. If fiscal screening is not available because of payer availability (i.e. evenings or weekends),
treatment should not be delayed if the delay may cause an adverse clinical outcome.
ii. The priority for fiscal screening should be on coverage for ongoing outpatient coverage to tailor the
inpatient therapeutic plan based upon patient access post-discharge.
iii. For a minority of payers, prior authorization for inpatient administration is required.
C. Prior to dispensing the pharmacist will obtain authorization from the Manager, Drug Policy Program or
Pharmacy Manager On-Call.
D. After manager approval, the pharmacist must coordinate procurement with the central pharmacy and work
with the prescriber to adjust the administration time accordingly based upon procurement timeline.
E. If consensus cannot be achieved between the pharmacist, pharmacy manager, and attending physician on
clinical rationale for inpatient administration, an appeal should be made to the Chair of the Pharmacy and
Therapeutics Committee or their delegate.
UW HEALTH CLINICAL POLICY 2
Policy Title: Restricted Primarily Ambulatory Administered Medications in Hospitalized Patients
Policy Number: 6.1.9
F. In addition to listing in Appendix A, a reference to this policy will be included in the online UW Health
Formulary and within the ordering instructions of relevant electronic medication records.
Author: Manager, Drug Policy Program
Senior Management Sponsor: SVP, Chief Operating Officer
Approval committees: UW Health Clinic Administered and Specialty Medications Committee; UW Health
Pharmacy and Therapeutics Committee; UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: November 21, 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 Hospitals 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
Pharmacy departmental policy #13.6, Drug Formulary
Pharmacy department policy #13.21, Admitting a Drug to the Formulary
Pharmacy department policy #9.1, Non-Formulary Medications for Inpatient Use
VIII. REVIEW DETAILS
Next Revision Due: December 2019
Formerly Known as: Hospital Administrative policy #8.95, Restricted Clinic Administered Medications in