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Policies,Clinical,UWHC Clinical,Department Specific,Pharmacy,Purchasing and Inventory

Non-Formulary Medications for Inpatients Use (9.1)

Non-Formulary Medications for Inpatients Use (9.1) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Purchasing and Inventory

9.1









Effective Date:

March 2003
 Pharmacy Policy Manual
Chapter: Purchasing - Inventory

Chapter:

Policy #: 9.1


Revised: 3/17

Page 1
of 5

Title: Non-Formulary Medications for
Inpatient Use

I. PURPOSE: UW Health has an established closed formulary, which covers all medication
therapeutic classes. Medication orders must be processed in compliance with the
established formulary. In the event a patient requires a medication not on the UW Health
formulary, this document establishes the procedure for obtaining non-formulary
medications for inpatient and ambulatory use.

II. POLICY: Medication orders are processed in adherence with the UW Health formulary at
all times, unless an extraordinary patient care need exists (e.g. documented allergies
and/or adverse reactions to formulary medications, or clinically relevant needs as
determined by the attending physician).

Non-formulary requests needed for clinically urgent/emergent needs may be obtained by
borrowing from another hospital or pharmacy, or ordered for emergency delivery.

Data related to non-formulary orders will be compiled monthly, quarterly, and yearly and
be reviewed by the Medication Use Evaluation Committee, the Drug Product Selection and
Supply Committee, and P & T Committee.

III. DEFINITIONS:

A. Non-formulary drugs are medications that are not approved formulary agents and are
not stocked in the UW Health inventory.
B. Next Delivery Day – Typically orders placed to the wholesaler on Sunday through
Friday will be delivered Monday through Saturday. The one exception is Holidays.
Holiday shipping schedules change from year-to-year and the pharmacy stockroom
should be contacted for more information (608-263-1274).

IV. PROCEDURE:

Central Pharmacy, American Family Children’s Hospital (AFCH) Pharmacy, and
Ambulatory Clinic Locations:
A. Non-formulary medications must be ordered via the electronic health record with the
appropriate exception code selected.
B. Requests verified by 1300 are generally ordered and should arrive the next delivery day.
Requests verified after 1300 will be ordered on the next day and should arrive the day
after the order was placed.
C. Reference section “M” for more urgent requests.
D. Responsibilities of the decentral pharmacist:

1. Clinically and critically evaluate the use of non-formulary medications.

2. Use strategies such as the UW Health therapeutic interchange or use of the
patient’s own supply to curb the use of non-formulary medications.
3. Communicate with providers that all non-formulary medications are
considered not stocked in the inpatient pharmacy.
a. “STAT” non-formulary medication requests do not exist.









Effective Date:

March 2003
 Pharmacy Policy Manual
Chapter: Purchasing - Inventory

Chapter:

Policy #: 9.1


Revised: 3/17

Page 2
of 5

Title: Non-Formulary Medications for
Inpatient Use


4. Contact the manager of the drug policy program (pager #5072) from 8am – 5pm
Monday through Friday if you are placing an order for a clinically appropriate
non-formulary medication. If outside these times, page the Pharmacy Manager
on call (pager #8771). The pharmacy manager will either approve or deny the
request. The pharmacy manager, central pharmacist, and decentral pharmacist
will work together to procure the medication through the loan borrow process,
emergency procurement process, or the standard ordering process.
a. Information that should be included in non-formulary request pages is
name of the drug, patient name, MRN, and call back number with
pager ID number.
b. The pharmacist should be ready to answer the following:
i. Why the drug is necessary and clinically appropriate.
ii. What strategies have been attempted and failed.
iii. What other options still remain.
c. If approved, communicate with the provider the expected arrival time
of the medication.
d. If denied, communicate with the provider that the request was denied
and the rationale for denial.

5. Verify/Modify the order to contain the appropriate start date and time, based on
the date and time the medication is expected to be delivered to the unit.
a. Consider the time of day you are verifying the order and, as a general
rule for non-urgent requests, the medication will not be available for
patient administration until 1400 the day the medication arrives to the
inpatient pharmacy.
b. Additionally, a note should be left in the “RPh to RPh communication”
field within the patients HealthLink record indicating who approved the
order and the anticipated arrival time.
6. For infusion center and ambulatory clinic medication orders the pharmacist will
follow the Ordering and Dispensing Special Medication Orders procedure.
E. Responsibilities of the MedCarousel technician:

1. Triage labels will generate for all non-formulary requests once they are
verified by the decentral pharmacist.
2. The technician will place the HealthLink label on a baggie and look in
the appropriate non-formulary medication bin for the medication.
3. If the medication is available in the non-formulary medication bin, the
technician will fill the order and give it to the central pharmacist for
verification.
4. If the medication is not available in the non-formulary medication bin, the
technician should place the baggie in the non-formulary bin for review by the
inventory control technician.









Effective Date:

March 2003
 Pharmacy Policy Manual
Chapter: Purchasing - Inventory

Chapter:

Policy #: 9.1


Revised: 3/17

Page 3
of 5

Title: Non-Formulary Medications for
Inpatient Use


a. If the inventory control technician is not available, the technician
should inform stockroom staff. If stockroom staff is not available, the
technician should inform the central pharmacist.
F. Responsibilities of the inventory control technician:
1. Prior to 1500 the inventory control technician will review the HealthLink
actively running non-formulary report and the active custom medication report
daily. The report lists all previously approved non-formulary orders and
custom medication orders. The technician will ensure a sufficient quantity of
medication remains on hand until the supplies are again checked.
a. If quantity is on hand to fill only the next 48 hours of previously
approved active orders.
i. Alert the central pharmacist.
ii. Take the label to the purchasing agent to order the
medication.
iii. After the medication has been ordered, the inventory
control technician will document on the medication label and
on all reports that an order has been placed. The label should
then be place in the “central pharmacy medication on order”
bin located by the triage technician.
b. If sufficient quantity is not on hand to fill the next 24 hours of
previously approved active orders.
i. Alert the central pharmacist.

ii. Central pharmacist will communicate with the Decentral
pharmacist to determine the appropriate course of action.
2. After all reports are reviewed and appropriate actions are taken a copy of the
last 24-hour report, the active orders report, and the custom medication report
are placed in the non-formulary bin as a reference for the central pharmacists.
G. The purchasing agent will prepare a purchase order to arrive with the next routine
delivery based upon non-formulary request.
1. Non-formulary medications are ordered via account number 651340.
H. The stockroom technician will receive the non-formulary medications using the
standard stockroom receiving process on the next routine delivery day.

1. Forward all non-formulary medications to the inventory control technician.

I. The inventory control technician will match the received non-formulary medication to
the appropriate patient labeled baggie from the on order bin.
1. For medications that require packaging, the inventory control technician will
determine the appropriate number of doses to be packaged from the bulk bottle
and forward the bulk bottle and baggie to the packaging technician.
2. For unit dose or multi-dose non-formulary medications the inventory control
technician will stock the non-formulary item in the appropriate non- formulary









Effective Date:

March 2003
 Pharmacy Policy Manual
Chapter: Purchasing - Inventory

Chapter:

Policy #: 9.1


Revised: 3/17

Page 4
of 5

Title: Non-Formulary Medications for
Inpatient Use

medication shelf location and forward the labeled baggie to the medcarousel
technician to fill the request.
J. For medications requiring packaging, the packaging technician will package the
number of doses indicated for non-formulary medication using the standard
packaging process.
1. The packaging technician will note the number of doses remaining on the
outside of the bulk bottle.
K. The central pharmacist will check the packaged non-formulary medication and place the
correct number of doses needed to fill the request in the labeled baggie and placed the
medication in the bin for delivery to the patient care unit.
L. The central pharmacist will stock the bulk bottle in the appropriate non-formulary
medication shelf location with the correct number of doses remaining.
M. For clinically urgent or emergent non-formulary request, the decentral pharmacist will
contact the central pharmacist to discuss.
1. The central pharmacist or pharmacy manager will work with the
purchasing agent to attempt to obtain it the same day.
a. If the purchasing agent is not available, the central pharmacist or
pharmacy manager will work with the stockroom technician to initiate
the Loan and Borrow Procedure or Emergency Drug Procurement
process to obtain the item from an ambulatory UW Health pharmacy,
another hospital, pharmacy, or from our wholesaler (McKesson).
b. See Pharmacy Policy 9.4 for Emergency Drug Procurement
procedures.
c. If after purchasing/stockroom hours, the central pharmacist or
pharmacy manager will initiate the Loan Borrow Procedure or
Emergency Drug Procurement process.
2. Decentral pharmacist will communicate with the ordering provider the
expected arrival time.
N. Requests to re-order multi-dose items, where the entire supply is given to the nurse or
patient, will be the responsibility of the decentral pharmacist. The determination must
be made 48 hours before the current supply of medication is exhausted.
1. Pharmacists will re-order these items by generation of a HealthLink triage
label.
2. The medcarousel technician will give this label to the inventory control
technician who will follow the procedures outlined above.

UW Health Contracted Pharmacies:
A. Non-formulary medication request will follow the Central Pharmacy workflow with the
following exceptions:
1. The pharmacist should contact the pharmacy manager of the UW Health
contracted pharmacy or the covering pharmacy manager for all non-









Effective Date:

March 2003
 Pharmacy Policy Manual
Chapter: Purchasing - Inventory

Chapter:

Policy #: 9.1


Revised: 3/17

Page 5
of 5

Title: Non-Formulary Medications for
Inpatient Use

formulary requests. The pharmacy manager will either approve or deny the
request.
2. Once the request is approved, the UW Health contracted pharmacy should
attempt to procure the medication from University Hospital Central
Pharmacy by calling the triage technician (608-263-1272) and asking them to
check the non-formulary bin.
3. If UW Central pharmacy does not have the medication, the UW Health
contracted pharmacy will order the medication from McKesson or obtain the
medication from an ambulatory UW Health pharmacy.

V. REFERENCES AND RELATED POLICIES, PROCEDURES

A. Operating Procedure - Loan and Borrow Procedure

B. Pharmacy Policy 9.4 - Emergency Drug Procurement
C. Operating Procedure – OrdeRx Ordering Processing Procedure
D. Operating Procedure – Ordering and Dispensing Special Medication Orders

VI. COORDINATION:

A. AUTHORED BY: Anthony Hennes, PharmD and Jerame Hill, PharmD, MS

B. COMMITTEE APPROVAL BY:


Approved By: ____________________________ Date: ________________
Director of Pharmacy Services