Pharmacy Policy: Non-Formulary Drugs Procurement

What is Procurement of non-formulary drugs?

Procurement of non-formulary drugs is part of the pharmacy policy and procedures it’s being incorporated with the infection control department.

As usual with most of the policies sample posted here, there is some default data that should be listed in the policy header and footer. Below are some of the info that you need to include in your Procurement of non-formulary drugs policy header:

  • Hospital name, obviously.
  • Pharmacy department operational policy and procedure, this header just to notify the reader that the following policy belongs to which department.
  • Policy code or Number, for filing/indexing purposes.
  • Edition Number, same purpose as above.
  • The title of the policy, in our case; would be Procurement of non-formulary drugs.
  • Important dates [date reviewed, approved date, effective date, and due for review date].
  • Applies to [department] in this case it should be pharmacy department
  • And last but not least, you’ll mention the nature of the policy, whether it’s going to be multidisciplinary or department-specific. (Multidisciplinary policy)
Procurement of Non-Formulary Drugs
Procurement of Non-Formulary Drugs

Procurement of Non-Formulary Drugs Policy


The process of procurement of any medicine not listed in the hospital drug formulary and will be applicable for all clinical areas.


To identify the procedure should be followed for the procurement of non-formulary drugs.


  1. Non-formulary drugs will be procured only for a particular patient.
  2. Non-formulary drugs will be procured only on an exceptional basis with the approval of the concerned department head, medical director with the authorization of the pharmacy director.
  3. In case of urgent and life-threatening situations, the form could be filled by the treating physician, approved by the pharmacy director or his designee.

Procedures and responsibilities

  • Non-formulary drug request form is available in all patient care areas and pharmacy department.
  • The form shall be filled completely and signed by the treating physician.
  • The request shall be approved by the department head followed by the approval of the medical director or his designee.
  • The request shall be submitted subsequently to the pharmacy department for review, validation, cost evaluation, and procurement.
  • When the requested drug is out of stock in the local market it can be borrowed from other institutions by the pharmacy supervisor, or the equivalent substitute can be given after calling the treating physician.
  • Pharmacy department should procure urgent non-formulary and life-threatening drugs within one to two working days.
  • Pharmacy department should procure non-formulary drugs {non- Pharmacy department urgent basis) within five to seven working days.
  • Non-Formulary drug required during weekends, holidays, and non-official operating hours the pharmacist on duty could borrow it from other institution or sister hospital whenever possible using drug borrowing form.


  1. Attachment A-Non Formulary Drug Request form.
  2. Attachment B-Borrowing form.

You’re almost done and pharmacy procurement of non-formulary drugs policy is almost ready, what’s remaining is just few basic policy layout filling.

  • References.
  • Revisions: Revised as per timescale.
  • Distribution: Here you should mention where this policy will be sent, and which departments will get a notification for it:
    • Hospital/Medical Director.
    • All Department Heads.
    • Nursing Director/All Nursing Units.
    • Pharmacy Purchasing Office.
    • Pharmacy Store.
    • Pharmacy Department.
    • Signed originals are maintained in Manual & Indexing Office.

The policy is now finished, and it’s time to get proper signatures, whether your hospital is implementing an electronic signatures, or manual sign and stamp.

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