BOP Program Statement 6360.03 § 6

a. National Drug Formulary. Each institution will use the Bureau’s National Drug Formulary.

The Bureau formulary is a list of medications approved by HSD to ensure high-quality, cost-effective drug therapy for the population served. The P&T Committee is responsible for the

development and maintenance of the National Drug Formulary, with final approval by the

Bureau Medical Director. National P&T voting members will include, at a minimum, Regional

Medical Directors and Regional Chief Pharmacists. Additional members are assigned as

determined by the Bureau Medical Director or designee.

All Bureau institutions, including medical centers, are expected to abide by the formulary.

Requests for changes to the National Formulary (i.e., additions, deletions, changes in

restrictions) are sent through the process determined by the Bureau Chief Pharmacist. All

requests will be reviewed at the National P&T Meeting.

Unless indicated as a non-substitutable product, proprietary (brand or reference product) names

are used as examples for identification purposes only. All institutions will use the least expensive

A/B rated generic or biosimilar biologic when possible. Dispense as Written (DAW) orders will

be processed as non-formulary medication orders and must include appropriate justification from

the prescriber.

b. Local Drug Formulary. A local formulary may be more restrictive than the National

Formulary. Medications may not be added or national formulary use criteria removed. Any

changes to local formulary are made through the local P&T Committee. Changes to local

formulary outside of local P&T meetings may be necessary at times and require approval of the

Institution Chief Pharmacist, CD, and HSA at a minimum; and must be reviewed and

documented in the next local P&T minutes. Local formularies will be made available to all the

institution’s health services staff and consultants.

c. Utilization of Non-formulary Medications. Authorization for use of items not on the

National Formulary or beyond the listed restrictions must be requested using the Non-Formulary

Request process. The process is completed through the EHR.

 A new non-formulary request is not required for intra-system transfers who

previously had a non-formulary medication approved.

 All comments made on the request are expected to be medically appropriate and of a

nature conducive to being placed in the medical record.

 Non-urgent non-formulary medications will not be initiated until after authorization

is received, even if the medication is on the shelf from a previous request. Doing so

can be deemed an unauthorized procurement.

6360.03 5/7/2026 PROPERTY OF US GOVERNMENT 6

 Consultant providers are expected to utilize and stay within the Bureau National

Formulary when making recommendations and to provide specific and adequate

justification for the use of non-formulary medications.

 Court orders recommending or ordering specific treatments will be referred to the

appropriate Bureau attorney(s). All such orders/recommendations are still subject to

the non-formulary review process.

d. Non-formulary Medication Continuity of Care. There are times when inmates are

processed into an institution after normal working hours, weekends, and holidays. In these cases,

continuation of non-formulary medications prior to approval may be medically necessary

because of the following reasons:

 There is no formulary substitute or changing to a formulary substitute will not allow for

appropriate follow up monitoring until the next workday.

 Not providing the medication would pose a significant risk to the inmate.

When continuation of a non-formulary medication prior to approval is medically necessary, an

allowance is given to dispense/administer the medication for four days while awaiting approval.

This four-day allowance is only to be utilized for urgent continuity of care purposes and not for

the purpose of initiating routine/non-emergency non-formulary medications without appropriate

approval. It is the prescriber’s responsibility to ensure follow-up and submission of a non-formulary request prior to expiration of a currently approved non-formulary request.

Medication orders that do not meet the above criteria for continuity of care should not be written,

entered into the pharmacy software system, administered, or dispensed prior to appropriate non-formulary request approval.