28 Pa. Code § 113.24 – Medications dispensed.

(a) The hospital shall dispense only drugs which are listed in one or more of the references listed in subsection (b) or as provided in subsection (c). Any drug unfavorably evaluated in any of these references shall be used only in accordance with standards established by the hospital’s pharmacy and therapeutics committee.
(b) References containing lists of drugs which may be dispensed by hospi- tals shall be as follows:
1. (1) United States Pharmacopoeia.
2. (2) National Drug Formulary.
3. (3) AMA Drug Evaluation.
4. (4) Accepted Dental Remedies.
5. (5) Pennsylvania Generic Drug Formulary.
6. (6) The Physician’s Desk Reference.
(c) Any drug approved for use as an experimental drug or otherwise by the Food and Drug Administration but not listed in subsection (b) may be used in accordance with standards established by the hospital’s pharmacy and therapeutics committee, or its equivalent, and approved by the Food and Drug Administration.