Phone: (877) 868-4110 Fax: (877) 868-4144
Prescribers and Staff
YOUR ONE-STOP SOLUTION AMERICAN SPECIALTY PHARMACY is able to assist you. We are a Specialty Pharmacy with retail stores with the ability to fill ALL of your patient’s medications. Attached you will find a Prescription Referral Form for use with specific chronic illnesses. If your patients also need other medications not listed, just send the prescription along with it and we’ll take care of that too!
Our goal is to service all of the needs of your office and your patients.
• A member of our team will fax prescription and patient status updates throughout the prescription process • P rior authorizations to initiate treatment • R e-Authorization to prevent therapy interruption • C ost management • N o cost for delivery to patient home or your office • I njection training for self injectable medications at patient home or in your office • D isease and treatment education prior to therapy initiation • O ngoing side effects management • C ustomize patient monitoring • R efill reminders and coordination • R etail prescriptions to ensure patients have ONE PHARMACY • I nfusion & Compounding services available For more information please call or email: Phone: (877) 868-4110 | Fax: (888) 294-9434 | Email: info@americanspecialtypharmacy.com
PLANO,TX | DENTON, TX | SAN ANTONIO | EL PASO, TX | TYLER, TX www.AMERICANSPECIALTYPHARMACY.com
We look forward to serving you and meeting all of your pharmacy needs. OUR PRODUCTS & SERVICES
We are a full service pharmacy that specializes in: Compounded & Specialty Medications Durable Medical Equipment (DME) Nutritional Supplementation Workers’ Compensation Prescriptions Everyday Prescriptions
WE TAKE THE BURDEN OFF OF YOU
Our customer service is second to none; provided by highly trained sta . We assist each patient throughout the entire process. From contacting your insurance carrier to automatic re lls and overnight delivery.
www.AMERICANSPECIALTYPHARMACY.com
At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe and e ective customized medications. Our pharmacists are experts at compounding new, discontinued, back-ordered, or unavailable medications to meet speci c patient needs. We o er a full line of Professional Quality Vitamins,
Nutritional Supplements, OTC Medications, Everyday Prescriptions, Medical Equipment & Specialty Medications.
COMPLIMENTARY DELIVERY All deliveries are delivered straight to your door within 24 hours at no out-of-pocket cost to you.
AUTOMATIC REFILLS
Your re lls are lled automatically based on your prescription or physician’s approval. It is not necessary to reorder!
PLANO LOCATION
2743 West 15th Street Plano, TX 75075 P: 877-868-4110 . F: 877-868-4144
info@americanspecialtyrx.com
HOURS OF OPERATION Mon - Fri 9am until 7pm Sat & Sun 9am until 3pm
www.AMERICANSPECIALTYPHARMACY.com
PSORIASIS / DERMATOLOGY Form
American Specialty to Arrange
Ship to:
Pa ent Home MD e MD e FIRST FILL ONLY
CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com
Treating Patients Special PATIENT INFORMATION (Use this area or
ent demographi s)
Name: ______________________________________ Phone: __________________________ Phone 2: _________________________ Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________ INSURANCE INFORMATION (Use this area or a
opy of insuran e ard(s)
Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________ MEDICAL ASSESSMENT (Use this area or
Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________
ent labs and other authoriza on informa on)
Primary Diagnosis: _________________________ ICD9 Code: ________________________ 696.1 Psoriasis 696.0 Psor c Arthri s Secondary Diagnosis: _______________________ ICD9 Code: ________________________ Previous Treatment(s): ________________________________________________ Date of Diagnosis: __________________ Previous Treatment Outcome:___________________________________________ NO Is taking Methotrexate? YES NO Is nt at risk for Hepa B? YES NO Has ent tried and failed oral systemic DMARD agents? YES NO Results if YES: ________________________________________________________________ Has TB test been done? YES YES NO Is diagnosed with lymphoma? YES NO Is diagnosed with heart failure? PRESCRIPTION INFORMATION *(Use this area or
MEDICATION
Enbrel®
Humira®
Remi ade® Simponi®
STRENGTH
DIRECTIONS
QNTY.
50mg/ml Sureclick Autoinjector 50mg/ml Pre ed Syringe 25mg/0.5ml Pre ed Syringe 25mg Vial
50mg sub-q BIW (3-4 days apart) for 3 months then maintenance dose 50mg sub-q QW Other:
Psoriasis Starter Pack
80mg (2pens) sub-q day 1, then 40mg on day 8 then 40mg QOW 40mg sub-q QOW Other: _____________________________________
40mg/0.8ml Pen 20mg/0.4ml Pre ed Syringe 100mg Vial 50mg/0.5ml Pre ed SmartJect 50mg/0.5ml Pre ed Syringe 45mg/0.5ml Pre ed Syringe
Stelara®
opy of RX(s)
90mg/mL Pre led Syringe
REFILL
Infuse 5mg/kg at week 0, 2, 6 and every 8 weeks Other: _____________________________________ Inject 50mg/0.5ml sub-q once monthly Other: ___________________________________ <100kg: 45mg sub-q n and 4 weeks followed by 45mg every 12weeks >100kg: 90mg sub-q n and 4 weeks followed by 90mg every 12 weeks Other: ___________________________________
_____________
iber Signature: _____________________________________________________
Date: _____________
PRESCRIBER INFORMATION Prescriber Name: ________________________________________ NPI#: ______________________ Contact:__________________________________ Address:__________________________________ City: _________________ State: _________ ZIP: ____________ Ph: _________________________ Fax: ________________________________ DEA#: ________________________ St. License: ___________________________________ Email: ________________________________________________________________
FAX TO: (888) 294-9434 RFDRMVS.12
DERMATOLOGY / PSORIASIS COMPOUNDED PRESCRIPTION FORM
PRESCRIPTION
Today’s Date
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS
MID LEVEL TO HIGH LEVEL PSORIASIS - CREAM
PSORIASIS - SPRAY
SOOTHING CREAMS
WARTS
ROSACEA
ANESTHETICS
CHELOIDS
SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL):
Prescriber’s Signature
at 888-966-0188
www.AMERICANSPECIALTYRX.com Plano | Denton | El Paso | San Antonio | Miami | Tyler | Houston