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
HEPATITIS / CROHNS Form
Treating Patients Special PATIENT INFORMATION (Use this area or
American Specialty to Arrange
Ship to:
Pa ent Home
MD
e
CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com 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: ________________________ Secondary Diagnosis: _______________________ ICD9 Code: ________________________ Genotype: ______ Subtype: ______ Relapsed Par al Response Null Response Liver Biopsy Date: ___________ Result of Biopsy: __________________________________ Previous Treatment: ____________________________________________________________ PRESCRIPTION INFORMATION *(Use this area or
opy of RX(s)
PEGASYS® Pre-Filled Convenience Pack 180mcg (0.5mL) Sub-Q QW Other: ____________________________________ Qty: ______ Re : ______ month(s)
PEG–INTRON® Kg (Lbs) Redipen Vials <40 (<88) Inject 50mcg (0.5mL) Sub-Q QW 40-50 (89-110) Inject 64mcg (0.4mL) Sub-Q QW 51-60 (111-132) Inject 80mcg (0.5mL) Sub-Q QW 61-75 (133-165) Inject 96mcg (0.4mL) Sub-Q QW 76-85(166-187) Inject 120mcg (0.5mL) Sub-Q QW >85 (>187) Inject 150mcg (0.5mL) Sub-Q QW Qty: __________ Re : _______ Month(s)
RIBAPAK® 800mg PO QD: (1)400mg QAM – (1)400mg QPM 1000mg PO QD: (1)400mg QAM – (1)600mg QPM 1200mg PO QD: (1)600mg QAM – (1)600mg QPM 1400mg PO QD: (1)600mg QAM – (1)600mg + (1)200mg QPM Re : _____ Month(s) DO NOT SUBSTITUTE / D.A.W.
HUMIRA® Humira Pen Starter Pack 40mg/pen, 6/box Other: _____________________________________ Sig:
Inject 160mg (4-pens) sub-q ini al dose then 80mg (2-pens) sub-q on day 15 then 40mg (1-pen) sub-q QOW Inject 80mg (2-pens) sub-q QD for 2 days l dose, then 80mg(2-pens) sub-q day 15, then 40mg (1-pen) sub-q QOW 40mg sub-q every 2 weeks 40mg sub-q every week Other: _________________________________
Quan ty: _______
Re : _______
HCV RNA: _________________ Hemoglobin: ______________ Hematocrit: _______________ ALT: _____________________ AST: _____________________
INFERGEN® 9mcg Sub-Q TIW 15mcg Sub-Q TIW 9mcg Sub-Q QD 15mcg Sub-Q QD Other: _______________________________ Qty: _____ Re : _______Month(s) RIBAVIRIN 200mg 600mg PO QD: 200mg-QAM 400mg-QPM Qty: 84 800mg PO QD: 400mg-QAM 400mg-QPM Qty: 112 1000mg PO QD: 400mg-QAM 600mg-QPM Qty: 140 1200mg PO QD: 600mg-QAM 600mg-QPM Qty: 168 1400mg PO QD: 600mg-QAM 800mg-QPM Qty: 196 Other PO QD: _______QAM / ______QPM Qty: ___ Re :_______ Month(s)
CIMZIA® 200mg single dose vials 2/box Qty: ____ boxes 200mg single use PFS 2/box Qty: ____ boxes Sig: Ini al dose: 400mg sub-q at week 0, 2, and 4 Maintenance: 400mg sub-q every 4 weeks Re : _________ REMICADE® Single use 100mg vial #____vials Excel sodium chloride 250ml bag #____bags Sterile water / injec on 10ml/vial #____vials Normal saline 10mL/PFS #____syringes Epipen® Benadryl® 50mg vial PRN Direc : __________________________________ Re : __________
VICTRELIS® 200mg caps 800mg PO TID: (4)200mg caps Q7-9hrs w/ food. Begin day 29 of interferon/ribavirin Qty: 336 Re : _______
INCIVEK® 375mg tabs 750mg PO TID: (2)375mg tabs Q7-9hrs w/ food for 12 weeks with interferon/ribavirin Qty: 168 tablets Aranesp® Neulasta®
Re : _______ Epogen® Neupogen®
Dose: ___________________ Sig: ________________________ Qty: ______
Re : ______
HEPATITIS B ORAL THERAPIES Baraclude 1 Tablet po QD 0.5mg 1.0mg Epivir HBV 100mg __________ Hepsara 10mg _____________ Tyzeka 600mg _____________ Viread 300mg _____________
Signature: _________________________________ Date: _________
PRESCRIBER INFORMATION
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________
FAX TO: (888)294-9434
HCVFRMVS.912
GASTROENTEROLOGY/PROCTOLOGY COMPOUNDS 2743 West 15th Street, Plano, TX 75075 P: 877-753-6877 Fax: 888-966-0188
PRESCRIPTION CAPSULES
Today’s Date
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS
ENEMA
SOLUTION SUPPOSITORY
CREAMS
Prescriber’s Signature IMPORTANCE NOTICE:
at 888-966-0188
www.AMERICANSPECIALTYRX.com Plano | Denton | El Paso | San Antonio | Miami | Tyler | Houston