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
ALLERGY & IMMUNOLOGY
American Specialty to Arrange
Ship to:
Treating Patients Special
CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com
PATIENT INFORMATION (Use this area or
Pa ent Home
MD
e
American Specialty Pharmacy
nt 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
opy of insuran
Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________ MEDICAL ASSESSMENT (Use this area or
ent
ard(s)
Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________
s 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
Xolair ® (omalizumab) Prescription type: Naïve/new start Restart Continued therapy Prescription to include diluent and ancillary supplies as needed for medication administration.
Hizentra® 20%
Infuse total dose of immune globulin divided over 1–4 subcutaneous sites simultaneously, as appropriate; administer over 1–2 hours via infusion pump
Gammagard® liquid 10% Infuse total dose of immune globulin divided over 1–4 subcutaneous sites simultaneously, as appropriate; administer over 1–2 hours via infusion pump
Firazyr®
Administer one 30 mg subcutaneous injection in the abdominal area
Cinryze® Dispense 1 vial of Sterile Water for Injection (USP) 5 mL per 500 Unit vial of CINRYZE Sig: Use 1,000 Units IV as directed by physician (2 vials = 1,000 U dose)
Ilaris®
HCV RNA: _________________ Hemoglobin: ______________ Hematocrit: _______________ ALT: _____________________ AST: _____________________
opy of RX(s) Dose: 150 mg/dose subcutaneously every 4 weeks 300 mg/dose subcutaneously every 4 weeks
Dispense: 30-day supply 90 -day supply
Re ll: ______________ times
Other____________
225 mg/dose subcutaneously every 2 weeks 300 mg/dose subcutaneously every 2 weeks 375 mg/dose subcutaneously every 2 weeks
_______ mg per kg (rounded to nearest vial size) OR _______ gm to be administered subcutaneously
______ day(s) per week OR daily for _____day(s)
# _________________ OR Date ____________
every ______ week(s)
_______ mg per kg (rounded to nearest vial size) OR _______ gm to be administered subcutaneously
______ day(s) per week OR daily for _____day(s)
# _________________ OR Date ____________
every ______ week(s)
One (1) syringe Three (3) syringes
# _________________ OR Date ____________
________ vials (2 vials = 1,000 U dose)
# _________________ OR Date ____________
Given every 8 weeks as a subcutaneous injection
Date ____________
One (1) subcutaneous injection 30 mg
1 Dose (2 vials = 1,000 U dose) every three days Quantity: 20 vials, Number of Days’ Supply: 30 day 1 Dose (2 vials = 1,000 U dose) every four days Quantity: 16 vials, Number of Days’ Supply: 30 day Other _____ Dose_____________ every ___ days Quantity: ___ vials, Number of Days’ Supply: ___ day 150 mg for body weight >40 kg 2 mg/kg for body weight ≥15 kg and ≤40 kg
*Dose can be increased to 3 mg/kg if response is inadequate
Signature: ______________________________________________
Date: ___________________
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________
FAX TO: (888)294-9434
HCVFRMVS.912
COMPOUNDED NON-STERILE REFERRAL FORM
PRESCRIPTION
Today’s Date
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS
Cream Size (Pump)
Prescriber’s Signature
at 888-966-0188
www.AMERICANSPECIALTYRX.com Plano | Denton | El Paso | San Antonio | Miami | Tyler | Houston