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
2743 W. 15th St., Plano, TX 75075 Ph: 877-868-4110 Fax: 877-868-4144
INJECTABLE LIST Betamethasone Acetate/Phospate (Soluspan) 6mg/ml P/F
Methylprednisolone Suspension 40mg/ml and 80mg/ml P/F
Size
Size
2ml vial 5ml vial 10ml vial
2ml vial (min 20 vials) 5ml vial (min 6 vials) 10ml vial (min 6 vials)
Betamethasone Sodium Phospate 12mg/ml P/F
Ondansetron 2mg/ml
Size
Size
2ml vial (min 20 vials) 5ml vial (min 6 vials)
2ml vial (min 50 vials)
Chondroitin / Glucosamine / DMSO
Midazolam* 1-5mg/ml
Size
Size
2ml vial (min 3 vials)
1-2ml vial (min 50 vials)
Hyaluronidase 150u/ml P/F
Fentanyl* 50mcg/ml
Size
Size
10ml vial preservative free
2ml vial (min 50 vials)
Dexamethasone (Decadron equiv.) P/F same price as Triamcinolone (same min. quantities apply Triamcinolone Acetonide P/F 40mg/ml P/F
Sodium Bicarbonate 4.2% - 8.4%
Size 1ml vial (min 20 vials) 2ml vial (min 20 vials)
Size 50ml vial (min 12 vials) Lidocaine 1-2% Size 50ml vial (min 12 vials)
PLANO - DENTON - TYLER - SAN ANTONIO - EL PASO - MIAMI
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
MULTIPLE SCLEROSIS / NEUROLOGY
Form CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com
Treating Patients Special PATIENT INFORMATION (Use this area or
American Specialty to Arrange
Ship to:
Pa ent Home
MD
e
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
ard(s)
Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________
h pa ent labs and other authoriz
Primary Dx: ___________________________________ ICD9 Code: ________________________ Secondary Dx: _________________________________ ICD9 Code: ________________________ Previous Treatment: ______________________________________________________________ Previous Treatment Outcome:______________________________________________________ YES NO Med(s): _________________________________ Is currently on Therapy? PRESCRIPTION INFORMATION *(Use this area or Pre ed Syringe Vials 30mcg
Avonex
Betaseron
Extavia
Relapsing Remi Primary Progressive Secondary Progressive Progressive Relapsing Other: ______________
opy of RX(s) Qnty:
Re :
Betaject Lite Week 1&2 0.0625mg (0.25ml) SQ QOD Week 3&4 0.125mg (0.5ml) SQ QOD Week 5&6 0.1875mg (0.75ml) SQ QOD Week 7+ 0.25mg (1ml) SQ QOD 0.25 mg (1ml) SQ QOD
Qnty:
Re :
Week 1&2 0.0625mg (0.25ml) SQ QOD Week 3&4 0.125mg (0.5ml) SQ QOD Week 5&6 0.1875mg (0.75ml) SQ QOD Week 7+ 0.25mg (1ml) SQ QOD 0.25 mg (1ml) SQ QOD Other: _______________________________________________________
Qnty:
Re :
30mcg IM QW Other: _____________________________
Copaxone
Copaxone Autoject 20mg SQ QD
Qnty:
Re :
Gilenya
0.5mg Capsule PO QD Other: ____________________________________________________
Qnty:
Re :
Rebiject Auto Injec n Week 1&2 4.4mcg (0.1ml) SQ TIW Week 3&4 11mcg (0.25ml) SQ TIW Week 5+ 22mcg (0.5ml) SQ TIW Other: _________________________________________________________
Qnty:
Re :
Rebiject Auto Injec n Week 1&2 8.8mcg (0.2ml) SQ TIW Week 3&4 22mcg (0.5ml) SQ TIW Week 5+ 44mcg (0.5ml) SQ TIW Other: _________________________________________________________
Qnty:
Re :
Rebif 22mcg/0.5ml
Rebif 44mcg/0.5ml Other:
Dose /
ns:
Qnty:
Re :
Other:
Dose /
ns:
Qnty:
Re :
Signature: ______________________________________________
Date: ___________________
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________
FAX TO: (888) 294-9434
MSFRMVS.912
NEUROLOGY & PAIN REFERRAL FORM
PRESCRIPTION
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS
FIBROMYALGIA (TOPICAL): *A
Cream Size (Pump): 75gm (Seventy-Five Grams)
FORMULAS FOR TOPICAL PAIN/ARTHRITIS/SPASM/NEUROPATHY:
SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL):
NEUROPATHIC PAIN & ANTI - INFLAMMATORY SPRAY:
MIGRAINE HEADACHE:
Prescriber’s Signature
Today’s Date
Spray Size:
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