Oncology by American Specialty Pharmacy

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

FREE DELIVERY

2743 W. 15th St., Plano, TX 75075 Ph: 877-868-4110 Fax: 877-868-4144 INTRATHECAL MEDICATION LIST BACLOFEN

Strengths up to 1000mcg/ml 1001mcg/nl up to 2000mcg/ml 2001mcg/ml up to 4000mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

BUPIVACAINE

Strengths up to 8mg/ml (.8%) 8.1mg/ml up to 40mgml (4%)

Up to 20cc

21 to 30cc

31 to 60cc

CLONIDINE

Strengths up to 2000mcg/ml 2001mcg/ml to 4000mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

DROPERIDOL

Strengths up to 20mcg/ml 21mcg/ml and up

Up to 20cc

21 to 30cc

31 to 60cc

FENTANYL

Strengths up to 50mcg/ml 51mcg/ml up to 500mcg/ml 501mcg/ml up to 1000mcg/ml 1001mcg/ml up to 3000mcg/ml 3001mcg/ml up to 5000mcg/ml 5001mcg/ml up to 7500mcg/ml 7501mcg/ml up to 10,000mcg/ml 10,001mcg/ml up to 15,000mcg/ml 15,001mcg/ml up to 20,000mcg/ml 20,001mcg/ml up to 25,000mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

HYDROMORPHONE

Strengths up to 15mg/ml 15.1mg/ml up to 30.1mg/ml up to 45.1mg/ml up to 60.1mg/ml up to 80.1mg/ml up to 90.1mg/ml up to

Up to 20cc

21 to 30cc

31 to 60cc

30mg/ml 45mg/ml 60mg/ml 80mg/ml 90mg/ml 150mg/ml

KETAMINE

Strengths up to 20mcg/ml 21mcg/ml and up

Up to 20cc

21 to 30cc

31 to 60cc

MEPERIDINE

Strengths up to 50mg/ml 50.1mg/ml up to 100mg/ml 100.1mg/ml up to 200mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

METHADONE

Strengths up to 25mg/ml 25.1mg/ml up to 50mg/ml 50.1mg/ml up to 80mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

MORPHINE

Strengths up to 25mg/ml 25.1mg/ml up to 50mg/ml 50.1mg/ml up to 60mg/ml 60.1mg/ml up to 70mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

ROPIVACAINE

Strengths up to 10mg/ml

Up to 20cc

21 to 30cc

31 to 60cc

PRIALT

CALL FOR PRICING

SUFENTANIL

Strengths up to 50mcg/ml 51mcg/ml up to 100mcg/ml

Up to 20cc

21 to 30cc

31 to 60cc

TETRACAINE

Strengths up to 10mg/ml (1%) 10.1mg/ml up to 20mg/ml (2%)

Up to 20cc

21 to 30cc

31 to 60cc

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 Workersâ&#x20AC;&#x2122; 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 physicianâ&#x20AC;&#x2122;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

CANCER / ONCOLOGY 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

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 Diagnosis: ___________________________________ Secondary / Other Diagnosis: ____________________________________ ICD9 Code: _________________________________ ICD9 Code: ______________________________________ Previous Treatment(s): _________________________________________ Outcome: __________________________________________ Revlimid® – RevAssist Physican Auth#: ____________ PRESCRIPTION INFORMATION *(Use this area or Medi

Aranesp Av Erivedge Gleevec

Thalomid® – STEPS Program Physician Auth#: ______________ opy of RX(s)

/ Write in other(s)

Hycam n Inlyta Neulasta

Neupogen Nexavar Perjeta Procrit Revlimid

Rituxan Sprycel Sutent Sylatron Tarceva

Tasigna Temodar Thalomid Tykerb

Votrient Xalkori Xeloda Zelboraf Zolinza

Other: _____________ Other: _____________

This is a list of the most common Specialty Cancer / Oncology medica Dose / Strength:

American Specialty Pharmacy is available to all of your needs.

Sig /

Re l(s): ____________

____________

Date: _______________

Prescriber Signature: ___________________________________________________

Please include any other medica your needs including IV

PRESCRIBER INFORMATION

Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________

FAX TO: (888) 294-9434 ONCFRMVS.912

LOW MOLECULAR WEIGHT REFERRAL FORM

PRESCRIPTION

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

FRAGMIN

LOVENOX

ARIXTRA

ADDITIONAL NOTES:

HEPARIN SODIUM

OTHER

Prescriber’s Signature IMPORTANCE NOTICE:

at 888-966-0188

PAIN AND EMETIC REFERRAL FORM

PRESCRIPTION

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

Hydromorphone:

Morphine:

Oxycodone:

Fentanyl:

SIG: ___________________________________________________________________________________________ QTY: _____ Refill: _____ Hydrocodone:

Zofran:

Prescriber’s Signature IMPORTANCE NOTICE:

at 888-966-0188

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:

CYTOTOXIC, STEROIDS & DIAGNOSTICS

PRESCRIPTION

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

Prescriber’s Signature IMPORTANCE NOTICE:

at 888-966-0188

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