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
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
Corporate Offices 2743 W. 15 Street, Plano, TX 75075 Phone (214) 919-2090 Fax (214) 919-2091 Toll Free (877) 868-4110 Fax (877) 868-4144 Web www.AmericanSpecialtyPharmacy.com th
Treating)Patients)Special) FOR MORE INFORMATION PLEASE CALL (877) 868-4110 American Specialty Pharmacy is a Formulation Development and Pharmaceutical Compounding Company. Providing superior customer service along with quality custom compounded prescription drugs at competitive pricing is what we strive to achieve. With an outstanding reputation as an authority in dosage form, product development, and pain management therapies it’s no wonder why American Specialty Pharmacy has become our customers Pharmacy of choice. All questions or concerns are encouraged and welcomed by our amazing and highly trained staff. •
American Specialty Pharmacy uses USP and FDA approved products to insure industry quality and safety standards.
•
Superior customer service is our promise. With licensed technicians we insure the highest quality of compounded products.
•
Sterile products are compounded in ISO-5 Class-100 certified clean rooms and are 797 compliant.
PLANO – DENTON – TYLER – SAN ANTONIO – EL PASO – MIAMI
! ! ! ! ! ! !
Treating)Patients)Special)
•
) ) American Specialty Pharmacy has 4 Pharmacists on site to help ensure quality of compounded products.
•
American Specialty Pharmacy has Two “State of the Art” ISO-5 Class-100 clean rooms. One for compounding all sterile preparations & one negative pressure chemo room for compounding Chemotherapy medications.
•
American Specialty Pharmacy is fully compliant with USP797
•
E-Prescribing capability with real time order entry and tracking system
•
Specialized Customer Service
•
One stop for all your Pharmaceutical needs
For all questions or concerns please feel free to call us any time at (877) 868-4110
Pharmacy Locations Plano 2743 W. 15th Street Plano, TX 75075 Ph: (214) 919-2090 Fax: (214) 919-2091
Denton 2436 S. Interstate 35E Suite 360 Denton, TX 76205 Ph: (940) 383-1222 Fax: (940) 383-1444
San Antonio 2414 Babcock Rd. Suite 111 San Antonio, TX 78229 Ph: (210) 615-7400 Fax: (210) 615-7401
Tyler 1109 E. 5th Street Tyler, TX 75701 Ph: (903) 533-9100 Fax: (903) 533-9101
El Paso 1015 N. Zaragoza St. El Paso, TX 79907 Ph: (915) 860-7225 Fax: (915) 860-7320
Miami 2389 SW 22nd Street (Coral Way) Miami, FL 33145 Ph: (305) 856-0070 Fax: (305) 856-0072
Providing quality & personalized
prescription services for the
INJURED PERSON WE TAKE THE BURDEN OFF OF YOU Our customer service is second to none;; provided by highly trained staff. We assist the injured person throughout the entire process. From contacting your insurance carrier and attorney to automatic refills and overnight delivery. Please see reverse side for more detail.
OUR SERVICES We are a full service pharmacy that specializes in: Letter of Protection Workers’ Compensation Prescriptions Compounded & Specialty Medications Durable Medical Equipment (DME) Nutritional Supplementation
ABOUT US At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe and effective customized medications. Our pharmacists are experts at compounding new, discountinued, back-ordered, or unavailable medications to meet specific patient needs. We offer a full line of professional quality vitamins, nutritional supplements, OTC medications, medical equipment and home delivery. We look forward to serving you and meeting your pharmacy needs.
www.AMERICANSPECIALTYRX.com
Providing quality & personalized
prescription services for the
INJURED PERSON HOW IT WORKS... WE HELP SET UP YOUR PRESCRIPTION A member of our customer service team will help you set up your prescription and answer any questions that you may have. WE CALL YOUR INSURANCE & ATTORNEY Our dedicated staff will call your carrier to verify that your claim is active as well as handle any claim reviews and reimbursements. WE DELIVER RIGHT TO YOUR DOOR We will call and schedule your first delivery. All deliveries are delivered to your door within 24 hours. This service is offered at no out-of-pocket cost to you. WE TAKE CARE OF YOUR REFILLS Your refills are filled automatically based on your prescription or physician’s approval. It is not necessary to reorder! We bill the insurance carrier directly for all cost. We will glady work with your legal counsel to resolve any issues related to your claim. DALLAS AREA LOCATIONS PLANO 877-868-4110 PLANO 877-868-4 2743 West 15th Street - Suite B - Plano, TX EMAIL - info@americanspecialtyrx.com HOURS OF OPERATION Mon - Fri 9am until 7pm Sat & Sun 9am until 3pm
www.AMERICANSPECIALTYRX.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
Viscosupplementation Injectable Medication Precertification Request
American Specialty to Arrange
Ship to:
Pa ent Home
MD
e
CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com
Treating Patients Special PATIENT INFORMATION (Use this area or
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: __________________________________________ Please indicate:
Start of treatment
Continuation of therapy: Right knee Left knee D a te of la s t tre a tme nt:
both knees
T oday’s date:
Date needed:
Requesting prior authorization for viscosupplementation therapy for: Right knee Left knee both knees Please indicate which drug you are requesting : (P is preferred, NP is non-preferred) Euflexxa ® (P) Hyalgan ® (NP) Orthovisc ® (P) Supartz ® (NP) Synvisc ® (NP) Synvisc One ® (NP) Yes No Does the patient have documented symptomatic osteoarthritis of the knee? Yes No Has the patient had a documented failure after at least 3 months of conservative therapy (including physical therapy, pharmacotherapy, i.e. non steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and/or topical capsaicin cream)? Yes No Is the patient unable to tolerate conservative therapy because of adverse side effects? Yes No Has the patient failed to adequately respond to aspiration and injection of intra-articular steroids? Yes No Does the patient report pain which interferes with functional activities (i.e., ambulation, prolonged standing)? If Yes, is the pain attributed to other forms of joint disease? Yes No Yes No Does the patient have any contraindications to the injections (i.e., active joint infection, bleeding disorder)? Yes No Has the patient had a documented trial and failure of Euflexxa and Orthovisc? If Yes, please provide the dates of treatment for both products: Euflexxa: Orthovisc: If requesting additional series of injections for patient: Date of last injection from prior series: Yes No Did the patient respond adequately to the prior series of injections? Yes No Does the patient’s medical record demonstrate a reduction in the dose of NSAIDs (or other analgesics or anti-inflammatory medication) during the period following the previous series of injections? Yes No Does the patient’s medical record document significant improvement in pain and functional capacity as the result of the previous injections?
PRESCRIPTION INFORMATION *(Use this area or MEDICATION - Refer to CPB # 0179
opy of RX(s) ASRx DISPENSING?
Euflexxa (sodium hyaluronate 1%)
Yes
No
Hyalgan (sodium hyaluronate)
Yes
No
Orthovisc (high molecular weight form of hyaluronic acid)
Yes
No
Supartz (sodium hyaluronate)
Yes
No
Synvisc (hylan G-F 20)
Yes
No
Synvisc One
Yes
No
(hylan G-F 20)
DIRECTIONS
QUANTITY
PRESCRIBER INFORMATION
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________
FAX TO: (888) 294-9434
HIVFRMVS.12
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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