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
ARTHRITIS / RHEUMATOLOGY 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
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: ________________________ 714.0 Rheumatoid Arthri s 720.0 Ankylosing Spond Secondary Diagnosis: _______________________ ICD9 Code: ________________________ 733.0 Osteoperosis Previous Treatment: ____________________________________________________________ 696.0 Psor c Arthri s Previous Treatment Outcome:____________________________________________________ NO 714.3 Juvenile Idiopathic Arthri s Is taking Methotrexate? YES NO Is nt at risk for Hepa B? YES NO Has ent tried and failed oral systemic DMARD agents? YES NO Results if YES: ________________________________________________________________ Has TB test been done? YES YES NO Is diagnosed with lymphoma? YES NO Is diagnosed with heart failure? PRESCRIPTION INFORMATION *(Use this area or
MEDICATION Actemra
Cimzia
Enbrel Humira Kineret
80mg/4mL 200mg/10mL 400mg/20mL
DIRECTIONS
QNTY.
Ini al Dose: 400mg sub-q day 1. Week 2, week 4 Maintenance Dose: 200mg sub-q QOW Maintenance Dose: 400mg sub-q every 4 weeks Other: __________________________________ 50mg sub-q QW 25mg sub-q BIW (72-96 hrs apart) Other: ___________________________________
40mg/0.8ml Pen 40mg/0.8ml Pre ed Syringe 20mg/0.4ml Pre ed Syringe
40mg sub-q QOW 20mg sub-q QOW Other:
100mg Pre ed Syringe
_________________
100mg Vial
REFILL
Ini al Dose: 4mg/kg every 4 weeks Maintenance Dose: 8mg/kg every 4 weeks Other:
50mg/ml Sureclick Autoinjector 50mg/ml Pre ed Syringe 25mg/0.5ml Pre ed Syringe 25mg Vial
125mg Orencia sub-q
Remicade
______mg/kg
STARTER KIT 200mg/1mL Pre ed Syringe 400mg vial
250mg Vial
Orencia
opy of RX(s)
STRENGTH
100mg sub-q QD Infuse ____mg at wks 0,2, 4 then every 4 wks Other: _________________________________________________ r single IV ini al dose, inject 125mg sub-q within a day followed by 125mg sub-q QW 125mg sub-q QW
mg/kg
Rituxan
100mg/10ml vial 500mg/50ml vial
Simponi
50mg/0.5ml Pre ed SmartJect 50mg/0.5ml Pre ed Syringe
Infuse 2 doses of 1000mg separated by 2 weeks Other: _______________________________________ Inject 50mg/0.5ml sub-q once monthly Other: ___________________________________
Signature: ______________________________________________
Date: ___________________
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________
FAX TO: (888) 294-9434
RHUMFRMVS.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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