Workers comp visit 1 by American Specialty Pharmacy

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.

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American Specialty Pharmacy is fully compliant with USP797

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E-Prescribing capability with real time order entry and tracking system

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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) 753-6877

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

2743 W. 15th St., Plano, TX 75075 Ph: 877-753-6877 Fax: 888-966-0188

INJECTABLE LIST Betamethasone Acetate/Phospate (Soluspan) 6mg/ml P/F

Methylprednisolone Suspension 40mg/ml and 80mg/ml P/F

Size

Betamethasone Sodium Phospate 12mg/ml P/F

Ondansetron 2mg/ml

Size

Chondroitin / Glucosamine / DMSO

Midazolam* 1-5mg/ml

Size

Hyaluronidase 150u/ml P/F

Fentanyl* 50mcg/ml

Size

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%

2ml vial 5ml vial 10ml vial

2ml vial (min 20 vials) 5ml vial (min 6 vials) 10ml vial (min 6 vials)

2ml vial (min 20 vials) 5ml vial (min 6 vials)

2ml vial (min 3 vials)

10ml vial preservative free

Size

1ml vial (min 20 vials) 2ml vial (min 20 vials)

2ml vial (min 50 vials)

1-2ml vial (min 50 vials)

2ml vial (min 50 vials) Size 50ml vial (min 12 vials) Lidocaine 1-2% Size 50ml vial (min 12 vials)

PLANO - DENTON - TYLER - SAN ANTONIO - EL PASO - MIAMI

PROCEDURES FOR OUT OF TOWN OR OUT OF STATE CII'S WHEN DEALING WITH OUT OF TOWN OR OUT OF STATE CII'S THE CLINIC WILL NEED TO: • FAX THE HARDCOPY TO THE PHARMACY • MAIL THE HARDCOPY TO THE PHARMACY IN A PREPAID FED-EX ENVELOPE PROVIDED BY THE PHARMACY. (THE PRESCRIPTION WILL NOT BE MAILED TO THE PATIENT UNTIL HARDCOPY IS RECEIVED) TO THE MARKETERS: IF YOU HAVE A CLINIC THAT WANTS TO USE US FOR THEIR CII MEDICATIONS PLEASE CONTACT THE DELIVERY MANAGER AT THE PHARMCY SO HE CAN PROVIDE YOU WITH THE PREPAID ENVELOPES TO BE GIVEN TO THE CLINIC. (PLEASE HAVE THE CORRECT ADDRESS FOR THE CLINC READY) PLEASE KEEP IN MIND WE DO NOT WANT CLINICS TO ONLY USE OUR PHARMACY FOR CII'S, WE WILL FILL CII'S AS A CURTISY WHEN FILLING OTHER MEDICATIONS FOR THAT CLINIC. WE DO NOT WANT ONLY CII'S COMING FROM ANY CLINIC. IF YOU HAVE ANY QUESTIONS PLEASE FEEL FREE TO CONTACT MAJA @ 214478-8564 OR RENEE @ 214-733-0741 DELIVERY MANAGER (HAIDER) 214-919-2090

Plano Ph: (214) 919-2090 Fax: (214) 919-2091 San Antonio Ph: (210) 615-7400 Fax: (210) 615-7401

Denton Ph: (940) 383-1222 Fax: (940) 383-1444 El Paso Ph: (915) 860-7225 Fax: (915) 860-7320

Miami Ph: (305) 856-0070 Fax: (305) 856-0072

Houston Tyler

WE HELP SET UP YOUR PRESCRIPTION

HASSLE FREE WE INSURANCE WECALL CALLYOUR YOUR ATTORNEY& &ATTORNEY INSURANCE

INJURED PERSON

WE DELIVER RIGHT TO YOUR DOOR

phone calls and paperwork”

Assistance is only a Phone Call away!

WE TAKE CARE OF YOUR REFILLS Open 7 Days a Week Corporate Oﬃce

Contact Us at: info@AmericanSpecialtyPharmacy.com lop@AmericanSpecialtyPharmacy.com Tel: (877) 753-6877 Fax: (888) 966-0188

2743 West 15th Street, Plano, TX 75075 Toll Free: 877-753-6877 www.AmericanSpecialtyPharmacy.com

PLEASE HAVE THE FOLLOWING INFORMATION AVAILABLE:

• Name, address and phone number.

• Employer & Insurance carrier name, address, phone number, adjuster name and claim number. • Doctor’s name, phone number and being prescribed.

Tel: (877) 753-6877 Fax: (888) 966-0188

CONVENIENCE IS OUR BUSINESS About Us • American Specialty Pharmacy is one of the leading providers of pharmaceu services in the United States. Our knowledge and exper in the business makes us recognizable in the industry. pharmaceu

• At American Specialty Pharmacy, we are

dedicated to address the well-being of our customers. We are driven by our commitment to be the best and strive to bring the best services and solu to all our clients.

solu

r all your prescrip

• Our dedicated staﬀ works diligently to reduce the stress, put into handling each claim.

• Assist with complicated claim forms • No Out-of-pocket expenses* • FREE Home Delivery Service Assis ng the

• By allowing us to manage your clients

department will promptly and carefully a end all phone calls, faxes, and requests.

American Specialty Pharmacy is able to assist you in resolving all injury claims. •Handle all Insurance Paperwork •Hassle Free Delivery •Drug Formulary Management &

• We will ensure that your clients' have all their prescrip completely sa

t and are

Data Maintainance & Side-Eﬀect

•

Management

the client's needs.

We can also ﬁll your regular prescriptons with a simple transfer.

*On approved claims

For the Physicians

orney

• Our experienced customer service

t that is

• We will CUSTOMIZE our services to ﬁt

Our professional and courteous staﬀ will ensure that your prescrip in a .

prescrip providing the best possible care for their other medical needs.

Why choose us?

• We are a FULL SERVICE, ONE STOP

Taking care of the t

*On approved claims

•Compounding & Infusion Services (supplements available upon request)

Triplicate Form for C-2 Fax us your prescription

Mail us the Triplicate Form in prepaid FedEx Next Day envelope*

Once received, our Pharmacy will dispense medicaton.

*Provided by our rep

www.AMERICANSPECIALTYRX.com

HOW IT WORKS: AUTO INJURY, WORKERS COMP

behalf

Upon receiving the prescription, we call you to schedule delivery (If you don’t hear from us within 24 hours, please contact our pharmacy)

(If applicable)

We file the insurance claim on your or bill your attorney

Automatic prescription refills (if necessary)

no out-of-pocket expenses*

FREE Delivery within 24 hours &

*On approved claims

We can also fill your regular prescriptions with a simple transfer

2743 W 15th Street, Plano, TX 75075 P: 214-919-2090 Fax: 214-919-2091

New Work Comp / PIP / LOP Information Today’s Date:____________________________ Date Of Injury:____________________________________ Patient’s Name:___________________________________________________________________________ Street Address:___________________________________________________________________________ City:______________________________ State:________________________

Zip Code:______________

Patient’s Home Phone:_________________________________ Cell:_______________________________ Patient’s Date Of Birth:_________________________________ Patient’s SSN:_______________________ Injured Body Area:________________________________________________________________________ Employer:______________________________________________________________________________ Street Address:__________________________________________________________________________ City:______________________________ State:________________________ Zip Code:_____________ Phone:______________________________________ Fax:______________________________________ Supervisor’s Full Name:___________________________________________________________________ WC Insurance Company:__________________________________________ Claim#:_________________ Street Address:__________________________________________________________________________ City:__________________________________________ State:_____________ Zip Code:_____________ Phone:______________________________________ Fax:______________________________________ Adjuster’s Full Name:_____________________________________________________________________ Phone Number:______________________________________________________ Ext#: ______________ Attorney’s Full Name:______________________________________________________________________ Phone Number: _________________________________ Fax: ____________________________________ Adress: ________________________________________________________________________________

Notes / Delivery Notes: ________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ www.AmericanSpecialtyPharmacy.com

Viscosupplementation Injectable Medication Precertification Request

Treating Patients Special

Injection Training:

Ship to:

MD Oﬃce American Specialty to Arrange

Patient Home

MD Oﬃce

CALL:(877)753-6877 FAX:(888)966-0188 EMAIL: info@americanspecialtyrx.com

PATIENT INFORMATION (Use this area or attach patient demographics) Name: ______________________________________ Phone: __________________________ Phone 2: _________________________ Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________ INSURANCE INFORMATION (Use this area or attach copy of insurance card(s) Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________

Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________

MEDICAL ASSESSMENT (Use this area or attach patient labs and other authorization information) 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:

CLINICAL INFORMATION - all clinical questions must be completed for precertiﬁcation request. 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 attach copy of RX(s) MEDICATION - Refer to CPB # 0179

ASRx DISPENSING?

Euflexxa (sodium hyaluronate 1%)

Yes

Hyalgan (sodium hyaluronate)

Yes

Orthovisc (high molecular weight form of hyaluronic acid)

Yes

Supartz (sodium hyaluronate)

Yes

Synvisc (hylan G-F 20)

Yes

Synvisc One

Yes

(hylan G-F 20)

DIRECTIONS

QUANTITY

PRESCRIBER INFORMATION

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

FAX TO: (888) 966-0188

HIVFRMVS.12

REFERRAL FORM Today’s Date

P: 877-753-6877 Fax: 888-966-0188 info@AmericanSpecialtyRX.com

NEW PATIENT

CURRENT PATIENT

Patient Name _____________________________________ DOB ____________ Weight ________ Male Female Street Address ________________________________________________________________________________________ Apt # _________ City ___________________________________________ State ____________________ Zip ___________ Daytime Ph ____________________________ Evening Ph ___________________________ Cell _____________________ Allergies_____________________________________________________________________________________________ Prescriber’s Name _____________________________________________ Oﬃce Contact_________________________ Street Address _________________________________________________________________________Suite#________ City ___________________________________ State ___________ Zip ________________ Tel____________________ License # _____________________ NPI # _____________________ DPS # ____________________ DEA #___________

PRESCRIPTION

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

Zofran 4 mg 8 mg Phenergan 25 mg Qty:___Sig:__________________Reﬁlls___

amitriptyline 10mg 25mg 75mg 100mg Venlafexine 37.5mg 50mg 100mg Qty:___Sig:__________________Reﬁlls___

cyclobenzaprine 5mg 7.5mg Tizanidine 2mg 4mg 6mg methocarbamol 500mg 750mg Qty:___Sig:__________________Reﬁlls___

Celebrex

100mg

200mg

400mg