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Treating)Patients)Special)
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) ) American Specialty Pharmacy has 4 Pharmacists on site to help ensure quality of compounded products.
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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
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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
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
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
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
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 2743 West 15th Street, Plano, TX 75075 P: 877-753-6877 Fax: 888-966-0188
PRESCRIPTION
Today’s Date NEW PATIENT
CURRENT PATIENT
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS
FIBROMYALGIA (TOPICAL):
Cream Size (Pump): 75gm (Seventy-Five Grams) 100gm (One-Hundred Grams)
*A
1 (One) 2 (Two) 3 (Three)
C-
FORMULAS FOR TOPICAL PAIN/ARTHRITIS/SPASM/NEUROPATHY:
Smallest Size
CCCC-
SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL): C-
ADDITIONAL INJURED WORKER MEDICATION Medrox Patches
SLEEP DISORDER: Somnicin
SentraPM Procomycin
STOOL SOFTNER: Laxacin Promolaxin
OSTEOARTHRITIS: Synovacin Genicin
Prescriber’s Signature then
at 888-966-0188
2743 W 15th Street, Plano, TX 75075 P: 214-919-2090 Fax: 214-919-2091
New Work Comp / PIP / LOP Information
Notes / Delivery Notes: ________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ www
y
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