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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.
• 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
2743 W. 15th St., Plano, TX 75075Ph: 877-868-4110 Fax: 877-868-4144
INJECTABLE LIST
BetamethasoneAcetate/Phospate (Soluspan)6mg/ml P/F
2ml vial5ml vial10ml vial
Size
Betamethasone Sodium Phospate12mg/ml P/F
2ml vial (min 20 vials)5ml vial (min 6 vials)
Size
Chondroitin / Glucosamine / DMSO
2ml vial (min 3 vials)Size
Hyaluronidase150u/ml P/F
10ml vial preservative freeSize
Dexamethasone (Decadron equiv.)P/F same price as Triamcinolone(same min. quantities applyTriamcinolone Acetonide P/F 40mg/ml P/F
1ml vial (min 20 vials)2ml vial (min 20 vials)
Size
Methylprednisolone Suspension40mg/ml and 80mg/ml P/F
2ml vial (min 20 vials)5ml vial (min 6 vials)10ml vial (min 6 vials)
Size
Ondansetron2mg/ml
2ml vial (min 50 vials)Size
Midazolam* 1-5mg/ml
1-2ml vial (min 50 vials)Size
Fentanyl*50mcg/ml
2ml vial (min 50 vials)Size
Sodium Bicarbonate 4.2% - 8.4%
Size 50ml vial (min 12 vials)Lidocaine 1-2%
Size 50ml vial (min 12 vials)
PLANO - DENTON - TYLER - SAN ANTONIO - EL PASO - MIAMI
BACLOFEN Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 1000mcg/ml 1001mcg/nl up to 2000mcg/ml 2001mcg/ml up to 4000mcg/ml
BUPIVACAINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 8mg/ml (.8%) 8.1mg/ml up to 40mgml (4%)
CLONIDINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 2000mcg/ml 2001mcg/ml to 4000mcg/ml
DROPERIDOL Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 20mcg/ml 21mcg/ml and up
FENTANYL Strengths Up to 20cc 21 to 30cc 31 to 60cc 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
HYDROMORPHONE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 15mg/ml 15.1mg/ml up to 30mg/ml 30.1mg/ml up to 45mg/ml 45.1mg/ml up to 60mg/ml 60.1mg/ml up to 80mg/ml 80.1mg/ml up to 90mg/ml 90.1mg/ml up to 150mg/ml
KETAMINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 20mcg/ml 21mcg/ml and up
MEPERIDINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 50mg/ml 50.1mg/ml up to 100mg/ml 100.1mg/ml up to 200mg/ml
METHADONE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 25mg/ml 25.1mg/ml up to 50mg/ml 50.1mg/ml up to 80mg/ml
MORPHINE Strengths Up to 20cc 21 to 30cc 31 to 60cc 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
ROPIVACAINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 10mg/ml
PRIALT CALL FOR PRICING
SUFENTANIL Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 50mcg/ml 51mcg/ml up to 100mcg/ml
TETRACAINE Strengths Up to 20cc 21 to 30cc 31 to 60cc up to 10mg/ml (1%) 10.1mg/ml up to 20mg/ml (2%)
INTRATHECAL MEDICATION LIST
FREE DELIVERY2743 W. 15th St., Plano, TX 75075
Ph: 877-868-4110 Fax: 877-868-4144
/GFKECVKQPUECPDGRTQXKFGFKPU[TKPIGUQTXKCNU8KCNUYKNNDGWUGFWPNGUUQVJGTYKUGURGEKƂGF 3WGUVKQPUQT%QPEGTPUECNN PLANO - DENTON - TYLER - SAN ANTONIO - EL PASO - MIAMI
Corporate Offices 2743 W. 15th 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
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)
OUR PRODUCTS & SERVICES We are a full service pharmacy that specializes in:
Compounded & Specialty MedicationsDurable Medical Equipment (DME)
Nutritional SupplementationWorkers’ Compensation Prescriptions
Everyday Prescriptions
WE TAKE THE BURDEN OFF OF YOUOur 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.
We look forward to serving you and meeting all of your pharmacy needs.
www.AMERICANSPECIALTYPHARMACY.com
HOURS OF OPERATIONMon - Fri 9am until 7pm Sat & Sun 9am until 3pm
COMPLIMENTARY DELIVERYAll deliveries are delivered straight to
your door within 24 hours at no out-of-pocket cost to you.
AUTOMATIC REFILLSYour re lls are lled automatically based on
your prescription or physician’s approval. It is not necessary to reorder!
PLANO LOCATION2743 West 15th Street
Plano, TX 75075P: 877-868-4110 . F: 877-868-4144
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.
www.AMERICANSPECIALTYPHARMACY.com
PATIENT INFORMATION (Use this area or ĂƩĂĐŚ ƉĂƟĞnt demographiĐs)
Name: ______________________________________ Phone: __________________________ Phone 2: _________________________Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________
INSURANCE INFORMATION (Use this area or ĂƩĂĐŚ Đopy of insuranĐĞ Đard(s)
Primary Name: _____________________________________ Secondary / RX: _____________________________________________Phone: ___________________________________________ Phone: ____________________________________________________ ID#: _______________________ Group: _______________ ID#: _________________________ Group: ______________________
MEDICAL ASSESSMENT (Use this area or ĂƩĂĐh paƟent labs and other authorizĂƟŽŶ ŝŶĨŽƌŵĂƟŽŶͿ
Primary Diagnosis: ___________________________________ Secondary / Other Diagnosis: ____________________________________ICD9 Code: _________________________________ ICD9 Code: ______________________________________ Previous Treatment(s): _________________________________________ Outcome: __________________________________________
PRESCRIPTION INFORMATION *(Use this area or ĂƩĂĐŚ Đopy of RX(s)
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ Oĸce Contact: __________________________________________
HIVFRMVS.12
Viscosupplementation InjectableMedication Precertification Request
PRESCRIBER INFORMATION
Treating Patients SpecialShip to: PaƟent Home MD KĸĐe
/ŶũĞĐƟŽŶdƌĂŝŶŝŶŐ DKĸĐĞAmerican Specialty to Arrange
FAX TO: (888) 294-9434
CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: [email protected]
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)
Eu!exxa ® (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-in!ammatory drugs (NSAIDs), acetaminophen, and/or topical capsaicin cream)? Yes No Is the patient unable to tolerate conservative therapy because of adverse side e"ects? 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 Eu!exxa and Orthovisc?
If Yes, please provide the dates of treatment for both products: Eu!exxa: 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-in!ammatory medication)
during the period following the previous series of injections? Yes No Does the patient’s medical record document signi#cant improvement in pain and functional capacity as the result of the previous injections?
>/E/>/E&KZDd/KE ͲĂůůĐůŝŶŝĐĂůƋƵĞƐƟŽŶƐŵƵƐƚďĞĐŽŵƉůĞƚĞĚĨŽƌƉƌĞĐĞƌƟĮĐĂƟŽŶƌĞƋƵĞƐƚ
MEDICATION - Refer to CPB # 0179 ASRx DISPENSING? DIRECTIONS QUANTITY
Eu!exxa (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 (hylan G-F 20) Yes No
Please indicate: Start of treatment Continuation of therapy: Right knee Left knee both knees :tnemtaert tsal fo etaD
T oday’s date: Date needed:
Today’s Date
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS
NEUROLOGY & PAIN REFERRAL FORM
PRESCRIPTION
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FIBROMYALGIA (TOPICAL):*AƉƉůLJϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůLJůůŽǁĂƚůĞĂƐƚϮϬŵŝŶƚŽĂďƐŽƌď;ϭƉƵŵƉсϭϱŐŵͿ
Ͳ'ƵĂŝĨĞŶĞƐŝŶϭϬйн&ůƵƌďŝƉƌŽĨĞŶϯϱйн<ĞƚĂŵŝŶĞϯйн>ŝĚŽĐĂŝŶĞϮйнWŝƌŽdžŝĐĂŵϭйнLJĐůŽďĞŶnjĂƉƌŝŶĞϭйнDĂŐŶĞƐŝƵŵŚůŽƌŝĚĞϭϬйнWĞƉƉĞƌŵŝŶƚϬϭйͲ&ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϭϬйнEŝĨĞĚŝƉŝŶĞϮйнWĞŶƚŽdžLJĨLJůůŝŶĞϮйнůƉŚĂ>ŝƉŽŝĐĐŝĚϮйFORMULAS FOR TOPICAL PAIN/ARTHRITIS/SPASM/NEUROPATHY:ΎŽƐŝŶŐсƉƉůLJϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůLJ;ϭƉƵŵƉсϭϱŐŵͿͲ&ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϭϬйͲ&ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн<ĞƚĂŵŝŶĞϭϬйн>ŝĚŽĐĂŝŶĞϱйͲ&ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂnjĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϮйͲ&ůƵƌďŝƉƌŽĨĞŶϱйнLJĐůŽďĞŶnjĂƉƌŝŶĞϭйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭйͲŝĐůŽĨĞŶĂĐϱйнWƌŝůŽĐĂŝŶĞϮйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭйͲ&ůƵƌďŝƉƌŽĨĞŶϳйнLJĐůŽďĞŶnjĂƉƌŝŶĞϮйнKƌƉŚĞŶĂĚƌŝŶĞϱйн'ĂďĂƉĞŶƟŶϱйн<ĞƚĂŵŝŶĞϱйͲdƌĂŵĂĚŽůϭϬйнWƌŝůŽĐĂŝŶĞϮйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭй
SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL):ΎƉƉůLJϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůLJ;ϭƉƵŵƉсϭϱŐŵͿͲ&ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂnjĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϰйн<ĞƚĂŵŝŶĞϮйнϬϮйϮĞŽdžLJͲͲ'ůƵĐŽƐĞнϯйĐLJĐůŽǀŝƌ
WůĞĂƐĞƐƉĞĐŝĨLJďŽĚLJĂƌĞĂͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
NEUROPATHIC PAIN & ANTI - INFLAMMATORY SPRAY:ΎƉƉůLJϯ;ϭŵůͿƐƉƌĂLJƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϰƟŵĞƐĚĂŝůLJͲ&ůƵƌďŝƉƌŽĨĞŶϳϱйнLJĐůŽďĞŶnjĂƉƌŝŶĞϮйнDĞŶƚŚŽůϯйн>ŝĚŽĐĂŝŶĞϮϬйнD^KͲ<ĞƚĂŵŝŶĞϮϬйнDĞƚŚLJů^ĂůŝĐLJůĂƚĞϯϬйнDĞŶƚŚŽůϯйнD^KͲdƌĂŵĂĚŽůϮϬйнLJĐůŽďĞŶnjĂƉƌŝŶĞϮйнWƌŝŽůŽĐĂŝŶĞϮϱйн>ŝĚŽĐĂŝŶĞϭϮϱйнDĞŶƚŚŽůϯйMIGRAINE HEADACHE:ΎWůĞĂƐĞƐƉĞĐŝĨLJĚŽƐĞĂŶĚĨƌĞƋƵĞŶĐLJͲƌŐŽƚĂŵŝŶĞϭŵŐĂīĞŝŶĞϭϬϬŵŐĞůůĂĚŽŶŶĂϭϬŵŐĂƉƐƵůĞͲƌŐŽƚĂŵŝŶĞdĂƌƚƌĂƚĞϮŵŐ^ƵďůŝŶŐƵĂůdĂďůĞƚƐ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ
Cream Size (Pump): 75gm (Seventy-Five Grams)ϭϬϬŐŵ;KŶĞͲ,ƵŶĚƌĞĚ'ƌĂŵƐͿZĞĮůůƐͺͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ^ŵĂůůĞƐƚ^ŝnjĞϱϬŐŵ;&ŝŌLJ'ƌĂŵƐͿ
Spray Size:ϲϬŵů;^ŝdžƚLJŵŝůůŝůŝƚĞƌƐͿϭϮϬŵů;KŶĞŚƵŶĚƌĞĚdǁĞŶƚLJŵŝůůŝůŝƚĞƌƐͿZĞĮůůƐͺͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ
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