Orthopedics / Ortho Surgeon

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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


Midazolam* 1-5mg/ml

1-2ml vial (min 50 vials)Size

Fentanyl*50mcg/ml


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

[email protected]

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?

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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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ϮϳϰϯtĞƐƚϭϱƚŚ^ƚƌĞĞƚWůĂŶŽdyϳϱϬϳϱWϴϳϳͲϳϱϯͲϲϴϳϳ&ĂǆϴϴϴͲϵϲϲͲϬϭϴϴ

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

Orthopedics / Ortho Surgeon

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