!!!!!!

!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

www.AMERICANSPECIALTYRX.com

HOW IT WORKS...

Providing quality & personalizedprescription services for theINJURED PERSON

WE HELP SET UP YOUR PRESCRIPTIONA member of our customer service team will help youset up your prescription and answer any questions that

you may have.

WE CALL YOUR INSURANCE & ATTORNEYOur dedicated staff will call your carrier to verify thatyour claim is active as well as handle any claim reviewsyour claim is active as well as handle any claim reviews

and reimbursements.

WE DELIVER RIGHT TO YOUR DOORWe 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 REFILLSYYour 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 LOCATIONSPLANO 877-­868-­4PLANO 877-­868-­4110

2743 West 15th Street -­ Suite B -­ Plano, TX

EMAIL -­ info@americanspecialtyrx.com

HOURS OF OPERATIONMon -­ Fri 9am until 7pm Sat & Sun 9am until 3pm

Providing quality & personalizedprescription services for the

INJURED PERSONWE 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 SERVICESWe are a full service pharmacy that specializes in:

Letter of Protection

Workers’ Compensation Prescriptions

Compounded & Specialty Medications

Durable Medical Equipment (DME)

Nutritional SupplementationNutritional Supplementation

ABOUT USAt 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.

WWe 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

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: info@americanspecialtyrx.com

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 DateNEUROLOGY & PAIN REFERRAL FORMNEW PATIENT CURRENT PATIENT

2743 West 15th Street, Plano, TX 75075P: 877-753-6877 Fax: 888-966-0188

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDSPRESCRIPTION

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&ĂdžĐŽŵƉůĞƚĞĚĨŽƌŵƚŽDZ/E^W/>dzW,ZDzat 888-966-0188

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&ŝƌƐƚ DŝĚĚůĞ >ĂƐƚ

OSTEOARTHRITIS:ΎŽƐŝŶŐсdĂŬĞϭĐĂƉƐƵůĞϯƟŵĞƐĚĂŝůLJ Synovacin;'ůƵĐŽƐĂŵŝŶĞ^ƵůĨĂƚĞĂƉƐƵůĞƐϱϬϬŵŐͿ Genicin;'ůƵĐŽƐĂŵŝŶĞ^ƵůĨĂƚĞĂƉƐƵůĞƐϱϬϬŵŐͿYdz ϵϬ;EŝŶƚLJͿϭϴϬ;KŶĞͲ,ƵŶĚƌĞĚŝŐŚƚLJͿZĞĮůůƐ ϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

SLEEP DISORDER: Somnicin ;DĞůĂƚŽŶŝŶнϱͲ,LJĚƌŽdžLJƚƌLJƉƚŽƉŚĂŶнdƌLJƉƚŽƉŚĂŶͿΎŽƐŝŶŐсdĂŬĞϭƚĂďůĞƚϯϬŵŝŶƵƚĞƐƉƌŝŽƌƚŽďĞĚƟŵĞ SentraPM ;ŚŽůŝŶĞŝƚĂƌƚƌĂƚĞ'ůƵƚĂŵŝĐĐŝĚĐĞƚLJů>ͲĂƌŶŝƟŶĞ'ŝŶŬŐŽŝůŽďĂ'ƌŝīŽŶŝĂdžƚƌĂĐƚ;ϱ,dWϵϱйͿ,ĂǁƚŚŽƌŶĞƌƌLJĂŶĚŽĐŽĂͿ

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ADDITIONAL INJURED WORKER MEDICATION Medrox Patches ;ĂƉƐĂŝĐŝŶϬϬϯϴйнDĞŶƚŚŽůϱйͿ;&ŽƌWĂŝŶͿΎŽƐŝŶŐсƉƉůLJϭͲϯƉĂƚĐŚĞƐƚŽĂīĞĐƚĞĚĂƌĞĂĚĂŝůLJYdz ϯϬ;dŚŝƌƚLJͿϲϬ;^ŝdžƚLJͿϵϬ;EŝŶƚLJͿZĞĮůůƐ ϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ Procomycin;ĂĐŝƚƌĂĐŝŶŝŶĐϱϬϬƵнEĞŽŵLJĐŝŶϯϱŵŐнWŽůLJŵLJdžŝŶϭϬϬϬϬƵн>ŝĚŽĐĂŝŶĞŚLJĚƌŽĐŚŽůŽƌŝĚĞͿ;&ŽƌtŽƵŶĚͿΎŽƐŝŶŐсƉƉůLJϱŐŵ;&ŝǀĞŐƌĂŵƐͿƚŽĂīĞĐƚĞĚĂƌĞĂϯƟŵĞƐĚĂŝůLJYdz ϭϬ;dĞŶͿϭϱ;&ŝŌĞĞŶͿϯϬ;dŚŝƌƚLJͿZĞĮůůƐ ϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

STOOL SOFTNER:ΎŽƐŝŶŐсdĂŬĞǁŝƚŚĨƵůůŐůĂƐƐŽĨǁĂƚĞƌ;ϴŽnjͿŽŶŽƚƚĂŬĞŵĞĚŝĐŝŶĞŵŽƌĞƚŚĂŶĚŝƌĞĐƚĞĚ

Laxacin;^ĞŶŶŽƐŝĚĞƐϴϲŵŐнŽĐƵƐĂƚĞϱϬŵŐͿ Promolaxin;ŽĐƵƐĂƚĞϭϬϬŵŐͿYdz ϭϬϬ ZĞĮůůƐϭ;KŶĞͿϮ;dǁŽͿ ϯ;dŚƌĞĞͿ

FIBROMYALGIA (TOPICAL):*AƉƉůLJϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůLJůůŽǁĂƚůĞĂƐƚϮϬŵŝŶƚŽĂďƐŽƌď;ϭƉƵŵƉсϭϱŐŵͿ

Ͳ'ƵĂŝĨĞŶĞƐŝŶϭϬйн&ůƵƌďŝƉƌŽĨĞŶϯϱйн<ĞƚĂŵŝŶĞϯйн>ŝĚŽĐĂŝŶĞϮйнWŝƌŽdžŝĐĂŵϭйнLJĐůŽďĞŶnjĂƉƌŝŶĞϭйнDĂŐŶĞƐŝƵŵŚůŽƌŝĚĞϭϬйнWĞƉƉĞƌŵŝŶƚϬϭй C - &ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϭϬйнEŝĨĞĚŝƉŝŶĞϮйнWĞŶƚŽdžLJĨLJůůŝŶĞϮйнůƉŚĂ>ŝƉŽŝĐĐŝĚϮйFORMULAS FOR TOPICAL PAIN/ARTHRITIS/SPASM/NEUROPATHY:ΎŽƐŝŶŐсƉƉůLJϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůLJ;ϭƉƵŵƉсϭϱŐŵͿ C- &ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϭϬй C- &ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн<ĞƚĂŵŝŶĞϭϬйн>ŝĚŽĐĂŝŶĞϱй C- &ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂnjĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϮй C- &ůƵƌďŝƉƌŽĨĞŶϱйнLJĐůŽďĞŶnjĂƉƌŝŶĞϭйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭйͲŝĐůŽĨĞŶĂĐϱйнWƌŝůŽĐĂŝŶĞϮйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭйͲ&ůƵƌďŝƉƌŽĨĞŶϳйнLJĐůŽďĞŶnjĂƉƌŝŶĞϮйнKƌƉŚĞŶĂĚƌŝŶĞϱйн'ĂďĂƉĞŶƟŶϱйн<ĞƚĂŵŝŶĞϱйͲdƌĂŵĂĚŽůϭϬйнWƌŝůŽĐĂŝŶĞϮйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭй

SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL):ΎƉƉůLJϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůLJ;ϭƉƵŵƉсϭϱŐŵͿ C- &ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂnjĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϰйн<ĞƚĂŵŝŶĞϮйнϬϮйϮĞŽdžLJͲͲ'ůƵĐŽƐĞнϯйĐLJĐůŽǀŝƌ

WůĞĂƐĞƐƉĞĐŝĨLJďŽĚLJĂƌĞĂͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

Cream Size (Pump): 75gm (Seventy-Five Grams) 100gm (One-Hundred Grams)ZĞĮůůƐͺͺͺͺͺͺͺ 1 (One) 2 (Two) 3 (Three)Smallest SizeϱϬŐŵ;&ŝŌLJ'ƌĂŵƐͿ

New Work Comp / PIP / LOP Information

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

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