Therapeutic Interchange Authorization

Transcription

1 Therapeutic Interchange Authorization Authority As a provider who holds an active license to practice medicine as authorized by the appropriate state medical board, I,, State license Number: NPI: ("Prescriber"), authorize the Pharmacist listed on the signature page, who holds an active pharmacist license issued by the their respective State Board of Pharmacy ("Pharmacist'') to manage and/or treat patients under my care pursuant to a written order from me. Scope of Authorization Under receipt of this executed order, Pharmacist will have the authority to modify a patient's prescription ordered by the provider defined in this agreement, when reasonable cause for a medication change is substantiated. In managing and/or treating patients, the Pharmacist may modify transdermal pain cream therapy, transdermal scar treatment therapy and nutritional supplements therapy as described on the attached Exhibit A. In addition, in the event the originally-ordered quantity of the prescribed medication is not covered by the patient's insurance due to such quantity exceeding patient's insurance plan limitations, Pharmacist may change such originally-prescribed quantity to an adequate lesser quantity as approved by the patient's insurance. Documentation The patient's pharmaceutical care record will contain a notation of this change. That documentation will include, at a minimum, the reason for the encounter, prescription changes and all necessary patient demographic information. Record Retention Each signatory to this Authorization shall keep a signed copy of this document on file at their primary place of practice. Additionally, the records maintained in the pharmaceutical care record shall be kept by Pharmacist and be available for at least two (2) years from the date of such record. Pharmacist shall report back to Prescriber any specific decisions made during the course of disease state management by means of electronic mail, hand-delivered mail, or fax the patient's clinical medical record. Review and Duration This Authorization may be reviewed and revised at any time at the time of request of any signatories. Rescindment or Alteration of Agreement A signatory may rescind from this Authorization or a patient may withdraw from treatment under at any time. Prescriber may override this Authorization whenever he or she deems such action necessary or appropriate for a specific patient without affecting any authorization relative to other patients. This Authorization includes patients currently under the care of Prescriber and extends for a period of one (1) year from this date unless rescinded earlier in writing.

2 IN WITNESS WHEREOF, this Authorization has been signed by the parties hereto as of the date indicated below. Signature Page harmacist allowed to execute this Therapeutic Interchange: ~ -.,,~--#-====-----::>'""""'::-- ~ Date:~e::1 IF lic#: 50/.)7' Date: / I lie #: Date:.J1:IYIr{. lie #: 4c)t{."Zl' Date: / I lie #: ~~ By~ Ct1YVl AlHMt)""JLZ{l-'L Date: ~ f1j lie #: S3fj&X Date: / I lie #: ~ Lt?l5t!-'LMChh:-<...,- Date: \ 2-1~I ~ lie #: 7:{;"e S C, Date: I I lie #: Prescriber: PrintName: Date: J 5

3 EXHIBIT A General Pain Formulation Originally Prescribed: Any Pain Formulation First Substitute Formula: Either Solaice,Qroxin,Sinelee,RelyyksPatch, Synvexia,or Reciphexamin 4-1% (Menthol 4%, Lidocaine 1%), or Lidocaine 5% pad. Apply 1 patch twice daily to affected area. Apply up to 8hrs. Remove old patch. May adjust Quantity/Days supply between 7-30 days depending on insurance. AND NSAID(either Rexaphenac 1%, Active Ketoprofen 5% KIT, EnovaRX-NaproxenKit 10%, or EnovaRX-lbuprofenKit 10%),either EnovaRX-CyciobenzaprineKit 2% or Active Cyclobenzaprine 5% KIT, EnovaRX-BaciofenKit 2%, EnovaRX Amitriptyline KIT 2%, either EnovaRX-LidocaineKit 5%, Lidovex 3.75% cream or Lidocin 3% gel, and Active-pac with Gabapentin 4% KIT,and Active Tramadol Kit 8% KIT.Any combination as determined by the pharmacists accepted under my medical care.(pharmacy isauthorized to admix all the prescribed kits together before dispensing to the patient). Qty can range from 60to 360gm depending on original pain formulation qty. If original RXwritten for 300gm, okay to round up to nearest Qty for products that come as "Eaches" (example, 300gm NCP-7 ordered, Ketoprofen would dispense as 360gm due to fact it comes as 120gm per each product). Apply 2-4 grams on insurance. AND topically four times daily for pain. May adjust Qty/Days supply between 7-30 days depending Alegenix (capsaicin %/ menthol 5%) bio frequency chip bandage. Apply one unit over affected area(s) twice daily. May adjust Qty/Days supply between 7-30 days depending on insurance. Second Substitute Formula: Unit doses containing an NSAID (either Dsquared-Diclofenac 1.2gm/100gm, Dsquared Ketoprofen 12gm/100gm, EnovaRX-diciofenac 0.6gm/100gm, EnovaRX-lbuprofen 9gm/100gm, or EnovaRX Naproxen 6gm/100gm), either Dsquared-Cyclobenzaprine 5gm/100gm or EnovaRX-Cyciobenzaprine 3gm/100gm, Dsquared-Baclofen 5gm/100gm, Dsquared-Gabapentin 12gm/100gm, and EnovaRX-Lidocaine 6gm/100gm. Any unit dose combination determined by the pharmacists accepted under my medical care. Pharmacy is authorized to admix al the prescribed unit doses together before dispensing to the patient. Quantity offinal product can range from 100gm to 300gm depending on the original pain formulation quantity. If original RX is written for a quantity not consistent with dispensing size of product, okay to round up to nearest quantity for said product. Example, 180gm NCP-7 ordered, EnovaRX-Ketoprofen 12gm/100gm would be dispensed as 2 "eaches" for 200GM total. Apply 2-4 grams topically four times daily for pain. May adjust quantity/days supply between 7-30 days depending on insurance. Or Lidocaine 5% ointment Apply 2-4 grams topically four times daily for pain. May adjust quantity/days supply between 7-30 days depending on insurance, AND either Diclofenac 3% gel or Diclofenac 1.5% solution Apply 2-4 grams topically four times daily for pain. May adjust quantity/days supply between 7-30 days depending on insurance. Third Substitute Formula: NCP1ALT(gabapentin 4%/baclofen 2%/ketoprofen4%/lidocaine 2%) gms/month or Voltaren GeI100gm/month, or DermacinRx Inflammatral Pak (Diclofenac 1%/ Ranitidine 3%/ Capsaicin 0.025%) gms/month (whichever iscovered by the patient insurance). Apply 2-4 grams topically four times daily for pain. Mayadjust Qty/Dayssupplybetween 7-30 days depending on insurance. Fourth substitute formula: Gabapentin 6%/Lidocaine 2.5%/Prilocaine 2.5%/ Topiramate l%/meloxicam 1% gms/month using FDA approved tablets crushed into cream. Apply 2-4 grams topically four times daily for pain. May adjust Qty/Days supply between 7-30 days depending on insurance. MD/DO 12-g-l5 Date RPh wr QrJI\'- Date

4 Originally Prescribed :Any searformulation Scar formulations Substitution: SCARPATCHPAD, Renuu Pad (Allantoin 2%, Lidocaine 5%, Petrolatum 30%), or Renuu NL Pad (Allantoin 2%, Petrolatum 30%) twice daily up to 8 hours per site and either SRC2ALT(Triamcinolone O.l%/Levocetirizine 1%) or either Dermacin SilaPak or SilkPak (Triamcinolone 0.1%/ Dimethicone 5%/ Silicone Tape). Apply 2-4 grams topically four times daily to scar. Qty to match original RX. Days' supply canbe adjusted between 7 to 30 days depending on insurance. And either EnovaRX Lidocaine 5% cream, or Lidocin 3% gel, or Lidovex 3.75% cream. Apply 2-4 grams topically four times daily to scar. Qty to match original RX. Days'supply can be adjusted between 7 to 30 days depending on insurance. Or SRC1ALT(Triamcinolone 0.1 %/Levocetirizi ne l%/lidocaine 5%). Apply 2-4 grams topically four times daily to scar. Qty to match original RX. Days' supply can be adjusted between 7 to 30 days depending on insurance. either one of the following: Hydrocortisone l%/pramoxine 1%, Fluocinonide 0.1%, Nystatin/Triamcinolone, Clobetasol 0.05%, Desonide 0.05%, or Betamethasone 0.05% cream. Apply 2-4 grams topically four times daily to affected area. Qty to match original RX, or rounded to nearest unit size. Days' supply can be adjusted between 7 to 30 days depending on insurance. Wound Care Originally Prescribed: TW1001, TWI001 + Gentamicin 0.2%, TW1002, TIW001, TIW002 (Fluconazole 2%, Pentoxifylline 0.5%, Lidocaine 2%, Hydroxyzine 2%) Substitution: Active Prep Kit V (Itraconazole 4%, Phenytoin Sodium 3% in Stera-base ). Apply 2-4 pumps (lpump = 1 gram) twice daily to wound. May adjust Qty/Days supply between 7-30 days depending on insurance. And either EnovaRX Lidocaine 5% cream, or Lidocin 3% gel, or Lidovex 3.75% cream. Apply 2-4 grams topically four times daily to wound. May adjust Qty/Days supply between 7-30 days depending on insurance. Either one of the following: Neomycin/Polymyxin/Bacitracin ointment or Bacitracin ointment. Apply 2-4 grams topically four times daily to affected area. Qty to match original RX, or rounded to nearest unit size. Days' supply can be adjusted between 7 to 30 days depending on insurance j1r (L./ f MD/DO Date RPh Date \lr1s"'v \[-~ C-Nr-. I;..--'8

5 Metabolic Supplements Originally Prescribed: MS-99 (Coenzyme QI0 100mg, Alpha-LipoicAcid 250 mg, Vitamin D31000 IU, Methylcobalamin 5 mg, Pyridoxal-5- Phosphate 70 mg, Resveratrol150 rng, 5-MTHF 25 mg, Hyaluronic Acid 75 mg or MS-98 (Coenzyme QI0 100mg, Alpha-LipoicAcid 250mg, Vitamin D310001U, Methylcobalamin 5mg, Pyridoxal-5- Phosphate 70mg, Resveratrol100mg, 5-MTHF 25mg, Hyaluronic Acid 75mg) or MS-49 (CoenzymeQ10100mg, Alpha-LipoicAcid 250mg, Vitamin D31000i U,Resveratrol150mg) or MS-59 (Coenzyme QlO 100mg, Alpha-LipoicAcid250mg, Vitamin D310oo1U,Resveratrol150mg) or MS-60 (Methylcobalamin Smg, Pyridoxal-S-Phosphate70mg, S-MTHF2Smg, Hyaluronic Acid 7Smg) MS-81: (Methylcobalamin 20mg, Pyridoxal-S-Phosphate70mg, S-MTHFlOmg, Resveratrol loomg, Piperine 10mg) or MS-82: (Coenzyme QI0 100mg, Alpha LipoicAcid 125mg, N-Acetyl-cysteine 250mg, Vitamin D3 1,000 IU, Resveratrol 100mg, Piperine 10mg, HyaluronicAcid 75mg). Take two capsules by mouth daily. May adjust Qty/Days supply between 7-30 days depending on insurance. First Substitute Formula:MS-97: CoenzymeQ10 75mg, Alpha LipoicAcid 50mg, N-Acetyl-cysteine250mg, Vitamin D U, Methylcobalamin lomg, Pyridoxal-5-Phosphate70mg, Resveratroll00mg, 5-MTH F10mg. Take one capsule by mouth twice daily. May adjust Qty/Days supply between 7-30 days depending on insurance. May also use MS-99, MS-49, MS-59, MS-60 without following ingredients added: Hyaluronic acid, Resveratrol if not covered by insurance. Second Substitute Formula: MS-96: Methylcobalamin 5mg, Vitamin D U, Pyridoxal-5-Phosphate 35mg, Chromium Picolinate loomcg. Third substitute formula: MS-95: Coenzyme QI0 100mg, Alpha-LipoicAcid 250mg, Vitamin D U, Methylcobalamin 10mg, Pyridoxal-5-Phosphate70mg, Resveratroll00mg, FolicAcid Img. Takeonecapsule by mouth twice daily. May adjust Qty/Days supply between 7-30 days depending on insurance. MS-l (Coenzyme QI0 75mg, Alpha LipoicAcid 50mg, N-Acetyl-cysteine 250mg, Vitamin D31,0001 U) Take one capsule by mouth twice daily. May adjust Qty/Days supply between 7-30 days depending on insurance. MS-31 (Resveratroll00mg, Piperine 20 mg) take two capsules by mouth in morning. Dispense 60 capsules/30 days. May adjust Qty/Days supply between 7-30 days depending on insurance. AND/ MS-32 (Hydroxycobalamin 20mg, Alpha Lipoic Acid 250 mg, Coenzyme QI0 100mg, Vitamin D31,000IU). Take two capsules by mouth at night. May adjust Qty/Days supply between 7-30 days depending on insurance. MS-3 (Coenzyme QI0 100mg, Alpha LipoicAcid 100mg, N-Acetyl-cysteine 250mg, Vitamin D31000IU). Take one capsule by mouth twice daily. May adjust Qty/Days supply between 7-30 days depending on insurance. Durachol (Folic Acid Img, Cholecalciferol 3775iu) capsule. Take one capsule by mouth daily. May adjust Qty/Days supply between 7-30 days depending on insurance. Active Life NutrientCapsules(Vitamin A35001U, Vitamin C150mg, Vitamin D U, Vitamin E301U,Thiamine 5mg, Riboflavin 3.5mg, Niacin 20mg, Folate 400mcg, Vitamin B12 as Methylcobalamin 500mcg, Biotin 300mcg, Pantothenic Acid 10mg, Iodine 150mcg, Zinc 25mg, Selenium 50mcg, Manganese 2mg, Chromium Picolinate 200 mcg, Molybdenum 75mcg, Coenzyme QI0 50mg, Alpha lipoic Acid 50mg, Choline 25mg, Inositol 25mg, Lutein 3mg, Boron Img, Lycopene 500mcg, Zeaxanthin 500mcg) ' 1/ /L/( MD/DO Date RPh Date M v- C)\J1 (L-~ 1)- r

6 Originally Prescribed: MS-49 (CoenzymeQ10 100mg,Alpha-LipoicAcid 2S0mg,Vitamin D310001U,Resveratrol1S0mg) with MS-59 (CoenzymeQ10 100mg, AIpha-LipoicAcid 250mg, Vitami n D310001U,Resveratrol150mg) or MS-60 (Methylcobalamin Smg, Pyridoxal-S-Phosphate70mg, S-MTHF2Smg, Hyaluronic Acid 7Smg) Substitution: MS-99 (Coenzyme Q10 100mg, Alpha-LipoicAcid 2S0mg, Vitamin D310001U,Methylcobala min 5mg, Pyridoxal-S-Phosphate 70mg, Resveratrol1S0mg, 5-MTHF 25mg, Hyaluronic Acid 75mg). Take one capsule by mouth twice daily. May adjust Qty/Dayssupply between 7-30daysdependingon insurance. Migraine Originally Prescribed: Cyclobenzaprine 2%, Flurbiprofen 10%, Sumatriptan 10% with or without Ketamine 5%. Apply 1-2 pumps topically to temple area, behind ear, and back of neck twice daily. (1 pump = 1 gram; Sterabase ) Dispense 240gm. May adjust Qty/Days supply between 7-30 days depending on insurance. Substitution: Sumatriptan 2%, Ibuprofen 5% or Sumatriptan 10%, cyclobenzaprine 2%, and Flurbiprofen 10% (using FDA approved tablets) or NSAID (EnovaRX-Naproxen 10%, Ketoprofen 5%, or EnovaRx-lbuprofen10%, or Rexaphenac 1%) plus Cyclobenzaprine (either EnovaRX-Cyciobenzaprine 2% or Cyclobenzaprine 5%) kit. Apply 1-2 pumps topically to temple area, behind ear, and back of neck twice daily. (1 pump = 1 gram) Dispense 240gm. May adjust Qty/Days supply between 7-30 days depending on insurance. Anti-wart Originally Prescribed: CDF-7 Cimetidine 10%, 2-Deoxy-D-Glucose 0.3%, Flurbiprofen 10%, Fluorouracil 5% in Stera-base. Apply 2-4 grams (1 pump = 1 gram) topically to affected area(s) twice daily. Dispense 240 gm. May adjust Qty/Days supply between 7-30 days depending on insurance. Substitution CDF-7 (versabase ) Cimetidine 10%, Deoxy-Glucose 0.3%, Flurbiprofen 3%, Fluorouracil5%in Versa base, or Salicylic Acid 80%. Apply 2-4 grams (1 pump = 1 gram) topically to affected area(s) twice daily. May adjust Qty/Days supply between 7-30days depending on insurance. Anti-Fungal Originally Prescribed: Itraconazole 5%, Fluticasone 1%, Mupirocin 5%. Apply 2-4 grams (1 pump = 1 gram) topically to affected insurance. area 3-4 times daily. Dispense 240gm. May adjust Qty/Days supply between 7-30 days depending on Substitution: Itraconazole 5%, Mupirocin 5%, Triamcinolone 0.1%. Apply 2-4 grams (1 pump = 1 gram) topically to affected area up to 4 times daily. May adjust Qty/Days supply between 7-30 days depending on insurance. Substitution: Itraconazole 5%, Mupirocin 5% Cream. Apply 2-4 grams (1 pump= 1 gram) topically to affected area up to 4 times daily. May adjust Qty/Days supply between 7-30 days depending on insurance. And Dermacin SilaPak (Triamcinolone 0.1%/ Dimethicone 5%/ Silicone Tape). Apply 2-4 grams topically four times daily to affected area. Qty to match original RX. Days supply can be adjusted between 7 to 30 days depending on insurance. Substitution: Active Prep Kit V (Itraconazole 4%, Phenytoin Sodium 3% in Stera-base ). Apply 2-4 pumps (lpump= 1 gram) twice daily to wound. May adjust Qty/Days supply between 7-30 days depending on insurance. Substitution: Mupirocin 2%/Betamethasone 0.1%/ Miconzaole 2% cream. Apply 2-4 pumps (lpump= 1 gram) twice daily to affected area. May adjust Qty/Days supply between 7-30 days depending on insurance Either one of the following: Econazole 1% or Ketoconazole 2% cream. Apply 2-4 grams topically four times daily to affected area. Qty to match original RX, or rounded to nearest unit size. Days' supply can be adjusted between 7 to 30 days depending on insurance..» /l/~ MD/DO Date RPh Date \1~~ ~ CN\Y I'). -<?