Established in Locally Owned & Independently Operating. Physicians, Nurse Practitioners, Physician Assistants

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1 Established in 1987 Locally Owned & Independently Operating Physicians, Nurse Practitioners, Physician Assistants Please Fax all Compounding RX s to: Fax: For assistance call: East North Avenue, Suite 16, Villa Park, IL We look forward to helping you with you patients.

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4 Authorization to Change Prescription Dear Medical Provider: Pharmacy Critical Care Pharmacy Address 401 E North Ave #16 Villa Park, IL Phone (855) Fax (630) sales@criticalpharmacy.com By signing this Authorization to Change Prescription Form ( Form ), you are providing the Pharmacy with the following: 1) Substitution Authorization for Insurance Purposes Authorization to substitute your prescribed formula when insurance does not cover your prescribed formula to an alternate formula covered by insurance or to an alternative formula to be paid with cash. This may entail changing or reducing the original quantity prescribed and/or directions for use as necessary to reflect the change in therapy (pharmacist to provide equivalent). 2) Substitution Authorization for Diagnosis, Adverse Reactions, and/or Clinical Effectiveness Authorization to change a formula based upon diagnosis, adverse reactions, and/or clinical effectiveness. This may entail changing or reducing the original quantity prescribed and/or directions for use as necessary to reflect the change in therapy (pharmacist to provide equivalent). 3) Authorization to Convert to a Verbal Order Authorization to convert prescription to a verbal order. This may entail changing or reducing the original quantity prescribed and/or directions for use as necessary. Attached is an algorithm showing some of the common formulas the Pharmacy will use as substitutions to ensure faster processing of your prescription. This Form will serve as an official authorization to change the original prescribed prescription to a legally acceptable equivalent and provided that the Pharmacy adheres to procedures mandated by States Pharmacy Boards wherever Pharmacy operates. The Form will be valid for one (1) year after the signed date. The original copy will be kept in the Pharmacy and you may request a copy if needed. The provider has the right to reverse his/her original decision at any time throughout this period. The pharmacy will notify your office via fax or phone of any changes made to your patients formulas. Yes, I agree to the terms. Please fax my office the new formula dispensed for office records. No, do not substitute formulas. Contact my office for a change request. Provider Name Primary Contact Person In Office DEA or NPI Office Phone & Fax Signature Date

5 Migraine Scar Pain Preferred Alternate Formulas Original Formula Chronic Pain/Inflammation: 10% Ketoprofen + 6% Gabapentin + 5% Bupivacaine + 1% Fluticasone + 2% Cyclobenzaprine + 0.2% Clonidine + 0.2% Hyaluronic Acid + 2% Baclofen Neuropathic Pain: 2% Baclofen + 6% Gabapentin + 3% Amitriptyline + 2% Nifedipine + 5% Bupivacaine HCL + 5% Dextromethorphan + 10% Flurbiprofen Joint/Musculoskeletal Pain: 8% Amantadine + 2% Baclofen + 5% Bupivacaine + 2% Cyclobenzaprine + 3% Diclofenac + 10% Gabapentin + 10% Petnoxifylline Scar + Pain: 1% Fluticasone + 2% Levocetirizine + 0.5% Pentoxifylline + 3% Prilocaine + 15% Gabapentin Scar Only: 1% Fluticasone + 2% Levocetirizine + 0.5% Pentoxifylline Migraine: 5% Sumatriptain + 5% Loperamide + 5% Gabapentin + 5% Doxepin + 5% Indomethacin Alternate Formulas LPKG 1.25% Lidocaine % Prilocain + 6% Gabapentin + 10% Ketoprofen Pain Sub 1: 5%Amitriptyline + 0.2% Clonidine + 6% Gabapentin + 8%Loperamide + 2%Nifedipine + 5%Tetracaine Pain Sub 2: 1% Meloxicam + 2.5% Topiramate + 0.5% Baclofen + 4% Gabapentin % Lidocaine % Prilocaine Pain sub 3:.01% Meloxicam + 2.5% Topiramate + 0.5% Baclofen + 4% Gabapentin % Lidocaine % Prilocaine Pain Sub 4: 5% Gabapentin + 1% Topiramate + 0.1% Meloxicam + 4% Amitriptyline % Lidocaine % Prilocaine Scar Alternate: 1% Fluticasone + 2% Levocetirizine + 0.5% Pentoxifylline + 3% Prilocaine + 15% Gabapentin Scar Alternate: 1% Fluticasone + 2% Levocetirizine + 0.5% Pentoxifylline Scar Alternate: 0.05% Desoximetasone + 1% Levocetirizine + 0.1% Tamoxifen % Tretinoin + 0.1% Lidocaine Migraine Alternate: 4% Sumatriptain + 1% Meloxicam + 0.4% Ondansetron + 2% Duloxetine % Lidocaine % Prilocaine *THIS LIST IS A SAMPLE OF THE MOST COMMON ITEMS WE CURRENTLY USE. IT IS NOT ALL-INCLUSIVE AND WE MAY USE OTHER FORMULAS AS NEEDED. THE PHARMACY WILL NOTIFY THE PRESCRIBER VIA FAX AS TO WHAT IS DISPENSED TO THE PATIENT, UNLESS YOUR OFFICE HAS REQUESTED TO NOT RECEIVE FAX COMMUNICATIONS. **ALL PAIN/NEUROPATHIC RELATED CREAMS MAY ALSO BE CHANGED OUT FOR A COMBINATION OF DICLOFENAC 1.5% + LIDOCAINE 2.5%, WHICH MAY REQUIRE A CHANGE IN DIRECTIONS AND QUANTITY IN ORDER TO PROVIDE AMPLE PAIN RELIEF. ***ALL PAIN/NEUROPATHIC RELATED CREAMS MAY ALSO BE CHANGED OUT TO DICLOFENAC 3% GEL AND LIDOCAINE 5% OINTMENT AS TWO SEPARATE PRODUCTS, WHICH MAY REQUIRE A CHANGE IN DIRECTIONS AND QUANTITY IN ORDER TO PROVIDE AMPLE PAIN RELIEF. (EXAMPLE OF WHAT MAY BE DISPENSED TO PATIENT: DICLOFENAC 3% GEL, QUANTITY 200GM, APPLY 1-2 GRAMS TO AFFECTED AREA TWICE DAILY AND LIDOCAINE 5% OINTMENT, QUANTITY 213GM, APPLY 1-2 GRAMS TO AFFECTED AREA TWICE DAILY)

6 Prior Authorization Letter TO: CompoundClaims.com, LLC Address 519 S Orem Blvd Orem, UT Phone (855) Fax (855) In the course of submitting claims to health insurance companies, it is common that a prior authorization must be obtained in order for the medication to be approved. Typically, the pharmacy is able to carry out the prior authorization; however, under some circumstances the insurance company requires the prescribing physician to call and initiate the prior authorization. By signing below, I hereby authorize CompoundClaims.com, LLC (the third-party billing service for your pharmacy), and its business associates, under those circumstances to call and obtain a prior authorization on behalf of my practice. Provider Name Primary Contact Person In Office DEA or NPI Office Phone & Fax Signature Date