Delta Drugs II Industry Ave. Pico Rivera Ca Tel: (800) Fax: 1 (866)
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2 Delta Drugs II 7739 Industry Ave. Pico Rivera Ca Tel: (800) Fax: 1 (866) Delta Drugs II (formerly Prescriptions Plus) is specialized pharmacy excepting Medi-Cal a variety of other insurances. One of our specialties is to offer solutions for all nutritional needs with exceptional customer service knowledgeable staff with the billing expertise for hassle free ordering. We carry a full line of products from Mead-Johnson Nestle, Ross Novartis, we offer all specialty formulas including Enfacare 22 or 24 Calorie, Pregestimil, Alimentum, Neocate, Pediasure, Pediasure with Fiber, Nutramigen Neosure. Upon approval of insurance or Medi-Cal patients orders are processed quickly efficiently. Patients will receive their monthly supplies free of charge via courier. Our goal is to be a convenient resource for the patients throughout California includes In house inventory as well as VIP service with the overnight monthly shipping. Delta Drugs II is local has been offering reliable services to physicians other healthcare providers throughout California with a solid reputation for over 18 years. We are looking forward to continue offering our services for all our clients throughout California. La Vina Turner* * We have been committed to providing easy access to nutritional supplements sales source foods for the Medi-Cal population throughout California for over 18 years have worked with county officials to develop the vendor list throughout California WIC s.
3 Insurances Rep: La Vina Turner C (310) Delta Drugs 2 Insurance Programs 7739 Industry Ave. Pico Rivera CA TEL: 1 (800) FAX: 1 (866) Monday Friday 8:00AM 5:00PM Servicing California Alameda Alliance Allied Health Care Services (IPA) Alta Med CHLA Alta Med Pace Program Angeles IPA Anthem Blue Cross Direct Patients only (Not IPA) Avante Best Care (IPA) Bella Vista Medical Group Cal Care (IPA) Care 1st Health Plan California Children Services (CCS) Central Health Plan Central Coast Alliance for Health CHP Clinical Medical San Miguel (IPA) Community Family Medical Group Community Healthcare Network El Proyecto De Barrio Family Care Specialist Gold Coast Health Plan Good Samaritan Medical Practice Association (AMM) Health Net CALVIVA Direct Patients only (Not IPA) Hispanic Physicians IPA Inl Empire Health Plan (IEHP) LA Care MD Health Plan Medi-Cal Medicare Mission Community Molina Health Plan MSSP Partners in Care Physicians Alliance Network Premier IPA of Northern California Regal Medical Group (IPA) San Mateo Health Plan Southern California Children IPA SynerMed EHS CHW lives Br New Day/Universal Care Ventura Country Area Agency on Aging
4 Delta Drugs II Quick Easy Baby Formula Referrals 7739 Industry Ave. Pico Rivera Ca Tel: 1(800) Fax: 1 (866) Referral From Hospital NICU s Discharge: Mother s can receive 2 Cans of formula upon discharge of baby: 1. Intake/Referral Form (Can opt as RX with doctor signature) or 2. Prescription (You can tape to white piece of paper) 3. Demographic/Face Sheet 4. Copy of Insurance Card (Front back) Mother /or baby 5. MD Notes 6. Growth Chart ***Note*** Next day delivery on orders received by 2 PM PST. Referral From A physicians Office: 1. Intake/Referral Form (Can opt as RX with doctor signature) or 2. Prescription (You can tape to a white piece of paper) 3. Demographic/ Face Sheet 4. Copy of Insurance Card (Front back) Mother /or baby 5. MD Notes 6. Growth Chart ***NOTE**** Due to Medi-Cal changes we can no longer provide 2 Cans of formula upfront. Please fax referral the above documents so we can process order quickly. Please give patient formula if possible as insurance approval can up to TWO weeks. Referral From The WIC: 1. Intake/Referral Form (Can opt as RX with doctor signature) or 2. Prescription (You can tape to a white piece of paper) 3. Demographic/ Face Sheet 4. Copy of Insurance Card (Front back) Mother /or baby 5. MD Notes / or Growth Charts if you have them ***NOTE**** Due to Medi-Cal changes we can no longer provide 2 Cans of formula upfront. Please fax referral the above documents so we can process order quickly. Please give patient formula if possible as insurance approval can up to TWO weeks. Please Note: WIC only covers Enfamil, Premium, Enfamil AR, Prosobee Gentle Ease The baby may be covered under the mothers Medi-Cal through the month the baby is born the following month. This gives the mom time to obtain Medi-Cal for the baby. Pediasure approvals require the following: Most current MD Notes Growth Charts. Prescription must be written for a minimum of 2 cans per day or more. Medi-Cal will also only pay for Pediasure for children 1 year of age over. Prescription requires at least two diagnosis. Rep: La Vina Turner C (310)
5 DELTA DRUGS 7739 INDUSTRY AVE. PICO RIVERA CA PHONE: FAX: CUSTOMER INTAKE FORM: Sales Rep.: La Vina Turner C (310) Date: / / Referral Contact Phone #: ( ) - Insurance: Medi-Cal #: Medi-Cal ID Card Date of Issue / / Mother s Name: Mother s Date of Birth: / / Mother s ID#: Patient Last Name: First: Address: Apt # City: CA Zip: Phone #: ( ) - Emergency Contact: Contact Phone #: ( ) - Cell Phone: ( ) - Social Security #: Male Female Date of Birth: / / If under 1 year old: Birth Weight: lbs. Birth Height: inches. Formula / Product needed: Quantity: QM Failed Formulas: Is patient suffering from MALABSORPTION? YES OR NO GTUBE OR ORAL Please justify cause of MALABSORPTION: Height: Weight: Weight for Height (%): Weight Loss (Past 3 Months) List All Diagnoses (Please Include ICD9 Codes): List All Medications: Patient Experience (Please Circle): Vomiting Diarrhea GI Pain Fatigue Colic Constipation Rashes Bloody Stools Congestion Developmental Delay Food Allergy Gas Bloating Thrush- Difficulty Chewing / Swallowing Poor Appetite Difficulty Digesting Solids *** Please Fax Growth Chart/Progress Notes/RD NOTES to 1 (866) *** Why patient is unable to ingest or absorb nutrients from regular foods, please justify? NAME AND PHONE NUMBER FOR DIETICIAN/NUTRITIONIST: Medical Prescription I have reviewed my patient s medical records the items above, I verify that this patient s medical condition requires the products described the usage quantities are medically necessary for the patient. I will maintain a copy of this prescription in the patient s file to meet carrier documentation requirements. Authorization period: / / TO / / NPI# Physician Signature: Date: / / Physician Name: License #: Attending Physician Name: DEA #: Address: Phone #: ( ) - Fax #: ( ) - LT
6 Specialty infant nutrition products are subject to the following limitations*; Medi-Cal Changes Premature or Low Birth Weight: 20 kcal/ounce 24 or 30 kcal/ounce Human Milk Fortifier (HMF) Enfamil Premature Lipil (20 or 24) 0-9 months current Corrected Age*(CA), Enfacare Lipil (22) Born prior to 37 weeks Similac Expert Care gestation, Neosure Infant (22) Birth weight <3500 g, Similac Expert Care Neosure Advance Similac Special Care HMF), (24 or 30) Similac Human Milk Fortifier (HMF) If HMF, patient may only receive product until weight reaches 3600 g. No product shall be authorized after 3600 g body weight is achieved (weight gain is presumed to be g/day when calculation 31 day supply limits). authorization term(one month maximum authorization term for Authorization ends at 9 months post-hospital discharge date for 20 kcal products, or If product is 22 Kcal or 24 kcal or 30 Kcal infant shall be currently <3500 g maximum authorization term is one month per authorization; If HMF, infant shall be fully breast fed no other infant nutrition product is covered simultaneously. Exte nsi ve l y H ydr ol yze d ( hypo-al l er ge ni c, se -e le me ntal ) Nutramigen Lipil (not Nutramigen AA) Nutramigen Enflora LGG Lipil ** (contains 0-9 months Actual Age, Di agnose d c ow s mi l k pr otei n Allergy, or Other diagnosed breast milk or infant probiotic) formula intolerance exists is Pregestimil documented in the medical record Similac Expert Care (see medical criteria in this section). Alimentum Powdered form only, or Liquid form is permitted when infant is born <34 weeks gestation or birth weight is <1800 g. authorization term, Actual Age, **Nutramigen Enflora LGG Lipil is not authorized for infants: a. With Immune function disorders. Or b. <3500 g at authorization, or c. Prior to documented medical intolerance to Nutramigen Lipil (ready to feed or concentrate, not Nutramigen AA), or Similac Expert Care Alimentum. d.
7 100% Amino Acid Based (entire protein content is in the form of AA) Nutramigen AA Lipil 0-9 months Actual Age, EleCare Neocate Only after extensively hydrolyzed protein products are medically documented as tried, failed, unsafe for use, or in hospital use established need for product at discharge, Other diagnosed breast milk or infant formula intolerance exists is documented in the medical record (see Medical Criteria in this section). authorization term, Fat Malabsorption Products EleCare 0-9 months Actual Age, Neocate Pregestimil Diagnosed fat malabsorption not effectively addressed by breast milk, regular infant formula, extensively hydrolyzed protein products authorization term, Renal, Infant Product Similac PM 60/ months Actual Age, Diagnosed renal function impairment, or hypercalcemia, or hypocalcemia to due hyperphosphatemia authorization term, Chylothorax or LCHAD Product Enfaport Lipil 0-9 months Actual Age, Only for diagnosed chylothorax or LCHAD deficiency (Longchain 3-hydroxyacyl- CoA dehydrogenase deficiency) authorization term, All specialty infant product types are authorized as sole source nutrition only for patients between birth 6 months of age because the introduction of solid foods begins at 6 months (per American Academy of Pediatrics recommendation). Infant nutrition product in quantities that exceed the 6-month-old's daily caloric requirement is therefore not authorized beyond 6 months of age unless significant medical criteria documentation demonstration complete intolerance to early solid foods accompanies a request for authorization for any infant product, for purposes of calculating 31-day supply quantity limits. See the Medical Criteria Requirement Documentation portions of the Enteral Nutrition overview for requirements. * Corrected Age (CA) example: If birth date is 36 weeks gestation (4 weeks early ) then remove 4 weeks from Actual Age since birth to get CA. CA is always younger than Actual Age when infant is born prior to 37 weeks gestation. Infants born after 37 weeks gestation are not premature by definition.
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