Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 

Qutenza Reimbursement Support

For Healthcare Professionals Only

Provided by: Acorda Therapeutics, Inc.

Qutenza Reimbursement Support Services
999 Bayhill Drive, Suite 300
San Bruno, CA 94066

TEL: 877-900-6479, opt. 3


FAX: 877-304-1045
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Reimbursement Support Form and Prescription for Qutenza

Qutenza HIPAA Authorization Form

 

Brand Name Medications Covered

 
  • Qutenza patch
 

Generic Name

 
  • capsaicin patch
 

Eligibility Requirements   

Insurance Status Must not have any insurance or be eligible for state or federal funded healthcare
Those with Part D Eligible? No
Income At or below 300% of FPL
Diagnosis/Medical Criteria Post Herpetic Neuralgia (PHN)
US Residency Required? Yes
   

Application

Obtaining Call
Receiving Faxed or mailed
Returning Fax
Doctor's Action Complete section and sign
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Doctor notified
Decision Timeframe Within 2-3 days
   

Medication

Amount/Supply Up to 3 months supply
Sent To Doctor's office
Delivery Time Within 2-3 days
Refill Process New application process required
Limit None
Re-application Every 3 months copy of prescription and current documentation required
   

Additional Information

This program is intended for US HEALTHCARE PROFESSIONALS and/or Professionals involved in Healthcare Reimbursement ONLY. The Doctor must contact the program.


Updated April 25, 2017