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:


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


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


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 August 06, 2018