See how QUTENZA works differently to target pain associated with PHN.
This site is intended for residents of the United States only.
This site is intended for residents of the United States only.
Get downloadable resources and forms for your practice and patients
Resources
Patient Guide
Download this brochure to give to your appropriate patients.
MyQutenzaCoverage Program Overview
Contains information to better understand the reimbursement landscape and help your appropriate patients gain access to QUTENZA.
Reimbursement Guide
Includes coverage, coding, and reimbursement for QUTENZA, to ensure patient access and successful claims.
PHN Administration Guide
View this complete step-by-step guide on how to administer QUTENZA for PHN.
QUTENZA Ordering Guide
Contains information on how to order QUTENZA for your patients.
Forms
Benefit Request and Prescription Form
Download and fax form to request benefits and prescriptions for appropriate patients.
Business Associate Agreement (BAA)
Navigate to MyQutenzaCoverage.com to submit an enrollment request for your practice.
HIPAA Release Form
Download and have your appropriate patients sign this form to obtain QUTENZA Reimbursement Support Services.
Procedural Notes
Download and document appropriate patient information and history, coding, and additional notes during QUTENZA application.
Letter of Medical Necessity
Download and complete this form on behalf of your patients who require specific treatment.
Letter of Appeal
Download and complete this letter to review a denied claim on behalf of your patients.
PHN Application Training Video
Provides instruction and Important Safety Information for QUTENZA.
