For US Healthcare Professionals

Qutenza Logo
Hero

Actor portrayals.

The QUTENZA Patient Cost Savings Program

Two options to help patients save on their QUTENZA treatments

The amount of your patients’ copay may differ based on insurance provider.

Your patients may be eligible if:

  • They have commercial insurance (OCC8)
  • They are 18 years of age or older

Your patients may not be eligible if:

  • They have Medicare, Medicaid, or any other state or federal health insurance
  • They pay for their prescription with cash
Hero

Select the best option for your practice to enroll your patients in the QUTENZA Cost Savings Program.

option header

Option 1: Electronic Claim Submission

STEP 1

Register your practice through the Patient Cost Savings Portal

STEP 2

Complete account activation following practice verification

STEP 3

Begin submitting claims

option header

Option 2: Mail or Fax Claim Submission

STEP 1

Download and complete the pre-populated Patient Cost Savings Program Enrollment Form for QUTENZA.

STEP 2

Bill the patient's primary insurance using a standard HCFA 1500 CMS form.

STEP 3

Obtain the Patient's Explanation of Benefits (EOB).

STEP 4

Mail or fax all completed forms to:

Mail: Attn: Claims Processing Department
IQVIA, Inc.
77 Corporate Drive
Bridgewater, NJ 08807

Fax: 631-822-2893

For questions regarding the QUTENZA Patient Cost Savings Program, please contact the QUTENZA Patient Support Services and Customer Service Center at 833-295-3579.

*Eligibility Criteria, Terms and Conditions

By using this offer, you confirm that you currently meet all eligibility criteria and will comply with all terms and conditions, as described below:

  1. The QUTENZA® Patient Cost Savings Program (the “Program”) is available only to eligible, adult patients prescribed QUTENZA for use consistent with approved indications in US product labeling for QUTENZA. Eligible patients must reside in the US, Puerto Rico, or the US territories based on the patient’s address, and must be insured by a commercial insurer that covers QUTENZA and does not prohibit participation in patient assistance programs. Uninsured or cash-paying patients, and patients with coverage for QUTENZA through federal- or state-funded government healthcare programs, including Medicare, Medicaid, Medigap, TRICARE, Veterans Affairs (“VA”), or Department of Defense (“DoD”), are not eligible for the Program. A patient who begins receiving benefits for QUTENZA from a government healthcare program will no longer be eligible for the Program.
  2. This Program will only accept applications by mail or fax. No phone or email requests will be honored. Applications must be fully completed based on the instructions stated on the QUTENZA Patient Cost Savings Program Enrollment Form. Averitas Pharma, Inc. is not responsible for lost, late, damaged, misdirected, incomplete, or illegible submissions. All submissions become the property of Averitas Pharma, Inc. and its agents. Please retain copies of any materials you submit.
  3. Any refund under this Program may not exceed the eligible patient’s medication copayment, co-insurance, or deductible costs (“Patient Responsibility”) for QUTENZA, whether covered under the medical or pharmacy benefit. For pharmacy claims, this offer can be used only with a valid QUTENZA prescription at the time the prescription is filled by the pharmacist and dispensed to the patient, and is good only at participating pharmacies in the US. The Program is valid only for the patient’s out-of-pocket costs for QUTENZA, and cannot be used if the patient is eligible to be reimbursed for the entire cost of QUTENZA. The patient and patient’s healthcare provider may not seek other reimbursement of Patient Responsibility for QUTENZA. Patient Responsibility for QUTENZA must be isolated on the claim and separate from other services and products. Any out-of-pocket costs associated with office visits and any other ancillary services or costs included in Patient Responsibility are excluded from refunds.
  4. Refunds will be processed in the order in which they are received. Approved claims will be processed and paid in the subsequent billing cycle. Please allow 10-14 business days for delivery of refund checks. Tampering with, altering, or falsifying payment information is prohibited by law.
  5. Program is effective July 1, 2021. This offer is limited to 1 per person, is non-transferable, and is valid for the eligible patient only. No other purchase is necessary. This offer has no cash value and cannot be combined with any other patient assistance program, free trial, discount, prescription savings card, or other offer. Averitas Pharma, Inc. reserves the right to cancel, modify, or rescind this Program at any time. Aggregate and non-identifiable patient information may be used by Averitas Pharma, Inc. for market research and other related purposes. This Program is not insurance and is not intended to substitute for insurance. This offer is void where prohibited or restricted by law.
  • Carton with one topical system + Cleansing Gel: NDC #72512-928-01
  • Carton with two topical systems + Cleansing Gel: NDC #72512-929-01
  • Carton with four topical systems + Cleansing Gel: NDC #72512-930-01