Capsaicin (Qutenza®) patch


Indications for Prior Authorization:

  • For diagnosis of Post herpetic Neuralgia (PHN)

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:

  • Any other diagnosis not listed in the approved indications

All of the following must be met:

  • Inadequate response, intolerable side effect(s) or contra-indication to at least two oral drugs [e.g. tricyclic antidepressants, anticonvulsants, opioids] and a self-administered topical patch [e.g. lidocaine patch] used for PHN, OR
  • If pt is ≥ 65 yrs old, inadequate response, intolerable side effect(s) or contra-indication to an oral drug [e.g. anticonvulsants, opioids] and a self administered topical patch [e.g. lidocaine patch] used for PHN


  • Up to 4 patches per treatment session, and not more frequently than every three months
  • Administration of Qutenza®:
    • Only physicians or health care professionals under the close supervision of a physician are to administer Qutenza®
    • Use only nitrile (not latex) gloves when handling Qutenza® and when cleaning treatment areas
    • Burning and erythema reported in majority of patients treated with Qutenza®


Initial coverage for 3 months

Reauthorize yearly based upon continued response to treatment


Last review date: December 2, 2013

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