CurrentAlaska MedicaidPolicy N/A

Prior authorization criteria for Qutenza (capsaicin) topical patch

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Prior authorization criteria for Qutenza (capsaicin) patches for treatment of neuropathic pain (PHN or DPN of the feet) for Alaska Medicaid members; describes approval, denial, cautions, duration, and quantity limits.

Policy Summary

PayerAlaska Medicaid

PolicyQutenza (capsaicin) topical patch prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document patient age ≥18, diagnosis of PHN or DPN of the feet, prior trials or contraindications to listed therapies, and that a licensed health care professional will apply the patch.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18minimum patient age for approval

1 moinitial authorization duration

up to 12 moreauthorization duration

Up to 4quantity limit

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CurrentAlaska MedicaidPolicy N/A

Prior authorization criteria for Qutenza (capsaicin) topical patch

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Policy Summary

PayerAlaska Medicaid

PolicyQutenza (capsaicin) topical patch prior authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥18minimum patient age for approval

1 moinitial authorization duration

up to 12 moreauthorization duration

Up to 4quantity limit

Coverage Criteria for Qutenza (capsaicin) Patch

Initial approval

Covered when ALL of the following are met

Approval criteria: 1. Patient is ≥ 18 years of age

Approval criteria: 2. Diagnosis of neuropathic pain associated with postherpetic neuralgia (PHN) OR neuropathic pain associated with diabetic peripheral neuropathy of the feet (DPN)

Approval criteria

All alternatives (member must have failed or be contraindicated to each of the following)
- a: Gabapentin or pregabalin
- b: Any tricyclic antidepressant
- c: Topical diclofenac
- d: Lidocaine 5% patch

Approval criteria: 4. Product will only be applied by a health care professional (not self-administered)

Include safety cautions and applicability: Qutenza patches must be applied by a licensed health care professional and are not appropriate for self-administration. Do not apply on or near the eyes or on mucous membranes because unintended capsaicin exposure can cause severe irritation. Be aware that application can cause transient increases in blood pressure, substantial burning or pain, and reductions in sensory function; these risks inform patient selection and monitoring during and immediately after application.

If the request does not meet the listed approval criteria (for example, the member is under the age threshold, does not have an eligible diagnosis, lacks required prior trials or documented contraindications, or the product will not be applied by a licensed health care professional), the service is considered not medically necessary and the prior authorization request will be denied.

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior authorization, duration, and quantity limits

Prior authorization is required. Initial approvals are for 1 month; reauthorization may be approved for up to 12 months. Quantity is limited to up to 4 patches per application, and the dose may be repeated up to once every 90 days.

Step Therapy

Required prior medication trials (step therapy)

Patient must have tried and failed for a minimum of four weeks at a recognized therapeutic dose or have a documented contraindication to ALL of the following: gabapentin or pregabalin; any tricyclic antidepressant; topical diclofenac; lidocaine 5% patch.

Minimum trial duration: 4 weeks
Required agents: gabapentin or pregabalin; any tricyclic antidepressant; topical diclofenac; lidocaine 5% patch

Required Conservative Therapies Before Approval

Trials of gabapentin or pregabalin; any tricyclic antidepressant; topical diclofenac; lidocaine 5% patch — 4 week trial requirements

Minimum trial requirements before approval

Conservative treatment requirements: Patient must have tried and failed for a minimum of four weeks at a recognized therapeutic dose, or have documented contraindications to ALL listed agents4 weeks

Trials should be at recognized therapeutic doses and documented in the record.

Required agents: The trial or documented contraindication must apply to each of the following agents:

Agent a: Gabapentin or pregabalin

Application Frequency and Quantity Limits

Frequency and quantity limits for Qutenza patch application

Repeat intervalMay be repeated once every 90 days

Quantity per applicationUp to 4 patches per application

Maximum applications per year (implicit)Approximately up to 4 applications per 12 months if spaced every 90 days

Definitions

Qutenza (capsaicin) — indication

Mechanism and formulationQutenza is a capsaicin topical patch that acts as a TRPV1 channel agonist

Indication 1Neuropathic pain associated with postherpetic neuralgia (PHN)

Indication 2Neuropathic pain associated with diabetic peripheral neuropathy (DPN) of the feet

Background

Qutenza is a high‑concentration topical capsaicin patch (a TRPV1 agonist) used for localized neuropathic pain. It is indicated for neuropathic pain associated with postherpetic neuralgia and for diabetic peripheral neuropathy of the feet. Because of its potency, application is performed by a licensed health care professional; unintended exposure may cause severe irritation and other transient adverse effects such as increased blood pressure, substantial burning/pain, and sensory changes.

Not Covered

Not covered: Self-administration of Qutenza patches is not appropriate and therefore is not covered. Do not use the product on or near the eyes or on mucous membranes due to the risk of severe irritation from unintended capsaicin exposure.