Ask The Pharmacist: What Adjusters Need to Know About Trubrexa, a High-Cost Topical Analgesic

Are private-label topicals like Trubrexa worth the cost in workers’ comp? 

Private label topical analgesics (PLTAs) continue to push pharmacy spend higher in workers' compensation claims. Trubrexa is starting to stand out on volume and cost, especially in Florida and Georgia. You often see these products dispensed out-of-network through physician offices or specialty mail order pharmacies. That trend mirrors a larger pattern where topical analgesics make up 13.9% of out-of-network prescriptions but 40.2% of out-of-network spending. Manage PLTAs proactively and guide care to evidence-based, lower-cost options to protect outcomes and budgets.

What Is Trubrexa?

Trubrexa is a prescription patch with lidocaine 4.75% and capsaicin 0.025%. While assigned a National Drug Code (NDC)—a universal standardized identifier that supports drug safety, tracking and reimbursement through the medication supply chain—it has not undergone rigorous clinical trials demonstrating superiority over existing treatments, such as standalone lidocaine in 4% or 5% and capsaicin in varying strengths or formulations. 

How It Works

Trubrexa combines two well-established active ingredients:

• Lidocaine: A local anesthetic that temporarily blocks sodium channels in nerve membranes, preventing pain signal transmission
• Capsaicin: A natural compound derived from chili peppers that depletes substance P, reducing pain signal transmission over time

Clinical Considerations

Current evidence does not show Trubrexa outperforms standard topical analgesics. In a 2019 analysis, novel specialty formulations were no more effective than placebo despite significantly higher costs. The authors advised limiting use due to "higher costs compared to proven compounds and a lack of superior efficacy."

Cost Implications

Average wholesale price (AWP) estimates for Trubrexa patches range from approximately $200 for four patches to over $2,000 for 32 patches. That can be a 20- to 50-fold increase over therapeutically similar options. This pricing disparity creates significant cost concerns, particularly when:

• PLTAs account for only 3.9% of prescription volume but 20.5% of total pharmacy costs.
• Opportunistic categories such as select topicals and PLTAs are frequently dispensed out-of-network and average 34% higher costs than in-network alternatives.
• Products lack clinical evidence of better outcomes than lower-priced options.

Evidence-Based Alternatives 

(Illustrative examples, not exhaustive)

OTC Options

• Use lidocaine 4% or less (e.g., Aspercreme with Lidocaine, Salonpas Lidocaine patches) Typical retail $8-15 per unit/pack.
• Use capsaicin 0.025%-0.1% (e.g., Capzasin, Capsaicin, Salonpas Hot patches). Typical retail $10-30 per tube, roll-on, or box.
• Consider combination products that combine cooling agents with lidocaine or capsaicin when appropriate. 

Prescription Alternatives

• Choose generic lidocaine 5% patches, creams, or ointments.
• Consider generic lidocaine/prilocaine cream.
• Use diclofenac 1% gel when indicated. This is available OTC and by prescription. 

Non-Pharmacological Approaches

• Refer to physical therapy focused on function and return to work.
• Offer a TENS unit when appropriate. 
• Apply heat or cold therapy per injury phase. 

Recommendations for Claims Management

Based on current evidence and best practices, claims professionals should consider following prior authorization requirements for PLTAs such as Trubrexa. Request documentation that lower-cost alternatives were tried and failed before approving higher-priced products. Encourage prescribers to choose evidence-based, cost-effective options aligned with guidelines. Generate regular utilization reports to identify prescriber trends and outliers for targeted support outreach. Integrate pharmacy and bill review systems so you can manage these products consistently regardless of billing channel.

Rising Trubrexa use can create significant cost concerns without demonstrated clinical benefits over established alternatives. By promoting evidence-based alternatives and implementing appropriate utilization management, you can help injured employees receive effective pain management relief while controlling avoidable pharmacy spend. To learn more about PLTAs and significant cost drivers in workers’ compensation claims, see the 2025 Enlyte Drug Trends Report. 

This information is meant to serve as a general overview, and any specific questions should be fully reviewed with a health care professional such as the prescribing doctor or dispensing pharmacist.

Do you have a workers’ compensation or auto-related pharmacy question? Send us an email at AskThePharmacist@enlyte.com.

To read more Ask The Pharmacist articles, please visit enlyte.com/ask-the-pharmacist.