Paxlovid: Guidance for B.C. pharmacists

Contents: Paxlovid expiry dates | Background | Federal supply winding down | Drug-drug interactions (DDI) | Adjusting Paxlovid packages | Claims procedures | Patient counselling | Resources | Additional resources - CanTreatCOVID and BC Cancer

Important update: Paxlovid expiry dates

Most existing federal supply expired before or on March 31, 2024. Some lots of the renal impairment dose pack will expire on May 31, 2024. To extend the available supply, pharmacists are encouraged to dispense Paxlovid with the earliest expiry dates first, regardless of full dose or renal impairment dosing, adjusting tablets, instructions and counselling as needed. For supply that expired on March 31, 2024, pharmacists were encouraged to dispense Paxlovid only until March 26, 2024 to ensure the product did not expire part way through the five-day treatment course. For the limited supply that expires at the end of May 2024, dispense only until May 26, 2024.

Adjusting Paxlovid packages

To use full dose packaging (DIN: 02524031) for patient requiring renal impairment dose adjustment:

• Remove 1 nirmatrelvir 150 mg (pink tablet) from both the morning and evening dose of each daily card and discard the extra nirmatrelvir tablets

To use renal impairment dose packaging (DIN: 02527804) for patient requiring full dose:

• Dispense 2 renal impairment dose packages. From 1 package, remove 1 ritonavir 100 mg (white tablet) from both the morning and evening dose of each daily card and discard the extra ritonavir tablets

Disposal of expired product

• Pharmacies should dispose of expired federal supply as they would normally dispose of medications in their pharmacy, usually through a medication disposal bin. Do not return expired product to the distributor

Background

Nirmatrelvir/ritonavir (Paxlovid™) is an oral antiviral treatment indicated to reduce the risk of hospitalization in adults with mild to moderate COVID-19 at high risk of progressing to severe COVID-19. Treatment is for a total of 5 days. If a patient remains symptomatic after 5 days of treatment, another course of Paxlovid is not indicated.

Paxlovid is supplied federally and covered under Plan Z at no cost for anyone in B.C., including residents and visitors. Read about Plan Z coverage of Paxlovid.

Prescribers are encouraged to use the nirmatrelvir/ritonavir (Paxlovid™) 5-day treatment pack prescription form (PDF, 1066KB).

Federal supply winding down

The federal supply of Paxlovid is ending. B.C. pharmacies can continue to order federally-supplied Paxlovid through their regular suppliers until it runs out or expires. Paxlovid is currently under review for PharmaCare coverage.

Most existing federal supply expired before or on March 31, 2024. Some lots of the renal impairment dose pack will expire on May 31, 2024. To extend the available supply, pharmacists are encouraged to dispense Paxlovid with the earliest expiry dates first, regardless of full dose or renal impairment dosing, adjusting tablets, instructions and counselling as needed. Refer to Adjusting Paxlovid dispenses for instructions.

Consider carrying enough on hand to avoid treatment delays, as patients need to start treatment within 5 days of symptom onset.

Refer to Pfizer shelf-life correction – June 14, 2023 (PDF, 62KB) for lot numbers with expiry dates.

Drug-drug interactions (DDI)

Paxlovid has many drug-drug interactions. It is recommended to refer to at least 2 interaction checkers before dispensing, such as BCCDC’s Practice Tool # 3, Lexicomp and University of Liverpool’s interaction checker.

Adjusting Paxlovid packages

To use full dose packaging (DIN: 02524031) for patient requiring renal impairment dose adjustment:

• Remove 1 nirmatrelvir 150 mg (pink tablet) from both the morning and evening dose of each daily card and discard the extra nirmatrelvir tablets

To use renal impairment dose packaging (DIN: 02527804) for patient requiring full dose:

• Dispense 2 renal impairment dose packages. From 1 package, remove 1 ritonavir 100 mg (white tablet) from both the morning and evening dose of each daily card and discard the extra ritonavir tablets

Claims procedures

In PharmaNet, enter:

• Drug cost: $0.01 per pack
• Dispensing fee: $10 maximum
• Quantity: 1 or 2 packs depending on the dose adjustments required

If adjusting a regular dose for renal:

• Enter “renal” at the beginning of the SIG. Example: *Renal* Take 2 tablets in the morning and 2 tablets at night for 5 days

If a patient has renal dose adjustments and DDI(s):

• Enter “renal” and “DDI” at the beginning of the SIG. Example: *DDI* *Renal* Take 2 tablets in the morning and 2 tablets at night for 5 days

If patient has DDIs and associated management plans:

• Enter “DDI” at the beginning of the SIG. Example: *DDI* Take 3 tablets in the morning and 3 tablets at night for 5 days

If pharmacist determines it is inappropriate or unsafe to dispense Paxlovid:

• Claim a Refusal to Fill fee using the appropriate intervention code (such as "CI- Significant Drug Interaction (Drug-to-Drug)") to communicate to others in the patient's circle of care that an assessment was done but drug was not dispensed.

The Full Payment Policy applies to Paxlovid. Providers may not charge patients any costs associated with the dispense of Paxlovid.

Plan Z coverage

Plan Z coverage of Paxlovid is available for any patient receiving treatment in B.C., with exceptional coverage available for people in the MSP wait period, or visiting from a different home province or country. To apply, the prescriber or pharmacist calls the HIBC Help Desk. Be prepared to provide:

• college ID
• patient’s name, PHN (if applicable), date of birth, and address
• confirmation that the patient requires treatment in B.C.
• if applicable, confirmation that the patient has current medical coverage in another Canadian province or territory
• patient’s out-of-province medical plan number, if possible
• country of residence (if applicable)

Patient counselling

• Provide patient with a copy of BCCDC’s Paxlovid™ Patient Information sheet
• Discuss any drug interaction management plans and adjustments to other medications as necessary
• Advise the patient to contact the pharmacy if they experience adverse events or worsening of their condition
• Advise the patient to contact 911 if their symptoms worsen

For information about patient eligibility, please consult BCCDC’s Practice Tool #1.

Disposal of expired product

Pharmacies should dispose of expired federal supply as they would normally dispose of medications in their pharmacy, usually through a medication disposal bin. Do not return expired product to the distributor.

Reduced patient need for Paxlovid

B.C. residents have developed strong immunity to COVID-19 through widespread vaccinations and previous infections. As such, Paxlovid is unnecessary for most people living in B.C. – the drug is only beneficial to groups considered at higher risk of progressing to serious illness.

Fees history

PharmaCare previously paid two fees to pharmacists. Pharmacists claimed the PAX-F fee (ended March 31, 2023) for following up and monitoring patients for adverse drug events, and the PAX-A fee (ended December 31, 2023) for assessing Paxlovid prescriptions, including completing a drug-drug interaction (DDI) check with two independent sources.

Resources

• Pfizer shelf-life correction – June 14, 2023 (PDF, 62KB) – lot numbers and expiry dates
• Exceptional Plan Z coverage of Paxlovid is available for any patient receiving treatment in B.C., including anyone in the wait period for MSP or who lives in another province or country. For further details, visit the Plan Z (Assurance) web page, and Assurance (Plan Z) — Section 7.13, PharmaCare Policy Manual

BCCDC Clinical Practice Guide and Practice Tools

• BCCDC COVID-19 Care and Treatments

Prescription form and coverage criteria

• Nirmatrelvir/ritonavir (Paxlovid^®) coverage criteria

Optional prescriber communication form

Click to download:

Additional resources - CanTreatCOVID and BC Cancer

CanTreatCOVID

CanTreatCOVID trial of treatments for COVID in community settings: https://cantreatcovid.org/about/

BC Cancer

BC Cancer pharmacists are available to answer questions between 8am - 4pm Monday through Friday. Emails sent on weekends and statutory holidays will be responded to by a pharmacist the following working day. Refer to the table to contact the correct centre:

St. Paul's Hospital Ambulatory Pharmacy (HIV)

• 1-888-511-6222