Government of New Brunswick

Antiviral Coverage for COVID-19

 

Overview


The New Brunswick Drug Plans cover nirmatrelvir/ritonavir (Paxlovid) as a special authorization benefit for individuals enrolled in Plans ACDEFGV.

Patients must meet the special authorization criteria outlined below.

Eligible Benefits

 

  • Nirmatrelvir/ritonavir (Paxlovid) 300 mg and 100 mg dose packs, DIN 02524031
  • Nirmatrelvir/ritonavir (Paxlovid) 150 mg and 100 mg dose packs, DIN 02527804

Nirmatrelvir/ritonavir will be covered for the treatment of mild to moderate coronavirus disease 2019 (COVID-19) in adult patients with a positive COVID-19 test who are within 5 days of symptom onset and meet one of the following clinical criteria:

Clinical Criteria

Intervention Code

Severely immunosuppressed due to one or more of the following:

  • Solid organ transplant
  • Receiving treatment for a malignant hematologic condition
  • Bone marrow transplant, stem cell transplant or transplant-related immunosuppressant use
  • Received an anti-CD20 therapy or B-cell depleting therapy (such as rituximab) in the previous two years
  • Severe primary immunodeficiencies
  • Other (details must be provided on the request form)

UT

Moderately immunosuppressed due to one or more of the following:

  • Receiving treatment for cancer including solid tumors
  • Receiving treatment with significantly immunosuppressing drugs (e.g., biologic in the past three months, oral immune-suppressing drug in the past month, oral glucocorticoid [20 mg per day of prednisone equivalent taken on an ongoing basis] in the past month, or immune-suppressing infusion or injection in the past three months).
  • Advanced HIV infection
  • Moderate primary immunodeficiencies
  • Renal conditions (i.e., hemodialysis, peritoneal dialysis, glomerulonephritis treated with a glucocorticoid, estimated glomerular filtration rate [eGFR] less than 15 mL/min/1.73 m2)
  • Other (details must be provided on the request form)

VE

COVID-19 testing to confirm diagnosis can be performed by polymerase chain reaction (PCR) or point-of-care test (POCT).

Treatment should be initiated as soon as possible after a diagnosis of COVID-19 is confirmed. Patients are not eligible for coverage if they are asymptomatic or if more than 5 days have elapsed since symptom onset.

If a prescription for future use is written, the patient must meet eligibility criteria at the time of filling the prescription.

Process for Coverage


Pharmacies must submit claims electronically using the CPhA intervention codes that corresponds to the clinical criteria as outlined above.

The patient must meet the criteria for coverage, and the nirmatrelvir/ritonavir (Paxlovid) special authorization request form must be completed and retained by pharmacy with the prescription. The request form does not need to be faxed to the NB Drug Plans.

The request form should be completed by the prescriber who is performing the assessment for nirmatrelvir/ritonavir treatment. If the request form is not provided with the prescription, the dispensing pharmacist can complete the form.

Documentation Requirements

 

The hard copy of the prescription, along with the completed special authorization request form must be retained by the dispensing pharmacy:

The request form must be retained for the retention period specified in the New Brunswick Pharmacy Act and related bylaws/guidelines.

Claim Submission

 

  • Claims for nirmatrelvir/ritonavir must be submitted electronically.
  • Information on NB Drug Plans Claim Submissions is available online. The fields applicable to nirmatrelvir/ritonavir are listed below.
Field Information Required
DIN/PIN nirmatrelvir/ritonavir (Paxlovid) 300/100 mg, DIN 02524031
nirmatrelvir/ritonavir (Paxlovid) 150/100 mg, DIN 02527804
Quantity 1 
Intervention and Exception Code Applicable CPhA intervention code for those patients meeting the clinical criteria outlined above

Pharmacy Audits

 
  • All claims submitted by participating providers for reimbursement are subject to audit and recovery.
  • All claims must be supported with documentation of the completed special authorization request form.