New Brunswick Drug Plans covers nirmatrelvir/ritonavir (Paxlovid) for adults who meet set clinical criteria, and this form documents them. Unlike other New Brunswick special authorization forms, it is not faxed to the plan: it stays with the prescription at the pharmacy, which bills electronically using the intervention code that matches the criterion selected.
The prescriber (requestor) completes all five sections, including the therapeutic criteria and the signature with licence or registration number; the pharmacy keeps the completed form with the prescription.
Download the current version from the source each time; forms change without notice.
Nirmatrelvir/Ritonavir (Paxlovid) Special Authorization Request
Nirmatrelvir/Ritonavir (Paxlovid) - Demande d'autorisation spéciale
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No. The form states it must be completed and retained with the prescription at the pharmacy and asks prescribers not to fax it to New Brunswick Drug Plans. The pharmacy submits the claim electronically, including the CPhA intervention code that matches the clinical criterion checked.
The form allows it: the requestor can indicate the prescription was written for future use, and the patient fills it only after testing positive for COVID-19 and within 5 days of symptom onset. The patient must still be 18 or older and meet one of the immunosuppression criteria.
Adults 18 or older who are severely immunosuppressed, for example after a solid organ, bone marrow or stem cell transplant, or moderately immunosuppressed, for example during cancer treatment, on significantly immunosuppressing drugs, with advanced HIV, or with renal conditions such as dialysis. Each group has an 'Other' option to specify.