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Pharmacists continue to face challenges with Paxlovid prescribing authority

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Lauren Howell, PharmD

Since July 2022, pharmacists have been able to prescribe Paxlovid (Pfizer) with certain limitations. They are able to order and prescribe the oral antiviral, under certain conditions, for eligible patients who test positive for COVID-19.

FDA revised Paxlovid’s EUA in July 2022 to include pharmacists among other health care professionals permitted to prescribe this therapeutic medication, recognizing pharmacists’ expertise and the accessibility of pharmacies to provide a test-to-treat model, especially in underserved areas. This authority provides a significant opportunity for pharmacists to demonstrate an enhanced level of service delivery and take advantage of the current scope of practice, while advocating for the scope to be broadened.

While this authority is a step in the right direction for pharmacists, few pharmacists and pharmacies have successfully incorporated prescribing of Paxlovid into their practice.

APhA survey data from August 2022 show that payment and access to laboratory data are the biggest barriers that prevent pharmacists from prescribing Paxlovid. Most pharmacists in pharmacies don’t have access to information from physician practices or hospital systems to receive the data needed to properly assess hepatic and renal function, despite pharmacists having the education and expertise needed to do so.

Payment pathways

While pharmacists receive reimbursement for dispensing of medications, including Paxlovid, there are very few pathways in place for payment for the pharmacist’s clinical assessment to determine if the patient is a candidate for Paxlovid.

Most clinical assessments for Paxlovid take 15–30 minutes or longer, and coverage for the pharmacist’s time is critical for creating a sustainable financial model to provide this service. It’s important that the pharmacist’s time for the clinical assessment is covered, regardless of whether the assessment results in a prescription or not. This approach is consistent with the way that other health care providers are paid for performing clinical assessments. However, the lack of incentive and reimbursement is leading many pharmacists to decide not to take advantage of the opportunity to offer this service. To solve the reimbursement issue for these services and to increase patient access to Paxlovid, several states have implemented pathways to payment for clinical assessments performed by pharmacists. Additionally, the federal employee benefit health program has issued a directive to care plans in their network to cover pharmacists’ provision of this service. Some large community and independent pharmacies have begun implementing a cash pay program for Paxlovid clinical assessments to provide needed access to the service and cover their costs.

Paxlovid prescribing in Canada

While the United States has seen limited uptake of pharmacists prescribing Paxlovid, a different narrative is playing out in Canada. In Quebec, 65% of prescriptions for Paxlovid have been written by pharmacists to date. More robust mechanisms are in place for Canadian pharmacists to access the kidney and liver function laboratory data that are needed for prescribing. There is also a payment mechanism in place for pharmacists to receive payment for performing a clinical assessment regardless of whether it results in a prescription.

The president of Association québécoise des pharmaciens propriétaires, Benoit Morin, said “With the ability to adjust medication dosage and to order and interpret lab results, as well as an existing compensation framework for the assessment and prescribing for minor ailments such as antivirals for influenza, pharmacists in Quebec have been able to contribute quickly and are now prescribers for approximately two-thirds of Paxlovid prescriptions dispensed in Quebec. With their great accessibility as frontline practitioners, Quebec pharmacists are thus contributing to public health efforts to protect patients at risk of complications of COVID-19.” ■


APhA has created several resources to help pharmacists implement these services and assess patients for treatment with Paxlovid. Access and for pharmacist decision-making support tools, training resources, information on APhA advocacy surrounding the topic, and information from FDA.

Paxlovid EUA specifics

To prescribe Paxlovid, a pharmacist must have

  • Access to patient’s medical records that are less than 12 months old for hepatic and renal function assessment.
  • Access to a comprehensive list of the patients’ current medications to assess for potential drug interactions.
  • A pharmacist must refer patients if there is
  • Lack of pharmacist access to the required information to assess renal and hepatic function or potential drug interactions.
  • A need for modification of medications due to drug interactions.

If the pharmacists’ assessment results in a prescription, the patient has the option to get the prescription filled at that pharmacy or the pharmacy of their choice.