The Newfoundland and Labrador Prescription Drug Program (NLPDP) Screening and Prescribing Form for Nirmatrelvir/Ritonavir (Paxlovid)

Is the patient a beneficiary of the NLPDP? Yes No If the answer is NO to any of the above questions, patient does not meet the NLPDP criteria. [...] If the answer is YES to all the above questions, proceed to Section #2. [...] Section #2: NLPDP Inclusion Criteria Please check all boxes that apply: Beneficiary has severe immunosuppression, such as: Recipient of solid organ transplant Treatment for a malignant hematologic condition Bone marrow, stem cell transplant, or transplant-related immunosuppressant use Receipt of an anti-CD20 drugs or B-cell depleting drugs (such as rituximab) in the past 2 years Severe p. [...] Specify drug name: ___________________________ Advanced HIV infection (treated or untreated) Moderate primary immunodeficiencies Renal conditions (i.e., hemodialysis, peritoneal dialysis, glomerulonephritis and dispensing of a steroid) If Section #1 requirements are met and at least one box is checked in Section #2, please proceed to Section #3 1 Section #3: Contraindications to Nirmatrelvir. [...] If YES to any of the above questions, the use of Nirmatrelvir/Ritonavir is contraindicated.