COVID-19: Providers

Outpatient Therapeutics

All outpatient therapeutics are provided for free by the U.S. Government. This COVID-19 Decision Support Tool (PDF) can help providers determine which COVID-19 treatment is appropriate for a patient.

Updates on Oral Antivirals

Paxlovid and molnupiravir are available in several pharmacies in NYC. To check their daily reported supplies on hand, visit the Test to Treat COVID-19 Therapeutics Locator.

See below for instructions on how to send a prescription to Alto Pharmacy for free delivery to patients.

Updates on Monoclonal Antibodies

Bebtelovimab is the only monoclonal antibody therapy currently authorized for emergency use to treat mild to moderate COVID-19. Due to the reduced activity of sotrovimab against the BA.2 subvariant, the Food and Drug Administration has removed its authorization. Health care providers in these states should use alternative therapies, such as oral antivirals and bebtelovimab.

Bebtelovimab must be administered within seven days of symptoms onset.

  • To find a monoclonal antibody treatment site, visit the NYC Health Map.

See below for more information on eligibility and patient prioritization.

Updates on Evusheld for Pre-Exposure Prophylaxis

The initial dose of Evusheld has been increased to 600 mg. People who received an initial dose of 300 mg should receive a second Evusheld dose as soon as possible.

  • If the patient received their initial dose less than three months ago, they should receive a dose of 150 mg of tixagevimab and 150 mg of cilgavimab.

  • If the patient received their initial dose more than three months ago, they should receive a dose of 300 mg of tixagevimab and 300 mg of cilgavimab.

To find health care facilities and pharmacies with Evusheld in stock, check the COVID-19 Therapeutics Locator. Evusheld can also be prescribed through Alto Pharmacy, which will deliver Evusheld to the prescribing provider/clinic’s address at no cost.

New Test to Treat Program

The federal government has launched a new initiative, Test to Treat, to facilitate early diagnosis and quick access to treatment. The initiative involves partnering with pharmacies to provide on-site testing (including evaluation of at-home test results), assessment, prescription and dispensing of COVID-19 oral antivirals.

For more information, visit HHS Test to Treat.


Monoclonal antibodies and oral antivirals are authorized for:

  • Treatment of non-hospitalized patients with mild to moderate COVID-19 who are at high risk of progressing to severe disease.

Monoclonal antibodies are also authorized for:

  • Pre-exposure prophylaxis for people who may not have an adequate immune response to the vaccine, or who cannot be vaccinated due to a history of severe adverse reaction to a COVID-19 vaccine or any of their components.

Currently, use as post-exposure prophylaxis is on hold due to previously authorized products lack of effectiveness against the omicron variant (REGEN-COV and bamlanivimab with etesevimab).

Monoclonal antibodies and oral antivirals are not a substitute for vaccination in people for whom vaccination is recommended. Recommend COVID-19 vaccination as the best strategy to prevent severe COVID-19 illness, hospitalization and death.

Monoclonal Antibodies

Monoclonal antibodies are made in a laboratory and work as substitute antibodies that can help fight an infection before the body mounts its own immune response. The antibodies are directed against specific targets on the spike protein of SARS-CoV-2, blocking viral entry into cells. They are recommended by the NIH COVID-19 Treatment Guidelines for outpatient treatment of COVID-19 and post-exposure prophylaxis.

Providers should refer all eligible symptomatic patients for monoclonal antibody treatment. Monoclonal antibodies can be given regardless of vaccination status.

If started soon after the onset of symptoms, monoclonal antibody treatment can decrease the risk of hospitalization and death due to COVID-19 and reduce hospital length of stay and emergency department visits.

As pre-exposure prophylaxis, monoclonal antibodies can reduce the risk of developing symptomatic COVID-19 disease by 77%.

Monoclonal Antibodies Eligibility

Monoclonal antibodies are currently only authorized as treatment and pre-exposure prophylaxis for people who have a medical condition or other factors that increase their risk for severe illness. There are currently no authorized monoclonal antibody products for post-exposure prophylaxis.

Specific Criteria for Treatment and Pre-Exposure Prophylaxis

For treatment, patients must meet all of these criteria:

  • Be 12 years or older
  • Weigh at least 88 pounds
  • Be 65 or older or have a medical condition or other factor that increases their risk for severe COVID-19
    • Consider race and ethnicity when assessing individual risk. Longstanding systemic health and social inequities may contribute to an increased risk of getting sick and dying from COVID-19.
  • Test positive for COVID-19 on a nucleic acid amplification test or antigen test
  • Have mild to moderate COVID-19 symptoms
  • Are able to start treatment within seven days of symptom onset
  • Are not hospitalized or receiving oxygen therapy due to COVID-19

For pre-exposure prophylaxis, patients must meet all of these conditions:

  • Be 12 years or older
  • Weigh at least 88 pounds
  • Are not currently infected with SARS-CoV-2
  • Have no known recent exposure to an individual infected with COVID-19
  • Have moderate to severe immune compromise due to a medical condition or receipt of immunosuppressive medications or treatments and may not mount an adequate immune response to COVID-19 vaccination, or COVID-19 vaccination is not recommended due to a history of severe adverse reaction, such as severe allergic reaction, to a COVID-19 vaccine or any of its components.

For additional guidance, see the Evusheld Prescriber Checklist (PDF).

COVID-19 Monoclonal Antibody Products Under FDA EUA

One product is currently authorized for emergency use for treatment in New York State. Sotrovimab is no longer authorized for use due to the prevalence of the BA.2 omicron subvariant and its reduced activity against this variant.

Bebtelovimab

Note: This product is expected to remain effective against the omicron BA.1 and BA.2 omicron variant sublineages (section 12.4, Fact Sheet for Providers).


Tixagevimab with Cilgavimab (EVUSHELD)

Note: This product is expected to remain effective against the omicron variant (section 12.4, Fact Sheet for Providers).

Clinical Considerations for Monoclonal Antibodies

To decide if monoclonal antibody is appropriate for a patient, refer to the COVID-19 Decision Support Tool (PDF, December 30, 2021).

Treatment is most effective when given as soon as possible after symptom onset and should be considered for eligible patients, regardless of vaccination status.

Due to limited clinical efficacy data, bebtelovimab is only authorized as a treatment for patients whom alternative COVID-19 treatment options approved or authorized by FDA are not accessible or clinically appropriate. However, based on the scientific evidence (Phase 2 trial and pharmacokinetic data), it is expected that bebtelovimab may be effective for the treatment of patients with mild-to-moderate COVID-19 to reduce the risk of progression to hospitalization or death (Section 14.4, bebtelovimab Fact Sheet For Providers).

For pre-exposure prophylaxis, long-term efficacy data indicate that EVUSHELD can be re-dosed every six months for people who continue to qualify for therapy. Due to limited supplies, EVUSHIELD is only available to select locations serving populations eligible for pre-exposure prophylaxis.

CDC guidelines no longer recommend delaying COVID-19 vaccination after receiving monoclonal antibody therapy.

Referring or Offering Monoclonal Antibody Therapy

Referring for Therapy

Here are some resources to help you find a referral site:


Offering Therapy

The following website has information for providers interested in offering monoclonal antibody therapy:

The following websites have information for monoclonal antibody treatment providers:

Accessing Evusheld

Offering Evusheld

Two options are available in NYC for offering Evusheld to your patients:

  1. To administer Evusheld in your practice, you can order from a pharmacy with Evusheld in stock by checking the COVID-19 Therapeutics Locator.
  2. Alternatively, providers can send a prescription to Alto Pharmacy, which will deliver Evusheld to the prescribing provider/clinic’s address at no cost. Prescriptions confirmed by 11 a.m. on weekdays will be delivered to the provider/clinic office on the same day during normal clinic business hours. Prescriptions confirmed after 11 a.m. will be delivered the following day.

When prescribing through Alto:

  1. Specify the appropriate dose of each product in the prescription:
    • The initial dose is 300 mg of tixagevimab and 300 mg of cilgavimab.
    • For patients who received the previously recommended dose (150 mg of tixagevimab and 150 mg of cilgavimab), administer a second dose of 150 mg of tixagevimab and 150 mg of cilgavimab as soon as possible.

  2. Send prescription through ePrescription. Search by:
    • Name: Alto Pharmacy
    • Address: 100 Park Avenue, Front E, New York, NY 10017
    • NPI: 1417578899
    • NCPDP: 5831866

    If you have trouble finding Alto Pharmacy, check search filters to remove mileage or radius limits and "favorites" or "recently viewed" filters.

    Alternatively, Alto Pharmacy accepts prescriptions by phone at 800-874-5881, or by fax at 415-484-7058.

  3. Once the prescription is sent, Alto will coordinate directly with provider/clinic for delivery directly to provider/clinic office. Verify the clinic/practice’s phone number and address for delivery. If an alternative phone number or address should be used, include that information in the "Notes to Pharmacist" section.

    Advise patients that they may receive a call or text message from the pharmacy; however, no action is needed by the patient.

    If you have any questions, call Alto Pharmacy at 800-874-5881. More information is available at the Alto Pharmacy website.

For more information on prescribing Evusheld, see the Evusheld Prescriber Checklist (PDF). For information on billing and reimbursement for the administration of Evusheld, visit the CMS Monoclonal Antibodies webpage. For details on coding, refer to the Evusheld Coding Resource (PDF, AstraZeneca).

Referring Patients for Evusheld

Evusheld will be offered soon at NYC Health + Hospitals. Community providers interested in referring their patients for Evusheld will need to either complete an eFax form or call 212-COVID-19 (212-268-4319). For more information on how to refer, visit NYC Health + Hospitals Evusheld Treatment.

Patient Education on Monoclonal Antibodies

People at increased risk of severe COVID-19 and their caregivers should be advised:

  • About the benefits of prompt monoclonal antibody therapy to reduce the risk of hospitalization and death.
  • To get tested immediately if they develop COVID-19 symptoms or were recently exposed.
  • To contact their provider right away if they test positive. People who do not have a provider can visit ExpressCare or call 212-COVID19 (212-268-4319) to speak with a doctor about treatment options.

Resources for Patients


Oral Antiviral Treatment

Authorized oral antiviral treatment works by targeting specific proteins on the SARS-CoV-2 virus to prevent virus replication within the host cell.

If started within five days of symptom onset, oral antivirals reduce the risk of hospitalization and death by 88% with Paxlovid and 30% with molnupiravir.

Oral antivirals are not authorized for pre-exposure or post-exposure prophylaxis to prevent COVID-19.

Oral Antiviral Eligibility

Oral antivirals are authorized for people who have tested positive for SARS-CoV-2, regardless of their vaccination status.

Paxlovid is the preferred oral antiviral. Molnupiravir is approved for use in people ages 18 years and older for whom alternative FDA-authorized COVID-19 treatment options are not accessible or clinically appropriate.

Neither product should be used for longer than five consecutive days.

Oral antiviral therapy is authorized for people who meet all of the following conditions:

  • Be age 12 years and older and weigh at least 88 pounds for Paxlovid; 18 years and older for molnupiravir
  • Be age 65 or older or have a medical condition or other factor that increase their risk for severe COVID-19
    • Consider race and ethnicity when assessing individual risk. Longstanding systemic health and social inequities may contribute to an increased risk of getting sick and dying from COVID-19.
  • Test positive for COVID-19 on a nucleic acid amplification test or antigen test. Results from an FDA-authorized home-test kit should be validated through video or photo but, if not possible, patient attestation is adequate.
  • Have mild to moderate COVID-19 symptoms
  • Are able to start treatment within five days of symptom onset
  • Are not hospitalized due to severe or critical COVID-19 when treatment is initiated

For Paxlovid Only

Precautions

Co-administration of Paxlovid can alter the plasma concentrations of other drugs, and other drugs may alter the plasma concentrations of Paxlovid. Consider the potential for drug interactions prior to and during Paxlovid therapy and review concomitant medications during Paxlovid therapy (see the NIH Treatment Guidelines Statement on Potential Paxlovid Drug-Drug Interactions and Section 7 of the Paxlovid Fact Sheet for Health Care Providers (PDF)). For additional guidance, providers can access the Liverpool Drug Interactions tool and Paxlovid Checklist Tool for Prescribers (PDF).

Therapy is not recommended for patients with severe kidney (eGFR <30 mL/min) or liver (Child-Pugh Class C) impairment. Dosage adjustments are needed for patients with moderate renal impairment (eGFR ≥30 to <60 mL/min). Providers should discuss with patients who have kidney or liver problems whether Paxlovid is right for them.

Paxlovid may lead to a risk of HIV-1 developing resistance to HIV protease inhibitors in patients with uncontrolled or undiagnosed HIV-1 infection. Patients on ritonavir- or cobicistat-containing HIV or HCV regimens should continue their treatment as indicated.


For Molnupiravir Only

Molnupiravir should be prescribed for patients ages 18 years and older for whom alternative FDA-authorized COVID-19 treatment options are not accessible or clinically appropriate.

Precautions

Molnupiravir is not recommended during pregnancy. Prescribing providers should advise individuals of childbearing potential to use effective contraception correctly and consistently for the duration of treatment and for four days after the last dose of molnupiravir.

Breastfeeding is not recommended during treatment and for four days after the last dose of molnupiravir. A lactating individual may consider interrupting breastfeeding and pumping and discarding breast milk during this time.

Men of reproductive potential who are sexually active with women of childbearing potential should use a reliable method of contraception correctly and consistently during treatment and for at least three months after the last dose.

For more information, see the Molnupiravir Fact Sheet for Providers (PDF) and the FDA Molnupiravir Checklist Tool for Prescribers (PDF).

COVID-19 Oral Antiviral Products Under FDA EUA

Two products have received emergency use authorization.

Nirmatrelvir with Ritonavir (Paxlovid)


Molnupiravir

Clinical Considerations for Oral Antivirals

Treatment must be administered within five days of symptom onset, but it is most effective when given as soon as possible after symptoms begin. High-risk patients who present within six to 10 days of symptoms onset should be referred for monoclonal antibody therapy. Treatment is appropriate for all eligible patients, regardless of vaccination status.

Prior to initiating treatment with molnupiravir, carefully consider the known and potential risks and benefits. See section on eligibility for information on prescribing precautions.

To decide if oral antiviral treatment is appropriate for a patient, providers can refer to the COVID-19 Decision Support Tool (PDF, December 30, 2021).

Prescribing Oral Antiviral Therapy

Paxlovid and molnupiravir are available in several pharmacies in NYC. To check their daily reported supplies on hand, visit the COVID-19 Therapeutics Locator. See below for instructions on how to send a prescription to Alto Pharmacy for free delivery to patients.

Oral antivirals can only be prescribed by a physician, advanced practice registered nurse or physician assistant. For more information on prescribing Paxlovid, see the Paxlovid Checklist Tool for Prescribers (PDF).

Prescriptions placed with Alto Pharmacy will be delivered to the patient’s preferred address at no cost. Once the prescription is placed, patients can schedule their delivery on the Alto mobile app, by text or by phone with Alto pharmacists.

Alto Pharmacy can offer direct support in English and Spanish and support in numerous other languages through language line.

Prescriptions confirmed by 5 p.m. on weekdays or 1 p.m. on weekends will be delivered the same day.

Complete the following steps to prescribe an oral antiviral medication for a patient:

  1. Add Alto Pharmacy to your electronic health record (EHR) system for e-prescribing. To locate Alto Pharmacy in your ePrescribing platform or EHR, search by:
    • Name: Alto Pharmacy
    • Address: 100 Park Avenue, Front E, New York, NY 10017
    • NPI: 1417578899
    • NCPDP: 5831866

      If you are having trouble finding Alto Pharmacy, check search filters to remove mileage or radius limits and "favorites" or "recently viewed" filters.

      Alternatively, Alto Pharmacy accepts prescriptions by phone at 800-874-5881, or by fax at 415-484-7058.

  2. Verify patient’s phone number and address for delivery.

  3. Choose the oral antiviral you would like to prescribe.
    • If you would like to automatically have molnupiravir substituted when Paxlovid is unavailable, you must submit two prescriptions — one for each medicine. State in the notes section of the molnupiravir prescription: "To be used in case Paxlovid prescription cannot be filled because of supply limitation." Substituting with molnupiravir can only be done for patients meeting eligibility criteria and with no contraindications for either product.

  4. In the note for pharmacist section, indicate the patient’s:
    • Race/ethnicity from the following options: Asian/Native Hawaiian or other Pacific Islander; Black; Hispanic/Latino; Native American/Alaska Native; and White
    • Date of symptom onset

  5. Submit prescription to Alto Pharmacy.

  6. Advise patient that they will receive a call or text message from the pharmacy (800-874-5881) and they must respond to schedule the delivery. More information is available at the Alto Pharmacy website.

  7. Contact Alto Pharmacy at 800-874-5881 for questions on medicine interactions or other concerns.

Patient Education on Oral Antivirals

People at increased risk of severe COVID-19 and their caregivers should be advised:

  • About the benefits of prompt oral antiviral treatment to reduce the risk of hospitalization and death
  • To immediately get tested if they develop COVID-19 symptoms or were recently exposed
  • To contact their provider right away if they test positive

Patient Handout: COVID-19 Treatments Are Available (PDF)


Additional Resources