COVID-19 Antiviral Eligibility Screening Form

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This form is for providers not affiliated with MU Health Care. To learn more about the MU Health Care treatment protocol, visit muhealth.org/covid-19-treatments.

Patient Name

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Patient Date of Birth

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Y-M-D

Is patient < 5 days from symptom onset?

Current antiviral treatments must be initiated within 5 days of symptom onset. If beyond 5 days, please do not attempt to order.

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Yes

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Eligibility Criteria Table

Tier	Risk Groups
1	Immunocompromised individuals not expected to mount an adequate immune response to COVID-19 vaccination or SARS-CoV-2 infection due to their underlying conditions, regardless of vaccine status (see Immunocompromising Conditions); or Unvaccinated individuals at the highest risk of severe disease (anyone aged ≥75 years or anyone aged ≥65 years with additional risk factors)
2	Unvaccinated individuals at risk of severe disease not included in Tier 1 (anyone aged ≥65 years or anyone aged < 65 years with clinical risk factors)
3	Vaccinated individuals at high risk of severe disease (anyone aged ≥75 years or anyone aged ≥65 years with clinical risk factors) Note: Vaccinated individuals who have not received a COVID-19 vaccine booster dose are likely at higher risk for severe disease; patients in this situation within this tier should be prioritized for treatment.
4	Vaccinated individuals at risk of severe disease (anyone aged ≥65 years or anyone aged < 65 with clinical risk factors) Note: Vaccinated individuals who have not received a COVID-19 vaccine booster dose are likely at higher risk for severe disease; patients in this situation within this tier should be prioritized for treatment.

Details on immunocompromising conditions and clinical risk factors can be found here:
https://www.covid19treatmentguidelines.nih.gov/therapies/statement-on-patient-prioritization-for-outpatient-therapies/

According to criteria in the table above, I attest that this patient meets criteria the following prioritization tier:

Use the dropdown at right to choose tier.

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According to criteria in the table above, I attest that this patient meets criteria for Tier [1/2/3/4] prioritization.

Prescriber Name

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According to criteria in the table above, I attest that this patient meets criteria for Tier [1/2/3/4] prioritization.

Prescriber Signature

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For Paxlovid Only:

Renal dosing is required. Check the selection that applies to the patient, and follow the corresponding prescribing guidelines.

Patient has eGFR > 60 mL/min.

Patient has eGFR = 30-59 mL/min.

Patient has eGFR < 30 mL/min.

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Dosing Instructions: Take 2 tablets of nirmatrelvir 150mg and 1 tablet of ritonavir 100mg together by mouth twice daily for 5 days as directed on package.

Type initials in box at right to continue.

Dosing Instructions: Take 1 tablet of nirmatrelvir and 1 tablet of ritonavir together by mouth twice daily for 5 days as directed on package.

Type initials in box at right to continue.

Dosing Instructions: Paxlovid is contraindicated. Consider antibody infusion, remdesivir infusion, or oral molnupiravir.

Type initials in box at right to continue.

Please let us know if you have any questions.

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