Provider Referral Form for Evaluation of COVID Therapeutics Treatment

PROVIDERS: Complete form below
PATIENTS: Click here

The U.S. Food and Drug Administration has issued emergency use authorization (EUA) for the following outpatient medications, listed below in order of treatment preference as recommended by the NIH. 

Patients with a test-confirmed COVID-19 diagnosis and are experiencing symptoms, may be eligible for an outpatient treatment option, based on when their symptoms started. 

NOTE:  These treatments are only viable if given within certain number of days from symptom onset. Paxlovid and molnupiravir within 5 days; bebtelovimab and remdesivir within 7 days. Learn more about these treatments at fda.gov. 

 

Preferred Therapeutics  
 

  • PaxlovidPreferred treatment for eligible patients. This is an oral treatment and it requires a prescription to the pharmacy. Reference the Paxlovid EUA fact sheet for dosing information, contraindications, and drug-drug interactions. 

  • Remdesivir Preferred treatment for eligible patients not able to receive Paxlovid. Given as an intravenous infusion over three consecutive days.   

  • At this time, we do not have this treatment available at GLFHC 

  • See here for information for providers about therapeutic treatment access 

 

Alternative Therapy  
  

  • Bebtelovimab Monoclonal antibody therapy given as a one-time intravenous injection.  It is active in vitro against omicron sub-variants, but there are no clinical efficacy data available. Recommended for use when preferred treatment options are not available, feasible to use, or clinically appropriate.  

  • GLFHC providers can place an internal referral order for bebtelovimab via the electronic medical record or complete form below.  

  • Outside providers not affiliated with GLFHC 

  • For patients 12+, submit order form below. A member of the COVID Therapeutics Team will contact the patient to schedule an appointment if patient qualifies. 

  • Disqualifiers 

  • Patient requiring oxygen therapy and/or respiratory support due to COVID-19,  

  • Patient requiring an increase in baseline oxygen flow rate, and/or respiratory support due to COVID-19 and are on chronic oxygen therapy 

  •  

  • Molnupiravir is an oral treatment for mild-to-moderate COVID-19 in adults who are at high risk for progression to severe COVID-19, including hospitalization or death, and for whom alternative COVID-19 treatment options authorized by the FDA are not accessible or clinically appropriate. Reference the Molnupiravir Fact Sheet for Healthcare Providers for dosing information and contraindications. 

  • If patient is eligible and there is no contraindications, send prescription electronically to GLFHC Pharmacy at 34 Haverhill St in Lawrence, MA or patient’s preferred pharmacy if available. 

GLFHC Locations, Hours and Phone Numbers

GLFHC Pharmacy (for oral treatment options) –  Located at Greater Lawrence Family Health Center 
34 Haverhill St. Lawrence, MA 01841 
Hours:  Mon-Thu 8:30 am-9 pm; Fri 9 am-9 pm; Sat-Sun 9 am-5 pm 
Phone:  978-688-1567 

GLFHC Infusion Clinic (for IV treatment options) – Located at Marston Medical Center 
25 Marston St, Suite 101 (1st floor)  Lawrence, MA 01841 
Hours:  Mon-Sat 8 am to 6 pm 
Phone:  978-722-2870