Subject: Paxlovid Limit 5099-H P09-2025
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PAXLOVID
(nirmatrelvir tablets and ritonavir tablets)
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Policy:
Indications
FDA-Approved Indications
Paxlovid is indicated for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) in adults who are at high risk for progression to severe COVID-19, including hospitalization or death.
Limitations of Use
- Paxlovid is not approved for use as pre-exposure or post-exposure prophylaxis for prevention of COVID-19.
Initial Limit Quantity
Limits should accumulate across all drugs and strengths up to highest quantity listed depending on the order the claims are processed.
These drugs are for short-term acute use.
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Drug
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Limit
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Paxlovid
(300 mg nirmatrelvir; 100 mg ritonavir)
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60 tablets (2 cartons containing 30 tablets (10 doses) each of 2 tablets of
nirmatrelvir 150 mg and 1 tablet of ritonavir 100 mg) / 30 days
|
|
Paxlovid
(150 mg nirmatrelvir; 100 mg ritonavir)
|
40 tablets (2 cartons containing 20 tablets (10 doses) each of 1 tablets of
nirmatrelvir 150 mg and 1 tablet of ritonavir 100 mg) / 30 days
|
|
Paxlovid
(300 mg nirmatrelvir; 100mg ritonavir) (Day 1)
(150 mg nirmatrelvir; 100 mg ritonavir) (Days 2-5)
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22 tablets (2 cartons containing 11 tablets (5 doses) each of 2 tablets of
nirmatrelvir 150 mg and 1 tablet of ritonavir 100 mg for day 1 and 1 tablet of
nirmatrelvir 150 mg and 1 tablet of ritonavir 100 mg for days 2-5) / 30 days
|
Place of Service:
Outpatient
The above policy is based on the following references:
- Paxlovid [package insert]. New York, NY: Pfizer Inc.; January 2025.
- Lexicomp Online, AHFS DI (Adult and Pediatric) Online. Waltham, MA: UpToDate, Inc.; 2025. https://online.lexi.com. Accessed August 12, 2025.
- Micromedex (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 08/12/2025).
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
February 14, 2026
