Paxlovid for Foreign Travel: What You Need to Know

If you’re planning a trip, you may wonder if you can get Paxlovid for foreign travel. The answers are murky at best. This is what we learned.

With the gray cloud of COVID still hanging over us, we gathered the courage to plan our next trip to Italy. Of course, as COVID virgins (knock on wood) we’ve taken every precaution we can think of. 

Our vaccine cards are full with entries, and we’ve recently had the updated COVID-19 booster—and the newest flu and RSV vaccines. 

But being over 65, mindful mask-wearers, and COVID-cautious, we began wondering whether we could pack a course of Paxlovid just in case we contracted a COVID-19 infection.

When we began reading and thinking about how to go about it, we realized that obtaining Paxlovid for foreign travel, both before and during, can be daunting.

What is Paxlovid? 

To provide some background, Paxlovid (nirmatrelvir/ritonavir tablets) is an FDA-approved antiviral medication used to treat mild-to-moderate coronavirus disease in individuals at high risk for progressing to severe illness.

On May 25, 2023, the FDA approved the medication as safe and effective for these high-risk individuals: older adults, those with chronic diseases, and individuals who are immunosuppressed.

Data from Pfizer (the drug maker) presented to the FDA stated that trial participants using Paxlovid were 89% less likely to develop severe illness and death than those receiving a placebo.

In addition, under a previous emergency use authorization (EUA), Paxlovid continues to be authorized for adults and eligible pediatric patients 12 years and older (who weigh at least 88 pounds) who are at high risk for progression to severe COVID-19, including hospitalization and death.

(Although best known, Paxlovid isn’t the only game in town. According to the CDC, it is one of two antiviral treatments that can be taken at home, the other one being Lagevrio. Velkury (remdesivir), is an IV infusion administered at a healthcare facility for three consecutive days.)

Who should take Paxlovid?

Specifically, the drug is offered for use to those over the age of 12 with weakened immune systems, which might include people with asthma, cancer, liver disease, lung disease, heart disease, and those who are obese.

People who are at the highest risk of adverse outcomes from COVID-19 are those who benefit most according to data from Pfizer.

What are the caveats to the use of Paxlovid?

• It is NOT approved for prevention, either pre- or post-exposure.

• It is NOT authorized for the treatment of patients requiring hospitalization due to severe or critical COVID-19.

• Pediatric use is authorized under the EUA but is NOT approved by the FDA because clinical development of Paxlovid for pediatric use is ongoing. (Pending commercial launch, the U.S. government maintains a supply of Paxlovid under the EUA to ensure access to all eligibles.)

• It should NOT be used longer than five consecutive days.

More details on the approval and emergency use of Paxlovid are available as a download on the FDA website (Frequently Asked Questions on the Emergency Use Authorization for Paxlovid for Treatment of COVID-19).

In that document, the question of traveling with Paxlovid—just in case—is specifically addressed:

Paxlovid for foreign travel

The Frequently Asked Questions (FAQ) section of the FDA document specifically addresses the availability of Paxlovid for foreign travel.

QUESTION: I am traveling soon. May I receive Paxlovid under the EUA before travel in case I become sick with COVID-19? 

ANSWER: Individuals being considered for Paxlovid treatment must meet the eligibility requirements under the EUA at the time of prescription. Providers must determine that patients have signs and symptoms consistent with mild-to-moderate COVID-19, assess risk for disease progression, assess renal and hepatic function, and review all medications taken by the patient to assess for potential drug-drug interactions and determine if other medicines that a patient may be taking require a dose adjustment, interruption and/or additional monitoring

Sounds like a disappointing NO, to me. 

Why would someone want to take Paxlovid with them when traveling?

There are several compelling reasons why it would be useful to have Paxlovid on hand while traveling:

Increased risk 

Travel tends to increase the risk of contracting viruses because travelers are more likely to be amongst crowds, whether on public transportation, busy restaurants, cruise ships, or tours. 

Travelers have less control over the COVID vigilance of the people they interact with than they would likely have at home. Unfortunately, COVID fatigue has set in and many people have stopped wearing masks, paying attention to social distancing, and/or getting vaccine boosters.

Limited access to physicians/prescribed medications

Travelers usually take sufficient supplies of their prescribed medications so they don’t have to navigate the healthcare system elsewhere (e.g., getting prescriptions and figuring out how to fill and pay for them.) There also can be language barriers.

Access to Paxlovid varies widely by destination because the medication isn’t authorized in all countries and isn’t always widely available in places where it is authorized.

In the U.S., the EUA permits prescription and distribution by health departments, doctor’s offices, clinics, hospitals, and urgent care centers at more than 38,000 locations. 

In addition, state-licensed pharmacists in the U.S. can prescribe Paxlovid, subject to the terms and conditions outlined in the EUA. (Pharmacists are required to have access to sufficient health information or consultation with a health care provider to assess the risk for potential adverse drug interactions.)

Another barrier: The cost of Paxlovid

An important aside, access to Paxlovid in the U.S. has become even more limited and cost-prohibitive as drugmaker Pfizer transitioned from government purchase of the drug to the commercial marketplace in November 2023.

In October 2023, Pfizer announced that the cost of the drug to consumers would more than double.  The list price for Paxlovid, before insurance, for a five-day course will be $1,390. The government previously paid $ 530 per course.

According to a recent article from JAMA, however, there are still opportunities to obtain COVID at no cost. The U.S. Patient Assistance Program will be offering treatment free of charge for Medicare and Medicaid beneficiaries and the uninsured until the end of 2024. Out-of-pocket costs for insured individuals is available through the Paxcess program.

How to access the Paxcess program

Writing in The Washington Post, Dr. Leana S. Wen cited many examples where pharmacies quoted eligible patients exorbitant prices for Paxlovid. However, after enrolling in the free program, they could obtain the medication for free from the same pharmacies.

To enroll in the program:

• Obtain a prescription for Paxlovid from a physician.

• Sign up for the Paxcess program on the Pfizer website.

• Approval should take place in less than five minutes.

Need for urgency

Because the drug should be taken within the first five days of onset of symptoms, having access to the drug is time-sensitive. (Individuals are prescribed three pills twice daily, with the full course totaling 30 pills.)

Paxlovid and Travel to Italy: What people are saying

Getting back to our trip to Italy, we looked at several popular travel forums to read about the real-world challenges posters had finding Paxlovid in Italy:

On Rick Steves’ travel forum

Mari365 wrote: 

Both my wife and I got Covid when we were in Italy. Early on, I became pretty ill. I tried to get Paxlovid and was told by two different doctors (one recommended by the American Embassy) to not even try. He also scarfed saying “in the states they give it out like cotton candy“. I took their course of preventative and comfort treatment, and became progressively worse. At that point, we made the decision to try to get out of Italy, and by the time we got to New York, I had passed the window for the antiviral, but also had full-blown pneumonia in both lungs diagnosed as Covid pneumonia. I am still very ill. If you are worried about getting Covid, Do Not Go to Italy!!! My background is in public health regulation. The physicians I have spoken with here in the states were appalled to hear what happened to me. 

Poster Hrhuntington wrote:

@martf365 So sorry to hear that. Yeah, we weren’t able to get Paxlovid in Italy at all and our experience with doctors/pharmacists there was the same as yours. Luckily our Covid was very mild, though. Looks like the move is to try to get a prescription for it as a precaution before you leave the states in future.

On Reddit

The chatter on Reddit offers some practical information and suggestions, as follows:

• Paxlovid is approved for emergency use in the EU.

• A poster who messaged their primary care physician at home from abroad was told that the doctor couldn’t send a prescription overseas.

• In most destinations, a traveler needs to see a doctor at their destination and based on their diagnosis, condition, and policies of the locale, the doctor will decide whether to prescribe it.

• It could be worthwhile to call your health insurer to see if they can refer you to an associated doctor and/or pharmacy. Many have 24-hour hotlines offering medical assistance.

• It could also be useful to bring a record of all the medications you have taken in the past year, information on other health issues, and a letter from your doctor explaining whether there are contraindications to using Paxlovid. Another poster recommended having access to your online medical records.

• A local pharmacist can often recommend how to see a doctor as a tourist and provide OTC medication to treat symptoms.

• It is always prudent to wear an N95 mask to reduce the risk of contracting COVID and to be aware of people around you with cold symptoms.

• Additionally, travel with the OTC meds you might need to treat the symptoms of COVID (e.g., anti-diarrheals, pain relievers, etc.)

• Be sure you have internet access and the financial resources you might need should you have to extend your stay or pay for treatment.

• One lucky poster asked their doctor to write a prescription for Paxlovid to take with them while traveling in Europe. The doctor did so without hesitation and the traveler filled it at  CVS the same day. (P.S. They were thankful to have it because they did test positive during the trip and were able to start taking it immediately.)

And then we turned to a physician friend in Italy

On our behalf, he emailed his GP and was told that the only way to obtain Paxlovid for people coming from other countries was to go to the Emergency Room of one of the public hospitals in Italy, to perform a COVID-19 test, and then (if you test positive), get the prescription for Paxlovid directly from the National Health System.

He added: 

The attitude here is very relaxed about COVID. Apparently, no one seems to care anymore (I don’t know if that’s a good thing…). No new COVID booster or restrictions. Everybody is living as if nothing had happened. I have heard from several people who have recently fallen ill with the new COVID, without having received any booster in the last year or so, but they have all described symptoms of moderate flu, without complications. 

However, an April 2022 article we found online states that The Italian Medicines Agency (AIFA) announced that general practitioners (GP) can prescribe Pfizer’s oral antiviral COVID-19 treatment.

The disappointing conclusion

Although it would make us feel safer and more secure, getting a prescription for Paxlovid for foreign travel remains challenging. 

And whether you are here or abroad, the likelihood of being able to pack it in your suitcase—just in case—is slim.

The Department of Health and Human Services operates a Test to Treat Program at certain participating pharmacies that was developed to provide access to lifesaving treatments for COVID-19.  According to the DHHS website, those participating pharmacists are required to obtain electronic or printed health records that are less than 12 months old and recent reports of laboratory blood work (to review for kidney or liver problems) to prescribe the drug to eligible patients.

The same website states clearly: that Paxlovid is “not a pre-treatment drug” and can’t be dispensed without someone having a current diagnosis of COVID-19.

Paxlovid for cruising: Just in case

The problem of access to Paxlovid is always a concern when booking a cruise.

A reader of the Washington Post recently wrote to the paper’s medical columnist, Dr. Leana Wen. She was preparing for a cruise to South America and wanted to take Paxlovid with her in case she contracted COVID during her voyage. Her doctor refused to fill the prescription.

Dr. Wen offered three good suggestions:

• She suggested that the reader raise the issue again with her doctor, reiterating she would only take the medication if she tested positive, and allay any concerns the physician might have about her taking it prophylactically. 

• If the doctor still refuses, she advised the reader to contact the cruise line to find out their policies on dispensing Paxlovid and to specifically ask if there the cruise line might require any blood work that she could do in advance.

• Finally, if she saw no path to obtaining the medication, she suggested that the reader visit another physician who might be willing to prescribe Paxlovid “just in case.”

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READ MORE

Med Page Today – Why Aren’t More Doctors Prescribing Paxlovid?

JAMA Medical News and Perspectives – Paxlovid Is Effective but Underused—Here’s What the Latest Research Says About Rebound and More

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We’d love to hear any other ideas or opinions.

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