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Monoclonal Antibody (MCA) Therapy Request Form

For Provider Use Only

READ THIS! Important information for referring physician

Stop!!! Important Information for referring physician

Jan. 18th Update: We currently do not have availability but if your patient meets criteria we will notify them and schedule when we have the medication available.

Jan. 11th Update: ETCH is receiving a small, intermittent allocation of the monoclonal antibody Sotrovimab and can accept requests for high-risk patients again. Sotrovimab is IV only, and the EUA for use from the FDA only goes down to 12yos. We will accept requests for 12-17yos. Because of the small number of doses coming available, prioritization will go to those with very high BMI or %wt for age, or those that are immunocompromised. At this time we will also not be able to approve those patients that are vaccinated. The MOD can be a resource for any questions. We will notify your practice if the request is denied.

For patients 18 and older, use the link for ordering at UTMC. https://www.utmedicalcenter.org/provider-referrals-covid-19-monoclonal-antibody-therapy/.

Treatment of Non-hospitalized Patients When Omicron is the Predominant Circulating Variant:

The oral product Paxlovid is available for consideration and in TN is available only through certain Walmart pharmacies. The link to check on possibilities is: http://www.walmart.com/covidmedication. This link only lists participating pharmacies but does not list which ones have product in stock.

Informed consent regarding Sotrovimab infusion is the responsibility of the requesting provider.

Order Form