Background and Objective: Ensuring the provision of health services in rural remote municipalities (MRR) remains a challenge for the Brazilian Public Health System-SUS. This problem increased dramatically during the COVID-19 pandemic, as MMR context amplifies the devastating potential of the virus, such as insufficient supply of professionals/services and the great distance from urban centers (technological density). Our aim is to analyze the initiatives to combat the pandemic adopted in Piauís MMR; discuss the role of primary healthcare (PHC) in the pandemic; and identify itineraries of patients diagnosed with COVID-19. Methods: Exploratory qualitative case study, developed in two MMR of Piauí, both with less than 4000 inhabitants. Data were collected in 2022, through individual in-depth interviews with PHC professionals, SUS users SARS-Cov-2 infected and community leaders. The interviews were conducted with open questions about coping with the pandemic (professionals and leaders) and the experience and care received during the illness caused by COVID-19 (users). The interviews were recorded, transcribed and treated qualitatively, applying content analysis technique. Results: Initiatives adopted: sanitary barriers, mandatory use of masks, social isolation, ban on parties/gatherings, closure of non-essential establishments, “covid kit”, distribution, testing of suspected cases and vaccination. PHC: concentrated care for COVID-19 cases, protagonism and work overload of community workers (CHW), on barriers, home visits, vaccination and service through messaging applications. Itineraries: non or mildly-symptomatic were advised to isolate themselves at home, severe cases were referred by ambulance to reference hospitals in other municipalities in Piauí. Conclusions: Primary care coordinated and/or actively participated in coping with the pandemic. Positive points: population bonds and CHW’s assistance. Users felt supported. Distance from larger cities was not considered a protective factor against COVID-19. Previous results suggest the existence of long-term Covid-19 cases, with different clinical presentations, and an increase in mental disorders’ prevalence (depression, alcoholism and drug use).