Palforzia level 1 — Blue Cross Blue Shield of Alabama

Initial criteria

• ONE of the following: - The patient has been treated with the requested agent within the past 30 days OR - The prescriber states the patient has been treated with the requested agent within the past 30 days AND is at risk if therapy is changed OR - BOTH of the following: • The patient has a diagnosed peanut allergy confirmed by ONE of the following: – A serum peanut-specific IgE level ≥ 0.35 kUA/L OR – A positive skin-prick test with mean wheal diameter ≥ 3 mm larger than the negative control OR – A positive result to an oral peanut food challenge • The patient was age 1–17 years at the time of initiating therapy AND - The prescriber is a specialist in the area of the patient’s diagnosis (e.g., allergist) or has consulted with such specialist AND - The patient has injectable epinephrine on hand AND - The requested agent is to be used in conjunction with a peanut-avoidance diet AND - The patient does not have any FDA-labeled contraindications to the requested agent

Approval duration

12 months