Palforzia (peanut [Arachis hypogaea] allergen powder-dnfp for oral administration – Aimmune) — Cigna

Peanut Allergy

Initial criteria

Patient is 1 to 17 years of age OR patient is ≥ 18 years of age AND has been previously started on therapy with Palforzia prior to becoming 18 years of age
According to the prescriber, the patient has a history of an allergic reaction to peanut that met ALL of the following: (i) patient demonstrated signs and symptoms of a significant systemic allergic reaction; (ii) this reaction occurred within a short period of time following a known ingestion of peanut or peanut-containing food; AND (iii) the prescriber deemed this reaction significant enough to require a prescription for an epinephrine self-administered injectable or nasal product
Patient has a positive skin prick test response to peanut OR a positive in vitro test (a blood test) for immunoglobulin E (IgE) to peanut
According to the prescriber, Palforzia will be used in conjunction with a peanut-avoidant diet
Patient does NOT have uncontrolled asthma
Medication is prescribed by or in consultation with an allergist or immunologist

1 year