Palforzia [peanut (Arachis hypogaea) allergen powder-dnfp] — Highmark
Mitigation of allergic reactions, including anaphylaxis, that may occur with accidental exposure to peanut in patients with a confirmed diagnosis of peanut allergy
Initial criteria
- Prescribed by or in consultation with an allergist or immunologist
- Member meets one of the following: age between 1 and 17 years for initial dose escalation OR age ≥ 1 year for up-dosing and maintenance
- Confirmed diagnosis of peanut allergy (ICD10: Z91.010) demonstrated by one of the following: peanut-specific skin prick test (SPT) OR peanut-specific IgE (sIgE) antibodies
- Member experienced an allergic reaction to peanut
- Member will be on a peanut-avoidant diet while on Palforzia therapy
- Member does not have uncontrolled asthma
- Member does not have eosinophilic esophagitis or eosinophilic gastrointestinal disease
- Member has a documented prescription for epinephrine
Reauthorization criteria
- Member has experienced a positive clinical response to therapy
- Member requires continuation of therapy
- Member has not missed three or more consecutive days of therapy as evidenced by claims
- Member will continue a peanut-avoidant diet while on Palforzia therapy
Approval duration
12 months