Palforzia — Medical Mutual

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
Medication is prescribed by or in consultation with an allergist or immunologist
Per the prescriber, the patient has a history of an allergic reaction to peanut that met EACH of the following: patient demonstrated signs and symptoms of a significant systemic allergic reaction AND the reaction occurred within a short period of time following a known ingestion of peanut or peanut‑containing food AND the prescriber deemed this reaction significant enough to require a prescription for an epinephrine auto‑injector
Patient meets ONE of the following diagnostic criteria: BOTH (positive skin prick test response to peanut with a wheal diameter ≥ 3 mm larger than negative control AND positive in vitro test for peanut‑specific IgE with level ≥ 0.35 kU/L) OR (positive skin prick test response to peanut with wheal diameter ≥ 8 mm larger than negative control OR positive in vitro test for peanut‑specific IgE with level ≥ 14 kU/L)
Per the prescriber, Palforzia will be used in conjunction with a peanut‑avoidant diet
Patient does NOT have uncontrolled asthma

1 year initial, 1 year reauth