Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] — United Healthcare

Initial criteria

• Diagnosis of peanut allergy as documented by BOTH of the following: (1) A serum peanut-specific IgE level ≥ 0.35 kUA/L AND (2) A mean wheal diameter ≥ 3 mm larger than the negative control on skin-prick testing for peanut
• AND One of the following: (1) BOTH: Patient is 1 to 17 years of age AND Patient is in the initial dose escalation phase therapy OR (2) BOTH: Patient is 1 year of age and older AND Patient is in the up-dosing or maintenance phase of therapy
• AND Used in conjunction with a peanut-avoidant diet

Reauthorization criteria

• Documentation of positive clinical response to Palforzia therapy
• AND Used in conjunction with a peanut-avoidant diet

Approval duration

12 months