Xolremdi (mavorixafor) — Blue Cross Blue Shield of Alabama

Initial criteria

• The requested agent is eligible for continuation of therapy AND ONE of the following:
• • The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
• • The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days AND is at risk if therapy is changed
• OR BOTH of the following:
• • The patient has a diagnosis of WHIM syndrome AND ALL of the following:
• – Genetic analysis confirms mutation in the CXC chemokine receptor 4 (CXCR4) gene
• – Confirmed absolute neutrophil count (ANC) OR total white blood cell (WBC) count ≤ 400 cells/microliter (prior to therapy with the requested agent AND during no clinical evidence of infection)
• – The prescriber has assessed baseline status (prior to therapy with the requested agent) of the patient's symptoms (e.g., ANC, ALC, number of infections)
• OR The patient has another FDA labeled indication for the requested agent and route of administration
• AND If the patient has an FDA labeled indication, then ONE of the following:
• – The patient’s age is within FDA labeling for the requested indication for the requested agent OR
• – There is support for using the requested agent for the patient’s age for the requested indication
• AND The patient will NOT be using the requested agent in combination with any other CXCR4 antagonists (e.g., plerixafor) for the requested indication
• AND The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, geneticist, hematologist, immunologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• AND The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• AND The patient has had clinical benefit with the requested agent
• AND The patient will NOT be using the requested agent in combination with any other CXCR4 antagonists (e.g., plerixafor) for the requested indication
• AND The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, geneticist, hematologist, immunologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• AND The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months