Skip to content
The Policy VaultThe Policy Vault

Xolremdi — Blue Cross Blue Shield of Illinois

other FDA labeled indication for the requested agent and route of administration

Initial criteria

  • BOTH of the following:
  • 1. ONE of the following:
  • A. 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 [chart notes required]
  • • 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
  • B. The patient has another FDA labeled indication for the requested agent and route of administration
  • AND
  • B. 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
  • 2. The patient will NOT be using the requested agent in combination with any other CXCR4 antagonists (e.g., plerixafor) for the requested indication
  • 3. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., dermatologist, geneticist, hematologist, immunologist) or has consulted with such a specialist
  • 4. The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

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

Approval duration

12 months