Xolremdi (mavorixafor) — Blue Cross Blue Shield of Kansas

Initial criteria

• 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 and during no clinical evidence of infection)
• The prescriber has assessed baseline status (prior to therapy) of the patient’s symptoms (e.g., ANC, ALC, number of infections)
• The patient’s age is within FDA labeling for the requested indication OR there is support for use by age for the indication
• The patient will NOT be using the requested agent in combination with any other CXCR4 antagonists (e.g., plerixafor)
• 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
• 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
• The patient has had clinical benefit with the requested agent
• The patient will NOT be using the requested agent in combination with any other CXCR4 antagonists (e.g., plerixafor)
• 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
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months