Xolremdi — Blue Cross Blue Shield of Montana

Initial criteria

• 1. BOTH of the following:
• A. ONE of the following:
• 1. The patient has a diagnosis of WHIM syndrome AND ALL of the following:
• A. Genetic analysis confirms mutation in the CXCR4 gene [chart notes required] AND
• B. 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) AND
• C. 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
• 2. 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:
• A. The patient’s age is within FDA labeling for the requested indication for the requested agent OR
• B. There is support for using the requested agent for the patient’s age for the requested indication AND
• 2. The patient will NOT be using the requested agent in combination with any other CXCR4 antagonists (e.g., plerixafor) for the requested indication AND
• 3. 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
• 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 AND
• 2. The patient has had clinical benefit with the requested agent AND
• 3. The patient will NOT be using the requested agent in combination with any other CXCR4 antagonists (e.g., plerixafor) for the requested indication AND
• 4. 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
• 5. The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

12 months