Xolremdi (mavorixafor) — CareFirst (Caremark)
WHIM syndrome (warts, hypogammaglobulinemia, infections, and myelokathexis)
Initial criteria
- Prescribed for treatment of WHIM syndrome
- Member has a genotype-confirmed variant of CXCR4 gene consistent with WHIM syndrome
- Member has a confirmed low neutrophil count based on the reference laboratory range or current practice guidelines
- Member exhibits at least one other clinical manifestation of disease (warts, hypogammaglobulinemia, infections, myelokathexis, lymphopenia, or monocytopenia)
- Member is age ≥ 12 years
- Medication is prescribed by or in consultation with an immunologist, pediatrician, hematologist, or dermatologist
Reauthorization criteria
- Member is experiencing benefit from therapy (e.g., improvement in absolute neutrophil count [ANC], improvement in absolute lymphocyte count [ALC], or reduction in infections)
Approval duration
Initial: 6 months; Continuation: 12 months