Xolremdi (mavorixafor capsules – X4 Pharmaceuticals) — Cigna

Initial criteria

• Patient is age ≥ 12 years; AND
• Genetic testing confirms pathogenic and/or likely pathogenic variants in the CXCR4 gene; AND
• Patient meets ONE of the following (a or b): a) At baseline, patient had an absolute neutrophil count ≤ 400 cells/µL; OR b) At baseline, patient had a white blood cell count ≤ 400 cells/µL; AND
• Medication is prescribed by or in consultation with an immunologist, hematologist, or dermatologist

Reauthorization criteria

• Patient is currently receiving Xolremdi; AND
• According to the prescriber, the patient is continuing to derive benefit from Xolremdi as determined by the most recent objective measurement (e.g., reduced frequency, duration, or severity of infections; less frequent treatment with antibiotics; fewer warts; or improved/stabilized clinical signs/symptoms of WHIM syndrome such as absolute neutrophil count, white blood cell count, or absolute lymphocyte count)

Approval duration

1 year