Xolremdi (mavorixafor) — Highmark

Initial criteria

• age ≥ 12 years
• diagnosis of WHIM syndrome (warts, hypogammaglobulinemia, infections, and myelokathexis)
• documentation of a genotype-confirmed variant of CXCR4
• absolute neutrophil count (ANC) ≤ 400 cells/µL

Reauthorization criteria

• prescriber attests that the member has experienced a reduction in the incidence of infections

Approval duration

12 months