Xolremdi (mavorixafor) — Medica

Initial criteria

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

Reauthorization criteria

• Patient is currently receiving Xolremdi and is continuing to derive benefit as determined by the most recent objective measurement (e.g., reduced infection frequency, less antibiotic use, fewer warts, or improved/stabilized clinical signs or laboratory measures)

Approval duration

1 year