Xolremdi — Medical Mutual

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) 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
• The medication is prescribed by or in consultation with an immunologist, hematologist, or dermatologist

Reauthorization criteria

• Patient is age ≥ 12 years; AND
• The medication is prescribed by or in consultation with an immunologist, hematologist, or dermatologist; 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 such as absolute neutrophil count, white blood cell count, absolute lymphocyte count)

Approval duration

initial 3 months; reauth 1 year