Pharmacy Prior Authorization Criteria

Xolremdi (mavorixafor)

Indications for Prior Authorization

Xolremdi (mavorixafor)

• For diagnosis of WHIM syndrome
  Indicated in patients 12 years of age and older with WHIM syndrome (warts, hypogammaglobulinemia, infections and myelokathexis) to increase the number of circulating mature neutrophils and lymphocytes.

Criteria

Xolremdi

Prior Authorization (Initial Authorization)

Length of Approval: 6 Month(s)
For diagnosis of WHIM syndrome

• Diagnosis of WHIM (warts, hypogammaglobulinemia, infections and myelokathexis) syndrome
AND
• Patient has genotype confirmed variant of CXCR4 as detected by an FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Patient has an absolute neutrophil count (ANC) less than 500 cells /µL [A]
AND
• Patient is 12 years of age or older
AND
• Prescribed by or in consultation with one of the following:
• Immunologist
• Hematologist
• Geneticist
• Allergist

Xolremdi

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of WHIM syndrome

• Patient demonstrates positive clinical response to therapy (e.g., improvement in ANC, reduction in infections)

P & T Revisions

2024-08-29, 2024-08-20, 2024-07-04

References

1. Xolremdi Prescribing Information. X4 Pharmaceuticals, Inc. Boston, MA. June 2024.
2. Per clinical consult with immunologist/ allergist, June 27, 2024.

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Revision History

• 2024-08-29: Attach EHB formulary. No changes to criteria.
• 2024-08-20: Updated ANC to less an 500 cells per microlitre.
• 2024-07-04: New Program.

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