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
- Presence of genotype-confirmed mutation 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
- Dermatologist
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
2025-07-29, 2024-08-29, 2024-08-20, 2024-07-04
References
- Xolremdi Prescribing Information. X4 Pharmaceuticals, Inc. Boston, MA. September 2024.
- Per clinical consult with immunologist/ allergist, June 27, 2024.
End Notes
- Per consult with immunologist/ allergist, severe neutropenia (less than or equal to 500 cells per µL) is used in standard practice as a cut off for ANC levels [2].
Revision History
- 2025-07-29: 2025 Annual Review. Added Dermatologist as accepted specialist to mirror Core-Ext. Update genetic testing requirement to "presence of genotype-confirmed mutation of CXCR4." Updated references.
- 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.
HEALTHY LIVING