Medicare AdvantagePrior AuthMedium impact
Xolremdi (mavorixafor) (Revised)
Humana·Allergy & Immunology, Hematology, Genetics +2 more·Medicare Advantage
Effective date
Sep 25, 2024
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage has issued a new prior authorization policy for Xolremdi (mavorixafor), a rare disease treatment for WHIM syndrome. All requests require prior authorization with three strict approval criteria: confirmed WHIM diagnosis via CXCR4 genotype, baseline ANC ≤400 cells/μL, and prescription by a specialist (immunologist, hematologist, geneticist, infectious disease, or dermatologist). Initial approvals are for 6 months; renewals require documented increase in ANC or decreased infection frequency.
Action Required
Effective immediately (September 25, 2024): Billing and clinical teams must implement prior authorization process for all Xolremdi (mavorixafor) requests in Humana Medicare Advantage plans. REQUIREMENTS: (1) Before submitting any Xolremdi claims, obtain prior authorization through Humana's PAL (Preauthorization and Notification List) system at www.humana.com/PAL; (2) Billing team must verify that prescribing provider is one of the five required specialties (immunologist, hematologist, geneticist, infectious disease specialist, or dermatologist) before submitting authorization request; (3) Clinical/billing staff must confirm member has documented CXCR4 genotype confirmation and baseline ANC ≤400 cells/μL in medical record before authorization submission; (4) For renewal requests after 6 months, obtain supporting documentation showing either ANC increase from baseline OR decreased infection frequency; (5) Update billing system workflows to flag Xolremdi as requiring prior auth for Humana MA; (6) Communicate to all providers prescribing this medication that claims will be DENIED without prior authorization. No billing codes were provided in this policy—contact Humana PAL for applicable medical and procedural codes.