Pharmacy Prior Authorization Criteria

Kygevvi (doxecitine/doxribtimine)

Indications for Prior Authorization

Kygevvi (doxecitine/doxribtimine)

• For diagnosis of Thymidine Kinase 2 Deficiency (TK2d)
  Indicated for the treatment of thymidine kinase 2 deficiency (TK2d) in adults and pediatric patients with an age of symptom onset on or before 12 years.

Criteria

Kygevvi

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Submission of medical records (e.g., chart notes) confirming a diagnosis of thymidine kinase 2 deficiency (TK2d)
AND
• Submission of medical records (e.g., chart notes) confirming the presence of a mutation in the TK2 gene as detected by a FDA-approved test or a test performed at a facility approved by Clinical Laboratory Improvement Amendments (CLIA)
AND
• Submission of medical records (e.g., chart notes) confirming the patient experienced symptom onset on or before 12 years of age
AND
• Prescribed by or in consultation with a clinical specialist knowledgeable in the treatment of TK2d (e.g., geneticist, neurologist)

Kygevvi

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Provider attests the patient would benefit from continued therapy
AND
• Prescribed by or in consultation with a clinical specialist knowledgeable in the treatment of TK2d (e.g., geneticist, neurologist)

P & T Revisions

2026-05-14

References

1. Kygevvi Prescribing Information. UCB, Inc. Smyrna, GA. November 2025.

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Revision History

• 2026-05-14: New program

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