MedicaidPrior AuthHigh impact
Pembrolizumab products (Keytruda, Keytruda Qlex) (New)
Humana·IN · Oncology, Hematology·Medicaid
Effective date
Feb 1, 2026
We identified it
Jun 24, 2026
Summary
Humana Indiana Medicaid has established a new comprehensive prior authorization policy for Keytruda and Keytruda Qlex covering 31 cancer indications including solid tumors, lymphomas, and various carcinomas. Each indication has specific approval criteria requiring diagnosis confirmation, biomarker testing results, and treatment combinations with 6-month initial approval periods.
Action Required
Before February 1, 2026: Billing team must implement prior authorization requirements for all Keytruda and Keytruda Qlex claims for Indiana Medicaid patients. Update billing system to flag these drugs for prior auth. Train staff on 31 covered cancer indications and specific criteria including required biomarker tests (PD-L1, CPS scores, MSI-H, dMMR status). Create workflow to verify diagnosis codes, treatment combinations, and obtain FDA-approved test results before treatment. Claims without proper prior authorization will be denied.