Medicare AdvantagePrior AuthHigh impact
Pembrolizumab products (Keytruda, Keytruda Qlex) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2025
We identified it
Jun 24, 2026
Summary
Humana has updated their prior authorization policy for Pembrolizumab products (Keytruda, Keytruda Qlex) effective January 1, 2025, covering multiple cancer indications across Medicare and Medicaid plans in Florida, Kentucky, and South Carolina. The policy includes detailed criteria for 30+ cancer types including biliary tract, cervical, lung, breast, and other cancers, with 6-month approval durations and specific combination therapy requirements.
Action Required
Immediately: Update prior authorization processes for all Keytruda/Keytruda Qlex requests to include new criteria requirements for each cancer indication. Billing team must verify PD-L1 expression scores, combination therapy requirements, and exclusion criteria before submitting requests. Ensure documentation includes FDA-approved test results where required. Claims without proper prior authorization will be denied.