MedicaidPrior AuthHigh impact
Pembrolizumab products (Keytruda, Keytruda Qlex) (New)
Humana·OH · Oncology·Medicaid
We identified it
Jul 2, 2026
Summary
Humana has issued a new Prior Authorization policy for Pembrolizumab products (Keytruda, Keytruda Qlex) effective for Ohio Medicaid members. This is a 1-day-old policy requiring immediate attention. The billing team must implement prior authorization requirements for these immunotherapy drugs before processing claims.
Action Required
Immediately: Billing team must implement prior authorization requirements for Pembrolizumab products (Keytruda, Keytruda Qlex) for all Ohio Medicaid claims. Contact Humana at the source URL (https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a56a5fc) to obtain the full policy document with specific codes, clinical criteria, and authorization procedures. Update billing system rules, provider alerts, and encounter templates to flag Pembrolizumab claims for prior auth submission before processing. Brief oncology and relevant clinical staff on new authorization workflow. Claims submitted without prior authorization will be denied by Humana Ohio Medicaid.