All PlansCoverageMedium impact
Pembrolizumab and Berahyaluronidase alfa-pmph (Keytruda Qlex™)
BCBS Tennessee·TN · Oncology, Hematology, Pulmonology +2 more·Medical Policy
Effective date
Sep 30, 2026
We identified it
Jul 17, 2026
Summary
This is a new medical policy covering Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) that establishes coverage criteria for multiple cancer indications including melanoma, NSCLC, mesothelioma, head/neck cancers, urothelial cancer, and others. The policy is approved but NOT yet implemented and should not be used until the September 30, 2026 effective date.
Action Required
By September 15, 2026: Billing and clinical teams must review and implement this new Keytruda Qlex coverage policy in preparation for the 9/30/26 effective date. Actions required: (1) Update billing system to recognize Keytruda Qlex (J9271 or applicable HCPCS code pending final determination) as a covered drug under the specified cancer indications; (2) Configure prior authorization logic in billing software to enforce the FDA-approved indication criteria and approval thresholds (e.g., PD-L1 TPS/CPS levels, genomic testing requirements); (3) Create or update prior authorization request templates for oncology providers documenting required clinical criteria by cancer type; (4) Train billing staff and provider offices on the multiple indication-specific requirements, testing mandates, and combination therapy rules; (5) Notify in-network oncology providers of coverage requirements and documentation needs. DO NOT implement this policy before 9/30/26. Failure to implement by the effective date will cause claims to be processed under outdated guidance and may result in denials or payment delays.