All PlansCoverageHigh impact
Pembrolizumab (Keytruda®)
BCBS Tennessee·Oncology, Hematology, Radiation Oncology·Medical Policy
Effective date
Sep 30, 2026
We identified it
Jul 17, 2026
Summary
This is a comprehensive new medical policy for Pembrolizumab (Keytruda®) covering FDA-approved indications across multiple cancer types including melanoma, NSCLC, head/neck cancer, lymphomas, urothelial carcinoma, and others. The policy establishes coverage criteria and approved uses but is NOT effective until September 30, 2026, and should NOT be implemented until that date.
Action Required
Before September 30, 2026: Billing and clinical teams must review this policy document to understand all Pembrolizumab (Keytruda®) coverage requirements, including indication-specific criteria, biomarker testing requirements (PD-L1, MSI-H, dMMR, HER2, EGFR, ALK status), and combination therapy specifications. Update billing system rules, prior authorization workflows, and provider education materials to reflect these covered indications and approval criteria. DO NOT implement any changes until the September 30, 2026 effective date. Coordinate with oncology providers and pharmacists to ensure claims are submitted with appropriate diagnosis codes and documentation of biomarker test results to support medical necessity. Failure to implement this policy by the effective date may result in incorrect claim denials or approvals after implementation.