MedicaidPrior AuthHigh impact
Pembrolizumab products (Keytruda, Keytruda Qlex)
Humana·OH · Oncology, Hematology, Internal Medicine·Medicaid
Effective date
Jul 1, 2026
We identified it
Aug 8, 2026
Summary
Humana Ohio Medicaid has updated its prior authorization policy for Pembrolizumab products (Keytruda, Keytruda Qlex) effective July 1, 2026, establishing comprehensive coverage criteria across 24+ cancer indications. This is a new policy document that requires prior authorization for all pembrolizumab use in the listed oncology diagnoses, with specific clinical criteria and disease progression exclusions.
Action Required
By June 15, 2026: Billing and prior authorization teams must implement this policy in all authorization systems and workflows for Ohio Medicaid members. (1) Configure billing software to require prior authorization for HCPCS codes J9271 and J9272 when billed under Ohio Medicaid plans. (2) Create and distribute prior authorization templates to oncology providers that include all 24+ listed cancer indications and specific clinical criteria (e.g., CPS scores, disease staging, chemotherapy regimens, biomarker requirements). (3) Train authorization staff on the exclusion criteria, particularly the disease progression restriction for prior anti-PD-1/PD-L1 therapy. (4) Update claim submission guidelines to require: diagnosis codes matching one of the listed indications, biomarker testing documentation (CPS scores, MSI-H/dMMR status as applicable), combination therapy specifications, and prior treatment history. (5) Configure denial rules: claims for pembrolizumab without prior authorization, for unlisted indications, or with documented prior anti-PD-1/PD-L1 disease progression will be denied. (6) Establish internal audit process to monitor compliance before July 1, 2026. Failure to implement prior authorization requirements will result in claim denials and potential recoupment from the practice.