MedicaidPrior AuthHigh impact
Pembrolizumab products (Keytruda, Keytruda Qlex)
Humana·IN · Oncology, Hematology, Pharmacy·Medicaid
Effective date
Jul 1, 2026
We identified it
Aug 8, 2026
Summary
Humana Indiana Medicaid has released a comprehensive prior authorization policy (effective 7/1/2026) for Pembrolizumab products (Keytruda IV/solution and Keytruda Qlex subcutaneous) covering 25+ cancer indications. The policy establishes specific clinical criteria for approval, including disease stage/progression status, biomarker requirements (PD-L1, MSI-H, dMMR), treatment combinations, and explicitly excludes patients with prior anti-PD-1/PD-L1 therapy progression. Billing teams must implement prior auth requirements before claims are submitted.
Action Required
By June 15, 2026: Billing team must implement prior authorization requirements in the practice management system for all Pembrolizumab claims (HCPCS J9271, J9272, J9273) submitted to Humana Indiana Medicaid. For each claim, obtain prior auth by verifying: (1) member has one of 25 listed cancer diagnoses with appropriate stage/progression status; (2) treatment regimen matches policy-approved combination or monotherapy; (3) required biomarkers documented (PD-L1 CPS score, MSI-H, dMMR status where specified); (4) member has NO prior disease progression on anti-PD-1/PD-L1 agents. Update encounter templates to capture disease stage, biomarker results, prior therapy history, and treatment plan. Train providers to document all clinical criteria before prescribing. Establish workflow to submit prior auth requests to Humana before dispensing. Claims submitted without prior authorization will be denied.