All PlansCoverageMedium impact
Pembrolizumab and Berahyaluronidase alfa-pmph (Keytruda Qlex™)
BCBS Tennessee·Oncology, Hematology, Dermatology +4 more·Medical Policy
Effective date
Oct 31, 2026
We identified it
Aug 13, 2026
Summary
This is a new medical policy for Pembrolizumab and Berahyaluronidase alfa-pmph (Keytruda Qlex™) that establishes coverage criteria for this oncology drug across multiple cancer types including melanoma, lung cancer, head and neck cancer, urothelial cancer, and others. The policy is not to be implemented until October 31, 2026, giving practices over 8 months to prepare billing and clinical workflows.
Action Required
By October 15, 2026 (16 days before implementation): Oncology practices and billing teams must review this policy and prepare systems for Keytruda Qlex coverage determinations. (1) Clinical staff should update treatment protocols and documentation templates to capture required testing (PD-L1/CPS scores, EGFR/ALK status, microsatellite instability testing) as specified for each cancer indication. (2) Billing team must establish prior authorization workflows in the billing system to verify all FDA-approved indication criteria are met before claim submission. (3) Update the encounter forms and clinical decision support tools to prompt providers to document which specific indication and approval criteria are being met. (4) Train billing and clinical staff on the specific indications and approval criteria outlined in the policy. Failure to implement proper documentation and prior authorization review will result in claim denials, as the policy explicitly states that 'all approval criteria must be met' for coverage.