All PlansCoverageHigh impact
Pembrolizumab (Keytruda®)
BCBS Tennessee·Oncology, Hematology, Radiation Oncology·Medical Policy
Effective date
Oct 31, 2026
We identified it
Aug 13, 2026
Summary
This is a comprehensive new medical policy for Pembrolizumab (Keytruda®) covering FDA-approved indications across 16+ cancer types including melanoma, NSCLC, head and neck cancer, urothelial carcinoma, and others. The policy establishes covered indications, approval criteria, and clinical parameters (e.g., PD-L1 expression thresholds, biomarker requirements) that billing teams must verify before processing claims. Policy is not yet active—implementation is blocked until 10/31/26.
Action Required
By October 31, 2026: Billing team must review and implement this Pembrolizumab policy across all oncology billing workflows. (1) Update billing system to recognize all 16+ covered cancer indications listed in the policy. (2) Establish prior authorization checklist requiring providers to submit: specific FDA-approved indication, biomarker/molecular test results (PD-L1 CPS/TPS scores, MSI-H, dMMR, EGFR/ALK status), prior treatment history, and clinical stage/resectability status as applicable to each indication. (3) Train oncology providers and billing staff on approval criteria specific to each indication—many require documented biomarker testing and specific thresholds (e.g., PD-L1 CPS ≥1 for gastric cancer, TPS ≥1% for NSCLC, CPS ≥10 for squamous esophageal cancer). (4) Create referral workflow to reject incomplete claims lacking required biomarker documentation before claim submission. (5) Update encounter templates and prior auth forms to capture stage, histology, prior therapy lines, and molecular test results. Failure to verify coverage criteria and biomarkers will result in claim denials and potential retrospective recovery. NOTE: Do not implement these changes until after October 31, 2026—policy is currently in draft status.