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Pembrolizumab products (Keytruda, Keytruda Qlex) (New)
Effective date
Nov 1, 2026
Identified
Nov 3, 2026
Summary
Humana Ohio Medicaid established a new prior authorization policy effective November 1, 2026, for pembrolizumab products (Keytruda intravenous powder, intravenous solution, and Keytruda Qlex subcutaneous solution) across 25 cancer indications. Each indication has specific clinical criteria, required combination or monotherapy regimens, biomarker requirements (CPS, PD-L1, dMMR/MSI-H, or TMB-high scores where applicable), and exclusions based on prior anti-PD-1/PD-L1 therapy. Initial and renewal approvals are granted for 6 months or as determined through clinical review.
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What to do
Action · 5 steps
01Effective November 1, 2026: Billing team must obtain prior authorization before any claims for pembrolizumab products (Keytruda IV powder, Keytruda IV solution, or Keytruda Qlex subcutaneous solution) are submitted to Humana Ohio Medicaid.
02For each requested authorization, providers must document the member's specific cancer diagnosis (from the 25 listed indications), relevant clinical criteria (disease stage, prior therapy history, biomarker status such as PD-L1 or MSI-H where required), treatment regimen (monotherapy vs. combination therapy with specified agents), and confirm the member does not have disease progression following prior anti-PD-1/PD-L1 therapy.
03Update the prior authorization tracking system to require this documentation before charge entry, and instruct front desk and provider staff that claims will be denied without prior authorization.
04Initial approvals are valid for 6 months; plan for renewal submissions before that period expires.
05Refer to the full 15-page policy document on Humana's website to verify the specific criteria for each indication, as requirements vary significantly by cancer type.
Codes mentioned
J9271J9272J9273
Original notice
Pembrolizumab products (Keytruda, Keytruda Qlex) (New)
mcp.humana.com · Always check the source before changing claims.
Related changes
See all Humana changes →Pembrolizumab products (Keytruda, Keytruda Qlex) (Revised)HighEffective Jan 1, 2025 · MedicaidPembrolizumab products (Keytruda, Keytruda Qlex) (New)HighEffective Nov 1, 2026 · MedicaidPembrolizumab products (Keytruda, Keytruda Qlex)HighEffective Jul 1, 2026 · MedicaidPembrolizumab products (Keytruda, Keytruda Qlex) (New)HighEffective Jul 1, 2026 · MedicaidBrowse every Humana change in the policy list