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Pembrolizumab products (Keytruda, Keytruda Qlex) (New)
Effective date
Nov 1, 2026
Identified
Nov 3, 2026
Summary
Humana Louisiana Medicaid has established a new prior authorization policy for pembrolizumab products (Keytruda IV powder, Keytruda IV solution, Keytruda Qlex subcutaneous) effective November 1, 2026. The policy covers 26 cancer indications with specific clinical criteria, combination therapy requirements, and exclusions (including disease progression on prior anti-PD-1/PD-L1 therapy). All pembrolizumab claims for these indications require prior authorization before the service is rendered or claims will be denied.
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What to do
Action · 8 steps
01Effective November 1, 2026.
02Billing team must obtain prior authorization from Humana Louisiana Medicaid before each pembrolizumab infusion or injection for any of the 26 covered indications (biliary tract cancer, cervical cancer, cutaneous squamous cell carcinoma, endometrial cancer, esophageal cancer, gastric cancer, head and neck squamous cell carcinoma, hepatocellular carcinoma, Hodgkin's lymphoma, malignant pleural mesothelioma, melanoma, Merkel cell carcinoma, MSI-high/dMMR solid tumors, NSCLC, ovarian/fallopian tube/primary peritoneal cancer, primary mediastinal large B-cell lymphoma, renal cell carcinoma, triple negative breast cancer, tumor mutational burden-high solid tumors, and urothelial cancer).
03Prior to scheduling or billing HCPCS J9271 or J9272, verify that the member meets all applicable criteria for the specific indication—including diagnosis type, disease stage, prior therapy history, biomarker status (CPS, PD-L1, dMMR/MSI-H, TMB-H where required), and combination therapy requirements.
04Confirm the member does not have disease progression on or following prior anti-PD-1/PD-L1 therapy, as this exclusion will result in denial.
05Update the prior authorization tracker and charge entry to include the indication, therapy setting (monotherapy vs. combination), and any required biomarker documentation.
06Tell providers that initial authorization is valid for 6 months or as determined by clinical review, and subsequent renewals are also valid for 6 months.
07Claims submitted without prior authorization will be denied.
08Retain a copy of the approved prior authorization with the claim to support payment.
Codes mentioned
J9271J9272
Original notice
Pembrolizumab products (Keytruda, Keytruda Qlex) (New)
mcp.humana.com · Always check the source before changing claims.
Related changes
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