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HumanaMedicaid · Prior Auth · Medicaid · IN · Oncology, PharmacyHigh impact

Pembrolizumab products (Keytruda, Keytruda Qlex) (New)

Effective date
Nov 1, 2026
Identified
Nov 3, 2026

Summary

Humana Indiana Medicaid has established a new prior authorization policy effective November 1, 2026, for pembrolizumab products (Keytruda intravenous powder, Keytruda intravenous solution, and Keytruda Qlex subcutaneous solution) covering 26 cancer indications. The policy specifies clinical criteria, exclusions (including prior anti-PD-1/PD-L1 therapy), and approval durations of 6 months or as determined through clinical review for each indication. Billing teams must obtain prior authorization before these drugs are dispensed or claims will be denied.

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What to do

Action · 5 steps
01Effective November 1, 2026, the billing team must obtain prior authorization from Humana Indiana Medicaid before pembrolizumab products (Keytruda intravenous powder [J9271], Keytruda intravenous solution [J9272], and Keytruda Qlex subcutaneous solution [J9273]) are dispensed for any of the 26 covered indications listed in the policy.
02Prior authorization requests must verify that the member meets all applicable clinical criteria for the specific indication (e.g., diagnosis, disease stage, biomarker status, combination therapy requirements) and does not meet any exclusions (particularly prior disease progression on anti-PD-1/PD-L1 therapy).
03Update the prior authorization tracker to flag all pembrolizumab orders for Indiana Medicaid members and ensure pharmacy staff confirm authorization status before filling.
04Tell providers and pharmacists that claims without prior authorization will be denied.
05For renewal, submit prior authorization requests within 30 days before the 6-month approval period expires or as determined by clinical review.

Codes mentioned

J9271J9272J9273

Original notice

Pembrolizumab products (Keytruda, Keytruda Qlex) (New)
mcp.humana.com · Always check the source before changing claims.
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Related changes

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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

Related policy hubs

Humana policiesIN policy changesOncologyPharmacyCode J9271Code J9272Code J9273

Summaries are AI-assisted. Always confirm against the original payer notice.

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