CommercialPrior AuthHigh impact
08.01.63f, Pembrolizumab (Keytruda®)
Independence Blue Cross·Oncology, Hematology·Pharmacy
Effective date
Apr 21, 2025
We identified it
Jun 19, 2026
Summary
Independence Blue Cross updated their medical necessity criteria and coding requirements for Pembrolizumab (Keytruda®), a cancer immunotherapy drug. This affects pharmacy benefit coverage and requires review of prior authorization and billing procedures for this high-cost oncology medication.
Action Required
Before April 21, 2025: Billing team must review updated medical necessity criteria for Pembrolizumab (Keytruda®) claims. Update prior authorization workflows and ensure documentation meets new requirements. Oncology providers should verify current coding guidelines for this medication. Claims not meeting updated criteria will be denied.