Medicare AdvantageCoverageMedium impact
MA08.189, Pembrolizumab and berahyaluronidase alfa-pmph (KEYTRUDA QLEX™)
Independence Blue Cross·Oncology, Pharmacy·Pharmacy
Effective date
Feb 2, 2026
We identified it
Jun 19, 2026
Summary
MA08.189 is a new Medicare Advantage policy establishing coverage and billing guidelines for Pembrolizumab and berahyaluronidase alfa-pmph (KEYTRUDA QLEX™), a subcutaneous formulation of the immunotherapy drug. This new policy effective February 2, 2026 requires billing teams to understand coverage criteria, prior authorization requirements, and proper coding for this newly covered therapeutic option to ensure claims are processed correctly and avoid denials.
Action Required
By February 2, 2026: Oncology billing team must obtain and review the complete MA08.189 policy text to identify specific billing codes (HCPCS J-codes for Pembrolizumab/berahyaluronidase), prior authorization requirements, and medical necessity documentation requirements. Update billing software system to reflect new coverage rules and any prior auth workflows. Notify providers prescribing this drug of coverage parameters and documentation requirements. Implement processes to capture required clinical documentation on claims to support medical necessity. Failure to follow coverage criteria will result in claim denials for this newly covered therapy.