MedicaidPrior AuthHigh impact
Pembrolizumab products (Keytruda, Keytruda Qlex) (New)
Humana·OH · Oncology, Hematology·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicaid Ohio has implemented a new prior authorization policy for Pembrolizumab products (Keytruda, Keytruda Qlex) effective July 1, 2026. The policy covers 26+ cancer indications with specific clinical criteria and exclusions. All pembrolizumab prescriptions for Ohio Medicaid members require prior authorization approval before dispensing, with initial and renewal approvals valid for 6 months.
Action Required
By June 15, 2026: Billing team must update prior authorization workflow in billing system to require PA submission for ALL pembrolizumab claims (J9271, J9272, J9273) for Ohio Medicaid members. Oncology providers must document in patient records: (1) cancer diagnosis matching one of the 26 covered indications, (2) all clinical criteria specific to that indication (e.g., PD-L1 CPS score, treatment line, combination therapy details), (3) confirmation patient has NOT experienced disease progression on prior anti-PD-1/PD-L1 therapy. Front desk staff must verify patient insurance is Ohio Medicaid before processing pembrolizumab orders. Implement 6-month renewal reminder system for approval tracking. Failure to obtain prior authorization will result in claim denials and patient out-of-pocket costs. Distribute policy summary to all providers prescribing pembrolizumab and ensure EMR templates capture all required clinical documentation elements.