MedicaidPrior AuthHigh impact
Pembrolizumab products (Keytruda, Keytruda Qlex) (New)
Humana·LA · Oncology, Hematology, Pediatrics·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicaid-Louisiana has implemented a new Prior Authorization policy effective July 1, 2026 for Pembrolizumab products (Keytruda IV/powder and Keytruda Qlex subcutaneous). The policy covers 25+ cancer indications with specific clinical criteria, biomarker requirements (PD-L1/CPS scores, MSI-H/dMMR status), and treatment regimens. All uses require prior authorization with 6-month approval durations.
Action Required
By June 1, 2026: Billing team must implement prior authorization requirement for ALL pembrolizumab claims in the billing system for Louisiana Medicaid members. (1) Configure system to auto-flag J9271, J9272, J9273 for prior auth processing before claim submission. (2) Update encounter templates and provider guidance to require: specific cancer diagnosis, treatment regimen (monotherapy vs. combination therapy details), and biomarker documentation (PD-L1 CPS score, MSI-H/dMMR status where applicable per indication). (3) Establish 6-month renewal tracking in authorization management system. (4) Train billing staff on 25 covered indications and exclusion criteria (prior anti-PD-1/PD-L1 therapy). (5) Communicate to all oncology providers that claims submitted without prior auth or missing clinical documentation will be denied. Providers must submit clinical documentation with auth requests. Beginning July 1, 2026, all pembrolizumab claims for Louisiana Medicaid will require prior authorization or face claim denial.