MedicaidPrior AuthHigh impact
Pembrolizumab products (Keytruda, Keytruda Qlex) (New)
Humana·IN · Oncology, Hematology, Pediatrics·Medicaid
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Indiana Medicaid has implemented a new Prior Authorization policy for Pembrolizumab products (Keytruda, Keytruda Qlex) effective July 1, 2026, covering 24 cancer indications with specific clinical criteria. All pembrolizumab claims for Indiana Medicaid members now require prior authorization with defined approval durations of 6 months or as determined through clinical review.
Action Required
By July 1, 2026: Billing and clinical teams must implement prior authorization requirements for all Pembrolizumab products (Keytruda IV powder, Keytruda IV solution, Keytruda Qlex subcutaneous) for Indiana Medicaid members. Update billing software to flag all pembrolizumab claims for prior auth submission before dispensing/administering. Providers must document: (1) specific cancer diagnosis matching one of 24 listed indications, (2) biomarker testing results where required (PD-L1 CPS scores, MSI-H/dMMR status, TMB status), (3) treatment regimen (monotherapy vs. combination therapy with specific agents), and (4) absence of prior anti-PD-1/PD-L1 therapy. Create encounter templates with required clinical criteria checkboxes for each indication. Contact Humana prior authorization line before claim submission; claims submitted without approved prior auth will be denied. Establish tracking system to monitor 6-month approval periods and manage renewal requests.