By Counterforce Health Team in Keytruda (pembrolizumab) —

How to Get Keytruda (Pembrolizumab) Covered by Humana in New Jersey: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Getting Keytruda Covered by Humana in New Jersey

Keytruda (pembrolizumab) requires prior authorization from Humana in New Jersey. Your oncologist must submit clinical documentation showing FDA-approved indication, prior therapy failures, and medical necessity. If denied, you have 65 days to appeal internally, then 180 days for New Jersey's Independent Health Care Appeals Program (IHCAP). Start today: Contact your oncologist to initiate the prior authorization through Humana's provider portal, ensuring all biomarker testing and staging documentation is included.

Table of Contents

  1. What Drives Keytruda Costs with Humana
  2. Benefit Investigation: Key Questions to Ask
  3. Financial Assistance Options
  4. Prior Authorization Requirements
  5. Appeals Process in New Jersey
  6. Specialty Pharmacy Coordination
  7. Common Denial Reasons & Solutions
  8. Annual Coverage Changes
  9. FAQ

What Drives Keytruda Costs with Humana

Keytruda costs approximately $23,591 per six-week dose, making it one of the most expensive cancer treatments. With Humana Medicare Advantage plans, several factors determine your out-of-pocket costs:

Formulary Tier: Keytruda is classified as a specialty drug requiring prior authorization under most Humana plans. As a Part B medical benefit (administered intravenously), it typically requires 20% coinsurance after you meet your annual deductible.

Prior Authorization Requirements: Humana requires preauthorization for Keytruda, meaning your oncologist must prove medical necessity before coverage begins. This process can take up to 30 days for standard reviews.

Step Therapy: Some Humana plans implement step therapy requirements for certain cancer treatments, requiring you to try preferred alternatives first unless contraindicated.

Note: Medicare Advantage plans like Humana must provide coverage at least equivalent to Original Medicare, but they can add additional requirements like prior authorization and step therapy.

Benefit Investigation: Key Questions to Ask

Before starting Keytruda, gather this essential information from Humana:

Call Humana Member Services (number on your insurance card) and ask:

  • Is Keytruda covered under my specific plan?
  • What is my annual deductible and have I met it?
  • What percentage coinsurance applies to Part B specialty drugs?
  • Does my plan require prior authorization for Keytruda?
  • Are there step therapy requirements I must complete first?
  • Which specialty pharmacies are in-network for Keytruda?

Document Everything: Record the representative's name, date, time, and reference number for each call. This information becomes crucial if you need to appeal later.

Financial Assistance Options

Merck Patient Assistance Programs

Co-pay Assistance (Commercial Insurance Only): If you have commercial insurance through an employer or marketplace plan, you may qualify for Merck's co-pay assistance program. This reduces your out-of-pocket cost to $25 per treatment, with up to $25,000 in annual benefits.

Patient Assistance Program (Uninsured): For uninsured patients, Merck's Patient Assistance Program provides free Keytruda to those earning less than $78,250 (individual) or $105,750 (couple).

Important: Medicare patients, including those with Humana Medicare Advantage, are not eligible for Merck's co-pay assistance programs due to federal anti-kickback laws.

Independent Foundation Support

Medicare patients may qualify for assistance through independent charitable foundations. Contact organizations like:

  • Patient Access Network Foundation
  • The Assistance Fund
  • CancerCare Co-Payment Assistance Foundation

These foundations have limited funding and specific eligibility criteria that change frequently.

Prior Authorization Requirements

Humana requires comprehensive documentation for Keytruda approval. Your oncologist must submit:

Required Clinical Documentation

Diagnosis and Staging:

  • Primary cancer diagnosis with ICD-10 codes
  • Complete staging information (TNM classification)
  • Pathology reports confirming tumor type
  • Required biomarker testing results (PD-L1 expression, MSI-H/TMB-H status where applicable)

Treatment History:

  • Documentation of prior therapies tried and failed
  • Reasons for treatment discontinuation (progression, intolerance, contraindications)
  • Performance status (ECOG 0-2 typically required)

Medical Necessity Statement:

  • Clear explanation of why Keytruda is appropriate for this patient
  • Reference to FDA-approved indications or NCCN guidelines
  • Planned treatment duration and monitoring schedule
Tip: Ask your oncologist to reference specific sections of Humana's medical policy in their prior authorization request. This demonstrates alignment with plan requirements.

Submission Process

  1. Provider Portal: Most efficient method is through Humana's provider portal
  2. Standard Timeline: 30 days for Part C (medical benefit) decisions
  3. Expedited Review: Available if delay would seriously jeopardize health; decision within 72 hours

Appeals Process in New Jersey

If Humana denies your Keytruda request, New Jersey offers robust appeal rights through a two-level process.

Internal Appeals with Humana

Timeline: You have 65 days from the denial notice to file an internal appeal.

Required Documents:

  • Copy of the original denial letter
  • Additional clinical documentation addressing denial reasons
  • Updated medical necessity letter from your oncologist
  • Any new test results or treatment history

Decision Timeline:

  • Standard appeals: 30 days for Part C, 7 days for Part D
  • Expedited appeals: 72 hours if health is at risk

External Review Through IHCAP

If Humana upholds their denial, you can request an external review through New Jersey's Independent Health Care Appeals Program (IHCAP).

Eligibility: Must complete Humana's internal appeal process first (unless expedited circumstances apply).

Timeline: 180 days from final internal denial to submit external appeal.

Process:

  1. Submit appeal directly to Maximus Federal Services (IHCAP contractor)
  2. Include all medical records, denial letters, and physician statements
  3. Independent physician reviewers evaluate the case
  4. Decision issued within 45 days (expedited cases much faster)

Contact: IHCAP Hotline at 1-888-393-1062

Important: IHCAP decisions are binding on Humana. If they overturn the denial, Humana must provide coverage.

Specialty Pharmacy Coordination

Keytruda requires coordination with specialty pharmacies for proper handling and delivery to your treatment facility.

In-Network Specialty Pharmacies

Humana typically contracts with:

  • AccredoHealth
  • CVS Specialty Pharmacy
  • Other regional specialty pharmacy networks

Verify Network Status: Always confirm which specialty pharmacy is preferred under your specific Humana plan, as this can vary by region and plan type.

Coordination Process

  1. Prescription Submission: Your oncologist sends the prescription to the specialty pharmacy
  2. Benefits Verification: Pharmacy confirms coverage and prior authorization status
  3. Clinical Coordination: Pharmacy may contact your doctor for additional information
  4. Delivery Scheduling: Medication is shipped directly to your infusion center
  5. Administration: Keytruda is administered intravenously over 30 minutes in a clinical setting
Note: Keytruda cannot be dispensed directly to patients for home administration due to its IV formulation and monitoring requirements.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Missing biomarker testing Submit PD-L1, MSI-H, or TMB-H results Lab reports with specific test values
Wrong line of therapy Document prior treatment failures Treatment timeline with progression dates
Off-label use Provide NCCN guideline support Guideline citations and medical literature
Inadequate staging Submit complete staging workup Imaging reports, pathology, TNM staging
Step therapy not completed Request step therapy exception Documentation of contraindications or prior failures

Medical Necessity Letter Checklist

When requesting appeals or exceptions, ensure your oncologist's letter includes:

  • Patient identification and diagnosis with ICD-10 codes
  • Treatment history with specific dates and outcomes
  • Clinical rationale for Keytruda based on tumor characteristics
  • Guideline references (FDA label, NCCN, ASCO guidelines)
  • Monitoring plan and expected treatment duration
  • Alternative therapy discussion and why they're inappropriate

Annual Coverage Changes

Open Enrollment Planning: Humana can modify formularies, prior authorization requirements, and preferred pharmacy networks annually during Medicare's Open Enrollment period (October 15 - December 7).

Mid-Year Changes: If you're already receiving Keytruda, Humana generally cannot make changes that affect your current treatment until the next plan year, but they may require updated prior authorizations.

Documentation Renewal: Even if coverage continues, you may need to resubmit prior authorization requests annually or when treatment protocols change.

At Counterforce Health, we help patients and clinicians navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to draft point-by-point rebuttals that align with each payer's specific requirements, including Humana's medical necessity criteria for specialty drugs like Keytruda.

FAQ

How long does Humana prior authorization take for Keytruda in New Jersey? Standard prior authorization decisions take up to 30 days for Part C medical benefits. Expedited reviews are available within 72 hours if delay would seriously jeopardize your health.

What if Keytruda is not on Humana's formulary? You can request a formulary exception with supporting documentation from your oncologist. The process follows the same timeline as prior authorization requests.

Can I get expedited appeals if my cancer is progressing? Yes, both Humana internal appeals and New Jersey IHCAP offer expedited reviews for urgent cases where delays could harm your health.

Does step therapy apply if I received prior treatment outside New Jersey? Prior treatments received anywhere should count toward step therapy requirements. Provide complete treatment records to document previous therapy failures.

What happens if IHCAP overturns Humana's denial? IHCAP decisions are legally binding. Humana must provide coverage and cannot appeal the external review decision.

Are there income limits for Keytruda patient assistance? Merck's Patient Assistance Program has income limits ($78,250 for individuals), but Medicare patients generally cannot use manufacturer co-pay assistance programs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures can change. Always verify current requirements with your insurance plan and consult your healthcare provider for medical decisions. For assistance with insurance appeals in New Jersey, contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.