By Counterforce Health Team in Keytruda (pembrolizumab) —

Work With Your Doctor to Get Keytruda (Pembrolizumab) Approved by Humana in Florida: Complete PA Guide

Quick Answer: Getting Keytruda Approved by Humana in Florida

Keytruda (pembrolizumab) requires prior authorization from Humana in Florida, with decisions typically within 72 hours for urgent cancer cases. Your oncologist must submit documentation including diagnosis staging, biomarker results (PD-L1 ≥1%, MSI-H, or TMB-H), and treatment history through Humana's provider portal. For NSCLC patients, Humana prefers Libtayo first—your doctor can request a step-therapy exception. If denied, you have 65 days to appeal via Humana's member portal or external review through Florida's Department of Financial Services.

First step today: Contact your oncologist's office to confirm they have your complete staging reports and biomarker testing ready for Humana's PA submission.

Table of Contents

  1. Set Your Goal: Understanding Humana's Approval Requirements
  2. Visit Prep: Organizing Your Medical History
  3. Evidence Kit: Essential Documents for Approval
  4. Medical Necessity Letter: Working With Your Doctor
  5. Peer-to-Peer Support: Helping Your Doctor Advocate
  6. After-Visit Summary: Tracking Your Case
  7. Respectful Persistence: Following Up Effectively
  8. Appeals Process in Florida
  9. FAQ

Set Your Goal: Understanding Humana's Approval Requirements

Working with your doctor to get Keytruda approved by Humana requires understanding exactly what the insurer expects. Humana requires prior authorization for Keytruda as a high-cost specialty oncology drug, with specific criteria varying by cancer type.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before first dose Humana PA Search Tool
Biomarker Testing PD-L1, MSI-H, or TMB-H results Pathology reports from your oncologist
Step Therapy (NSCLC) Libtayo preferred first Humana PD-1/PD-L1 Strategy
Medical Necessity FDA-approved indication Oncologist's letter with clinical rationale
Appeals Deadline 65 days from denial Humana Member Portal

Your partnership goal: Ensure your oncologist has complete documentation and understands Humana's specific requirements before submitting the PA request. This front-loaded approach prevents common denial reasons and speeds approval.

Visit Prep: Organizing Your Medical History

Before your oncology appointment, compile a comprehensive timeline that helps your doctor build the strongest possible case for Keytruda approval.

Essential Information to Gather

Treatment History:

  • Dates of previous cancer treatments (chemotherapy, radiation, surgery)
  • Specific drug names and dosages you've tried
  • Reasons each treatment was stopped (progression, intolerance, side effects)
  • Response to each treatment (stable disease, progression, partial response)

Symptom Timeline:

  • When symptoms first appeared
  • How they've changed over time
  • Functional impact (work, daily activities, quality of life)
  • Current performance status details

Test Results:

  • Most recent imaging (CT, PET, MRI) with dates
  • Pathology reports showing tumor type and staging
  • Biomarker testing results (PD-L1 expression, MSI status, TMB)
  • Laboratory values (CBC, comprehensive metabolic panel)
Tip: Create a simple chronological list with dates, treatments, and outcomes. This helps your oncologist quickly identify patterns that support medical necessity.

Evidence Kit: Essential Documents for Approval

Your doctor needs specific documentation to meet Humana's Keytruda coverage criteria. Help them compile a complete evidence package.

Required Clinical Documentation

Diagnosis and Staging:

  • Complete pathology report with ICD-10 diagnosis code
  • TNM staging per AJCC guidelines
  • Imaging confirming extent of disease

Biomarker Requirements:

  • NSCLC: PD-L1 expression ≥1% or ≥50% (depending on line of therapy)
  • Solid tumors: MSI-H/dMMR or TMB-H ≥10 mutations/Mb
  • Other cancers: Biomarker requirements per FDA labeling

Treatment Rationale:

  • Documentation of prior systemic therapies and progression
  • Contraindications to preferred alternatives
  • NCCN guideline support for Keytruda in your specific situation
Note: For lung cancer patients, Humana's 2025 policy prefers Libtayo for new starts. Your doctor should document why Keytruda is more appropriate than the preferred option.

Counterforce Health: Streamlining Complex Appeals

When facing insurance denials for specialty drugs like Keytruda, Counterforce Health helps patients and clinicians turn denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify specific reasons for rejection, then drafts point-by-point rebuttals using the right clinical evidence and payer-specific workflows.

Medical Necessity Letter: Working With Your Doctor

The medical necessity letter is often the deciding factor in Keytruda approval. Work with your oncologist to ensure it addresses every element Humana requires.

Letter Structure Your Doctor Should Follow

Patient Information Section:

  • Full name, date of birth, Humana policy/member ID
  • Oncologist's NPI number and contact information
  • Clear subject line: "Prior Authorization Request for Keytruda (pembrolizumab)"

Clinical Justification:

Request: Authorization for Keytruda 200mg IV every 3 weeks
Diagnosis: [Specific cancer type] with ICD-10 code [X]
Indication: FDA-approved use for [specific condition]

Supporting Evidence Framework:

  1. Disease status: Current staging and progression documentation
  2. Treatment history: Previous therapies tried, duration, and reasons for discontinuation
  3. Biomarker support: Test results supporting Keytruda eligibility
  4. Clinical rationale: Why Keytruda is medically necessary and appropriate
  5. Monitoring plan: How treatment response will be assessed

Key Talking Points for Your Doctor

Help your oncologist understand what strengthens the letter:

  • Specific FDA indication: Reference exact approved use from prescribing information
  • Guideline alignment: Cite NCCN or ASCO recommendations supporting Keytruda
  • Comparative effectiveness: Explain why alternatives are inappropriate
  • Urgency factors: Document any time-sensitive aspects of your case

Peer-to-Peer Support: Helping Your Doctor Advocate

If Humana requests a peer-to-peer review, you can help your oncologist prepare for this crucial conversation with Humana's medical director.

How to Support Your Doctor's Preparation

Provide Availability Windows:

  • Offer to adjust appointment schedules for peer-to-peer calls
  • Understand these typically occur within 24-72 hours of request
  • Ensure your doctor has protected time for the 15-30 minute discussion

Compile Concise Case Summary:

  • One-page overview of your diagnosis, treatments, and current status
  • Recent imaging results and tumor markers
  • Clear timeline of disease progression or response

Key Data Points for Discussion:

  • Performance status (ECOG scale rating)
  • Specific biomarker values and testing methodology
  • Quantitative response measures (tumor size changes, symptom improvement)
  • Quality of life impact documentation
From our advocates: We've seen peer-to-peer reviews succeed when oncologists present objective response data first, then explain why continuing or starting Keytruda aligns with evidence-based guidelines. Having recent imaging and biomarker results readily available often resolves questions quickly.

After-Visit Summary: Tracking Your Case

After your doctor submits the PA request, stay organized to ensure smooth follow-up and quick response to any additional requests.

Documents to Save

Submission Records:

  • Copy of completed PA form
  • Confirmation number or tracking ID from Humana
  • Date and method of submission (portal, fax, phone)

Clinical Support:

  • Medical necessity letter your doctor submitted
  • All supporting test results and imaging reports
  • Treatment timeline documentation

Communication Log:

  • Record of all calls to Humana with dates and representatives spoken to
  • Notes from any follow-up requests for additional information
  • Timeline of expected decision dates

Portal Monitoring Strategy

Check your Humana member portal every 2-3 days for:

  • PA status updates
  • Requests for additional information
  • Approval or denial notifications
  • Next steps if denied

Respectful Persistence: Following Up Effectively

Maintain appropriate follow-up without overwhelming your medical team or Humana's review process.

Optimal Follow-Up Cadence

Week 1: Confirm submission and tracking number Week 2: Check portal for status updates or additional information requests Week 3: If no decision, have your doctor's office call Humana PA department Beyond 30 days: Request expedited review due to treatment delay

Professional Communication Scripts

For Humana Customer Service: "I'm calling to check the status of a prior authorization for Keytruda submitted by Dr. [Name] on [date]. My member ID is [X] and the tracking number is [Y]. Can you tell me if any additional information is needed?"

For Your Doctor's Office: "I haven't heard back from Humana about my Keytruda PA submitted [timeframe] ago. Could someone please follow up to see if they need additional documentation or if we can request expedited review?"

When to Escalate Politely

  • No decision after standard timeframes (30 days for Medicare Advantage)
  • Multiple requests for the same documentation
  • Denial based on criteria your case clearly meets
  • Urgent clinical circumstances requiring immediate treatment

Counterforce Health's platform can help identify specific gaps in documentation that cause delays, turning around resubmissions faster than traditional manual processes.

Appeals Process in Florida

If Humana denies your Keytruda request, Florida provides clear pathways for challenging the decision through internal appeals and external review.

Internal Appeals Timeline

Filing Deadline: 65 days from denial notice (extended from 60 days in 2025)

Standard Review: 7 calendar days for Part D appeals Expedited Review: 24 hours if delay could harm your health

How to File Appeals

Via Humana Member Portal:

  1. Log into your online account
  2. Navigate to "Exceptions and Appeals" section
  3. Upload denial letter and supporting documents
  4. Check "expedited" box if clinically urgent

By Mail/Fax: Use Humana's "Request for Redetermination" form (available in English and Spanish) Mark clearly if requesting expedited review Include updated medical necessity letter addressing denial reasons

External Review in Florida

If Humana upholds the denial, you can request external review through Florida's Department of Financial Services:

Timeline: 4 months from final internal denial Process: Independent medical expert reviews your case Cost: No charge to you Decision: Binding on Humana if overturned

Contact Information: Florida Division of Consumer Services Insurance Consumer Helpline: 1-877-MY-FL-CFO (877-693-5236) Online complaint portal available at myfloridacfo.com

FAQ

How long does Humana PA take for Keytruda in Florida? Standard review takes up to 30 days for Medicare Advantage medical benefits. Expedited review decides within 72 hours if delay could harm your health.

What if Keytruda isn't on Humana's formulary? Keytruda is typically covered as a Part B medical benefit for IV infusion, not through Part D pharmacy formulary. Your doctor can request a formulary exception with medical necessity documentation.

Does step therapy apply if I've failed treatments in another state? Yes, treatment history from other states counts toward step therapy requirements. Ensure your Florida oncologist has complete records of prior therapies and progression.

Can I request expedited appeal for cancer treatment? Yes. Florida follows federal guidelines allowing expedited appeals when treatment delay could seriously jeopardize your health or ability to regain function.

What counts as medical necessity for Keytruda? FDA-approved indication for your cancer type, appropriate biomarker status, progression after required prior therapies, and NCCN guideline support for your specific clinical situation.

How much will Keytruda cost with Humana coverage? As a Part B covered drug, you typically pay 20% coinsurance after meeting your deductible. Check if your plan has a maximum out-of-pocket limit that includes medical benefits.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance requirements and appeal processes may change. Always verify current requirements with Humana and consult your healthcare provider for medical decisions. For assistance with complex insurance appeals, consider consulting with patient advocacy services or legal professionals specializing in healthcare coverage.

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