Does J9271 require prior authorization?

Yes, J9271 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for J9271?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J9271`, Injection, pembrolizumab, 1 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Complete Statement of Medical Necessity (SMN) precertification forms.
Procedure codes listed are for general reference and may not be all-inclusive.

Benefit coverage/reimbursement determinations must be based on the written coverage position in the Medical Policy, not on the presence or absence of listed codes.

Coverage determinations must include review of the member's benefit contract or SPD for coverage definitions, exclusions, and limitations (e.g., dollar or duration caps).

Key Coverage Criteria

Coverage of injectable oncology medications is based on NCCN Compendium Categories of Evidence and Consensus (1, 2A, 2B = proven/medically necessary; 3 = unproven/not medically necessary); if NCCN is unavailable, base decisions on FDA labeling.
FIGO stage III-IVA disease in combination with chemoradiation.
Pembrolizumab is covered for certain malignancies as per Aetna''s clinical guidelines.
Medically necessary for treatment of ampullary adenocarcinoma as single agent for MSI-H, dMMR, or TMB-H ampullary adenocarcinoma.
Medically necessary for subsequent treatment of metastatic anal carcinoma as a single agent.
Medically necessary for treatment of CNS brain metastases in members with melanoma or PD-L1 positive non-small cell lung cancer as a single agent.

20 Active Policies

ARKBLUE-PEMBROLIZUMAB-E-G-KEYTRUDA-D9DDA00336, Pembrolizumab (e.g., Keytruda)

FLORIDA_BLUE-FLBLUE-PEMBROLIZUMAB-KEYTRUDA-04982877DC, Pembrolizumab (Keytruda)

BCBSNJ-DRUGS-124-B81D0CE356, Pembrolizumab (Keytruda)

MODA-PEMBROLIZUMAB-E1821F4836, Keytruda (pembrolizumab)

HEALTHNET_OR-HNOR-PEMBROLIZUMAB-PEMBROLIZUMAB-BERAHYALURONIDASE-ALFA-PMPH-92B67BEF30, Pembrolizumab, Pembrolizumab/Berahyaluronidase Alfa-pmph (Keytruda, Keytruda Qlex); CP.PHAR.322

IBX-COMMERCIAL-08-01-63F-22203F496C, Pembrolizumab (Keytruda)

IBX-MEDICARE-ADVANTAGE-MA08-010J-01C2F16EDE, Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda, Opdivo) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq, Bavencio, Imfinzi)

IBX-MEDICARE-ADVANTAGE-MA08-121F-8C629A5AD1, Pembrolizumab (Keytruda)

BCBSMT-RX502.061, Oncology Medications

BCBSNM-RX502.061, Oncology Medications

BCBSOK-RX502.061, Oncology Medications

UMR-POL-UMR-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

EVICORE-HPLAN-CIGNA-729A536F50C8, Q3 - 2026 Cigna MedOnc Master Drug List.pdf

SUREST-POL-SUREST-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-4BC80209CCC5, Q3 - 2026 Jefferson Health Plans MedOnc Master Drug List

AETNA-pembrolizumab-keytruda-medical-clinical-policy-bulletins, Pembrolizumab (Keytruda)

AMERIHEALTH-COMMERCIAL-08-01-63F-844085C16F, Pembrolizumab (Keytruda)

AMERIHEALTH-MEDICARE-ADVANTAGE-MA08-121F-0B1ADFE369, Pembrolizumab (Keytruda)

BCBSTN-ada2befa6b, Pembrolizumab (Keytruda)

UHC-POL-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage

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J9271, Injection, pembrolizumab, 1 mg