CommercialPrior AuthHigh impact
Nivolumab (Opdivo®)
BCBS Tennessee·TN · Oncology, Hematology·Medical Policy
Effective date
Jun 30, 2026
We identified it
Jun 17, 2026
Summary
BlueCross BlueShield Tennessee has released a comprehensive new medical policy for Nivolumab (Opdivo®) that establishes coverage criteria, prior authorization requirements, and documentation standards for this cancer immunotherapy drug. The policy covers extensive FDA-approved and compendial uses across multiple cancer types but excludes patients who have progressed on prior PD-1/PD-L1 inhibitor therapy.
Action Required
Before June 30, 2026: Oncology billing teams must implement prior authorization processes for all Nivolumab (Opdivo®) claims. Update billing systems to require submission of MSI-H/dMMR/POLE status documentation, PD-L1 tumor expression levels, and EGFR/ALK mutation status where applicable. Train staff on new coverage exclusions for patients with disease progression on prior PD-1/PD-L1 inhibitor therapy. Create documentation checklists for providers to ensure all required lab reports and biomarker testing results are available before treatment initiation.