All PlansCoverageMedium impact
Nivolumab (Opdivo®)
BCBS Tennessee·Oncology, Hematology·Medical Policy
Effective date
Oct 31, 2026
We identified it
Aug 13, 2026
Summary
This is a NEW comprehensive medical policy for Nivolumab (Opdivo®) covering 14 FDA-approved cancer indications and 40+ compendial uses. The policy establishes coverage criteria, required documentation (including tumor biomarker testing), and exclusions. This policy is NOT YET EFFECTIVE—it will not be implemented until October 31, 2026, giving practices 10 months to prepare.
Action Required
Before October 31, 2026: (1) Billing team must review the full policy document (16 pages) to understand all coverage criteria and exclusions not shown in this excerpt. (2) Oncology providers must ensure they can document required biomarkers (MSI-H, dMMR, POLE/POLD1, PD-L1, EGFR, ALK, RET, ROS1, HER2 status) prior to submitting claims for Nivolumab. (3) Update prior authorization workflows to require the specified documentation for each indication. (4) Train staff on the distinction between FDA-approved indications, compendial uses, and experimental/investigational uses—only the first two are covered. (5) Implement system alerts to flag claims for indications NOT listed in either category as non-covered. The excerpt ends mid-page; review the complete 16-page policy document to identify any denial criteria, dosing requirements, or other exclusions that will affect billing. Failure to comply with documentation requirements will result in claim denials.