Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (CPB 0892, reviewed 2026-07-16)

By July 16, 2026: (1) Billing team must implement precertification requirement for all nivolumab products (Opdivo, Opdivo Qvantig, Opdualag) in billing system for all Aetna commercial plan members. Establish internal workflow to route all nivolumab requests to precertification department before claim submission. (2) Update claim edits to flag claims for these three products that lack evidence of precertification approval. (3) Providers must obtain precertification by calling (866) 752-7021 or faxing (888) 267-3277 before administering any nivolumab product; use Statement of Medical Necessity (SMN) forms available through Specialty Pharmacy Precertification portal. (4) Billing and clinical staff must document the specific cancer indication and verify it matches one of the approved criteria listed in policy (e.g., MSI-H colorectal cancer, PD-L1+ gastric cancer, unresectable melanoma, etc.). (5) Note that members with prior disease progression on PD-1/PD-L1 inhibitors are ineligible unless exception criteria apply (metastatic/unresectable melanoma, MSI-H small bowel adenocarcinoma with ipilimumab, or HCC progression after atezolizumab + bevacizumab). (6) Apply Site of Care Utilization Management Policy for specialty drug infusions per separate policy guidance. Failure to obtain precertification will result in claim denials for all nivolumab products on Aetna commercial plans.