All PlansCoverageHigh impact
Nivolumab (Opdivo®)
BCBS Tennessee·TN · Oncology, Hematology, Radiation Oncology·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
This is a comprehensive medical policy for Nivolumab (Opdivo®) covering FDA-approved indications across multiple cancer types (melanoma, NSCLC, RCC, Hodgkin lymphoma, urothelial carcinoma, colorectal cancer, HCC, esophageal cancer, gastric cancer, mesothelioma, SCCHN) and compendial uses. The policy establishes coverage criteria, documentation requirements (including tumor biomarker testing), and approval thresholds. DO NOT IMPLEMENT until 12/1/26.
Action Required
By November 1, 2026: (1) Billing and clinical teams must review all Nivolumab/Opdivo requests to ensure they align with FDA-approved indications and compendial uses listed in this policy. (2) Update prior authorization workflows to require documentation of applicable biomarkers (MSI-H, dMMR, PD-L1, EGFR/ALK status) where specified. (3) Confirm that encounter forms and EMR templates capture required documentation: laboratory reports confirming tumor status, treatment lines, and disease stage/progression status. (4) Train billing staff on coverage criteria—claims lacking required documentation will be denied. (5) Update system edits to flag Nivolumab claims for any indication NOT listed under FDA-approved or compendial uses (these are experimental/investigational and not covered). (6) Implement effective 12/1/26; no claims should be processed under this policy before that date.