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AetnaCommercial · Prior Auth · Medical Policy · Oncology, Hematology, Pharmacy +5 moreMedium impact

Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (CPB 0892, reviewed 2026-10-28)

Effective date
Not stated in the notice
Identified
Nov 4, 2026

Previous versions

Summary

Aetna's clinical policy bulletin CPB 0892, last reviewed 2026-10-28, sets the coverage criteria for nivolumab (Opdivo), nivolumab and hyaluronidase-nvhy (Opdivo Qvantig), and nivolumab and relatlimab-rmbw (Opdualag) for Aetna commercial medical plans, including indication-by-indication initial approval criteria, continuation-of-therapy criteria, and dosing references. Precertification is required for all three products, and the site-of-care utilization management policy applies. The practice's billing team should align charge entry, precertification tracking, and documentation with the indications and continuation limits listed for each product.

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What to do

Action · 5 steps
01Billing team: Before scheduling or infusing nivolumab, Opdivo Qvantig, or Opdualag for Aetna commercial members, confirm precertification has been obtained by calling (866) 752-7021 or faxing (888) 267-3277, or by using the Statement of Medical Necessity forms, and record the authorization number in the prior auth tracker.
02Providers and front desk staff: Verify the member's diagnosis and indication against the criteria for initial approval and continuation of therapy before scheduling, and document the clinical rationale, prior PD-1/PD-L1 therapy history, and biomarker results (such as EGFR, ALK, PD-L1, MSI-H/dMMR, or TMB status) in the chart.
03Charge entry: Route claims for these products through the site-of-care review under the Utilization Management Policy on Site of Care for Specialty Drug Infusions, and ensure the HCPCS J-code (J9299, J9289, or J9298), the ICD-10 diagnosis, and the administration CPT code (96413, 96401) are linked to the authorized indication.
04Claims for indications the policy lists as not medically necessary or experimental (for example, breast cancer, glioblastoma, pancreatic cancer, or use after progression on prior PD-1/PD-L1 therapy except as the policy allows) are at risk of denial, so flag these cases for provider review before submission.
05Watch for the payer's next notice of changes to these criteria.

Codes mentioned

J9299J9289J9298J92289641396401C43.9C34.92C44.92C49.9C48.8C64.9C67.9C73C76.0C83.30C25.0C71.0C78.5C82.00C60.9

Original notice

Nivolumab Products (Opdivo, Opdivo Qvantig, and Opdualag) (CPB 0892, reviewed 2026-10-28)
aetna.com · Always check the source before changing claims.
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Related policy hubs

Aetna policiesOncologyHematologyPharmacyDermatologyPulmonologyUrologyGastroenterologyRadiation OncologyCode J9299Code J9289Code J9298Code J9228Code 96413Code 96401Code C43.9Code C34.92Code C44.92Code C49.9Code C48.8Code C64.9Code C67.9Code C73Code C76.0Code C83.30Code C25.0Code C71.0Code C78.5Code C82.00Code C60.9

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