Medicare AdvantageCoverageMedium impact
MA08.120g, Nivolumab (Opdivo®), Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™)
Independence Blue Cross·Oncology, Pharmacy·Pharmacy
Effective date
Mar 23, 2026
We identified it
Jun 19, 2026
Summary
Policy MA08.120g has been updated with changes to medical necessity criteria and general guidelines for Nivolumab (Opdivo®) and Nivolumab and Hyaluronidase-nvhy (Opdivo Qvantig™). The billing team must review updated coverage criteria and ensure claims for these immunotherapy agents comply with new medical necessity requirements effective immediately.
Action Required
By March 23, 2026: Billing and prior authorization teams must obtain and review the complete policy text at the provided URL to identify specific medical necessity criteria changes for Nivolumab (Opdivo®) and Opdivo Qvantig™ claims. Update billing system rules and prior authorization workflows to reflect new requirements. Communicate updated criteria to oncology providers and ensure all claims include documentation supporting medical necessity per the revised policy. Claims submitted without compliance to updated criteria may be denied. Flag this policy for review on the source URL as specific criteria details are not provided in this summary.