Does Medicare Cover Opdivo?

Nivolumab (Opdivo) is a drug that treats cancer. It works by modifying the immune system’s function, rerouting it to fight cancer cells. Opdivo may be used alone or combined with another drug called ipilimumab (Yervoy) plus chemotherapy.

If this is a drug that can help you or a loved one, a common question you likely have is, “Does Medicare cover Opdivo?” In this article, we answer the question in clear, plain English. You will also find the average costs of Opdivo for those who have to pay out of pocket.

The short answer is yes; Medicare will cover the cost of Opdivo. But not 100% of the time. As is often the case with Medicare, certain conditions must be met for Medicare to pay for your Opdivo. Below we look at what these are so you know what to expect.

Original Medicare Coverage of Opdivo

Original Medicare (Medicare Part A and Part B) provides coverage for Opdivo. This plan provides coverage for your Opdivo if it is considered medically necessary.

When is Opdivo Covered by Part A?

Coverage for Opdivo is provided by Medicare Part A if your Opdivo takes place in an inpatient setting as part of your inpatient cancer treatment. Medicare Part A will cover 100 percent of the costs of hospital stays for up to 60 days.

When is Opdivo Covered by Part B?

On the other hand, coverage for the administration of Opdivo is provided by Medicare Part B as part of your outpatient cancer treatment. Medicare Part B will provide coverage for Opdivo if it is administered in an outpatient setting.

Once approved, Medicare Part B covers 80 percent of the costs of Opdivo. You will pay for the remaining 20 percent.

Medicare Advantage Coverage of Opdivo

Medicare Advantage plans (Medicare Part C) also provide coverage for Opdivo in the same situations that it’s covered by Original Medicare. That’s because Part C plans must cover all the same treatments, services, equipment, etc. that Original Medicare does.

However, Part C plans will also provide coverage for some things that Original Medicare does not. Precisely what a plan covers and how much the costs for this coverage will be will vary depending on your plan’s specifics.

Medicare Part D plans do not provide coverage for Opdivo. Medicare Part D only provides coverage for prescription drugs that are prescribed for you to take home. Original Medicare provides coverage for medications administered in an inpatient or outpatient setting as long as it is medically necessary.

Medicare Part D is a prescription drug plan, and just like Medicare Part C, Medicare Part D plans are provided by private insurance companies.

How Much Does Opdivo Cost?

The cost of 24ml of 240mg/ml of Opdivo ranges from $13,000 to $14,000 for those who do not have insurance.

However, you can reduce the cost of Opdivo through various federal and state programs if you are eligible.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.