Does Medicare Cover Opdivo?

Opdivo is an immunotherapy treatment for advanced cancer or cancers that have been resistant to other treatments. While this is a newer drug, Medicare will still cover the cost of cancer treatment with Opdivo.

Read on to find out how the different parts of Medicare cover Opdivo and other information about this treatment option.

What parts of Medicare cover Opdivo?

Opdivo is used to treat a variety of cancers. The amount of infusions you need depends on:

  • what type of cancer you have
  • how advanced it is
  • what treatments you’ve received in the past

Most patients receive an infusion of Opdivo at an outpatient treatment center every 2 weeks for about a month. Each infusion is given intravenously over 30 minutes.

Opdivo is fairly new, having been approved by the FDA in 2015. Despite this, cancer treatments are covered under original Medicare. Original Medicare is made up of two main parts: Part A and Part B.

The following is a breakdown of Medicare’s cancer treatment coverage.

Part A

Medicare Part A covers inpatient cancer care. This includes inpatient hospital stays, testing done during those stays, and medications given while you’re an inpatient.

Part B

Medicare Part B covers outpatient medical costs. For cancer care, this includes medication infusions you receive at an outpatient center or doctor’s office.

Part C

If you have Medicare Part C, also known as Medicare Advantage, your plan must cover at least as much as original Medicare covers.

This means that while your costs and plan details may vary based on the insurance company offering your plan, you should still receive the same basic level of coverage as people with parts A and B.

Unlike original Medicare, however, Part C does have a maximum out-of-pocket cost of $7,550 for 2021.

Part D

Medicare Part D is the part of Medicare that covers prescription drugs. These optional plans help you pay for medications you take at home.

Medicare Part D covers some oral chemotherapy medications that you have filled at the pharmacy and take at home. It can also cover medications to treat the side effects of cancer and cancer treatment, such as nausea or pain.

Opdivo is available only as an intravenous medication given by infusion at medical centers, so it’s not covered by Medicare Part D.

Medigap

Medicare supplemental insurance, or Medigap coverage, is an optional plan that can be used to help cover your share of your Medicare costs, such as out-of- pocket expenses or copayments. If you have costs left over from your Part A or Part B coverage of Opdivo, a Medigap plan may be able to help.

How much does Opdivo cost?

The cost of Opdivo depends on the dosage you receive and how long you receive treatment. Opdivo is considered a specialty medication in both its brand name and generic forms.

Depending on the dose, Opdivo can cost $6,580 per infusion. According to the manufacturer, more than 60 percent of patients pay only a quarter of this price or less with coverage from Medicare, Medicaid, or other insurance plans.

The following are some cost examples from Opdivo’s manufacturer with different coverage options.

Costs with Medicare

People with Medicare can expect to pay between $0 and $8,210 per infusion. The out-of-pocket cost for about half of the infusions given is $25 or less. However, what you pay depends on your specific Medicare coverage.

With Medicare Part B, you’ll pay 20 percent of the medication’s cost after you’ve met your deductible. If you have a Medigap plan, you can offset your share of the medication cost even more.

If you have Medicare Part C, your cost will depend on your plan coverage and your out-of-pocket maximum.

Costs with Medicaid

If you have Medicaid, costs range from $0 to $40 per infusion, depending on your state’s individual coverage.

Costs with other private insurance plans

Private insurance plans vary, so check with your individual plan for coverage and copayment info. The BMS Oncology Co-pay Assistance Program can help offset your share of the costs with a commercial insurance plan.

Costs without insurance

If you don’t have Medicare or private insurance and you don’t receive Medicaid, you’ll have to pay the full price of the medication. Contact the manufacturer at 855-OPDIVO-1 for payment options and savings programs.

What is Opdivo?

Opdivo (nivolumab) is a prescription immunotherapy medication that treats certain forms of cancer and is given intravenously. It can be used alone or in combination with another medication called Yervoy (ipilimumab) plus chemotherapy.

Opdivo is used as the first choice treatment for people with advanced small cell lung cancer. It’s also a preferred treatment for people with resistant cancers, such as those that:

  • metastasize (spread or grow)
  • return after remission
  • persist despite treatment with two rounds of chemotherapy — one containing platinum
  • come with tumors that lack certain genes

Opdivo can be used to treat the following cancers alone or in conjunction with other medications:

  • colorectal cancer
  • hepatocellular carcinoma
  • Hodgkin’s lymphoma
  • melanoma
  • non-
  • small cell lung cancer
  • renal cell carcinoma
  • small cell lung cancer
  • squamous cell carcinoma of the esophagus
  • squamous cell carcinoma of the head and neck
  • urothelial carcinoma

Opdivo is for adults only. Its safety has not been tested in people under age 18.

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