Medicare covers the cost of cancer treatments, including Opdivo. Doctors use this medication to treat cancers such as melanoma, lung cancer, Hodgkin lymphoma, and liver cancer.
The National Institutes for Health (NIH) report
This article discusses Opdivo and Medicare coverage. It also looks at associated costs and financial assistance options.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Nivolumab (Opdivo) is a medication that doctors prescribe for cancer treatment. It changes how the immune system works, redirecting it to attack cancer cells.
People may receive Opdivo alone or combined with another medication called ipilimumab (Yervoy) and chemotherapy. Bristol-Myers Squibb, who manufacture the drug, have not tested Opdivo in children, so doctors only prescribe it for adults.
They prescribe slow intravenous infusions of Opdivo as a first-line treatment for people with melanoma that has spread to other parts of the body. They may also prescribe Opdivo because the melanoma is not suitable for surgical removal.
Doctors may also prescribe Opdivo for the following conditions:
- bladder cancer
- head or neck cancer (squamous cell cancer)
- Hodgkin lymphoma
- kidney cancer
- liver cancer
- lung cancer (small cell and nonsmall cell)
Treatment regimens depend on a person’s specific circumstances. For example, for metastatic melanoma, the dosage is 240 milligrams (mg) of Opdivo every 2 weeks or 480 mg every 4 weeks. In an outpatient setting, a person will receive these doses as intravenous infusions over 30 minutes.
Medicare is a federal government health insurance program. It helps people aged 65 years and over pay their healthcare costs. Medicare also serves some younger people with certain disabilities or chronic health conditions.
Medicare has four parts:
- Part A covers inpatient care in a hospital, clinic, or skilled nursing facility.
- Part B covers outpatient medical care.
- Part C, or Medicare Advantage, combines the benefits of original Medicare (parts A and B), and it may also include Part D.
- Part D is a standalone prescription drug plan for individuals enrolled in original Medicare.
Learn more about original Medicare here.
Medicare Advantage plan details
Qualified individuals can choose to receive health benefits from either original Medicare (parts A and B) or a Medicare Advantage plan, which private insurance companies offer.
Medicare Advantage plans may include additional benefits, such as fitness, dental, hearing, and vision care.
Unlike original Medicare, Medicare Advantage plans have an annual maximum out-of-pocket (MOOP) limit. This means that the plan limits the amount that someone needs to spend on healthcare. In 2021, the MOOP limit is $7,550.
Common types of Medicare Advantage plan include the following:
- Health Maintenance Organization (HMO) plans use provider networks, and people must select a primary care physician to coordinate care and issue specialists’ referrals.
- HMO Point-of-Service plans allow members to use out-of-network providers at higher costs.
- Preferred Provider Organization plans use provider networks, but members do not need to select a primary care physician or request specialist referrals.
- Private Fee-for-Service plans set a specified amount that members pay for care.
- Special Needs Plans help people with certain health conditions, disabilities, or income restraints.
This online plan finder tool can help people find and compare Medicare Advantage plans in their location.
People may receive Opdivo treatment as an inpatient or an outpatient. Medicare’s coverage of Opdivo depends on the phase of treatment that someone is in and where they receive it.
Both original Medicare (parts A and B) and Medicare Advantage plans cover cancer treatments.
Part A
Medicare Part A covers cancer treatment that a person gets as an inpatient in a hospital or other facility. If someone undergoes tests or receives medications during their stay, Part A covers the cost.
Part B
Medicare Part B is medical insurance that covers outpatient cancer care, which means that it covers intravenous Opdivo infusions that a person gets as an outpatient in a health center or doctor’s clinic.
Part C
Part C, or Medicare Advantage, plans equal original Medicare coverage for cancer treatment. However, the costs involved and coverage details vary among the different plans.
Part D
Medicare Part D covers prescription drugs for medications that people take at home. Therefore, Part D does not cover Opdivo because the person will receive the drug through an intravenous infusion at a clinic or a hospital.
Opdivo costs depend on the treatment plan, including dosage and the number of infusions a person receives.
Bristol-Myers Squibb list the price for a single infusion of Opdivo, at 3 mg per kilogram (kg) for an 80-kg person, as $6,580. However, they state that most people pay less than the list price, with more than 60% of people paying $25 or less, on average.
Medicare
Medicare Part B covers 80% of Opdivo’s list price. The manufacturers say that a person receiving Opdivo at 240 mg every 2 weeks would pay $0–$1,352 per infusion.
Other Medicare costs include the standard Part B monthly premium of $148.50 and the $203 deductible.
Medicaid
Medicaid is a joint federal and state program that helps low income households and other qualified individuals access healthcare. Individual states administer the Medicaid programs, and eligibility criteria may differ.
If a person gets financial help through the Medicaid program, they may pay $0–$20 for each dose of Opdivo.
People can determine their eligibility for Medicaid or find further information about Opdivo copays by visiting the Medicaid website.
Medicare Advantage
For a person enrolled in a Medicare Advantage plan, the cost of Opdivo depends on the plan’s coverage.
With Medicare Advantage plans, a person pays the standard Part B premium of $148.50 plus an additional premium for the Medicare Advantage plan, which depends on several factors, including plan location and a person’s age.
The average plan premium is $25 per month, plus the deductible.
People may have out-of-pocket expenses to pay for Opdivo treatment. However, there are some programs that may help with the costs.
Medicaid
If a person has limited income and resources, the federally funded Medicaid program may be able to help with the costs. According to data from July 2020, more than 68 million people are currently enrolled in Medicaid.
Learn more about Medicaid here.
Federally qualified health centers
If a person does not have private health insurance, they can check for available assistance by asking at a federally qualified health center (FQHC). An FQHC may provide some coverage, depending on the person’s income.
Medigap
A person enrolled in original Medicare has an option to get a Medigap plan from a private insurance company.
Medigap is supplemental insurance that may cover some out-of-pocket expenses. However, a person will have to pay the monthly Medigap premium in addition to their original Medicare premium.
Opdivo is an immunotherapy cancer treatment that people receive as an intravenous infusion.
Because doctors usually administer Opdivo as an outpatient treatment, Medicare Part B covers 80% of the costs. Medicare beneficiaries pay 20% or less of the price after they have met the deductible.
Medicare Part D does not cover Opdivo because a doctor must administer it in a clinic or hospital setting.