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Does Medicare pay for Opdivo?

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By Daniel Petkevich
Nov 23, 2022

You're covered on Medicare

For Medicare beneficiaries seeking treatment for cancer, knowing that you have coverage can offer peace of mind amidst very challenging times. Medicare will offer coverage for Opdivo, but there are some plans that will lead to more out-of-pocket costs than others. Let's talk through your Medicare coverage options.

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What is Opdivo?

Opdivo is a prescription medication used to treat certain types of cancer. It works by blocking the activity of an enzyme called PD-1 which helps the body’s immune system recognize and attack cancer cells. By blocking this enzyme, Opdivo can help the body’s own immune system fight off cancer.
Doctor's may prescribe Opdivo to treat the following conditions:
  • Melanoma
  • Non-small cell lung cancer (NSCLC)
  • Urothelial carcinoma
  • Kidney cancer
  • Head and neck squamous cell carcinoma
Opdivo is administered intravenously and may be given in combination with other treatments such as chemotherapy or radiation.

How does Medicare cover Opdivo?

If you are receiving Opdivo in an in-patient setting, Medicare Part A will cover your treatment costs. In this instance, you will be responsible for paying the Part A deductible for each benefit period.
If you are receiving Opdivo in an out-patient setting, then Medicare Part B will cover the costs of your treatment. In this instance, you will be responsible for 20% coinsurance, and potentially copays as well.
Opdivo is not covered by Part D, because it is only administered intravenously. However, Part D covers some medications that may be related to your cancer treatment and can help reduce out-of-pocket costs.
To get the most protection against out-of-pocket expenses when paying for a treatment option like Opdivo, you should probably be on

Medicare Supplement Plan G

. With other plans, you might have to worry about 20% of the cost of Opdivo, which could quickly climb to thousands of dollars. Or you might have copayments on a Medicare Advantage plan that could pile up to your out-of-pocket maximum of around $6,000.

What are the side effects of Opdivo?

Opdivo can cause some side effects when used in the treatment of cancer. These may include nausea, fatigue, rash, diarrhea, fever, and chills. Other more serious side effects can occur, including an increased risk for lung inflammation or pneumonitis.

Conclusion

When it comes to Medicare coverage, it's important to know your options. With the right plan, you can get the most protection against out-of-pocket expenses associated with treatments like Opdivo. Be sure to speak with your doctor when considering treatment options. This content is for informational purposes only. And if you need to speak with a Medicare expert, give us a call at 888-376-2028.

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Join the Fair Square Medicare Newsletter to stay informed on cost savings, changes to Medicare, and other valuable healthcare information.

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