Opdivo (nivolumab) — HCPCS J9299

CareCost Estimate · Billing Cheat Sheet

Bristol Myers Squibb 40 / 100 / 120 / 240 mg single-dose vials (25 mg/mL) IV infusion (30 min) q2w or q4w Reviewed: May 2, 2026 ASP: Q2 2026

HCPCS

J9299

1 mg = 1 unit

Dose

240 units

240 mg q2w (or 480 q4w)

Modifier

No waste at flat dose

Admin CPT

96413

Chemo IV, 1st hr (+96415)

Medicare ASP+6%

$33.624

/mg · $8,069.76/240 mg

Codes & NDC

HCPCS	`J9299` — "Injection, nivolumab, 1 mg" (permanent, eff. 1/1/2016)
NDC (single)	`00003-3772-11` — 1-vial carton
NDC (dual)	`00003-3734-13` — 2-vial carton
Vials	40 mg / 4 mL, 100 mg / 10 mL, 120 mg / 12 mL, 240 mg / 24 mL (all 25 mg/mL, single-dose)
SC sister	Opdivo Qvantig (nivolumab + hyaluronidase) — HCPCS `J9289` "Inj nivolumab 2 mg hyaluron" eff. 7/1/2025
Benefit	Medical (provider buy-and-bill)

Dosing

240 mg IV every 2 weeks (26 doses/year) — 1 × 240 mg vial, no waste
480 mg IV every 4 weeks (13 doses/year) — 2 × 240 mg vials, no waste
Infused over 30 min; 1 mg = 1 unit
Combo (Yervoy/ipilimumab): nivolumab 3 mg/kg or 360 mg q3w + chemo — weight-based regimens may have waste → JW
Pediatric weight-based (cHL, MSI-H/dMMR): partial-vial waste → JW

Administration & modifiers

Code	When
`96413`	Chemo IV infusion, initial up to 1 hr (primary)
`96415`	Each additional hour (rare for 30-min Opdivo)
`96365/96366`	Not appropriate — PD-1 inhibitors use chemo admin codes
`96417`	Sequential infusion (Opdivo + Yervoy combo)

JZ required on flat-dose claims (240 mg, 480 mg) — no waste with 240 mg vial or 2×240 mg combo. JW on weight-based (mg/kg) doses with documented discard.

Site of care

Setting	POS	Notes
Physician office	11	30-min fits cleanly
Ambulatory infusion	49	Common; payer-preferred
Hospital outpatient	19/22	UHC/Aetna disfavor for non-complex pts
Home infusion	12	Rare; SC Qvantig may shift this

ICD-10 — common indications (15+ approved)

Indication	Code
Melanoma (adv/met, adjuvant)	`C43.x`
NSCLC (PD-L1 for 1L)	`C34.x`
Mesothelioma (+ Yervoy)	`C45.0`
HNSCC	`C00–C14`, `C32`
Classical Hodgkin Lymphoma	`C81.x`
Urothelial carcinoma	`C67.x`
MSI-H / dMMR CRC	`C18–C20` + biomarker
Gastric / GEJ / esophageal	`C15.x`, `C16.x`
HCC (2L+)	`C22.0`
RCC (+ Yervoy or + cabozantinib)	`C64–C66`

Payer requirements (May 2026)

Payer	PA	Notes
UnitedHealthcare	Yes	PD-L1/biomarker docs for select indications
Aetna	Yes	Strict for NSCLC 1L (TPS), HNSCC, gastric, CRC
Anthem / Carelon	Yes	Site-of-care steerage
Medicare (MAC LCDs)	No PA	Coverage per FDA label + NCCN

Biomarker: PD-L1 IHC Dako 28-8 pharmDx (CPT 88360/88361) for Opdivo — not 22C3. Submit with PA for NSCLC, HNSCC, gastric/GEJ, esophageal indications.

Medicare reimbursement (Q2 2026)

Field	Value
ASP + 6%	$33.624 / mg (4/1 – 6/30/2026)
240 mg dose (q2w)	$8,069.76
480 mg dose (q4w)	$16,139.52
Annualized (240 mg q2w × 26)	~$209,814
Sequestration ~2%	Net ~ASP + 4.3%

Patient assistance — BMS Access Support

Phone: 1-800-861-0048 (benefits, PA, appeals)
Web: bmsaccesssupport.com
Opdivo Co-Pay Assistance: commercially-insured pts; excludes Medicare/Medicaid/federal
BMS Patient Assistance Foundation: free product for uninsured/underinsured meeting income limits (501(c)(3))

BOXED WARNING — Immune-Mediated Adverse Reactions: Severe and fatal pneumonitis, colitis, hepatitis, endocrinopathies, nephritis, dermatologic, and other irAEs in any organ. Higher frequency with Opdivo + Yervoy combo. Monitor early; corticosteroids; permanent discontinuation may be required. Allogeneic HSCT post-Opdivo: severe GVHD/transplant complications.

Sources: BMS Access Support Codes & Coverage 2026, FDA label, CMS ASP Q2 2026, UHC/Aetna/Carelon PD-1 policies, AAPC J9299 / J9289. carecostestimate.com/drugs/opdivo