e18306 Background: New payment models in oncology will likely include taking risk on drug costs. While new drugs could be excluded, existing drugs with expanded indications are problematic as the payer has limited data needed to exclude these costs. Recent label expansion for pembrolizumab (PB) in 1st line NSCLC for > 50% PD-L1 expression is an example of this risk. A broader indication in the future will likely result in use of PB for almost all 1stline patients. Methods: We reviewed treatment starts documented by providers in the Via Portal (VP) for 1st, maintenance (MT) and 2nd lines of therapy in non-squamous mutation-negative NSCLC for the 12 months ended 11/30/16. We assumed 6 month treatment lengths and calculated cost to Medicare (MC). We calculated a hypothetical alternative where PB received full 1st line and maintenance indication given with pemetrexed (PM) and carboplatin (per recent FDA filing and results of KEYNOTE-021 trial1). We assumed 2nd line patients received either docetaxel or ramucirumab/docetaxel (using 3rd line treatments in VP). Results: Total MC cost in the actual arm (n = 208) was $13,943,412, $12,190,264 and $11,614,488 for 1st, MT and 2nd line, respectively. The total MC cost in the hypothetical arm (n = 208) was $25,477,452, $25,687,168 and $6,415,575 for 1st, MT and 2ndline, respectively. This represents a total increase of $19,832,031 (52.5%) or $95,346 per patient. Conclusions: Bundled rates and shared savings that include oncology drugs are subject to significant financial risk for providers when existing drugs receive expanded indications to a new, larger population of patients. Langer CJ, et al. Carboplatin and pemetrexed with or without pembrolizumab for advanced, non-squamous non-small-cell lung cancer: a randomised, phase 2 cohort of the open-label KEYNOTE-021 study. Lancet Oncol. 2016;17(11):1497-1508.