Upcoming updates: medical claims edit system for self‑administered drugs

Effective September 1, 2025, Anthem will enhance our medical claims edit system for medical claims submission of self‑administered drugs to align with the CMS Self Administration Drug Exclusion List, which specifies certain drugs that, when administered subcutaneously, do not need supervision by a physician or other qualified healthcare professional. These updates have no impact on member services or experiences, ensuring seamless continuity of care.

Drugs included on the CMS Self‑Administered Drug Exclusion List are not eligible for separate reimbursement when billed by care providers. Drugs categorized as not otherwise classified (NOC) are excluded. However, applying the appropriate modifier will ensure the claims line is processed correctly if the administration method is not subcutaneous.

If you believe a claim reimbursement decision should be reviewed, please follow the typical claims dispute process outlined in the Provider Manual, accessible on our https://anthem.com/provider.

If you have questions about this notification, contact your contract manager or provider relationship management representative.