HCPCS S-Codes
Commercial Payers (Temporary Codes)

Blue Cross/Blue Shield and other commercial payers develop S codes to report drugs, services, and supplies. These codes may not be used to bill services paid under any Medicare payment system. Medicare does not reimburse for services under S codes.

• S0012

  Butorphanol tartrate, nasal spray, 25 mg

• S0013

  Esketamine, nasal spray, 1 mg

• S0014

  Tacrine hydrochloride, 10 mg

• S0017

  Injection, aminocaproic acid, 5 grams

• S0020

  Injection, bupivicaine hydrochloride, 30 ml

• S0021

  Injection, cefoperazone sodium, 1 gram

• S0023

  Injection, cimetidine hydrochloride, 300 mg

• S0028

  Injection, famotidine, 20 mg

• S0030

  Injection, metronidazole, 500 mg

• S0032

  Injection, nafcillin sodium, 2 grams

• ---

  ---

  Continued

• S0034

  Injection, ofloxacin, 400 mg

• S0039

  Injection, sulfamethoxazole and trimethoprim, 10 ml

• S0040

  Injection, ticarcillin disodium and clavulanate potassium, 3.1 grams

• S0073

  Injection, aztreonam, 500 mg

• S0074

  Injection, cefotetan disodium, 500 mg

• S0077

  Injection, clindamycin phosphate, 300 mg

• S0078

  Injection, fosphenytoin sodium, 750 mg

• S0080

  Injection, pentamidine isethionate, 300 mg

• S0081

  Injection, piperacillin sodium, 500 mg

• S0088

  Imatinib, 100 mg

• S0090

  Sildenafil citrate, 25 mg

• S0091

  Granisetron hydrochloride, 1 mg (for circumstances falling under the medicare statute, use q0166)

• S0092

  Injection, hydromorphone hydrochloride, 250 mg (loading dose for infusion pump)

• S0093

  Injection, morphine sulfate, 500 mg (loading dose for infusion pump)

• S0104

  Zidovudine, oral, 100 mg

• S0106

  Bupropion hcl sustained release tablet, 150 mg, per bottle of 60 tablets

• S0108

  Mercaptopurine, oral, 50 mg

• S0109

  Methadone, oral, 5 mg

• S0117

  Tretinoin, topical, 5 grams

• S0119

  Ondansetron, oral, 4 mg (for circumstances falling under the medicare statute, use hcpcs q code)

• ---

  ---

  Continued

• S0122

  Injection, menotropins, 75 iu

• S0126

  Injection, follitropin alfa, 75 iu

• S0128

  Injection, follitropin beta, 75 iu

• S0132

  Injection, ganirelix acetate, 250 mcg

• S0136

  Clozapine, 25 mg

• S0137

  Didanosine (ddi), 25 mg

• S0138

  Finasteride, 5 mg

• S0139

  Minoxidil, 10 mg

• S0140

  Saquinavir, 200 mg

• S0142

  Colistimethate sodium, inhalation solution administered through dme, concentrated form, per mg

• S0144

  Injection, propofol, 10 mg

• S0145

  Injection, pegylated interferon alfa-2a, 180 mcg per ml

• S0148

  Injection, pegylated interferon alfa-2b, 10 mcg

• S0155

  Sterile dilutant for epoprostenol, 50 ml

• S0156

  Exemestane, 25 mg

• S0157

  Becaplermin gel 0.01%, 0.5 gm

• S0160

  Dextroamphetamine sulfate, 5 mg

• S0164

  Injection, pantoprazole sodium, 40 mg

• S0166

  Injection, olanzapine, 2.5 mg

• S0169

  Calcitrol, 0.25 microgram