HCPCS Range Non-Medicare Drug Codes

• 1 Butorphanol tartrate, nasal spray, 25 mg ( S0012 )

• 2 Tacrine hydrochloride, 10 mg ( S0014 )

• 3 Injection, cefoperazone sodium, 1 gram ( S0021 )

• 4 Injection, cimetidine hydrochloride, 300 mg ( S0023 )

• 5 Injection, ofloxacin, 400 mg ( S0034 )

• 6 Injection, ticarcillin disodium and clavulanate potassium, 3.1 grams ( S0040 )

• 7 Injection, fosphenytoin sodium, 750 mg ( S0078 )

• 8 Injection, pentamidine isethionate, 300 mg ( S0080 )

• 9 Injection, piperacillin sodium, 500 mg ( S0081 )

• 10 Imatinib, 100 mg ( S0088 )

• 11 Sildenafil citrate, 25 mg ( S0090 )

• 12 Granisetron hydrochloride, 1 mg (for circumstances falling under the Medicare statute, use Q0166) ( S0091 )

• 13 Injection, hydromorphone hydrochloride, 250 mg (loading dose for infusion pump) ( S0092 )

• 14 Injection, morphine sulfate, 500 mg (loading dose for infusion pump) ( S0093 )

• 15 Zidovudine, oral, 100 mg ( S0104 )

• 16 Bupropion HCL sustained release tablet, 150 mg, per bottle of 60 tablets ( S0106 )

• 17 Mercaptopurine, oral, 50 mg ( S0108 )

• 18 Methadone, oral, 5 mg ( S0109 )

• 19 Tretinoin, topical, 5 grams ( S0117 )

• 20 Ondansetron, oral, 4 mg (for circumstances falling under the Medicare statute, use HCPCS Q code) ( S0119 )

• 21 Injection, menotropins, 75 IU ( S0122 )

• 22 Injection, follitropin alfa, 75 IU ( S0126 )

• 23 Injection, follitropin beta, 75 IU ( S0128 )

• 24 Injection, ganirelix acetate, 250 mcg ( S0132 )

• 25 Clozapine, 25 mg ( S0136 )

• 26 Didanosine (ddi), 25 mg ( S0137 )

• 27 Finasteride, 5 mg ( S0138 )

• 28 Minoxidil, 10 mg ( S0139 )

• 29 Saquinavir, 200 mg ( S0140 )

• 30 Colistimethate sodium, inhalation solution administered through DME, concentrated form, per mg ( S0142 )

• 31 Injection, pegylated interferon alfa-2a, 180 mcg per ml ( S0145 )

• 32 Injection, pegylated interferon alfa-2b, 10 mcg ( S0148 )

• 33 Sterile dilutant for epoprostenol, 50ml ( S0155 )

• 34 Exemestane, 25 mg ( S0156 )

• 35 Becaplermin gel 0.01%, 0.5 gm ( S0157 )

• 36 Dextroamphetamine sulfate, 5 mg ( S0160 )

• 37 Calcitrol, 0.25 microgram ( S0169 )

• 38 Anastrozole, oral, 1 mg ( S0170 )

• 39 Chlorambucil, oral, 2 mg ( S0172 )

• 40 Dolasetron mesylate, oral 50 mg (for circumstances falling under the Medicare statute, use Q0180) ( S0174 )

• 41 Flutamide, oral, 125 mg ( S0175 )

• 42 Hydroxyurea, oral, 500 mg ( S0176 )

• 43 Levamisole hydrochloride, oral, 50 mg ( S0177 )

• 44 Lomustine, oral, 10 mg ( S0178 )

• 45 Megestrol acetate, oral, 20 mg ( S0179 )

• 46 Procarbazine hydrochloride, oral, 50 mg ( S0182 )

• 47 Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use Q0164) ( S0183 )

• 48 Tamoxifen citrate, oral, 10 mg ( S0187 )

• 49 Testosterone pellet, 75 mg ( S0189 )

• 50 Mifepristone, oral, 200 mg ( S0190 )

• 51 Misoprostol, oral, 200 mcg ( S0191 )

• 52 Dialysis/stress vitamin supplement, oral, 100 capsules ( S0194 )

• 53 Prenatal vitamins, 30-day supply ( S0197 )

• 54 Esketamine, nasal spray, 1 mg ( S0013 )