Important Billing Code Update for Unspecified Medication Codes with Charges Over $500

Fecha: 03/09/25

Effective 10/3/2025

Please Note:

As of the above date, codes S5000 and S5001 will require prior authorization on any billed charges that exceed $500.

A breakdown of the S5000 and S5001 codes is as follows for your reference:

• HCPCS code S5000 is a temporary national code used to identify a generic prescription drug. Part of the HCPCS level II codes, which are codes used for billing and reimbursement for healthcare services and supplies, the S5000 code is specifically used for generic medications that have been prescribed by a healthcare provider.

• HCPCS code S5001 is a billing and insurance code used for brand name prescription drugs only, prescribed by a healthcare provider. It falls under the category of “miscellaneous medications and therapeutic substances,” as maintained by the Centers for Medicare & Medicaid Services (CMS).

Codes S5000 and S5001 should only be used when a more appropriate or specific code is not available.

Questions? If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative.