S0104 Zidovudine, oral, 100 mg

Zidovudine, oral, 100 mg

Medicare pricing for S0104

Physician Fee Schedule (CY 2026, RVU26D)

Status I: not valid for Medicare (Medicare uses another code).

Payer policies and prior authorization for S0104

Payer coverage policies that name S0104

S0104 appears in 1 coverage policy from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaIbalizumab-uiyk (Trogarzo) (0936)listed, no stanceDec 30, 2025payer document

Medicaid fee-for-service

Prior authorization required or conditional in IN.

  • ND: $0.00 (physician), effective Aug 1, 2026
  • WA: $0.12 (professional_administered_drugs), effective Jul 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.