Illinois Department of Healthcare and Family Services State Maximum Allowable Cost (SMAC) List - Specialty Drugs PROPOSED Effective 03-01-2014 Label Name ADVATE 1,201-1,800 UNITS VIAL ADVATE 1,801-2,400 UNITS VIAL ADVATE 2,401-3,600 UNITS VIAL ADVATE 200-400 UNITS VIAL ADVATE 3,601-4,800 UNITS VIAL ADVATE 401-800 UNITS VIAL ADVATE 801-1,200 UNITS VIAL ALPHANATE 1,000-400 UNIT VIAL ALPHANATE 1,500-600 UNIT VIAL ALPHANATE 250-100 UNIT VIAL ALPHANATE 500-200 UNIT VIAL ALPHANINE SD 1,000 UNITS VIAL ALPHANINE SD 1,500 UNITS VIAL ALPHANINE SD 500 UNITS VIAL BEBULIN 200-1,200 UNITS VIAL CORIFACT KIT FEIBA NF 1,000 UNIT (NOMINAL) FEIBA NF 1,750-3,250 UNIT VIAL FEIBA NF 2,500 UNIT (NOMINAL) FEIBA NF 400-650 UNIT VIAL Current FUL Generic Name Current IL SMAC New IL SMAC Proposed 0.95000 0.94000 0.95000 0.94000 0.95000 0.94000 0.95000 0.94000 0.95000 0.94000 0.95000 0.94000 0.95000 0.94000 0.73000 0.72000 0.73000 0.72000 0.73000 0.72000 ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS VIAL (EA) 1500 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS VIAL (EA) 2000 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS VIAL (EA) 3000 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS VIAL (EA) 250 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS VIAL (EA) 4000 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS VIAL (EA) 500 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS VIAL (EA) 1000 (+/-) ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS VIAL (EA) 1000 (400) ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS VIAL (EA) 1500 (600) ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS VIAL (EA) 250 (100) ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS VIAL (EA) 500 (200) FACTOR IX INTRAVENOUS VIAL (EA) 1000 (+/-) 0.73000 0.72000 0.69500 0.68500 FACTOR IX INTRAVENOUS VIAL (EA) 1500 (+/-) 0.69500 0.68500 FACTOR IX INTRAVENOUS VIAL (EA) 500 (+/-) 0.69500 0.68500 FACTOR IX COMPLEX HUMAN INTRAVENOUS VIAL (EA) 700 (+/-) 0.91350 0.90350 FACTOR XIII INTRAVENOUS KIT 1000-1600 6.96000 6.95000 ANTI-INHIBITOR COAGULANT COMPLEX INTRAVENOUS VIAL (EA) 651-1200 U 1.38000 1.37000 ANTI-INHIBITOR COAGULANT COMPLEX INTRAVENOUS VIAL (EA) 1750-3250 1.38000 1.37000 ANTI-INHIBITOR COAGULANT COMPLEX INTRAVENOUS VIAL (EA) 1750-3250 1.38000 1.37000 ANTI-INHIBITOR COAGULANT COMPLEX INTRAVENOUS VIAL (EA) 400-650 U 1.38000 1.37000 ANTI-INHIBITOR COAGULANT COMPLEX INTRAVENOUS VIAL (EA) 400-650 U 1.38000 1.37000 ANTI-INHIBITOR COAGULANT COMPLEX INTRAVENOUS VIAL (EA) 651-1200 U 1.38000 1.37000 ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS VIAL (EA) 801-1500 0.76000 0.75000 ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS VIAL (EA) 1501-2000 0.76000 0.75000 ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS VIAL (EA) 220-400 0.76000 0.75000 FEIBA NF 500 UNIT (NOMINAL) FEIBA NF 651-1,200 UNIT VIAL HEMOFIL M 1,000 UNIT NOMINAL HEMOFIL M 1,700 UNIT NOMINAL HEMOFIL M 250 UNIT NOMINAL HEMOFIL M 500 UNIT NOMINAL HUMATE-P 1,200 UNIT VWF:RCO HUMATE-P 2,400 UNIT VWF:RCO HUMATE-P 600 UNIT VWF:RCO KOATE-DVI 1,000 UNITS VIAL ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS VIAL (EA) 401-800 0.76000 0.75000 ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS KIT 500-1200 U ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS KIT 1000-2400 ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS KIT 250-600 ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS VIAL (EA) 1000 (+/-) 0.72000 0.71000 0.72000 0.71000 0.72000 0.71000 0.62500 0.61500 KOATE-DVI 1,000 UNITS VIAL ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS KIT 1000 (+/-) 0.62500 0.61500 KOATE-DVI 250 UNITS VIAL ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS VIAL (EA) 250 (+/-) 0.62500 0.61500 2/19/2014 Page 1 of 2 Label Name Current FUL Generic Name Current IL SMAC New IL SMAC Proposed KOATE-DVI 250 UNITS VIAL ANTIHEMOPHILIC FACTOR,HUMAN INTRAVENOUS KIT 250 (+/-) 0.62500 0.61500 KOATE-DVI 500 UNITS KIT ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS KIT 500 (+/-) 0.62500 0.61500 KOGENATE FS 1,000 UNITS VIAL KOGENATE FS 2,000 UNIT VIAL KOGENATE FS 250 UNIT VIAL ANTIHEMOPHILIC FACTOR, HUM REC INTRAVENOUS VIAL (EA) 1000 (+/-) 0.89000 0.88000 ANTIHEMOPHILIC FACTOR, HUM REC INTRAVENOUS VIAL (EA) 2000 (+/-) 0.89000 0.88000 ANTIHEMOPHILIC FACTOR, HUM REC INTRAVENOUS VIAL (EA) 250 (+/-) 0.89000 0.88000 ANTIHEMOPHILIC FACTOR, HUM REC INTRAVENOUS VIAL (EA) 3000 (+/-) 0.89000 0.88000 ANTIHEMOPHILIC FACTOR, HUM REC INTRAVENOUS VIAL (EA) 500 (+/-) 0.89000 0.88000 ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS KIT 1000 (+/-) 0.62500 0.61500 ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS KIT 1500 (+/-) 0.62500 0.61500 FACTOR IX INTRAVENOUS KIT 1000 (+/-) 0.86000 0.85000 FACTOR IX COMPLEX HUMAN INTRAVENOUS VIAL (EA) 1000 (+/-) 0.59220 0.58220 FACTOR IX COMPLEX HUMAN INTRAVENOUS VIAL (EA) 1500 (+/-) 0.59220 0.58220 FACTOR IX COMPLEX HUMAN INTRAVENOUS VIAL (EA) 500 (+/-) 0.59220 0.58220 ANTIHEMOPHILIC FACTOR, HUM REC INTRAVENOUS VIAL (EA) 1500 (+/-) 0.94000 0.93000 ANTIHEMOPHILIC FACTOR, HUM REC INTRAVENOUS VIAL (EA) 2000 (+/-) 0.94000 0.93000 ANTIHEMOPHILIC FACTOR, HUM REC INTRAVENOUS VIAL (EA) 250 (+/-) 0.94000 0.93000 ANTIHEMOPHILIC FACTOR, HUM REC INTRAVENOUS VIAL (EA) 500 (+/-) 0.94000 0.93000 ANTIHEMOPHILIC FACTOR, HUM REC INTRAVENOUS VIAL (EA) 1000 (+/-) 0.94000 0.93000 FACTOR IX HUMAN RECOMBINANT INTRAVENOUS VIAL (EA) 1000 UNIT 1.12000 1.11000 FACTOR IX HUMAN RECOMBINANT INTRAVENOUS VIAL (EA) 2000 UNIT 1.12000 1.11000 FACTOR IX HUMAN RECOMBINANT INTRAVENOUS VIAL (EA) 250 UNIT 1.12000 1.11000 FACTOR IX HUMAN RECOMBINANT INTRAVENOUS VIAL (EA) 3000 UNIT 1.12000 1.11000 FACTOR IX HUMAN RECOMBINANT INTRAVENOUS VIAL (EA) 500 UNIT 1.12000 1.11000 ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS KIT 1K-1K UNIT ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS KIT 500-500 ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS KIT 900-900 ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS KIT 1000 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS KIT 2000 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS KIT 250 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS SYRINGE KIT (EA) 3000 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS KIT 500 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS SYRINGE KIT (EA) 1000 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS SYRINGE KIT (EA) 2000 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS SYRINGE KIT (EA) 250 (+/-) ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS SYRINGE KIT (EA) 500 (+/-) 0.72500 0.71500 0.72500 0.71500 0.72500 0.71500 0.94000 0.93000 0.94000 0.93000 0.94000 0.93000 0.94000 0.93000 0.94000 0.93000 0.94000 0.93000 0.94000 0.93000 0.94000 0.93000 0.94000 0.93000 KOGENATE FS 3,000 UNITS VIAL KOGENATE FS 500 UNIT VIAL MONOCLATE-P 1,000 UNITS KIT MONOCLATE-P 1,500 UNITS KIT MONONINE 1,000 UNITS KIT PROFILNINE SD 1,000 UNITS VIAL PROFILNINE SD 1,500 UNITS VIAL PROFILNINE SD 500 UNITS VIAL RECOMBINATE 1,241-1,800 UNIT V RECOMBINATE 1,801-2,400 UNIT V RECOMBINATE 220-400 UNIT VIAL RECOMBINATE 401-800 UNIT VIAL RECOMBINATE 801-1,240 UNIT VL RIXUBIS 1,000 UNIT NOMINAL RIXUBIS 2,000 UNIT NOMINAL RIXUBIS 250 UNIT NOMINAL RIXUBIS 3,000 UNIT NOMINAL RIXUBIS 500 UNIT NOMINAL WILATE 1,000-1,000 UNIT KIT WILATE 500-500 UNIT KIT WILATE 900-900 UNIT KIT XYNTHA 1,000 UNIT KIT XYNTHA 2,000 UNIT KIT XYNTHA 250 UNIT KIT XYNTHA 3,000 UNIT SYRINGE KIT XYNTHA 500 UNIT KIT XYNTHA SOLOFUSE 1,000 UNIT KIT XYNTHA SOLOFUSE 2,000 UNIT KIT XYNTHA SOLOFUSE 250 UNIT KIT XYNTHA SOLOFUSE 500 UNIT KIT 2/19/2014 Page 2 of 2
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