Il_new_proposed_smacs_for_nov1_2010_for_website_09142010.xls

Illinois Department of Healthcare and Family Services
State Maximum Allowable Cost (SMAC) List -
PROPOSED
Effective 11-01-2010
Current Current IL
Generic_Name
Proposed
ACETIC ACID/ALUMINUM ACETATE OTIC DROPS 2 % ACYCLOVIR ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200 MG/5ML ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (EA) 2.5 MG/0.5 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 1.25MG/3ML ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 2.5 MG/3ML AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5-10MG AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ORAL TABLET 10 MG AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ORAL TABLET 15 MG AMPHETAMINE ASPARTATE/AMPHETAMINE SULFATE/DEXTROAMPHETAMINE ORAL TABLET 30 MG AMPICILLIN SODIUM/SULBACTAM SODIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 15 G ATENOLOL/CHLORTHALIDONE ORAL TABLET 50 MG-25MG BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5-6.25MG BETAMETHASONE DIPROPIONATE TOPICAL CREAM (GRAMS) 0.05% BUPROPION HCL ORAL TABLET, SUSTAINED RELEASE 24HR 300 MG CARBAMAZEPINE ORAL TABLET, SUSTAINED RELEASE 12HR 200 MG CARBAMAZEPINE ORAL TABLET, SUSTAINED RELEASE 12HR 400 MG CEFACLOR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML CEFDINIR ORAL CAPSULE (HARD, SOFT, ETC.) 300 MG CEFTAZIDIME PENTAHYDRATE INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 1 G CEFTAZIDIME PENTAHYDRATE INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 G CEFTRIAXONE SODIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 1 G CICLOPIROX TOPICAL SOLUTION, NON-ORAL 8 % CLARITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML CLARITHROMYCIN ORAL TABLET, SUSTAINED RELEASE 24HR 500 MG CYCLOSPORINE, MODIFIED ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG CYCLOSPORINE, MODIFIED ORAL CAPSULE (HARD, SOFT, ETC.) 25 MG Illinois Department of Healthcare and Family Services
State Maximum Allowable Cost (SMAC) List -
PROPOSED
Effective 11-01-2010
DOXEPIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG FELODIPINE ORAL TABLET, SUSTAINED RELEASE 24HR 10 MG FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 100MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 12MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 25MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 50MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 75MCG/HR HYDROCHLOROTHIAZIDE ORAL CAPSULE (HARD, SOFT, ETC.) 12.5 MG IFOSFAMIDE INTRAVENOUS VIAL (SDV,MDV OR ADDITIVE) (EA) 1 G IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION AMPUL FOR NEBULIZATION (ML) 0.5-3MG/3 LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 30 MG MEGESTROL ACETATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 400MG/10ML METRONIDAZOLE VAGINAL GEL WITH APPLICATOR (GM) 0.75% MINOCYCLINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG MINOCYCLINE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 50 MG MORPHINE SULFATE ORAL TABLET, SUSTAINED ACTION 100 MG NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 90 MG OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 20 MG ONDANSETRON ORAL TABLET, RAPID DISSOLVE 8 MG ORPHENADRINE CITRATE ORAL TABLET, SUSTAINED ACTION 100 MG PANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 40 MG Illinois Department of Healthcare and Family Services
State Maximum Allowable Cost (SMAC) List -
PROPOSED
Effective 11-01-2010
PENICILLIN G POTASSIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 5MM UNIT PHENYTOIN SODIUM EXTENDED ORAL CAPSULE (HARD, SOFT, ETC.) 100 MG PODOPHYLLUM RESIN TOPICAL LIQUID (ML) 25 % PROCHLORPERAZINE MALEATE ORAL TABLET 10 MG PROPRANOLOL HCL ORAL CAPSULE, SUSTAINED ACTION 24 HR 160 MG RIVASTIGMINE TARTRATE ORAL CAPSULE (HARD, SOFT, ETC.) 1.5 MG RIVASTIGMINE TARTRATE ORAL CAPSULE (HARD, SOFT, ETC.) 3 MG RIVASTIGMINE TARTRATE ORAL CAPSULE (HARD, SOFT, ETC.) 4.5 MG RIVASTIGMINE TARTRATE ORAL CAPSULE (HARD, SOFT, ETC.) 6 MG SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL TABLET 800-160MG SUMATRIPTAN SUCCINATE SUBCUTANEOUS VIAL (SDV,MDV OR ADDITIVE) (ML) 6 MG/0.5ML TACROLIMUS ANHYDROUS ORAL CAPSULE (HARD, SOFT, ETC.) 1 MG TERAZOSIN HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5 MG TOBRAMYCIN SULFATE OPHTHALMIC DROPS 0.3 %

Source: http://www.ilsmac.com/uploads/m3/2K/m32KOeQfFRER-kL_l8mP2Q/IL_New_Proposed_SMACs_for_Nov1_2010_for_website_09142010.pdf