minnesota state maximum allowable cost (smac) specialty ...specialty drug list updated 12/16/2019...

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Change Healthcare Minnesota SMAC Help Desk Hours: 8:00 AM to 5:00 PM Monday – Friday Voice: (855) 389-9503 Fax: (877) 350-2810 Minnesota State Maximum Allowable Cost (SMAC) Specialty Drug List Updated 1/21/2020 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR SODIUM/LAMIVUDINE ORAL ANTIRETROVIRAL-NRTIS AND INTEGRASE INHIBITORS COMB TABLET 600 mg-50 mg-300 mg 94.37660 68180028607 ABACAVIR- LAMIVUDINE- ZIDOVUDINE ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE ORAL ANTIVIRALS, HIV- SPEC., NUCLEOSIDE ANALOG, RTI COMB TABLET 300 mg-150 mg-300 mg 19.74167 49702021718 TRIZIVIR ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE ORAL ANTIVIRALS, HIV- SPEC., NUCLEOSIDE ANALOG, RTI COMB TABLET 300 mg-150 mg-300 mg 19.74167 00003218811 ORENCIA ABATACEPT SUBCUTANEOUS ANTINFLAMMATORY, SEL.COSTIM.MOD.,T- CELL INHIBITOR SYRINGE (ML) 125 mg/mL 1,064.84784 00003281411 ORENCIA ABATACEPT SUBCUTANEOUS ANTINFLAMMATORY, SEL.COSTIM.MOD.,T- CELL INHIBITOR SYRINGE (ML) 50 mg/0.4 mL 2,344.99990 00003281811 ORENCIA ABATACEPT SUBCUTANEOUS ANTINFLAMMATORY, SEL.COSTIM.MOD.,T- CELL INHIBITOR SYRINGE (ML) 87.5 mg/0.7 mL 1,339.99949 57894015012 ZYTIGA ABIRATERONE ACETATE ORAL ANTINEOPLASTIC - ANTIANDROGENIC AGENTS TABLET 250 mg 87.63544 57894019506 ZYTIGA ABIRATERONE ACETATE ORAL ANTINEOPLASTIC - ANTIANDROGENIC AGENTS TABLET 500 mg 153.46604 47335040181 YONSA ABIRATERONE ACETATE, SUBMICRONIZED ORAL ANTINEOPLASTIC - ANTIANDROGENIC AGENTS TABLET 125 mg 76.43400 00074055402 HUMIRA(CF) PEN ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR PEN INJECTOR KIT (EA) 40 mg/0.4 mL 2,520.23570 00074012403 HUMIRA(CF) PEN CROHN'S- UC-HS ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR PEN INJECTOR KIT (EA) 80 mg/0.8 mL 4,852.55180 00074153903 HUMIRA(CF) PEN PSOR-UV- ADOL HS ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR PEN INJECTOR KIT (EA) 80 mg/0.8 mL (x 1)- 40 mg/0.4 mL (x 2) 3,340.74660 00074081702 HUMIRA(CF) ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 10 mg/0.1 mL 2,426.27094 00074061602 HUMIRA(CF) ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 20 mg/0.2 mL 2,426.27094 00074024302 HUMIRA(CF) ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 40 mg/0.4 mL 2,576.69680 00074379902 HUMIRA ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 40 mg/0.8 mL 2,576.69680

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Page 1: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

Change Healthcare Minnesota SMAC Help Desk

Hours: 8:00 AM to 5:00 PM Monday – Friday

Voice: (855) 389-9503

Fax: (877) 350-2810

Minnesota State Maximum Allowable Cost (SMAC) Specialty Drug List Updated 1/21/2020

NDC Label Generic Name SMAC Price

49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR SODIUM/LAMIVUDINE ORAL ANTIRETROVIRAL-NRTIS AND INTEGRASE INHIBITORS COMB TABLET 600 mg-50 mg-300 mg

94.37660

68180028607 ABACAVIR-LAMIVUDINE-ZIDOVUDINE

ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE ORAL ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB TABLET 300 mg-150 mg-300 mg

19.74167

49702021718 TRIZIVIR ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE ORAL ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMB TABLET 300 mg-150 mg-300 mg

19.74167

00003218811 ORENCIA ABATACEPT SUBCUTANEOUS ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR SYRINGE (ML) 125 mg/mL

1,064.84784

00003281411 ORENCIA ABATACEPT SUBCUTANEOUS ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR SYRINGE (ML) 50 mg/0.4 mL

2,344.99990

00003281811 ORENCIA ABATACEPT SUBCUTANEOUS ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR SYRINGE (ML) 87.5 mg/0.7 mL

1,339.99949

57894015012 ZYTIGA ABIRATERONE ACETATE ORAL ANTINEOPLASTIC - ANTIANDROGENIC AGENTS TABLET 250 mg

87.63544

57894019506 ZYTIGA ABIRATERONE ACETATE ORAL ANTINEOPLASTIC - ANTIANDROGENIC AGENTS TABLET 500 mg

153.46604

47335040181 YONSA ABIRATERONE ACETATE, SUBMICRONIZED ORAL ANTINEOPLASTIC - ANTIANDROGENIC AGENTS TABLET 125 mg

76.43400

00074055402 HUMIRA(CF) PEN

ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR PEN INJECTOR KIT (EA) 40 mg/0.4 mL

2,520.23570

00074012403 HUMIRA(CF) PEN CROHN'S-UC-HS

ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR PEN INJECTOR KIT (EA) 80 mg/0.8 mL

4,852.55180

00074153903 HUMIRA(CF) PEN PSOR-UV-ADOL HS

ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR PEN INJECTOR KIT (EA) 80 mg/0.8 mL (x 1)-40 mg/0.4 mL (x 2)

3,340.74660

00074081702 HUMIRA(CF) ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 10 mg/0.1 mL

2,426.27094

00074061602 HUMIRA(CF) ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 20 mg/0.2 mL

2,426.27094

00074024302 HUMIRA(CF) ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 40 mg/0.4 mL

2,576.69680

00074379902 HUMIRA ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 40 mg/0.8 mL

2,576.69680

Page 2: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00074254003 HUMIRA(CF) PEDIATRIC CROHN'S

ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 80 mg/0.8 mL

4,852.55184

00074006702 HUMIRA(CF) PEDIATRIC CROHN'S

ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 80 mg/0.8 mL-40 mg/0.4 mL

3,639.41388

58468035701 CAMPATH ALEMTUZUMAB INTRAVENOUS ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES VIAL (SDV,MDV OR ADDITIVE) (ML) 30 mg/mL

1,757.94000

58468035703 CAMPATH ALEMTUZUMAB INTRAVENOUS ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES VIAL (SDV,MDV OR ADDITIVE) (ML) 30 mg/mL

1,757.94000

00944281501 ARALAST NP ALPHA-1-PROTEINASE INHIBITOR INTRAVENOUS SYSTEMIC ENZYME INHIBITORS VIAL (EA) 1,000 mg

0.48804

13533070002 PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR INTRAVENOUS SYSTEMIC ENZYME INHIBITORS VIAL (EA) 1,000 mg

0.48804

00053720102 ZEMAIRA ALPHA-1-PROTEINASE INHIBITOR INTRAVENOUS SYSTEMIC ENZYME INHIBITORS VIAL (EA) 1,000 mg

0.48804

13533070501 PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR INTRAVENOUS SYSTEMIC ENZYME INHIBITORS VIAL (EA) 1,000 mg (+/-)/20 mL

0.49800

13533070511 PROLASTIN C ALPHA-1-PROTEINASE INHIBITOR INTRAVENOUS SYSTEMIC ENZYME INHIBITORS VIAL (EA) 1,000 mg (+/-)/20 mL

0.49800

50242004164 CATHFLO ACTIVASE

ALTEPLASE INJECTION THROMBOLYTIC ENZYMES VIAL (EA) 2 mg 120.48612

69911047602 AFSTYLA ANTIHEMOPHIL. FACTOR(FVIII)RECOMB, SINGLE-CHN,B-DM TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

1.25000

69911047702 AFSTYLA ANTIHEMOPHIL. FACTOR(FVIII)RECOMB, SINGLE-CHN,B-DM TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (+/-) unit range

1.25000

69911047402 AFSTYLA ANTIHEMOPHIL. FACTOR(FVIII)RECOMB, SINGLE-CHN,B-DM TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

1.25000

69911047802 AFSTYLA ANTIHEMOPHIL. FACTOR(FVIII)RECOMB, SINGLE-CHN,B-DM TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 3,000 (+/-) unit range

1.25000

69911047502 AFSTYLA ANTIHEMOPHIL. FACTOR(FVIII)RECOMB, SINGLE-CHN,B-DM TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

1.25000

00944292302 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

0.99000

00026378555 KOGENATE FS ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

0.99000

Page 3: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00026382425 KOVALTRY ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

1.69320

00026378665 KOGENATE FS ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (+/-) unit range

0.99000

00026382650 KOVALTRY ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (+/-) unit range

1.69320

00944292102 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

1.00520

00026378225 KOGENATE FS ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

1.00520

00026382125 KOVALTRY ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

1.69320

00944296510 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 3,000 (+/-) unit range

0.90000

00026378775 KOGENATE FS ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 3,000 (+/-) unit range

0.90000

00026382850 KOVALTRY ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 3,000 (+/-) unit range

1.69320

00944292202 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

1.01920

00026378335 KOGENATE FS ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

1.01920

00026382225 KOVALTRY ANTIHEMOPHILIC FACTOR (FVIII) RECOMB,FULL LENGTH (ALB-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

1.69320

00944462701 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,500 (+/-) unit range

1.90000

00944462702 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,500 (+/-) unit range

1.90000

00944425202 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

1.55000

00944462201 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

1.55000

00944462801 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 3,000 (+/-) unit range

1.55000

Page 4: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00944462802 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 3,000 (+/-) unit range

1.94040

00944425402 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

1.55000

00944462301 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

1.55000

00944462601 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 750 (+/-) unit range

1.55000

00944462602 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 750 (+/-) unit range

1.90000

00944305302 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,FULL LENGTH INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

1.17000

00944305402 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,FULL LENGTH INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,500 (+/-) unit range

1.17000

00944304510 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,FULL LENGTH INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (+/-) unit range

1.17000

00944305102 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,FULL LENGTH INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

1.17000

00944304610 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,FULL LENGTH INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 3,000 (+/-) unit range

1.17000

00944304710 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,FULL LENGTH INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 4,000 (+/-) unit

1.17000

00944305202 ADVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT,FULL LENGTH INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

1.17000

58394001501 XYNTHA ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS KIT 2,000 (+/-) unit range

0.97000

58394002403 XYNTHA SOLOFUSE

ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS SYRINGE KIT (EA) 1,000 (+/-) unit range

0.98000

58394002503 XYNTHA SOLOFUSE

ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS SYRINGE KIT (EA) 2,000 (+/-) unit range

0.96000

58394002203 XYNTHA SOLOFUSE

ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS SYRINGE KIT (EA) 250 (+/-) unit range

0.97000

58394002303 XYNTHA SOLOFUSE

ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS SYRINGE KIT (EA) 500 (+/-) unit

1.15920

68982014701 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,500 (+/-) unit range

1.21000

68982014801 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,500 (+/-) unit range

1.21000

Page 5: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

68982014901 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 3,000 (+/-) unit range

1.21000

68982015001 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 3,000 (+/-) unit range

1.21000

68982015101 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 4,000 (+/-) unit range

1.21000

68982015201 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 4,000 (+/-) unit range

1.21000

69911048002 AFSTYLA ANTIHEMOPHILIC FACTOR VIII RECOMB,SINGLE-CHN,B-DOM TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,500 (+/-) unit range

1.25000

69911048102 AFSTYLA ANTIHEMOPHILIC FACTOR VIII RECOMB,SINGLE-CHN,B-DOM TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,500 (+/-) unit range

1.25000

00169781001 NOVOEIGHT ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B-DOMAIN TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

1.02000

00169781501 NOVOEIGHT ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B-DOMAIN TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,500 (+/-) unit range

1.02000

00169782001 NOVOEIGHT ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B-DOMAIN TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (+/-) unit range

1.02000

00169782501 NOVOEIGHT ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B-DOMAIN TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

1.02000

00169783001 NOVOEIGHT ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B-DOMAIN TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 3,000 (+/-) unit range

1.02000

00169785001 NOVOEIGHT ANTIHEMOPHILIC FACTOR VIII RECOMBINANT, B-DOMAIN TRUNCATED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

1.02000

00944284410 RECOMBINATE ANTIHEMOPHILIC FACTOR VIII, HUMAN RECOMBINANT INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,500 (+/-) unit range

1.17000

00944284510 RECOMBINATE ANTIHEMOPHILIC FACTOR VIII, HUMAN RECOMBINANT INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (+/-) unit range

0.96000

00944500110 OBIZUR ANTIHEMOPHILIC FACTOR VIII, RECOMBINANT PORCINE SEQUENCE INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

3.96000

76125066830 KOATE ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

0.78000

68982018202 WILATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 unit-1,000 unit

0.73000

Page 6: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

68982018201 WILATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 unit-500 unit

0.73000

00003089321 ELIQUIS APIXABAN ORAL DIRECT FACTOR XA INHIBITORS TABLET 2.5 mg 7.11667

00003089331 ELIQUIS APIXABAN ORAL DIRECT FACTOR XA INHIBITORS TABLET 2.5 mg 7.11667

00003089421 ELIQUIS APIXABAN ORAL DIRECT FACTOR XA INHIBITORS TABLET 5 mg 7.24083

00003089431 ELIQUIS APIXABAN ORAL DIRECT FACTOR XA INHIBITORS TABLET 5 mg 7.24083

00003089470 ELIQUIS APIXABAN ORAL DIRECT FACTOR XA INHIBITORS TABLET 5 mg 7.24083

59148001870 ABILIFY MAINTENA

ARIPIPRAZOLE INTRAMUSCULAR ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED SUSPENSION,EXTENDED RELEASE VIAL 300 mg

1,637.23450

59148001871 ABILIFY MAINTENA

ARIPIPRAZOLE INTRAMUSCULAR ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED SUSPENSION,EXTENDED RELEASE VIAL 300 mg

1,637.23450

59148001970 ABILIFY MAINTENA

ARIPIPRAZOLE INTRAMUSCULAR ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED SUSPENSION,EXTENDED RELEASE VIAL 400 mg

2,210.61100

59148001971 ABILIFY MAINTENA

ARIPIPRAZOLE INTRAMUSCULAR ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED SUSPENSION,EXTENDED RELEASE VIAL 400 mg

2,210.61100

00003362212 REYATAZ ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE 300 mg

47.22303

00003363810 REYATAZ ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS POWDER IN PACKET (EA) 50 mg

6.56364

00003364111 EVOTAZ ATAZANAVIR SULFATE/COBICISTAT ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS TABLET 300 mg-150 mg

52.10412

44087353501 BAVENCIO AVELUMAB INTRAVENOUS ANTI-PROGRAMMED CELL DEATH-LIGAND 1 (PD-L1) MAB VIAL (ML) 200 mg/10 mL (20 mg/mL)

149.79840

49401008801 BENLYSTA BELIMUMAB SUBCUTANEOUS IMMUNOMODULATOR,B-LYMPHOCYTE STIM(BLYS)-SPEC INHIB AUTO-INJECTOR (ML) 200 mg/mL

878.97000

49401008835 BENLYSTA BELIMUMAB SUBCUTANEOUS IMMUNOMODULATOR,B-LYMPHOCYTE STIM(BLYS)-SPEC INHIB AUTO-INJECTOR (ML) 200 mg/mL

878.97000

49401008842 BENLYSTA BELIMUMAB SUBCUTANEOUS IMMUNOMODULATOR,B-LYMPHOCYTE STIM(BLYS)-SPEC INHIB SYRINGE (ML) 200 mg/mL

878.97000

49401008847 BENLYSTA BELIMUMAB SUBCUTANEOUS IMMUNOMODULATOR,B-LYMPHOCYTE STIM(BLYS)-SPEC INHIB SYRINGE (ML) 200 mg/mL

878.97000

70255001002 MEKTOVI BINIMETINIB ORAL ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS TABLET 15 mg

60.73939

55513016001 BLINCYTO BLINATUMOMAB INTRAVENOUS ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES KIT 35 mcg

3,165.85572

50474087015 BRIVIACT BRIVARACETAM ORAL ANTICONVULSANTS SOLUTION, ORAL 10 mg/mL 3.70300

50474077009 BRIVIACT BRIVARACETAM ORAL ANTICONVULSANTS TABLET 100 mg 18.73500

50474077066 BRIVIACT BRIVARACETAM ORAL ANTICONVULSANTS TABLET 100 mg 18.73500

50474047009 BRIVIACT BRIVARACETAM ORAL ANTICONVULSANTS TABLET 25 mg 16.11480

50474047066 BRIVIACT BRIVARACETAM ORAL ANTICONVULSANTS TABLET 25 mg 16.11480

50474057009 BRIVIACT BRIVARACETAM ORAL ANTICONVULSANTS TABLET 50 mg 19.00690

50474057066 BRIVIACT BRIVARACETAM ORAL ANTICONVULSANTS TABLET 50 mg 19.00690

Page 7: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

50474067066 BRIVIACT BRIVARACETAM ORAL ANTICONVULSANTS TABLET 75 mg 18.73500

54123091430 ZUBSOLV BUPRENORPHINE HCL/NALOXONE HCL SUBLINGUAL OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE TABLET, SUBLINGUAL 1.4 mg-0.36 mg

4.17392

54123095730 ZUBSOLV BUPRENORPHINE HCL/NALOXONE HCL SUBLINGUAL OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE TABLET, SUBLINGUAL 5.7 mg-1.4 mg

8.41194

54123098630 ZUBSOLV BUPRENORPHINE HCL/NALOXONE HCL SUBLINGUAL OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE TABLET, SUBLINGUAL 8.6 mg-2.1 mg

12.41266

76075010301 KYPROLIS CARFILZOMIB INTRAVENOUS ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS VIAL (EA) 10 mg

374.16730

66621015001 ANASCORP CENTRUROIDES (SCORPION) POLYVALENT ANTIVENOM INTRAVENOUS ANTIVENINS VIAL (SDV,MDV OR ADDITIVE) (EA) 120 mg

3,486.00000

50474071079 CIMZIA CERTOLIZUMAB PEGOL SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 400 mg/2 mL (200 mg/mL X 2)

4,064.52000

50474071081 CIMZIA CERTOLIZUMAB PEGOL SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 400 mg/2 mL (200 mg/mL X 2)

4,064.52000

00169720801 NOVOSEVEN RT

COAGULATION FACTOR VIIA (RECOMBINANT) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 8 mg (8,000 mcg)

1.41500

54482002001 CYSTARAN CYSTEAMINE HCL OPHTHALMIC OPHTHALMIC CYSTINE DEPLETING AGENTS DROPS 0.44 %

66.49296

00597035509 PRADAXA DABIGATRAN ETEXILATE MESYLATE ORAL THROMBIN INHIBITORS, SELECTIVE, DIRECT, REVERSIBLE CAPSULE 75 mg

6.90998

00597035556 PRADAXA DABIGATRAN ETEXILATE MESYLATE ORAL THROMBIN INHIBITORS, SELECTIVE, DIRECT, REVERSIBLE CAPSULE 75 mg

6.90998

00078068266 TAFINLAR DABRAFENIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 50 mg

59.25180

55513000601 ARANESP DARBEPOETIN ALFA IN POLYSORBATE 80 INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 200 mcg/mL

1,499.70400

59676056201 PREZISTA DARUNAVIR ETHANOLATE ORAL ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB TABLET 600 mg

27.47160

59676056630 PREZISTA DARUNAVIR ETHANOLATE ORAL ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB TABLET 800 mg

51.70012

59676057530 PREZCOBIX DARUNAVIR ETHANOLATE/COBICISTAT ORAL ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB TABLET 800 mg-150 mg

62.02930

00003085222 SPRYCEL DASATINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 100 mg

439.69835

00003052811 SPRYCEL DASATINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 50 mg

244.57989

00003052411 SPRYCEL DASATINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 70 mg

236.27270

Page 8: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00078065515 JADENU DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET 180 mg

56.43336

00078065415 JADENU DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET 90 mg 28.21668

55566840301 FIRMAGON DEGARELIX ACETATE SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) ANTAGONIST,PITUIT.SUPPRS VIAL (SDV,MDV OR ADDITIVE) (EA) 120 mg

628.40130

55566830301 FIRMAGON DEGARELIX ACETATE SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) ANTAGONIST,PITUIT.SUPPRS VIAL (SDV,MDV OR ADDITIVE) (EA) 80 mg

418.91760

55513071001 PROLIA DENOSUMAB SUBCUTANEOUS BONE RESORPTION INHIBITORS SYRINGE (ML) 60 mg/mL

1,178.52504

65862031030 DIDANOSINE DIDANOSINE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI CAPSULE,DELAYED RELEASE (ENTERIC COATED) 125 mg

2.81824

00087667117 VIDEX EC DIDANOSINE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI CAPSULE,DELAYED RELEASE (ENTERIC COATED) 125 mg

3.99838

49702022813 TIVICAY DOLUTEGRAVIR SODIUM ORAL ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR TABLET 50 mg

56.41156

49702024613 DOVATO DOLUTEGRAVIR SODIUM/LAMIVUDINE ORAL ANTIRETROVIRAL-INTEGRASE INHIBITOR AND NRTI COMB. TABLET 50 mg-300 mg

76.19000

49702024213 JULUCA DOLUTEGRAVIR SODIUM/RILPIVIRINE HCL ORAL ANTIRETROVIRAL-INTEGRASE INHIBITOR AND NNRTI COMB. TABLET 50 mg-25 mg

87.84979

50242010039 PULMOZYME DORNASE ALFA INHALATION MUCOLYTICS SOLUTION, NON-ORAL 1 mg/mL

44.84150

50242010040 PULMOZYME DORNASE ALFA INHALATION MUCOLYTICS SOLUTION, NON-ORAL 1 mg/mL

44.84150

00002143301 TRULICITY DULAGLUTIDE SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (ML) 0.75 mg/0.5 mL

369.28590

00002143380 TRULICITY DULAGLUTIDE SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (ML) 0.75 mg/0.5 mL

369.28590

00002143401 TRULICITY DULAGLUTIDE SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (ML) 1.5 mg/0.5 mL

369.28590

00002143480 TRULICITY DULAGLUTIDE SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (ML) 1.5 mg/0.5 mL

369.28590

00310450012 IMFINZI DURVALUMAB INTRAVENOUS ANTI-PROGRAMMED CELL DEATH-LIGAND 1 (PD-L1) MAB VIAL (ML) 120 mg/2.4 mL (50 mg/mL)

346.49179

00310461150 IMFINZI DURVALUMAB INTRAVENOUS ANTI-PROGRAMMED CELL DEATH-LIGAND 1 (PD-L1) MAB VIAL (ML) 500 mg/10 mL (50 mg/mL)

346.48947

70510217102 RADICAVA EDARAVONE INTRAVENOUS AMYOTROPHIC LATERAL SCLEROSIS AGENTS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 30 mg/100 mL

5.40820

15584010101 ATRIPLA EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE ORAL ARTV NUCLEOSIDE,NUCLEOTIDE,NON-NUCLEOSIDE RTI COMB TABLET 600 mg-200 mg-300 mg

89.09971

58468022001 CERDELGA ELIGLUSTAT TARTRATE ORAL DRUGS TO TX GAUCHER DX-TYPE 1, SUBSTRATE REDUCING CAPSULE 84 mg

423.30000

00078068615 PROMACTA ELTROMBOPAG OLAMINE ORAL THROMBOPOIETIN RECEPTOR AGONISTS TABLET 50 mg

274.06400

Page 9: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

61958190101 GENVOYA ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TENOFOVIR ALAFENAMIDE ORAL ARV-NUCLEOSIDE,NUCLEOTIDE RTI,INTEGRASE INHIBITORS TABLET 150 mg-150 mg-200 mg-10 mg

100.33190

61958120101 STRIBILD ELVITEGRAVIR/COBICISTAT/EMTRICITABINE/TENOFOVIR DISOPROXIL ORAL ARV COMB-NRTI,NUCLEOTIDE RTI, INTEGRASE INHIBITORS TABLET 150 mg-150 mg-200 mg-300 mg

100.93600

50242092201 HEMLIBRA EMICIZUMAB-KXWH SUBCUTANEOUS HEMOPHILIA TREATMENT AGENTS,NON-FACTOR REPLACEMENT VIAL (ML) 105 mg/0.7 mL

13,431.00000

50242092301 HEMLIBRA EMICIZUMAB-KXWH SUBCUTANEOUS HEMOPHILIA TREATMENT AGENTS,NON-FACTOR REPLACEMENT VIAL (ML) 150 mg/mL

13,160.00000

50242092001 HEMLIBRA EMICIZUMAB-KXWH SUBCUTANEOUS HEMOPHILIA TREATMENT AGENTS,NON-FACTOR REPLACEMENT VIAL (ML) 30 mg/mL

2,267.90000

50242092101 HEMLIBRA EMICIZUMAB-KXWH SUBCUTANEOUS HEMOPHILIA TREATMENT AGENTS,NON-FACTOR REPLACEMENT VIAL (ML) 60 mg/0.4 mL

13,527.85000

61958110101 COMPLERA EMTRICITABINE/RILPIVIRINE HCL/TENOFOVIR DISOPROXIL FUMARATE ORAL ARTV NUCLEOSIDE,NUCLEOTIDE,NON-NUCLEOSIDE RTI COMB TABLET 200 mg-25 mg-300 mg

91.18561

70255002001 BRAFTOVI ENCORAFENIB ORAL ANTINEOPLASTIC - BRAF KINASE INHIBITORS CAPSULE 50 mg

91.10910

70255002002 BRAFTOVI ENCORAFENIB ORAL ANTINEOPLASTIC - BRAF KINASE INHIBITORS CAPSULE 50 mg

91.10910

70255002501 BRAFTOVI ENCORAFENIB ORAL ANTINEOPLASTIC - BRAF KINASE INHIBITORS CAPSULE 75 mg

60.73939

70255002502 BRAFTOVI ENCORAFENIB ORAL ANTINEOPLASTIC - BRAF KINASE INHIBITORS CAPSULE 75 mg

60.73939

00469012599 XTANDI ENZALUTAMIDE ORAL ANTINEOPLASTIC - ANTIANDROGENIC AGENTS CAPSULE 40 mg

92.69410

59676034001 PROCRIT EPOETIN ALFA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 40,000 unit/mL

1,028.38417

58406045504 ENBREL ETANERCEPT SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE (ML) 25 mg/0.5 mL (0.5 mL)

1,231.94562

58406045501 ENBREL ETANERCEPT SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE (ML) 25 mg/0.5 mL (0.51 mL)

1,226.24990

59676057101 INTELENCE ETRAVIRINE ORAL ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI TABLET 200 mg

21.91077

00310653004 BYDUREON PEN

EXENATIDE MICROSPHERES SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (EA) 2 mg/0.65 mL

169.34240

00310652401 BYETTA EXENATIDE SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (ML) 10 mcg/0.04 mL per dose (250 mcg/mL) 2.4 mL

293.97700

00310651201 BYETTA EXENATIDE SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (ML) 5 mcg/0.02 mL per dose (250 mcg/mL) 1.2 mL

587.95530

00169790101 REBINYN FACTOR IX (HUMAN) RECOMBINANT, PEGYLATED INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 (+/-) unit range

3.98400

Page 10: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00169790201 REBINYN FACTOR IX (HUMAN) RECOMBINANT, PEGYLATED INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 2,000 (+/-) unit range

3.98400

00169790501 REBINYN FACTOR IX (HUMAN) RECOMBINANT, PEGYLATED INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 (+/-) unit range

3.98400

70504028805 IXINITY FACTOR IX HUMAN RECOMBINANT, THREONINE 148 INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 2,000 unit

1.22000

70504028705 IXINITY FACTOR IX HUMAN RECOMBINANT, THREONINE 148 INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 250 unit

1.22000

70504028905 IXINITY FACTOR IX HUMAN RECOMBINANT, THREONINE 148 INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 3,000 unit

1.22000

68516360302 ALPHANINE SD FACTOR IX INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,500 (+/-) unit range

0.83000

68516360602 ALPHANINE SD FACTOR IX INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,500 (+/-) unit range

0.83000

68516360902 ALPHANINE SD FACTOR IX INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,500 (+/-) unit range

0.83000

69911086902 IDELVION FACTOR IX RECOMBINANT,ALBUMIN FUSION PROTEIN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 3,500 (+/-) unit range

3.94000

63833051802 CORIFACT FACTOR XIII INTRAVENOUS FACTOR XIII PREPARATIONS KIT 1,000 unit-1,600 unit

6.33000

00078060715 GILENYA FINGOLIMOD HCL ORAL AGENTS TO TREAT MULTIPLE SCLEROSIS CAPSULE 0.5 mg

262.48000

68611019002 ILUVIEN FLUOCINOLONE ACETONIDE INTRAOCULAR EYE ANTI-INFLAMMATORY AGENTS IMPLANT (EA) 0.19 mg

8,764.80000

49702020718 LEXIVA FOSAMPRENAVIR CALCIUM ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS TABLET 700 mg

16.66125

00074262528 MAVYRET GLECAPREVIR/PIBRENTASVIR ORAL HEPATITIS C VIRUS- NS5A AND NS3/4A INHIBITOR COMB TABLET 100 mg-40 mg

156.51427

50633021011 VORAXAZE GLUCARPIDASE INTRAVENOUS CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS VIAL (SDV,MDV OR ADDITIVE) (EA) 1,000 unit

23,530.50000

57894007101 SIMPONI GOLIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR DISPOSABLE SYRINGE (ML) 100 mg/mL

2,904.27624

57894007002 SIMPONI GOLIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR PEN INJECTOR (ML) 50 mg/0.5 mL

9,327.11912

57894007001 SIMPONI GOLIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE (ML) 50 mg/0.5 mL

9,294.58580

57894064001 TREMFYA GUSELKUMAB SUBCUTANEOUS ANTIPSORIATIC AGENTS,SYSTEMIC SYRINGE (ML) 100 mg/mL

10,384.47000

70504005301 HEPAGAM B HEPATITIS B IMMUNE GLOBULIN/MALTOSE INJECTION ANTISERA VIAL (ML) greater than 312 unit/mL

159.16080

70504005302 HEPAGAM B HEPATITIS B IMMUNE GLOBULIN/MALTOSE INJECTION ANTISERA VIAL (ML) greater than 312 unit/mL

159.16080

70504005401 HEPAGAM B HEPATITIS B IMMUNE GLOBULIN/MALTOSE INJECTION ANTISERA VIAL (ML) greater than 312 unit/mL (5 mL)

139.31052

Page 11: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

70504005402 HEPAGAM B HEPATITIS B IMMUNE GLOBULIN/MALTOSE INJECTION ANTISERA VIAL (ML) greater than 312 unit/mL (5 mL)

139.31052

67979050001 VANTAS HISTRELIN ACETATE IMPLANTATION LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS KIT 50 mg

3,187.20000

57962014009 IMBRUVICA IBRUTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 140 mg

134.79060

57962014012 IMBRUVICA IBRUTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 140 mg

134.79060

57962007028 IMBRUVICA IBRUTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 70 mg

404.37280

57962001428 IMBRUVICA IBRUTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 140 mg

404.37280

57962028028 IMBRUVICA IBRUTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 280 mg

404.37280

57962042028 IMBRUVICA IBRUTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 420 mg

419.20750

57962056028 IMBRUVICA IBRUTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 560 mg

404.37280

00944270002 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270003 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270004 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270005 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270006 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270007 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270008 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270009 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270010 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270011 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270012 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

00944270013 GAMMAGARD LIQUID

IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INJECTION ANTISERA VIAL (ML) 10 %

8.89895

59730650201 BIVIGAM IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

Page 12: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00944285001 CUVITRU IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 1 gram/5 mL (20 %)

19.22000

00944285002 CUVITRU IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 1 gram/5 mL (20 %)

33.46560

00944285003 CUVITRU IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 2 gram/10 mL (20 %)

19.22000

00944285004 CUVITRU IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 2 gram/10 mL (20 %)

33.46560

00944285005 CUVITRU IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 4 gram/20 mL (20 %)

19.22000

00944285006 CUVITRU IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 4 gram/20 mL (20 %)

33.46560

00944285007 CUVITRU IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 8 gram/40 mL (20 %)

19.22000

00944285008 CUVITRU IMMUNE GLOBULIN,GAMM(IGG)/GLYCINE/IGA GREATER THAN 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 8 gram/40 mL (20 %)

33.46560

68982085001 OCTAGAM IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA GREATER THAN 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

68982085002 OCTAGAM IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA GREATER THAN 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

68982085003 OCTAGAM IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA GREATER THAN 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

68982085004 OCTAGAM IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA GREATER THAN 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

68982084001 OCTAGAM IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA GREATER THAN 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

6.89332

68982084002 OCTAGAM IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA GREATER THAN 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

6.89332

68982084003 OCTAGAM IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA GREATER THAN 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

6.89332

68982084004 OCTAGAM IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA GREATER THAN 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

6.89332

68982084005 OCTAGAM IMMUNE GLOBULIN,GAMM(IGG)/MALTOSE/IGA GREATER THAN 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

6.89332

64208823402 GAMMAPLEX IMMUNE GLOBULIN,GAMM(IGG)/SORBITOL/GLYCIN/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

7.59000

64208823403 GAMMAPLEX IMMUNE GLOBULIN,GAMM(IGG)/SORBITOL/GLYCIN/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

7.59000

64208823404 GAMMAPLEX IMMUNE GLOBULIN,GAMM(IGG)/SORBITOL/GLYCIN/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

7.59000

64208823406 GAMMAPLEX IMMUNE GLOBULIN,GAMM(IGG)/SORBITOL/GLYCIN/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

7.59000

64208823407 GAMMAPLEX IMMUNE GLOBULIN,GAMM(IGG)/SORBITOL/GLYCIN/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

7.59000

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NDC Label Generic Name SMAC Price

64208823408 GAMMAPLEX IMMUNE GLOBULIN,GAMM(IGG)/SORBITOL/GLYCIN/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

7.59000

64208823501 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG)/GLYCINE/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

64208823502 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG)/GLYCINE/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

64208823503 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG)/GLYCINE/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

64208823505 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG)/GLYCINE/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

64208823506 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG)/GLYCINE/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

64208823507 GAMMAPLEX IMMUNE GLOBULIN,GAMMA (IGG)/GLYCINE/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 10 %

8.31000

44206045101 HIZENTRA IMMUNE GLOBULIN,GAMMA (IGG)/PROLINE/IGA 0 TO 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 1 gram/5 mL (20 %)

19.95000

44206045510 HIZENTRA IMMUNE GLOBULIN,GAMMA (IGG)/PROLINE/IGA 0 TO 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 10 gram/50 mL (20 %)

19.95000

44206045202 HIZENTRA IMMUNE GLOBULIN,GAMMA (IGG)/PROLINE/IGA 0 TO 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 2 gram/10 mL (20 %)

19.95000

44206045404 HIZENTRA IMMUNE GLOBULIN,GAMMA (IGG)/PROLINE/IGA 0 TO 50 MCG/ML SUBCUTANEOUS ANTISERA VIAL (ML) 4 gram/20 mL (20 %)

19.95000

61953000400 FLEBOGAMMA DIF

IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

4.11680

61953000401 FLEBOGAMMA DIF

IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

4.11680

61953000402 FLEBOGAMMA DIF

IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

4.11680

61953000403 FLEBOGAMMA DIF

IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

4.11680

61953000404 FLEBOGAMMA DIF

IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

4.11680

61953000405 FLEBOGAMMA DIF

IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

4.11680

61953000406 FLEBOGAMMA DIF

IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

4.11680

61953000407 FLEBOGAMMA DIF

IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

4.11680

61953000408 FLEBOGAMMA DIF

IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

4.11680

61953000409 FLEBOGAMMA DIF

IMMUNE GLOBULIN,GAMMA (IGG)/SORBITOL/IGA 0 TO 50 MCG/ML INTRAVENOUS ANTISERA VIAL (ML) 5 %

4.11680

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NDC Label Generic Name SMAC Price

00944251202 HYQVIA IMMUNE GLOBULIN,GAMMA(IGG) HUMAN/HYALURONIDASE, HUMAN RECOMB SUBCUTANEOUS ANTISERA VIAL (ML) 10 gram/100 mL (10 %)-800 unit/5 mL

17.54856

00944251002 HYQVIA IMMUNE GLOBULIN,GAMMA(IGG) HUMAN/HYALURONIDASE, HUMAN RECOMB SUBCUTANEOUS ANTISERA VIAL (ML) 2.5 gram/25 mL (10 %)-200 unit/1.25 mL

17.54856

00944251302 HYQVIA IMMUNE GLOBULIN,GAMMA(IGG) HUMAN/HYALURONIDASE, HUMAN RECOMB SUBCUTANEOUS ANTISERA VIAL (ML) 20 gram/200 mL (10 %)-1,600 unit/10 mL

17.54856

00944251402 HYQVIA IMMUNE GLOBULIN,GAMMA(IGG) HUMAN/HYALURONIDASE, HUMAN RECOMB SUBCUTANEOUS ANTISERA VIAL (ML) 30 gram/300 mL (10 %)-2,400 unit/15 mL

17.54856

00944251102 HYQVIA IMMUNE GLOBULIN,GAMMA(IGG) HUMAN/HYALURONIDASE, HUMAN RECOMB SUBCUTANEOUS ANTISERA VIAL (ML) 5 gram/50 mL (10 %)-400 unit/2.5 mL

17.54856

76125090001 GAMMAKED IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 1 gram/10 mL (10 %)

10.46000

13533080012 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 1 gram/10 mL (10 %)

10.01000

13533080013 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 1 gram/10 mL (10 %)

10.01000

76125090010 GAMMAKED IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 10 gram/100 mL (10 %)

10.46000

13533080071 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 10 gram/100 mL (10 %)

10.01000

13533080072 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 10 gram/100 mL (10 %)

10.01000

13533080015 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 2.5 gram/25 mL (10 %)

10.01000

13533080016 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 2.5 gram/25 mL (10 %)

10.01000

76125090020 GAMMAKED IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 20 gram/200 mL (10 %)

10.46000

13533080024 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 20 gram/200 mL (10 %)

10.01000

13533080025 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 20 gram/200 mL (10 %)

10.01000

13533080040 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 40 gram/400 mL (10 %)

10.01000

13533080041 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 40 gram/400 mL (10 %)

10.01000

76125090050 GAMMAKED IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 5 gram/50 mL (10 %)

10.46000

13533080020 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 5 gram/50 mL (10 %)

10.01000

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NDC Label Generic Name SMAC Price

13533080021 GAMUNEX-C IMMUNE GLOBULIN,GAMMA(IGG)/GLYCINE/IGA AVERAGE 46 MCG/ML INJECTION ANTISERA VIAL (ML) 5 gram/50 mL (10 %)

10.01000

00008010001 BESPONSA INOTUZUMAB OZOGAMICIN INTRAVENOUS ANTINEOPLASTIC- CD22 ANTIBODY-CYTOTOXIC ANTIBIOTIC VIAL (EA) 0.9 mg (0.25 mg/mL initial concentration)

18,625.20000

00169369619 NOVOLOG MIX 70-30 FLEXPEN

INSULIN ASPART PROTAMINE HUMAN/INSULIN ASPART SUBCUTANEOUS INSULINS INSULIN PEN (ML) 100 unit/mL (70-30)

36.34250

00169330312 NOVOLOG INSULIN ASPART SUBCUTANEOUS INSULINS CARTRIDGE (ML) 100 unit/mL

34.95328

00169633910 NOVOLOG FLEXPEN

INSULIN ASPART SUBCUTANEOUS INSULINS INSULIN PEN (ML) 100 unit/mL

36.34246

00169291115 XULTOPHY 100-3.6

INSULIN DEGLUDEC/LIRAGLUTIDE SUBCUTANEOUS ANTIHYPERGLY,INSULIN,LONG ACT-GLP-1 RECEPT.AGONIST INSULIN PEN (ML) 100 unit-3.6 mg/mL (3 mL)

66.80008

00024576105 SOLIQUA 100-33

INSULIN GLARGINE,HUMAN RECOMBINANT ANALOG/LIXISENATIDE SUBCUTANEOUS ANTIHYPERGLY,INSULIN,LONG ACT-GLP-1 RECEPT.AGONIST INSULIN PEN (ML) 100 unit-33 mcg/mL (3 mL)

45.37318

00088250205 APIDRA SOLOSTAR

INSULIN GLULISINE SUBCUTANEOUS INSULINS INSULIN PEN (ML) 100 unit/mL

35.31048

00002879701 HUMALOG MIX 75-25 KWIKPEN

INSULIN LISPRO PROTAMINE & INSULIN LISPRO SUBCUTANEOUS INSULINS INSULIN PEN (ML) 100 unit/mL (75-25)

25.99560

00002879801 HUMALOG MIX 50-50 KWIKPEN

INSULIN LISPRO PROTAMINE AND INSULIN LISPRO SUBCUTANEOUS INSULINS INSULIN PEN (ML) 100 unit/mL (50-50)

30.38796

00002879859 HUMALOG MIX 50-50 KWIKPEN

INSULIN LISPRO PROTAMINE AND INSULIN LISPRO SUBCUTANEOUS INSULINS INSULIN PEN (ML) 100 unit/mL (50-50)

33.85411

00002879759 HUMALOG MIX 75-25 KWIKPEN

INSULIN LISPRO PROTAMINE AND INSULIN LISPRO SUBCUTANEOUS INSULINS INSULIN PEN (ML) 100 unit/mL (75-25)

33.99526

00002771401 HUMALOG JUNIOR KWIKPEN

INSULIN LISPRO SUBCUTANEOUS INSULINS INSULIN PEN, HALF-UNIT (ML) 100 unit/mL

35.21856

00002771459 HUMALOG JUNIOR KWIKPEN

INSULIN LISPRO SUBCUTANEOUS INSULINS INSULIN PEN, HALF-UNIT (ML) 100 unit/mL

35.21856

44087332201 REBIF REBIDOSE

INTERFERON BETA-1A/ALBUMIN HUMAN 691.40627

44087334401 REBIF REBIDOSE

INTERFERON BETA-1A/ALBUMIN HUMAN SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS PEN INJECTOR (ML) 44 mcg/0.5 mL

1,158.74000

44087018801 REBIF REBIDOSE

INTERFERON BETA-1A/ALBUMIN HUMAN SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS PEN INJECTOR (ML) 8.8 mcg/0.2 mL (6) - 22 mcg/0.5 mL (6)

1,146.91770

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NDC Label Generic Name SMAC Price

44087002203 REBIF INTERFERON BETA-1A/ALBUMIN HUMAN SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS SYRINGE (ML) 22 mcg/0.5 mL

1,201.06062

44087004403 REBIF INTERFERON BETA-1A/ALBUMIN HUMAN SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS SYRINGE (ML) 44 mcg/0.5 mL

1,235.87159

50419052435 BETASERON INTERFERON BETA-1B SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS KIT 0.3 mg

526.79732

00078056912 EXTAVIA INTERFERON BETA-1B SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS KIT 0.3 mg

217.05054

00002144501 TALTZ AUTOINJECTOR

IXEKIZUMAB SUBCUTANEOUS ANTIPSORIATIC AGENTS,SYSTEMIC AUTO-INJECTOR (ML) 80 mg/mL

5,228.96880

00002144511 TALTZ AUTOINJECTOR

IXEKIZUMAB SUBCUTANEOUS ANTIPSORIATIC AGENTS,SYSTEMIC AUTO-INJECTOR (ML) 80 mg/mL

5,228.96880

00002144527 TALTZ AUTOINJECTOR (2 PACK)

IXEKIZUMAB SUBCUTANEOUS ANTIPSORIATIC AGENTS,SYSTEMIC AUTO-INJECTOR (ML) 80 mg/mL

5,228.96880

00002144509 TALTZ AUTOINJECTOR (3 PACK)

IXEKIZUMAB SUBCUTANEOUS ANTIPSORIATIC AGENTS,SYSTEMIC AUTO-INJECTOR (ML) 80 mg/mL

5,228.96880

59572041000 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 10 mg

697.69600

59572041028 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 10 mg

697.69600

59572041500 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 15 mg

697.69600

59572041521 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 15 mg

697.69600

59572042500 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 25 mg

697.69600

59572042521 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 25 mg

697.69600

59572040500 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 5 mg

605.23830

59572040528 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 5 mg

605.23830

62856071030 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 10 mg/day (10 mg [1]/day)

415.00332

62856071205 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 12 mg/day (4 mg x 3)

187.80078

62856071230 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 12 mg/day (4 mg x 3)

187.80078

62856071430 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 14 mg/day (10 mg [1]-4 mg [1]/day)

207.49668

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NDC Label Generic Name SMAC Price

62856072030 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 20 mg/day (10 mg [2]/day)

231.57000

62856072430 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 24 mg/day (10 mg [2]-4 mg [1]/day)

154.38000

62856070405 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 4 mg

563.40330

62856070430 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 4 mg

563.40330

00074334603 LUPRON DEPOT

LEUPROLIDE ACETATE INTRAMUSCULAR ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. SYRINGE KIT (EA) 22.5 mg (3 month)

4,513.19324

00074364203 LUPRON DEPOT

LEUPROLIDE ACETATE INTRAMUSCULAR ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. SYRINGE KIT (EA) 7.5 mg (1 month)

1,499.80049

00074366303 LUPRON DEPOT

LEUPROLIDE ACETATE INTRAMUSCULAR LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS SYRINGE KIT (EA) 11.25 mg

3,756.51187

00074364103 LUPRON DEPOT

LEUPROLIDE ACETATE INTRAMUSCULAR LHRH (GNRH) AGONIST ANALOG PITUITARY SUPPRESSANTS SYRINGE KIT (EA) 3.75 mg

1,258.26972

50419042301 MIRENA LEVONORGESTREL INTRAUTERINE INTRA-UTERINE DEVICES (IUDS) INTRAUTERINE DEVICE 20 mcg/24 hour (5 years)

854.89668

00032121201 CREON LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 12,000 unit-38,000 unit-60,000 unit

3.00537

00032121207 CREON LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 12,000 unit-38,000 unit-60,000 unit

3.00537

00032122401 CREON LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 24,000 unit-76,000 unit-120,000 unit

5.96720

00032122407 CREON LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 24,000 unit-76,000 unit-120,000 unit

5.96720

59767002401 PERTZYE LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 24,000 unit-86,250 unit-90,750 unit

6.30468

00032120370 CREON LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 3,000 unit-9,500 unit-15,000 unit

1.27377

00032301613 CREON LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 36,000 unit-114,000 unit-180,000 unit

9.01745

00032301628 CREON LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 36,000 unit-114,000 unit-180,000 unit

9.01745

00032120601 CREON LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6,000 unit-19,000 unit-30,000 unit

1.51888

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NDC Label Generic Name SMAC Price

00032120607 CREON LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 6,000 unit-19,000 unit-30,000 unit

1.51888

59767000801 PERTZYE LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 8,000 unit-28,750 unit-30,250 unit

1.74300

59767000802 PERTZYE LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 8,000 unit-28,750 unit-30,250 unit

1.74300

58914011210 VIOKACE LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES TABLET 10,440 unit-39,150 unit-39,150 unit

2.65932

00169406012 VICTOZA 2-PAK LIRAGLUTIDE SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (ML) 0.6 mg/0.1 mL (18 mg/3 mL)

99.89000

00169406013 VICTOZA 3-PAK LIRAGLUTIDE SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (ML) 0.6 mg/0.1 mL (18 mg/3 mL)

99.89000

00024574502 ADLYXIN LIXISENATIDE SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (ML) 10 mcg/0.2 mL per dose (1)-20 mcg/0.2 mL per dose (1)

92.49513

00024574702 ADLYXIN LIXISENATIDE SUBCUTANEOUS ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1 RECEP.AGONIST) PEN INJECTOR (ML) 20 mcg/0.2 mL per dose

92.49513

58181304005 GLEOSTINE LOMUSTINE ORAL ANTINEOPLASTIC - ALKYLATING AGENTS CAPSULE 10 mg

67.67800

58181304205 GLEOSTINE LOMUSTINE ORAL ANTINEOPLASTIC - ALKYLATING AGENTS CAPSULE 100 mg

706.06000

58181304105 GLEOSTINE LOMUSTINE ORAL ANTINEOPLASTIC - ALKYLATING AGENTS CAPSULE 40 mg

106.28316

00074679922 KALETRA LOPINAVIR/RITONAVIR ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB TABLET 200 mg-50 mg

8.30494

51167080901 ORKAMBI LUMACAFTOR/IVACAFTOR ORAL CYSTIC FIBROSIS-CFTR POTENTIATOR-CORRECTOR COMBIN. TABLET 200 mg-125 mg

174.32695

58468008001 THYMOGLOBULIN

LYMPHOCYTE IMMUNE GLOBULIN, RABBIT INTRAVENOUS ANTISERA VIAL (EA) 25 mg

751.52184

00009722401 ATGAM LYMPHOCYTE IMMUNE GLOBULIN,ANTITHYMOCYTE (EQUINE) INTRAVENOUS ANTISERA AMPUL (ML) 50 mg/mL

362.91252

00009722402 ATGAM LYMPHOCYTE IMMUNE GLOBULIN,ANTITHYMOCYTE (EQUINE) INTRAVENOUS ANTISERA AMPUL (ML) 50 mg/mL

362.91252

15054104005 INCRELEX MECASERMIN SUBCUTANEOUS INSULIN-LIKE GROWTH FACTOR-1 (IGF-1) HORMONES VIAL (ML) 10 mg/mL

662.98740

59137051004 RASUVO METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 10 mg/0.2 mL

557.76000

54436001002 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 10 mg/0.4 mL

341.13000

54436001004 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 10 mg/0.4 mL

341.13000

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NDC Label Generic Name SMAC Price

59137051504 RASUVO METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 12.5 mg/0.25 mL

446.20800

59137052004 RASUVO METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 15 mg/0.3 mL

371.83668

54436001502 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 15 mg/0.4 mL

341.13000

54436001504 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 15 mg/0.4 mL

394.14375

59137052504 RASUVO METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 17.5 mg/0.35 mL

318.72000

54436002002 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 20 mg/0.4 mL

341.13000

54436002004 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 20 mg/0.4 mL

341.13000

59137053004 RASUVO METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 20 mg/0.4 mL

298.48151

59137053504 RASUVO METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 22.5 mg/0.45 mL

247.89444

54436002502 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 25 mg/0.4 mL

341.13000

54436002504 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 25 mg/0.4 mL

341.13000

59137054004 RASUVO METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 25 mg/0.5 mL

223.10400

59137055004 RASUVO METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 30 mg/0.6 mL

185.92332

59137050504 RASUVO METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 7.5 mg/0.15 mL

743.68332

59353040409 MIRCERA METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS SYRINGE (ML) 150 mcg/0.3 mL

1,369.50000

59353040009 MIRCERA METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS SYRINGE (ML) 30 mcg/0.3 mL

273.90000

65649015090 RELISTOR METHYLNALTREXONE BROMIDE ORAL MU-OPIOID RECEPTOR ANTAGONISTS,PERIPHERALLY-ACTING TABLET 150 mg

18.48934

65649055103 RELISTOR METHYLNALTREXONE BROMIDE SUBCUTANEOUS MU-OPIOID RECEPTOR ANTAGONISTS,PERIPHERALLY-ACTING SYRINGE (ML) 12 mg/0.6 mL

184.85000

65649055107 RELISTOR METHYLNALTREXONE BROMIDE SUBCUTANEOUS MU-OPIOID RECEPTOR ANTAGONISTS,PERIPHERALLY-ACTING SYRINGE (ML) 12 mg/0.6 mL

163.06000

65649055204 RELISTOR METHYLNALTREXONE BROMIDE SUBCUTANEOUS MU-OPIOID RECEPTOR ANTAGONISTS,PERIPHERALLY-ACTING SYRINGE (ML) 8 mg/0.4 mL

248.99288

65649055102 RELISTOR METHYLNALTREXONE BROMIDE SUBCUTANEOUS MU-OPIOID RECEPTOR ANTAGONISTS,PERIPHERALLY-ACTING VIAL (SDV,MDV OR ADDITIVE) (ML) 12 mg/0.6 mL

98.85300

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NDC Label Generic Name SMAC Price

65757030001 VIVITROL NALTREXONE MICROSPHERES INTRAMUSCULAR ANTI-ALCOHOLIC PREPARATIONS SUSPENSION, EXTENDED RELEASE, RECONST. 380 mg

1,266.33909

70437024018 NERLYNX NERATINIB MALEATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 40 mg

63.13808

00078059251 TASIGNA NILOTINIB HCL ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 150 mg

115.71000

00078059287 TASIGNA NILOTINIB HCL ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 150 mg

115.71000

00078052651 TASIGNA NILOTINIB HCL ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 200 mg

94.86000

00078052687 TASIGNA NILOTINIB HCL ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 200 mg

94.86000

00597014360 OFEV NINTEDANIB ESYLATE ORAL PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORS CAPSULE 100 mg

132.79668

00597014560 OFEV NINTEDANIB ESYLATE ORAL PULMONARY FIBROSIS - SYSTEMIC ENZYME INHIBITORS CAPSULE 150 mg

132.79668

00003377412 OPDIVO NIVOLUMAB INTRAVENOUS ANTINEOPLASTIC,ANTI-PROGRAMMED DEATH-1 (PD-1) MAB VIAL (ML) 100 mg/10 mL

257.29950

00003373413 OPDIVO NIVOLUMAB INTRAVENOUS ANTINEOPLASTIC,ANTI-PROGRAMMED DEATH-1 (PD-1) MAB VIAL (ML) 240 mg/24 mL

257.29950

00003377211 OPDIVO NIVOLUMAB INTRAVENOUS ANTINEOPLASTIC,ANTI-PROGRAMMED DEATH-1 (PD-1) MAB VIAL (ML) 40 mg/4 mL

257.29950

00310066812 LYNPARZA OLAPARIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 100 mg

111.90060

00310066860 LYNPARZA OLAPARIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 100 mg

111.90060

00310067912 LYNPARZA OLAPARIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 150 mg

115.25760

00310067960 LYNPARZA OLAPARIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 150 mg

115.25760

00310135030 TAGRISSO OSIMERTINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 80 mg

473.49690

00069018821 IBRANCE PALBOCICLIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 100 mg

535.92248

00069018921 IBRANCE PALBOCICLIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 125 mg

518.61800

00069018721 IBRANCE PALBOCICLIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 75 mg

527.89790

50458056201 INVEGA SUSTENNA

PALIPERIDONE PALMITATE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (ML) 117 mg/0.75 mL

1,733.29700

50458056301 INVEGA SUSTENNA

PALIPERIDONE PALMITATE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (ML) 156 mg/mL

1,733.29700

Page 21: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

50458056401 INVEGA SUSTENNA

PALIPERIDONE PALMITATE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (ML) 234 mg/1.5 mL

1,733.29700

50458056001 INVEGA SUSTENNA

PALIPERIDONE PALMITATE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (ML) 39 mg/0.25 mL

1,733.29700

50458060701 INVEGA TRINZA

PALIPERIDONE PALMITATE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (ML) 410 mg/1.315 mL

2,948.21100

50458060801 INVEGA TRINZA

PALIPERIDONE PALMITATE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (ML) 546 mg/1.75 mL

2,953.97200

50458056101 INVEGA SUSTENNA

PALIPERIDONE PALMITATE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (ML) 78 mg/0.5 mL

1,733.29700

50458060901 INVEGA TRINZA

PALIPERIDONE PALMITATE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (ML) 819 mg/2.625 mL

3,044.12490

00078065006 FARYDAK PANOBINOSTAT LACTATE ORAL ANTINEOPLAST,HISTONE DEACETYLASE (HDAC) INHIBITORS CAPSULE 10 mg

1,138.75668

00078065106 FARYDAK PANOBINOSTAT LACTATE ORAL ANTINEOPLAST,HISTONE DEACETYLASE (HDAC) INHIBITORS CAPSULE 15 mg

1,138.75668

00078065206 FARYDAK PANOBINOSTAT LACTATE ORAL ANTINEOPLAST,HISTONE DEACETYLASE (HDAC) INHIBITORS CAPSULE 20 mg

1,138.75668

00078074881 SIGNIFOR LAR PASIREOTIDE PAMOATE INTRAMUSCULAR SOMATOSTATIC AGENTS VIAL (EA) 10 mg

12,259.56400

00078064161 SIGNIFOR LAR PASIREOTIDE PAMOATE INTRAMUSCULAR SOMATOSTATIC AGENTS VIAL (EA) 20 mg

10,726.15308

00078064181 SIGNIFOR LAR PASIREOTIDE PAMOATE INTRAMUSCULAR SOMATOSTATIC AGENTS VIAL (EA) 20 mg

10,726.15308

00078074181 SIGNIFOR LAR PASIREOTIDE PAMOATE INTRAMUSCULAR SOMATOSTATIC AGENTS VIAL (EA) 30 mg

12,259.56400

00078064261 SIGNIFOR LAR PASIREOTIDE PAMOATE INTRAMUSCULAR SOMATOSTATIC AGENTS VIAL (EA) 40 mg

10,726.15308

00078064281 SIGNIFOR LAR PASIREOTIDE PAMOATE INTRAMUSCULAR SOMATOSTATIC AGENTS VIAL (EA) 40 mg

10,726.15308

00078064361 SIGNIFOR LAR PASIREOTIDE PAMOATE INTRAMUSCULAR SOMATOSTATIC AGENTS VIAL (EA) 60 mg

10,726.15308

00078064381 SIGNIFOR LAR PASIREOTIDE PAMOATE INTRAMUSCULAR SOMATOSTATIC AGENTS VIAL (EA) 60 mg

10,726.15308

55513019001 NEULASTA PEGFILGRASTIM SUBCUTANEOUS LEUKOCYTE (WBC) STIMULANTS SYRINGE (ML) 6 mg/0.6 mL

10,074.86714

55513019201 NEULASTA PEGFILGRASTIM SUBCUTANEOUS LEUKOCYTE (WBC) STIMULANTS SYRINGE, WITH WEARABLE INJECTOR 6 mg/0.6 mL deliverable (0.64 mL)

7,777.43532

Page 22: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00009517802 SOMAVERT PEGVISOMANT SUBCUTANEOUS GROWTH HORMONE RECEPTOR ANTAGONISTS VIAL (EA) 15 mg

222.83508

00009518002 SOMAVERT PEGVISOMANT SUBCUTANEOUS GROWTH HORMONE RECEPTOR ANTAGONISTS VIAL (EA) 20 mg

297.09684

00009519901 SOMAVERT PEGVISOMANT SUBCUTANEOUS GROWTH HORMONE RECEPTOR ANTAGONISTS VIAL (EA) 25 mg

371.37852

00009520104 SOMAVERT PEGVISOMANT SUBCUTANEOUS GROWTH HORMONE RECEPTOR ANTAGONISTS VIAL (EA) 25 mg

371.38000

00009520001 SOMAVERT PEGVISOMANT SUBCUTANEOUS GROWTH HORMONE RECEPTOR ANTAGONISTS VIAL (EA) 30 mg

445.64028

00009537604 SOMAVERT PEGVISOMANT SUBCUTANEOUS GROWTH HORMONE RECEPTOR ANTAGONISTS VIAL (EA) 30 mg

445.64000

00006302601 KEYTRUDA PEMBROLIZUMAB INTRAVENOUS ANTINEOPLASTIC,ANTI-PROGRAMMED DEATH-1 (PD-1) MAB VIAL (ML) 100 mg/4 mL (25 mg/mL)

1,079.00000

00006302602 KEYTRUDA PEMBROLIZUMAB INTRAVENOUS ANTINEOPLASTIC,ANTI-PROGRAMMED DEATH-1 (PD-1) MAB VIAL (ML) 100 mg/4 mL (25 mg/mL)

1,074.68400

50242012301 ESBRIET PIRFENIDONE ORAL ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS TABLET 801 mg

31.54667

00024586201 MOZOBIL PLERIXAFOR SUBCUTANEOUS CXCR4 CHEMOKINE RECEPTOR ANTAGONIST VIAL (ML) 24 mg/1.2 mL (20 mg/mL)

5,896.00128

50419020801 XOFIGO RADIUM-223 DICHLORIDE INTRAVENOUS RADIOACTIVE THERAPEUTIC AGENTS VIAL (EA) 1,100 kBq/mL (30 microcurie/mL)

21,962.43744

00006022761 ISENTRESS RALTEGRAVIR POTASSIUM ORAL ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR TABLET 400 mg

25.51401

00006308001 ISENTRESS HD RALTEGRAVIR POTASSIUM ORAL ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR TABLET 600 mg

25.52840

50419017101 STIVARGA REGORAFENIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 40 mg

195.33430

50419017103 STIVARGA REGORAFENIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 40 mg

195.33430

70504300001 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE INJECTION ANTISERA VIAL (ML) 15,000 unit (3,000 mcg)/13 mL

314.69998

70504300002 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE INJECTION ANTISERA VIAL (ML) 15,000 unit (3,000 mcg)/13 mL

314.69998

70504350001 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE INJECTION ANTISERA VIAL (ML) 2,500 unit (500 mcg)/2.2 mL

309.93256

70504350002 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE INJECTION ANTISERA VIAL (ML) 2,500 unit (500 mcg)/2.2 mL

309.93256

70504310001 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE INJECTION ANTISERA VIAL (ML) 5,000 unit (1,000 mcg)/4.4 mL

309.93256

70504310002 WINRHO SDF RHO(D) IMMUNE GLOBULIN/MALTOSE INJECTION ANTISERA VIAL (ML) 5,000 unit (1,000 mcg)/4.4 mL

309.93256

Page 23: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00078090961 KISQALI FEMARA CO-PACK

RIBOCICLIB SUCCINATE/LETROZOLE ORAL ANTINEOPLASTIC COMB - KINASE AND AROMATASE INHIBIT TABLET 200 mg/day (200 mg x 1)-2.5 mg

87.59999

00078091661 KISQALI FEMARA CO-PACK

RIBOCICLIB SUCCINATE/LETROZOLE ORAL ANTINEOPLASTIC COMB - KINASE AND AROMATASE INHIBIT TABLET 400 mg/day (200 mg x 2)-2.5 mg

122.63999

00078092361 KISQALI FEMARA CO-PACK

RIBOCICLIB SUCCINATE/LETROZOLE ORAL ANTINEOPLASTIC COMB - KINASE AND AROMATASE INHIBIT TABLET 600 mg/day (200 mg x 3)-2.5 mg

117.92308

61755000101 ARCALYST RILONACEPT SUBCUTANEOUS ANTI-INFLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST VIAL (SDV,MDV OR ADDITIVE) (EA) 220 mg

4,980.00000

59676027801 EDURANT RILPIVIRINE HCL ORAL ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI TABLET 25 mg

36.20761

50458030911 RISPERDAL CONSTA

RISPERIDONE MICROSPHERES INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (EA) 12.5 mg/2 mL

231.85250

50458030711 RISPERDAL CONSTA

RISPERIDONE MICROSPHERES INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (EA) 37.5 mg/2 mL

701.65420

50458030811 RISPERDAL CONSTA

RISPERIDONE MICROSPHERES INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (EA) 50 mg/2 mL

929.01020

50242010801 RITUXAN HYCELA

RITUXIMAB/HYALURONIDASE, HUMAN RECOMBINANT SUBCUTANEOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY VIAL (ML) 1,400 mg/11.7 mL (120 mg/mL)

537.17100

50242010901 RITUXAN HYCELA

RITUXIMAB/HYALURONIDASE, HUMAN RECOMBINANT SUBCUTANEOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY VIAL (ML) 1,600 mg/13.4 mL (120 mg/mL)

537.17100

50458058010 XARELTO RIVAROXABAN ORAL DIRECT FACTOR XA INHIBITORS TABLET 10 mg 12.73820

50458058030 XARELTO RIVAROXABAN ORAL DIRECT FACTOR XA INHIBITORS TABLET 10 mg 13.32970

69660020191 RUBRACA RUCAPARIB CAMSYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 200 mg

114.04200

69660020391 RUBRACA RUCAPARIB CAMSYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 300 mg

114.04200

62856058446 BANZEL RUFINAMIDE ORAL ANTICONVULSANTS SUSPENSION, ORAL (FINAL DOSE FORM) 40 mg/mL

3.38816

62856058252 BANZEL RUFINAMIDE ORAL ANTICONVULSANTS TABLET 200 mg 11.50902

62856058352 BANZEL RUFINAMIDE ORAL ANTICONVULSANTS TABLET 400 mg 22.97433

66215061006 UPTRAVI SELEXIPAG ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET 1,000 mcg

241.03200

66215061206 UPTRAVI SELEXIPAG ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET 1,200 mcg

241.03200

66215061406 UPTRAVI SELEXIPAG ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET 1,400 mcg

241.03200

Page 24: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

66215061606 UPTRAVI SELEXIPAG ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET 1,600 mcg

241.03200

66215060206 UPTRAVI SELEXIPAG ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET 200 mcg

155.04400

66215060214 UPTRAVI SELEXIPAG ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET 200 mcg

154.94914

66215060406 UPTRAVI SELEXIPAG ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET 400 mcg

241.03200

66215060606 UPTRAVI SELEXIPAG ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET 600 mcg

241.03200

66215060806 UPTRAVI SELEXIPAG ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET 800 mcg

241.03200

66215062820 UPTRAVI SELEXIPAG ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET, DOSE PACK 200 mcg (140)-800 mcg (60)

108.46440

00078097912 MAYZENT SIPONIMOD ORAL AGENTS TO TREAT MULTIPLE SCLEROSIS TABLET, DOSE PACK 0.25 mg (12 tabs)

60.37000

00008103004 RAPAMUNE SIROLIMUS ORAL IMMUNOSUPPRESSIVES SOLUTION, ORAL 1 mg/mL 28.22343

00008103006 RAPAMUNE SIROLIMUS ORAL IMMUNOSUPPRESSIVES SOLUTION, ORAL 1 mg/mL 28.22343

00517312025 NUTRILYTE SODIUM/POTASSIUM/MAGNES/CALCIUM/CHLORIDE/ACETATE/GLUCONATE INTRAVENOUS ELECTROLYTE MAINTENANCE VIAL (ML) 25 mEq-40.6 mEq-5 mEq-8 mEq-33.6 mEq-40.5 mEq-5 mEq/20 mL

0.17928

00013262681 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES CARTRIDGE (EA) 5 mg/mL (15 unit/mL)

620.95832

00781300407 OMNITROPE SOMATROPIN SUBCUTANEOUS GROWTH HORMONES CARTRIDGE (ML) 10 mg/1.5 mL (6.7 mg/mL)

651.81000

50242007601 NUTROPIN AQ NUSPIN

SOMATROPIN SUBCUTANEOUS GROWTH HORMONES PEN INJECTOR (ML) 20 mg/2 mL (10 mg/mL)

1,117.47010

50242007501 NUTROPIN AQ NUSPIN

SOMATROPIN SUBCUTANEOUS GROWTH HORMONES PEN INJECTOR (ML) 5 mg/2 mL (2.5 mg/mL)

249.78500

44087000401 SEROSTIM SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (SDV,MDV OR ADDITIVE) (EA) 4 mg

193.14672

44087000407 SEROSTIM SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (SDV,MDV OR ADDITIVE) (EA) 4 mg

201.11256

44087000601 SEROSTIM SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (SDV,MDV OR ADDITIVE) (EA) 6 mg

289.72008

44087000607 SEROSTIM SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (SDV,MDV OR ADDITIVE) (EA) 6 mg

301.66824

44087108801 SAIZEN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (SDV,MDV OR ADDITIVE) (EA) 8.8 mg

596.48780

44087338807 ZORBTIVE SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (SDV,MDV OR ADDITIVE) (EA) 8.8 mg

774.60106

50419048858 NEXAVAR SORAFENIB TOSYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 200 mg

150.74450

Page 25: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00069055038 SUTENT SUNITINIB MALATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 12.5 mg

176.81292

00069077038 SUTENT SUNITINIB MALATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 25 mg

356.99546

00069083038 SUTENT SUNITINIB MALATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 37.5 mg

392.99172

43068022001 HETLIOZ TASIMELTEON ORAL HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS CAPSULE 20 mg

269.15904

00002840001 FORTEO TERIPARATIDE SUBCUTANEOUS BONE FORMATION STIM. AGENTS - PARATHYROID HORMONE PEN INJECTOR (ML) 20 mcg/dose (600 mcg/2.4 mL)

1,390.73120

62064001160 EGRIFTA TESAMORELIN ACETATE SUBCUTANEOUS GROWTH HORMONE RELEASING HORMONE(GHRH) AND ANALOGS VIAL (EA) 1 mg

70.55000

13533063402 HYPERTET S-D TETANUS IMMUNE GLOBULIN/PF INTRAMUSCULAR ANTISERA SYRINGE (EA) 250 unit

496.03788

13533063420 HYPERTET S-D TETANUS IMMUNE GLOBULIN/PF INTRAMUSCULAR ANTISERA SYRINGE (EA) 250 unit

496.03788

76388088025 TABLOID THIOGUANINE ORAL ANTIMETABOLITES TABLET 40 mg 12.50976

17478034038 TOBRAMYCIN TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/5 mL

12.81852

00781717156 TOBRAMYCIN TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/5 mL

20.51760

10122082028 BETHKIS TOBRAMYCIN INHALATION AMINOGLYCOSIDE ANTIBIOTICS AMPUL FOR NEBULIZATION (ML) 300 mg/4 mL

26.52140

10122082056 BETHKIS TOBRAMYCIN INHALATION AMINOGLYCOSIDE ANTIBIOTICS AMPUL FOR NEBULIZATION (ML) 300 mg/4 mL

26.52140

10122082004 BETHKIS TOBRAMYCIN INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/4 mL

25.33000

00078063011 TOBI PODHALER

TOBRAMYCIN INHALATION AMINOGLYCOSIDES CAPSULE 28 mg 26.68827

00069100201 XELJANZ TOFACITINIB CITRATE ORAL JANUS KINASE (JAK) INHIBITORS TABLET 10 mg

71.31908

00069100101 XELJANZ TOFACITINIB CITRATE ORAL JANUS KINASE (JAK) INHIBITORS TABLET 5 mg

67.44130

00078066615 MEKINIST TRAMETINIB DIMETHYL SULFOXIDE ORAL ANTINEOPLASTIC - MEK1 AND MEK2 KINASE INHIBITORS TABLET 0.5 mg

97.43660

50242013201 HERCEPTIN TRASTUZUMAB INTRAVENOUS ANTINEOPLASTIC EGF RECEPTOR BLOCKER MCLON ANTIBODY VIAL (EA) 150 mg

1,397.64660

66302035001 ORENITRAM ER

TREPROSTINIL DIOLAMINE ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET, EXTENDED RELEASE 5 mg

194.22000

66302035010 ORENITRAM ER

TREPROSTINIL DIOLAMINE ORAL PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE TABLET, EXTENDED RELEASE 5 mg

194.22000

24338015020 TRIPTODUR TRIPTORELIN PAMOATE INTRAMUSCULAR LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY VIAL (EA) 22.5 mg

15,936.00000

Page 26: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00004003909 VALCYTE VALGANCICLOVIR HCL ORAL ANTIVIRALS, GENERAL SOLUTION, RECONSTITUTED, ORAL 50 mg/mL

11.42674

00187560015 VISUDYNE VERTEPORFIN INTRAVENOUS OCULAR PHOTOACTIVATED VESSEL-OCCLUDING AGENTS VIAL (EA) 15 mg

1,612.22520

00003218710 ORENCIA ABATACEPT/MALTOSE INTRAVENOUS ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR VIAL (SDV,MDV OR ADDITIVE) (EA) 250 mg

576.07810

00003218713 ORENCIA ABATACEPT/MALTOSE INTRAVENOUS ANTINFLAMMATORY, SEL.COSTIM.MOD.,T-CELL INHIBITOR VIAL (SDV,MDV OR ADDITIVE) (EA) 250 mg

576.07810

15054053006 DYSPORT ABOBOTULINUMTOXINA INTRAMUSCULAR NEUROMUSCULAR BLOCKING AGENTS VIAL (SDV,MDV OR ADDITIVE) (EA) 300 unit

424.29600

15054050001 DYSPORT ABOBOTULINUMTOXINA INTRAMUSCULAR NEUROMUSCULAR BLOCKING AGENTS VIAL (SDV,MDV OR ADDITIVE) (EA) 500 unit

707.16000

00074937402 HUMIRA ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR KIT 20 mg/0.4 mL

1,246.29970

00074634702 HUMIRA ADALIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR SYRINGE KIT (EA) 10 mg/0.2 mL

1,344.75936

42794000308 ADEFOVIR DIPIVOXIL

ADEFOVIR DIPIVOXIL ORAL HEPATITIS B TREATMENT AGENTS TABLET 10 mg

34.94731

60505394703 ADEFOVIR DIPIVOXIL

ADEFOVIR DIPIVOXIL ORAL HEPATITIS B TREATMENT AGENTS TABLET 10 mg

34.94731

61958050101 HEPSERA ADEFOVIR DIPIVOXIL ORAL HEPATITIS B TREATMENT AGENTS TABLET 10 mg

34.94731

50242008801 KADCYLA ADO-TRASTUZUMAB EMTANSINE INTRAVENOUS ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES VIAL (SDV,MDV OR ADDITIVE) (EA) 100 mg

2,762.47600

50242008701 KADCYLA ADO-TRASTUZUMAB EMTANSINE INTRAVENOUS ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES VIAL (SDV,MDV OR ADDITIVE) (EA) 160 mg

4,419.95900

00597014130 GILOTRIF AFATINIB DIMALEATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 20 mg

199.00080

00597013730 GILOTRIF AFATINIB DIMALEATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 30 mg

199.00080

00597013830 GILOTRIF AFATINIB DIMALEATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 40 mg

199.00080

58468004001 FABRAZYME AGALSIDASE BETA INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT, FABRY'S DX VIAL (EA) 35 mg

5,466.86000

58468004101 FABRAZYME AGALSIDASE BETA INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT, FABRY'S DX VIAL (EA) 5 mg

774.88800

58468020001 LEMTRADA ALEMTUZUMAB INTRAVENOUS AGENTS TO TREAT MULTIPLE SCLEROSIS VIAL (ML) 12 mg/1.2 mL

16,392.49900

58468016001 LUMIZYME ALGLUCOSIDASE ALFA INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT,POMPE DISEASE VIAL (EA) 50 mg

750.98000

Page 27: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

58468016002 LUMIZYME ALGLUCOSIDASE ALFA INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT,POMPE DISEASE VIAL (EA) 50 mg

750.98000

00944281401 ARALAST NP ALPHA-1-PROTEINASE INHIBITOR INTRAVENOUS SYSTEMIC ENZYME INHIBITORS VIAL (EA) 500 mg

0.51792

00944288401 GLASSIA ALPHA-1-PROTEINASE INHIBITOR INTRAVENOUS SYSTEMIC ENZYME INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (EA) 1 gram/50 mL (2 %)

0.46480

00944288402 GLASSIA ALPHA-1-PROTEINASE INHIBITOR INTRAVENOUS SYSTEMIC ENZYME INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (EA) 1 gram/50 mL (2 %)

0.46480

00378427193 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

200.26704

00591240630 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

200.26704

42794005208 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

200.26704

47335023783 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

200.26704

49884035411 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

200.26704

49884035462 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

200.26704

69097038702 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

200.26704

70710118003 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

200.26704

61958080201 LETAIRIS AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

200.26704

61958080205 LETAIRIS AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

200.26704

00378427093 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 5 mg

200.26704

00591240530 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 5 mg

200.26704

42794005108 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 5 mg

200.26704

47335023683 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 5 mg

200.26704

49884035311 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 5 mg

200.26704

49884035362 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 5 mg

200.26704

69097038602 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 5 mg

200.26704

70710117903 AMBRISENTAN AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 5 mg

200.26704

Page 28: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

61958080101 LETAIRIS AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 5 mg

200.26704

61958080105 LETAIRIS AMBRISENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 5 mg

200.26704

66658023407 KINERET ANAKINRA SUBCUTANEOUS ANTI-INFLAM. INTERLEUKIN-1 RECEPTOR ANTAGONIST DISPOSABLE SYRINGE (ML) 100 mg/0.67 mL

136.97600

64193042502 FEIBA NF ANTI-INHIBITOR COAGULANT COMPLEX INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,750 unit-3,250 unit

1.57500

00944425602 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

1.90000

00944462401 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

1.90000

00944425802 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (+/-) unit range

1.90000

00944462501 ADYNOVATE ANTIHEMOPHILIC FACTOR (FVIII) RECOMBINANT, FULL LENGTH, PEG INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (+/-) unit range

1.90000

58394001401 XYNTHA ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS KIT 1,000 (+/-) unit range

0.98000

58394001201 XYNTHA ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS KIT 250 (+/-) unit range

0.97000

58394001301 XYNTHA ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS KIT 500 (+/-) unit range

0.97000

58394001603 XYNTHA SOLOFUSE

ANTIHEMOPHILIC FACTOR VIII (PLASMA/ALBUMIN-FREE) INTRAVENOUS ANTIHEMOPHILIC FACTORS SYRINGE KIT (EA) 3,000 (+/-) unit

0.96720

68982014301 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

1.21000

68982014401 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

1.21000

68982014501 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (+/-) unit range

1.21000

68982014601 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (+/-) unit range

1.21000

68982013901 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

1.21000

68982014001 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

1.21000

Page 29: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

68982014101 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

1.21000

68982014201 NUWIQ ANTIHEMOPHILIC FACTOR VIII REC HEK CELL, B-DOMAIN DELETED INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

1.21000

00944284310 RECOMBINATE ANTIHEMOPHILIC FACTOR VIII, HUMAN RECOMBINANT INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

0.91000

00944284110 RECOMBINATE ANTIHEMOPHILIC FACTOR VIII, HUMAN RECOMBINANT INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

0.91000

00944284210 RECOMBINATE ANTIHEMOPHILIC FACTOR VIII, HUMAN RECOMBINANT INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (+/-) unit range

0.88000

76125067351 KOATE ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

0.68120

76125067650 KOATE ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,000 (+/-) unit range

0.68120

76125025620 KOATE ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (+/-) unit range

0.71469

00944394602 HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (SDV,MDV OR ADDITIVE) (EA) 1,501 unit-2,000 unit

0.78000

00944394002 HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (SDV,MDV OR ADDITIVE) (EA) 220 unit-400 unit

0.79040

00944394202 HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (SDV,MDV OR ADDITIVE) (EA) 401 unit-800 unit

0.78000

00944394402 HEMOFIL M ANTIHEMOPHILIC FACTOR, HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (SDV,MDV OR ADDITIVE) (EA) 801 unit-1,500 unit

0.78000

68516460302 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACT,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (SDV,MDV OR ADDITIVE) (EA) 1,000 (400 VWF) unit/10 mL

0.69530

68516460702 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACT,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (SDV,MDV OR ADDITIVE) (EA) 1,000 (400 VWF) unit/10 mL

0.69530

68516461302 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACT,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (SDV,MDV OR ADDITIVE) (EA) 1,000 (400 VWF) unit/10 mL

0.69530

63833061702 HUMATE-P ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS KIT 1,000 unit-2,400 unit

0.75000

63833061502 HUMATE-P ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS KIT 250 unit-600 unit

0.75000

63833061602 HUMATE-P ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS KIT 500 unit-1,200 unit

0.75000

68516460402 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,500 (600 VWF) unit/10 mL

0.75000

68516460802 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,500 (600 VWF) unit/10 mL

0.75000

Page 30: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

68516461402 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1,500 (600 VWF) unit/10 mL

0.75000

68516460902 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (800 VWF) unit/10 mL

0.79000

68516461002 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (800 VWF) unit/10 mL

0.79000

68516461502 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2,000 (800 VWF) unit/10 mL

0.79000

68516460101 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (100 VWF) unit/5 mL

0.77000

68516460501 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (100 VWF) unit/5 mL

0.77000

68516461101 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 250 (100 VWF) unit/5 mL

0.77000

68516460201 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (200 VWF) unit/5 mL

0.75000

68516460601 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (200 VWF) unit/5 mL

0.75000

68516461201 ALPHANATE ANTIHEMOPHILIC FACTOR, HUMAN/VON WILLEBRAND FACTOR,HUMAN INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 500 (200 VWF) unit/5 mL

0.75000

27505000401 APOKYN APOMORPHINE HCL SUBCUTANEOUS ANTIPARKINSONISM DRUGS,OTHER CARTRIDGE (ML) 10 mg/mL

330.33999

27505000405 APOKYN APOMORPHINE HCL SUBCUTANEOUS ANTIPARKINSONISM DRUGS,OTHER CARTRIDGE (ML) 10 mg/mL

330.33999

25682001001 STRENSIQ ASFOTASE ALFA SUBCUTANEOUS METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIA VIAL (ML) 18 mg/0.45 mL

2,788.80000

25682001012 STRENSIQ ASFOTASE ALFA SUBCUTANEOUS METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIA VIAL (ML) 18 mg/0.45 mL

2,788.80000

25682001301 STRENSIQ ASFOTASE ALFA SUBCUTANEOUS METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIA VIAL (ML) 28 mg/0.7 mL

2,788.80000

25682001312 STRENSIQ ASFOTASE ALFA SUBCUTANEOUS METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIA VIAL (ML) 28 mg/0.7 mL

2,788.80000

25682001601 STRENSIQ ASFOTASE ALFA SUBCUTANEOUS METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIA VIAL (ML) 40 mg/mL

2,788.80000

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NDC Label Generic Name SMAC Price

25682001612 STRENSIQ ASFOTASE ALFA SUBCUTANEOUS METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIA VIAL (ML) 40 mg/mL

2,788.80000

25682001901 STRENSIQ ASFOTASE ALFA SUBCUTANEOUS METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIA VIAL (ML) 80 mg/0.8 mL

6,972.00000

25682001912 STRENSIQ ASFOTASE ALFA SUBCUTANEOUS METABOLIC DISEASE ENZYME REPLACE, HYPOPHOSPHATASIA VIAL (ML) 80 mg/0.8 mL

6,972.00000

00093552706 ATAZANAVIR SULFATE

ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE (HARD, SOFT, ETC.) 200 mg

19.90570

16714086101 ATAZANAVIR SULFATE

ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE (HARD, SOFT, ETC.) 200 mg

19.90570

51407017260 ATAZANAVIR SULFATE

ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE (HARD, SOFT, ETC.) 200 mg

19.90570

65862071260 ATAZANAVIR SULFATE

ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE (HARD, SOFT, ETC.) 200 mg

19.90570

69097044503 ATAZANAVIR SULFATE

ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE (HARD, SOFT, ETC.) 200 mg

19.90570

00003363112 REYATAZ ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE (HARD, SOFT, ETC.) 200 mg

19.90570

50090158100 REYATAZ ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE (HARD, SOFT, ETC.) 200 mg

19.90570

00093552606 ATAZANAVIR SULFATE

ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE 150 mg

21.23737

16714086001 ATAZANAVIR SULFATE

ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE 150 mg

21.23737

51407017160 ATAZANAVIR SULFATE

ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE 150 mg

21.23737

65862071160 ATAZANAVIR SULFATE

ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE 150 mg

21.23737

69097044403 ATAZANAVIR SULFATE

ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE 150 mg

21.23737

00003362412 REYATAZ ATAZANAVIR SULFATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS CAPSULE 150 mg

21.23737

00069014501 INLYTA AXITINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 1 mg

48.80400

00069015111 INLYTA AXITINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 5 mg

188.62547

61958090101 CAYSTON AZTREONAM LYSINE INHALATION BETALACTAMS VIAL, NEBULIZER (ML) 75 mg/mL

86.22810

49401010201 BENLYSTA BELIMUMAB INTRAVENOUS IMMUNOMODULATOR,B-LYMPHOCYTE STIM(BLYS)-SPEC INHIB VIAL (EA) 400 mg

1,585.06000

49401010101 BENLYSTA BELIMUMAB INTRAVENOUS IMMUNOMODULATOR,B-LYMPHOCYTE STIM(BLYS)-SPEC INHIB VIAL (SDV,MDV OR ADDITIVE) (EA) 120 mg

441.40728

68152010809 BELEODAQ BELINOSTAT INTRAVENOUS ANTINEOPLAST,HISTONE DEACETYLASE (HDAC) INHIBITORS VIAL (EA) 500 mg

1,494.00000

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NDC Label Generic Name SMAC Price

50242006001 AVASTIN BEVACIZUMAB INTRAVENOUS ANTINEOPLAST HUM VEGF INHIBITOR RECOMB MC ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 25 mg/mL

148.59905

50242006010 AVASTIN BEVACIZUMAB INTRAVENOUS ANTINEOPLAST HUM VEGF INHIBITOR RECOMB MC ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 25 mg/mL

148.59905

50242006101 AVASTIN BEVACIZUMAB INTRAVENOUS ANTINEOPLAST HUM VEGF INHIBITOR RECOMB MC ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 25 mg/mL

148.59905

50242006110 AVASTIN BEVACIZUMAB INTRAVENOUS ANTINEOPLAST HUM VEGF INHIBITOR RECOMB MC ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 25 mg/mL

148.59905

63020004901 VELCADE BORTEZOMIB INJECTION ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (EA) 3.5 mg

1,465.11600

63020004904 VELCADE BORTEZOMIB INJECTION ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (EA) 3.5 mg

1,465.11600

00069013501 BOSULIF BOSUTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 100 mg

67.90437

00069013601 BOSULIF BOSUTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 500 mg

271.61749

51144005001 ADCETRIS BRENTUXIMAB VEDOTIN INTRAVENOUS ANTINEOPLASTICS ANTIBODY/ANTIBODY-DRUG COMPLEXES VIAL (SDV,MDV OR ADDITIVE) (EA) 50 mg

4,590.00000

50474097063 BRIVIACT BRIVARACETAM INTRAVENOUS ANTICONVULSANTS VIAL (ML) 50 mg/5 mL

7.76880

50474097075 BRIVIACT BRIVARACETAM INTRAVENOUS ANTICONVULSANTS VIAL (ML) 50 mg/5 mL

7.76880

50474037066 BRIVIACT BRIVARACETAM ORAL ANTICONVULSANTS TABLET 10 mg 15.10599

63833082502 BERINERT C1 ESTERASE INHIBITOR INTRAVENOUS C1 ESTERASE INHIBITORS KIT 500 unit (10 mL)

2,803.74000

42227008105 CINRYZE C1 ESTERASE INHIBITOR INTRAVENOUS C1 ESTERASE INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (EA) 500 unit (5 mL)

2,147.11040

68012035001 RUCONEST C1 ESTERASE INHIBITOR, RECOMBINANT INTRAVENOUS C1 ESTERASE INHIBITORS VIAL (EA) 2,100 unit

4,731.00000

68012035002 RUCONEST C1 ESTERASE INHIBITOR, RECOMBINANT INTRAVENOUS C1 ESTERASE INHIBITORS VIAL (EA) 2,100 unit

4,731.00000

71274035001 RUCONEST C1 ESTERASE INHIBITOR, RECOMBINANT INTRAVENOUS C1 ESTERASE INHIBITORS VIAL (EA) 2,100 unit

4,731.00000

71274035002 RUCONEST C1 ESTERASE INHIBITOR, RECOMBINANT INTRAVENOUS C1 ESTERASE INHIBITORS VIAL (EA) 2,100 unit

4,731.00000

42388001214 COMETRIQ CABOZANTINIB S-MALATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE (HARD, SOFT, ETC.) 100 mg/day (80 mg [1]-20 mg [1]/day)

176.07900

42388001114 COMETRIQ CABOZANTINIB S-MALATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE (HARD, SOFT, ETC.) 140 mg/day (80 mg [1]-20 mg [3]/day)

88.03900

42388001314 COMETRIQ CABOZANTINIB S-MALATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE (HARD, SOFT, ETC.) 60 mg/day (20 mg [3]/day)

117.38600

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NDC Label Generic Name SMAC Price

76075010101 KYPROLIS CARFILZOMIB INTRAVENOUS ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (EA) 60 mg

1,651.36800

24338005008 GLIADEL CARMUSTINE IN POLIFEPROSAN 20 IMPLANTATION ALKYLATING AGENTS WAFER 7.7 mg-192.3 mg

3,286.17750

50474070062 CIMZIA CERTOLIZUMAB PEGOL SUBCUTANEOUS DRUGS TO TX CHRONIC INFLAMMATORY DISEASE OF COLON KIT 400 mg (200 mg X 2)

1,960.56790

00169720101 NOVOSEVEN RT

COAGULATION FACTOR VIIA (RECOMBINANT) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 1 mg (1,000 mcg)

1.47000

00169720201 NOVOSEVEN RT

COAGULATION FACTOR VIIA (RECOMBINANT) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 2 mg (2,000 mcg)

1.42000

00169720501 NOVOSEVEN RT

COAGULATION FACTOR VIIA (RECOMBINANT) INTRAVENOUS ANTIHEMOPHILIC FACTORS VIAL (EA) 5 mg (5,000 mcg)

1.58016

64208775201 COAGADEX COAGULATION FACTOR X INTRAVENOUS FACTOR X PREPARATIONS VIAL (EA) 250 (+/-) unit range

6.52000

64208775301 COAGADEX COAGULATION FACTOR X INTRAVENOUS FACTOR X PREPARATIONS VIAL (EA) 500 (+/-) unit range

6.52000

66887000301 XIAFLEX COLLAGENASE CLOSTRIDIUM HISTOLYTICUM INJECTION JOINT CONTRACTURE THERAPY, COLLAGENASE ENZYME VIAL (SDV,MDV OR ADDITIVE) (EA) 0.9 mg

3,237.00000

63004871001 ACTHAR CORTICOTROPIN INJECTION ADRENOCORTICOTROPHIC HORMONES VIAL (ML) 80 unit/mL

6,779.57280

00069814120 XALKORI CRIZOTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE (HARD, SOFT, ETC.) 200 mg

158.90128

00069814020 XALKORI CRIZOTINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 250 mg

198.95827

70564080260 MYTESI CROFELEMER ORAL ANTIDIARRHEAL - G.I. CHLORIDE CHANNEL INHIBITORS TABLET, DELAYED RELEASE (ENTERIC COATED) 125 mg

8.96400

10144042760 AMPYRA DALFAMPRIDINE ORAL AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR TABLET, EXTENDED RELEASE 12 HR 10 mg

21.67435

00378050991 DALFAMPRIDINE ER

DALFAMPRIDINE ORAL AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR TABLET, EXTENDED RELEASE 12 HR 10 mg

21.67435

16729029212 DALFAMPRIDINE ER

DALFAMPRIDINE ORAL AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR TABLET, EXTENDED RELEASE 12 HR 10 mg

21.67435

42571027560 DALFAMPRIDINE ER

DALFAMPRIDINE ORAL AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR TABLET, EXTENDED RELEASE 12 HR 10 mg

21.67435

51407024660 DALFAMPRIDINE ER

DALFAMPRIDINE ORAL AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR TABLET, EXTENDED RELEASE 12 HR 10 mg

21.67435

62756042986 DALFAMPRIDINE ER

DALFAMPRIDINE ORAL AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR TABLET, EXTENDED RELEASE 12 HR 10 mg

21.67435

65862086360 DALFAMPRIDINE ER

DALFAMPRIDINE ORAL AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR TABLET, EXTENDED RELEASE 12 HR 10 mg

21.67435

67877044460 DALFAMPRIDINE ER

DALFAMPRIDINE ORAL AGTS TX NEUROMUSC TRANSMISSION DIS,POT-CHAN BLKR TABLET, EXTENDED RELEASE 12 HR 10 mg

21.67435

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NDC Label Generic Name SMAC Price

00069022301 FRAGMIN DALTEPARIN SODIUM,PORCINE SUBCUTANEOUS HEPARIN AND RELATED PREPARATIONS DISPOSABLE SYRINGE (ML) 15,000 unit/0.6 mL

163.54636

00069022302 FRAGMIN DALTEPARIN SODIUM,PORCINE SUBCUTANEOUS HEPARIN AND RELATED PREPARATIONS DISPOSABLE SYRINGE (ML) 15,000 unit/0.6 mL

163.54636

00069023201 FRAGMIN DALTEPARIN SODIUM,PORCINE SUBCUTANEOUS HEPARIN AND RELATED PREPARATIONS VIAL (SDV,MDV OR ADDITIVE) (ML) 25,000 unit/mL

145.34174

57894050205 DARZALEX DARATUMUMAB INTRAVENOUS ANTINEOPLASTIC - ANTI-CD38 MONOCLONAL ANTIBODY VIAL (ML) 100 mg/5 mL (20 mg/mL)

89.64000

57894050220 DARZALEX DARATUMUMAB INTRAVENOUS ANTINEOPLASTIC - ANTI-CD38 MONOCLONAL ANTIBODY VIAL (ML) 400 mg/20 mL (20 mg/mL)

89.64000

55513002501 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 100 mcg/0.5 mL

1,192.41120

55513002504 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 100 mcg/0.5 mL

1,192.41120

55513002701 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 150 mcg/0.3 mL

2,981.02800

55513002704 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 150 mcg/0.3 mL

2,981.02800

55513002801 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 200 mcg/0.4 mL

2,981.02800

55513005701 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 25 mcg/0.42 mL

354.88429

55513005704 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 25 mcg/0.42 mL

354.88429

55513011101 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 300 mcg/0.6 mL

2,981.02800

55513003201 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 500 mcg/mL

2,981.02800

55513002301 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 60 mcg/0.3 mL

1,192.37800

55513002304 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS DISPOSABLE SYRINGE (ML) 60 mcg/0.3 mL

1,192.37800

55513011001 ARANESP DARBEPOETIN ALFA IN POLYSORBAT INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (SDV,MDV OR ADDITIVE) (ML) 300 mcg/mL

1,788.61680

55513002101 ARANESP DARBEPOETIN ALFA IN POLYSORBATE 80 INJECTION ERYTHROPOIESIS-STIMULATING AGENTS SYRINGE (ML) 40 mcg/0.4 mL

741.89550

55513002104 ARANESP DARBEPOETIN ALFA IN POLYSORBATE 80 INJECTION ERYTHROPOIESIS-STIMULATING AGENTS SYRINGE (ML) 40 mcg/0.4 mL

741.89550

55513000501 ARANESP DARBEPOETIN ALFA IN POLYSORBATE 80 INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 100 mcg/mL

672.69840

55513000504 ARANESP DARBEPOETIN ALFA IN POLYSORBATE 80 INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 100 mcg/mL

672.69840

59676056501 PREZISTA DARUNAVIR ETHANOLATE ORAL ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB SUSPENSION, ORAL (FINAL DOSE FORM) 100 mg/mL

3.01800

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NDC Label Generic Name SMAC Price

59676056401 PREZISTA DARUNAVIR ETHANOLATE ORAL ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB TABLET 150 mg

4.52673

59676056301 PREZISTA DARUNAVIR ETHANOLATE ORAL ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB TABLET 75 mg

2.26337

00003085722 SPRYCEL DASATINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 140 mg

360.69907

00003052711 SPRYCEL DASATINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 20 mg

67.90465

00003085522 SPRYCEL DASATINIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 80 mg

360.69907

00093351556 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET 360 mg

128.97700

43598085130 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET 360 mg

128.97700

62332041230 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET 360 mg

128.97700

69238148803 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET 360 mg

128.97700

70710127703 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET 360 mg

128.97700

00078065615 JADENU DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET 360 mg

128.97700

43598085530 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET, DISPERSIBLE 125 mg

19.70144

45963045430 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET, DISPERSIBLE 125 mg

19.70144

62332032430 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET, DISPERSIBLE 125 mg

19.70144

62756056883 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET, DISPERSIBLE 125 mg

19.70144

67877054930 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET, DISPERSIBLE 125 mg

19.70144

68462049430 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET, DISPERSIBLE 125 mg

19.70144

69452015913 DEFERASIROX DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET, DISPERSIBLE 125 mg

19.70144

00078046815 EXJADE DEFERASIROX ORAL METALLIC POISON,AGENTS TO TREAT TABLET, DISPERSIBLE 125 mg

19.70144

52609000601 FERRIPROX DEFERIPRONE ORAL METALLIC POISON,AGENTS TO TREAT TABLET 500 mg

49.43600

68727080001 DEFITELIO DEFIBROTIDE SODIUM INTRAVENOUS THROMBOLYTIC - NUCLEOTIDE TYPE VIAL (ML) 80 mg/mL

328.68000

68727080002 DEFITELIO DEFIBROTIDE SODIUM INTRAVENOUS THROMBOLYTIC - NUCLEOTIDE TYPE VIAL (ML) 80 mg/mL

328.68000

Page 36: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

55513073001 XGEVA DENOSUMAB SUBCUTANEOUS BONE RESORPTION INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (ML) 120 mg/1.7 mL (70 mg/mL)

966.70588

65862031130 DIDANOSINE DIDANOSINE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI CAPSULE,DELAYED RELEASE (ENTERIC COATED) 200 mg

3.89000

00087667217 VIDEX EC DIDANOSINE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI CAPSULE,DELAYED RELEASE (ENTERIC COATED) 200 mg

3.89000

65862031230 DIDANOSINE DIDANOSINE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI CAPSULE,DELAYED RELEASE (ENTERIC COATED) 250 mg

5.10000

00087667317 VIDEX EC DIDANOSINE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI CAPSULE,DELAYED RELEASE (ENTERIC COATED) 250 mg

5.10000

65862031330 DIDANOSINE DIDANOSINE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI CAPSULE,DELAYED RELEASE (ENTERIC COATED) 400 mg

8.35000

00087663241 VIDEX DIDANOSINE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI SOLUTION, RECONSTITUTED, ORAL 10 mg/mL (Final concentration)

0.49236

64406000501 TECFIDERA DIMETHYL FUMARATE ORAL AGENTS TO TREAT MULTIPLE SCLEROSIS CAPSULE,DELAYED RELEASE (ENTERIC COATED) 120 mg

81.71468

64406000703 TECFIDERA DIMETHYL FUMARATE ORAL AGENTS TO TREAT MULTIPLE SCLEROSIS CAPSULE,DELAYED RELEASE (ENTERIC COATED) 120 mg (14)-240 mg (46)

81.80477

64406000602 TECFIDERA DIMETHYL FUMARATE ORAL AGENTS TO TREAT MULTIPLE SCLEROSIS CAPSULE,DELAYED RELEASE (ENTERIC COATED) 240 mg

99.83240

00338006301 DOXIL DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

00338006701 DOXIL DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

00338008001 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

00338008601 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

16714074201 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

16714085601 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

43598028335 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

43598054125 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

43598068235 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

43598068325 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

47335004940 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

47335005040 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

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NDC Label Generic Name SMAC Price

59676096601 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

59676096602 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

68001034526 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

68001034536 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

72603010301 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

72603020001 DOXORUBICIN HCL LIPOSOME

DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

47335008350 LIPODOX 50 DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS ANTIBIOTIC ANTINEOPLASTICS VIAL (ML) 2 mg/mL

107.35000

47783010101 KALBITOR ECALLANTIDE SUBCUTANEOUS PLASMA KALLIKREIN INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (ML) 10 mg/mL (1 mL)

3,486.00000

68135010001 VIMIZIM ELOSULFASE ALFA INTRAVENOUS METABOLIC DX ENZYME REPLACE, MUCOPOLYSACCHARIDOSIS VIAL (ML) 5 mg/5 mL (1 mg/mL)

212.74560

00003229111 EMPLICITI ELOTUZUMAB INTRAVENOUS ANTINEOPLASTIC - ANTI-SLAMF7 MONOCLONAL ANTIBODY VIAL (EA) 300 mg

1,768.89000

00003452211 EMPLICITI ELOTUZUMAB INTRAVENOUS ANTINEOPLASTIC - ANTI-SLAMF7 MONOCLONAL ANTIBODY VIAL (EA) 400 mg

2,358.52000

00078068415 PROMACTA ELTROMBOPAG OLAMINE ORAL THROMBOPOIETIN RECEPTOR AGONISTS TABLET 12.5 mg

75.19192

00004038140 FUZEON ENFUVIRTIDE SUBCUTANEOUS ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (EA) 90 mg

44.94062

00003161412 BARACLUDE ENTECAVIR ORAL HEPATITIS B TREATMENT AGENTS SOLUTION, ORAL 0.05 mg/mL

2.84567

55513047801 EPOGEN EPOETIN ALFA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 20,000 unit/mL

317.87340

55513047810 EPOGEN EPOETIN ALFA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 20,000 unit/mL

317.87340

59676032000 PROCRIT EPOETIN ALFA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 20,000 unit/mL

317.87340

59676032004 PROCRIT EPOETIN ALFA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 20,000 unit/mL

317.87340

55513026701 EPOGEN EPOETIN ALFA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 3,000 unit/mL

47.67852

55513026710 EPOGEN EPOETIN ALFA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 3,000 unit/mL

47.67852

59676030300 PROCRIT EPOETIN ALFA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 3,000 unit/mL

47.67852

59676030301 PROCRIT EPOETIN ALFA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (ML) 3,000 unit/mL

47.67852

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NDC Label Generic Name SMAC Price

59676034000 PROCRIT EPOETIN ALFA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS VIAL (SDV,MDV OR ADDITIVE) (ML) 40,000 unit/mL

699.88920

59676057001 INTELENCE ETRAVIRINE ORAL ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI TABLET 100 mg

9.04742

00078062651 AFINITOR DISPERZ

EVEROLIMUS ORAL ANTINEOPLASTIC - MTOR KINASE INHIBITORS TABLET FOR SUSPENSION 2 mg

258.68280

00078062661 AFINITOR DISPERZ

EVEROLIMUS ORAL ANTINEOPLASTIC - MTOR KINASE INHIBITORS TABLET FOR SUSPENSION 2 mg

258.68280

00078062751 AFINITOR DISPERZ

EVEROLIMUS ORAL ANTINEOPLASTIC - MTOR KINASE INHIBITORS TABLET FOR SUSPENSION 3 mg

261.27420

00078062761 AFINITOR DISPERZ

EVEROLIMUS ORAL ANTINEOPLASTIC - MTOR KINASE INHIBITORS TABLET FOR SUSPENSION 3 mg

261.27420

00078062851 AFINITOR DISPERZ

EVEROLIMUS ORAL ANTINEOPLASTIC - MTOR KINASE INHIBITORS TABLET FOR SUSPENSION 5 mg

264.89080

00078062861 AFINITOR DISPERZ

EVEROLIMUS ORAL ANTINEOPLASTIC - MTOR KINASE INHIBITORS TABLET FOR SUSPENSION 5 mg

264.89080

68516320202 PROFILNINE FACTOR IX COMPLEX HUMAN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 (+/-) unit range

0.62217

68516320502 PROFILNINE FACTOR IX COMPLEX HUMAN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 (+/-) unit range

0.62217

68516320802 PROFILNINE FACTOR IX COMPLEX HUMAN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 (+/-) unit range

0.62217

68516320302 PROFILNINE FACTOR IX COMPLEX HUMAN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,500 (+/-) unit range

0.62000

68516320602 PROFILNINE FACTOR IX COMPLEX HUMAN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,500 (+/-) unit range

0.62000

68516320902 PROFILNINE FACTOR IX COMPLEX HUMAN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,500 (+/-) unit range

0.62000

68516320101 PROFILNINE FACTOR IX COMPLEX HUMAN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 (+/-) unit range

0.62217

68516320401 PROFILNINE FACTOR IX COMPLEX HUMAN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 (+/-) unit range

0.62217

68516320701 PROFILNINE FACTOR IX COMPLEX HUMAN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 (+/-) unit range

0.62217

00944303002 RIXUBIS FACTOR IX HUMAN RECOMBINANT INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 unit

1.10000

00944303202 RIXUBIS FACTOR IX HUMAN RECOMBINANT INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 2,000 unit

1.10000

00944302602 RIXUBIS FACTOR IX HUMAN RECOMBINANT INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 250 unit

1.10000

00944303402 RIXUBIS FACTOR IX HUMAN RECOMBINANT INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 3,000 unit

1.10000

00944302802 RIXUBIS FACTOR IX HUMAN RECOMBINANT INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 unit

1.10000

Page 39: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

70504028305 IXINITY FACTOR IX HUMAN RECOMBINANT, THREONINE 148 INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 unit

1.47408

70504028405 IXINITY FACTOR IX HUMAN RECOMBINANT, THREONINE 148 INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,500 unit

1.47408

70504028205 IXINITY FACTOR IX HUMAN RECOMBINANT, THREONINE 148 INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 unit

1.47408

68516360202 ALPHANINE SD FACTOR IX INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 (+/-) unit range

0.78521

68516360502 ALPHANINE SD FACTOR IX INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 (+/-) unit range

0.78521

68516360802 ALPHANINE SD FACTOR IX INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 (+/-) unit range

0.78521

68516360102 ALPHANINE SD FACTOR IX INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 (+/-) unit range

0.77000

68516360402 ALPHANINE SD FACTOR IX INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 (+/-) unit range

0.77000

68516360702 ALPHANINE SD FACTOR IX INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 (+/-) unit range

0.77000

71104092201 ALPROLIX FACTOR IX RECOMBINANT, FC FUSION PROTEIN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 unit

2.83860

71104093301 ALPROLIX FACTOR IX RECOMBINANT, FC FUSION PROTEIN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 2,000 unit

2.83860

71104094401 ALPROLIX FACTOR IX RECOMBINANT, FC FUSION PROTEIN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 3,000 unit

2.83860

71104091101 ALPROLIX FACTOR IX RECOMBINANT, FC FUSION PROTEIN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 unit

2.83860

69911086602 IDELVION FACTOR IX RECOMBINANT,ALBUMIN FUSION PROTEIN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 1,000 (+/-) unit range

3.94000

69911086702 IDELVION FACTOR IX RECOMBINANT,ALBUMIN FUSION PROTEIN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 2,000 (+/-) unit range

3.94000

69911086402 IDELVION FACTOR IX RECOMBINANT,ALBUMIN FUSION PROTEIN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 250 (+/-) unit range

3.94000

69911086502 IDELVION FACTOR IX RECOMBINANT,ALBUMIN FUSION PROTEIN INTRAVENOUS FACTOR IX PREPARATIONS VIAL (EA) 500 (+/-) unit range

3.94000

00054041413 FEBUXOSTAT FEBUXOSTAT ORAL HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS TABLET 80 mg

9.01679

00378392693 FEBUXOSTAT FEBUXOSTAT ORAL HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS TABLET 80 mg

9.01679

47335072283 FEBUXOSTAT FEBUXOSTAT ORAL HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS TABLET 80 mg

9.01679

51407029430 FEBUXOSTAT FEBUXOSTAT ORAL HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS TABLET 80 mg

9.01679

62332019130 FEBUXOSTAT FEBUXOSTAT ORAL HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS TABLET 80 mg

9.01679

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NDC Label Generic Name SMAC Price

72205002930 FEBUXOSTAT FEBUXOSTAT ORAL HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS TABLET 80 mg

9.01679

64764067730 ULORIC FEBUXOSTAT ORAL HYPERURICEMIA TX - XANTHINE OXIDASE INHIBITORS TABLET 80 mg

9.01679

63833089151 RIASTAP FIBRINOGEN INTRAVENOUS ANTIFIBRINOLYTIC AGENTS EACH 1 gram (900 mg-1,300 mg)

0.90636

63833089190 RIASTAP FIBRINOGEN INTRAVENOUS ANTIFIBRINOLYTIC AGENTS EACH 1 gram (900 mg-1,300 mg)

0.90636

55513020901 NEUPOGEN FILGRASTIM INJECTION LEUKOCYTE (WBC) STIMULANTS SYRINGE (ML) 480 mcg/0.8 mL

614.90550

55513020910 NEUPOGEN FILGRASTIM INJECTION LEUKOCYTE (WBC) STIMULANTS SYRINGE (ML) 480 mcg/0.8 mL

614.90550

55513020991 NEUPOGEN FILGRASTIM INJECTION LEUKOCYTE (WBC) STIMULANTS SYRINGE (ML) 480 mcg/0.8 mL

614.90550

55513053001 NEUPOGEN FILGRASTIM INJECTION LEUKOCYTE (WBC) STIMULANTS VIAL (SDV,MDV OR ADDITIVE) (ML) 300 mcg/mL

255.97200

55513053010 NEUPOGEN FILGRASTIM INJECTION LEUKOCYTE (WBC) STIMULANTS VIAL (SDV,MDV OR ADDITIVE) (ML) 300 mcg/mL

255.97200

55513054601 NEUPOGEN FILGRASTIM INJECTION LEUKOCYTE (WBC) STIMULANTS VIAL (SDV,MDV OR ADDITIVE) (ML) 480 mcg/1.6 mL

254.72700

55513054610 NEUPOGEN FILGRASTIM INJECTION LEUKOCYTE (WBC) STIMULANTS VIAL (SDV,MDV OR ADDITIVE) (ML) 480 mcg/1.6 mL

254.72700

49702020853 LEXIVA FOSAMPRENAVIR CALCIUM ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS SUSPENSION, ORAL (FINAL DOSE FORM) 50 mg/mL

0.50169

00378352091 FOSAMPRENAVIR CALCIUM

FOSAMPRENAVIR CALCIUM ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS TABLET 700 mg

15.58500

68135002001 NAGLAZYME GALSULFASE INTRAVENOUS METABOLIC DX ENZYME REPLACE, MUCOPOLYSACCHARIDOSIS VIAL (SDV,MDV OR ADDITIVE) (ML) 5 mg/5 mL

339.43680

00310048230 IRESSA GEFITINIB 56.50241

75987005006 RAVICTI GLYCEROL PHENYLBUTYRATE ORAL AMMONIA INHIBITORS LIQUID (ML) 1.1 gram/mL

150.81432

57894035001 SIMPONI ARIA GOLIMUMAB INTRAVENOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR VIAL (SDV,MDV OR ADDITIVE) (ML) 50 mg/4 mL (12.5 mg/mL)

286.35000

57894007102 SIMPONI GOLIMUMAB SUBCUTANEOUS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR PEN INJECTOR (ML) 100 mg/mL

2,716.81900

70720095130 ZOLADEX GOSERELIN ACETATE SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. IMPLANT (EA) 10.8 mg

1,123.47140

70720095036 ZOLADEX GOSERELIN ACETATE SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. IMPLANT (EA) 3.6 mg

374.48770

00597019705 PRAXBIND IDARUCIZUMAB INTRAVENOUS ANTICOAGULANT REVERSAL AGENTS VIAL (ML) 2.5 gram/50 mL

34.86000

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NDC Label Generic Name SMAC Price

61958170101 ZYDELIG IDELALISIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 100 mg

119.52000

61958170201 ZYDELIG IDELALISIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 150 mg

119.52000

54092070001 ELAPRASE IDURSULFASE INTRAVENOUS METABOLIC DX ENZYME REPLACE, MUCOPOLYSACCHARIDOSIS VIAL (ML) 6 mg/3 mL

1,001.05300

66215030300 VENTAVIS ILOPROST INHALATION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE AMPUL FOR NEBULIZATION (ML) 20 mcg/mL

69.22200

66215030330 VENTAVIS ILOPROST INHALATION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE AMPUL FOR NEBULIZATION (ML) 20 mcg/mL

69.22200

66215030200 VENTAVIS ILOPROST TROMETHAMINE INHALATION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE AMPUL FOR NEBULIZATION (ML) 10 mcg/mL

117.22920

66215030230 VENTAVIS ILOPROST TROMETHAMINE INHALATION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE AMPUL FOR NEBULIZATION (ML) 10 mcg/mL

117.22920

58468466301 CEREZYME IMIGLUCERASE INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DX VIAL (SDV,MDV OR ADDITIVE) (EA) 400 unit

1,579.65600

57894003001 REMICADE INFLIXIMAB INTRAVENOUS DRUGS TO TX CHRONIC INFLAMMATORY DISEASE OF COLON VIAL (SDV,MDV OR ADDITIVE) (EA) 100 mg

741.93700

00002850101 HUMULIN R U-500

INSULIN REGULAR, HUMAN SUBCUTANEOUS INSULINS VIAL (ML) 500 unit/mL (Concentrated)

68.67420

59627033304 AVONEX PEN INTERFERON BETA-1A INTRAMUSCULAR AGENTS TO TREAT MULTIPLE SCLEROSIS PEN INJECTOR KIT (EA) 30 mcg/0.5 mL

5,797.71600

44087002209 REBIF INTERFERON BETA-1A/ALBUMIN HUMAN SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS DISPOSABLE SYRINGE (ML) 22 mcg/0.5 mL

551.53500

44087882201 REBIF INTERFERON BETA-1A/ALBUMIN HUMAN SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS DISPOSABLE SYRINGE (ML) 8.8 mcg/0.2 mL (6) - 22 mcg/0.5 mL (6)

787.90714

00078056999 EXTAVIA INTERFERON BETA-1B SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS KIT 0.3 mg

290.61130

00078056961 EXTAVIA INTERFERON BETA-1B SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS VIAL (SDV,MDV OR ADDITIVE) (EA) 0.3 mg

253.82064

75987011110 ACTIMMUNE INTERFERON GAMMA-1B,RECOMB. SUBCUTANEOUS IMMUNOMODULATORS VIAL (ML) 100 mcg (2 million unit)/0.5 mL

7,191.10008

75987011111 ACTIMMUNE INTERFERON GAMMA-1B,RECOMB. SUBCUTANEOUS IMMUNOMODULATORS VIAL (ML) 100 mcg (2 million unit)/0.5 mL

7,191.10008

00003232822 YERVOY IPILIMUMAB INTRAVENOUS CYTOTOXIC T-LYMPHOCYTE ANTIGEN(CTLA-4)RMC ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 200 mg/40 mL (5 mg/mL)

597.60000

00003232711 YERVOY IPILIMUMAB INTRAVENOUS CYTOTOXIC T-LYMPHOCYTE ANTIGEN(CTLA-4)RMC ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 50 mg/10 mL (5 mg/mL)

597.60000

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NDC Label Generic Name SMAC Price

63020007801 NINLARO IXAZOMIB CITRATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 2.3 mg

2,874.44000

63020007802 NINLARO IXAZOMIB CITRATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 2.3 mg

2,874.44000

63020007901 NINLARO IXAZOMIB CITRATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 3 mg

2,874.44000

63020007902 NINLARO IXAZOMIB CITRATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 3 mg

2,874.44000

63020008001 NINLARO IXAZOMIB CITRATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 4 mg

2,874.44000

63020008002 NINLARO IXAZOMIB CITRATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 4 mg

2,874.44000

00002772401 TALTZ SYRINGE IXEKIZUMAB SUBCUTANEOUS ANTIPSORIATIC AGENTS,SYSTEMIC SYRINGE (ML) 80 mg/mL

4,087.23540

00002772411 TALTZ SYRINGE IXEKIZUMAB SUBCUTANEOUS ANTIPSORIATIC AGENTS,SYSTEMIC SYRINGE (ML) 80 mg/mL

4,087.23540

00173066300 EPIVIR HBV LAMIVUDINE ORAL HEPATITIS B TREATMENT AGENTS SOLUTION, ORAL 25 mg/5 mL (5 mg/mL)

0.63717

58468007001 ALDURAZYME LARONIDASE INTRAVENOUS METABOLIC DX ENZYME REPLACE, MUCOPOLYSACCHARIDOSIS VIAL (ML) 2.9 mg/5 mL

166.92000

59572040200 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 2.5 mg

534.72608

59572040228 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 2.5 mg

534.72608

59572042000 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 20 mg

534.72630

59572042021 REVLIMID LENALIDOMIDE ORAL ANTINEOPLASTIC IMMUNOMODULATOR AGENTS CAPSULE 20 mg

534.72630

62856071005 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 10 mg/day (10 mg [1]/day)

415.00000

62856071405 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 14 mg/day (10 mg [1]-4 mg [1]/day)

207.50000

62856072005 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 20 mg/day (10 mg [2]/day)

231.57000

62856072405 LENVIMA LENVATINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 24 mg/day (10 mg [2]-4 mg [1]/day)

154.38000

00074368303 LUPRON DEPOT

LEUPROLIDE ACETATE INTRAMUSCULAR ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. SYRINGE KIT (EA) 30 mg

4,068.96870

00074347303 LUPRON DEPOT

LEUPROLIDE ACETATE INTRAMUSCULAR ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. SYRINGE KIT (EA) 45 mg (6 month)

7,456.16556

00074228203 LUPRON DEPOT-PED

LEUPROLIDE ACETATE INTRAMUSCULAR LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY KIT 11.25 mg

1,586.93510

00074210803 LUPRON DEPOT-PED

LEUPROLIDE ACETATE INTRAMUSCULAR LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY KIT 7.5 mg

874.10620

Page 43: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00074377903 LUPRON DEPOT-PED

LEUPROLIDE ACETATE INTRAMUSCULAR LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY SYRINGE KIT (EA) 11.25 mg

4,760.82190

00074969403 LUPRON DEPOT-PED

LEUPROLIDE ACETATE INTRAMUSCULAR LHRH(GNRH)AGNST PIT.SUP-CENTRAL PRECOCIOUS PUBERTY SYRINGE KIT (EA) 30 mg

5,762.66676

62935022305 ELIGARD LEUPROLIDE ACETATE SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. DISPOSABLE SYRINGE (EA) 22.5 mg

1,228.06800

62935030330 ELIGARD LEUPROLIDE ACETATE SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. DISPOSABLE SYRINGE (EA) 30 mg

1,637.42400

62935045345 ELIGARD LEUPROLIDE ACETATE SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. DISPOSABLE SYRINGE (EA) 45 mg

2,456.13600

62935075375 ELIGARD LEUPROLIDE ACETATE SUBCUTANEOUS ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. DISPOSABLE SYRINGE (EA) 7.5 mg

409.35600

59767001601 PERTZYE LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 16,000 unit-57,500 unit-60,500 unit

3.93420

59767001602 PERTZYE LIPASE/PROTEASE/AMYLASE ORAL PANCREATIC ENZYMES CAPSULE,DELAYED RELEASE (ENTERIC COATED) 16,000 unit-57,500 unit-60,500 unit

3.93420

00074052260 KALETRA LOPINAVIR/RITONAVIR ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB TABLET 100 mg-25 mg

3.19118

52959096812 KALETRA LOPINAVIR/RITONAVIR ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMB TABLET 100 mg-25 mg

3.19118

66215050115 OPSUMIT MACITENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

227.08800

66215050130 OPSUMIT MACITENTAN ORAL PULMONARY ANTI-HTN, ENDOTHELIN RECEPTOR ANTAGONIST TABLET 10 mg

227.08800

00173088101 NUCALA MEPOLIZUMAB SUBCUTANEOUS MONOCLONAL ANTIBODY - INTERLEUKIN-5 ANTAGONISTS VIAL (EA) 100 mg

2,490.00000

54436001702 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 17.5 mg/0.4 mL

357.93750

54436001704 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 17.5 mg/0.4 mL

357.93750

54436002202 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 22.5 mg/0.4 mL

357.93750

54436002204 OTREXUP METHOTREXATE/PF SUBCUTANEOUS ANTI-ARTHRITIC, FOLATE ANTAGONIST AGENTS AUTO-INJECTOR (ML) 22.5 mg/0.4 mL

357.93750

59353040309 MIRCERA METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS SYRINGE (ML) 100 mcg/0.3 mL

597.60000

00004040509 MIRCERA METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS SYRINGE (ML) 200 mcg/0.3 mL

1,197.60000

59353040509 MIRCERA METHOXY POLYETHYLENE GLYCOL-EPOETIN BETA INJECTION ERYTHROPOIESIS-STIMULATING AGENTS SYRINGE (ML) 200 mcg/0.3 mL

1,197.60000

64406000801 TYSABRI NATALIZUMAB INTRAVENOUS LEUKOCYTE ADHESION INHIB,ALPHA4-MEDIAT IGG4K MC AB VIAL (ML) 300 mg/15 mL

310.68550

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NDC Label Generic Name SMAC Price

63010001030 VIRACEPT NELFINAVIR MESYLATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS TABLET 250 mg

3.23484

63010002770 VIRACEPT NELFINAVIR MESYLATE ORAL ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS TABLET 625 mg

8.08710

50242007001 GAZYVA OBINUTUZUMAB INTRAVENOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY VIAL (ML) 1,000 mg/40 mL

135.64773

00078081181 SANDOSTATIN LAR DEPOT

OCTREOTIDE ACETATE, MICROSPHERES INTRAMUSCULAR SOMATOSTATIC AGENTS VIAL (EA) 10 mg

2,536.78212

00078069061 ARZERRA OFATUMUMAB INTRAVENOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 1,000 mg/50 mL

87.64800

00078066913 ARZERRA OFATUMUMAB INTRAVENOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 100 mg/5 mL

87.64800

00078066961 ARZERRA OFATUMUMAB INTRAVENOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 100 mg/5 mL

87.64800

00517095501 OLANZAPINE OLANZAPINE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST VIAL (EA) 10 mg

29.58000

00781315972 OLANZAPINE OLANZAPINE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST VIAL (EA) 10 mg

29.58000

00781910572 OLANZAPINE OLANZAPINE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST VIAL (EA) 10 mg

29.58000

00002759701 ZYPREXA OLANZAPINE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST VIAL (EA) 10 mg

29.58000

00002763511 ZYPREXA RELPREVV

OLANZAPINE PAMOATE INTRAMUSCULAR ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG VIAL (SDV,MDV OR ADDITIVE) (EA) 210 mg

554.27400

00002765801 ZYPREXA RELPREVV

OLANZAPINE PAMOATE INTRAMUSCULAR ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG VIAL (SDV,MDV OR ADDITIVE) (EA) 210 mg

554.27400

00002763611 ZYPREXA RELPREVV

OLANZAPINE PAMOATE INTRAMUSCULAR ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG VIAL (SDV,MDV OR ADDITIVE) (EA) 300 mg

791.82000

00002765901 ZYPREXA RELPREVV

OLANZAPINE PAMOATE INTRAMUSCULAR ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG VIAL (SDV,MDV OR ADDITIVE) (EA) 300 mg

791.82000

00002763711 ZYPREXA RELPREVV

OLANZAPINE PAMOATE INTRAMUSCULAR ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG VIAL (SDV,MDV OR ADDITIVE) (EA) 405 mg

1,068.95700

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NDC Label Generic Name SMAC Price

00002766001 ZYPREXA RELPREVV

OLANZAPINE PAMOATE INTRAMUSCULAR ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG VIAL (SDV,MDV OR ADDITIVE) (EA) 405 mg

1,068.95700

63459017714 SYNRIBO OMACETAXINE MEPESUCCINATE SUBCUTANEOUS ANTINEOPLASTICS,MISCELLANEOUS VIAL (SDV,MDV OR ADDITIVE) (EA) 3.5 mg

831.66000

50242004062 XOLAIR OMALIZUMAB SUBCUTANEOUS MONOCLONAL ANTIBODIES TO IMMUNOGLOBULIN E (IGE) VIAL (SDV,MDV OR ADDITIVE) (EA) 150 mg

687.98700

00310134930 TAGRISSO OSIMERTINIB MESYLATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 40 mg

423.30000

50458060601 INVEGA TRINZA

PALIPERIDONE PALMITATE INTRAMUSCULAR ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST SYRINGE (ML) 273 mg/0.875 mL

2,399.47214

60574411301 SYNAGIS PALIVIZUMAB INTRAMUSCULAR ANTIVIRAL MONOCLONAL ANTIBODIES VIAL (ML) 100 mg/mL

2,618.62510

60574411401 SYNAGIS PALIVIZUMAB INTRAMUSCULAR ANTIVIRAL MONOCLONAL ANTIBODIES VIAL (ML) 50 mg/0.5 mL

2,773.54460

55513095401 VECTIBIX PANITUMUMAB INTRAVENOUS ANTINEOPLASTIC EGF RECEPTOR BLOCKER MCLON ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 100 mg/5 mL (20 mg/mL)

172.45740

55513095601 VECTIBIX PANITUMUMAB INTRAVENOUS ANTINEOPLASTIC EGF RECEPTOR BLOCKER MCLON ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 400 mg/20 mL (20 mg/mL)

177.45732

00944381001 ONCASPAR PEGASPARGASE INJECTION ANTINEOPLASTICS,MISCELLANEOUS VIAL (ML) 750 unit/mL

2,682.66020

00004035730 PEGASYS PEGINTERFERON ALFA-2A SUBCUTANEOUS HEPATITIS C TREATMENT AGENTS DISPOSABLE SYRINGE (ML) 180 mcg/0.5 mL

1,341.90000

00004035009 PEGASYS PEGINTERFERON ALFA-2A SUBCUTANEOUS HEPATITIS C TREATMENT AGENTS VIAL (SDV,MDV OR ADDITIVE) (ML) 180 mcg/mL

614.42410

00085434701 SYLATRON PEGINTERFERON ALFA-2B SUBCUTANEOUS ANTINEOPLASTIC IMMUNOMODULATOR AGENTS KIT 200 mcg

1,539.80604

00085434801 SYLATRON PEGINTERFERON ALFA-2B SUBCUTANEOUS ANTINEOPLASTIC IMMUNOMODULATOR AGENTS KIT 300 mcg

2,309.68416

00085435301 PEGINTRON PEGINTERFERON ALFA-2B SUBCUTANEOUS HEPATITIS C TREATMENT AGENTS KIT 50 mcg/0.5 mL

637.08100

64406001101 PLEGRIDY PEN PEGINTERFERON BETA-1A SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS PEN INJECTOR (ML) 125 mcg/0.5 mL

4,752.91200

64406001102 PLEGRIDY PEN PEGINTERFERON BETA-1A SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS PEN INJECTOR (ML) 125 mcg/0.5 mL

4,752.91200

64406001201 PLEGRIDY PEN PEGINTERFERON BETA-1A SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS PEN INJECTOR (ML) 63 mcg/0.5 mL (1)-94 mcg/0.5 mL (1)

4,752.91200

64406001501 PLEGRIDY PEGINTERFERON BETA-1A SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS SYRINGE (ML) 125 mcg/0.5 mL

4,752.91200

64406001502 PLEGRIDY PEGINTERFERON BETA-1A SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS SYRINGE (ML) 125 mcg/0.5 mL

4,752.91200

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NDC Label Generic Name SMAC Price

64406001601 PLEGRIDY PEGINTERFERON BETA-1A SUBCUTANEOUS AGENTS TO TREAT MULTIPLE SCLEROSIS SYRINGE (ML) 63 mcg/0.5 mL (1)-94 mcg/0.5 mL (1)

4,752.91200

50242014501 PERJETA PERTUZUMAB INTRAVENOUS ANTINEOPLASTIC EGF RECEPTOR BLOCKER MCLON ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 420 mg/14 mL (30 mg/mL)

289.95398

50242012101 ESBRIET PIRFENIDONE ORAL ANTIFIBROTIC THERAPY - PYRIDONE ANALOGS CAPSULE 267 mg

28.77332

00002766901 CYRAMZA RAMUCIRUMAB INTRAVENOUS ANTINEOPLASTIC - VEGFR ANTAGONIST VIAL (ML) 100 mg/10 mL (10 mg/mL)

101.59000

00002767801 CYRAMZA RAMUCIRUMAB INTRAVENOUS ANTINEOPLASTIC - VEGFR ANTAGONIST VIAL (ML) 500 mg/50 mL (10 mg/mL)

101.59000

59310061031 CINQAIR RESLIZUMAB INTRAVENOUS MONOCLONAL ANTIBODY - INTERLEUKIN-5 ANTAGONISTS VIAL (ML) 10 mg/mL

83.16600

66435010656 RIBASPHERE RIBAPAK

RIBAVIRIN ORAL HEPATITIS C TREATMENT AGENTS TABLET, DOSE PACK 600 mg (7)-400 mg (7)

24.48400

66435010756 RIBASPHERE RIBAPAK

RIBAVIRIN ORAL HEPATITIS C TREATMENT AGENTS TABLET, DOSE PACK 600 mg (7)-600 mg (7)

24.48400

10454071210 MYOBLOC RIMABOTULINUMTOXINB INTRAMUSCULAR NEUROMUSCULAR BLOCKING AGENTS VIAL (SDV,MDV OR ADDITIVE) (ML) 10,000 unit/2 mL

521.90400

10454071110 MYOBLOC RIMABOTULINUMTOXINB INTRAMUSCULAR NEUROMUSCULAR BLOCKING AGENTS VIAL (SDV,MDV OR ADDITIVE) (ML) 5,000 unit/mL

521.90400

50419025001 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 0.5 mg

82.99900

50419025003 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 0.5 mg

82.99900

50419025091 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 0.5 mg

82.99900

50419025101 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 1 mg

82.99900

50419025103 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 1 mg

82.99900

50419025191 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 1 mg

82.99900

50419025201 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 1.5 mg

82.99900

50419025203 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 1.5 mg

82.99900

50419025291 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 1.5 mg

82.99900

50419025301 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 2 mg

82.99900

50419025303 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 2 mg

82.99900

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NDC Label Generic Name SMAC Price

50419025391 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 2 mg

82.99900

50419025401 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 2.5 mg

82.99900

50419025403 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 2.5 mg

82.99900

50419025491 ADEMPAS RIOCIGUAT ORAL PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASE STIMULATOR TABLET 2.5 mg

82.99900

50242005110 RITUXAN RITUXIMAB INTRAVENOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 10 mg/mL

64.72605

50242005121 RITUXAN RITUXIMAB INTRAVENOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 10 mg/mL

64.72605

50242005306 RITUXAN RITUXIMAB INTRAVENOUS ANTI-CD20 (B LYMPHOCYTE) MONOCLONAL ANTIBODY VIAL (SDV,MDV OR ADDITIVE) (ML) 10 mg/mL

64.72605

55513022101 NPLATE ROMIPLOSTIM SUBCUTANEOUS THROMBOPOIETIN RECEPTOR AGONISTS VIAL (SDV,MDV OR ADDITIVE) (EA) 250 mcg

1,221.59400

55513022201 NPLATE ROMIPLOSTIM SUBCUTANEOUS THROMBOPOIETIN RECEPTOR AGONISTS VIAL (SDV,MDV OR ADDITIVE) (EA) 500 mcg

2,320.87920

68135030002 KUVAN SAPROPTERIN DIHYDROCHLORIDE ORAL PKU TX AGENT-COFACTOR OF PHENYLALANINE HYDROXYLASE TABLET, SOLUBLE 100 mg

31.52340

00024584301 LEUKINE SARGRAMOSTIM INJECTION LEUKOCYTE (WBC) STIMULANTS VIAL (SDV,MDV OR ADDITIVE) (EA) 250 mcg

169.97736

00024584305 LEUKINE SARGRAMOSTIM INJECTION LEUKOCYTE (WBC) STIMULANTS VIAL (SDV,MDV OR ADDITIVE) (EA) 250 mcg

169.97736

25682000701 KANUMA SEBELIPASE ALFA INTRAVENOUS METABOLIC DX ENZYME REPLACEMENT,LYSO.ACID LIP.DEF. VIAL (ML) 20 mg/10 mL (2 mg/mL)

996.00000

57894042001 SYLVANT SILTUXIMAB INTRAVENOUS ANTINEOPLASTIC-INTERLEUKIN-6(IL-6)INHIB,ANTIBODY VIAL (EA) 100 mg

829.66800

57894042101 SYLVANT SILTUXIMAB INTRAVENOUS ANTINEOPLASTIC-INTERLEUKIN-6(IL-6)INHIB,ANTIBODY VIAL (EA) 400 mg

3,318.67200

00002814801 HUMATROPE SOMATROPIN INJECTION GROWTH HORMONES CARTRIDGE (EA) 12 mg (36 unit)

895.80240

00002814901 HUMATROPE SOMATROPIN INJECTION GROWTH HORMONES CARTRIDGE (EA) 24 mg (72 unit)

1,791.60480

00002814701 HUMATROPE SOMATROPIN INJECTION GROWTH HORMONES CARTRIDGE (EA) 6 mg (18 unit)

447.90120

00013264681 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES CARTRIDGE (EA) 12 mg/mL (36 unit/mL)

954.51600

44087001601 SAIZEN-SAIZENPREP

SOMATROPIN SUBCUTANEOUS GROWTH HORMONES CARTRIDGE (EA) 8.8 mg/1.5 mL (Final concentration)

596.48780

00781300107 OMNITROPE SOMATROPIN SUBCUTANEOUS GROWTH HORMONES CARTRIDGE (ML) 5 mg/1.5 mL (3.3 mg/mL)

333.11552

00013264902 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES DISPOSABLE SYRINGE (EA) 0.2 mg/0.25 mL

15.15106

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NDC Label Generic Name SMAC Price

00013265002 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES DISPOSABLE SYRINGE (EA) 0.4 mg/0.25 mL

36.41376

00013265102 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES DISPOSABLE SYRINGE (EA) 0.6 mg/0.25 mL

45.45199

00013265202 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES DISPOSABLE SYRINGE (EA) 0.8 mg/0.25 mL

60.60186

00013265302 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES DISPOSABLE SYRINGE (EA) 1 mg/0.25 mL

75.75291

00013265402 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES DISPOSABLE SYRINGE (EA) 1.2 mg/0.25 mL

90.90397

00013265502 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES DISPOSABLE SYRINGE (EA) 1.4 mg/0.25 mL

106.05266

00013265602 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES DISPOSABLE SYRINGE (EA) 1.6 mg/0.25 mL

121.20134

00013265702 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES DISPOSABLE SYRINGE (EA) 1.8 mg/0.25 mL

136.35477

00013265802 GENOTROPIN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES DISPOSABLE SYRINGE (EA) 2 mg/0.25 mL

151.50464

00169770321 NORDITROPIN FLEXPRO

SOMATROPIN SUBCUTANEOUS GROWTH HORMONES PEN INJECTOR (ML) 30 mg/3 mL (10 mg/mL)

948.78960

44087100502 SAIZEN SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (EA) 5 mg 288.84000

44087000501 SEROSTIM SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (EA) 5 mg 288.84000

44087000507 SEROSTIM SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (EA) 5 mg 288.84000

55566180101 ZOMACTON SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (EA) 5 mg 288.84000

00781400436 OMNITROPE SOMATROPIN SUBCUTANEOUS GROWTH HORMONES VIAL (SDV,MDV OR ADDITIVE) (EA) 5.8 mg

201.31956

00069098038 SUTENT SUNITINIB MALATE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS CAPSULE 50 mg

524.98300

00069010601 ELELYSO TALIGLUCERASE ALFA INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DX VIAL (SDV,MDV OR ADDITIVE) (EA) 200 unit

592.62000

55513007801 IMLYGIC TALIMOGENE LAHERPAREPVEC INJECTION ANTINEOPLASTIC - IMMUNOTHERAPY, VIRUS-BASED AGENTS VIAL (ML) 10exp6 (1 million) PFU/mL

43.82400

55513007901 IMLYGIC TALIMOGENE LAHERPAREPVEC INJECTION ANTINEOPLASTIC - IMMUNOTHERAPY, VIRUS-BASED AGENTS VIAL (ML) 10exp8 (100 million) PFU/mL

4,382.40000

61958040301 VIREAD TENOFOVIR DISOPROXIL FUMARATE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI POWDER (GRAM) 40 mg/scoop (40 mg/gram)

7.10729

61958040401 VIREAD TENOFOVIR DISOPROXIL FUMARATE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI TABLET 150 mg

24.16074

61958040501 VIREAD TENOFOVIR DISOPROXIL FUMARATE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI TABLET 200 mg

24.16074

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NDC Label Generic Name SMAC Price

61958040601 VIREAD TENOFOVIR DISOPROXIL FUMARATE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI TABLET 250 mg

24.16074

58468021101 AUBAGIO TERIFLUNOMIDE ORAL AGENTS TO TREAT MULTIPLE SCLEROSIS TABLET 7 mg

123.13191

58468021104 AUBAGIO TERIFLUNOMIDE ORAL AGENTS TO TREAT MULTIPLE SCLEROSIS TABLET 7 mg

123.13191

59572022016 THALOMID THALIDOMIDE ORAL ANTILEPROTICS CAPSULE (HARD, SOFT, ETC.) 200 mg

279.49656

59572022096 THALOMID THALIDOMIDE ORAL ANTILEPROTICS CAPSULE (HARD, SOFT, ETC.) 200 mg

279.49656

59572020514 THALOMID THALIDOMIDE ORAL ANTILEPROTICS CAPSULE (HARD, SOFT, ETC.) 50 mg 151.23591

59572020517 THALOMID THALIDOMIDE ORAL ANTILEPROTICS CAPSULE (HARD, SOFT, ETC.) 50 mg 151.23591

59572020594 THALOMID THALIDOMIDE ORAL ANTILEPROTICS CAPSULE (HARD, SOFT, ETC.) 50 mg 151.23591

59572020597 THALOMID THALIDOMIDE ORAL ANTILEPROTICS CAPSULE (HARD, SOFT, ETC.) 50 mg 151.23591

60793020505 THROMBIN-JMI

THROMBIN (BOVINE) NASAL TOPICAL HEMOSTATICS NASAL SPRAY SYRINGE (EA) 5,000 unit

72.91716

00597000302 APTIVUS TIPRANAVIR ORAL ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB CAPSULE (HARD, SOFT, ETC.) 250 mg

9.23472

00597000201 APTIVUS TIPRANAVIR/VITAMIN E TPGS ORAL ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB SOLUTION, ORAL 100 mg/mL

3.88816

00781717175 TOBRAMYCIN TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/5 mL

26.10163

43598060556 TOBRAMYCIN TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/5 mL

26.10163

65162091446 TOBRAMYCIN TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/5 mL

26.10163

68180096204 TOBRAMYCIN TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/5 mL

26.10163

68180096256 TOBRAMYCIN TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/5 mL

26.10163

00078049461 TOBI TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/5 mL

26.10163

00078049471 TOBI TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/5 mL

26.10163

00093408563 TOBRAMYCIN TOBRAMYCIN IN 0.225 % SODIUM CHLORIDE INHALATION AMINOGLYCOSIDES AMPUL FOR NEBULIZATION (ML) 300 mg/5 mL

26.10163

00078063019 TOBI PODHALER

TOBRAMYCIN INHALATION AMINOGLYCOSIDES CAPSULE, WITH INHALATION DEVICE 28 mg

39.40674

00078063035 TOBI PODHALER

TOBRAMYCIN INHALATION AMINOGLYCOSIDES CAPSULE, WITH INHALATION DEVICE 28 mg

39.40674

50242013601 ACTEMRA TOCILIZUMAB INTRAVENOUS INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (ML) 200 mg/10 mL (20 mg/mL)

68.77961

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NDC Label Generic Name SMAC Price

50242013701 ACTEMRA TOCILIZUMAB INTRAVENOUS INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (ML) 400 mg/20 mL (20 mg/mL)

68.77961

50242013501 ACTEMRA TOCILIZUMAB INTRAVENOUS INTERLEUKIN-6 (IL-6) RECEPTOR INHIBITORS VIAL (SDV,MDV OR ADDITIVE) (ML) 80 mg/4 mL (20 mg/mL)

68.77795

42747032730 FARESTON TOREMIFENE CITRATE ORAL SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM) TABLET 60 mg

25.64700

64980040403 TOREMIFENE CITRATE

TOREMIFENE CITRATE ORAL SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM) TABLET 60 mg

25.64700

59676061001 YONDELIS TRABECTEDIN INTRAVENOUS ANTINEOPLASTIC - TOPOISOMERASE I INHIBITORS VIAL (EA) 1 mg

2,689.20000

00078066815 MEKINIST TRAMETINIB DIMETHYL SULFOXIDE ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 2 mg

334.36848

66302020603 TYVASO TREPROSTINIL INHALATION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE AMPUL FOR NEBULIZATION (ML) 1.74 mg/2.9 mL (0.6 mg/mL)

148.60344

66302011001 REMODULIN TREPROSTINIL SODIUM INJECTION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE VIAL (ML) 10 mg/mL

459.81000

00703069601 TREPROSTINIL TREPROSTINIL SODIUM INJECTION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE VIAL (ML) 10 mg/mL

459.81000

00781343080 TREPROSTINIL TREPROSTINIL SODIUM INJECTION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE VIAL (ML) 10 mg/mL

459.81000

42023020901 TREPROSTINIL TREPROSTINIL SODIUM INJECTION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE VIAL (ML) 10 mg/mL

459.81000

66302020602 TYVASO REFILL KIT

TREPROSTINIL/NEBULIZER ACCESSORIES INHALATION PULMONARY ANTIHYPERTENSIVES, PROSTACYCLIN-TYPE AMPUL FOR NEBULIZATION (ML) 1.74 mg/2.9 mL (0.6 mg/mL)

148.60344

58468782003 CAPRELSA VANDETANIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 100 mg

164.34000

58468784003 CAPRELSA VANDETANIB ORAL ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS TABLET 300 mg

328.68000

64764030020 ENTYVIO VEDOLIZUMAB INTRAVENOUS INTEGRIN RECEPTOR ANTAGONIST, MONOCLONAL ANTIBODY VIAL (EA) 300 mg

4,799.72400

54092070104 VPRIV VELAGLUCERASE ALFA INTRAVENOUS METABOLIC DISEASE ENZYME REPLACEMENT, GAUCHER'S DX VIAL (SDV,MDV OR ADDITIVE) (EA) 400 unit

1,344.60000

00074056111 VENCLEXTA VENETOCLAX ORAL ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS TABLET 10 mg

7.93314

00074056114 VENCLEXTA VENETOCLAX ORAL ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS TABLET 10 mg

7.93314

00074057611 VENCLEXTA VENETOCLAX ORAL ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS TABLET 100 mg

79.34625

00074057622 VENCLEXTA VENETOCLAX ORAL ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS TABLET 100 mg

79.34625

Page 51: Minnesota State Maximum Allowable Cost (SMAC) Specialty ...Specialty Drug List Updated 12/16/2019 NDC Label Generic Name SMAC Price 49702023113 TRIUMEQ ABACAVIR SULFATE/DOLUTEGRAVIR

NDC Label Generic Name SMAC Price

00074057634 VENCLEXTA VENETOCLAX ORAL ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS TABLET 100 mg

79.34625

00074056607 VENCLEXTA VENETOCLAX ORAL ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS TABLET 50 mg

39.67352

00074056611 VENCLEXTA VENETOCLAX ORAL ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS TABLET 50 mg

39.67352

00074057928 VENCLEXTA STARTING PACK

VENETOCLAX ORAL ANTINEOPLASTIC-B CELL LYMPHOMA-2(BCL-2) INHIBITORS TABLET, DOSE PACK 10 mg (14)-50 mg (7)-100 mg (21)

48.93015

20536032201 MARQIBO VINCRISTINE SULFATE LIPOSOMAL INTRAVENOUS ANTINEOPLASTIC - VINCA ALKALOIDS KIT 5 mg/31 mL (0.16 mg/mL) (final concentration)

9,711.00000

50242014001 ERIVEDGE VISMODEGIB ORAL ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITOR CAPSULE (HARD, SOFT, ETC.) 150 mg

266.78571

00944755302 VONVENDI VON WILLEBRAND FACTOR (RECOMBINANT) INTRAVENOUS BLOOD FACTORS,MISCELLANEOUS VIAL (EA) 1,300 (+/-) unit range

1.97208

00944755102 VONVENDI VON WILLEBRAND FACTOR (RECOMBINANT) INTRAVENOUS BLOOD FACTORS,MISCELLANEOUS VIAL (EA) 650 (+/-) unit range

1.97208

49702021248 RETROVIR ZIDOVUDINE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI SYRUP 10 mg/mL

0.15000

65862004824 ZIDOVUDINE ZIDOVUDINE ORAL ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI SYRUP 10 mg/mL

0.15000

00049120301 GEODON ZIPRASIDONE MESYLATE INTRAMUSCULAR ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG VIAL (SDV,MDV OR ADDITIVE) (EA) 20 mg

16.79837

00049120310 GEODON ZIPRASIDONE MESYLATE INTRAMUSCULAR ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG VIAL (SDV,MDV OR ADDITIVE) (EA) 20 mg

16.79837

00049392020 GEODON ZIPRASIDONE MESYLATE INTRAMUSCULAR ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG VIAL (SDV,MDV OR ADDITIVE) (EA) 20 mg

16.79837

00049392083 GEODON ZIPRASIDONE MESYLATE INTRAMUSCULAR ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG VIAL (SDV,MDV OR ADDITIVE) (EA) 20 mg

16.79837