West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 0.9 % SODIUM CHLORIDE PGY VL PRT 0.07096 0.07291 2/22/2013 0.9 % SODIUM CHLORIDE 0.9 % IV SOLN 0.00000 0.00174 12/1/2012 0.9 % SODIUM CHLORIDE 0.9 % VIAL 0.04800 0.05830 1/25/2013 ABACAVIR SULFATE 300 MG TABLET 7.03103 6.36133 2/15/2013 ACARBOSE 100 MG TABLET 0.52380 0.52381 2/15/2013 ACARBOSE 25 MG TABLET 0.47800 0.47798 2/15/2013 ACARBOSE 50 MG TABLET 0.49810 0.49808 2/15/2013 ACEBUTOLOL HCL 200 MG CAPSULE 0.21353 0.21350 12/14/2012 ACEBUTOLOL HCL 400 MG CAPSULE 0.00000 0.45180 1/25/2013 ACETAMINOPHEN 100 MG/ML DROPS 0.00000 0.15340 12/1/2012 ACETAMINOPHEN 120 MG SUPP.RECT 0.16289 0.16290 12/14/2012 ACETAMINOPHEN 160 MG/5ML ELIXIR 0.01085 0.01090 12/14/2012 ACETAMINOPHEN 160 MG/5ML LIQUID 0.00970 0.00950 1/25/2013 ACETAMINOPHEN 160 MG/5ML ORAL SUSP 0.02410 0.02251 2/1/2013 ACETAMINOPHEN 325 MG SUPP.RECT 0.00000 0.45850 12/1/2012 ACETAMINOPHEN 325 MG TABLET 0.00616 0.00830 1/25/2013 ACETAMINOPHEN 500 MG CAPSULE 0.03448 0.02940 1/25/2013 ACETAMINOPHEN 500 MG TABLET 0.00950 0.00951 2/1/2013 ACETAMINOPHEN 650 MG SUPP.RECT 0.21683 0.21680 12/14/2012 ACETAMINOPHEN 80 MG TAB CHEW 0.04854 0.04850 12/14/2012 ACETAMINOPHEN 80 MG TAB RAPDIS 0.00000 0.05113 12/1/2012 ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION 0.00000 0.15890 12/1/2012 ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION 0.01487 0.01490 12/14/2012 ACETAMINOPHEN WITH CODEINE 240-24/10 SOLUTION 0.08525 0.08530 12/14/2012 ACETAMINOPHEN WITH CODEINE 300MG-15MG TABLET 0.14090 0.14200 2/8/2013 ACETAMINOPHEN WITH CODEINE 300MG-30MG TABLET 0.12415 0.10690 12/14/2012 ACETAMINOPHEN WITH CODEINE 300MG-60MG TABLET 0.00000 0.22820 12/1/2012 ACETAMINOPHEN WITH CODEINE 300MG/12.5 SOLUTION 0.07500 0.04760 1/25/2013 ACETAMINOPHEN WITH CODEINE 360-36/15 SOLUTION 0.06620 0.04150 1/25/2013 ACETAMINOPHEN/DIPHENHYDRAMINE 325-12.5MG TABLET 0.15370 0.15400 1/25/2013 ACETAMINOPHEN/DIPHENHYDRAMINE 500MG-25MG TABLET 0.00000 0.03653 12/1/2012 ACETAMINOPHEN/DP-HYDRAMINE 500MG-38MG TABLET 0.10563 0.11550 1/25/2013 ACETAZOLAMIDE 125 MG TABLET 0.38950 0.46732 2/15/2013 ACETAZOLAMIDE 250 MG TABLET 0.53750 0.57212 2/15/2013 ACETAZOLAMIDE 500 MG CAPSULE ER 3.00454 3.00400 1/25/2013 ACETIC ACID 0.25 % IRRIG SOLN 0.00322 0.00270 1/25/2013 ACETIC ACID 2 % SOLUTION 1.03260 1.70070 2/1/2013 ACETIC ACID/ALUMINUM ACETATE 2 % DROPS 0.00000 0.84000 12/1/2012 ACETIC ACID/HYDROCORTISONE 2 %-1 % DROPS 0.00000 9.82215 12/1/2012 ACETYL/METHYL-B12/LMEFOLATE CA 600-2-6 MG TABLET 1.86527 1.23520 1/25/2013 ACETYLCYSTEINE 100 MG/ML VIAL 0.24110 0.25700 1/25/2013 ACETYLCYSTEINE 200 MG/ML VIAL 0.00000 5.26400 12/1/2012 ACYCLOVIR 200 MG CAPSULE 0.10620 0.10616 2/22/2013 ACYCLOVIR 200 MG/5ML ORAL SUSP 0.16860 0.16775 2/22/2013 ACYCLOVIR 800 MG TABLET 0.26850 0.26819 2/22/2013 ACYCLOVIR SODIUM 1000 MG VIAL 7.68600 9.04800 1/25/2013 ACYCLOVIR SODIUM 50 MG/ML VIAL 0.00000 2.85501 12/1/2012 ADAPALENE 0.1 % CREAM (G) 0.00000 3.66909 12/1/2012 ADAPALENE 0.1 % GEL (GRAM) 0.00000 3.05760 12/1/2012 ALBUMIN HUMAN 25 % IV SOLN 0.90300 0.91240 1/25/2013 ALBUMIN HUMAN 25 % VIAL 1.51200 1.54350 1/25/2013 ALBUMIN HUMAN 5 % IV SOLN 0.21000 0.21150 1/25/2013 ALBUTEROL SULFATE 0.63MG/3ML VIAL-NEB 0.00000 0.37527 12/1/2012 ALBUTEROL SULFATE 1.25MG/3ML VIAL-NEB 0.00000 0.37674 12/1/2012 Page 1 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 ALBUTEROL SULFATE 2 MG TABLET 0.14480 0.14470 1/25/2013 ALBUTEROL SULFATE 2 MG/5 ML SYRUP 0.01268 0.01270 12/14/2012 ALBUTEROL SULFATE 2.5 MG/0.5 VIAL-NEB 0.64220 0.64672 2/22/2013 ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB 0.05490 0.05487 2/1/2013 ALBUTEROL SULFATE 4 MG TAB ER 12H 0.86170 0.98160 2/8/2013 ALBUTEROL SULFATE 4 MG TABLET 0.20558 0.20560 12/14/2012 ALBUTEROL SULFATE 5 MG/ML SOLUTION 0.00000 0.54600 12/1/2012 ALBUTEROL SULFATE 8 MG TAB ER 12H 1.82767 1.84058 12/14/2012 ALCLOMETASONE DIPROPIONATE 0.05 % CREAM (G) 0.56414 0.56410 12/14/2012 ALCLOMETASONE DIPROPIONATE 0.05 % OINT. (G) 0.58692 0.58690 12/14/2012 ALENDRONATE SODIUM 10 MG TABLET 0.18747 0.18750 12/14/2012 ALENDRONATE SODIUM 35 MG TABLET 0.00000 0.69010 12/1/2012 ALENDRONATE SODIUM 40 MG TABLET 6.63531 6.63530 12/14/2012 ALENDRONATE SODIUM 5 MG TABLET 0.18150 0.18110 1/25/2013 ALENDRONATE SODIUM 70 MG TABLET 0.71360 0.69010 1/25/2013 ALFUZOSIN HCL 10 MG TAB ER 24H 0.22726 0.22040 1/25/2013 ALLOPURINOL 100 MG TABLET 0.03685 0.03690 12/14/2012 ALLOPURINOL 300 MG TABLET 0.06646 0.06650 12/14/2012 ALPHA LIPOIC ACID 200 MG CAPSULE 0.09765 0.10000 1/25/2013 ALPHA LIPOIC ACID 50 MG CAPSULE 0.04900 0.10210 1/25/2013 ALPRAZOLAM 0.25 MG TAB RAPDIS 0.00000 1.28921 12/1/2012 ALPRAZOLAM 0.25 MG TABLET 0.01541 0.01540 12/14/2012 ALPRAZOLAM 0.5 MG TAB ER 24H 0.33259 0.33260 12/14/2012 ALPRAZOLAM 0.5 MG TAB RAPDIS 0.00000 1.51669 12/1/2012 ALPRAZOLAM 0.5 MG TABLET 0.01809 0.01810 12/14/2012 ALPRAZOLAM 1 MG TAB ER 24H 0.43081 0.43080 12/14/2012 ALPRAZOLAM 1 MG TAB RAPDIS 0.00000 2.02358 12/1/2012 ALPRAZOLAM 1 MG TABLET 0.00000 0.02010 12/1/2012 ALPRAZOLAM 2 MG TAB ER 24H 0.38600 0.57960 12/21/2012 ALPRAZOLAM 2 MG TAB RAPDIS 0.00000 3.00202 12/1/2012 ALPRAZOLAM 2 MG TABLET 0.04090 0.04087 2/22/2013 ALPRAZOLAM 3 MG TAB ER 24H 0.79700 0.79340 1/25/2013 ALUM/SALICYLIC ACID/TALC/BENT POWDER 0.06733 0.06740 1/25/2013 ALUMINUM HYDROXIDE OINT. (G) 0.00000 0.06484 12/1/2012 AMANTADINE HCL 100 MG CAPSULE 0.00000 1.36390 12/1/2012 AMANTADINE HCL 100 MG TABLET 0.92490 1.24870 2/1/2013 AMANTADINE HCL 50 MG/5 ML SYRUP 0.01740 0.01970 1/25/2013 AMCINONIDE 0.1 % CREAM (G) 3.29673 2.82140 1/25/2013 AMCINONIDE 0.1 % LOTION 3.80018 1.90000 1/25/2013 AMCINONIDE 0.1 % OINT. (G) 4.53600 2.26800 1/25/2013 AMIKACIN SULFATE 100 MG/2ML VIAL 0.00000 2.90325 12/1/2012 AMIKACIN SULFATE 1000MG/4ML VIAL 0.00000 2.74505 12/1/2012 AMIKACIN SULFATE 500 MG/2ML VIAL 1.97400 2.24760 1/25/2013 AMILORIDE HCL 5 MG TABLET 0.58045 0.60654 2/22/2013 AMILORIDE/HYDROCHLOROTHIAZIDE 5MG-50MG TABLET 0.24130 0.24680 1/25/2013 AMINO ACIDS POWDER 0.53784 0.25540 1/25/2013 AMINOCAPROIC ACID 1000 MG TABLET 16.95015 18.30610 12/21/2012 AMINOCAPROIC ACID 250 MG/ML SOLUTION 1.08423 1.11560 1/25/2013 AMINOCAPROIC ACID 500 MG TABLET 2.03918 2.10790 1/25/2013 AMINOPHYLLINE 250MG/10ML AMPUL 0.05712 0.05540 1/25/2013 AMINOPHYLLINE 250MG/10ML VIAL 0.10836 0.10840 1/25/2013 AMINOPHYLLINE 500MG/20ML VIAL 0.07266 0.07270 1/25/2013 AMIODARONE HCL 200 MG TABLET 0.16281 0.16280 12/14/2012 AMIODARONE HCL 400 MG TABLET 6.08860 3.70417 2/15/2013 Page 2 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 AMIODARONE HCL 50 MG/ML AMPUL 0.27720 0.33600 1/25/2013 AMITRIP HCL/CHLORDIAZEPOXIDE 12.5MG-5MG TABLET 0.73458 0.77870 1/25/2013 AMITRIP HCL/CHLORDIAZEPOXIDE 25 MG-10MG TABLET 1.03640 1.09860 1/25/2013 AMITRIPTYLINE HCL 10 MG TABLET 0.02000 0.01970 1/25/2013 AMITRIPTYLINE HCL 100 MG TABLET 0.05507 0.05510 12/14/2012 AMITRIPTYLINE HCL 150 MG TABLET 0.10760 0.09920 1/25/2013 AMITRIPTYLINE HCL 25 MG TABLET 0.02265 0.02270 12/14/2012 AMITRIPTYLINE HCL 50 MG TABLET 0.02747 0.02750 12/14/2012 AMITRIPTYLINE HCL 75 MG TABLET 0.00000 0.04690 12/1/2012 AMLODIPINE BESYLATE 10 MG TABLET 0.02533 0.02530 1/25/2013 AMLODIPINE BESYLATE 2.5 MG TABLET 0.02104 0.01980 1/25/2013 AMLODIPINE BESYLATE 5 MG TABLET 0.02170 0.02131 2/15/2013 AMLODIPINE BESYLATE/BENAZEPRIL 10MG-20MG CAPSULE 0.86484 0.86480 12/14/2012 AMLODIPINE BESYLATE/BENAZEPRIL 10MG-40MG CAPSULE 0.97485 0.97470 1/25/2013 AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG CAPSULE 1.69273 1.69270 12/14/2012 AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-10 MG CAPSULE 0.00000 0.81700 12/1/2012 AMLODIPINE BESYLATE/BENAZEPRIL 5MG-20MG CAPSULE 0.82477 0.82480 12/14/2012 AMLODIPINE BESYLATE/BENAZEPRIL 5MG-40MG CAPSULE 0.00000 0.80695 12/1/2012 AMLODIPINE/ATORVASTATIN 10MG-10MG TABLET 0.00000 3.52613 12/1/2012 AMLODIPINE/ATORVASTATIN 10MG-20MG TABLET 4.82420 4.82418 2/8/2013 AMLODIPINE/ATORVASTATIN 10MG-40MG TABLET 4.82430 4.82425 2/8/2013 AMLODIPINE/ATORVASTATIN 10MG-80MG TABLET 4.82417 4.82430 1/25/2013 AMLODIPINE/ATORVASTATIN 2.5MG-10MG TABLET 3.52621 3.52616 2/22/2013 AMLODIPINE/ATORVASTATIN 2.5MG-20MG TABLET 4.82421 4.82420 2/22/2013 AMLODIPINE/ATORVASTATIN 2.5MG-40MG TABLET 4.82417 4.82420 1/25/2013 AMLODIPINE/ATORVASTATIN 5 MG-10 MG TABLET 0.00000 3.52617 12/1/2012 AMLODIPINE/ATORVASTATIN 5MG-20MG TABLET 4.82421 4.82420 1/25/2013 AMLODIPINE/ATORVASTATIN 5MG-40MG TABLET 4.82421 4.82420 1/25/2013 AMLODIPINE/ATORVASTATIN 5MG-80MG TABLET 4.82421 4.82420 12/21/2012 AMMONIUM ALUM/TALC/BENTONITE POWDER 0.07538 0.07530 1/25/2013 AMMONIUM CHLORIDE 5MEQ/ML VIAL 0.28522 0.42630 1/25/2013 AMMONIUM LACTATE 12 % CREAM (G) 0.03501 0.03670 12/14/2012 AMMONIUM LACTATE 12 % LOTION 0.01943 0.01940 12/14/2012 AMOXAPINE 100 MG TABLET 0.00000 0.72280 12/1/2012 AMOXAPINE 150 MG TABLET 0.00000 1.28830 12/1/2012 AMOXAPINE 25 MG TABLET 0.00000 0.27027 12/1/2012 AMOXAPINE 50 MG TABLET 0.40846 0.40850 12/14/2012 AMOXICILLIN 125 MG TAB CHEW 0.00000 0.15067 12/1/2012 AMOXICILLIN 125 MG/5ML SUSP RECON 0.01849 0.01850 12/14/2012 AMOXICILLIN 200 MG/5ML SUSP RECON 0.02840 0.02880 1/25/2013 AMOXICILLIN 250 MG CAPSULE 0.06258 0.06260 12/14/2012 AMOXICILLIN 250 MG/5ML SUSP RECON 0.02320 0.02318 2/1/2013 AMOXICILLIN 400 MG/5ML SUSP RECON 0.03002 0.03000 12/14/2012 AMOXICILLIN 500 MG CAPSULE 0.09018 0.09020 12/14/2012 AMOXICILLIN 500 MG TABLET 0.00000 0.28243 12/1/2012 AMOXICILLIN 875MG TABLET 0.18412 0.18410 12/14/2012 AMOXICILLIN/POTASSIUM CLAV 1000-62.5 TAB ER 12H 2.58600 2.71530 2/8/2013 AMOXICILLIN/POTASSIUM CLAV 200-28.5/5 SUSP RECON 0.11030 0.10960 1/25/2013 AMOXICILLIN/POTASSIUM CLAV 200-28.5MG TAB CHEW 0.97341 0.96700 1/25/2013 AMOXICILLIN/POTASSIUM CLAV 400-57MG TAB CHEW 1.40043 1.40040 12/14/2012 AMOXICILLIN/POTASSIUM CLAV 400-57MG/5 SUSP RECON 0.16060 0.16063 2/1/2013 AMOXICILLIN/POTASSIUM CLAV 500-125 MG TABLET 1.25730 1.24476 2/22/2013 AMOXICILLIN/POTASSIUM CLAV 600-42.9/5 SUSP RECON 0.00000 0.21300 12/1/2012 AMOXICILLIN/POTASSIUM CLAV 875-125 MG TABLET 1.03113 1.03110 12/14/2012 Page 3 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 AMPHOTERICIN B 50 MG VIAL 0.00000 12.76000 12/1/2012 AMPICILLIN SODIUM 1 G VIAL 0.00000 2.89120 12/1/2012 AMPICILLIN SODIUM 1 G VIAL PORT 0.00000 12.52460 12/1/2012 AMPICILLIN SODIUM 10 G VIAL 0.00000 40.47315 12/1/2012 AMPICILLIN SODIUM 125 MG VIAL 3.65400 3.50250 1/25/2013 AMPICILLIN SODIUM 2 G VIAL 0.00000 4.74500 12/1/2012 AMPICILLIN SODIUM 2 G VIAL PORT 0.00000 23.62640 12/1/2012 AMPICILLIN SODIUM 250 MG VIAL 0.00000 1.41638 12/1/2012 AMPICILLIN SODIUM 500 MG VIAL 0.00000 1.62006 12/1/2012 AMPICILLIN SODIUM/SULBACTAM NA 1.5 G VIAL 0.00000 2.20296 12/1/2012 AMPICILLIN SODIUM/SULBACTAM NA 1.5 G VIAL PORT 0.00000 3.24240 1/11/2013 AMPICILLIN SODIUM/SULBACTAM NA 15 G VIAL 0.00000 21.31500 12/1/2012 AMPICILLIN SODIUM/SULBACTAM NA 3 G VIAL 0.00000 4.18470 12/1/2012 AMPICILLIN SODIUM/SULBACTAM NA 3 G VIAL PORT 0.00000 5.22060 1/11/2013 AMPICILLIN TRIHYDRATE 125 MG/5ML SUSP RECON 0.03530 0.03950 2/8/2013 AMPICILLIN TRIHYDRATE 250 MG CAPSULE 0.08999 0.09000 12/14/2012 AMPICILLIN TRIHYDRATE 250 MG/5ML SUSP RECON 0.05200 0.06860 2/8/2013 AMPICILLIN TRIHYDRATE 500 MG CAPSULE 0.00000 0.14370 12/1/2012 ANAGRELIDE HCL 0.5 MG CAPSULE 0.00000 0.22620 12/1/2012 ANAGRELIDE HCL 1 MG CAPSULE 0.43732 0.43730 12/14/2012 ANASTROZOLE 1 MG TABLET 0.15142 0.15140 12/14/2012 ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4 %-1.4% DROPS 0.57710 0.57013 2/22/2013 ANTIVENIN,LATRODECTUS MACTANS COMBO. PKG 0.00000 28.66500 12/1/2012 ANTIVENIN,MICRURUS FULVIUS COMBO. PKG 0.00000 1,496.32000 12/1/2012 APRACLONIDINE HCL 0.5 % DROPS 0.00000 12.32550 12/1/2012 ARGATROBAN 100 MG/ML VIAL 1,319.78700 1,124.62000 1/25/2013 ARGATROBAN IN 0.9 % SOD CHLOR 125 MG/125 VIAL 0.00000 11.61817 12/1/2012 ARGININE 500 MG CAPSULE 0.08120 0.08060 1/25/2013 ARGININE HCL 1000 MG TABLET 0.14760 0.13360 1/25/2013 ASCORBIC ACID 1000 MG TABLET 0.05570 0.05571 2/8/2013 ASCORBIC ACID 1000 MG TABLET ER 0.00000 0.05330 12/1/2012 ASCORBIC ACID 250 MG TAB CHEW 0.02522 0.02510 1/25/2013 ASCORBIC ACID 250 MG TABLET 0.01788 0.01670 1/25/2013 ASCORBIC ACID 500 MG TAB CHEW 0.00000 0.04453 12/1/2012 ASCORBIC ACID 500 MG TABLET 0.02198 0.02280 1/25/2013 ASPIRIN 325 MG TABLET 0.00804 0.00800 12/14/2012 ASPIRIN 325 MG TABLET DR 0.00858 0.00860 12/14/2012 ASPIRIN 81 MG TAB CHEW 0.02194 0.02200 1/25/2013 ASPIRIN 81 MG TABLET DR 0.00720 0.00724 2/1/2013 ASPIRIN/ACETAMINOPHEN/CAFFEINE 250-250-65 TABLET 0.00000 0.04476 12/1/2012 ASPIRIN/CALCIUM CARBONATE/MAG 325 MG TABLET 0.00000 0.02015 12/1/2012 ASPIRIN/SOD BICARB/CITRIC ACID 325-1916MG TABLET EFF 0.08770 0.07967 2/8/2013 ATENOLOL 100 MG TABLET 0.00000 0.03400 12/1/2012 ATENOLOL 25 MG TABLET 0.01420 0.01330 1/25/2013 ATENOLOL 50 MG TABLET 0.01690 0.01640 1/25/2013 ATENOLOL/CHLORTHALIDONE 100MG-25MG TABLET 0.16820 0.16830 1/25/2013 ATENOLOL/CHLORTHALIDONE 50 MG-25MG TABLET 0.10530 0.10570 1/25/2013 ATORVASTATIN CALCIUM 10 MG TABLET 0.00000 0.55680 12/1/2012 ATORVASTATIN CALCIUM 20 MG TABLET 0.00000 0.79430 12/1/2012 ATORVASTATIN CALCIUM 40 MG TABLET 0.00000 0.79430 12/1/2012 ATORVASTATIN CALCIUM 80 MG TABLET 0.00000 0.95320 12/1/2012 ATOVAQUONE/PROGUANIL HCL 250-100 MG TABLET 5.00300 5.00297 2/22/2013 ATOVAQUONE/PROGUANIL HCL 62.5-25MG TABLET 0.00000 1.85045 12/1/2012 ATROPINE SULFATE 0.05MG/ML DISP SYRIN 0.00000 2.23272 12/1/2012 Page 4 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 ATROPINE SULFATE 0.1 MG/ML DISP SYRIN 0.00000 0.43014 12/1/2012 ATROPINE SULFATE 0.4 MG/ML VIAL 1.02665 0.85480 1/25/2013 ATROPINE SULFATE 1 % DROPS 1.39710 1.76890 2/1/2013 ATROPINE SULFATE 1 % OINT. (G) 3.06200 3.98000 2/8/2013 ATROPINE SULFATE 1 MG/ML VIAL 1.48447 1.50320 1/25/2013 AZATHIOPRINE 50 MG TABLET 0.15938 0.15940 12/14/2012 AZATHIOPRINE SODIUM 100 MG VIAL 8.98980 10.56045 12/14/2012 AZELASTINE HCL 0.05 % DROPS 0.00000 11.59817 12/1/2012 AZELASTINE HCL 137 MCG SPRAY/PUMP 0.00000 2.41583 12/1/2012 AZITHROMYCIN 1 G PACKET 0.00000 13.46447 12/1/2012 AZITHROMYCIN 100 MG/5ML SUSP RECON 0.79589 0.79590 12/14/2012 AZITHROMYCIN 200 MG/5ML SUSP RECON 0.00000 0.71130 1/25/2012 AZITHROMYCIN 250 MG TABLET 0.61200 0.61940 2/8/2013 AZITHROMYCIN 500 MG TABLET 0.00000 1.78220 12/1/2012 AZITHROMYCIN 500 MG VIAL 0.00000 3.97150 12/1/2012 AZITHROMYCIN 500 MG VIAL PORT 0.00000 12.68820 12/1/2012 AZITHROMYCIN 600 MG TABLET 3.25871 3.25870 12/14/2012 AZTREONAM 1 G VIAL 0.00000 27.67800 12/1/2012 AZTREONAM 2 G VIAL 0.00000 56.23800 12/1/2012 B COMPLEX WITH VITAMIN C TABLET 0.00000 0.02613 12/1/2012 BACITRACIN 500 UNIT/G OINT. (G) 0.00000 13.86800 12/1/2012 BACITRACIN 500 UNIT/G OINT. (G) 0.06639 0.06640 12/14/2012 BACITRACIN ZINC 500 UNIT/G OINT. (G) 0.00000 0.10720 12/1/2012 BACITRACIN/POLYMYXIN B SULFATE 500-10K/G OINT. (G) 0.00000 0.27376 12/1/2012 BACITRACIN/POLYMYXIN B SULFATE 500-10K/G OINT. (G) 3.37025 3.37030 12/14/2012 BACLOFEN 10 MG TABLET 0.04380 0.04382 2/15/2013 BACLOFEN 100 % POWDER 0.00000 3.64650 12/1/2012 BACLOFEN 20 MG TABLET 0.08200 0.08060 1/25/2013 BALSALAZIDE DISODIUM 750 MG CAPSULE 0.24639 0.24640 1/25/2013 BCG LIVE 50 MG VIAL 0.00000 291.39600 12/1/2012 BENAZEPRIL HCL 10 MG TABLET 0.05186 0.05190 12/14/2012 BENAZEPRIL HCL 20 MG TABLET 0.05507 0.05510 12/14/2012 BENAZEPRIL HCL 40 MG TABLET 0.06941 0.06940 12/14/2012 BENAZEPRIL HCL 5 MG TABLET 0.04904 0.04900 12/14/2012 BENAZEPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.44670 0.43940 1/25/2013 BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.44700 0.44400 1/25/2013 BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.45310 0.44810 1/25/2013 BENAZEPRIL/HYDROCHLOROTHIAZIDE 5-6.25MG TABLET 0.00000 0.45890 12/1/2012 BENZOCAINE/MENTHOL 15MG-3.6MG LOZENGE 0.10327 0.12198 2/8/2013 BENZONATATE 100 MG CAPSULE 0.00000 0.09072 12/1/2012 BENZONATATE 200 MG CAPSULE 0.00000 0.13306 12/1/2012 BENZOYL PEROXIDE 10 % CLEANSER 0.06330 0.04190 1/25/2013 BENZOYL PEROXIDE 10 % GEL (GRAM) 0.18950 0.19200 1/25/2013 BENZOYL PEROXIDE 4.25 % CLEANSER 0.00000 0.17892 12/1/2012 BENZOYL PEROXIDE 5 % CLEANSER 0.04760 0.04757 2/1/2013 BENZOYL PEROXIDE 5 % GEL (GRAM) 0.18364 0.18360 12/14/2012 BENZOYL PEROXIDE 5.3% FOAM 0.00000 2.02384 12/1/2012 BENZOYL PEROXIDE 9.8 % FOAM 0.00000 1.61098 12/1/2012 BENZPHETAMINE HCL 50 MG TABLET 0.00000 0.47918 12/1/2012 BENZTROPINE MESYLATE 0.5 MG TABLET 0.00000 0.04770 12/1/2012 BENZTROPINE MESYLATE 1 MG TABLET 0.04931 0.04930 12/14/2012 BENZTROPINE MESYLATE 2 MG TABLET 0.06713 0.06710 12/14/2012 BENZTROPINE MESYLATE 2 MG/2 ML AMPUL 0.00000 23.40625 12/1/2012 BENZTROPINE MESYLATE 2 MG/2 ML VIAL 0.00000 40.39560 12/1/2012 Page 5 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 BETAMET ACET/BETAMET NA PH 6 MG/ML VIAL 0.00000 5.60000 12/1/2012 BETAMET DIPROP/PROP GLY 0.05 % CREAM (G) 0.25916 0.25920 12/14/2012 BETAMET DIPROP/PROP GLY 0.05 % LOTION 0.00000 0.70578 12/1/2012 BETAMETHASONE DIPROPIONATE 0.05 % CREAM (G) 1.04840 1.36200 2/1/2013 BETAMETHASONE DIPROPIONATE 0.05 % GEL (GRAM) 1.59404 1.21450 1/25/2013 BETAMETHASONE DIPROPIONATE 0.05 % LOTION 0.23550 0.54060 2/1/2013 BETAMETHASONE DIPROPIONATE 0.05 % OINT. (G) 1.59530 1.63323 2/22/2013 BETAMETHASONE VALERATE 0.1 % CREAM (G) 0.59220 0.60742 2/22/2013 BETAMETHASONE VALERATE 0.1 % LOTION 0.79430 0.35000 1/25/2013 BETAMETHASONE VALERATE 0.12 % FOAM 0.00000 2.71317 1/25/2013 BETAXOLOL HCL 0.5 % DROPS 0.00000 7.27680 12/1/2012 BETAXOLOL HCL 10 MG TABLET 0.70620 0.72400 2/15/2013 BETHANECHOL CHLORIDE 10 MG TABLET 0.07812 0.07810 12/14/2012 BETHANECHOL CHLORIDE 25 MG TABLET 0.16134 0.16130 12/14/2012 BETHANECHOL CHLORIDE 5 MG TABLET 0.05548 0.05550 12/14/2012 BETHANECHOL CHLORIDE 50 MG TABLET 0.32150 0.45410 2/8/2013 BICALUTAMIDE 50 MG TABLET 0.32321 0.32320 12/14/2012 BIOFLAV,LEMON/VIT BCOMP&C 200-100 MG TABLET 0.00000 0.14285 12/1/2012 BIOTIN 2500MCG CAPSULE 0.08104 0.09390 1/25/2013 BISACODYL 10 MG SUPP.RECT 0.00000 0.09487 12/1/2012 BISACODYL 5 MG TABLET DR 0.00000 0.00951 12/1/2012 BISMUTH SUBSALICYLATE 262 MG TAB CHEW 0.07430 0.06890 1/25/2013 BISMUTH SUBSALICYLATE 262MG/15ML ORAL SUSP 0.00737 0.00740 1/25/2013 BISMUTH SUBSALICYLATE 525MG/15ML ORAL SUSP 0.00000 0.01099 12/1/2012 BISOPROLOL FUMARATE 10 MG TABLET 0.29170 0.29920 1/25/2013 BISOPROLOL FUMARATE 5 MG TABLET 0.29170 0.29920 1/25/2013 BISOPROLOL FUMARATE/HCTZ 10-6.25MG TABLET 0.06340 0.06060 1/25/2013 BISOPROLOL FUMARATE/HCTZ 2.5-6.25MG TABLET 0.05830 0.05910 1/25/2013 BISOPROLOL FUMARATE/HCTZ 5-6.25MG TABLET 0.00000 0.37000 12/1/2012 BRIMONIDINE TARTRATE 0.15 % DROPS 12.45300 13.44910 1/25/2013 BRIMONIDINE TARTRATE 0.2 % DROPS 0.58424 0.58420 12/14/2012 BROMFENAC SODIUM 0.09% DROPS 37.45560 40.47120 2/8/2013 BROMOCRIPTINE MESYLATE 2.5 MG TABLET 0.00000 1.07776 12/1/2012 BROMOCRIPTINE MESYLATE 5 MG CAPSULE 0.00000 3.23180 12/1/2012 BROMPHENIRAMIN/PE/DEXTROMETHOR 1-2.5-5/5 SOLUTION 0.00000 0.02385 12/1/2012 BROMPHENIRAMIN/PE/DEXTROMETHOR 4-10-20/5 LIQUID 0.00000 0.11830 12/1/2012 BROMPHENIRAMIN/PE/DEXTROMETHOR 4-7.5-15/5 LIQUID 0.09481 0.08550 1/25/2013 BUDESONIDE 0.25MG/2ML AMPUL-NEB 3.02400 3.29490 2/22/2013 BUDESONIDE 0.5 MG/2ML AMPUL-NEB 3.55640 3.87765 2/22/2013 BUDESONIDE 3 MG CAPDR & ER 11.98525 11.98500 1/25/2013 BUMETANIDE 0.25 MG/ML VIAL 0.00000 0.26572 12/1/2012 BUMETANIDE 0.5 MG TABLET 0.07600 0.06990 1/25/2013 BUMETANIDE 1 MG TABLET 0.08230 0.08370 1/25/2013 BUMETANIDE 2 MG TABLET 0.09836 0.09840 12/14/2012 BUPIVACAINE HCL 2.5 MG/ML VIAL 0.04183 0.04200 1/25/2013 BUPIVACAINE HCL 5 MG/ML VIAL 0.00000 0.05090 12/1/2012 BUPIVACAINE HCL/EPINEPHRINE 0.25-.0005 VIAL 0.00000 0.12253 12/1/2012 BUPIVACAINE HCL/EPINEPHRINE 0.5-1:200K CARTRIDGE 0.27533 0.26130 1/25/2013 BUPIVACAINE HCL/EPINEPHRINE 0.5-1:200K VIAL 0.00000 0.11900 12/1/2012 BUPIVACAINE HCL/EPINEPHRINE/PF 0.25-.0005 VIAL 0.00000 0.27733 12/1/2012 BUPIVACAINE HCL/EPINEPHRINE/PF 0.5-1:200K VIAL 0.00000 0.25992 12/1/2012 BUPIVACAINE HCL/PF 2.5 MG/ML AMPUL 0.11788 0.11790 1/25/2013 BUPIVACAINE HCL/PF 2.5 MG/ML VIAL 0.00000 0.06646 12/1/2012 BUPIVACAINE HCL/PF 5 MG/ML AMPUL 0.08685 0.08690 1/25/2013 Page 6 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 BUPIVACAINE HCL/PF 5 MG/ML VIAL 0.05068 0.05100 1/25/2013 BUPIVACAINE HCL/PF 7.5 MG/ML AMPUL 0.00000 0.10478 12/1/2012 BUPIVACAINE HCL/PF 7.5 MG/ML VIAL 0.00000 0.14727 12/1/2012 BUPRENORPHINE HCL 0.3 MG/ML DISP SYRIN 8.12070 12.18000 1/25/2013 BUPRENORPHINE HCL 2 MG TAB SUBL 1.64260 1.62020 1/25/2013 BUPRENORPHINE HCL 8 MG TAB SUBL 2.79190 2.81880 2/22/2013 BUPROPION HCL 100 MG TABLET 0.42760 0.34760 2/22/2013 BUPROPION HCL 100 MG TABLET ER 0.24656 0.24660 12/14/2012 BUPROPION HCL 150 MG TAB ER 24H 0.80110 0.64762 2/22/2013 BUPROPION HCL 150 MG TABLET ER 0.28247 0.28250 12/14/2012 BUPROPION HCL 150 MG TABLET ER 0.52270 0.56248 2/22/2013 BUPROPION HCL 200 MG TABLET ER 0.50357 0.50360 12/14/2012 BUPROPION HCL 300 MG TAB ER 24H 0.85358 0.85360 12/14/2012 BUPROPION HCL 75 MG TABLET 0.00000 0.40820 12/1/2012 BUSPIRONE HCL 10 MG TABLET 0.06419 0.06420 1/25/2013 BUSPIRONE HCL 15 MG TABLET 0.10291 0.10290 12/14/2012 BUSPIRONE HCL 30 MG TABLET 0.67937 0.67880 1/25/2013 BUSPIRONE HCL 5 MG TABLET 0.04449 0.04450 12/14/2012 BUSPIRONE HCL 7.5 MG TABLET 1.84422 1.84460 1/25/2013 BUTALB/ACETAMINOPHEN/CAFFEINE 50-325-40 TABLET 0.00000 0.05990 12/1/2012 BUTALB/ACETAMINOPHEN/CAFFEINE 50-500-40 TABLET 0.06352 0.06350 12/14/2012 BUTALBIT/ACETAMIN/CAFF/CODEINE 50-325-30 CAPSULE 0.28609 0.28610 12/14/2012 BUTALBITAL/ACETAMINOPHEN 50MG-325MG TABLET 0.00000 0.26453 12/1/2012 BUTALBITAL/ACETAMINOPHEN 50MG-650MG TABLET 0.69720 1.35760 2/1/2013 BUTALBITAL/ASPIRIN/CAFFEINE 50-325-40 CAPSULE 0.36350 0.34702 2/22/2013 BUTALBITAL/ASPIRIN/CAFFEINE 50-325-40 TABLET 0.10295 0.10300 12/14/2012 BUTENAFINE HCL 1 % CREAM (G) 0.00000 0.40179 12/1/2012 BUTORPHANOL TARTRATE 1 MG/ML VIAL 0.00000 1.94300 12/1/2012 BUTORPHANOL TARTRATE 10 MG/ML SPRAY 4.68429 4.68430 12/14/2012 BUTORPHANOL TARTRATE 2 MG/ML VIAL 0.00000 1.94300 12/1/2012 CABERGOLINE 0.5 MG TABLET 15.29063 15.29060 12/14/2012 CAFFEINE CITRATED 60 MG/3 ML SOLUTION 4.81689 6.70190 1/25/2013 CAFFEINE CITRATED 60 MG/3 ML VIAL 0.00000 4.29429 12/1/2012 CAFFEINE/SODIUM BENZOATE 250 MG/ML VIAL 3.77000 2.73000 1/25/2013 CALCIPOTRIENE 0.005 % CREAM (G) 5.02770 4.93520 1/25/2013 CALCIPOTRIENE 0.005 % OINT. (G) 0.00000 4.22205 12/1/2012 CALCIPOTRIENE 0.005 % SOLUTION 3.91644 3.92430 1/25/2013 CALCITONIN,SALMON,SYNTHETIC 200/DOSE SPRAY/PUMP 0.00000 13.67625 12/1/2012 CALCITRIOL 0.25 MCG CAPSULE 0.00000 0.52970 12/1/2012 CALCITRIOL 0.5 MCG CAPSULE 1.17683 1.17680 12/14/2012 CALCITRIOL 1MCG/ML AMPUL 0.00000 4.68130 12/1/2012 CALCITRIOL 1MCG/ML SOLUTION 7.03043 7.00450 1/25/2013 CALCITRIOL 3MCG/G OINT. (G) 0.00000 10.42220 12/1/2012 CALCIUM ACETATE 667 MG CAPSULE 0.00000 0.60520 12/1/2012 CALCIUM ACETATE 667 MG TABLET 0.00000 0.08750 12/1/2012 CALCIUM ACETATE/ALUMINUM SULF 839-1191MG POWD PACK 0.00000 0.50621 12/1/2012 CALCIUM ACETATE/ALUMINUM SULF 952-1347MG POWD PACK 0.67677 0.72740 1/25/2013 CALCIUM CARBONATE 200(500)MG TAB CHEW 0.00000 0.01353 12/1/2012 CALCIUM CARBONATE 300MG(750) TAB CHEW 0.00000 0.02330 12/1/2012 CALCIUM CARBONATE 500 MG/5ML ORAL SUSP 0.00000 0.01799 12/1/2012 CALCIUM CARBONATE 500(1250) TAB CHEW 0.04429 0.03420 1/25/2013 CALCIUM CARBONATE 500(1250) TABLET 0.01434 0.01430 12/14/2012 CALCIUM CARBONATE 600 MG TABLET 0.00000 0.02144 12/1/2012 CALCIUM CARBONATE/VITAMIN D2 250 MG-125 TABLET 0.01841 0.02170 1/25/2013 Page 7 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CALCIUM CARBONATE/VITAMIN D3 250 MG-125 TABLET 0.00000 0.01032 12/1/2012 CALCIUM CARBONATE/VITAMIN D3 500 MG-200 TABLET 0.00000 0.01273 12/1/2012 CALCIUM CARBONATE/VITAMIN D3 500 MG-400 TABLET 0.03049 0.02790 1/25/2013 CALCIUM CARBONATE/VITAMIN D3 500 MG-600 TAB CHEW 0.00000 0.17903 12/1/2012 CALCIUM CARBONATE/VITAMIN D3 600 MG-200 TABLET 0.00000 0.01899 12/1/2012 CALCIUM CARBONATE/VITAMIN D3 600 MG-400 CAPSULE 0.05516 0.04580 1/25/2013 CALCIUM CARBONATE/VITAMIN D3 600 MG-400 TAB CHEW 0.07946 0.09660 1/25/2013 CALCIUM CARBONATE/VITAMIN D3 600 MG-400 TABLET 0.01960 0.01956 2/15/2013 CALCIUM CHLORIDE 100 MG/ML DISP SYRIN 0.50020 0.47124 2/1/2013 CALCIUM CHLORIDE 100 MG/ML VIAL 0.00000 0.17500 12/1/2012 CALCIUM CITRATE 200(950)MG TABLET 0.05593 0.03070 1/25/2013 CALCIUM CITRATE 250 MG TABLET 0.00000 0.05565 12/1/2012 CALCIUM CITRATE/VITAMIN D3 200 MG-250 TABLET 0.03894 0.04220 1/25/2013 CALCIUM CITRATE/VITAMIN D3 315 MG-200 TABLET 0.05724 0.04370 1/25/2013 CALCIUM CITRATE/VITAMIN D3 315 MG-250 TABLET 0.04481 0.04700 1/25/2013 CALCIUM POLYCARBOPHIL 625 MG TABLET 0.00000 0.05896 12/1/2012 CANDESARTAN/HYDROCHLOROTHIAZID 16-12.5MG TABLET 0.00000 2.86251 12/14/2012 CANDESARTAN/HYDROCHLOROTHIAZID 32-12.5MG TABLET 0.00000 2.91948 12/14/2012 CANDESARTAN/HYDROCHLOROTHIAZID 32MG-25MG TABLET 0.00000 3.15928 12/14/2012 CAPSAICIN 0.025 % CREAM (G) 0.06673 0.06590 1/25/2013 CAPSAICIN 0.075 % CREAM (G) 0.00000 0.08472 12/1/2012 CAPSAICIN/ME-SALICYLATE/MENTH 0.002%-20% LOTION 0.00000 2.36327 12/1/2012 CAPTOPRIL 100 % POWDER 33.69341 56.85764 2/22/2013 CAPTOPRIL 100 MG TABLET 0.06980 0.07480 1/25/2013 CAPTOPRIL 12.5 MG TABLET 0.01313 0.01310 12/14/2012 CAPTOPRIL 25 MG TABLET 0.01943 0.01940 1/25/2013 CAPTOPRIL 50 MG TABLET 0.02950 0.02948 2/15/2013 CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-25MG TABLET 0.29705 0.29710 12/14/2012 CAPTOPRIL/HYDROCHLOROTHIAZIDE 50 MG-15MG TABLET 0.86296 0.86300 12/14/2012 CARBAMAZEPINE 100 MG CPMP 12HR 1.25787 1.26685 2/22/2013 CARBAMAZEPINE 100 MG TAB CHEW 0.05701 0.05700 12/14/2012 CARBAMAZEPINE 200 MG CPMP 12HR 1.27160 1.25110 2/8/2013 CARBAMAZEPINE 200 MG TAB ER 12H 0.68100 0.67900 1/25/2013 CARBAMAZEPINE 200 MG TABLET 0.04569 0.04570 12/14/2012 CARBAMAZEPINE 300 MG CPMP 12HR 1.27348 1.25110 2/22/2013 CARBAMAZEPINE 400 MG TAB ER 12H 0.00000 1.55680 12/1/2012 CARBAMIDE PEROXIDE 6.5 % DROPS 0.00000 0.12690 12/1/2012 CARBIDOPA/LEVODOPA 10MG-100MG TAB RAPDIS 0.00000 0.77305 12/1/2012 CARBIDOPA/LEVODOPA 10MG-100MG TABLET 0.14686 0.14690 12/14/2012 CARBIDOPA/LEVODOPA 25MG-100MG TAB RAPDIS 0.87334 0.86710 1/25/2013 CARBIDOPA/LEVODOPA 25MG-100MG TABLET 0.13802 0.13800 12/14/2012 CARBIDOPA/LEVODOPA 25MG-100MG TABLET ER 0.31500 0.35941 2/22/2013 CARBIDOPA/LEVODOPA 25MG-250MG TAB RAPDIS 1.11111 1.10100 1/25/2013 CARBIDOPA/LEVODOPA 25MG-250MG TABLET 0.18653 0.18650 12/14/2012 CARBIDOPA/LEVODOPA 50MG-200MG TABLET ER 0.00000 0.72000 11/1/2012 CARBIDOPA/LEVODOPA/ENTACAPONE 12.5-50MG TABLET 0.00000 2.62406 12/1/2012 CARBIDOPA/LEVODOPA/ENTACAPONE 18.75-75MG TABLET 0.00000 2.62406 12/1/2012 CARBIDOPA/LEVODOPA/ENTACAPONE 25-100-200 TABLET 0.00000 2.62406 12/1/2012 CARBIDOPA/LEVODOPA/ENTACAPONE 31.25-125 TABLET 0.00000 2.62406 12/1/2012 CARBIDOPA/LEVODOPA/ENTACAPONE 37.5-150MG TABLET 0.00000 2.62406 12/1/2012 CARBIDOPA/LEVODOPA/ENTACAPONE 50-200-200 TABLET 0.00000 2.62406 12/1/2012 CARBINOXAMINE MALEATE 4 MG TABLET 0.00000 0.49602 12/1/2012 CARBINOXAMINE MALEATE 4 MG/5 ML LIQUID 0.00000 0.09112 12/1/2012 CARBOXYMETHYLCELLULOSE SODIUM 0.5 % DROPERETTE 0.20588 0.19940 1/25/2013 Page 8 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CARBOXYMETHYLCELLULOSE SODIUM 0.5 % DROPS 0.28694 0.32289 2/15/2013 CARISOPRODOL 250 MG TABLET 2.22150 2.31410 2/8/2013 CARISOPRODOL 350 MG TABLET 0.06350 0.06352 2/1/2013 CARISOPRODOL/ASPIRIN 200-325 MG TABLET 1.66120 1.52430 1/25/2013 CARTEOLOL HCL 1 % DROPS 0.00000 1.17210 12/1/2012 CARVEDILOL 12.5 MG TABLET 0.04167 0.04170 12/14/2012 CARVEDILOL 25 MG TABLET 0.04904 0.04860 12/14/2012 CARVEDILOL 3.125 MG TABLET 0.04234 0.04060 12/14/2012 CARVEDILOL 6.25 MG TABLET 0.05080 0.03890 1/25/2013 CASTOR OIL OIL 0.00000 0.05545 12/1/2012 CEFACLOR 125 MG/5ML SUSP RECON 0.00000 0.68231 12/1/2012 CEFACLOR 250 MG CAPSULE 0.00000 1.39260 12/1/2012 CEFACLOR 250 MG/5ML SUSP RECON 0.00000 1.36453 12/1/2012 CEFACLOR 375 MG/5ML SUSP RECON 0.00000 2.04680 12/1/2012 CEFACLOR 500 MG CAPSULE 1.61041 1.61040 12/14/2012 CEFACLOR 500 MG TAB ER 12H 0.00000 3.48600 12/1/2012 CEFADROXIL HYDRATE 1 G TABLET 0.00000 2.32518 12/1/2012 CEFADROXIL HYDRATE 250 MG/5ML SUSP RECON 0.00000 0.36218 12/1/2012 CEFADROXIL HYDRATE 500 MG CAPSULE 0.31383 0.31380 12/14/2012 CEFADROXIL HYDRATE 500 MG/5ML SUSP RECON 0.56459 0.46350 1/25/2013 CEFAZOLIN SODIUM 1 G VIAL 0.87320 0.90290 1/25/2013 CEFAZOLIN SODIUM 1 G VIAL PORT 0.00000 4.26300 12/1/2012 CEFAZOLIN SODIUM 10 G VIAL 0.00000 7.51332 12/1/2012 CEFAZOLIN SODIUM 500 MG VIAL 0.00000 1.03662 12/1/2012 CEFAZOLIN SODIUM/DEXTROSE,ISO 1 G/50 ML FROZ.PIGGY 0.12224 0.23170 1/25/2013 CEFAZOLIN SODIUM/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.00000 0.20427 12/1/2012 CEFAZOLIN SODIUM/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 17.93574 12/1/2012 CEFDINIR 125 MG/5ML SUSP RECON 0.46900 0.52740 12/14/2012 CEFDINIR 250 MG/5ML SUSP RECON 0.91321 0.98740 12/14/2012 CEFDINIR 300 MG CAPSULE 2.05768 2.05770 12/14/2012 CEFDITOREN PIVOXIL 200 MG TABLET 0.00000 10.31835 12/1/2012 CEFEPIME HCL 1 G VIAL 5.26810 5.31940 1/25/2013 CEFEPIME HCL 2 G VIAL 0.00000 8.69760 12/1/2012 CEFEPIME HCL/D5W 1 G/50 ML PIGGYBACK 0.00000 0.55476 12/1/2012 CEFEPIME HCL/D5W 2 G/50 ML PIGGYBACK 0.85405 14.59910 1/25/2013 CEFEPIME HCL/DEXTROSE, ISO-OSM 1 G/50 ML FROZ.PIGGY 0.00000 1.09878 12/1/2012 CEFEPIME HCL/DEXTROSE, ISO-OSM 2 G/100 ML FROZ.PIGGY 0.00000 0.88078 12/1/2012 CEFOTAXIME SODIUM 1 G VIAL 0.00000 1.38268 12/1/2012 CEFOTAXIME SODIUM 10 G VIAL 0.00000 18.35400 12/1/2012 CEFOTAXIME SODIUM 2 G VIAL 0.00000 4.12516 12/1/2012 CEFOTAXIME SODIUM 500 MG VIAL 0.00000 1.31950 12/1/2012 CEFOTETAN DISOD/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 12.30600 12.81880 1/25/2013 CEFOTETAN DISOD/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 17.59800 12/1/2012 CEFOTETAN DISODIUM 1 G VIAL 0.00000 9.55920 12/1/2012 CEFOTETAN DISODIUM 10 G VIAL 0.00000 98.60200 12/1/2012 CEFOTETAN DISODIUM 2 G VIAL 19.11840 19.91500 1/25/2013 CEFOXITIN SODIUM 1 G VIAL 0.00000 4.45380 12/1/2012 CEFOXITIN SODIUM 10 G VIAL 0.00000 32.13068 12/1/2012 CEFOXITIN SODIUM 2 G VIAL 0.00000 8.21424 12/1/2012 CEFOXITIN SODIUM/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.00000 0.50369 12/1/2012 CEFOXITIN SODIUM/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 0.92383 12/1/2012 CEFPODOXIME PROXETIL 100 MG TABLET 3.92980 4.30660 1/25/2013 CEFPODOXIME PROXETIL 100 MG/5ML SUSP RECON 1.00530 1.20640 2/8/2013 CEFPODOXIME PROXETIL 50 MG/5 ML SUSP RECON 0.45411 0.48050 1/25/2013 Page 9 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CEFPROZIL 125 MG/5ML SUSP RECON 0.29300 0.29320 1/25/2013 CEFPROZIL 250 MG TABLET 1.82470 1.85121 2/22/2013 CEFPROZIL 250 MG/5ML SUSP RECON 0.00000 0.54020 12/1/2012 CEFPROZIL 500 MG TABLET 3.28620 3.21324 2/22/2013 CEFTAZIDIME PENTAHYDRATE 1 G VIAL 5.07676 5.07680 12/14/2012 CEFTAZIDIME PENTAHYDRATE 2 G VIAL 0.00000 8.99040 12/1/2012 CEFTAZIDIME PENTAHYDRATE 6G VIAL 21.71750 21.86100 1/25/2013 CEFTAZIDIME PENTAHYDRATE/D5W 1 G/50 ML PIGGYBACK 0.00000 9.03846 12/1/2012 CEFTAZIDIME PENTAHYDRATE/D5W 2 G/50 ML PIGGYBACK 0.00000 13.01154 12/1/2012 CEFTRIAXONE NA/DEXTROSE,ISO 1 G/50 ML FROZ.PIGGY 0.00000 0.33575 12/1/2012 CEFTRIAXONE NA/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.00000 0.54291 12/1/2012 CEFTRIAXONE NA/DEXTROSE,ISO 2 G/50 ML FROZ.PIGGY 0.56295 3.69970 1/25/2013 CEFTRIAXONE NA/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 0.94697 12/1/2012 CEFTRIAXONE SODIUM 1 G PGGYBK BTL 0.00000 33.53700 12/1/2012 CEFTRIAXONE SODIUM 1 G VIAL 1.65892 1.65890 12/14/2012 CEFTRIAXONE SODIUM 1 G VIAL PORT 4.62840 3.51120 2/15/2013 CEFTRIAXONE SODIUM 10 G VIAL 0.00000 17.20950 12/1/2012 CEFTRIAXONE SODIUM 2 G PGGYBK BTL 0.00000 65.91900 12/1/2012 CEFTRIAXONE SODIUM 2 G VIAL 0.00000 3.43070 12/1/2012 CEFTRIAXONE SODIUM 2 G VIAL PORT 8.30760 6.39660 1/25/2013 CEFTRIAXONE SODIUM 250 MG VIAL 0.93080 1.03050 1/25/2013 CEFTRIAXONE SODIUM 500 MG VIAL 1.21806 1.21810 12/14/2012 CEFUROXIME AXETIL 250 MG TABLET 0.45590 0.45720 1/25/2013 CEFUROXIME AXETIL 500 MG TABLET 0.00000 0.73340 12/1/2012 CEFUROXIME SODIUM 1.5 G VIAL 4.36887 4.33520 1/25/2013 CEFUROXIME SODIUM 7.5G VIAL 0.00000 19.28430 12/1/2012 CEFUROXIME SODIUM 750 MG VIAL 0.00000 2.24102 12/1/2012 CEFUROXIME SODIUM/DEXTROSE,ISO 1.5G/50ML PIGGYBACK 0.00000 0.53477 12/1/2012 CEFUROXIME SODIUM/DEXTROSE,ISO 750MG/50ML PIGGYBACK 0.00000 0.42827 12/1/2012 CELLULOSE 80 % POWDER 0.00000 0.03535 12/1/2012 CEPHALEXIN 125 MG/5ML SUSP RECON 0.00000 0.05280 12/1/2012 CEPHALEXIN 250 MG CAPSULE 0.06995 0.07000 1/25/2013 CEPHALEXIN 250 MG TABLET 0.00000 0.40092 12/1/2012 CEPHALEXIN 250 MG/5ML SUSP RECON 0.06845 0.06850 12/14/2012 CEPHALEXIN 500 MG CAPSULE 0.10020 0.09715 2/22/2013 CEPHALEXIN 500 MG TABLET 0.00000 0.80132 12/1/2012 CETIRIZINE HCL 1 MG/ML SOLUTION 0.03471 0.02747 2/22/2013 CETIRIZINE HCL 10 MG TAB CHEW 0.56333 0.56330 12/14/2012 CETIRIZINE HCL 10 MG TABLET 0.06914 0.06910 12/14/2012 CETIRIZINE HCL 5 MG TAB CHEW 0.00000 0.96200 12/1/2012 CETIRIZINE HCL 5 MG TABLET 0.08440 0.08420 1/25/2013 CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H 0.60560 0.64287 2/22/2013 CEVIMELINE HCL 30 MG CAPSULE 2.44096 2.43970 1/25/2013 CHLOPHEDIANOL HCL/GUAIFENESIN 25-200MG/5 LIQUID 0.09157 0.08650 1/25/2013 CHLORAMPHENICOL NA SUCC 1 G VIAL 0.00000 2.64689 12/1/2012 CHLORDIAZEPOXIDE HCL 10 MG CAPSULE 0.07238 0.07240 12/14/2012 CHLORDIAZEPOXIDE HCL 25 MG CAPSULE 0.08947 0.08950 12/14/2012 CHLORDIAZEPOXIDE HCL 5 MG CAPSULE 0.10604 0.10600 12/14/2012 CHLORDIAZEPOXIDE/CLIDINIUM BR 5 MG-2.5MG CAPSULE 0.00000 0.28408 12/1/2012 CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH 0.00582 0.00580 12/14/2012 CHLOROPROCAINE HCL/PF 20 MG/ML VIAL 0.55650 0.49140 1/25/2013 CHLOROQUINE PHOSPHATE 250 MG TABLET 1.16775 1.16780 12/14/2012 CHLOROQUINE PHOSPHATE 500 MG TABLET 1.86000 2.61400 1/25/2013 CHLOROTHIAZIDE 500 MG TABLET 0.24115 0.25560 1/25/2013 Page 10 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CHLOROTHIAZIDE SODIUM 500 MG VIAL 0.00000 222.92725 12/1/2012 CHLORPHENIRAMINE MALEATE 12 MG TABLET ER 0.29912 0.34710 12/21/2012 CHLORPHENIRAMINE MALEATE 2 MG/5 ML SYRUP 0.00000 0.01798 12/1/2012 CHLORPHENIRAMINE MALEATE 4 MG TABLET 0.00563 0.00560 12/14/2012 CHLORPROMAZINE HCL 25 MG/ML AMPUL 10.56020 8.27700 1/25/2013 CHLORPROPAMIDE 100 MG TABLET 0.33400 0.34550 1/25/2013 CHLORPROPAMIDE 250 MG TABLET 0.81158 0.85230 1/25/2013 CHLORTHALIDONE 25 MG TABLET 0.00000 0.34700 12/1/2012 CHLORTHALIDONE 50 MG TABLET 0.44933 0.47630 1/25/2013 CHLORZOXAZONE 500 MG TABLET 0.08918 0.08920 12/14/2012 CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT TAB CHEW 0.07209 0.07210 1/25/2013 CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT TABLET 0.01920 0.01924 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 1000/SPRAY SPRAY SUSP 0.00000 0.30847 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT CAPSULE 0.00000 0.71680 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT TABLET 0.02980 0.03040 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 3000 UNIT TABLET 0.00000 0.05516 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT CAPSULE 0.01810 0.01652 2/15/2013 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TAB CHEW 0.00000 0.02509 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TABLET 0.00000 0.01560 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/5 LIQUID 0.00000 0.02914 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 4000 UNIT CAPSULE 0.00000 0.06993 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT TABLET 0.04473 0.05090 1/25/2013 CHOLECALCIFEROL (VITAMIN D3) 5000/ML DROPS 0.00000 0.07973 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT CAPSULE 0.32250 0.36797 2/22/2013 CHOLESTYRAMINE (WITH SUGAR) 4 G PACKET 0.23210 0.43000 1/25/2013 CHOLESTYRAMINE (WITH SUGAR) 4 G POWDER 0.07879 0.07880 12/14/2012 CHOLESTYRAMINE/ASPARTAME 4 G PACKET 0.22940 0.43400 2/1/2013 CHOLESTYRAMINE/ASPARTAME 4 G POWDER 0.13870 0.14980 1/25/2013 CHOLINE SAL/MAG SALICYLATE 500 MG/5ML LIQUID 0.00000 0.12848 12/1/2012 CHORIONIC GONADOTROPIN, HUMAN 10000 UNIT VIAL 0.00000 15.45915 12/1/2012 CICLOPIROX 0.77 % GEL (GRAM) 1.48043 1.36830 1/25/2013 CICLOPIROX 1 % SHAMPOO 0.61126 0.57510 12/21/2012 CICLOPIROX 8 % SOLUTION 0.62210 0.63930 1/25/2013 CICLOPIROX OLAMINE 0.77 % CREAM (G) 0.12420 0.13750 1/25/2013 CICLOPIROX OLAMINE 0.77 % SUSPENSION 0.00000 0.37748 12/1/2012 CICLOPIROX/URE/CAMPH/MENTH/EUC 8 % SOLUTION 0.00000 266.99400 12/1/2012 CIDOFOVIR 75 MG/ML VIAL 0.00000 87.02400 12/1/2012 CILOSTAZOL 100 MG TABLET 0.13494 0.13490 12/14/2012 CILOSTAZOL 50 MG TABLET 0.15283 0.15280 12/14/2012 CIMETIDINE 200 MG TABLET 0.18934 0.18930 12/14/2012 CIMETIDINE 300 MG TABLET 0.03913 0.03910 12/14/2012 CIMETIDINE 400 MG TABLET 0.05092 0.05090 12/14/2012 CIMETIDINE 800 MG TABLET 0.30277 0.30280 12/14/2012 CIMETIDINE HCL 150 MG/ML VIAL 1.00538 1.02300 1/25/2013 CIMETIDINE HCL 300 MG/5ML SOLUTION 0.00000 0.03350 12/1/2012 CIPROFLOXACIN HCL 0.2 % DROPERETTE 0.00000 5.25900 12/1/2012 CIPROFLOXACIN HCL 0.3 % DROPS 0.66060 0.66062 2/1/2013 CIPROFLOXACIN HCL 100 MG TABLET 0.00000 2.35900 12/1/2012 CIPROFLOXACIN HCL 250 MG TABLET 0.00000 0.14150 12/1/2012 CIPROFLOXACIN HCL 500 MG TABLET 0.16960 0.16964 2/8/2013 CIPROFLOXACIN HCL 750 MG TABLET 0.27859 0.27860 12/14/2012 CIPROFLOXACIN LACTATE 200MG/20ML VIAL 0.00000 0.08890 12/1/2012 CIPROFLOXACIN LACTATE 400MG/40ML VIAL 0.06318 0.06320 1/25/2013 CIPROFLOXACIN LACTATE/D5W 200MG/0.1L PIGGYBACK 0.00000 0.01697 12/1/2012 Page 11 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CIPROFLOXACIN LACTATE/D5W 400MG/0.2L PIGGYBACK 0.01008 0.01250 1/25/2013 CIPROFLOXACIN/CIPROFLOXA HCL 1000 MG TBMP 24HR 0.00000 7.79233 12/1/2012 CIPROFLOXACIN/CIPROFLOXA HCL 500 MG TBMP 24HR 0.00000 6.85916 12/1/2012 CISATRACURIUM BESYLATE 10 MG/ML VIAL 0.00000 10.93957 12/1/2012 CISATRACURIUM BESYLATE 2 MG/ML VIAL 0.00000 2.16839 12/1/2012 CITALOPRAM HYDROBROMIDE 10 MG TABLET 0.02921 0.02920 12/14/2012 CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION 0.00000 0.18230 1/25/2012 CITALOPRAM HYDROBROMIDE 20 MG TABLET 0.03564 0.03560 12/14/2012 CITALOPRAM HYDROBROMIDE 40 MG TABLET 0.04700 0.04780 1/25/2013 CITRATE-PHOS-DEX SOLUTION 2.63G/100 SOLUTION 0.00000 0.08318 12/1/2012 CITRIC ACID/SODIUM CITRATE 334-500MG SOLUTION 0.00971 0.00970 1/25/2013 CLARITHROMYCIN 125 MG/5ML SUSP RECON 0.00000 0.34465 12/1/2012 CLARITHROMYCIN 250 MG TABLET 3.85130 3.82136 2/22/2013 CLARITHROMYCIN 500 MG TAB ER 24H 3.50443 3.47640 1/25/2013 CLARITHROMYCIN 500 MG TABLET 3.84310 3.86660 2/22/2013 CLEMASTINE FUMARATE 1.34 MG TABLET 0.12753 0.12750 12/14/2012 CLEMASTINE FUMARATE 2.68 MG TABLET 0.17217 0.17190 1/25/2013 CLINDAMYCIN HCL 150 MG CAPSULE 0.00000 0.08790 12/1/2012 CLINDAMYCIN HCL 300 MG CAPSULE 0.29550 0.28640 1/25/2013 CLINDAMYCIN HCL 75 MG CAPSULE 0.00000 0.41720 12/1/2012 CLINDAMYCIN PALMITATE HCL 75 MG/5 ML SOLN RECON 0.00000 0.43421 12/1/2012 CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GEL (GRAM) 0.00000 3.76642 12/1/2012 CLINDAMYCIN PHOS/BENZOYL PEROX 1.2(1)%-5% GEL ER (G) 3.16403 3.16110 1/25/2013 CLINDAMYCIN PHOSPHATE 1 % FOAM 0.00000 1.92528 12/1/2012 CLINDAMYCIN PHOSPHATE 1 % LOTION 0.91520 1.11980 2/1/2013 CLINDAMYCIN PHOSPHATE 1 % MED. SWAB 0.40374 0.40370 12/14/2012 CLINDAMYCIN PHOSPHATE 1 % SOLUTION 0.22280 0.91410 1/25/2013 CLINDAMYCIN PHOSPHATE 150 MG/ML VIAL 0.30610 0.35600 12/21/2012 CLINDAMYCIN PHOSPHATE 2 % CREAM/APPL 1.23060 1.57590 2/1/2013 CLINDAMYCIN PHOSPHATE 300 MG/2ML VIAL PORT 0.00000 2.99418 12/1/2012 CLINDAMYCIN PHOSPHATE 600 MG/4ML VIAL PORT 0.00000 1.60881 12/1/2012 CLINDAMYCIN PHOSPHATE 900MG/6ML VIAL PORT 0.00000 1.51899 12/1/2012 CLINDAMYCIN PHOSPHATE/D5W 300MG/50ML PIGGYBACK 0.00000 0.13773 2/15/2013 CLINDAMYCIN PHOSPHATE/D5W 600MG/50ML PIGGYBACK 0.00000 0.20775 2/15/2013 CLINDAMYCIN PHOSPHATE/D5W 900MG/50ML PIGGYBACK 0.00000 0.25374 2/15/2013 CLOBETASOL PROPIONATE 0.05 % CREAM (G) 0.11926 0.11930 12/14/2012 CLOBETASOL PROPIONATE 0.05 % FOAM 1.88149 1.88150 12/14/2012 CLOBETASOL PROPIONATE 0.05 % GEL (GRAM) 0.36716 0.36720 12/14/2012 CLOBETASOL PROPIONATE 0.05 % LOTION 0.00000 3.23864 12/1/2012 CLOBETASOL PROPIONATE 0.05 % OINT. (G) 0.11460 0.23120 12/21/2012 CLOBETASOL PROPIONATE 0.05 % SHAMPOO 2.31009 2.38350 1/25/2013 CLOBETASOL PROPIONATE 0.05 % SOLUTION 0.31088 0.31090 12/14/2012 CLOBETASOL PROPIONATE/EMOLL 0.05 % CREAM (G) 0.29212 0.29210 12/14/2012 CLOBETASOL PROPIONATE/EMOLL 0.05 % FOAM 1.88149 3.22118 2/15/2013 CLOMIPHENE CITRATE 50 MG TABLET 0.00000 1.01304 12/1/2012 CLOMIPRAMINE HCL 25 MG CAPSULE 0.27760 0.27880 1/25/2013 CLOMIPRAMINE HCL 50 MG CAPSULE 0.37410 0.37650 1/25/2013 CLOMIPRAMINE HCL 75 MG CAPSULE 0.49580 0.49240 1/25/2013 CLONAZEPAM 0.125 MG TAB RAPDIS 0.76366 0.75640 1/25/2013 CLONAZEPAM 0.25 MG TAB RAPDIS 0.73986 0.74620 1/25/2013 CLONAZEPAM 0.5 MG TAB RAPDIS 0.00000 0.78857 12/1/2012 CLONAZEPAM 0.5 MG TABLET 0.01648 0.01650 12/14/2012 CLONAZEPAM 1 MG TAB RAPDIS 0.00000 0.90253 12/1/2012 CLONAZEPAM 1 MG TABLET 0.02610 0.02613 2/8/2013 Page 12 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CLONAZEPAM 2 MG TAB RAPDIS 0.00000 1.09330 12/1/2012 CLONAZEPAM 2 MG TABLET 0.04234 0.04230 12/14/2012 CLONIDINE 0.1MG/24HR PATCH TDWK 23.19664 23.19800 1/25/2013 CLONIDINE 0.2MG/24HR PATCH TDWK 39.06832 36.67630 1/25/2013 CLONIDINE 0.3MG/24HR PATCH TDWK 54.17242 54.19070 1/25/2013 CLONIDINE HCL 0.1 MG TABLET 0.03020 0.03015 2/8/2013 CLONIDINE HCL 0.2 MG TABLET 0.04370 0.04368 2/8/2013 CLONIDINE HCL 0.3 MG TABLET 0.05387 0.05390 12/14/2012 CLONIDINE HCL/PF 1000MCG/10 VIAL 0.00000 2.18075 12/1/2012 CLONIDINE HCL/PF 5000MCG/10 VIAL 10.09700 8.35920 1/25/2013 CLOPIDOGREL BISULFATE 300 MG TABLET 18.92559 15.16650 1/25/2013 CLOPIDOGREL BISULFATE 75 MG TABLET 0.00000 0.35570 12/1/2012 CLORAZEPATE DIPOTASSIUM 15 MG TABLET 0.23745 0.23750 12/14/2012 CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET 0.08455 0.08460 12/14/2012 CLORAZEPATE DIPOTASSIUM 7.5 MG TABLET 0.14240 0.14330 1/25/2013 CLOTRIMAZOLE 1 % CREAM (G) 0.07544 0.07540 12/14/2012 CLOTRIMAZOLE 1 % CREAM/APPL 0.07730 0.07790 1/25/2013 CLOTRIMAZOLE 1 % SOLUTION 0.00000 0.32656 12/1/2012 CLOTRIMAZOLE 10 MG TROCHE 0.35770 0.36150 1/25/2013 CLOTRIMAZOLE 2 % CREAM/APPL 0.27430 0.33420 1/25/2013 CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % CREAM (G) 1.32070 1.32987 2/22/2013 CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % LOTION 3.16550 3.28873 2/22/2013 CLOZAPINE 100 MG TAB RAPDIS 5.72241 5.72222 2/15/2013 CLOZAPINE 100 MG TABLET 0.00000 1.62860 9/27/2012 CLOZAPINE 12.5 MG TAB RAPDIS 0.00000 1.55925 12/1/2012 CLOZAPINE 200 MG TABLET 4.37050 4.37030 1/25/2013 CLOZAPINE 25 MG TAB RAPDIS 0.00000 2.09823 12/1/2012 CLOZAPINE 25 MG TABLET 0.89560 0.90840 2/8/2013 CLOZAPINE 50 MG TABLET 0.00000 1.15500 12/1/2012 COAL TAR 1 % SHAMPOO 0.03451 0.03020 1/25/2013 COCAINE HCL 10 % SOLUTION 0.00000 39.32250 12/1/2012 COCAINE HCL 4 % SOLUTION 17.36630 15.19980 1/25/2013 CODEINE SULFATE 15 MG TABLET 0.33397 0.30360 1/25/2013 CODEINE SULFATE 30 MG TABLET 0.35952 0.39550 2/15/2013 CODEINE SULFATE 30 MG/5 ML SOLUTION 0.00000 0.50492 12/1/2012 CODEINE SULFATE 60 MG TABLET 0.65850 0.72436 2/15/2013 CODEINE/BUTALBITAL/ASA/CAFFEIN 30-50-325 CAPSULE 0.66280 0.65796 2/15/2013 CODEINE/CARISOPRODOL/ASPIRIN 16-200-325 TABLET 0.00000 1.94250 12/1/2012 CODEINE/PROMETHAZINE HCL 10-6.25/5 SYRUP 0.01530 0.01528 2/1/2013 COLCHICINE/PROBENECID 0.5-500MG TABLET 0.00000 0.67760 12/1/2012 COLESTIPOL HCL 1 G TABLET 0.46048 0.46050 12/14/2012 COLESTIPOL HCL 5 G GRANULES 0.00000 0.20871 12/1/2012 COLESTIPOL HCL 5 G PACKET 0.00000 3.51494 12/1/2012 COLISTIN (COLISTIMETHATE NA) 150 MG VIAL 1.59621 19.47030 12/14/2012 CORTISONE ACETATE 25 MG TABLET 0.00000 0.75600 12/1/2012 COSYNTROPIN 0.25 MG VIAL 0.00000 64.39973 12/1/2012 COSYNTROPIN 0.25 MG/ML VIAL 0.00000 151.55280 12/1/2012 CROMOLYN SODIUM 20 MG/2 ML AMPUL-NEB 0.58772 0.58770 12/14/2012 CROMOLYN SODIUM 20 MG/ML SOLUTION 0.87924 0.87900 1/25/2013 CROMOLYN SODIUM 4 % DROPS 0.69948 0.69950 12/14/2012 CROMOLYN SODIUM 5.2 MG SPRAY/PUMP 0.00000 0.33554 12/1/2012 CUPRIC CHLORIDE 0.4 MG/ML VIAL 0.12348 0.15460 1/25/2013 CUPRIC SULFATE 0.4 MG/ML VIAL 0.00000 0.12958 12/1/2012 CYANOCOBALAMIN (VITAMIN B-12) 100 MCG TABLET 0.00000 0.01242 12/1/2012 Page 13 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TAB SUBL 0.05332 0.05840 1/25/2013 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TABLET ER 0.04580 0.04583 2/8/2013 CYANOCOBALAMIN (VITAMIN B-12) 1000MCG/ML VIAL 0.48575 0.48580 12/14/2012 CYANOCOBALAMIN (VITAMIN B-12) 500 MCG TABLET 0.00000 0.01867 12/1/2012 CYANOCOBALAMIN/FA/PYRIDOXINE 2-2.5-25MG TABLET 0.63825 0.63880 1/25/2013 CYANOCOBALAMIN/FOLIC ACID 0.5 MG-1MG TABLET 0.00000 0.12600 12/1/2012 CYCLOBENZAPRINE HCL 10 MG TABLET 0.03149 0.03020 12/14/2012 CYCLOBENZAPRINE HCL 5 MG TABLET 0.05780 0.05775 2/1/2013 CYCLOPENTOLATE HCL 1 % DROPS 1.18992 1.18990 12/14/2012 CYCLOPENTOLATE HCL 2 % DROPS 1.73600 3.33840 2/8/2013 CYCLOPHOSPHAMIDE 1 G VIAL 371.08400 289.48850 1/25/2013 CYCLOPHOSPHAMIDE 2 G VIAL 742.15400 578.96300 1/25/2013 CYCLOPHOSPHAMIDE 25 MG TABLET 0.00000 1.41297 12/1/2012 CYCLOPHOSPHAMIDE 50 MG TABLET 0.00000 2.59285 12/1/2012 CYCLOPHOSPHAMIDE 500 MG VIAL 185.54200 144.74250 1/25/2013 CYCLOSPORINE 100 MG CAPSULE 5.41333 5.41330 12/14/2012 CYCLOSPORINE 25 MG CAPSULE 1.48550 1.35543 2/15/2013 CYCLOSPORINE 250 MG/5ML VIAL 0.00000 7.95732 12/1/2012 CYCLOSPORINE, MODIFIED 100 MG CAPSULE 3.84730 3.84740 1/25/2013 CYCLOSPORINE, MODIFIED 100 MG/ML SOLUTION 2.88899 2.88900 12/14/2012 CYCLOSPORINE, MODIFIED 25 MG CAPSULE 0.96260 0.96270 1/25/2013 CYCLOSPORINE, MODIFIED 50 MG CAPSULE 0.00000 1.91683 12/1/2012 CYPROHEPTADINE HCL 2 MG/5 ML SYRUP 0.07420 0.09530 2/1/2013 CYPROHEPTADINE HCL 4 MG TABLET 0.09058 0.09060 12/14/2012 CYTARABINE 20 MG/ML VIAL 0.39573 0.40080 1/25/2013 CYTARABINE/PF 1 G VIAL 0.00000 40.61400 12/1/2012 CYTARABINE/PF 100 MG VIAL 0.00000 7.10640 12/1/2012 CYTARABINE/PF 100 MG/5ML VIAL 0.00000 1.97106 12/1/2012 CYTARABINE/PF 2 G/20 ML VIAL 0.00000 0.87780 12/1/2012 CYTARABINE/PF 20 MG/ML VIAL 0.00000 0.75096 12/1/2012 CYTARABINE/PF 500 MG VIAL 6.30000 6.56250 1/25/2013 D-CHLORPHENIRA/PSE/CHLOPHEDIAN 1-30-12.5 LIQUID 0.08693 0.08050 1/25/2013 D-METHORPHAN HB/P-EPD HCL/BPM 10-30-2/5 SYRUP 0.13311 0.13310 1/25/2013 D-METHORPHAN HB/P-EPD HCL/BPM 15-30-3/5 LIQUID 0.04126 0.06230 1/25/2013 D-METHORPHAN HB/P-EPD HCL/BPM 20-20-4/5 LIQUID 0.21004 0.21000 1/25/2013 D-METHORPHAN HB/P-EPD HCL/BPM 30-50-3MG LIQUID 0.07317 0.06910 1/25/2013 D-METHORPHAN HB/P-EPD HCL/BPM 5-15-1MG/5 ELIXIR 0.00000 0.01127 12/1/2012 D-METHORPHAN HB/P-EPHED HCL/CP 15-15-2/5 SYRUP 0.00000 0.04846 12/1/2012 D-METHORPHAN HB/P-EPHED HCL/CP 3-9-0.8/ML DROPS 0.00000 1.30760 12/1/2012 D-METHORPHAN HB/P-EPHED HCL/CP 5-15-1MG/5 LIQUID 0.00000 0.01868 12/1/2012 D-METHORPHAN HB/PROMETH HCL 15-6.25/5 SYRUP 0.01370 0.01365 2/1/2013 D-METHORPHAN/ACETAMIN/DOXYLAMN 15-325/15 LIQUID 0.01860 0.01541 2/15/2013 D-METHORPHAN/PE/DEXBROMPHENIR 20-10-2/5 SYRUP 0.06080 0.05168 2/22/2013 DACARBAZINE 100 MG VIAL 0.00000 7.93800 12/1/2012 DACTINOMYCIN 0.5 MG VIAL 0.00000 1,065.68700 12/1/2012 DANAZOL 100 MG CAPSULE 0.00000 2.00515 12/1/2012 DANAZOL 200 MG CAPSULE 3.79003 3.79000 1/25/2013 DANAZOL 50 MG CAPSULE 1.33637 1.26890 1/25/2013 DANTROLENE SODIUM 100 MG CAPSULE 1.39490 1.51750 2/8/2013 DANTROLENE SODIUM 20 MG VIAL 0.00000 68.04000 12/1/2012 DANTROLENE SODIUM 25 MG CAPSULE 0.00000 0.74851 12/1/2012 DANTROLENE SODIUM 50 MG CAPSULE 0.00000 1.21009 12/1/2012 DAPSONE 100 MG TABLET 0.00000 0.91000 12/1/2012 DAPSONE 25 MG TABLET 0.00000 0.74200 12/1/2012 Page 14 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 DAUNORUBICIN HCL 5 MG/ML VIAL 14.20913 14.58975 12/14/2012 DEFEROXAMINE MESYLATE 2 G VIAL 0.00000 26.33481 12/1/2012 DEFEROXAMINE MESYLATE 500 MG VIAL 0.00000 8.40600 12/1/2012 DEMECLOCYCLINE HCL 150 MG TABLET 0.00000 2.01027 12/1/2012 DEMECLOCYCLINE HCL 300 MG TABLET 0.00000 3.80900 12/1/2012 DESIPRAMINE HCL 10 MG TABLET 0.81010 0.81680 1/25/2013 DESIPRAMINE HCL 100 MG TABLET 2.88720 3.05540 1/25/2013 DESIPRAMINE HCL 150 MG TABLET 3.84390 4.42710 2/1/2013 DESIPRAMINE HCL 25 MG TABLET 0.96960 0.98480 2/8/2013 DESIPRAMINE HCL 75 MG TABLET 2.26422 2.26420 12/14/2012 DESLORATADINE 2.5 MG TAB RAPDIS 0.00000 4.07750 1/25/2013 DESLORATADINE 5 MG TAB RAPDIS 0.00000 4.07750 1/25/2013 DESLORATADINE 5 MG TABLET 0.00000 1.03622 12/1/2012 DESMOPRESSIN ACETATE 0.1 MG TABLET 1.25640 1.21190 1/25/2013 DESMOPRESSIN ACETATE 0.1 MG/ML SOLUTION 25.31760 25.20840 1/25/2013 DESMOPRESSIN ACETATE 0.2 MG TABLET 1.39170 1.29270 1/25/2013 DESMOPRESSIN ACETATE 10/SPRAY SPRAY/PUMP 0.00000 33.88710 12/1/2012 DESMOPRESSIN ACETATE 4MCG/ML AMPUL 5.56080 7.12530 12/21/2012 DESMOPRESSIN ACETATE 4MCG/ML VIAL 13.84457 13.84460 12/14/2012 DESOG-ET ESTRA/ETHIN ESTRA 21-5 TABLET 1.47570 1.49950 2/8/2013 DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.03 TABLET 0.64440 0.68090 12/21/2012 DESOGESTREL-ETHINYL ESTRADIOL 7 DAYS X 3 TABLET 0.00000 0.83100 12/1/2012 DESONIDE 0.05 % CREAM (G) 0.56600 0.57120 2/8/2013 DESONIDE 0.05 % LOTION 0.00000 1.83560 12/1/2012 DESONIDE 0.05 % OINT. (G) 0.51711 0.51710 12/14/2012 DESOXIMETASONE 0.05 % GEL (GRAM) 0.00000 2.73169 12/1/2012 DESOXIMETASONE 0.25 % OINT. (G) 3.99777 3.96501 2/22/2013 DEXAMETHASONE 0.5 MG/5ML ELIXIR 0.00000 0.18810 12/1/2012 DEXAMETHASONE 0.5 MG/5ML SOLUTION 0.00000 0.12675 12/1/2012 DEXAMETHASONE SOD PHOSPHATE 0.1 % DROPS 2.59590 2.96250 2/8/2013 DEXAMETHASONE SOD PHOSPHATE 10 MG/ML VIAL 0.66069 0.66970 1/25/2013 DEXAMETHASONE SOD PHOSPHATE 4 MG/ML VIAL 0.20515 0.19600 1/25/2013 DEXAMETHASONE SOD PHOSPHATE/PF 10 MG/ML VIAL 0.00000 6.35376 12/1/2012 DEXMETHYLPHENIDATE HCL 10 MG TABLET 0.00000 1.92570 12/1/2012 DEXMETHYLPHENIDATE HCL 2.5 MG TABLET 0.96705 0.94880 1/25/2013 DEXMETHYLPHENIDATE HCL 5 MG TABLET 0.00000 1.37844 12/1/2012 DEXPANTHENOL 250 MG/ML VIAL 1.36500 1.42180 1/25/2013 DEXTRAN 70/HYPROMELLOSE DROPS 0.59858 0.43960 1/25/2013 DEXTROMETHORPHAN HBR 7.5 MG/5ML SYRUP 0.02922 0.03070 1/25/2013 DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML SUS ER 12H 0.06322 0.08530 1/25/2013 DEXTROSE 10 % AND 0.2 % NACL 10 %-0.2 % DEHP FR BG 0.00000 0.04179 12/1/2012 DEXTROSE 10 % AND 0.2 % NACL 10 %-0.2 % IV SOLN 0.00000 0.03704 12/1/2012 DEXTROSE 10 % AND 0.45 % NACL 10%-0.45% IV SOLN 0.00000 0.01077 12/1/2012 DEXTROSE 10 % IN WATER 10 % DEHP FR BG 0.00000 0.00819 12/1/2012 DEXTROSE 10 % IN WATER 10 % IV SOLN 0.00000 0.00281 12/1/2012 DEXTROSE 2.5 % AND 0.45 % NACL 2.5%-0.45% IV SOLN 0.00252 0.00250 1/25/2013 DEXTROSE 20 % IN WATER 20 % IV SOLN 0.00000 0.00864 12/1/2012 DEXTROSE 25 % IN WATER 25 % DISP SYRIN 0.42672 0.38140 1/25/2013 DEXTROSE 30 % IN WATER 30 % IV SOLN 0.00000 0.00877 12/1/2012 DEXTROSE 40 % IN WATER 40 % IV SOLN 0.01091 0.00870 1/25/2013 DEXTROSE 5 % AND 0.3 % NACL 5 %-0.3 % IV SOLN 0.00213 0.00230 1/25/2013 DEXTROSE 5 % AND 0.9 % NACL 5 %-0.9 % IV SOLN 0.00000 0.00201 12/1/2012 DEXTROSE 5 % IN WATER PGGYBK PRT 0.04099 0.03320 1/25/2013 DEXTROSE 5 % IN WATER PGY VL PRT 0.00000 0.07096 12/1/2012 Page 15 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 DEXTROSE 5 % IN WATER 5 % IV SOLN 0.00000 0.00174 12/1/2012 DEXTROSE 5 % IN WATER 5 % VIAL 0.00000 0.53214 12/1/2012 DEXTROSE 5 % SOLUTION 0.01868 0.01680 1/25/2013 DEXTROSE 5 %-0.2 % NACL 5 %-0.2 % IV SOLN 0.00000 0.00228 12/1/2012 DEXTROSE 5 %-0.45 % NACL 5 %-0.45 % IV SOLN 0.00190 0.00145 2/15/2013 DEXTROSE 5% IN RINGERS 5 % IV SOLN 0.00160 0.00170 1/25/2013 DEXTROSE 5%-LACTATED RINGERS 5 % IV SOLN 0.00000 0.00214 12/1/2012 DEXTROSE 50 % IN WATER 50 % DISP SYRIN 0.00000 0.12516 12/1/2012 DEXTROSE 50 % IN WATER 50 % IV SOLN 0.00000 0.00630 12/1/2012 DEXTROSE 50 % IN WATER 50 % VIAL 0.02537 0.02540 1/25/2013 DEXTROSE 70 % IN WATER 70 % IV SOLN 0.00520 0.00540 2/8/2013 DIAZEPAM 10 MG TABLET 0.02466 0.02470 1/25/2013 DIAZEPAM 12.5-15-20 KIT 0.00000 156.22100 12/1/2012 DIAZEPAM 2 MG TABLET 0.02372 0.02370 12/14/2012 DIAZEPAM 2.5 MG KIT 0.00000 129.16538 12/1/2012 DIAZEPAM 5 MG TABLET 0.02224 0.02220 12/14/2012 DIAZEPAM 5 MG/5 ML SOLUTION 0.00000 0.16829 12/1/2012 DIAZEPAM 5 MG/CUP SOLUTION 0.00000 0.34174 12/1/2012 DIAZEPAM 5 MG/ML DISP SYRIN 3.37260 3.71280 1/25/2013 DIAZEPAM 5 MG/ML ORAL CONC 0.00000 1.54209 12/1/2012 DIAZEPAM 5 MG/ML VIAL 1.17516 1.36920 1/25/2013 DIAZEPAM 5-7.5-10MG KIT 0.00000 252.35700 12/1/2012 DICLOFENAC POTASSIUM 50 MG TABLET 0.15008 0.20410 12/14/2012 DICLOFENAC SODIUM 0.1 % DROPS 1.02376 1.02380 12/14/2012 DICLOFENAC SODIUM 100 MG TAB ER 24H 0.51523 0.51520 12/14/2012 DICLOFENAC SODIUM 25 MG TABLET DR 0.99526 0.99530 12/14/2012 DICLOFENAC SODIUM 50 MG TABLET DR 0.36408 0.36410 12/14/2012 DICLOFENAC SODIUM 75 MG TABLET DR 0.38220 0.38217 2/15/2013 DICLOFENAC SODIUM/MISOPROSTOL 50 MG-200 TAB IR DR 0.00000 2.34693 12/1/2012 DICLOFENAC SODIUM/MISOPROSTOL 75 MG-200 TAB IR DR 0.00000 2.34697 12/1/2012 DICLOXACILLIN SODIUM 250 MG CAPSULE 0.24120 0.23840 1/25/2013 DICLOXACILLIN SODIUM 500 MG CAPSULE 0.47527 0.47650 1/25/2013 DICYCLOMINE HCL 10 MG CAPSULE 0.03500 0.03497 2/1/2013 DICYCLOMINE HCL 10 MG/5 ML SYRUP 0.00000 0.06924 12/1/2012 DICYCLOMINE HCL 20 MG TABLET 0.02774 0.02770 12/14/2012 DIDANOSINE 125 MG CAPSULE DR 0.00000 2.70223 12/1/2012 DIDANOSINE 200 MG CAPSULE DR 4.25300 4.32270 2/8/2013 DIDANOSINE 250 MG CAPSULE DR 0.00000 5.50853 12/1/2012 DIDANOSINE 400 MG CAPSULE DR 8.39520 8.60350 2/8/2013 DIETHYLPROPION HCL 25 MG TABLET 0.23594 0.23090 1/25/2013 DIETHYLPROPION HCL 75 MG TABLET ER 0.85826 0.80950 1/25/2013 DIFLORASONE DIACETATE 0.05 % CREAM (G) 0.00000 3.29067 12/1/2012 DIFLORASONE DIACETATE 0.05 % OINT. (G) 2.91054 2.47670 1/25/2013 DIFLUNISAL 500 MG TABLET 1.10230 1.19440 2/1/2013 DIGOXIN 125 MCG TABLET 0.13811 0.13790 1/25/2013 DIGOXIN 250 MCG TABLET 0.13683 0.13680 1/25/2013 DIGOXIN 250 MCG/ML DISP SYRIN 0.00000 1.58760 12/1/2012 DIGOXIN 50 MCG/ML SOLUTION 0.44648 0.45435 2/15/2013 DIHYDROERGOTAMINE MESYLATE 1 MG/ML AMPUL 53.12400 54.10623 2/22/2013 DIHYDROERGOTAMINE MESYLATE 1 MG/ML VIAL 0.00000 37.55430 12/1/2012 DILTIAZEM HCL 100 MG VIAL PORT 15.81300 14.71680 1/25/2013 DILTIAZEM HCL 120 MG CAP ER 24H 0.40520 0.48510 1/25/2013 DILTIAZEM HCL 120 MG CAP ER DEG 0.55012 0.55010 12/14/2012 DILTIAZEM HCL 120 MG CAPSULE ER 0.00000 0.54190 12/1/2012 Page 16 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 DILTIAZEM HCL 120 MG TABLET 0.12370 0.12170 1/25/2013 DILTIAZEM HCL 180 MG CAP ER 24H 0.48050 0.48070 1/25/2013 DILTIAZEM HCL 180 MG CAP ER DEG 0.62752 0.62750 12/14/2012 DILTIAZEM HCL 180 MG CAPSULE ER 0.65390 0.72827 2/22/2013 DILTIAZEM HCL 180 MG TAB ER 24H 0.00000 2.08282 12/1/2012 DILTIAZEM HCL 240 MG CAP ER 24H 0.67400 0.66950 12/21/2012 DILTIAZEM HCL 240 MG CAP ER DEG 0.69467 0.69470 12/14/2012 DILTIAZEM HCL 240 MG CAPSULE ER 0.92780 0.90409 2/22/2013 DILTIAZEM HCL 240 MG TAB ER 24H 2.33435 2.33440 1/25/2013 DILTIAZEM HCL 30 MG TABLET 0.03323 0.03320 12/14/2012 DILTIAZEM HCL 300 MG CAP ER 24H 0.61600 0.71100 12/21/2012 DILTIAZEM HCL 300 MG CAPSULE ER 1.20200 1.39010 2/22/2013 DILTIAZEM HCL 300 MG TAB ER 24H 3.03668 3.03690 1/25/2013 DILTIAZEM HCL 360 MG CAP ER 24H 7.14911 7.10510 1/25/2013 DILTIAZEM HCL 360 MG CAPSULE ER 1.15560 1.27916 2/22/2013 DILTIAZEM HCL 360 MG TAB ER 24H 3.26731 3.26730 1/25/2013 DILTIAZEM HCL 420MG CAPSULE ER 0.00000 1.72005 12/1/2012 DILTIAZEM HCL 420MG TAB ER 24H 0.00000 3.54216 12/1/2012 DILTIAZEM HCL 60 MG CAP ER 12H 0.81870 0.86790 2/8/2013 DILTIAZEM HCL 60 MG TABLET 0.05883 0.05880 12/14/2012 DILTIAZEM HCL 90 MG TABLET 0.08453 0.11020 12/14/2012 DIMENHYDRINATE 50 MG TABLET 0.00000 0.01809 12/1/2012 DIMENHYDRINATE 50 MG/ML VIAL 0.00000 4.98960 12/1/2012 DIMETHICONE 1 % CREAM(ML) 0.05662 0.06020 1/25/2013 DIMETHICONE 2 % SPRAY 0.02996 0.03000 1/25/2013 DIMETHICONE 5 % CREAM(ML) 0.03770 0.03810 1/25/2013 DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR 0.00000 0.00512 1/11/2013 DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID 0.00000 0.00590 12/1/2012 DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP 0.01259 0.01260 1/25/2013 DIPHENHYDRAMINE HCL 25 MG CAPSULE 0.01640 0.01635 2/15/2013 DIPHENHYDRAMINE HCL 25 MG TABLET 0.02104 0.02100 12/14/2012 DIPHENHYDRAMINE HCL 50 MG CAPSULE 0.01742 0.01740 12/14/2012 DIPHENHYDRAMINE HCL 50 MG/ML VIAL 0.68880 0.68820 1/25/2013 DIPHENOXYLATE HCL/ATROPINE 2.5-.025/5 LIQUID 0.00000 0.10803 12/1/2012 DIPHENOXYLATE HCL/ATROPINE 2.5-.025MG TABLET 0.12154 0.12150 12/14/2012 DIPYRIDAMOLE 25 MG TABLET 0.06874 0.06870 12/14/2012 DIPYRIDAMOLE 50 MG TABLET 0.10814 0.10810 12/14/2012 DIPYRIDAMOLE 75 MG TABLET 0.13681 0.13680 12/14/2012 DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE 0.30511 0.30510 12/14/2012 DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE 0.35458 0.35460 12/14/2012 DISULFIRAM 250 MG TABLET 0.00000 2.37497 12/1/2012 DISULFIRAM 500 MG TABLET 4.54673 4.53960 1/25/2013 DIVALPROEX SODIUM 125 MG CAP SPRINK 0.00000 0.49955 12/1/2012 DIVALPROEX SODIUM 125 MG TABLET DR 0.05186 0.05190 12/14/2012 DIVALPROEX SODIUM 250 MG TAB ER 24H 0.00000 0.20690 12/1/2012 DIVALPROEX SODIUM 250 MG TABLET DR 0.09072 0.09070 12/14/2012 DIVALPROEX SODIUM 500 MG TAB ER 24H 0.00000 0.38780 12/1/2012 DIVALPROEX SODIUM 500 MG TABLET DR 0.15812 0.15810 12/14/2012 DM/PHENYLEPH/CHLORPHENIRAMINE 15-10-2/5 SYRUP 0.02330 0.04650 1/25/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 15-10-4/5 LIQUID 0.04836 0.04500 1/25/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 15-5-2MG/5 LIQUID 0.04477 0.06860 1/25/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 3-2-1MG/ML DROPS 0.55499 0.55500 1/25/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 3-3.5-1/ML DROPS 0.00000 1.37627 12/1/2012 DOBUTAMINE HCL 250MG/20ML VIAL 0.14557 0.15780 1/25/2013 Page 17 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 DOBUTAMINE HCL 500MG/40ML VIAL 0.15834 0.15830 1/25/2013 DOBUTAMINE HCL/D5W 1000MG/250 IV SOLN 0.06402 0.08730 1/25/2013 DOBUTAMINE HCL/D5W 250MG/250 IV SOLN 0.03994 0.04960 1/25/2013 DOBUTAMINE HCL/D5W 500 MG/500 IV SOLN 0.02779 0.02810 1/25/2013 DOBUTAMINE HCL/D5W 500MG/250 IV SOLN 0.05540 0.05620 1/25/2013 DOCETAXEL 160 MG/8ML VIAL 0.00000 255.60500 12/1/2012 DOCETAXEL 160MG/16ML VIAL 0.00000 159.40890 12/1/2012 DOCETAXEL 20 MG/2 ML VIAL 0.00000 150.34425 12/1/2012 DOCETAXEL 20MG/ML(1) VIAL 428.92500 265.52500 1/25/2013 DOCETAXEL 80 MG/4 ML VIAL 428.92500 265.52500 1/25/2013 DOCETAXEL 80 MG/8 ML VIAL 0.00000 150.33770 12/1/2012 DOCETAXEL FNL 20MG/2 VIAL 0.00000 148.61475 12/1/2012 DOCETAXEL FNL 80MG/8 VIAL 0.00000 297.22950 12/1/2012 DOCOSAHEXANOIC ACID 200 MG CAPSULE 0.19600 0.18670 1/25/2013 DOCUSATE CALCIUM 240 MG CAPSULE 0.00000 0.05132 12/1/2012 DOCUSATE SODIUM 100 MG CAPSULE 0.00000 0.01501 12/1/2012 DOCUSATE SODIUM 100 MG TABLET 0.00000 0.03068 12/1/2012 DOCUSATE SODIUM 250 MG CAPSULE 0.00000 0.03978 12/1/2012 DOCUSATE SODIUM 283 MG/5ML ENEMA 0.00000 2.91026 12/1/2012 DOCUSATE SODIUM 50 MG/5 ML LIQUID 0.00000 0.00737 12/1/2012 DOCUSATE SODIUM 60 MG/15ML SYRUP 0.00000 0.00657 12/1/2012 DOCUSATE SODIUM/BENZOCAINE 283-20MG/5 ENEMA 0.00000 2.92776 12/1/2012 DONEPEZIL HCL 10 MG TAB RAPDIS 0.27257 0.27260 12/14/2012 DONEPEZIL HCL 10 MG TABLET 0.07520 0.07705 2/22/2013 DONEPEZIL HCL 5 MG TAB RAPDIS 0.27257 0.27260 12/14/2012 DONEPEZIL HCL 5 MG TABLET 0.07517 0.07520 12/14/2012 DOPAMINE HCL 400 MG/5ML VIAL 0.00000 0.50263 12/1/2012 DOPAMINE HCL 400MG/10ML VIAL 0.07476 0.07980 1/25/2013 DOPAMINE HCL 800MG/10ML VIAL 0.00000 0.20101 12/1/2012 DOPAMINE HCL 800MG/5ML VIAL 0.00000 0.62837 12/1/2012 DOPAMINE HCL/D5W 200MG/.25L PLAST. BAG 0.03060 0.02960 1/25/2013 DOPAMINE HCL/D5W 400MG/.25L PLAST. BAG 0.03721 0.03690 1/25/2013 DOPAMINE HCL/D5W 400MG/0.5L PLAST. BAG 0.04374 0.04060 1/25/2013 DOPAMINE HCL/D5W 800MG/.25L PLAST. BAG 0.05361 0.08010 1/25/2013 DOPAMINE HCL/D5W 800MG/0.5L PLAST. BAG 0.06031 0.05100 1/25/2013 DORZOLAMIDE HCL 2 % DROPS 1.45792 1.45790 12/14/2012 DORZOLAMIDE HCL/TIMOLOL MALEAT 2%-0.5% DROPS 0.00000 2.89120 12/1/2012 DOXAZOSIN MESYLATE 1 MG TABLET 0.05600 0.05630 1/25/2013 DOXAZOSIN MESYLATE 2 MG TABLET 0.06280 0.06100 1/25/2013 DOXAZOSIN MESYLATE 4 MG TABLET 0.07130 0.07320 1/25/2013 DOXAZOSIN MESYLATE 8 MG TABLET 0.10420 0.09060 1/25/2013 DOXEPIN HCL 10 MG CAPSULE 0.15110 0.16016 2/22/2013 DOXEPIN HCL 10 MG/ML ORAL CONC 0.05716 0.05720 12/14/2012 DOXEPIN HCL 100 MG CAPSULE 0.47710 0.50570 2/22/2013 DOXEPIN HCL 150 MG CAPSULE 0.00000 0.50211 12/1/2012 DOXEPIN HCL 25 MG CAPSULE 0.19890 0.21073 2/22/2013 DOXEPIN HCL 50 MG CAPSULE 0.26430 0.28019 2/22/2013 DOXORUBICIN HCL 10 MG VIAL 8.96000 9.08830 1/25/2013 DOXORUBICIN HCL 50 MG VIAL 0.00000 23.25700 12/1/2012 DOXORUBICIN HCL PEG-LIPOSOMAL 2 MG/ML VIAL 0.00000 80.58400 12/1/2012 DOXYCYCLINE HYCLATE 100 MG CAPSULE 0.05936 0.07745 2/22/2013 DOXYCYCLINE HYCLATE 100 MG TABLET DR 0.00000 19.21626 12/1/2012 DOXYCYCLINE HYCLATE 100 MG VIAL 12.55800 13.37070 1/25/2013 DOXYCYCLINE HYCLATE 150 MG TABLET DR 0.00000 25.72164 12/1/2012 Page 18 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 DOXYCYCLINE HYCLATE 20 MG TABLET 0.83286 0.76630 1/25/2013 DOXYCYCLINE HYCLATE 50 MG CAPSULE 0.07500 0.07660 2/8/2013 DOXYCYCLINE HYCLATE 75 MG TABLET DR 0.00000 14.94291 12/1/2012 DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE 0.00000 0.41162 12/1/2012 DOXYCYCLINE MONOHYDRATE 100 MG TABLET 0.95110 0.95020 1/25/2013 DOXYCYCLINE MONOHYDRATE 150 MG CAPSULE 0.00000 17.25512 12/1/2012 DOXYCYCLINE MONOHYDRATE 150 MG TABLET 0.00000 4.39361 12/1/2012 DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE 0.00000 0.21255 12/1/2012 DOXYCYCLINE MONOHYDRATE 50 MG TABLET 1.35064 1.35060 12/14/2012 DOXYCYCLINE MONOHYDRATE 75 MG CAPSULE 0.00000 9.06192 12/1/2012 DOXYCYCLINE MONOHYDRATE 75 MG TABLET 0.86431 0.73370 1/25/2013 DRONABINOL 10 MG CAPSULE 0.00000 12.58532 12/1/2012 DRONABINOL 2.5 MG CAPSULE 0.00000 3.72548 12/1/2012 DRONABINOL 5 MG CAPSULE 0.00000 7.47720 12/1/2012 DROPERIDOL 2.5 MG/ML AMPUL 0.50820 0.84840 1/25/2013 DROPERIDOL 2.5 MG/ML VIAL 1.42800 1.48750 1/25/2013 ECONAZOLE NITRATE 1 % CREAM (G) 0.16335 0.16340 12/14/2012 ELECTROLYTE,ORAL SOLUTION 0.00000 0.00415 12/1/2012 ELECTROLYTE-48 SOLUTION/D5W 5 % IV SOLN 0.00433 0.00430 1/25/2013 EMOL53/NAMGFS/HA/NAHYPOCHLORIT 96.53 %-3% KT CRM GE 0.00000 138.64900 12/1/2012 EMOLLIENT COMBINATION NO.10 EMULSN(G) 0.00000 0.44835 12/1/2012 EMOLLIENT COMBINATION NO.32 EMULSN(G) 0.00000 0.61081 12/1/2012 EMOLLIENT COMBINATION NO.44 FOAM 0.00000 0.90811 12/1/2012 EMOLLIENT COMBINATION NO.53 CREAM (G) 0.00000 0.51341 12/1/2012 EMOLLIENT COMBINATION NO.53 FOAM 0.00000 1.01001 12/1/2012 ENALAPRIL MALEATE 10 MG TABLET 0.02961 0.02960 12/14/2012 ENALAPRIL MALEATE 100 % POWDER 8.58004 3.35240 1/25/2013 ENALAPRIL MALEATE 2.5 MG TABLET 0.02439 0.02440 12/14/2012 ENALAPRIL MALEATE 20 MG TABLET 0.03630 0.03631 2/8/2013 ENALAPRIL MALEATE 5 MG TABLET 0.02479 0.02480 12/14/2012 ENALAPRIL/HYDROCHLOROTHIAZIDE 10MG-25MG TABLET 0.11725 0.11730 12/14/2012 ENALAPRIL/HYDROCHLOROTHIAZIDE 5MG-12.5MG TABLET 0.09988 0.09990 12/14/2012 ENALAPRILAT DIHYDRATE 1.25MG/ML VIAL 1.81436 1.71820 1/25/2013 ENOXAPARIN SODIUM 100 MG/ML DISP SYRIN 0.00000 26.00835 12/1/2012 ENOXAPARIN SODIUM 120MG/.8ML DISP SYRIN 0.00000 31.20920 12/1/2012 ENOXAPARIN SODIUM 150 MG/ML DISP SYRIN 0.00000 39.01150 12/1/2012 ENOXAPARIN SODIUM 300MG/3ML VIAL 0.00000 41.71412 12/1/2012 ENOXAPARIN SODIUM 30MG/0.3ML DISP SYRIN 0.00000 9.13440 12/1/2012 ENOXAPARIN SODIUM 40MG/0.4ML DISP SYRIN 0.00000 11.16500 12/1/2012 ENOXAPARIN SODIUM 60MG/0.6ML DISP SYRIN 0.00000 15.98520 12/1/2012 ENOXAPARIN SODIUM 80MG/0.8ML DISP SYRIN 0.00000 21.31395 12/1/2012 ENTACAPONE 200 MG TABLET 0.00000 2.76836 12/1/2012 ENZYMES,DIGESTIVE CAPSULE 0.04515 0.05940 1/25/2013 ENZYMES,DIGESTIVE TABLET 0.06552 0.07230 1/25/2013 EPHEDRINE SULFATE 50 MG/ML VIAL 4.92170 4.10130 1/25/2013 EPINASTINE HCL 0.05 % DROPS 0.00000 10.45350 12/1/2012 EPINEPHRINE 0.1 MG/ML DISP SYRIN 0.52584 0.47910 1/25/2013 EPINEPHRINE 1 MG/ML VIAL 0.00000 0.18800 12/1/2012 EPIRUBICIN HCL 200 MG VIAL 0.00000 1,992.09500 12/1/2012 EPIRUBICIN HCL 50 MG VIAL 0.00000 76.67100 12/1/2012 EPLERENONE 25 MG TABLET 2.33425 2.33430 12/14/2012 EPLERENONE 50 MG TABLET 2.33797 2.33800 12/14/2012 EPOPROSTENOL SODIUM (GLYCINE) 0.5 MG VIAL 10.12200 12.85200 1/25/2013 EPOPROSTENOL SODIUM (GLYCINE) 1.5 MG VIAL 0.00000 24.45100 12/1/2012 Page 19 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 EPROSARTAN MESYLATE 600 MG TABLET 0.00000 2.39820 12/1/2012 ERGOCALCIFEROL (VITAMIN D2) 2000 UNIT TABLET 0.00000 0.05446 12/1/2012 ERGOCALCIFEROL (VITAMIN D2) 400 UNIT TABLET 0.02270 0.02380 2/8/2013 ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT CAPSULE 0.24937 0.24940 12/14/2012 ERGOLOID MESYLATES 1 MG TABLET 2.17620 3.26420 2/1/2013 ERGOTAMINE TARTRATE/CAFFEINE 1MG-100MG TABLET 0.84553 0.84550 12/14/2012 ERY E-SUCC/SULFISOXAZOLE 200-600/5 SUSP RECON 0.18300 0.19120 2/8/2013 ERYTHROMYCIN BASE 250 MG CAPSULE DR 2.04160 2.65410 2/1/2013 ERYTHROMYCIN BASE 250 MG TABLET 1.82910 2.37790 1/25/2013 ERYTHROMYCIN BASE 500 MG TABLET 2.79500 2.79496 2/15/2013 ERYTHROMYCIN BASE 5MG/G OINT. (G) 2.97960 3.00872 2/22/2013 ERYTHROMYCIN BASE/ETHANOL 2 % MED. SWAB 1.04870 1.10370 2/8/2013 ERYTHROMYCIN/BENZOYL PEROXIDE 3 %-5 % GEL (GRAM) 1.11770 1.08702 2/22/2013 ESCITALOPRAM OXALATE 10 MG TABLET 0.00000 0.16950 2/1/2013 ESCITALOPRAM OXALATE 20 MG TABLET 0.16723 0.19890 2/8/2013 ESCITALOPRAM OXALATE 5 MG TABLET 0.11350 0.15950 2/8/2013 ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION 0.00000 0.55475 12/1/2012 ESTAZOLAM 1 MG TABLET 0.26774 0.26770 1/25/2013 ESTAZOLAM 2 MG TABLET 0.29328 0.29330 1/25/2013 ESTRADIOL .025MG/24H PATCH TDWK 0.00000 11.57200 12/1/2012 ESTRADIOL .0375MG/24 PATCH TDWK 11.33125 11.57200 1/25/2013 ESTRADIOL .075MG/24H PATCH TDWK 0.00000 11.57200 12/1/2012 ESTRADIOL 0.05MG/24H PATCH TDWK 0.00000 11.57200 12/1/2012 ESTRADIOL 0.06MG/24H PATCH TDWK 0.00000 11.57200 12/1/2012 ESTRADIOL 0.1MG/24HR PATCH TDWK 0.00000 11.57200 12/1/2012 ESTRADIOL 0.5 MG TABLET 0.05960 0.07535 2/22/2013 ESTRADIOL 1 MG TABLET 0.05120 0.08683 2/22/2013 ESTRADIOL 2 MG TABLET 0.06220 0.11216 2/22/2013 ESTRADIOL/NORETHINDRONE ACET 0.5-0.1MG TABLET 0.00000 5.28900 12/1/2012 ESTRADIOL/NORETHINDRONE ACET 1 MG-0.5MG TABLET 2.48790 2.68830 2/1/2013 ESTROGEN,ESTER/ME-TESTOSTERONE 0.625-1.25 TABLET 0.00000 0.54404 12/1/2012 ESTROGEN,ESTER/ME-TESTOSTERONE 1.25-2.5MG TABLET 0.00000 0.54404 12/1/2012 ESTROPIPATE 0.75 MG TABLET 0.23634 0.23630 12/14/2012 ESTROPIPATE 1.5 MG TABLET 0.33059 0.33060 12/14/2012 ESTROPIPATE 3 MG TABLET 0.70273 0.70270 12/14/2012 ETHAMBUTOL HCL 100 MG TABLET 0.29991 0.30650 1/25/2013 ETHAMBUTOL HCL 400 MG TABLET 0.00000 0.62310 12/1/2012 ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) TABLET 0.00000 1.77025 12/1/2012 ETHINYL ESTRADIOL/DROSPIRENONE 0.03-3MG TABLET 1.53508 2.02110 2/22/2013 ETHOSUXIMIDE 250 MG CAPSULE 0.85460 0.83706 2/22/2013 ETHOSUXIMIDE 250 MG/5ML SOLUTION 0.00000 0.06070 12/1/2012 ETHYL ALCOHOL 98 % AMPUL 6.51850 6.26450 2/15/2013 ETHYL ALCOHOL 98 % VIAL 12.15186 12.10060 1/25/2013 ETHYNODIOL D-ETHINYL ESTRADIOL 1 MG-35MCG TABLET 0.74020 0.74700 2/8/2013 ETIDRONATE DISODIUM 200 MG TABLET 2.69197 2.85340 1/25/2013 ETIDRONATE DISODIUM 400 MG TABLET 5.38250 5.70550 2/8/2013 ETODOLAC 200 MG CAPSULE 0.40000 0.92480 1/25/2013 ETODOLAC 300 MG CAPSULE 0.00000 1.13180 12/1/2012 ETODOLAC 400 MG TAB ER 24H 0.67987 0.68430 1/25/2013 ETODOLAC 500 MG TAB ER 24H 0.84570 0.83911 2/22/2013 ETODOLAC 500 MG TABLET 0.30130 0.30110 1/25/2013 ETODOLAC 600 MG TAB ER 24H 1.32650 1.33730 1/25/2013 ETOPOSIDE 50 MG CAPSULE 46.79400 56.82120 2/15/2013 EXEMESTANE 25 MG TABLET 6.92820 7.01333 2/22/2013 Page 20 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 FA/ARGININE HCL/B12/B6/PEP EX 2-500-500 TABLET 0.00000 0.56210 12/1/2012 FAMCICLOVIR 125 MG TABLET 0.00000 1.06080 12/1/2012 FAMCICLOVIR 250 MG TABLET 1.09504 1.09500 12/14/2012 FAMCICLOVIR 500 MG TABLET 2.16230 2.16190 1/25/2013 FAMOTIDINE 10 MG TABLET 0.08308 0.08310 12/14/2012 FAMOTIDINE 10 MG/ML VIAL 0.00000 0.27792 12/1/2012 FAMOTIDINE 20 MG TABLET 0.03792 0.03790 12/14/2012 FAMOTIDINE 40 MG TABLET 0.06727 0.06730 12/14/2012 FAMOTIDINE 40MG/5ML ORAL SUSP 0.00000 1.73584 12/1/2012 FAMOTIDINE IN NACL,ISO-OSM/PF 20MG/50ML PIGGYBACK 0.00000 0.13650 12/1/2012 FAMOTIDINE/PF 20 MG/2 ML VIAL 0.37429 0.37780 1/25/2013 FE FUMARATE/VIT C/B12-IF/FA 110-0.5MG CAPSULE 0.18620 0.19760 1/25/2013 FELBAMATE 400 MG TABLET 0.00000 3.64207 12/1/2012 FELBAMATE 600 MG TABLET 0.00000 4.17758 12/1/2012 FELBAMATE 600MG/5ML ORAL SUSP 0.00000 1.87137 12/1/2012 FELODIPINE 10 MG TAB ER 24H 0.79047 0.79050 1/25/2013 FELODIPINE 2.5 MG TAB ER 24H 0.54216 0.54220 1/25/2013 FELODIPINE 5 MG TAB ER 24H 0.54377 0.54380 1/25/2013 FENOFIBRATE 160 MG TABLET 1.53564 1.53510 1/4/2013 FENOFIBRATE 54 MG TABLET 0.00000 0.55448 12/1/2012 FENOFIBRATE NANOCRYSTALLIZED 145MG TABLET 3.96421 3.82670 2/22/2013 FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET 1.31113 1.33669 2/22/2013 FENOFIBRATE,MICRONIZED 200 MG CAPSULE 0.00000 2.31300 12/1/2012 FENOFIBRATE,MICRONIZED 67 MG CAPSULE 0.65280 0.73960 2/8/2013 FENOFIBRIC ACID 105 MG TABLET 0.00000 3.96959 12/1/2012 FENOFIBRIC ACID 35 MG TABLET 0.00000 1.32159 12/1/2012 FENTANYL 100 MCG/HR PATCH TD72 0.00000 21.12400 12/1/2012 FENTANYL 25MCG/HR PATCH TD72 4.22500 4.22240 1/25/2013 FENTANYL 50MCG/HR PATCH TD72 6.54560 9.08500 2/8/2013 FENTANYL 75MCG/HR PATCH TD72 11.08370 13.25120 2/22/2013 FENTANYL CITRATE 1200 MCG LOZENGE HD 0.00000 31.46500 12/1/2012 FENTANYL CITRATE 1600 MCG LOZENGE HD 0.00000 38.80683 12/1/2012 FENTANYL CITRATE 200 MCG LOZENGE HD 0.00000 13.16280 12/1/2012 FENTANYL CITRATE 400 MCG LOZENGE HD 0.00000 16.67657 12/1/2012 FENTANYL CITRATE 600 MCG LOZENGE HD 0.00000 20.42600 12/1/2012 FENTANYL CITRATE 800 MCG LOZENGE HD 0.00000 24.20180 12/1/2012 FENTANYL CITRATE/PF 100MCG/2ML DISP SYRIN 0.59640 0.65520 1/25/2013 FERROUS GLUCONATE 240(27)MG TABLET 0.04165 0.05160 1/25/2013 FERROUS SULFATE 140(45)MG TABLET ER 0.00000 0.15868 12/1/2012 FERROUS SULFATE 15 MG/ML DROPS 0.00000 0.06137 12/1/2012 FERROUS SULFATE 220(44)/5 SOLUTION 0.00000 0.00697 12/1/2012 FERROUS SULFATE 325(65) MG TABLET 0.00830 0.00831 2/1/2013 FERROUS SULFATE/VIT C/FA 105-500-.8 TABLET ER 0.00000 0.45920 12/1/2012 FEXOFENADINE HCL 180 MG TABLET 0.36690 0.36689 2/15/2013 FEXOFENADINE HCL 30 MG TAB RAPDIS 0.00000 1.63275 12/1/2012 FEXOFENADINE HCL 30 MG TABLET 0.00000 0.71400 12/1/2012 FEXOFENADINE HCL 30 MG/5 ML ORAL SUSP 0.00000 0.16328 12/1/2012 FEXOFENADINE HCL 60 MG TABLET 0.55637 0.55640 12/14/2012 FEXOFENADINE/PSEUDOEPHEDRINE 180-240MG TAB ER 24H 0.00000 0.96973 12/1/2012 FEXOFENADINE/PSEUDOEPHEDRINE 60MG-120MG TAB ER 12H 0.00000 0.66733 12/1/2012 FINASTERIDE 5 MG TABLET 0.16522 0.16520 1/25/2013 FISH OIL/BORAGE/FLAX/OM3,6,9#1 400-400 MG CAPSULE 0.06168 0.06490 1/25/2013 FISH OIL/DHA/EPA 1200-144MG CAPSULE 0.00000 0.01579 12/1/2012 FLAVOXATE HCL 100 MG TABLET 0.00000 0.95488 12/1/2012 Page 21 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 FLECAINIDE ACETATE 100 MG TABLET 0.27700 0.27770 1/25/2013 FLECAINIDE ACETATE 150 MG TABLET 0.54565 0.54570 12/14/2012 FLECAINIDE ACETATE 50 MG TABLET 0.19030 0.19060 1/25/2013 FLUCONAZOLE 10 MG/ML SUSP RECON 0.27150 0.26780 1/25/2013 FLUCONAZOLE 100 MG TABLET 0.17956 0.17960 12/14/2012 FLUCONAZOLE 150 MG TABLET 0.34610 0.34612 2/1/2013 FLUCONAZOLE 200 MG TABLET 0.28944 0.28940 12/14/2012 FLUCONAZOLE 40 MG/ML SUSP RECON 0.64574 0.64570 12/14/2012 FLUCONAZOLE 50 MG TABLET 0.10640 0.10870 1/25/2013 FLUCONAZOLE IN DEXTROSE,ISO-OS 200MG/0.1L PIGGYBACK 0.12630 0.09490 1/25/2013 FLUCONAZOLE IN DEXTROSE,ISO-OS 400MG/0.2L PIGGYBACK 0.07050 0.05300 1/25/2013 FLUCONAZOLE IN NACL,ISO-OSM 100MG/50ML PGGYBK BTL 0.00000 0.25410 12/1/2012 FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L PGGYBK BTL 0.00000 0.12676 12/1/2012 FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L PIGGYBACK 0.00000 0.05186 12/1/2012 FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L PGGYBK BTL 0.00000 0.09450 12/1/2012 FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L PIGGYBACK 0.00000 0.03268 12/1/2012 FLUCYTOSINE 250 MG CAPSULE 0.00000 16.21200 12/1/2012 FLUCYTOSINE 500 MG CAPSULE 0.00000 31.37400 12/1/2012 FLUDROCORTISONE ACETATE 0.1 MG TABLET 0.51856 0.51920 1/25/2013 FLUNISOLIDE 25 MCG SPRAY 0.00000 1.92500 12/1/2012 FLUNISOLIDE 29MCG SPRAY 0.00000 1.53888 12/1/2012 FLUOCINOLONE ACETONIDE 0.01 % OIL 0.00000 0.21619 12/1/2012 FLUOCINOLONE ACETONIDE 0.01 % SOLUTION 0.00000 2.10000 12/1/2012 FLUOCINOLONE ACETONIDE 0.025 % CREAM (G) 1.27060 1.27055 2/15/2013 FLUOCINOLONE ACETONIDE 0.025 % OINT. (G) 1.41411 1.32643 2/22/2013 FLUOCINOLONE ACETONIDE OIL 0.01 % DROPS 0.00000 1.10145 12/1/2012 FLUOCINOLONE/SHOWER CAP 0.01 % OIL 0.00000 0.22282 12/1/2012 FLUOCINONIDE 0.05 % CREAM (G) 0.35080 0.35081 2/1/2013 FLUOCINONIDE 0.05 % GEL (GRAM) 0.80260 0.84670 1/25/2013 FLUOCINONIDE 0.05 % OINT. (G) 0.00000 0.78790 12/1/2012 FLUOCINONIDE 0.05 % SOLUTION 0.00000 1.20370 12/1/2012 FLUOCINONIDE/EMOLLIENT 0.05 % CREAM (G) 0.25690 0.20660 1/25/2013 FLUOROMETHOLONE 0.1 % DROPS SUSP 1.26018 1.21060 1/25/2013 FLUOROURACIL 1 G/20 ML VIAL 0.00000 0.49482 12/1/2012 FLUOROURACIL 2 % SOLUTION 5.29235 4.95080 1/25/2013 FLUOROURACIL 2.5 G/50ML VIAL 0.21580 0.21630 1/25/2013 FLUOROURACIL 5 % CREAM (G) 5.17900 5.21610 1/25/2013 FLUOROURACIL 5 % SOLUTION 5.57050 7.86240 1/25/2013 FLUOROURACIL 5 G/100 ML VIAL 0.21320 0.29560 2/1/2013 FLUOROURACIL 500MG/10ML VIAL 0.26070 0.25082 2/15/2013 FLUOXETINE HCL 10 MG CAPSULE 0.03120 0.03030 1/25/2013 FLUOXETINE HCL 10 MG TABLET 0.05199 0.05200 12/14/2012 FLUOXETINE HCL 20 MG CAPSULE 0.02480 0.02479 2/22/2013 FLUOXETINE HCL 20 MG TABLET 0.00000 0.60474 12/1/2012 FLUOXETINE HCL 20 MG/5 ML SOLUTION 0.03444 0.03440 12/14/2012 FLUOXETINE HCL 40 MG CAPSULE 0.21373 0.21370 12/14/2012 FLUOXETINE HCL 60 MG TABLET 4.83141 5.03440 1/25/2013 FLUOXETINE HCL 90 MG CAPSULE DR 0.00000 25.89300 12/1/2012 FLUPHENAZINE DECANOATE 25 MG/ML VIAL 0.00000 17.59500 11/16/2012 FLUPHENAZINE HCL 1 MG TABLET 0.12800 0.11230 1/25/2013 FLUPHENAZINE HCL 10 MG TABLET 0.16540 0.22160 1/25/2013 FLUPHENAZINE HCL 2.5 MG TABLET 0.19820 0.18330 1/25/2013 FLUPHENAZINE HCL 2.5 MG/5ML ELIXIR 0.00000 0.26710 12/1/2012 FLUPHENAZINE HCL 2.5 MG/ML VIAL 6.84110 8.55120 2/8/2013 Page 22 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 FLUPHENAZINE HCL 5 MG TABLET 0.21690 0.22020 1/25/2013 FLUPHENAZINE HCL 5 MG/ML ORAL CONC 0.00000 0.81136 12/1/2012 FLURAZEPAM HCL 15 MG CAPSULE 0.06291 0.06290 12/14/2012 FLURAZEPAM HCL 30 MG CAPSULE 0.06950 0.07260 12/14/2012 FLURBIPROFEN 100 MG TABLET 0.13655 0.13660 12/14/2012 FLURBIPROFEN 50 MG TABLET 0.00000 0.10517 12/1/2012 FLURBIPROFEN SODIUM 0.03 % DROPS 0.00000 1.74850 12/1/2012 FLUTAMIDE 125 MG CAPSULE 0.70380 0.71030 1/25/2013 FLUTICASONE PROPIONATE 0.005 % OINT. (G) 0.49071 0.49070 12/14/2012 FLUTICASONE PROPIONATE 0.05 % CREAM (G) 0.00000 0.55080 12/1/2012 FLUTICASONE PROPIONATE 0.05 % LOTION 0.00000 4.54942 12/1/2012 FLUTICASONE PROPIONATE 50 MCG SPRAY SUSP 1.06710 1.06720 2/22/2013 FLUVASTATIN SODIUM 20 MG CAPSULE 0.00000 2.64297 12/1/2012 FLUVASTATIN SODIUM 40 MG CAPSULE 0.00000 2.64300 12/1/2012 FLUVOXAMINE MALEATE 100 MG TABLET 0.32330 0.32140 2/22/2013 FLUVOXAMINE MALEATE 25 MG TABLET 0.29790 0.28890 1/25/2013 FLUVOXAMINE MALEATE 50 MG TABLET 0.31200 0.29948 2/22/2013 FOLIC ACID 0.4 MG TABLET 0.00000 0.01005 12/1/2012 FOLIC ACID 1 MG TABLET 0.00000 0.02320 12/1/2012 FOLIC ACID 5 MG/ML VIAL 1.49520 1.79410 2/15/2013 FOLIC ACID/MULTIVITS-MIN 0.4 MG TABLET 0.70885 0.80780 1/25/2013 FOLIC ACID/MULTIVITS-MIN/LUT 0.4MG-250 TABLET 0.04845 0.03600 1/25/2013 FOLIC ACID/MV,FE,OTHER MIN/LUT 0.4-18-250 TABLET 0.04533 0.04360 1/25/2013 FOLIC ACID/VITAMIN B COMP W-C 0.8 MG TABLET 0.09958 0.09960 12/14/2012 FOLIC ACID/VITAMIN B COMP W-C 1 MG CAPSULE 0.50090 0.59080 1/25/2013 FONDAPARINUX SODIUM 10MG/0.8ML DISP SYRIN 0.00000 94.71000 1/25/2012 FONDAPARINUX SODIUM 2.5 MG/0.5 DISP SYRIN 63.17080 59.81030 1/25/2013 FONDAPARINUX SODIUM 5MG/0.4ML DISP SYRIN 0.00000 176.97650 12/1/2012 FONDAPARINUX SODIUM 7.5MG/0.6 DISP SYRIN 147.48213 132.73867 2/22/2013 FORMALDEHYDE 10 % SOL W/APPL 0.00000 0.36953 12/1/2012 FOSINOPRIL SODIUM 10 MG TABLET 0.20530 0.19770 1/25/2013 FOSINOPRIL SODIUM 20 MG TABLET 0.18520 0.15510 1/25/2013 FOSINOPRIL SODIUM 40 MG TABLET 0.17670 0.17840 1/25/2013 FOSINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 1.08073 0.97530 1/25/2013 FOSINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 1.00740 0.97530 1/25/2013 FOSPHENYTOIN SODIUM 100MG PE/2 VIAL 0.65940 0.84210 1/25/2013 FOSPHENYTOIN SODIUM 500 PE/10 VIAL 0.00000 0.46214 12/1/2012 FUROSEMIDE 10 MG/ML DISP SYRIN 0.00000 0.71988 12/1/2012 FUROSEMIDE 10 MG/ML SOLUTION 0.10880 0.11130 2/8/2013 FUROSEMIDE 10 MG/ML VIAL 0.09072 0.09070 12/14/2012 FUROSEMIDE 20 MG TABLET 0.01030 0.01032 2/15/2013 FUROSEMIDE 40 MG TABLET 0.01150 0.01152 2/22/2013 FUROSEMIDE 40MG/5ML SOLUTION 0.00000 0.14150 12/1/2012 FUROSEMIDE 80 MG TABLET 0.02730 0.02710 1/25/2013 GABAPENTIN 100 MG CAPSULE 0.04221 0.04220 12/14/2012 GABAPENTIN 250 MG/5ML SOLUTION 0.13521 0.13390 1/25/2013 GABAPENTIN 250 MG/CUP SOLUTION 0.00000 0.29166 12/1/2012 GABAPENTIN 300 MG CAPSULE 0.06807 0.06810 12/14/2012 GABAPENTIN 300 MG/6ML SOLUTION 0.00000 0.29164 12/1/2012 GABAPENTIN 400 MG CAPSULE 0.09072 0.09070 12/14/2012 GABAPENTIN 600 MG TABLET 0.26170 0.27550 1/25/2013 GABAPENTIN 800 MG TABLET 0.00000 0.42880 12/1/2012 GALANTAMINE HBR 12 MG TABLET 0.00000 1.78863 12/1/2012 GALANTAMINE HBR 16 MG CAP24H PEL 0.00000 2.23110 12/1/2012 Page 23 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 GALANTAMINE HBR 24 MG CAP24H PEL 2.45528 2.45490 1/25/2013 GALANTAMINE HBR 4 MG TABLET 0.00000 1.78863 12/1/2012 GALANTAMINE HBR 4 MG/ML SOLUTION 0.00000 2.95575 12/1/2012 GALANTAMINE HBR 8 MG CAP24H PEL 2.36510 2.18150 1/25/2013 GALANTAMINE HBR 8 MG TABLET 0.00000 1.78863 12/1/2012 GANCICLOVIR SODIUM 500 MG VIAL 9.30936 9.65940 1/25/2013 GANIRELIX ACETATE 250MCG/0.5 DISP SYRIN 221.90700 243.87300 1/25/2013 GEMCITABINE HCL 1 G VIAL 0.00000 39.63675 12/1/2012 GEMCITABINE HCL 1 G/26.3ML VIAL 0.00000 3.16329 12/1/2012 GEMCITABINE HCL 2 G VIAL 0.00000 92.63950 12/1/2012 GEMCITABINE HCL 2 G/52.6ML VIAL 0.00000 3.58109 12/1/2012 GEMCITABINE HCL 200 MG VIAL 0.00000 9.28800 12/1/2012 GEMCITABINE HCL 200MG/5.26 VIAL 0.00000 3.79680 12/1/2012 GEMFIBROZIL 600 MG TABLET 0.13040 0.12920 1/25/2013 GENTAMICIN IN NACL, ISO-OSM 100MG/50ML PIGGYBACK 0.00000 0.13213 12/1/2012 GENTAMICIN IN NACL, ISO-OSM 120MG/0.1L PIGGYBACK 0.00000 0.06630 12/1/2012 GENTAMICIN IN NACL, ISO-OSM 70 MG/50ML PIGGYBACK 0.00000 0.15469 12/1/2012 GENTAMICIN IN NACL, ISO-OSM 90MG/100ML PIGGYBACK 0.00000 0.07491 12/1/2012 GENTAMICIN SULFATE 0.1 % CREAM (G) 0.62140 0.61870 1/25/2013 GENTAMICIN SULFATE 0.1 % OINT. (G) 0.61070 0.72750 12/21/2012 GENTAMICIN SULFATE 0.3 % DROPS 1.24084 1.24080 12/14/2012 GENTAMICIN SULFATE 0.3 % OINT. (G) 0.00000 3.02900 12/1/2012 GENTAMICIN SULFATE 10 MG/ML VIAL 0.00000 1.45158 12/1/2012 GENTAMICIN SULFATE 40 MG/ML VIAL 0.58290 0.59490 1/25/2013 GENTAMICIN SULFATE/PF 100MG/10ML VIAL PORT 0.00000 0.29434 12/1/2012 GENTAMICIN SULFATE/PF 20 MG/2 ML VIAL 0.00000 1.25658 12/1/2012 GENTAMICIN SULFATE/PF 60 MG/6 ML VIAL PORT 0.00000 0.39255 12/1/2012 GENTAMICIN SULFATE/PF 80 MG/8 ML VIAL PORT 0.00000 0.34262 12/1/2012 GLIMEPIRIDE 1 MG TABLET 0.02908 0.02910 12/14/2012 GLIMEPIRIDE 2 MG TABLET 0.05350 0.05347 2/22/2013 GLIMEPIRIDE 4 MG TABLET 0.06860 0.06861 2/22/2013 GLIPIZIDE 10 MG TAB ER 24 0.00000 0.40120 12/1/2012 GLIPIZIDE 10 MG TABLET 0.04330 0.04328 2/22/2013 GLIPIZIDE 2.5 MG TAB ER 24 0.28467 0.28470 12/14/2012 GLIPIZIDE 5 MG TAB ER 24 0.00000 0.18940 12/1/2012 GLIPIZIDE 5 MG TABLET 0.01970 0.03000 1/25/2013 GLIPIZIDE/METFORMIN HCL 2.5-250 MG TABLET 0.00000 0.34151 12/1/2012 GLIPIZIDE/METFORMIN HCL 2.5-500 MG TABLET 0.00000 0.39585 12/1/2012 GLIPIZIDE/METFORMIN HCL 5 MG-500MG TABLET 0.39746 0.39590 1/25/2013 GLUC/CHON-MSM#1/C/MANG/BOS/BOR 750-625MG TABLET 0.00000 0.20448 12/1/2012 GLUCOSAMINE SULF/CHONDROITIN A 250-200 MG CAPSULE 0.12690 0.10590 1/25/2013 GLUCOSAMINE SULFATE 750 MG TABLET 0.00000 0.33095 12/1/2012 GLUCOSAMINE/MSM/CHONDROITIN A 500-150 MG TABLET 0.00000 1.20120 12/1/2012 GLUTAMINE 500 MG TABLET 0.09395 0.11400 1/25/2013 GLYBURIDE 1.25 MG TABLET 0.12315 0.12320 12/14/2012 GLYBURIDE 2.5 MG TABLET 0.14767 0.14770 12/14/2012 GLYBURIDE 5 MG TABLET 0.22579 0.22580 12/14/2012 GLYBURIDE,MICRONIZED 1.5 MG TABLET 0.02587 0.02590 12/14/2012 GLYBURIDE,MICRONIZED 3 MG TABLET 0.02841 0.02840 12/14/2012 GLYBURIDE,MICRONIZED 6 MG TABLET 0.05507 0.05510 12/14/2012 GLYBURIDE/METFORMIN HCL 1.25-250MG TABLET 0.09935 0.09940 12/14/2012 GLYBURIDE/METFORMIN HCL 2.5-500 MG TABLET 0.10479 0.10480 12/14/2012 GLYBURIDE/METFORMIN HCL 5 MG-500MG TABLET 0.09514 0.09510 12/14/2012 GLYCINE POWDER 0.20644 0.21190 1/25/2013 Page 24 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 GLYCINE 1.5 % IRRIG SOLN 0.00000 0.00300 12/1/2012 GLYCINE/SOD/WATER/SOD HYDROX VIAL 0.00000 0.14700 12/1/2012 GLYCOPYRROLATE 1 MG TABLET 0.25250 0.23370 2/22/2013 GLYCOPYRROLATE 2 MG TABLET 0.00000 0.95797 12/1/2012 GRANISETRON HCL 1 MG/ML VIAL 0.00000 4.71250 12/1/2012 GRANISETRON HCL 1 MG/ML(1) VIAL 0.00000 7.21995 12/1/2012 GRANISETRON HCL/PF 1 MG/ML(1) VIAL 0.00000 9.00000 12/1/2012 GRANISETRON HCL/PF 100 MCG/ML VIAL 0.00000 2.49240 12/1/2012 GRISEOFULVIN ULTRAMICROSIZE 125 MG TABLET 3.68837 3.68840 1/25/2013 GRISEOFULVIN ULTRAMICROSIZE 250 MG TABLET 4.71086 4.71090 1/25/2013 GRISEOFULVIN,MICROSIZE 125 MG/5ML ORAL SUSP 0.14400 0.14580 2/8/2013 GRISEOFULVIN,MICROSIZE 500 MG TABLET 0.00000 5.40337 12/14/2012 GUAIFENESIN 100 MG/5ML LIQUID 0.00520 0.00523 2/1/2013 GUAIFENESIN 200 MG TABLET 0.05376 0.05110 12/14/2012 GUAIFENESIN 400 MG TABLET 0.10184 0.10180 1/25/2013 GUAIFENESIN 600 MG TABLET ER 0.31161 0.30670 1/25/2013 GUAIFENESIN/CODEINE PHOSPHATE 100-10MG/5 LIQUID 0.00000 0.00965 12/1/2012 GUAIFENESIN/CODEINE PHOSPHATE 100-6.3/5 LIQUID 0.03518 0.06360 1/25/2013 GUAIFENESIN/CODEINE PHOSPHATE 200MG-9MG CAPSULE 0.00000 0.25375 12/1/2012 GUAIFENESIN/CODEINE PHOSPHATE 225-7.5/5 LIQUID 0.04710 0.04970 1/25/2013 GUAIFENESIN/D-METHORPHAN HB/PE 100-10-5MG LIQUID 0.00000 0.01943 12/1/2012 GUAIFENESIN/D-METHORPHAN HB/PE 100-15-5/5 LIQUID 0.04730 0.08670 1/25/2013 GUAIFENESIN/D-METHORPHAN HB/PE 200-10-5/5 LIQUID 0.00000 0.02586 12/1/2012 GUAIFENESIN/D-METHORPHAN HB/PE 200-20-10 LIQUID 0.08187 0.07980 1/25/2013 GUAIFENESIN/D-METHORPHAN HB/PE 200-20-5/5 ORAL SUSP 0.08509 0.06490 1/25/2013 GUAIFENESIN/D-METHORPHAN HB/PE 380-15-10 TABLET 0.47192 0.43610 1/25/2013 GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 LIQUID 0.03820 0.03160 1/25/2013 GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 SYRUP 0.00643 0.00640 12/14/2012 GUAIFENESIN/DEXTROMETHORPHAN 400-20MG/5 LIQUID 0.07583 0.06510 2/22/2013 GUAIFENESIN/DM/PSEUDOEPHEDRINE 400-15-45 TABLET 0.47192 0.43610 1/25/2013 GUAIFENESIN/PHENYLEPHRINE HCL 380MG-10MG TABLET 0.46550 0.43170 1/25/2013 GUAIFENESIN/PSEUDOEPHEDRNE HCL 400MG-45MG TABLET 0.46550 0.43170 1/25/2013 GUANFACINE HCL 1 MG TABLET 0.07830 0.07990 1/25/2013 GUANFACINE HCL 2 MG TABLET 0.11356 0.11360 12/14/2012 GUANIDINE HCL 125 MG TABLET 0.00000 0.17724 12/1/2012 HALOBETASOL PROPIONATE 0.05 % CREAM (G) 0.88020 0.92355 2/22/2013 HALOBETASOL PROPIONATE 0.05 % OINT. (G) 0.89030 0.84296 2/22/2013 HALOPERIDOL 0.5 MG TABLET 0.05940 0.06867 2/22/2013 HALOPERIDOL 1 MG TABLET 0.09240 0.10231 2/22/2013 HALOPERIDOL 10 MG TABLET 0.97720 0.97162 2/22/2013 HALOPERIDOL 2 MG TABLET 0.12610 0.13398 2/22/2013 HALOPERIDOL 20 MG TABLET 1.69890 1.65845 2/22/2013 HALOPERIDOL 5 MG TABLET 0.14970 0.14260 2/22/2013 HALOPERIDOL DECANOATE 100 MG/ML AMPUL 0.00000 41.45400 12/1/2012 HALOPERIDOL DECANOATE 100 MG/ML VIAL 31.00500 30.47697 2/22/2013 HALOPERIDOL DECANOATE 50 MG/ML AMPUL 0.00000 21.74667 12/1/2012 HALOPERIDOL DECANOATE 50 MG/ML VIAL 14.87250 15.45660 2/22/2013 HALOPERIDOL LACTATE 2 MG/ML ORAL CONC 0.04033 0.04030 12/14/2012 HALOPERIDOL LACTATE 5 MG/ML AMPUL 0.00000 5.15760 12/1/2012 HALOPERIDOL LACTATE 5 MG/ML VIAL 1.14838 1.14840 12/14/2012 HC/MINERAL OIL/PETROLAT,WHT 1 % OINT. (G) 0.00000 0.12564 12/1/2012 HEPARIN SOD,PORK IN 0.45% NACL 12500/250 IV SOLN 0.03562 0.03400 1/25/2013 HEPARIN SOD,PORK IN 0.45% NACL 25000/250 IV SOLN 0.00000 0.02288 12/1/2012 HEPARIN SOD,PORK IN 0.45% NACL 25000/500 IV SOLN 0.00000 0.01749 12/1/2012 Page 25 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 HEPARIN SODIUM,PORCINE 10 UNIT/ML DISP SYRIN 0.64407 0.65250 1/25/2013 HEPARIN SODIUM,PORCINE 100/ML VIAL 0.08940 0.03720 1/25/2013 HEPARIN SODIUM,PORCINE 1000/ML VIAL 0.00000 0.21199 12/1/2012 HEPARIN SODIUM,PORCINE 10000/ML VIAL 2.33147 2.33150 12/14/2012 HEPARIN SODIUM,PORCINE 20000/ML VIAL 8.60700 9.83865 2/22/2013 HEPARIN SODIUM,PORCINE 5000/ML CARTRIDGE 0.00000 3.65400 12/1/2012 HEPARIN SODIUM,PORCINE 5000/ML VIAL 0.72534 0.72530 12/14/2012 HEPARIN SODIUM,PORCINE/D5W 12500/250 IV SOLN 0.04076 0.03780 1/25/2013 HEPARIN SODIUM,PORCINE/D5W 20K/500ML IV SOLN 0.01172 0.00870 1/25/2013 HEPARIN SODIUM,PORCINE/NS/PF 1000/500ML IV SOLN 0.00579 0.00720 1/25/2013 HEPARIN SODIUM,PORCINE/NS/PF 2K/1000ML IV SOLN 0.00370 0.00440 1/25/2013 HEPARIN SODIUM,PORCINE/PF 10 UNIT/ML VIAL 1.27811 1.27250 1/25/2013 HEPARIN SODIUM,PORCINE/PF 100/ML VIAL 0.00000 1.63384 12/1/2012 HEPARIN SODIUM,PORCINE/PF 1000/ML VIAL 0.00000 4.02116 12/1/2012 HEPARIN SODIUM,PORCINE/PF 25K/10ML VIAL PORT 0.00000 0.64512 12/1/2012 HEPARIN SODIUM,PORCINE/PF 5000/0.5ML DISP SYRIN 0.00000 7.45725 12/1/2012 HEPARIN SODIUM,PORCINE/PF 5000/0.5ML VIAL 0.00000 9.36923 12/1/2012 HYDRALAZINE HCL 10 MG TABLET 0.05708 0.05710 12/14/2012 HYDRALAZINE HCL 100 MG TABLET 0.16320 0.18850 1/25/2013 HYDRALAZINE HCL 20 MG/ML VIAL 0.00000 4.60408 12/1/2012 HYDRALAZINE HCL 25 MG TABLET 0.05896 0.05900 12/14/2012 HYDRALAZINE HCL 50 MG TABLET 0.06526 0.06530 12/14/2012 HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE 0.04074 0.04070 12/14/2012 HYDROCHLOROTHIAZIDE 12.5 MG TABLET 0.12831 0.12830 12/14/2012 HYDROCHLOROTHIAZIDE 25 MG TABLET 0.01020 0.01018 2/8/2013 HYDROCHLOROTHIAZIDE 50 MG TABLET 0.01770 0.01890 1/25/2013 HYDROCODONE BIT/ACETAMINOPHEN 10-660MG TABLET 0.20194 0.20190 12/14/2012 HYDROCODONE BIT/ACETAMINOPHEN 10-750MG TABLET 0.00000 0.53554 12/1/2012 HYDROCODONE BIT/ACETAMINOPHEN 10MG-325MG TABLET 0.12370 0.12368 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 10MG-500MG TABLET 0.00000 0.21500 12/1/2012 HYDROCODONE BIT/ACETAMINOPHEN 10MG-650MG TABLET 0.00000 0.06660 12/1/2012 HYDROCODONE BIT/ACETAMINOPHEN 2.5-167/5 SOLUTION 0.00000 0.47191 12/1/2012 HYDROCODONE BIT/ACETAMINOPHEN 2.5-500 MG TABLET 0.20220 0.20210 1/25/2013 HYDROCODONE BIT/ACETAMINOPHEN 5 MG-500MG TABLET 0.04074 0.04070 1/25/2013 HYDROCODONE BIT/ACETAMINOPHEN 5-334MG/10 SOLUTION 0.00000 0.26732 12/1/2012 HYDROCODONE BIT/ACETAMINOPHEN 5MG-325MG TABLET 0.12960 0.12958 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-300MG TABLET 0.00000 1.34459 12/1/2012 HYDROCODONE BIT/ACETAMINOPHEN 7.5-325/15 SOLUTION 0.08902 0.08900 1/25/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-325/CP SOLUTION 0.00000 0.15120 12/1/2012 HYDROCODONE BIT/ACETAMINOPHEN 7.5-325MG TABLET 0.15544 0.15540 12/14/2012 HYDROCODONE BIT/ACETAMINOPHEN 7.5-500/15 SOLUTION 0.01726 0.01730 12/14/2012 HYDROCODONE BIT/ACETAMINOPHEN 7.5-500/CP SOLUTION 0.18080 0.18960 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-500MG TABLET 0.05110 0.05105 2/1/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-650 MG TABLET 0.06486 0.06490 12/14/2012 HYDROCODONE BIT/ACETAMINOPHEN 7.5-750MG TABLET 0.05588 0.05590 1/25/2013 HYDROCODONE BIT/HOMATROP ME-BR 5 MG-1.5MG TABLET 0.00000 0.42566 12/1/2012 HYDROCODONE BIT/HOMATROP ME-BR 5-1.5 MG/5 SYRUP 0.12020 0.06580 1/25/2013 HYDROCODONE BIT/HOMATROP ME-BR 5-1.5/CUP SYRUP 0.00000 0.52500 12/1/2012 HYDROCODONE/CHLORPHEN POLIS 10-8MG/5ML SUS ER 12H 0.00000 0.46202 12/1/2012 HYDROCODONE/IBUPROFEN 10MG-200MG TABLET 0.00000 2.86300 12/1/2012 HYDROCODONE/IBUPROFEN 2.5-200MG TABLET 0.00000 2.04491 12/1/2012 HYDROCODONE/IBUPROFEN 5MG-200MG TABLET 0.00000 2.17077 12/1/2012 HYDROCODONE/IBUPROFEN 7.5-200 MG TABLET 0.23930 0.23920 1/25/2013 HYDROCORT/PRAMOXN/SKN CLNSR#16 2.35 %-1 % KT CRM TW 0.00000 115.64000 12/1/2012 Page 26 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 HYDROCORTISONE POWDER 2.52900 2.52898 2/15/2013 HYDROCORTISONE 0.5 % CREAM (G) 0.09690 0.08089 2/15/2013 HYDROCORTISONE 1 % CREAM (G) 0.04382 0.04380 12/14/2012 HYDROCORTISONE 1 % CREAM (G) 0.00000 0.66820 12/1/2012 HYDROCORTISONE 1 % LOTION 0.03220 0.03080 1/25/2013 HYDROCORTISONE 1 % OINT. (G) 0.06810 0.10490 1/25/2013 HYDROCORTISONE 10 MG TABLET 0.00000 0.31148 12/1/2012 HYDROCORTISONE 100MG/60ML ENEMA 0.08616 0.08620 12/14/2012 HYDROCORTISONE 2.5 % CREAM (G) 0.14257 0.14260 12/14/2012 HYDROCORTISONE 2.5 % CREAM (G) 0.08750 0.10320 12/14/2012 HYDROCORTISONE 2.5 % LOTION 0.23930 0.23780 1/25/2013 HYDROCORTISONE 2.5 % OINT. (G) 0.00000 0.11200 12/1/2012 HYDROCORTISONE 20 MG TABLET 0.60568 0.60570 1/25/2013 HYDROCORTISONE 5 MG TABLET 0.00000 0.23730 12/1/2012 HYDROCORTISONE AC/LIDOCAINE 0.5 %-3 % CREAM/APPL 0.00000 1.78500 12/1/2012 HYDROCORTISONE AC/LIDOCAINE 1%-3%(7G) CREAM/APPL 0.00000 251.09000 12/1/2012 HYDROCORTISONE AC/LIDOCAINE 2.5-3%(7G) GEL W/APPL 0.00000 251.09000 12/1/2012 HYDROCORTISONE ACETATE POWDER 0.00000 3.23180 12/1/2012 HYDROCORTISONE ACETATE 25 MG SUPP.RECT 0.00000 1.44809 12/1/2012 HYDROCORTISONE ACETATE 30 MG SUPP.RECT 4.26360 3.95180 1/25/2013 HYDROCORTISONE ACETATE/UREA 1 %-10 % CREAM (G) 0.00000 0.88025 12/1/2012 HYDROCORTISONE BUTYRATE 0.1 % CREAM (G) 0.99540 1.02530 2/15/2013 HYDROCORTISONE BUTYRATE 0.1 % OINT. (G) 1.02527 1.05690 2/22/2013 HYDROCORTISONE BUTYRATE 0.1 % SOLUTION 0.00000 0.17360 12/1/2012 HYDROCORTISONE VALERATE 0.2 % CREAM (G) 0.00000 0.50250 12/1/2012 HYDROCORTISONE/IODOQUINOL 1 %-1 % CREAM (G) 0.43203 0.43200 12/14/2012 HYDROCORTISONE/LIDOCAINE/ALOE 2.5-3%(7G) KIT 0.00000 3.05119 12/1/2012 HYDROCORTISONE/PRAMOXINE 2.5 %-1 % CREAM (G) 0.00000 1.30835 12/1/2012 HYDROMORPHONE HCL 1 MG/ML LIQUID 0.00000 0.27988 12/1/2012 HYDROMORPHONE HCL 2 MG TABLET 0.09350 0.09310 1/25/2013 HYDROMORPHONE HCL 2 MG/ML VIAL 0.00000 0.53935 12/1/2012 HYDROMORPHONE HCL 3 MG SUPP.RECT 7.77580 8.58670 2/1/2013 HYDROMORPHONE HCL 4 MG TABLET 0.10969 0.10980 1/25/2013 HYDROMORPHONE HCL 8 MG TABLET 0.39543 0.39540 1/25/2013 HYDROMORPHONE HCL/PF 1 MG/ML AMPUL 0.84000 0.87360 1/25/2013 HYDROMORPHONE HCL/PF 1 MG/ML DISP SYRIN 3.54900 3.90600 1/25/2013 HYDROMORPHONE HCL/PF 10 MG/ML VIAL 1.54850 1.61984 2/22/2013 HYDROMORPHONE HCL/PF 2 MG/ML AMPUL 0.86520 0.94080 1/25/2013 HYDROMORPHONE HCL/PF 2 MG/ML DISP SYRIN 3.79050 4.17900 1/25/2013 HYDROMORPHONE HCL/PF 2 MG/ML VIAL 0.00000 1.74300 12/1/2012 HYDROMORPHONE HCL/PF 4 MG/ML AMPUL 1.27680 1.33560 1/25/2013 HYDROMORPHONE HCL/PF 4 MG/ML DISP SYRIN 3.42300 3.78000 1/25/2013 HYDROQUINONE 2 % CREAM (G) 0.09516 0.06280 1/25/2013 HYDROQUINONE 4 % CREAM (G) 0.00000 0.35360 12/1/2012 HYDROQUINONE MICROSPHERES 4 % CRM ER (G) 0.00000 2.49387 12/1/2012 HYDROXOCOBALAMIN 1000MCG/ML VIAL 0.00000 0.89273 12/1/2012 HYDROXYCHLOROQUINE SULFATE 200 MG TABLET 0.00000 0.10720 12/1/2012 HYDROXYUREA 500 MG CAPSULE 0.35220 0.35210 1/25/2013 HYDROXYZINE HCL 10 MG TABLET 0.07343 0.07340 12/14/2012 HYDROXYZINE HCL 10 MG/5 ML SYRUP 0.03810 0.05910 2/1/2013 HYDROXYZINE HCL 25 MG TABLET 0.00000 0.08630 12/1/2012 HYDROXYZINE HCL 25 MG/ML VIAL 2.62500 0.51630 1/25/2013 HYDROXYZINE HCL 50 MG TABLET 0.11015 0.11020 12/14/2012 HYDROXYZINE HCL 50 MG/ML VIAL 0.00000 1.75000 12/1/2012 Page 27 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 HYDROXYZINE PAMOATE 100 MG CAPSULE 0.29887 0.29890 12/14/2012 HYDROXYZINE PAMOATE 25 MG CAPSULE 0.00000 0.06620 12/1/2012 HYDROXYZINE PAMOATE 50 MG CAPSULE 0.00000 0.08680 12/1/2012 HYOSCYAMINE SULFATE 0.125 MG TAB RAPDIS 0.00000 0.20020 12/1/2012 HYOSCYAMINE SULFATE 0.125 MG TAB SUBL 0.22713 0.44000 1/11/2013 HYOSCYAMINE SULFATE 0.125 MG TABLET 0.00000 0.21869 12/1/2012 HYOSCYAMINE SULFATE 0.125MG/ML DROPS 1.12198 1.09080 1/25/2013 HYOSCYAMINE SULFATE 0.375 MG TAB ER 12H 0.69730 0.42399 2/15/2013 HYOSCYAMINE SULFATE 125MCG/5ML ELIXIR 0.05400 0.04790 1/25/2013 HYPROMELLOSE 0.3 % DROPS 0.35978 0.33450 1/25/2013 HYPROMELLOSE 0.4 % DROPS 0.00000 0.17850 12/1/2012 IBANDRONATE SODIUM 150 MG TABLET 97.13129 97.13590 1/25/2013 IBUPROFEN 100 MG TAB CHEW 0.12702 0.18350 1/25/2013 IBUPROFEN 100 MG TABLET 0.12702 0.18350 1/25/2013 IBUPROFEN 100 MG/5ML ORAL SUSP 0.02690 0.02669 2/15/2013 IBUPROFEN 200 MG CAPSULE 0.00000 0.05530 12/1/2012 IBUPROFEN 200 MG TABLET 0.01470 0.01474 2/15/2013 IBUPROFEN 400 MG TABLET 0.02910 0.02908 2/8/2013 IBUPROFEN 50 MG/1.25 DROPS SUSP 0.21986 0.21630 1/25/2013 IBUPROFEN 600 MG TABLET 0.03900 0.03899 2/8/2013 IBUPROFEN 800 MG TABLET 0.05090 0.05092 2/8/2013 IBUPROFEN/OXYCODONE HCL 400MG-5MG TABLET 1.03152 1.03130 1/25/2013 IFOSFAMIDE 1 G/20 ML VIAL 0.00000 5.07623 12/1/2012 IFOSFAMIDE 3 G VIAL 0.00000 88.61300 12/1/2012 IFOSFAMIDE 3G/60ML VIAL 0.00000 3.11430 12/1/2012 IFOSFAMIDE/MESNA 3G-1G KIT 0.00000 281.14725 12/1/2012 IMIPENEM/CILASTATIN SODIUM 250 MG VIAL 7.62120 6.52680 1/25/2013 IMIPENEM/CILASTATIN SODIUM 500 MG VIAL 13.13180 9.87840 1/25/2013 IMIPRAMINE HCL 10 MG TABLET 0.12570 0.12569 2/1/2013 IMIPRAMINE HCL 25 MG TABLET 0.16250 0.16254 2/1/2013 IMIPRAMINE HCL 50 MG TABLET 0.23250 0.23249 2/1/2013 IMIPRAMINE PAMOATE 100 MG CAPSULE 0.00000 5.39803 12/1/2012 IMIPRAMINE PAMOATE 125 MG CAPSULE 0.00000 11.40705 12/1/2012 IMIPRAMINE PAMOATE 150 MG CAPSULE 11.40705 10.62040 1/25/2013 IMIPRAMINE PAMOATE 75 MG CAPSULE 7.41580 7.92025 2/22/2013 IMIQUIMOD 5 % CREAM PACK 23.85100 23.46208 2/22/2013 INDAPAMIDE 1.25 MG TABLET 0.10850 0.07660 1/25/2013 INDAPAMIDE 2.5 MG TABLET 0.11850 0.08740 1/25/2013 INDOMETHACIN 25 MG CAPSULE 0.13226 0.13230 12/14/2012 INDOMETHACIN 50 MG CAPSULE 0.16660 0.16656 2/15/2013 INDOMETHACIN 75 MG CAPSULE ER 1.64020 1.64016 2/15/2013 INDOMETHACIN SODIUM 1 MG VIAL 0.00000 409.47900 12/1/2012 IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION 0.06160 0.06120 1/25/2013 IPRATROPIUM BROMIDE 21 MCG SPRAY 0.19060 0.19370 1/25/2013 IPRATROPIUM BROMIDE 42MCG SPRAY 0.38270 0.38870 1/25/2013 IPRATROPIUM/ALBUTEROL SULFATE 0.5-3MG/3 AMPUL-NEB 0.10747 0.10750 1/25/2013 IRBESARTAN 150 MG TABLET 0.00000 0.19430 12/1/2012 IRBESARTAN 300 MG TABLET 0.32950 0.32830 2/22/2013 IRBESARTAN 75 MG TABLET 0.15020 0.15021 2/22/2013 IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG TABLET 0.19260 0.19296 2/22/2013 IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG TABLET 0.32118 0.31951 2/22/2013 IRON FUMARATE/VIT C/VIT B12/FA 460-60MG CAPSULE 0.00000 0.43155 12/1/2012 IRON POLYSACCH/IRON HEME POLYP 28 MG TABLET 0.39748 0.37090 1/25/2013 IRON POLYSACCHARIDES COMPLEX 150 MG CAPSULE 0.18890 0.12990 1/25/2013 Page 28 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 IRON PS CMPLX/VIT B12/FA 150-25-1 CAPSULE 0.18410 0.17323 2/15/2013 IRON PS/IRON HEM POLY/FA/B12 22-6-1-25 TABLET 0.00000 2.61148 1/25/2013 IRON,CARB/DSS/B12IF/FA/MV-MN 150-50-1MG TAB ER 24H 0.00000 0.47055 12/1/2012 IRON,CARBONYL 15 MG TAB CHEW 0.00000 0.42735 12/1/2012 IRON,CARBONYL 15MG/1.25 ORAL SUSP 0.11965 0.12650 1/25/2013 IRON,CARBONYL/VIT C/VIT B12/FA 100-250-1 TABLET 0.00000 0.39480 12/1/2012 ISOMETHEPTENE/ACETAMINOPH/CAFF 130-500-20 TABLET 2.50320 2.71180 1/25/2013 ISONIAZID 100 MG TABLET 0.04090 0.04355 2/1/2013 ISONIAZID 100 MG/ML VIAL 0.00000 63.03150 12/1/2012 ISONIAZID 300 MG TABLET 0.07343 0.07340 2/8/2013 ISONIAZID 50 MG/5 ML SOLUTION 0.00000 0.09983 12/1/2012 ISOPROPYL ALCOHOL/GLYCERIN 95%-5% DROPS 0.08660 0.07020 1/25/2013 ISOSORBIDE DINITRATE 10 MG TABLET 0.74220 0.77340 2/8/2013 ISOSORBIDE DINITRATE 2.5 MG TAB SUBL 0.04407 0.04410 12/14/2012 ISOSORBIDE DINITRATE 20 MG TABLET 0.65840 0.83430 2/1/2013 ISOSORBIDE DINITRATE 30 MG TABLET 0.13735 0.13740 12/14/2012 ISOSORBIDE DINITRATE 40 MG TABLET ER 0.55289 0.55290 12/14/2012 ISOSORBIDE DINITRATE 5 MG TAB SUBL 0.00000 0.04407 12/1/2012 ISOSORBIDE MONONITRATE 10 MG TABLET 0.25337 0.19730 1/25/2013 ISOSORBIDE MONONITRATE 120 MG TAB ER 24H 0.42484 0.42480 12/14/2012 ISOSORBIDE MONONITRATE 20 MG TABLET 0.10238 0.10240 12/14/2012 ISOSORBIDE MONONITRATE 30 MG TAB ER 24H 0.24937 0.24940 12/14/2012 ISOSORBIDE MONONITRATE 60 MG TAB ER 24H 0.26572 0.26570 12/14/2012 ISOSULFAN BLUE 1 % VIAL 99.96000 102.04250 1/25/2013 ISOTRETINOIN 10 MG CAPSULE 10.59300 12.13310 2/1/2013 ISOTRETINOIN 20 MG CAPSULE 14.05840 14.16710 2/22/2013 ISOTRETINOIN 30 MG CAPSULE 0.00000 11.51617 12/1/2012 ISOTRETINOIN 40 MG CAPSULE 16.34670 16.49626 2/22/2013 ISOXSUPRINE HCL 10 MG TABLET 0.80892 0.67470 1/25/2013 ISRADIPINE 2.5 MG CAPSULE 0.00000 0.95543 12/1/2012 ISRADIPINE 5 MG CAPSULE 0.00000 1.39713 12/1/2012 ITRACONAZOLE 100 MG CAPSULE 6.49422 6.36994 12/14/2012 KETOCONAZOLE 2 % CREAM (G) 0.16660 0.16350 1/25/2013 KETOCONAZOLE 2 % FOAM 2.58804 2.49940 1/25/2013 KETOCONAZOLE 2 % SHAMPOO 0.14440 0.10040 1/25/2013 KETOCONAZOLE 200 MG TABLET 0.20130 0.20110 1/25/2013 KETOPROFEN 200 MG CAP24H PEL 4.81290 5.10170 2/8/2013 KETOPROFEN 75 MG CAPSULE 0.09554 0.09150 1/25/2013 KETOROLAC TROMETHAMINE 0.4 % DROPS 2.08530 2.03680 1/25/2013 KETOROLAC TROMETHAMINE 0.5 % DROPS 1.29578 1.29580 12/14/2012 KETOROLAC TROMETHAMINE 10 MG TABLET 0.38910 0.36960 1/25/2013 KETOROLAC TROMETHAMINE 15 MG/ML VIAL 0.00000 0.92058 12/1/2012 KETOROLAC TROMETHAMINE 30 MG/ML VIAL 0.00000 1.31943 12/1/2012 KETOROLAC TROMETHAMINE 30MG/ML(1) VIAL 0.64680 0.70560 2/15/2013 KETOROLAC TROMETHAMINE 60 MG/2 ML VIAL 0.49170 0.50176 2/15/2013 KETOTIFEN FUMARATE 0.025 % DROPS 1.12683 1.03944 2/22/2013 L-NORGEST-ETH ESTR/ETHIN ESTRA 100-20(84) TBDSPK 3MO 0.00000 2.06577 12/1/2012 L-NORGEST-ETH ESTR/ETHIN ESTRA 150-30(84) TBDSPK 3MO 0.00000 2.06577 12/1/2012 LABETALOL HCL 100 MG TABLET 0.00000 0.38550 11/1/2012 LABETALOL HCL 20 MG/4 ML DISP SYRIN 0.00000 0.65310 12/1/2012 LABETALOL HCL 200 MG TABLET 0.44434 0.44430 12/14/2012 LABETALOL HCL 300 MG TABLET 0.00000 0.64820 12/1/2012 LACTIC ACID 10 % CREAM (G) 0.00000 0.08303 12/1/2012 LACTIC ACID 10 % LOTION 0.05446 0.04280 1/25/2013 Page 29 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 LACTULOSE 10 G/15 ML SOLUTION 0.01367 0.01370 12/14/2012 LACTULOSE 10 G/15 ML SOLUTION 0.01367 0.01370 12/14/2012 LACTULOSE 10 G/CUP SOLUTION 0.03815 0.04189 2/22/2013 LAMIVUDINE 150 MG TABLET 5.19198 5.01270 2/22/2013 LAMIVUDINE 300 MG TABLET 0.00000 10.01992 12/1/2012 LAMIVUDINE/ZIDOVUDINE 150-300MG TABLET 10.84763 10.46390 1/25/2013 LAMOTRIGINE 100 MG TABLET 0.06850 0.06847 2/22/2013 LAMOTRIGINE 150 MG TABLET 0.10390 0.10385 2/22/2013 LAMOTRIGINE 200 MG TABLET 0.11200 0.11202 2/22/2013 LAMOTRIGINE 25 MG TABLET 0.05560 0.05561 2/22/2013 LAMOTRIGINE 25 MG TB CHW DSP 0.26689 0.26690 12/14/2012 LAMOTRIGINE 25MG (35) TAB DS PK 0.00000 2.90500 12/1/2012 LAMOTRIGINE 5 MG TB CHW DSP 0.26610 0.25483 2/22/2013 LANOLIN/MIN OIL/PETROLAT,WHT OINT. (G) 0.00000 0.91000 12/1/2012 LANSOPRAZOLE 15 MG CAPSULE DR 0.49988 0.49990 1/25/2013 LANSOPRAZOLE 30 MG CAPSULE DR 1.23450 1.23454 2/1/2013 LATANOPROST 0.005 % DROPS 4.29871 4.29870 12/14/2012 LEFLUNOMIDE 10 MG TABLET 0.51429 0.51230 1/25/2013 LEFLUNOMIDE 20 MG TABLET 0.70792 0.70790 1/25/2013 LETROZOLE 2.5 MG TABLET 0.00000 0.15182 12/1/2012 LEUCOVORIN CALCIUM 10 MG TABLET 5.26466 5.25150 1/25/2013 LEUCOVORIN CALCIUM 10 MG/ML VIAL 0.53387 0.29460 1/25/2013 LEUCOVORIN CALCIUM 15 MG TABLET 0.00000 5.85368 12/1/2012 LEUCOVORIN CALCIUM 200 MG VIAL 19.88700 18.73200 1/25/2013 LEUCOVORIN CALCIUM 25 MG TABLET 7.60430 7.52650 1/25/2013 LEUCOVORIN CALCIUM 5 MG TABLET 0.89418 0.89420 12/14/2012 LEUCOVORIN CALCIUM 50 MG VIAL 6.62940 6.93000 1/25/2013 LEUCOVORIN CALCIUM 500 MG VIAL 0.00000 99.22500 12/1/2012 LEUCOVORIN CALCIUM 500MG/50ML VIAL 0.81228 1.29948 12/14/2012 LEUPROLIDE ACETATE 1MG/0.2ML KIT 0.00000 231.00000 2/15/2013 LEVALBUTEROL HCL 0.31MG/3ML VIAL-NEB 1.48690 1.45257 2/15/2013 LEVALBUTEROL HCL 0.63MG/3ML VIAL-NEB 1.49730 1.45126 2/15/2013 LEVALBUTEROL HCL 1.25MG/0.5 VIAL-NEB 2.79420 4.68950 2/1/2013 LEVALBUTEROL HCL 1.25MG/3ML VIAL-NEB 1.49330 1.45257 2/15/2013 LEVETIRACETAM 100 MG/ML SOLUTION 0.00000 0.06070 12/1/2012 LEVETIRACETAM 1000 MG TABLET 0.00000 0.39570 12/1/2012 LEVETIRACETAM 250 MG TABLET 0.09996 0.09900 1/25/2013 LEVETIRACETAM 500 MG TAB ER 24H 0.00000 0.39021 12/1/2012 LEVETIRACETAM 500 MG TABLET 0.16562 0.16560 12/14/2012 LEVETIRACETAM 500 MG/5ML SOLUTION 1.06824 1.06820 12/14/2012 LEVETIRACETAM 500 MG/5ML VIAL 1.68384 1.65800 1/25/2013 LEVETIRACETAM 750 MG TAB ER 24H 0.81259 0.71598 2/22/2013 LEVETIRACETAM 750 MG TABLET 0.23222 0.23220 12/14/2012 LEVETIRACETAM IN NACL (ISO-OS) 1000MG/100 PIGGYBACK 0.00000 0.59877 12/1/2012 LEVETIRACETAM IN NACL (ISO-OS) 1500MG/100 PIGGYBACK 0.00000 0.77967 12/1/2012 LEVETIRACETAM IN NACL (ISO-OS) 500MG/0.1L PIGGYBACK 0.00000 0.36284 12/1/2012 LEVOBUNOLOL HCL 0.25 % DROPS 0.00000 1.24280 12/1/2012 LEVOBUNOLOL HCL 0.5 % DROPS 2.86600 3.21780 2/8/2013 LEVOCARNITINE (WITH SUGAR) 100 MG/ML SOLUTION 0.15402 0.15410 1/25/2013 LEVOCARNITINE 330 MG TABLET 0.60253 0.60260 1/25/2013 LEVOCARNITINE 500 MG TABLET 0.00000 0.20201 12/21/2012 LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 MG/5ML SOLUTION 0.00000 0.43653 12/1/2012 LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG TABLET 0.22240 0.22244 2/1/2013 LEVOFLOXACIN 0.5 % DROPS 0.00000 7.88880 12/1/2012 Page 30 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 LEVOFLOXACIN 25 MG/ML VIAL 0.00000 0.67200 12/1/2012 LEVOFLOXACIN 250 MG TABLET 0.14767 0.14770 12/14/2012 LEVOFLOXACIN 250MG/10ML SOLUTION 0.88822 0.88710 1/25/2013 LEVOFLOXACIN 500 MG TABLET 0.29534 0.29530 1/25/2013 LEVOFLOXACIN 750 MG TABLET 0.69428 0.65493 2/22/2013 LEVOFLOXACIN/D5W 250MG/50ML PIGGYBACK 0.11945 0.11530 1/25/2013 LEVOFLOXACIN/D5W 500MG/0.1L PIGGYBACK 0.00000 0.08576 12/1/2012 LEVOFLOXACIN/D5W 750MG/.15L PIGGYBACK 0.05548 0.05200 1/25/2013 LEVOMEFOLATE CALCIUM 15 MG TABLET 2.02080 2.02070 1/25/2013 LEVOMEFOLATE CALCIUM 7.5 MG TABLET 1.98276 2.02070 12/14/2012 LEVONORGESTREL 0.75 MG TABLET 0.00000 12.79600 12/1/2012 LEVONORGESTREL 1.5 MG TABLET 0.00000 25.59200 12/1/2012 LEVONORGESTREL-ETH ESTRADIOL 0.1-0.02 TABLET 0.76326 0.76330 12/14/2012 LEVONORGESTREL-ETH ESTRADIOL 0.15-0.03 TABLET 0.76850 0.77320 2/8/2013 LEVONORGESTREL-ETH ESTRADIOL 0.15-0.03 TBDSPK 3MO 1.12576 1.12000 1/25/2013 LEVONORGESTREL-ETH ESTRADIOL 6-5-10 TABLET 0.00000 0.68717 12/1/2012 LEVORPHANOL TARTRATE 2 MG TABLET 1.23865 1.12600 1/25/2013 LEVOTHYROXINE SODIUM 100 MCG TABLET 0.12210 0.11840 2/22/2013 LEVOTHYROXINE SODIUM 100 MCG VIAL 0.00000 111.63600 12/1/2012 LEVOTHYROXINE SODIUM 112 MCG TABLET 0.14445 0.16800 2/22/2013 LEVOTHYROXINE SODIUM 125 MCG TABLET 0.15260 0.14810 2/22/2013 LEVOTHYROXINE SODIUM 137 MCG TABLET 0.15570 0.18900 2/22/2013 LEVOTHYROXINE SODIUM 150 MCG TABLET 0.15075 0.14620 2/22/2013 LEVOTHYROXINE SODIUM 175MCG TABLET 0.18080 0.20870 2/22/2013 LEVOTHYROXINE SODIUM 200 MCG TABLET 0.18730 0.21450 2/22/2013 LEVOTHYROXINE SODIUM 25 MCG TABLET 0.09890 0.09590 2/22/2013 LEVOTHYROXINE SODIUM 300 MCG TABLET 0.31700 0.33890 2/22/2013 LEVOTHYROXINE SODIUM 50 MCG TABLET 0.10220 0.09920 2/22/2013 LEVOTHYROXINE SODIUM 500 MCG VIAL 0.00000 44.60050 12/1/2012 LEVOTHYROXINE SODIUM 75 MCG TABLET 0.12030 0.12530 2/22/2013 LEVOTHYROXINE SODIUM 88 MCG TABLET 0.12931 0.14713 2/22/2013 LIDOCAINE 5 % CREAM (G) 0.00000 1.01056 12/1/2012 LIDOCAINE 5 % OINT. (G) 1.41230 1.38446 2/15/2013 LIDOCAINE HCL 2 % JEL (ML) 0.29628 0.29710 1/25/2013 LIDOCAINE HCL 2 % JEL/PF APP 0.56690 0.66020 1/25/2013 LIDOCAINE HCL 20 MG/ML SOLUTION 0.02360 0.02337 2/22/2013 LIDOCAINE HCL 20 MG/ML VIAL 0.00000 0.06084 12/1/2012 LIDOCAINE HCL 4 % SOLUTION 0.00000 1.05248 12/1/2012 LIDOCAINE HCL 40 MG/ML SOLUTION 0.07040 0.07070 1/25/2013 LIDOCAINE HCL/D5W/PF 4 MG/ML IV SOLN 0.01313 0.01280 1/25/2013 LIDOCAINE HCL/D5W/PF 8 MG/ML IV SOLN 0.00000 0.02029 12/1/2012 LIDOCAINE HCL/D7.5W/PF 5 % AMPUL 4.77036 6.05930 1/25/2013 LIDOCAINE HCL/EPINEPHRINE 1%-1:100K VIAL 0.00000 0.06995 12/1/2012 LIDOCAINE HCL/EPINEPHRINE 2%-1:100K VIAL 0.07848 0.07910 1/25/2013 LIDOCAINE HCL/EPINEPHRINE BIT 2%-1:100K CARTRIDGE 0.00000 0.14933 12/1/2012 LIDOCAINE HCL/EPINEPHRINE BIT 2%-1:50000 CARTRIDGE 0.00000 0.14933 12/1/2012 LIDOCAINE HCL/EPINEPHRINE/PF 2%-1:200K VIAL 0.35742 0.35740 1/25/2013 LIDOCAINE HCL/PF 10 MG/ML AMPUL 0.35751 0.35750 12/14/2012 LIDOCAINE HCL/PF 100 MG/5ML DISP SYRIN 0.60251 0.66080 1/25/2013 LIDOCAINE HCL/PF 15 MG/ML AMPUL 0.00000 0.66715 12/1/2012 LIDOCAINE HCL/PF 20 MG/ML VIAL 0.00000 0.28224 12/1/2012 LIDOCAINE HCL/PF 20 MG/ML VIAL 0.37128 0.34100 1/25/2013 LIDOCAINE HCL/PF 40 MG/ML AMPUL 0.56784 0.56780 1/25/2013 LIDOCAINE HCL/PF 5 MG/ML VIAL 0.00000 0.11002 12/1/2012 Page 31 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 LIDOCAINE HCL/PF 50 MG/5 ML DISP SYRIN 0.88704 0.88790 1/25/2013 LIDOCAINE/PRILOCAINE 2.5%-2.5% CREAM (G) 0.56106 0.56110 12/14/2012 LIDOCAINE/PRILOCAINE 2.5%-2.5% KIT 0.00000 1.40764 12/1/2012 LINDANE 1 % LOTION 1.51940 1.59670 2/8/2013 LINDANE 1 % SHAMPOO 1.51940 1.59670 2/8/2013 LIOTHYRONINE SODIUM 25 MCG TABLET 0.73800 0.73760 1/25/2013 LIOTHYRONINE SODIUM 5 MCG TABLET 0.56147 0.56180 1/25/2013 LIOTHYRONINE SODIUM 50 MCG TABLET 1.13064 1.13120 1/25/2013 LISINOPRIL 10 MG TABLET 0.02117 0.02120 12/14/2012 LISINOPRIL 2.5 MG TABLET 0.01809 0.01810 12/14/2012 LISINOPRIL 20 MG TABLET 0.03280 0.03283 2/15/2013 LISINOPRIL 30 MG TABLET 0.09310 0.09250 1/25/2013 LISINOPRIL 40 MG TABLET 0.06137 0.06140 12/14/2012 LISINOPRIL 5 MG TABLET 0.01715 0.01720 12/14/2012 LISINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.03160 0.02960 1/25/2013 LISINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.04120 0.04194 2/22/2013 LISINOPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.04870 0.05080 12/21/2012 LITHIUM CARBONATE 150 MG CAPSULE 0.05534 0.05490 1/25/2013 LITHIUM CARBONATE 300 MG CAPSULE 0.03082 0.03080 12/14/2012 LITHIUM CARBONATE 300 MG TABLET 0.14917 0.14910 1/25/2013 LITHIUM CARBONATE 300 MG TABLET ER 0.23710 0.23934 2/22/2013 LITHIUM CARBONATE 450 MG TABLET ER 0.26770 0.26780 1/25/2013 LITHIUM CARBONATE 600 MG CAPSULE 0.12956 0.12860 1/25/2013 LITHIUM CITRATE 8MEQ/5ML SOLUTION 0.00000 0.03921 12/1/2012 LOPERAMIDE HCL 1MG/7.5ML LIQUID 0.02830 0.02772 2/15/2013 LOPERAMIDE HCL 2 MG CAPSULE 0.15080 0.15076 2/22/2013 LOPERAMIDE HCL 2 MG TABLET 0.00000 0.08951 12/1/2012 LORATADINE 10 MG TAB RAPDIS 0.00000 0.38100 12/1/2012 LORATADINE 10 MG TABLET 0.05130 0.05132 2/8/2013 LORATADINE 5 MG/5 ML SOLUTION 0.03650 0.03645 2/8/2013 LORATADINE/PSEUDOEPHEDRINE 10MG-240MG TAB ER 24H 0.64530 0.63939 2/15/2013 LORAZEPAM 0.5 MG TABLET 0.00000 0.02680 12/1/2012 LORAZEPAM 1 MG TABLET 0.02770 0.02774 2/1/2013 LORAZEPAM 2 MG TABLET 0.00000 0.04770 12/1/2012 LORAZEPAM 2 MG/ML DISP SYRIN 1.83960 1.76400 2/15/2013 LORAZEPAM 2 MG/ML ORAL CONC 0.36582 0.60470 2/1/2013 LORAZEPAM 2 MG/ML VIAL 0.64070 0.72360 2/8/2013 LORAZEPAM 4 MG/ML DISP SYRIN 0.00000 2.46960 12/1/2012 LORAZEPAM 4 MG/ML VIAL 0.00000 1.14324 12/1/2012 LOSARTAN POTASSIUM 100 MG TABLET 0.10360 0.10430 1/25/2013 LOSARTAN POTASSIUM 25 MG TABLET 0.00000 0.05440 12/1/2012 LOSARTAN POTASSIUM 50 MG TABLET 0.07276 0.07280 12/14/2012 LOSARTAN/HYDROCHLOROTHIAZIDE 100-12.5MG TABLET 0.11202 0.11200 12/14/2012 LOSARTAN/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET 0.10184 0.10180 12/14/2012 LOSARTAN/HYDROCHLOROTHIAZIDE 50-12.5 MG TABLET 0.06730 0.07450 1/25/2013 LOVASTATIN 10 MG TABLET 0.09610 0.09540 1/25/2013 LOVASTATIN 20 MG TABLET 0.10372 0.10370 12/14/2012 LOVASTATIN 40 MG TABLET 0.11122 0.11120 12/14/2012 LOXAPINE SUCCINATE 10 MG CAPSULE 0.50999 0.51000 12/14/2012 LOXAPINE SUCCINATE 25 MG CAPSULE 0.73150 0.73120 1/25/2013 LOXAPINE SUCCINATE 5 MG CAPSULE 0.37145 0.37150 12/14/2012 LOXAPINE SUCCINATE 50 MG CAPSULE 0.97950 0.97350 1/25/2013 MAG CARB/AL HYDROX/ALGINIC AC 358-95/15 ORAL SUSP 0.00000 0.01253 12/1/2012 MAG HYDROX/AL HYDROX/SIMETH 200-200-20 ORAL SUSP 0.00000 0.00590 12/1/2012 Page 32 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 MAG HYDROX/AL HYDROX/SIMETH 200-200-25 TAB CHEW 0.00000 0.03029 12/1/2012 MAG HYDROX/AL HYDROX/SIMETH 400-400-40 ORAL SUSP 0.00000 0.00735 12/1/2012 MAGNESIUM CHLORIDE 64 MG TABLET ER 0.00000 0.08364 12/1/2012 MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP 0.00415 0.00420 12/14/2012 MAGNESIUM OXIDE 400 MG CAPSULE 0.08181 0.08450 1/25/2013 MAGNESIUM OXIDE 400 MG TABLET 0.02908 0.02910 12/14/2012 MAGNESIUM SULFATE 2 G/50 ML PIGGYBACK 0.27600 0.24560 1/25/2013 MAGNESIUM SULFATE 20 G/500ML IV SOLN 0.02031 0.01970 1/25/2013 MAGNESIUM SULFATE 4 G/100 ML PIGGYBACK 0.12464 0.11860 1/25/2013 MAGNESIUM SULFATE 4 G/50 ML PIGGYBACK 0.24644 0.23100 1/25/2013 MAGNESIUM SULFATE 4 MEQ/ML DISP SYRIN 0.00000 0.63168 12/1/2012 MAGNESIUM SULFATE 40G/1000ML IV SOLN 0.01537 0.01440 1/25/2013 MAGNESIUM SULFATE/D5W 1 G/100 ML PIGGYBACK 0.11997 0.11630 1/25/2013 MALATHION 0.5 % LOTION 2.98650 2.15921 2/15/2013 MANGANESE CHLORIDE 0.1 MG/ML VIAL 0.14448 0.17390 1/25/2013 MANGANESE SULFATE 0.1 MG/ML VIAL 0.00000 0.21874 12/1/2012 MANNITOL 10 % IV SOLN 0.01210 0.01620 1/25/2013 MANNITOL 20 % IV SOLN 0.00000 0.03980 12/1/2012 MANNITOL 5 % IV SOLN 0.00000 0.00866 12/1/2012 MANNITOL/SORBITOL SOLUTION 0.54G-2.7G IRRIG SOLN 0.00000 0.00569 12/1/2012 MAPROTILINE HCL 25 MG TABLET 0.59885 0.59890 1/25/2013 MAPROTILINE HCL 50 MG TABLET 0.88660 0.93980 2/8/2013 MAPROTILINE HCL 75 MG TABLET 1.21653 1.28950 1/25/2013 MECLIZINE HCL 12.5 MG TABLET 0.03139 0.03140 12/14/2012 MECLIZINE HCL 25 MG TABLET 0.31260 0.28090 12/21/2012 MECLOFENAMATE SODIUM 100 MG CAPSULE 3.34761 3.34760 1/25/2013 MECLOFENAMATE SODIUM 50 MG CAPSULE 1.80334 1.91160 1/25/2013 MEDROXYPROGESTERONE ACETATE 10 MG TABLET 0.00000 0.12690 12/1/2012 MEDROXYPROGESTERONE ACETATE 2.5 MG TABLET 0.06137 0.06140 12/14/2012 MEDROXYPROGESTERONE ACETATE 5 MG TABLET 0.08400 0.08240 1/25/2013 MEFENAMIC ACID 250 MG CAPSULE 10.96296 10.93970 1/25/2013 MEFLOQUINE HCL 250 MG TABLET 3.87036 4.71900 12/21/2012 MEGESTROL ACETATE 20 MG TABLET 0.00000 0.15410 12/1/2012 MEGESTROL ACETATE 40 MG TABLET 0.19484 0.19480 12/14/2012 MEGESTROL ACETATE 400MG/10ML ORAL SUSP 0.30390 0.42530 1/25/2013 MEGESTROL ACETATE 400MG/10ML ORAL SUSP 0.08930 0.09010 1/25/2013 MELATONIN 3 MG TABLET ER 0.00000 0.06370 12/1/2012 MELOXICAM 15 MG TABLET 0.02600 0.03280 1/25/2013 MELOXICAM 7.5 MG TABLET 0.02330 0.02920 1/25/2013 MELOXICAM 7.5 MG/5ML ORAL SUSP 0.00000 1.10061 12/1/2012 MENTHOL 10 % GEL (GRAM) 0.00000 0.11397 12/1/2012 MENTHOL 3.5 % GEL (GRAM) 0.00000 0.10042 12/1/2012 MENTHOL 8 MG LOZENGE 0.06965 0.06420 1/25/2013 MEPERIDINE HCL 10 MG/ML CARTRIDGE 0.00000 0.49911 12/1/2012 MEPERIDINE HCL 100 MG TABLET 0.38670 0.32670 2/15/2013 MEPERIDINE HCL 50 MG TABLET 0.00000 0.20435 12/1/2012 MEPERIDINE HCL 50 MG/5 ML SOLUTION 0.00000 0.14191 12/1/2012 MEPERIDINE HCL/PF 100 MG/ML VIAL 0.00000 2.35200 12/1/2012 MEPERIDINE HCL/PF 25 MG/ML VIAL 0.00000 2.12100 12/1/2012 MEPERIDINE HCL/PF 50 MG/ML VIAL 0.00000 0.94080 12/1/2012 MEPIVACAINE HCL/PF 30 MG/ML CARTRIDGE 0.18667 0.17730 1/25/2013 MEPROBAMATE 200 MG TABLET 0.92989 0.90910 1/25/2013 MEPROBAMATE 400 MG TABLET 1.24995 0.98070 1/25/2013 MERCAPTOPURINE 50 MG TABLET 0.00000 1.91920 12/1/2012 Page 33 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 MEROPENEM 1 G VIAL 10.68250 11.02510 2/22/2013 MEROPENEM 500 MG VIAL 7.53950 4.50240 2/15/2013 MESALAMINE 4G/60ML ENEMA 0.22790 0.22632 2/22/2013 MESALAMINE W/CLEANSING WIPES 4G/60ML KIT 0.00000 0.29920 12/1/2012 METAPROTERENOL SULFATE 10 MG TABLET 0.00000 0.69965 12/1/2012 METAPROTERENOL SULFATE 10 MG/5 ML SYRUP 0.04721 0.02460 1/25/2013 METAPROTERENOL SULFATE 20 MG TABLET 0.00000 0.97496 12/1/2012 METAXALONE 800 MG TABLET 3.26060 3.42370 1/25/2013 METFORMIN HCL 1000 MG TAB ER 24 6.34280 7.32690 2/1/2013 METFORMIN HCL 1000 MG TABLET 0.04500 0.04502 2/15/2013 METFORMIN HCL 500 MG TAB ER 24 3.25400 4.02380 2/8/2013 METFORMIN HCL 500 MG TAB ER 24H 0.04540 0.04543 2/15/2013 METFORMIN HCL 500 MG TABLET 0.02470 0.02466 2/8/2013 METFORMIN HCL 750 MG TAB ER 24H 0.09179 0.09180 1/25/2013 METFORMIN HCL 850 MG TABLET 0.04210 0.04208 2/15/2013 METHADONE HCL 10 MG TABLET 0.09840 0.09837 2/1/2013 METHADONE HCL 10 MG/5 ML SOLUTION 0.00000 0.20658 12/1/2012 METHADONE HCL 10 MG/ML ORAL CONC 0.00000 0.62300 12/1/2012 METHADONE HCL 10 MG/ML VIAL 0.00000 6.01720 12/1/2012 METHADONE HCL 40 MG TABLET SOL 0.00000 0.22381 12/1/2012 METHADONE HCL 5 MG TABLET 0.05980 0.05983 2/8/2013 METHADONE HCL 5 MG/5 ML SOLUTION 0.00000 0.12491 12/1/2012 METHAMPHETAMINE HCL 5 MG TABLET 0.00000 3.02617 12/1/2012 METHAZOLAMIDE 25 MG TABLET 1.02360 0.70710 1/25/2013 METHAZOLAMIDE 50 MG TABLET 2.01810 2.01080 1/25/2013 METHENAMINE HIPPURATE 1 G TABLET 1.46376 1.46380 1/25/2013 METHENAMINE MANDELATE 1 G TABLET 0.75330 1.15690 2/1/2013 METHENAMINE MANDELATE 500 MG TABLET 0.00000 0.62041 12/1/2012 METHIMAZOLE 10 MG TABLET 0.27175 0.27180 12/14/2012 METHIMAZOLE 5 MG TABLET 0.15678 0.15680 12/14/2012 METHOCARBAMOL 500 MG TABLET 0.05390 0.05387 2/8/2013 METHOCARBAMOL 750 MG TABLET 0.00000 0.15530 12/1/2012 METHOTREXATE SODIUM 2.5 MG TABLET 0.34974 0.34970 12/14/2012 METHOTREXATE SODIUM 25 MG/ML VIAL 1.34658 1.69330 1/25/2013 METHOTREXATE SODIUM/PF 25 MG/ML VIAL 0.68246 0.68608 2/22/2013 METHSCOPOLAMINE BROMIDE 2.5 MG TABLET 0.00000 1.54629 12/1/2012 METHSCOPOLAMINE BROMIDE 5 MG TABLET 0.00000 2.40598 12/1/2012 METHYCLOTHIAZIDE 5 MG TABLET 1.14772 1.21660 1/25/2013 METHYL SALICYLATE OIL 0.47545 0.47540 1/25/2013 METHYL-B12/L-MEFOLATE/B6 PHOS 2-3-35 MG TABLET 0.91348 1.01041 12/14/2012 METHYLDOPA 250 MG TABLET 0.09820 0.09822 2/1/2013 METHYLDOPA 500 MG TABLET 0.17648 0.17650 12/14/2012 METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-15MG TABLET 0.63380 0.67180 1/25/2013 METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-25MG TABLET 0.74683 0.79160 1/25/2013 METHYLENE BLUE 1 % AMPUL 2.74680 2.76330 1/25/2013 METHYLERGONOVINE MALEATE .2MG/ML(1) AMPUL 5.36060 4.35610 1/25/2013 METHYLERGONOVINE MALEATE .2MG/ML(1) VIAL 0.00000 6.39450 12/1/2012 METHYLERGONOVINE MALEATE 0.2 MG TABLET 1.03250 5.39630 2/1/2013 METHYLPHENIDATE HCL 10 MG CPMP 30-70 0.00000 3.98052 12/1/2012 METHYLPHENIDATE HCL 10 MG TABLET 0.10385 0.10390 1/25/2013 METHYLPHENIDATE HCL 10 MG TABLET ER 0.00000 0.58513 12/1/2012 METHYLPHENIDATE HCL 10 MG/5 ML SOLUTION 0.00000 1.91621 12/1/2012 METHYLPHENIDATE HCL 18 MG TAB ER 24 4.12800 4.35530 2/1/2013 METHYLPHENIDATE HCL 20 MG CPMP 30-70 3.98052 4.03960 1/25/2013 Page 34 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 METHYLPHENIDATE HCL 20 MG CPMP 50-50 3.45371 3.45450 1/25/2013 METHYLPHENIDATE HCL 20 MG TABLET 0.16871 0.16870 1/25/2013 METHYLPHENIDATE HCL 27 MG TAB ER 24 4.46450 4.46446 2/15/2013 METHYLPHENIDATE HCL 30 MG CPMP 30-70 3.98052 3.96870 1/25/2013 METHYLPHENIDATE HCL 30 MG CPMP 50-50 3.33630 3.53310 2/8/2013 METHYLPHENIDATE HCL 36 MG TAB ER 24 0.00000 4.60502 12/1/2012 METHYLPHENIDATE HCL 40 MG CPMP 30-70 5.17986 5.13010 1/25/2013 METHYLPHENIDATE HCL 40 MG CPMP 50-50 3.31780 3.62990 2/1/2013 METHYLPHENIDATE HCL 5 MG TABLET 0.08723 0.08720 1/25/2013 METHYLPHENIDATE HCL 5 MG/5 ML SOLUTION 0.00000 1.34413 12/1/2012 METHYLPHENIDATE HCL 50 MG CPMP 30-70 5.78640 6.70877 2/22/2013 METHYLPHENIDATE HCL 54 MG TAB ER 24 0.00000 5.01081 12/1/2012 METHYLPHENIDATE HCL 60 MG CPMP 30-70 6.70877 6.73360 1/25/2013 METHYLPREDNISOLONE 16 MG TABLET 0.00000 2.17406 12/1/2012 METHYLPREDNISOLONE 32 MG TABLET 0.00000 3.23736 12/1/2012 METHYLPREDNISOLONE 4 MG TAB DS PK 1.00050 1.00070 2/8/2013 METHYLPREDNISOLONE 4 MG TABLET 0.00000 1.24060 12/1/2012 METHYLPREDNISOLONE 8 MG TABLET 0.00000 1.40728 12/1/2012 METHYLPREDNISOLONE ACETATE 40 MG/ML VIAL 0.00000 3.04720 12/1/2012 METHYLPREDNISOLONE ACETATE 80 MG/ML VIAL 6.38400 6.81700 1/25/2013 METHYLPREDNISOLONE SOD SUCC 1000 MG VIAL 0.00000 17.05200 12/1/2012 METHYLPREDNISOLONE SOD SUCC 125 MG VIAL 0.00000 4.08408 12/1/2012 METHYLPREDNISOLONE SOD SUCC 40 MG VIAL 0.00000 3.53132 12/1/2012 METIPRANOLOL 0.3 % DROPS 0.00000 2.91720 12/1/2012 METOCLOPRAMIDE HCL 10 MG TABLET 0.03890 0.04340 1/25/2013 METOCLOPRAMIDE HCL 10 MG/2 ML DISP SYRIN 0.39900 0.38640 1/25/2013 METOCLOPRAMIDE HCL 5 MG TABLET 0.03910 0.04250 1/25/2013 METOCLOPRAMIDE HCL 5 MG/5 ML SOLUTION 0.01032 0.01030 12/14/2012 METOLAZONE 10 MG TABLET 0.00000 0.77720 12/1/2012 METOLAZONE 2.5 MG TABLET 0.44046 0.50100 12/14/2012 METOLAZONE 5 MG TABLET 0.56830 0.56910 1/25/2013 METOPROLOL SUCCINATE 100 MG TAB ER 24H 0.00000 0.90700 12/1/2012 METOPROLOL SUCCINATE 200 MG TAB ER 24H 1.79600 1.79440 1/25/2013 METOPROLOL SUCCINATE 25 MG TAB ER 24H 0.64990 0.63890 1/25/2013 METOPROLOL SUCCINATE 50 MG TAB ER 24H 0.63918 0.63920 12/14/2012 METOPROLOL TARTRATE 100 MG TABLET 0.03216 0.03220 12/14/2012 METOPROLOL TARTRATE 25 MG TABLET 0.02399 0.02400 12/14/2012 METOPROLOL TARTRATE 5 MG/5 ML AMPUL 0.18818 0.23020 1/25/2013 METOPROLOL TARTRATE 5 MG/5 ML DISP SYRIN 0.65333 0.70560 1/25/2013 METOPROLOL TARTRATE 50 MG TABLET 0.02140 0.02080 1/25/2013 METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET 1.32970 1.38830 2/8/2013 METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-50MG TABLET 1.44730 1.53410 2/8/2013 METOPROLOL/HYDROCHLOROTHIAZIDE 50 MG-25MG TABLET 0.85280 0.89170 2/8/2013 METRONIDAZOLE 0.75 % CREAM (G) 0.00000 2.72580 12/1/2012 METRONIDAZOLE 0.75 % GEL (GRAM) 0.00000 2.65770 8/3/2012 METRONIDAZOLE 0.75 % GEL W/APPL 0.00000 0.41004 12/1/2012 METRONIDAZOLE 0.75 % LOTION 0.00000 2.93220 12/1/2012 METRONIDAZOLE 250 MG TABLET 0.00000 0.30300 12/1/2012 METRONIDAZOLE 500 MG TABLET 0.50380 0.50366 2/22/2013 METRONIDAZOLE/SODIUM CHLORIDE 500MG/0.1L PIGGYBACK 0.01404 0.01290 1/25/2013 MEXILETINE HCL 150 MG CAPSULE 0.29172 0.29170 12/14/2012 MEXILETINE HCL 200 MG CAPSULE 0.40235 0.40240 12/14/2012 MEXILETINE HCL 250 MG CAPSULE 0.48191 0.48190 12/14/2012 MICONAZOLE NITRATE 100 MG SUPP.VAG 0.42710 0.44030 12/21/2012 Page 35 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 MICONAZOLE NITRATE 2 % CREAM (G) 0.05722 0.05720 12/14/2012 MICONAZOLE NITRATE 2 % CREAM/APPL 0.09072 0.09070 12/14/2012 MICONAZOLE NITRATE 2 % OINT. (G) 0.08474 0.08500 1/25/2013 MICONAZOLE NITRATE 2 % TINCTURE 0.44138 0.39340 1/25/2013 MICONAZOLE NITRATE 200 MG SUPP.VAG 0.00000 12.26633 12/1/2012 MICONAZOLE NITRATE 200 MG-2 % COMBO. PKG 0.00000 1.21793 12/1/2012 MIDODRINE HCL 10 MG TABLET 0.93009 0.93010 12/14/2012 MIDODRINE HCL 2.5 MG TABLET 0.32321 0.32320 12/14/2012 MIDODRINE HCL 5 MG TABLET 0.38530 0.60470 2/8/2013 MILRINONE LACTATE 1 MG/ML VIAL 0.00000 0.46056 12/1/2012 MILRINONE LACTATE/D5W 20MG/100ML PIGGYBACK 0.13279 0.13280 1/25/2013 MILRINONE LACTATE/D5W 40MG/200ML PIGGYBACK 0.13655 0.12430 1/25/2013 MINERAL OIL ENEMA 0.01182 0.01320 1/25/2013 MINERAL OIL LOTION 0.01828 0.00480 1/25/2013 MINERAL OIL/PETROLATUM,WHITE 15 %-83 % OINT. (G) 0.72313 0.81740 1/25/2013 MINERAL OIL/PETROLATUM,WHITE 15%-85% OINT. (G) 4.41666 4.48140 1/25/2013 MINOCYCLINE HCL 100 MG CAPSULE 0.26690 0.26693 2/1/2013 MINOCYCLINE HCL 100 MG TABLET 0.00000 2.49210 12/1/2012 MINOCYCLINE HCL 135 MG TAB ER 24H 0.00000 3.56811 12/1/2012 MINOCYCLINE HCL 45 MG TAB ER 24H 0.00000 3.56811 12/1/2012 MINOCYCLINE HCL 50 MG CAPSULE 0.13710 0.13690 1/25/2013 MINOCYCLINE HCL 50 MG TABLET 0.00000 1.44008 12/1/2012 MINOCYCLINE HCL 75 MG CAPSULE 0.30240 0.31020 12/21/2012 MINOCYCLINE HCL 75 MG TABLET 0.00000 1.69228 12/1/2012 MINOCYCLINE HCL 90 MG TAB ER 24H 0.00000 3.56811 12/1/2012 MINOXIDIL 10 MG TABLET 0.27483 0.27480 12/14/2012 MINOXIDIL 2.5 MG TABLET 0.16028 0.16030 12/14/2012 MIRTAZAPINE 15 MG TAB RAPDIS 1.09650 0.95310 1/25/2013 MIRTAZAPINE 15 MG TABLET 0.00000 0.09420 12/1/2012 MIRTAZAPINE 30 MG TAB RAPDIS 1.12868 1.12870 12/14/2012 MIRTAZAPINE 30 MG TABLET 0.13936 0.13940 1/25/2013 MIRTAZAPINE 45 MG TAB RAPDIS 1.10740 1.06427 2/22/2013 MIRTAZAPINE 45 MG TABLET 0.00000 0.24830 12/1/2012 MIRTAZAPINE 7.5 MG TABLET 0.06029 0.06030 1/25/2013 MISOPROSTOL 100 MCG TABLET 0.41165 0.41170 12/14/2012 MITOMYCIN 40 MG VIAL 0.00000 235.39125 12/1/2012 MODAFINIL 100 MG TABLET 0.00000 12.89673 12/1/2012 MODAFINIL 200 MG TABLET 0.00000 18.65619 12/1/2012 MOEXIPRIL HCL 15 MG TABLET 0.36582 0.37580 2/8/2013 MOEXIPRIL HCL 7.5 MG TABLET 0.37583 0.37580 12/14/2012 MOEXIPRIL/HYDROCHLOROTHIAZIDE 15-12.5MG TABLET 0.51305 0.51310 12/14/2012 MOEXIPRIL/HYDROCHLOROTHIAZIDE 15-25MG TABLET 0.00000 0.37076 12/1/2012 MOEXIPRIL/HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET 0.00000 0.50960 12/1/2012 MOLYBDENUM(AMMONIUM MOLYBDATE) 25 MCG/ML VIAL 0.00000 0.32672 12/1/2012 MOMETASONE FUROATE 0.1 % CREAM (G) 0.23020 0.20998 2/22/2013 MOMETASONE FUROATE 0.1 % OINT. (G) 0.22950 0.20998 2/22/2013 MOMETASONE FUROATE 0.1 % SOLUTION 0.00000 0.21480 12/1/2012 MONTELUKAST SODIUM 10 MG TABLET 0.00000 0.61330 8/17/2012 MONTELUKAST SODIUM 4 MG TAB CHEW 0.00000 0.61330 8/17/2012 MONTELUKAST SODIUM 5 MG TAB CHEW 0.00000 0.61330 8/17/2012 MORPHINE SULFATE 10 MG SUPP.RECT 4.37500 3.85880 1/25/2013 MORPHINE SULFATE 10 MG/5 ML SOLUTION 0.00000 0.06164 12/1/2012 MORPHINE SULFATE 10 MG/ML DISP SYRIN 0.00000 1.28520 12/1/2012 MORPHINE SULFATE 10 MG/ML VIAL 0.00000 0.74480 12/1/2012 Page 36 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 MORPHINE SULFATE 100 MG CAP ER PEL 13.29280 13.29300 1/25/2013 MORPHINE SULFATE 100 MG TABLET ER 0.80350 0.80353 2/8/2013 MORPHINE SULFATE 100 MG/4ML VIAL PORT 4.75650 4.96650 1/25/2013 MORPHINE SULFATE 100 MG/5ML SOLUTION 0.00000 0.29011 12/1/2012 MORPHINE SULFATE 15 MG TABLET 0.07826 0.08606 2/22/2013 MORPHINE SULFATE 15 MG TABLET ER 0.19760 0.19755 2/8/2013 MORPHINE SULFATE 15 MG/ML DISP SYRIN 1.29360 1.36920 1/25/2013 MORPHINE SULFATE 15 MG/ML VIAL 0.52528 0.69440 1/25/2013 MORPHINE SULFATE 2 MG/ML DISP SYRIN 0.00000 1.28520 12/1/2012 MORPHINE SULFATE 20 MG CAP ER PEL 3.65670 3.65672 2/8/2013 MORPHINE SULFATE 20 MG SUPP.RECT 0.00000 5.25000 12/1/2012 MORPHINE SULFATE 20 MG/5 ML SOLUTION 0.09160 0.09368 2/15/2013 MORPHINE SULFATE 200 MG TABLET ER 1.31140 1.31144 2/8/2013 MORPHINE SULFATE 250MG/10ML VIAL PORT 1.90680 1.99080 1/25/2013 MORPHINE SULFATE 30 MG CAP ER PEL 0.00000 3.97649 12/1/2012 MORPHINE SULFATE 30 MG SUPP.RECT 0.00000 6.56250 12/1/2012 MORPHINE SULFATE 30 MG TABLET 0.09945 0.12130 2/8/2013 MORPHINE SULFATE 30 MG TABLET ER 0.28660 0.28570 1/25/2013 MORPHINE SULFATE 30 MG/30ML PCA SYRING 0.00000 0.43749 2/15/2013 MORPHINE SULFATE 4 MG/ML DISP SYRIN 1.29360 1.36920 1/25/2013 MORPHINE SULFATE 5 MG SUPP.RECT 0.00000 3.50000 12/1/2012 MORPHINE SULFATE 5 MG/ML VIAL 0.00000 0.83160 12/1/2012 MORPHINE SULFATE 50 MG CAP ER PEL 0.00000 6.64531 12/1/2012 MORPHINE SULFATE 50 MG/ML VIAL 0.36449 0.39830 1/25/2013 MORPHINE SULFATE 60 MG CAP ER PEL 7.95284 7.95280 1/25/2013 MORPHINE SULFATE 60 MG TABLET ER 0.52660 0.52662 2/8/2013 MORPHINE SULFATE 8 MG/ML DISP SYRIN 0.00000 1.25160 12/1/2012 MORPHINE SULFATE 8 MG/ML VIAL 0.00000 0.94080 12/1/2012 MORPHINE SULFATE 80 MG CAP ER PEL 10.60283 10.60090 1/25/2013 MORPHINE SULFATE/PF 0.5 MG/ML AMPUL 0.00000 2.23713 12/1/2012 MORPHINE SULFATE/PF 0.5 MG/ML VIAL 0.36624 0.42080 1/25/2013 MORPHINE SULFATE/PF 1 MG/ML AMPUL 0.00000 3.80940 12/1/2012 MORPHINE SULFATE/PF 1 MG/ML VIAL 0.41244 0.41240 1/25/2013 MORPHINE SULFATE/PF 10 MG/ML CARTRIDGE 3.06600 3.25500 1/25/2013 MORPHINE SULFATE/PF 15 MG/ML CARTRIDGE 3.17100 3.25500 1/25/2013 MORPHINE SULFATE/PF 150MG/30ML PCA VIAL 0.00000 0.61320 12/1/2012 MORPHINE SULFATE/PF 2 MG/ML CARTRIDGE 3.06600 3.25500 1/25/2013 MORPHINE SULFATE/PF 25 MG/ML VIAL 0.43120 0.48370 1/25/2013 MORPHINE SULFATE/PF 30 MG/30ML PCA VIAL 0.00000 0.50469 12/1/2012 MORPHINE SULFATE/PF 4 MG/ML CARTRIDGE 3.08700 3.25500 1/25/2013 MORPHINE SULFATE/PF 8 MG/ML CARTRIDGE 0.00000 2.98200 12/1/2012 MTH/ME BLUE/SOD PHOS/PHEN/HYOS 81.6-10.8 TABLET 0.00000 0.91000 12/1/2012 MU-VITS-MIN TH/LYCOPENE/LUTEIN .4-300-250 TABLET 0.04449 0.04529 12/14/2012 MULTIVITAMIN TABLET 0.01085 0.01090 12/14/2012 MULTIVITAMIN W-MINERALS/LUTEIN TABLET 0.04529 0.04780 1/25/2013 MULTIVITAMINS WITH IRON TABLET 0.01581 0.01580 12/14/2012 MULTIVITAMINS WITH MIN NO.7/FA 1 MG CAPSULE 0.06227 0.17550 2/15/2013 MULTIVITAMINS,THER W-MINERALS CAPSULE 0.06622 0.05780 1/25/2013 MULTIVITAMINS,THERAPEUTIC TABLET 0.02439 0.02440 12/14/2012 MULTIVITS W-MIN/FERROUS GLUC 9 MG/15 ML LIQUID 0.01443 0.01350 1/25/2013 MULTIVITS,CA,MINERALS/IRON/FA 9MG-400MCG TABLET 0.00000 0.03497 12/1/2012 MULTIVITS,STRESS FORMULA/ZINC TABLET 0.00000 0.04810 12/1/2012 MULTIVITS-MIN/FA/LYCOPENE/LUT 500-300MCG TABLET 0.05011 0.04800 1/25/2013 MUPIROCIN 2 % OINT. (G) 0.00000 0.47610 12/1/2012 Page 37 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 MUPIROCIN CALCIUM 2 % CREAM (G) 0.00000 3.12644 2/15/2013 MYCOPHENOLATE MOFETIL 250 MG CAPSULE 0.28971 0.28970 12/14/2012 MYCOPHENOLATE MOFETIL 500 MG TABLET 0.55302 0.52260 12/14/2012 NA NITRITE/NA THIOSUL/AMYL NIT 300-12.5 KIT 321.77600 300.50300 1/25/2013 NA PHOS,M-B/NA PHOS,DI-BA 19G-7G/118 ENEMA 0.00580 0.00575 2/1/2013 NABUMETONE 500 MG TABLET 0.15544 0.15540 12/14/2012 NABUMETONE 750 MG TABLET 0.24290 0.23120 1/25/2013 NADOLOL 20 MG TABLET 0.20660 1.13470 2/22/2013 NADOLOL 80 MG TABLET 0.39250 1.83321 2/22/2013 NADOLOL/BENDROFLUMETHIAZIDE 40 MG-5 MG TABLET 0.00000 1.72368 12/1/2012 NADOLOL/BENDROFLUMETHIAZIDE 80 MG-5 MG TABLET 0.00000 2.25914 12/1/2012 NAFCILLIN IN DEXTROSE,ISO-OSM 1 G/50 ML FROZ.PIGGY 0.00000 0.25511 12/1/2012 NAFCILLIN IN DEXTROSE,ISO-OSM 2 G/100 ML FROZ.PIGGY 0.00000 0.17407 12/1/2012 NAFCILLIN SODIUM 1 G VIAL 10.06800 9.54200 1/25/2013 NAFCILLIN SODIUM 1 G VIAL PORT 12.26400 12.56750 1/25/2013 NAFCILLIN SODIUM 10 G VIAL 0.00000 97.14110 12/1/2012 NAFCILLIN SODIUM 2 G VIAL 19.37390 19.82470 2/22/2013 NAFCILLIN SODIUM 2 G VIAL PORT 23.79067 24.57580 1/25/2013 NALBUPHINE HCL 10 MG/ML VIAL 0.00000 1.19280 12/1/2012 NALBUPHINE HCL 20 MG/ML AMPUL 2.89120 3.45670 1/25/2013 NALBUPHINE HCL 20 MG/ML VIAL 1.70016 1.70020 1/25/2013 NALOXONE HCL 0.4 MG/ML DISP SYRIN 0.00000 3.15000 12/1/2012 NALOXONE HCL 1 MG/ML DISP SYRIN 0.00000 7.11900 12/1/2012 NALTREXONE HCL 50 MG TABLET 0.00000 1.16580 12/1/2012 NAPHAZOLINE HCL 0.1 % DROPS 0.00000 0.11787 12/1/2012 NAPHAZOLINE HCL/GLYCERIN 0.012-0.2% DROPS 0.15261 0.13640 1/25/2013 NAPROXEN 125 MG/5ML ORAL SUSP 0.00000 0.13839 12/1/2012 NAPROXEN 250 MG TABLET 0.00000 0.04730 12/1/2012 NAPROXEN 375 MG TABLET 0.05695 0.05700 12/14/2012 NAPROXEN 375 MG TABLET DR 0.14960 0.14870 1/25/2013 NAPROXEN 500 MG TABLET 0.06630 0.06633 2/15/2013 NAPROXEN 500 MG TABLET DR 0.00000 0.17420 12/1/2012 NAPROXEN SODIUM 220 MG TABLET 0.00000 0.05775 12/1/2012 NAPROXEN SODIUM 275 MG TABLET 0.08900 0.08830 1/25/2013 NAPROXEN SODIUM 550 MG TABLET 0.11600 0.11604 2/15/2013 NARATRIPTAN HCL 1 MG TABLET 4.95490 4.87429 2/22/2013 NARATRIPTAN HCL 2.5 MG TABLET 3.83120 5.29830 1/25/2013 NATEGLINIDE 120 MG TABLET 0.00000 0.90490 12/1/2012 NATEGLINIDE 60 MG TABLET 0.00000 1.07160 12/1/2012 NEFAZODONE HCL 100 MG TABLET 0.00000 0.57850 12/1/2012 NEFAZODONE HCL 150 MG TABLET 0.60797 0.60800 12/14/2012 NEFAZODONE HCL 200 MG TABLET 0.63678 0.63680 12/14/2012 NEFAZODONE HCL 250 MG TABLET 0.66582 0.66580 12/14/2012 NEFAZODONE HCL 50 MG TABLET 0.00000 0.52117 12/1/2012 NEO/POLYMYX B SULF/DEXAMETH 0.1 % DROPS SUSP 3.81290 3.76220 2/22/2013 NEO/POLYMYX B SULF/DEXAMETH 3.5-10K-.1 OINT. (G) 1.60000 4.73550 2/1/2013 NEOMY SULF/BACITRA/POLYMYXIN B PACKET 0.19333 0.19440 1/25/2013 NEOMY SULF/BACITRA/POLYMYXIN B 3.5MG-400 OINT. (G) 0.00000 8.35200 12/1/2012 NEOMY SULF/BACITRAC ZN/POLY 3.5-400-5K OINT. (G) 0.00000 0.08536 12/1/2012 NEOMY SULF/BACITRAC ZN/POLY/HC 3.5-10K-1 OINT. (G) 0.00000 12.81000 12/1/2012 NEOMY SULF/POLYMYXIN B SULFATE 40-200K/ML AMPUL 0.00000 7.75416 12/1/2012 NEOMY SULF/POLYMYXIN B SULFATE 40-200K/ML VIAL 0.00000 5.02645 12/1/2012 NEOMYCIN SULFATE 500 MG TABLET 0.88474 0.90100 1/25/2013 NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-1 DROPS SUSP 2.15600 2.15657 2/1/2013 Page 38 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-1 SOLUTION 0.00000 1.65100 12/1/2012 NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-10 DROPS SUSP 11.83750 12.73118 2/15/2013 NEOMYCIN/POLYMYXN B/GRAMICIDIN 1.75MG-10K DROPS 1.31075 1.30890 1/25/2013 NEOMYCN/BACI ZN/PMYX BS/PRAMOX 3.5-10K-10 OINT. (G) 0.00000 0.16978 12/1/2012 NEVIRAPINE 200 MG TABLET 0.17702 0.19200 1/25/2013 NEVIRAPINE 50 MG/5 ML ORAL SUSP 0.00000 0.40225 12/1/2012 NIACIN 100 MG TABLET 0.01268 0.01270 12/14/2012 NIACIN 1000 MG TABLET ER 0.00000 0.05775 12/14/2012 NIACIN 250 MG CAPSULE ER 0.00000 0.04147 12/1/2012 NIACIN 250 MG TABLET ER 0.03660 0.03662 2/8/2013 NIACIN 50 MG TABLET 0.00000 0.01274 12/1/2012 NIACIN 500 MG CAPSULE ER 0.04927 0.04930 12/14/2012 NIACIN 500 MG TABLET 0.01997 0.02000 12/14/2012 NIACIN 500 MG TABLET ER 0.00000 0.03296 12/1/2012 NIACIN 750 MG TABLET ER 0.10383 0.05020 1/25/2013 NIACINAMIDE 500 MG TABLET 0.00000 0.02415 12/1/2012 NICARDIPINE HCL 20 MG CAPSULE 0.32760 0.34500 2/8/2013 NICARDIPINE HCL 30 MG CAPSULE 0.48220 0.35170 1/25/2013 NICOTINE 14MG/24HR PATCH TD24 1.82613 1.78695 2/22/2013 NICOTINE 21 MG/24HR PATCH TD24 1.81520 1.79131 2/22/2013 NICOTINE 7MG/24HR PATCH TD24 1.79740 1.74771 2/15/2013 NICOTINE POLACRILEX 2 MG GUM 0.19220 0.19560 1/25/2013 NICOTINE POLACRILEX 2 MG LOZENGE 0.00000 0.36791 12/1/2012 NICOTINE POLACRILEX 4 MG GUM 0.23880 0.23879 2/8/2013 NICOTINE POLACRILEX 4 MG LOZENGE 0.36380 0.36377 2/8/2013 NIFEDIPINE 10 MG CAPSULE 0.00000 0.73000 1/25/2013 NIFEDIPINE 20 MG CAPSULE 1.40160 1.61180 2/1/2013 NIFEDIPINE 30 MG TAB ER 24 0.41430 0.41433 2/22/2013 NIFEDIPINE 30 MG TABLET ER 0.46565 0.46570 1/25/2013 NIFEDIPINE 60 MG TAB ER 24 0.58799 0.58800 12/14/2012 NIFEDIPINE 60 MG TABLET ER 0.97350 0.97351 2/15/2013 NIFEDIPINE 90 MG TAB ER 24 1.30850 1.33460 1/25/2013 NIFEDIPINE 90 MG TABLET ER 1.87299 1.89110 1/25/2013 NIMODIPINE 30 MG CAPSULE 6.40815 6.55030 12/21/2012 NISOLDIPINE 17 MG TAB ER 24H 0.00000 5.38832 12/1/2012 NISOLDIPINE 20 MG TAB ER 24H 6.10110 6.46710 2/1/2013 NISOLDIPINE 25.5 MG TAB ER 24H 0.00000 5.87636 12/1/2012 NISOLDIPINE 30 MG TAB ER 24H 6.65350 7.05270 2/8/2013 NISOLDIPINE 34 MG TAB ER 24H 0.00000 5.87636 12/1/2012 NISOLDIPINE 40 MG TAB ER 24H 0.00000 6.65350 12/1/2012 NISOLDIPINE 8.5MG TAB ER 24H 0.00000 4.29926 12/1/2012 NITROFURANTOIN 25 MG/5 ML ORAL SUSP 1.94398 1.95310 1/25/2013 NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE 1.68384 1.68380 12/14/2012 NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE 0.95837 0.95840 12/14/2012 NITROFURANTOIN MONOHYD/M-CRYST 100 MG CAPSULE 2.44360 2.45180 1/25/2013 NITROGLYCERIN 0.1MG/HR PATCH TD24 0.66370 0.66430 1/25/2013 NITROGLYCERIN 0.2MG/HR PATCH TD24 0.00000 0.58250 12/1/2012 NITROGLYCERIN 0.4MG/DOSE SPRAY 0.00000 27.46701 1/4/2013 NITROGLYCERIN 0.4MG/DOSE SPRAY 19.36030 16.29250 1/25/2013 NITROGLYCERIN 0.4MG/HR PATCH TD24 0.62846 0.62850 12/14/2012 NITROGLYCERIN 0.6MG/HR PATCH TD24 1.01610 1.01700 1/25/2013 NITROGLYCERIN 2.5 MG CAPSULE ER 0.09960 0.22630 2/8/2013 NITROGLYCERIN 50 MG/10ML VIAL 0.00000 0.47040 12/1/2012 NITROGLYCERIN 6.5 MG CAPSULE ER 0.13830 0.32960 2/15/2013 Page 39 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 NITROGLYCERIN 9 MG CAPSULE ER 0.49568 0.17330 1/25/2013 NITROGLYCERIN/D5W 200MG/500 INFUS. BTL 0.01446 0.01110 1/25/2013 NITROGLYCERIN/D5W 50MG/500ML INFUS. BTL 0.02648 0.02260 1/25/2013 NIZATIDINE 150 MG CAPSULE 0.29920 0.28050 1/25/2013 NIZATIDINE 150MG/10ML SOLUTION 0.48900 0.49350 2/22/2013 NIZATIDINE 300 MG CAPSULE 0.85586 0.85590 12/14/2012 NORETH A-ET ESTRA/FE FUMARATE 1.5-0.03MG TABLET 0.72337 0.77854 2/22/2013 NORETH A-ET ESTRA/FE FUMARATE 1MG-20MCG TABLET 0.71642 0.71640 1/25/2013 NORETH A-ET ESTRA/FE FUMARATE 5-7-9-7 TABLET 1.42883 1.42880 12/14/2012 NORETH-ETHINYL ESTRADIOL/IRON 0.4-35(21) TAB CHEW 1.82948 1.82950 1/25/2013 NORETHINDRONE 0.35 MG TABLET 0.85586 0.85590 12/14/2012 NORETHINDRONE A-E ESTRADIOL 1.5-0.03MG TABLET 0.00000 0.96454 12/1/2012 NORETHINDRONE A-E ESTRADIOL 1MG-20MCG TABLET 0.00000 0.95522 12/1/2012 NORETHINDRONE ACETATE 5 MG TABLET 1.82000 1.85400 2/8/2013 NORETHINDRONE-ETHINYL ESTRAD 0.4-0.035 TABLET 1.10350 0.92527 2/22/2013 NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET 0.80430 0.80140 1/25/2013 NORETHINDRONE-ETHINYL ESTRAD 1 MG-35MCG TABLET 0.74110 0.72034 2/22/2013 NORETHINDRONE-ETHINYL ESTRAD 7 DAYS X 3 TABLET 0.80860 0.81210 1/25/2013 NORETHINDRONE-ETHINYL ESTRAD 7-9-5 TABLET 0.00000 0.98375 12/1/2012 NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 TABLET 0.47409 0.45250 1/25/2013 NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 28 TABLET 0.45253 0.45250 1/25/2013 NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET 0.75000 0.76300 2/8/2013 NORTRIPTYLINE HCL 10 MG CAPSULE 0.09916 0.09920 12/14/2012 NORTRIPTYLINE HCL 10 MG/5 ML SOLUTION 0.17685 0.20683 12/14/2012 NORTRIPTYLINE HCL 25 MG CAPSULE 0.13601 0.13600 12/14/2012 NORTRIPTYLINE HCL 50 MG CAPSULE 0.16643 0.16640 12/14/2012 NORTRIPTYLINE HCL 75 MG CAPSULE 0.23061 0.23060 12/14/2012 NYSTATIN 100000/G CREAM (G) 0.33340 0.58920 2/1/2013 NYSTATIN 100000/G OINT. (G) 0.00000 0.95120 12/1/2012 NYSTATIN 100000/G POWDER 0.77360 1.01120 2/1/2013 NYSTATIN 10B UNIT POWDER(EA) 0.00000 ########## 12/1/2012 NYSTATIN 150MM UNIT POWDER(EA) 0.00000 70.10500 12/1/2012 NYSTATIN 150MM UNIT POWDER(EA) 408.51650 98.76650 1/25/2013 NYSTATIN 1B UNIT POWDER(EA) 523.22200 404.56500 1/25/2013 NYSTATIN 2B UNIT POWDER(EA) 0.00000 459.38450 12/1/2012 NYSTATIN 500K UNIT TABLET 0.46209 0.46100 1/25/2013 NYSTATIN 500MM UNIT POWDER(EA) 0.00000 156.49700 12/1/2012 NYSTATIN 500MM UNIT POWDER(EA) 0.00000 2.78014 12/1/2012 NYSTATIN 50MM UNIT POWDER(EA) 0.00000 47.31300 12/1/2012 NYSTATIN 50MM UNIT POWDER(EA) 0.00000 3.91430 12/1/2012 NYSTATIN 5B UNIT POWDER(EA) 0.00000 742.07950 12/1/2012 OCTREOTIDE ACETATE 100 MCG/ML AMPUL 0.00000 5.70960 12/1/2012 OCTREOTIDE ACETATE 100 MCG/ML DISP SYRIN 0.00000 10.04850 12/1/2012 OCTREOTIDE ACETATE 100 MCG/ML VIAL 0.00000 4.39920 12/1/2012 OCTREOTIDE ACETATE 1000MCG/ML VIAL 0.00000 30.52860 12/1/2012 OCTREOTIDE ACETATE 200 MCG/ML VIAL 0.00000 7.30800 12/1/2012 OCTREOTIDE ACETATE 50 MCG/ML AMPUL 0.00000 2.84310 12/1/2012 OCTREOTIDE ACETATE 50 MCG/ML DISP SYRIN 0.00000 5.98920 12/1/2012 OCTREOTIDE ACETATE 50 MCG/ML VIAL 3.08845 3.08850 12/14/2012 OCTREOTIDE ACETATE 500 MCG/ML AMPUL 0.00000 29.90650 12/1/2012 OCTREOTIDE ACETATE 500 MCG/ML DISP SYRIN 0.00000 45.22560 12/1/2012 OCTREOTIDE ACETATE 500 MCG/ML VIAL 0.00000 16.18890 12/1/2012 OFLOXACIN 0.3 % DROPS 0.46500 0.61370 1/25/2013 OFLOXACIN 0.3 % DROPS 0.37250 0.37252 2/15/2013 Page 40 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 OFLOXACIN 200 MG TABLET 0.00000 3.34859 12/1/2012 OFLOXACIN 300 MG TABLET 0.00000 3.98503 12/1/2012 OFLOXACIN 400 MG TABLET 4.20252 4.20250 12/14/2012 OLANZAPINE 10 MG TAB RAPDIS 0.00000 8.72300 12/1/2012 OLANZAPINE 10 MG TABLET 0.00000 1.29440 12/1/2012 OLANZAPINE 10 MG VIAL 0.00000 29.05000 12/1/2012 OLANZAPINE 15 MG TAB RAPDIS 0.00000 12.86570 12/1/2012 OLANZAPINE 15 MG TABLET 0.00000 1.94180 12/1/2012 OLANZAPINE 2.5 MG TABLET 0.00000 0.40630 12/1/2012 OLANZAPINE 20 MG TAB RAPDIS 0.00000 17.00830 12/1/2012 OLANZAPINE 20 MG TABLET 0.00000 2.58900 12/1/2012 OLANZAPINE 5 MG TAB RAPDIS 0.00000 5.93670 12/1/2012 OLANZAPINE 5 MG TABLET 0.00000 0.85890 12/1/2012 OLANZAPINE 7.5 MG TABLET 0.00000 0.54020 12/1/2012 OLANZAPINE/FLUOXETINE HCL 12MG-25MG CAPSULE 0.00000 15.27470 12/1/2012 OLANZAPINE/FLUOXETINE HCL 12MG-50MG CAPSULE 0.00000 15.27470 12/1/2012 OLANZAPINE/FLUOXETINE HCL 3MG-25MG CAPSULE 0.00000 7.57062 12/1/2012 OLANZAPINE/FLUOXETINE HCL 6MG-25MG CAPSULE 0.00000 10.13740 12/1/2012 OLANZAPINE/FLUOXETINE HCL 6MG-50MG CAPSULE 0.00000 10.13740 12/1/2012 OM-3/DHA/EPA/B12/FA/B6/PHYTOST 500-0.5-1 CAPSULE 0.64330 0.76420 1/25/2013 OMEGA-3/DHA/EPA/FISH OIL 1000 MG CAPSULE 0.03652 0.04020 1/25/2013 OMEGA-3/DHA/EPA/FISH OIL 500-1000MG CAPSULE 0.00000 0.10952 12/1/2012 OMEPRAZOLE 10 MG CAPSULE DR 0.27832 0.27680 1/25/2013 OMEPRAZOLE 20 MG CAPSULE DR 0.11780 0.11779 2/22/2013 OMEPRAZOLE 20 MG TABLET DR 0.00000 0.60836 12/1/2012 OMEPRAZOLE 40 MG CAPSULE DR 0.23986 0.23990 1/25/2013 OMEPRAZOLE/SODIUM BICARBONATE 20MG-1.1G CAPSULE 0.00000 0.48869 12/1/2012 OMEPRAZOLE/SODIUM BICARBONATE 40MG-1.1G CAPSULE 4.52340 7.97440 2/1/2013 ONDANSETRON 4 MG TAB RAPDIS 0.42190 0.42185 2/22/2013 ONDANSETRON 8 MG TAB RAPDIS 0.55074 0.55070 12/14/2012 ONDANSETRON HCL 4 MG TABLET 0.12560 0.12556 2/22/2013 ONDANSETRON HCL 4 MG/5 ML SOLUTION 0.60530 1.94420 2/8/2013 ONDANSETRON HCL 8 MG TABLET 0.15906 0.15910 12/14/2012 ONDANSETRON HCL/PF 4 MG/2 ML AMPUL 0.00000 8.31950 12/1/2012 ONDANSETRON HCL/PF 4 MG/2 ML DISP SYRIN 0.00000 1.10670 12/1/2012 ONDANSETRON HCL/PF 4 MG/2 ML VIAL 0.32428 0.32430 12/14/2012 ONDANSETRON IN 0.9 % NACL/PF 32 MG/50ML PIGGYBACK 0.00000 1.51196 12/1/2012 OPIUM TINCTURE 10 MG/ML TINCTURE 4.94574 4.99300 1/25/2013 OPIUM/BELLADONNA ALKALOIDS 30-16.2MG SUPP.RECT 14.87500 16.21380 2/8/2013 OPIUM/BELLADONNA ALKALOIDS 60-16.2MG SUPP.RECT 0.00000 19.71083 12/1/2012 ORPHENADRINE CITRATE 100 MG TABLET ER 0.57480 0.57830 1/25/2013 ORPHENADRINE/ASPIRIN/CAFFEINE 25-385-30 TABLET 1.05640 1.26658 2/22/2013 ORPHENADRINE/ASPIRIN/CAFFEINE 50-770-60 TABLET 0.00000 1.83323 12/1/2012 OXACILLIN SODIUM 1 G VIAL 9.75910 10.07977 2/1/2013 OXACILLIN SODIUM 1 G VIAL PORT 0.00000 0.86301 12/1/2012 OXACILLIN SODIUM 10 G VIAL 88.62910 90.95850 2/1/2013 OXACILLIN SODIUM 2 G VIAL 18.87810 18.97980 2/1/2013 OXACILLIN SODIUM 2 G VIAL PORT 0.00000 2.23201 12/1/2012 OXACILLIN SODIUM/DEXTROSE,ISO 1 G/50 ML FROZ.PIGGY 0.25511 0.25790 1/25/2013 OXACILLIN SODIUM/DEXTROSE,ISO 2 G/50 ML FROZ.PIGGY 0.00000 0.21527 12/1/2012 OXANDROLONE 10 MG TABLET 0.00000 9.27840 12/1/2012 OXANDROLONE 2.5 MG TABLET 2.95953 2.93260 1/25/2013 OXAPROZIN 600 MG TABLET 2.34180 2.56480 2/22/2013 OXAZEPAM 10 MG CAPSULE 0.00000 0.73300 12/1/2012 Page 41 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 OXAZEPAM 15 MG CAPSULE 0.00000 1.20600 12/1/2012 OXCARBAZEPINE 150 MG TABLET 0.13735 0.13740 1/25/2013 OXCARBAZEPINE 300 MG TABLET 0.28502 0.28110 1/25/2013 OXCARBAZEPINE 300 MG/5ML ORAL SUSP 0.53140 0.57900 12/21/2012 OXCARBAZEPINE 600 MG TABLET 0.56990 0.54910 1/25/2013 OXYBUTYNIN CHLORIDE 10 MG TAB ER 24 1.32660 1.45930 1/25/2013 OXYBUTYNIN CHLORIDE 15 MG TAB ER 24 2.15887 2.15890 12/14/2012 OXYBUTYNIN CHLORIDE 5 MG TAB ER 24 1.32660 1.45930 1/25/2013 OXYBUTYNIN CHLORIDE 5 MG TABLET 0.04221 0.04220 12/14/2012 OXYBUTYNIN CHLORIDE 5 MG/5 ML SYRUP 0.01956 0.01960 12/14/2012 OXYCODONE HCL 10 MG TABLET 0.24700 0.26460 12/21/2012 OXYCODONE HCL 15 MG TABLET 0.00000 0.16080 12/1/2012 OXYCODONE HCL 20 MG/ML ORAL CONC 3.69130 5.15820 2/1/2013 OXYCODONE HCL 30 MG TABLET 0.00000 0.32160 12/1/2012 OXYCODONE HCL 5 MG CAPSULE 1.15260 1.13078 2/22/2013 OXYCODONE HCL 5 MG TABLET 0.00000 0.10720 12/1/2012 OXYCODONE HCL/ACETAMINOPHEN 10MG-325MG TABLET 0.39170 0.36780 1/25/2013 OXYCODONE HCL/ACETAMINOPHEN 10MG-650MG TABLET 0.73184 0.37370 2/15/2013 OXYCODONE HCL/ACETAMINOPHEN 2.5-325MG TABLET 0.00000 2.87868 12/1/2012 OXYCODONE HCL/ACETAMINOPHEN 5MG-325MG TABLET 0.04864 0.04860 1/25/2013 OXYCODONE HCL/ACETAMINOPHEN 7.5-325MG TABLET 0.33070 0.30820 2/15/2013 OXYCODONE HCL/ACETAMINOPHEN 7.5-500MG TABLET 0.00000 0.45240 12/1/2012 OXYMORPHONE HCL 10 MG TAB ER 12H 0.00000 2.43642 1/4/2013 OXYMORPHONE HCL 10 MG TABLET 3.74451 4.11894 2/15/2013 OXYMORPHONE HCL 15 MG TAB ER 12H 0.00000 3.61963 12/1/2012 OXYMORPHONE HCL 20 MG TAB ER 12H 0.00000 4.32131 1/4/2013 OXYMORPHONE HCL 30 MG TAB ER 12H 0.00000 6.21978 1/4/2013 OXYMORPHONE HCL 40 MG TAB ER 12H 0.00000 8.11846 1/4/2013 OXYMORPHONE HCL 5 MG TAB ER 12H 0.00000 1.26882 1/4/2013 OXYMORPHONE HCL 5 MG TABLET 2.06227 2.26849 2/15/2013 OXYMORPHONE HCL 7.5 MG TAB ER 12H 4.41000 1.91860 1/4/2013 P-EPHED HCL/CODEINE/GUAIFEN 30-10-100 SYRUP 0.00000 0.04770 12/1/2012 P-EPHED HCL/TRIPROLIDINE HCL 10-0.938/1 LIQUID 1.25623 1.59900 1/25/2013 P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP 0.00790 0.05830 1/25/2013 P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET 0.00000 0.05247 12/1/2012 PAMIDRONATE DISODIUM 30 MG VIAL 0.00000 15.22500 12/1/2012 PAMIDRONATE DISODIUM 30MG/10ML VIAL 0.00000 1.51688 12/1/2012 PAMIDRONATE DISODIUM 60 MG/10ML VIAL 0.00000 4.62000 12/1/2012 PAMIDRONATE DISODIUM 90 MG VIAL 0.00000 56.47750 12/1/2012 PAMIDRONATE DISODIUM 90 MG/10ML VIAL 0.00000 4.14700 12/1/2012 PANTOPRAZOLE SODIUM 20 MG TABLET DR 0.12220 0.12223 2/8/2013 PANTOPRAZOLE SODIUM 40 MG TABLET DR 0.10360 0.10358 2/8/2013 PANTOPRAZOLE SODIUM 40 MG VIAL 0.00000 3.94100 12/21/2012 PAREGORIC 2 MG/5 ML LIQUID 0.00000 0.19635 12/1/2012 PAROMOMYCIN SULFATE 250 MG CAPSULE 0.00000 3.13066 12/1/2012 PAROXETINE HCL 10 MG TABLET 0.12234 0.12230 12/14/2012 PAROXETINE HCL 12.5 MG TAB ER 24H 2.53237 2.53190 1/25/2013 PAROXETINE HCL 20 MG TABLET 0.11926 0.11930 1/25/2013 PAROXETINE HCL 25 MG TAB ER 24H 2.63724 2.64470 1/25/2013 PAROXETINE HCL 30 MG TABLET 0.16844 0.16840 12/14/2012 PAROXETINE HCL 37.5 MG TAB ER 24H 2.72364 2.72360 1/25/2013 PAROXETINE HCL 40 MG TABLET 0.17862 0.17860 12/14/2012 PEANUT OIL OIL 0.09602 0.09990 1/25/2013 PEG 3350/NA SULF,BICARB,CL/KCL 236-22.74G SOLN RECON 0.00316 0.00310 1/25/2013 Page 42 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PEG 3350/NA SULF,BICARB,CL/KCL 240-22.72G SOLN RECON 0.00210 0.00220 2/8/2013 PEG 400/HYPROMELLOSE/GLYCERIN 1-0.2-0.2% DROPS 0.15805 0.06720 1/25/2013 PEN G POT/DEXTROSE-WATER 1MM/50ML FROZ.PIGGY 0.00000 0.19490 12/1/2012 PEN G POT/DEXTROSE-WATER 2MM/50ML FROZ.PIGGY 0.00000 0.21880 12/1/2012 PEN G POT/DEXTROSE-WATER 3MM/50ML FROZ.PIGGY 0.24007 0.13440 1/25/2013 PENICILLIN G POTASSIUM 20MM UNIT VIAL 119.09100 95.11250 1/25/2013 PENICILLIN G POTASSIUM 5MM UNIT VIAL 29.52250 21.69720 1/25/2013 PENICILLIN G PROCAINE 1.2MM/2 ML DISP SYRIN 10.86715 11.84540 1/25/2013 PENICILLIN G PROCAINE 600000/ML DISP SYRIN 0.00000 13.05360 12/1/2012 PENICILLIN G SODIUM 5MM UNIT VIAL 40.12055 38.58720 1/25/2013 PENICILLIN V POTASSIUM 125 MG/5ML SOLN RECON 0.01900 0.02410 2/8/2013 PENICILLIN V POTASSIUM 250 MG TABLET 0.07520 0.07517 2/22/2013 PENICILLIN V POTASSIUM 250 MG/5ML SOLN RECON 0.01590 0.02520 2/1/2013 PENICILLIN V POTASSIUM 500 MG TABLET 0.12300 0.12301 2/1/2013 PENTAZOCINE HCL/ACETAMINOPHEN 25-650MG TABLET 0.83851 0.84920 1/25/2013 PENTAZOCINE HCL/NALOXONE HCL 50MG-0.5MG TABLET 0.98390 0.98370 1/25/2013 PENTOXIFYLLINE 400 MG TABLET ER 0.18117 0.18120 12/14/2012 PERINDOPRIL ERBUMINE 2 MG TABLET 0.00000 0.85163 12/1/2012 PERINDOPRIL ERBUMINE 4 MG TABLET 0.00000 0.75205 12/1/2012 PERINDOPRIL ERBUMINE 8 MG TABLET 0.00000 0.85631 12/1/2012 PERMETHRIN 5 % CREAM (G) 0.00000 0.82930 12/1/2012 PERPHENAZINE 16 MG TABLET 1.29000 1.33480 2/8/2013 PERPHENAZINE 2 MG TABLET 0.57910 0.57560 1/25/2013 PERPHENAZINE 4 MG TABLET 0.81904 0.79040 1/11/2013 PERPHENAZINE 8 MG TABLET 0.95890 0.98910 2/1/2013 PERPHENAZINE/AMITRIPTYLINE HCL 2 MG-10 MG TABLET 0.42510 0.45060 2/8/2013 PERPHENAZINE/AMITRIPTYLINE HCL 2 MG-25 MG TABLET 0.00000 0.60030 12/1/2012 PERPHENAZINE/AMITRIPTYLINE HCL 4 MG-25 MG TABLET 0.58947 0.62230 1/25/2013 PERPHENAZINE/AMITRIPTYLINE HCL 4MG-10MG TABLET 0.47565 0.47570 1/25/2013 PETROLATUM,WHITE OINT PACK 0.00000 13.09140 12/1/2012 PETROLATUM,WHITE/WATER LOTION 0.01034 0.00860 1/25/2013 PHENAZOPYRIDINE HCL 100 MG TABLET 0.08684 0.08680 12/14/2012 PHENAZOPYRIDINE HCL 200 MG TABLET 0.00000 0.21310 12/1/2012 PHENDIMETRAZINE TARTRATE 35 MG TABLET 0.14340 0.13900 1/25/2013 PHENELZINE SULFATE 15 MG TABLET 0.00000 0.58450 12/1/2012 PHENOBARBITAL 100 MG TABLET 0.21660 0.21430 1/25/2013 PHENOBARBITAL 15 MG TABLET 0.11070 0.11560 1/25/2013 PHENOBARBITAL 16.2 MG TABLET 0.04330 0.08270 2/1/2013 PHENOBARBITAL 20 MG/5 ML ELIXIR 0.02900 0.03730 2/1/2013 PHENOBARBITAL 30 MG TABLET 0.05930 0.08000 1/25/2013 PHENOBARBITAL 32.4MG TABLET 0.04170 0.10390 2/1/2013 PHENOBARBITAL 64.8MG TABLET 0.13251 0.13240 1/25/2013 PHENOBARBITAL 97.2MG TABLET 0.19016 0.19010 1/25/2013 PHENOBARBITAL SODIUM 130MG/ML VIAL 24.19200 13.60800 1/25/2013 PHENOBARBITAL SODIUM 65 MG/ML VIAL 0.00000 18.26916 12/1/2012 PHENTERMINE HCL 15 MG CAPSULE 0.76600 0.76603 2/22/2013 PHENTERMINE HCL 30 MG CAPSULE 0.00000 0.20502 12/1/2012 PHENTERMINE HCL 37.5 MG CAPSULE 0.00000 0.31195 12/1/2012 PHENTERMINE HCL 37.5 MG TABLET 0.00000 0.10693 12/1/2012 PHENTOLAMINE MESYLATE 5 MG VIAL 44.58750 59.45000 12/14/2012 PHENTOLAMINE MESYLATE 5 MG/ML(1) VIAL 0.00000 257.37180 12/1/2012 PHENYLEPHRINE HCL 10 % DROPS 0.00000 0.88140 12/1/2012 PHENYLEPHRINE HCL 10 MG TABLET 0.00000 0.03575 12/1/2012 PHENYLEPHRINE HCL 2.5 % DROPS 0.00000 0.93706 12/1/2012 Page 43 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PHENYLEPHRINE HCL 2.5 MG/5ML SOLUTION 0.05222 0.04150 1/25/2013 PHENYLEPHRINE HCL/COD/PROMETH 5-10-6.25 SYRUP 0.08488 0.08490 12/14/2012 PHENYLEPHRINE HCL/PROMETH HCL 5-6.25MG/5 SYRUP 0.06230 0.06050 1/25/2013 PHENYLEPHRINE/BROMPHENIRAMINE 10-4MG/5ML LIQUID 0.00000 0.15294 12/1/2012 PHENYLEPHRINE/BROMPHENIRAMINE 10MG-6MG/5 ORAL SUSP 0.00000 0.25513 12/1/2012 PHENYLEPHRINE/CHLOPHEDIANOL/GG 5-12.5-120 LIQUID 0.09590 0.08960 1/25/2013 PHENYLEPHRINE/CHLORPHENIRAMINE 10-4MG/5ML LIQUID 0.02657 0.02660 1/25/2013 PHENYLEPHRINE/CHLORPHENIRAMINE 2MG-1MG/ML DROPS 0.00000 0.45951 12/1/2012 PHENYLEPHRINE/CHLORPHENIRAMINE 3.5-1MG/ML DROPS 0.37657 0.37660 12/14/2012 PHENYLEPHRINE/PYRILAMINE 5-16MG/5ML ORAL SUSP 0.40979 0.40980 1/25/2013 PHENYTOIN 100 MG/4ML ORAL SUSP 0.27300 0.24360 1/25/2013 PHENYTOIN 125 MG/5ML ORAL SUSP 0.09340 0.09450 2/8/2013 PHENYTOIN 50 MG TAB CHEW 0.00000 0.36840 1/4/2013 PHENYTOIN SODIUM 50 MG/ML AMPUL 0.00000 0.57670 1/25/2013 PHENYTOIN SODIUM 50 MG/ML DISP SYRIN 0.62160 0.68460 1/25/2013 PHENYTOIN SODIUM 50 MG/ML VIAL 0.36005 0.37560 1/25/2013 PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE 0.08831 0.08830 12/14/2012 PHENYTOIN SODIUM EXTENDED 200 MG CAPSULE 0.55987 0.55990 1/25/2013 PHENYTOIN SODIUM EXTENDED 300 MG CAPSULE 0.00000 0.83864 12/1/2012 PHOSP ACID/DEXTROSE/FRUCTOSE SOLUTION 0.00000 0.02023 12/1/2012 PHOSPHORUS #1 250 MG TABLET 0.00000 0.13195 12/1/2012 PHYTONADIONE 10 MG/ML AMPUL 7.92240 7.53480 1/25/2013 PHYTONADIONE 100 MCG TABLET 0.02195 0.02140 1/25/2013 PILOCARPINE HCL 1 % DROPS 1.45513 1.49990 12/21/2012 PILOCARPINE HCL 2 % DROPS 0.00000 1.68036 12/1/2012 PILOCARPINE HCL 4 % DROPS 0.00000 2.08598 12/1/2012 PILOCARPINE HCL 5 MG TABLET 0.23249 0.23250 12/14/2012 PILOCARPINE HCL 7.5 MG TABLET 0.00000 1.12463 12/1/2012 PINDOLOL 10 MG TABLET 0.93352 0.98950 1/25/2013 PINDOLOL 5 MG TABLET 0.68520 0.72630 2/8/2013 PIOGLITAZONE HCL 15 MG TABLET 2.33917 2.33780 1/25/2013 PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G VIAL 4.41090 4.27310 1/25/2013 PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G VIAL PORT 0.00000 8.32230 12/1/2012 PIPERACILLIN SODIUM/TAZOBACTAM 3.375 G VIAL 6.37032 5.91185 12/14/2012 PIPERACILLIN SODIUM/TAZOBACTAM 3.375 G VIAL PORT 0.00000 11.57100 12/1/2012 PIPERACILLIN SODIUM/TAZOBACTAM 4.5G VIAL 7.87680 7.49400 1/25/2013 PIPERACILLIN SODIUM/TAZOBACTAM 4.5G VIAL PORT 0.00000 15.73320 12/1/2012 PIPERACILLIN SODIUM/TAZOBACTAM 40.5G VIAL 54.97700 77.53100 12/21/2012 PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% SHAMPOO 0.03613 0.03610 12/14/2012 PIROXICAM 10 MG CAPSULE 1.05400 0.98560 1/25/2013 PIROXICAM 20 MG CAPSULE 1.84730 1.80000 2/8/2013 PN W-CA64/IRON CB&GL/FA/DSS/DH 90-1-300MG COMBO. PKG 0.00000 0.76697 1/25/2013 PNV #8/IRON PS CMP&ASPG/FA/DHA 22-6-1-200 COMBO. PKG 0.49554 0.51920 1/25/2013 PNV #87/IRON BISGLY/FA/DHA 32-1-230MG COMBO. PKG 0.65438 0.65450 1/25/2013 PNV 11-IRON FUM-FOLIC ACID-OM3 28-1-200MG CAPSULE 0.00000 1.71267 12/1/2012 PNV CMB#21/IRON/FOLIC ACID 14 MG-400 TABLET 0.00000 0.06411 12/1/2012 PNV CMB#95/FERROUS FUMARATE/FA 28MG-0.8MG TABLET 0.04200 0.05040 2/15/2013 PNV COMBO #22/IRON/FA/OM3/DHA 28-6-1-203 COMBO. PKG 0.00000 0.62148 1/25/2013 PNV COMBO#47/IRON/FA #1/DHA 27-1-300MG CAPSULE 1.59623 1.59290 1/25/2013 PNV NO.15/IRON FUM & PS CMP/FA 85 MG-1 MG CAPSULE 0.00000 1.15359 12/1/2012 PNV NO.22/IRON CBN&GLUC/FA/DSS 27-1-50MG TABLET 0.00000 0.34913 12/1/2012 PNV NO.23-IRON PS COMPLEX-FA 155 MG-1MG CAPSULE 0.00000 0.20689 12/1/2012 PNV W-CA #40/IRON FUM/FA CMB#1 27 MG-1 MG TABLET 0.00000 1.77551 12/1/2012 PNV W-CA NO.37/IRON/FA/OMEGA-3 27-1-330MG CAPSULE 0.99992 0.74533 12/14/2012 Page 44 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PNV W-O CA NO5/FE FUMARATE/FA 106.5-1MG CAPSULE 0.00000 0.24367 12/1/2012 PNV W-O IRON/FA/CALCIUM/B6/B12 1-200-75 TBMP 24HR 0.00000 0.70590 12/1/2012 PNV WITH CA #68/IRON/FA#1/DHA 28-1-300MG CAPSULE 0.00000 1.68677 12/1/2012 PNV WITH CA,NO.71/IRON/FA 27 MG-1 MG TABLET 0.00000 0.06240 12/1/2012 PNV WITH CA,NO.72/IRON,CARB/FA 29 MG-1 MG TABLET 0.06740 0.13210 1/25/2013 PNV WITH CA,NO.72/IRON/FA 27 MG-1 MG TABLET 0.00000 0.06740 12/1/2012 PNV WITH CA,NO.74/IRON/FA 27 MG-1 MG TABLET 0.12360 0.02207 2/15/2013 PNV#16/IRON FUM & PS/FA/OM-3 35-1-200MG CAPSULE 0.00000 1.28451 12/1/2012 PNV#75/IRON FUM/FA/OM3/DHA/EPA 28-800-440 COMBO. PKG 0.00000 0.13988 12/1/2012 PNV#79/IRON/FA/LMFOLATE CA/DHA 27-1.13 MG CAPSULE 1.63357 1.81370 1/25/2013 PNV,CA42/IRON/FA/LMEFOL CA/DHA 27-1.13 MG CAPSULE 0.00000 1.36127 12/1/2012 PNV/FA/B6/CALCIUM PHOS/GINGER 1.2-40-100 TABLET 0.00000 0.72360 12/1/2012 PNV17/IRON/FA/FISH OIL/DHA/OM 35-5-1.2MG CAPSULE 0.00000 1.61980 12/1/2012 PNV2/IRON B-G SUC-P/FA/OMEGA-3 29-1-250MG COMBO. PKG 0.00000 0.36225 12/1/2012 PNV22/IRON CBN&GLUC/FA/DSS/DHA 27-1-50MG COMBO. PKG 0.00000 0.63047 12/1/2012 PNV34/IRON,CARBONYL/FA/DSS/DHA 30-1-50 MG CAPSULE 0.00000 1.58305 12/1/2012 PNV38/IRON CBN&GLUC/FA/DSS/DHA 35-1-50MG COMBO. PKG 0.00000 0.78493 1/25/2013 PNV53/IRON B-G HCL-P/FA/OMEGA3 29-1-400MG COMBO. PKG 0.00000 0.43260 12/1/2012 PNV54/IRON B-G HCL-P/FA/OMEGA3 29-1-430MG COMBO. PKG 0.00000 0.43260 12/1/2012 PNV66/IRON FUMARATE/FA/DSS/DHA 27-1.25-55 CAPSULE 0.00000 1.36056 12/1/2012 PNV80/IRON FUMARATE/FA/DSS/DHA 29-1.25-55 CAPSULE 0.00000 1.98769 12/1/2012 PNV81/SOD IRON EDTA& PS/FA/OM3 27-1-430MG CMBPKGDRCP 0.00000 0.86509 12/1/2012 PNV94/SOD IRON EDTA& PS/FA/OM3 26-1-374MG CMBPKGDRCP 0.00000 1.13225 12/1/2012 PODOFILOX 0.5 % SOLUTION 0.00000 14.15050 12/1/2012 POLYETHYLENE GLYCOL 3350 17G POWD PACK 0.10921 0.10920 12/14/2012 POLYETHYLENE GLYCOL 3350 17G/DOSE POWDER 0.00000 0.04100 12/1/2012 POLYMYXIN B SULF/TRIMETHOPRIM 10K/ML-0.1 DROPS 0.00000 0.89840 12/1/2012 POLYVINYL ALCOHOL 1.4 % DROPS 0.00000 0.13400 12/1/2012 POT CHLORIDE/POT BICARB/CIT AC 25 MEQ TABLET EFF 0.00000 0.68997 12/1/2012 POTASSIUM ACETATE 4 MEQ/ML VIAL 0.00000 0.08400 12/1/2012 POTASSIUM BICARBONATE/CIT AC 25 MEQ TABLET EFF 0.22560 0.21200 2/15/2013 POTASSIUM CHLORIDE 10 MEQ CAPSULE ER 0.67210 0.69480 2/1/2013 POTASSIUM CHLORIDE 10 MEQ TAB ER PRT 0.27510 0.38630 2/1/2013 POTASSIUM CHLORIDE 10MEQ/0.1L PIGGYBACK 0.00000 0.02218 12/1/2012 POTASSIUM CHLORIDE 10MEQ/50ML PIGGYBACK 0.04368 0.06570 1/25/2013 POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN 0.00000 0.02806 12/1/2012 POTASSIUM CHLORIDE 2 MEQ/ML VIAL 0.05052 0.06470 1/25/2013 POTASSIUM CHLORIDE 20 MEQ TAB ER PRT 0.39491 0.39490 1/25/2013 POTASSIUM CHLORIDE 20MEQ/0.1L PIGGYBACK 0.02268 0.02180 1/25/2013 POTASSIUM CHLORIDE 20MEQ/15ML LIQUID 0.00000 0.01350 12/1/2012 POTASSIUM CHLORIDE 20MEQ/50ML PIGGYBACK 0.10777 0.10610 1/25/2013 POTASSIUM CHLORIDE 30MEQ/0.1L PIGGYBACK 0.00000 0.04528 12/1/2012 POTASSIUM CHLORIDE 40MEQ/0.1L PIGGYBACK 0.00000 0.04897 12/1/2012 POTASSIUM CHLORIDE 40MEQ/15ML LIQUID 0.02955 0.02960 12/14/2012 POTASSIUM CHLORIDE 8 MEQ CAPSULE ER 0.62810 0.65780 2/1/2013 POTASSIUM CHLORIDE IN 0.9%NACL 20 MEQ/L IV SOLN 0.00254 0.00300 1/25/2013 POTASSIUM CHLORIDE IN 0.9%NACL 40 MEQ/L IV SOLN 0.00601 0.00510 1/25/2013 POTASSIUM CHLORIDE IN D5W 20 MEQ/L IV SOLN 0.00233 0.00310 1/25/2013 POTASSIUM CHLORIDE IN D5W 30 MEQ/L IV SOLN 0.00000 0.00266 12/1/2012 POTASSIUM CHLORIDE IN D5W 40 MEQ/L IV SOLN 0.00000 0.00209 12/1/2012 POTASSIUM CHLORIDE IN LR-D5 20 MEQ/L IV SOLN 0.00739 0.00610 1/25/2013 POTASSIUM CHLORIDE IN LR-D5 40 MEQ/L IV SOLN 0.00000 0.00403 12/1/2012 POTASSIUM CHLORIDE-0.45% NACL 20 MEQ/L IV SOLN 0.00542 0.00410 1/25/2013 POTASSIUM CHLORIDE/D5-0.2%NACL 10 MEQ/L IV SOLN 0.00000 0.00234 12/1/2012 Page 45 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 POTASSIUM CHLORIDE/D5-0.2%NACL 20 MEQ/L IV SOLN 0.00000 0.00322 12/1/2012 POTASSIUM CHLORIDE/D5-0.2%NACL 30 MEQ/L IV SOLN 0.00231 0.00200 1/25/2013 POTASSIUM CHLORIDE/D5-0.2%NACL 40 MEQ/L IV SOLN 0.00000 0.00227 12/1/2012 POTASSIUM CHLORIDE/D5-0.3%NACL 20 MEQ/L IV SOLN 0.00000 0.00322 12/1/2012 POTASSIUM CHLORIDE/D5-0.45NACL 10 MEQ/L IV SOLN 0.00230 0.00320 1/25/2013 POTASSIUM CHLORIDE/D5-0.45NACL 20 MEQ/L IV SOLN 0.00150 0.00230 1/25/2013 POTASSIUM CHLORIDE/D5-0.45NACL 30 MEQ/L IV SOLN 0.00000 0.00236 12/1/2012 POTASSIUM CHLORIDE/D5-0.45NACL 40 MEQ/L IV SOLN 0.00000 0.00228 12/1/2012 POTASSIUM CHLORIDE/D5-0.9%NACL 20 MEQ/L IV SOLN 0.00254 0.00320 1/25/2013 POTASSIUM CHLORIDE/D5-0.9%NACL 40 MEQ/L IV SOLN 0.00645 0.00540 1/25/2013 POTASSIUM CITRATE 10 MEQ TABLET ER 0.99255 0.99260 12/14/2012 POTASSIUM CITRATE 5 MEQ TABLET ER 0.00000 0.70811 12/1/2012 POVIDONE-IODINE 0.3 % SOLUTION 0.00901 0.00990 1/25/2013 POVIDONE-IODINE 10 % MED. SWAB 0.12280 0.14540 1/25/2013 POVIDONE-IODINE 10 % OINT. (G) 0.00000 0.06258 12/1/2012 POVIDONE-IODINE 10 % SOLUTION 0.00000 0.00643 12/1/2012 PRAMIPEXOLE DI-HCL 0.125 MG TABLET 0.05320 0.06071 2/22/2013 PRAMIPEXOLE DI-HCL 0.25 MG TABLET 0.06560 0.06920 12/21/2012 PRAMIPEXOLE DI-HCL 0.5 MG TABLET 0.08830 0.09020 1/25/2013 PRAMIPEXOLE DI-HCL 0.75 MG TABLET 0.10120 0.10720 12/21/2012 PRAMIPEXOLE DI-HCL 1 MG TABLET 0.09591 0.09590 12/14/2012 PRAMIPEXOLE DI-HCL 1.5 MG TABLET 0.10170 0.09910 1/25/2013 PRAMOXINE HCL 1 % TOWELETTE 0.00000 0.35233 12/1/2012 PRAVASTATIN SODIUM 10 MG TABLET 0.07517 0.07520 12/14/2012 PRAVASTATIN SODIUM 20 MG TABLET 0.07732 0.07730 12/14/2012 PRAVASTATIN SODIUM 40 MG TABLET 0.10157 0.10160 12/14/2012 PRAVASTATIN SODIUM 80 MG TABLET 0.00000 0.19350 12/1/2012 PRAZOSIN HCL 1 MG CAPSULE 0.09715 0.09720 12/14/2012 PRAZOSIN HCL 2 MG CAPSULE 0.19140 0.19135 2/15/2013 PRAZOSIN HCL 5 MG CAPSULE 0.30498 0.30500 12/14/2012 PREDNICARBATE 0.1 % CREAM (G) 0.00000 0.86964 12/1/2012 PREDNICARBATE 0.1 % OINT. (G) 1.13044 1.17750 1/25/2013 PREDNISOLONE 15 MG/5 ML SOLUTION 0.02250 0.02251 2/1/2013 PREDNISOLONE ACETATE 1 % DROPS SUSP 1.65620 1.65624 2/22/2013 PREDNISOLONE SOD PHOSPHATE 1 % DROPS 3.22840 4.19720 2/8/2013 PREDNISOLONE SOD PHOSPHATE 15 MG/5 ML SOLUTION 0.07060 0.06980 1/25/2013 PREDNISOLONE SOD PHOSPHATE 25 MG/5 ML SOLUTION 0.00000 1.31101 12/1/2012 PREDNISONE 1 MG TABLET 0.06760 0.06450 1/25/2013 PREDNISONE 10 MG TAB DS PK 0.00000 0.17809 12/1/2012 PREDNISONE 10 MG TABLET 0.03060 0.03055 2/1/2013 PREDNISONE 2.5 MG TABLET 0.03471 0.03470 12/14/2012 PREDNISONE 20 MG TABLET 0.05490 0.05494 2/22/2013 PREDNISONE 5 MG TAB DS PK 0.09290 0.09286 2/1/2013 PREDNISONE 5 MG TABLET 0.01740 0.01742 2/15/2013 PREDNISONE 5 MG/5 ML SOLUTION 0.12890 0.14180 2/15/2013 PREDNISONE 50 MG TABLET 0.21685 0.21720 1/25/2013 PRENATAL #57/IRON/FA/DSS/DHA 29-1.25-55 CAPSULE 0.00000 1.99010 1/11/2013 PRENATAL VIT #76/IRON,CARB/FA 29 MG-1 MG TABLET 0.00000 0.11903 12/1/2012 PRENATAL VIT 15/IRON CB/FA/DSS 90-1-50 MG TABLET 0.11779 0.11780 12/14/2012 PRENATAL VIT 16/IRON CB/FA/DSS 90-1-50 MG TABLET 0.00000 0.21984 12/1/2012 PRENATAL VIT 18/IRON CB/FA/DSS 90-1-50 MG TABLET 0.08177 0.08180 12/14/2012 PRENATAL VIT NO.73/IRON/FA 28 MG-1 MG TABLET 0.00000 0.18018 12/1/2012 PRENATAL VIT#86/IRON BISGLY/FA 32 MG-1 MG TABLET 0.83875 0.83900 1/25/2013 PRENATAL VIT#96/FERROUS FUM/FA 27MG-0.8MG TABLET 0.00000 0.06840 12/1/2012 Page 46 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PRENATAL VIT/FE FUM/DOSS/FA 29 MG-1 MG TABLET 0.26712 0.36358 2/15/2013 PRENATAL VIT/FE FUMARATE/FA/SE 27 MG-1 MG TABLET 0.00000 0.15301 12/1/2012 PRENATAL VIT/IRON FUMARATE/FA 27MG-0.8MG TABLET 0.00000 0.03120 12/1/2012 PRENATAL VIT/IRON FUMARATE/FA 28MG-0.8MG TABLET 0.00000 0.04810 12/1/2012 PRENATAL VIT/IRON FUMARATE/FA 29 MG-1 MG TAB CHEW 0.30968 0.42805 2/15/2013 PRENATAL VIT/IRON FUMARATE/FA 65 MG-1 MG TABLET 0.00000 0.07504 12/1/2012 PRENATAL VIT27&CALCIUM/IRON/FA 60 MG-1 MG TABLET 0.18200 0.18210 1/25/2013 PRENATAL VITAMINS#21, IRON, FA 28-6-1 MG TABLET 0.00000 1.46985 1/25/2013 PRENATAL VITS #90/IRON FUM/FA 9 MG-0.5MG TABLET 0.00000 0.08394 12/1/2012 PRENATAL VITS W-CA,FE,FA(<1MG) TABLET 0.02980 0.03470 2/8/2013 PRIMAQUINE PHOSPHATE 26.3 MG TABLET 0.00000 1.25286 12/1/2012 PRIMIDONE 250 MG TABLET 0.18425 0.18430 12/14/2012 PRIMIDONE 50 MG TABLET 0.08938 0.08940 12/14/2012 PROBENECID 500 MG TABLET 0.51700 0.51720 1/25/2013 PROCAINAMIDE HCL 100 MG/ML VIAL 1.80852 1.98490 1/25/2013 PROCAINAMIDE HCL 500 MG/ML VIAL 7.35000 8.23200 1/25/2013 PROCHLORPERAZINE EDISYLATE 10 MG/2 ML VIAL 1.93200 1.44060 1/25/2013 PROCHLORPERAZINE EDISYLATE 5 MG/ML VIAL 1.95300 1.68000 1/25/2013 PROCHLORPERAZINE MALEATE 10 MG TABLET 0.06590 0.06594 2/15/2013 PROCHLORPERAZINE MALEATE 25 MG SUPP.RECT 3.05845 3.08070 1/25/2013 PROCHLORPERAZINE MALEATE 5 MG TABLET 0.05963 0.05960 12/14/2012 PROGESTERONE 50 MG/ML VIAL 2.08370 2.02150 1/25/2013 PROGESTERONE,MICRONIZED 100 MG CAPSULE 0.00000 1.49219 12/1/2012 PROGESTERONE,MICRONIZED 200 MG CAPSULE 0.00000 2.83472 12/1/2012 PROMETHAZINE HCL 12.5 MG SUPP.RECT 0.00000 3.15330 1/25/2012 PROMETHAZINE HCL 12.5 MG TABLET 0.08013 0.08010 12/14/2012 PROMETHAZINE HCL 25 MG SUPP.RECT 3.43641 3.41940 1/25/2013 PROMETHAZINE HCL 25 MG TABLET 0.00000 0.09320 12/1/2012 PROMETHAZINE HCL 25 MG/ML AMPUL 0.00000 1.10880 12/1/2012 PROMETHAZINE HCL 25 MG/ML DISP SYRIN 0.00000 1.04160 12/1/2012 PROMETHAZINE HCL 25 MG/ML VIAL 0.81384 0.76920 1/25/2013 PROMETHAZINE HCL 50 MG TABLET 0.00000 0.12958 12/1/2012 PROMETHAZINE HCL 50 MG/ML AMPUL 1.61870 1.55400 2/15/2013 PROMETHAZINE HCL 50 MG/ML VIAL 2.01600 1.94330 1/25/2013 PROMETHAZINE HCL 6.25MG/5ML SYRUP 0.01501 0.01500 12/14/2012 PROPAFENONE HCL 150 MG TABLET 0.22539 0.22540 12/14/2012 PROPAFENONE HCL 225 MG CAP ER 12H 4.46763 4.78090 2/8/2013 PROPAFENONE HCL 225 MG TABLET 0.35730 0.37440 12/21/2012 PROPAFENONE HCL 300 MG TABLET 1.00958 1.00960 12/14/2012 PROPAFENONE HCL 325 MG CAP ER 12H 5.66020 6.05700 2/1/2013 PROPAFENONE HCL 425 MG CAP ER 12H 5.66020 6.05700 2/8/2013 PROPANTHELINE BROMIDE 15 MG TABLET 0.46520 0.50037 2/15/2013 PROPARACAINE HCL 0.5 % DROPS 0.83316 0.41510 1/25/2013 PROPRANOLOL HCL POWDER 10.29208 1.69830 1/25/2013 PROPRANOLOL HCL 10 MG TABLET 0.00000 0.02090 12/1/2012 PROPRANOLOL HCL 120 MG CAP SA 24H 0.86631 0.86630 12/14/2012 PROPRANOLOL HCL 160 MG CAP SA 24H 1.17049 1.17050 12/14/2012 PROPRANOLOL HCL 20 MG TABLET 0.02211 0.02210 12/14/2012 PROPRANOLOL HCL 20 MG/5 ML SOLUTION 0.00000 0.13142 12/1/2012 PROPRANOLOL HCL 40 MG TABLET 0.00000 0.02640 12/1/2012 PROPRANOLOL HCL 40MG/5ML SOLUTION 0.00000 0.18736 12/1/2012 PROPRANOLOL HCL 60 MG CAP SA 24H 0.59777 0.59780 12/14/2012 PROPRANOLOL HCL 60 MG TABLET 0.54766 0.54770 12/14/2012 PROPRANOLOL HCL 80 MG CAP SA 24H 0.82359 0.82360 12/14/2012 Page 47 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PROPRANOLOL HCL 80 MG TABLET 0.04208 0.04210 12/14/2012 PROPRANOLOL/HYDROCHLOROTHIAZID 40 MG-25MG TABLET 0.71603 0.71600 12/14/2012 PROPRANOLOL/HYDROCHLOROTHIAZID 80 MG-25MG TABLET 0.87941 0.87940 12/14/2012 PROTAMINE SULFATE 10 MG/ML VIAL 0.94451 0.75770 1/25/2013 PROTECT CMB2/CERAMIDE 1,3,6-11 CREAM (G) 1.88196 1.87360 1/25/2013 PROTRIPTYLINE HCL 10 MG TABLET 1.43130 1.43134 2/15/2013 PROTRIPTYLINE HCL 5 MG TABLET 0.79017 0.76792 2/22/2013 PSEUDOEPH/CHLOPHEDIANOL/GG 30-12.5/5 LIQUID 0.08693 0.08600 1/25/2013 PSEUDOEPHED/CHLORPHENIRAMINE 60 MG-4 MG TABLET 0.05308 0.05310 12/14/2012 PSEUDOEPHED/CHLORPHENIRAMINE 9-0.8MG/ML DROPS 1.18744 1.18740 1/25/2013 PSEUDOEPHEDRINE HCL 30 MG TABLET 0.02210 0.02205 2/15/2013 PSEUDOEPHEDRINE HCL 60 MG TABLET 0.02105 0.04790 1/25/2013 PSEUDOEPHEDRINE/BROMPHENIRAMIN 20-4MG/5ML LIQUID 0.19214 0.19210 1/25/2013 PSEUDOEPHEDRINE/BROMPHENIRAMIN 7.5-1MG/ML DROPS 0.00000 1.53592 12/1/2012 PSYLLIUM HUSK (WITH SUGAR) 3.4 G/7 G POWDER 0.01230 0.01170 1/25/2013 PSYLLIUM SEED PACKET 0.00000 0.06499 12/1/2012 PSYLLIUM SEED POWDER 0.01968 0.01780 1/25/2013 PSYLLIUM SEED (WITH DEXTROSE) POWDER 0.01161 0.01140 1/25/2013 PSYLLIUM SEED (WITH SUGAR) PACKET 0.20919 0.22940 1/25/2013 PSYLLIUM SEED (WITH SUGAR) POWDER 0.00990 0.00920 1/25/2013 PSYLLIUM SEED/ASPARTAME POWDER 0.01835 0.01710 1/25/2013 PYRANTEL PAMOATE 50 MG/ML ORAL SUSP 0.16727 0.16310 1/25/2013 PYRAZINAMIDE 500 MG TABLET 0.69121 0.71150 1/25/2013 PYRIDOSTIGMINE BROMIDE 60 MG TABLET 0.56210 0.74589 2/22/2013 PYRIDOXINE HCL 100 MG TABLET 0.00000 0.02399 12/1/2012 PYRIDOXINE HCL 100 MG/ML VIAL 0.00000 7.86632 12/1/2012 PYRIDOXINE HCL 25 MG TABLET 0.02342 0.02190 1/25/2013 PYRIDOXINE HCL 50 MG TABLET 0.00000 0.01407 12/1/2012 QUETIAPINE FUMARATE 100 MG TABLET 0.00000 0.37260 12/1/2012 QUETIAPINE FUMARATE 200 MG TABLET 0.00000 0.70330 12/1/2012 QUETIAPINE FUMARATE 25 MG TABLET 0.00000 0.21760 12/1/2012 QUETIAPINE FUMARATE 300 MG TABLET 0.00000 0.92200 12/1/2012 QUETIAPINE FUMARATE 400 MG TABLET 0.00000 1.14370 12/1/2012 QUETIAPINE FUMARATE 50 MG TABLET 0.00000 0.35700 12/1/2012 QUINAPRIL HCL 10 MG TABLET 0.19230 0.19240 1/25/2013 QUINAPRIL HCL 20 MG TABLET 0.00000 0.19240 12/1/2012 QUINAPRIL HCL 40 MG TABLET 0.19060 0.18590 1/25/2013 QUINAPRIL HCL 5 MG TABLET 0.19240 0.18690 1/25/2013 QUINAPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.00000 0.74317 12/1/2012 QUINAPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.70756 0.70590 1/25/2013 QUINAPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.00000 0.67571 12/1/2012 QUINIDINE GLUCONATE 324 MG TABLET ER 0.95830 0.84810 1/25/2013 QUINIDINE GLUCONATE 80 MG/ML VIAL 0.00000 3.64770 12/1/2012 QUINIDINE SULFATE 200 MG TABLET 0.14147 0.09930 1/25/2013 QUINIDINE SULFATE 300 MG TABLET 0.27039 0.18360 1/25/2013 QUINIDINE SULFATE 300 MG TABLET ER 0.70850 0.67330 1/25/2013 QUININE SULFATE 324 MG CAPSULE 0.00000 5.12820 12/1/2012 RAMIPRIL 1.25 MG CAPSULE 0.16690 0.15740 1/25/2013 RAMIPRIL 10 MG CAPSULE 0.05842 0.05840 12/14/2012 RAMIPRIL 2.5 MG CAPSULE 0.06930 0.09530 12/21/2012 RAMIPRIL 5 MG CAPSULE 0.06606 0.06610 12/14/2012 RANITIDINE HCL 15 MG/ML SYRUP 0.02157 0.02160 12/14/2012 RANITIDINE HCL 150 MG CAPSULE 0.89981 0.89980 12/14/2012 RANITIDINE HCL 150 MG TABLET 0.02590 0.02586 2/1/2013 Page 48 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 RANITIDINE HCL 25 MG/ML VIAL 0.00000 0.86997 12/1/2012 RANITIDINE HCL 300 MG CAPSULE 0.00000 1.57430 12/1/2012 RANITIDINE HCL 300 MG TABLET 0.05186 0.05190 1/25/2013 RANITIDINE HCL 75 MG TABLET 0.00000 0.08884 12/1/2012 RIBAVIRIN 200 MG CAPSULE 0.37788 0.37790 12/14/2012 RIBAVIRIN 200 MG TABLET 0.64520 0.62030 1/25/2013 RIBOFLAVIN 25 MG TABLET 0.01929 0.02310 1/25/2013 RIFAMPIN 150 MG CAPSULE 0.00000 1.02336 12/1/2012 RIFAMPIN 300 MG CAPSULE 0.00000 0.70390 12/1/2012 RIMANTADINE HCL 100 MG TABLET 2.00122 1.70880 1/25/2013 RINGERS SOLUTION IRRIG SOLN 0.00368 0.00710 1/25/2013 RINGERS SOLUTION IV SOLN 0.00243 0.00250 1/25/2013 RINGERS SOLUTION,LACTATED IRRIG SOLN 0.00000 0.00220 12/1/2012 RINGERS SOLUTION,LACTATED IV SOLN 0.00190 0.00179 2/15/2013 RISPERIDONE 0.25 MG TAB RAPDIS 0.00000 5.90310 12/1/2012 RISPERIDONE 0.25 MG TABLET 0.08469 0.06810 12/14/2012 RISPERIDONE 0.5 MG TAB RAPDIS 1.63350 1.85472 2/22/2013 RISPERIDONE 0.5 MG TABLET 0.08080 0.07680 12/14/2012 RISPERIDONE 1 MG TAB RAPDIS 2.58520 2.67598 2/22/2013 RISPERIDONE 1 MG TABLET 0.09581 0.09410 12/14/2012 RISPERIDONE 1 MG/ML SOLUTION 0.39838 0.39840 12/14/2012 RISPERIDONE 2 MG TAB RAPDIS 3.00100 3.13350 2/22/2013 RISPERIDONE 2 MG TABLET 0.10157 0.10160 12/14/2012 RISPERIDONE 3 MG TAB RAPDIS 0.00000 7.26000 12/1/2012 RISPERIDONE 3 MG TABLET 0.11296 0.11300 12/14/2012 RISPERIDONE 4 MG TAB RAPDIS 0.00000 9.32984 12/1/2012 RISPERIDONE 4 MG TABLET 0.00000 0.22070 12/1/2012 RIVASTIGMINE TARTRATE 1.5 MG CAPSULE 0.00000 2.05087 12/1/2012 RIVASTIGMINE TARTRATE 3 MG CAPSULE 0.00000 2.05087 12/1/2012 RIVASTIGMINE TARTRATE 4.5 MG CAPSULE 0.00000 2.05087 12/1/2012 RIVASTIGMINE TARTRATE 6 MG CAPSULE 0.00000 2.05087 12/1/2012 RIZATRIPTAN BENZOATE 10 MG TAB RAPDIS 23.26722 23.25010 2/22/2013 RIZATRIPTAN BENZOATE 10 MG TABLET 8.45000 5.14855 2/22/2013 RIZATRIPTAN BENZOATE 5 MG TAB RAPDIS 0.00000 23.26722 1/11/2013 RIZATRIPTAN BENZOATE 5 MG TABLET 8.45000 5.19459 2/22/2013 ROPINIROLE HCL 0.25 MG TABLET 0.16777 0.16780 1/25/2013 ROPINIROLE HCL 0.5 MG TABLET 0.16777 0.16780 12/14/2012 ROPINIROLE HCL 1 MG TABLET 0.16780 0.16777 2/22/2013 ROPINIROLE HCL 12 MG TAB ER 24H 0.00000 9.57763 12/1/2012 ROPINIROLE HCL 2 MG TAB ER 24H 0.00000 1.91454 12/1/2012 ROPINIROLE HCL 2 MG TABLET 0.17165 0.17170 12/14/2012 ROPINIROLE HCL 3 MG TABLET 0.17165 0.17170 12/14/2012 ROPINIROLE HCL 4 MG TAB ER 24H 0.00000 3.82900 12/1/2012 ROPINIROLE HCL 4 MG TABLET 0.17165 0.17170 12/14/2012 ROPINIROLE HCL 5 MG TABLET 0.17165 0.17170 12/14/2012 ROPINIROLE HCL 6 MG TAB ER 24H 0.00000 5.74373 12/1/2012 ROPINIROLE HCL 8 MG TAB ER 24H 0.00000 5.74373 12/1/2012 SALICYLIC ACID 26 % LIQUID 0.00000 6.03610 12/1/2012 SALICYLIC ACID 27.5 % LIQ-FILM 0.00000 7.24360 12/1/2012 SALICYLIC ACID/COAL TAR/SULFUR 2 %-1 %-2% SHAMPOO 0.00000 0.20597 12/1/2012 SALSALATE 500 MG TABLET 0.24616 0.24620 12/14/2012 SALSALATE 750 MG TABLET 0.32817 0.32820 12/14/2012 SCOPOLAMINE HYDROBROMIDE 0.4 MG/ML VIAL 6.67800 3.78000 1/25/2013 SELEGILINE HCL 5 MG CAPSULE 1.42820 1.61280 2/8/2013 Page 49 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 SELEGILINE HCL 5 MG TABLET 1.25173 1.25200 12/14/2012 SELENIUM 200 MCG TABLET 0.05575 0.05760 1/25/2013 SELENIUM 40MCG/ML VIAL 0.00000 0.24063 12/1/2012 SELENIUM SULFIDE 2.5 % SUSPENSION 0.07745 0.07750 12/14/2012 SENNOSIDES 8.6 MG TABLET 0.00000 0.00978 12/1/2012 SENNOSIDES 8.8MG/5ML SYRUP 0.04365 0.04077 12/14/2012 SENNOSIDES/DOCUSATE SODIUM 8.6MG-50MG TABLET 0.00000 0.01849 12/1/2012 SERTRALINE HCL 100 MG TABLET 0.07210 0.07209 2/1/2013 SERTRALINE HCL 25 MG TABLET 0.04543 0.04540 12/14/2012 SERTRALINE HCL 50 MG TABLET 0.05410 0.05414 2/1/2013 SILDENAFIL CITRATE 20 MG TABLET 0.00000 0.57580 12/1/2012 SILVER GEL ER(ML) 0.00000 48.44700 12/1/2012 SILVER NITRATE 0.5 % SOLUTION 0.00000 0.03476 12/1/2012 SILVER SULFADIAZINE 1 % CREAM (G) 0.00000 0.23000 12/1/2012 SIMETHICONE 125 MG CAPSULE 0.00000 0.09822 12/1/2012 SIMETHICONE 125 MG TAB CHEW 0.00000 0.07236 12/1/2012 SIMETHICONE 180 MG CAPSULE 0.07812 0.07370 1/25/2013 SIMETHICONE 40MG/0.6ML DROPS SUSP 0.00000 0.08040 12/1/2012 SIMETHICONE 80 MG TAB CHEW 0.00000 0.02425 12/1/2012 SIMVASTATIN 10 MG TABLET 0.03471 0.03470 1/25/2013 SIMVASTATIN 20 MG TABLET 0.04420 0.04422 2/1/2013 SIMVASTATIN 40 MG TABLET 0.06204 0.06200 12/14/2012 SIMVASTATIN 5 MG TABLET 0.04167 0.04170 12/14/2012 SIMVASTATIN 80 MG TABLET 0.10200 0.10100 1/25/2013 SOD/POT/K CIT/SOD CIT/CIT ACID 500-550/5 SOLUTION 0.01770 0.02050 1/25/2013 SODIUM BENZOATE POWDER 0.00000 0.04664 12/1/2012 SODIUM BICARBONATE 0.5MEQ/ML DISP SYRIN 0.46452 0.44100 1/25/2013 SODIUM BICARBONATE 0.5MEQ/ML VIAL 0.34272 0.35700 1/25/2013 SODIUM BICARBONATE 0.9MEQ/ML DISP SYRIN 0.00000 0.12734 12/1/2012 SODIUM BICARBONATE 1 MEQ/ML DISP SYRIN 0.10248 0.09770 1/25/2013 SODIUM BICARBONATE 1 MEQ/ML VIAL 0.01900 0.01764 2/15/2013 SODIUM BICARBONATE 10MEQ/10ML DISP SYRIN 0.00000 0.74256 12/1/2012 SODIUM BICARBONATE 325 MG TABLET 0.00000 0.02155 12/1/2012 SODIUM BICARBONATE 650 MG TABLET 0.00956 0.00960 1/25/2013 SODIUM CHLORIDE 0.45 % PGGYBK PRT 0.04282 0.03640 1/25/2013 SODIUM CHLORIDE 0.45 % 0.45 % IV SOLN 0.00190 0.00151 2/15/2013 SODIUM CHLORIDE 0.65 % SPRAY 0.00000 0.02466 12/1/2012 SODIUM CHLORIDE 2.5 MEQ/ML VIAL 0.02985 0.02990 12/14/2012 SODIUM CHLORIDE 3 % 3 % IV SOLN 0.00000 0.00947 12/1/2012 SODIUM CHLORIDE 4 MEQ/ML VIAL 0.00000 0.02077 12/1/2012 SODIUM CHLORIDE 5 % 5 % IV SOLN 0.00761 0.00770 1/25/2013 SODIUM CHLORIDE 5 % OINT. (G) 0.00000 2.49240 12/1/2012 SODIUM CHLORIDE FOR INHALATION 0.9 % VIAL-NEB 0.02990 0.03000 1/25/2013 SODIUM CHLORIDE FOR INHALATION 10 % VIAL-NEB 0.00000 0.05592 12/1/2012 SODIUM CHLORIDE FOR INHALATION 3 % VIAL-NEB 0.04200 0.04247 2/22/2013 SODIUM CHLORIDE FOR INHALATION 7 % VIAL-NEB 0.00000 0.07000 12/1/2012 SODIUM CHLORIDE IRRIG SOLUTION 0.9 % IRRIG SOLN 0.00560 0.00580 1/25/2013 SODIUM CHLORIDE/NAHCO3/KCL/PEG 420G SOLN RECON 0.00000 0.00375 12/1/2012 SODIUM FERRIC GLUCONAT/SUCROSE 62.5MG/5ML VIAL 0.00000 5.15216 12/1/2012 SODIUM FLUORIDE 0.25(0.55) TAB CHEW 0.03813 0.03780 1/25/2013 SODIUM FLUORIDE 0.5 MG/ML DROPS 0.20420 0.20410 1/25/2013 SODIUM FLUORIDE 0.5(1.1)MG TAB CHEW 0.03540 0.03740 2/22/2013 SODIUM FLUORIDE 1.1 % CREAM (G) 0.07600 0.08010 1/25/2013 SODIUM FLUORIDE 1.1 % GEL (GRAM) 0.10130 0.06890 2/22/2013 Page 50 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 SODIUM FLUORIDE 1MG(2.2MG) TAB CHEW 0.03913 0.03880 1/25/2013 SODIUM FLUORIDE 1MG(2.2MG) TABLET 0.03570 0.02730 1/25/2013 SODIUM HYPOCHLORITE 0.125 % SOLUTION 0.04078 9.54390 1/25/2013 SODIUM HYPOCHLORITE 0.25 % SOLUTION 0.03904 0.04024 12/14/2012 SODIUM HYPOCHLORITE 0.5 % SOLUTION 0.03904 0.04024 12/14/2012 SODIUM LACTATE 5MEQ/ML VIAL 0.00000 0.39992 12/1/2012 SODIUM MORRHUATE 50 MG/ML VIAL 0.00000 1.96000 12/1/2012 SODIUM POLYSTYRENE SULFONATE POWDER 0.23186 0.23190 12/14/2012 SODIUM POLYSTYRENE SULFONATE 15G/60ML ORAL SUSP 0.09412 0.09470 1/25/2013 SODIUM THIOSULFATE 1 G/10 ML VIAL 0.00000 1.26000 12/1/2012 SODIUM THIOSULFATE 12.5G/50ML VIAL 0.00000 0.30240 12/1/2012 SORBITOL SOLUTION 3 % IRRIG SOLN 0.00000 0.00351 12/1/2012 SORBITOL SOLUTION 3.3% IRRIG SOLN 0.00000 0.00332 12/1/2012 SOTALOL HCL 120 MG TABLET 0.17098 0.17100 1/25/2013 SOTALOL HCL 150MG/10ML VIAL 5.46000 5.68750 1/25/2013 SOTALOL HCL 160 MG TABLET 0.26270 0.25980 1/25/2013 SOTALOL HCL 240 MG TABLET 0.56986 0.56990 12/14/2012 SOTALOL HCL 80 MG TABLET 0.00000 0.10130 12/1/2012 SPINOSAD 0.9 % SUSPENSION 0.00000 3.07772 12/1/2012 SPIRONOLACT/HYDROCHLOROTHIAZID 25 MG-25MG TABLET 0.21750 0.21410 1/25/2013 SPIRONOLACTONE 100 % POWDER 25.36170 18.81550 1/25/2013 SPIRONOLACTONE 100 MG TABLET 0.55704 0.55700 12/14/2012 SPIRONOLACTONE 25 MG TABLET 0.09822 0.09820 12/14/2012 SPIRONOLACTONE 50 MG TABLET 0.28502 0.28500 12/14/2012 SPIRONOLACTONE, MICRONIZED 100 % POWDER 10.61375 9.66880 1/25/2013 STAVUDINE 1 MG/ML SOLN RECON 0.00000 0.27563 12/1/2012 STAVUDINE 15 MG CAPSULE 1.32503 1.32500 12/14/2012 STAVUDINE 20 MG CAPSULE 1.66710 1.31140 1/25/2013 STAVUDINE 30 MG CAPSULE 1.46814 1.46810 12/14/2012 STAVUDINE 40 MG CAPSULE 1.87450 1.40760 1/25/2013 STREPTOMYCIN SULFATE 1 G VIAL 0.00000 11.16500 12/1/2012 SUCRALFATE 1 G TABLET 0.22284 0.22280 12/14/2012 SUCRALFATE 1 G/10 ML ORAL SUSP 0.41390 0.41780 2/22/2013 SULFACETAMIDE SOD/SULFUR/UREA 10%-4%-10% CLEANSER 0.00000 0.15690 12/1/2012 SULFACETAMIDE SOD/SULFUR/UREA 10%-5%-10% CLEANSER 0.00000 0.49178 12/1/2012 SULFACETAMIDE SODIUM 10 % CLEANSER 0.00000 0.34668 12/1/2012 SULFACETAMIDE SODIUM 10 % DROPS 1.40450 2.76010 2/1/2013 SULFACETAMIDE SODIUM 10 % OINT. (G) 0.00000 13.17200 12/1/2012 SULFACETAMIDE SODIUM 10 % SUSPENSION 0.00000 0.61247 12/1/2012 SULFACETAMIDE SODIUM/SULFUR 10%-1% CLEANSER 0.00000 0.12531 12/1/2012 SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) CLEANSER 0.10660 0.09838 2/22/2013 SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) CREAM (G) 0.00000 4.57333 12/1/2012 SULFACETAMIDE SODIUM/SULFUR 8 %-4 % SUSPENSION 0.00000 0.20795 12/1/2012 SULFACETAMIDE SODIUM/SULFUR 9 %-4 % CLEANSER 0.00000 0.22315 12/1/2012 SULFACETAMIDE SODIUM/SULFUR 9 %-4.5 % CLEANSER 0.24901 0.24900 1/25/2013 SULFACETAMIDE/PREDNISOLONE SP 10 %-0.23% DROPS 2.49760 2.56476 2/15/2013 SULFADIAZINE 500 MG TABLET 2.50090 3.00100 2/8/2013 SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ORAL SUSP 0.07069 0.07070 12/14/2012 SULFAMETHOXAZOLE/TRIMETHOPRIM 400MG-80MG TABLET 0.08107 0.08110 12/14/2012 SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML VIAL 0.53850 0.45860 1/25/2013 SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160 MG TABLET 0.07000 0.06180 1/25/2013 SULFASALAZINE 500 MG TABLET 0.09393 0.09920 12/14/2012 SULFASALAZINE 500 MG TABLET DR 0.23852 0.23850 12/14/2012 SULINDAC 150 MG TABLET 0.14270 0.14040 1/25/2013 Page 51 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 SULINDAC 200 MG TABLET 0.16308 0.16310 1/25/2013 SUMATRIPTAN 20 MG SPRAY 27.22070 30.21550 2/1/2013 SUMATRIPTAN 5 MG SPRAY 27.22070 30.21550 2/8/2013 SUMATRIPTAN SUCCINATE 100 MG TABLET 0.95480 0.94483 2/22/2013 SUMATRIPTAN SUCCINATE 25 MG TABLET 0.95400 0.92822 2/22/2013 SUMATRIPTAN SUCCINATE 4 MG/0.5ML CARTRIDGE 0.00000 142.35900 12/1/2012 SUMATRIPTAN SUCCINATE 4 MG/0.5ML PEN INJCTR 0.00000 150.29700 12/1/2012 SUMATRIPTAN SUCCINATE 50 MG TABLET 0.95740 0.84380 1/25/2013 SUMATRIPTAN SUCCINATE 6 MG/0.5ML CARTRIDGE 0.00000 129.12200 12/1/2012 SUMATRIPTAN SUCCINATE 6 MG/0.5ML PEN INJCTR 131.41621 136.48620 1/25/2013 SUMATRIPTAN SUCCINATE 6 MG/0.5ML VIAL 0.00000 26.86187 12/1/2012 TACROLIMUS 0.5 MG CAPSULE 1.31590 1.32070 1/25/2013 TACROLIMUS 1 MG CAPSULE 0.00000 2.53863 12/1/2012 TACROLIMUS 5 MG CAPSULE 0.00000 11.32336 12/1/2012 TAMOXIFEN CITRATE 10 MG TABLET 0.15799 0.15800 12/14/2012 TAMOXIFEN CITRATE 20 MG TABLET 0.00000 0.38860 12/1/2012 TAMSULOSIN HCL 0.4 MG CAP ER 24H 0.22200 0.21270 1/25/2013 TEA TREE OIL 100 % OIL 0.25509 0.23180 1/25/2013 TEMAZEPAM 15 MG CAPSULE 0.06955 0.06960 1/25/2013 TEMAZEPAM 22.5 MG CAPSULE 0.00000 6.10781 12/1/2012 TEMAZEPAM 30 MG CAPSULE 0.08804 0.08800 12/14/2012 TEMAZEPAM 7.5 MG CAPSULE 5.38680 5.50681 2/22/2013 TERAZOSIN HCL 1 MG CAPSULE 0.05414 0.05410 12/14/2012 TERAZOSIN HCL 10 MG CAPSULE 0.06941 0.06940 12/14/2012 TERAZOSIN HCL 2 MG CAPSULE 0.06097 0.06100 12/14/2012 TERAZOSIN HCL 5 MG CAPSULE 0.06271 0.06270 12/14/2012 TERBINAFINE HCL 1 % CREAM (G) 0.00000 0.29480 12/1/2012 TERBINAFINE HCL 250 MG TABLET 0.17192 0.17190 12/14/2012 TERBUTALINE SULFATE 2.5 MG TABLET 0.25240 0.28250 2/1/2013 TERBUTALINE SULFATE 5 MG TABLET 0.35682 0.35640 1/25/2013 TERCONAZOLE 0.4 % CREAM/APPL 0.22420 0.22440 1/25/2013 TERCONAZOLE 0.8 % CREAM/APPL 0.46160 0.46600 1/25/2013 TERCONAZOLE 80 MG SUPP.VAG 0.00000 11.41933 12/1/2012 TESTOSTERONE CYPIONATE 100 MG/ML VIAL 0.00000 4.13980 12/1/2012 TESTOSTERONE CYPIONATE 200 MG/ML VIAL 7.12343 7.12340 1/25/2013 TESTOSTERONE ENANTHATE 200 MG/ML VIAL 0.00000 11.07040 12/1/2012 TETANUS & DIPHTHERIA TOX,ADULT 2-2LF/0.5 VIAL 32.12160 30.27570 1/25/2013 TETANUS,DIPHTHERIA TOXD PED/PF 5-25/0.5ML VIAL 69.10470 75.04140 1/25/2013 TETRACAINE HCL 0.5 % DROPS 0.00000 0.49187 12/1/2012 TETRACAINE HCL/PF 0.5 % DROPS 7.84613 8.12960 1/25/2013 TETRACYCLINE POWDER 0.00000 3.08672 12/14/2012 TETRACYCLINE HCL POWDER 0.61740 0.64823 2/15/2013 TETRACYCLINE HCL 250 MG CAPSULE 0.03102 0.03000 1/25/2013 TETRACYCLINE HCL 500 MG CAPSULE 0.00000 0.05521 12/1/2012 THEOPHYLLINE ANHYDROUS 100 MG TAB ER 12H 0.12865 0.12830 1/25/2013 THEOPHYLLINE ANHYDROUS 200 MG TAB ER 12H 0.15480 0.15430 1/25/2013 THEOPHYLLINE ANHYDROUS 300 MG TAB ER 12H 0.19370 0.19410 1/25/2013 THEOPHYLLINE ANHYDROUS 400 MG TABLET ER 0.91040 0.95030 2/1/2013 THEOPHYLLINE ANHYDROUS 450 MG TAB ER 12H 0.00000 0.47789 12/1/2012 THEOPHYLLINE ANHYDROUS 600 MG TABLET ER 1.29650 1.37320 2/1/2013 THEOPHYLLINE ANHYDROUS 80 MG/15ML SOLUTION 0.00000 0.13875 12/1/2012 THEOPHYLLINE/D5W 200MG/0.1L IV SOLN 0.00000 0.03335 12/1/2012 THEOPHYLLINE/D5W 200MG/50ML IV SOLN 0.10836 0.09490 1/25/2013 THEOPHYLLINE/D5W 400MG/.25L IV SOLN 0.00000 0.01852 12/1/2012 Page 52 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 THEOPHYLLINE/D5W 400MG/0.5L IV SOLN 0.00000 0.00730 12/1/2012 THEOPHYLLINE/D5W 800MG/.25L IV SOLN 0.02150 0.01890 1/25/2013 THEOPHYLLINE/D5W 800MG/0.5L IV SOLN 0.00000 0.00508 12/1/2012 THIAMINE HCL 100 MG TABLET 0.00000 0.01380 12/1/2012 THIAMINE HCL 100 MG/ML VIAL 3.94044 3.29150 1/25/2013 THIAMINE HCL 50 MG TABLET 0.00000 0.01586 12/1/2012 THIAMINE MONONITRATE 100 MG TABLET 0.02643 0.02940 1/25/2013 THIORIDAZINE HCL 10 MG TABLET 0.15300 0.20200 1/25/2013 THIORIDAZINE HCL 100 MG TABLET 0.24630 0.41700 1/25/2013 THIORIDAZINE HCL 25 MG TABLET 0.28980 0.24040 2/15/2013 THIORIDAZINE HCL 50 MG TABLET 0.36620 0.31898 2/15/2013 THIOTEPA 15 MG VIAL 89.16988 111.46363 12/14/2012 THIOTHIXENE 10 MG CAPSULE 0.00000 0.42000 12/1/2012 THIOTHIXENE 2 MG CAPSULE 0.18415 0.20030 12/14/2012 THIOTHIXENE 5 MG CAPSULE 0.27833 0.30260 12/14/2012 THYROID,PORK 30 MG TABLET 0.00000 0.09114 12/1/2012 THYROID,PORK 60 MG TABLET 0.00000 0.10129 12/1/2012 THYROID,PORK 90 MG TABLET 0.00000 0.15974 12/1/2012 TIAGABINE HCL 2 MG TABLET 4.67694 4.67690 1/25/2013 TIAGABINE HCL 4 MG TABLET 4.67694 4.67690 1/25/2013 TICLOPIDINE HCL 250 MG TABLET 0.65364 0.65360 12/14/2012 TIMOLOL MALEATE 0.25 % DROPS 0.66102 0.66100 12/14/2012 TIMOLOL MALEATE 0.25 % SOL-GEL 0.00000 6.93000 12/1/2012 TIMOLOL MALEATE 0.5 % DROPS 0.00000 0.75330 12/1/2012 TIMOLOL MALEATE 0.5 % SOL-GEL 5.97720 8.19000 2/1/2013 TIMOLOL MALEATE 10 MG TABLET 0.52003 0.55130 1/25/2013 TIMOLOL MALEATE 20 MG TABLET 0.95956 1.01710 1/25/2013 TIMOLOL MALEATE 5 MG TABLET 0.42042 0.44560 1/25/2013 TINIDAZOLE 250 MG TABLET 0.00000 3.68381 12/1/2012 TINIDAZOLE 500 MG TABLET 0.00000 7.36765 12/1/2012 TIZANIDINE HCL 2 MG CAPSULE 1.74226 1.72990 1/25/2013 TIZANIDINE HCL 2 MG TABLET 0.05159 0.05160 12/14/2012 TIZANIDINE HCL 4 MG CAPSULE 0.00000 2.19301 12/1/2012 TIZANIDINE HCL 4 MG TABLET 0.06177 0.06000 12/14/2012 TIZANIDINE HCL 6 MG CAPSULE 0.00000 3.40453 12/1/2012 TOBRAMYCIN 0.3 % DROPS 1.07200 2.11500 2/15/2013 TOBRAMYCIN SULFATE 1.2 G VIAL 0.00000 74.31250 12/1/2012 TOBRAMYCIN SULFATE 10 MG/ML VIAL 0.00000 1.10250 12/1/2012 TOBRAMYCIN SULFATE 40 MG/ML VIAL 0.00000 0.56843 12/1/2012 TOBRAMYCIN/DEXAMETHASONE 0.3 %-0.1% DROPS SUSP 10.29250 15.43847 2/22/2013 TOBRAMYCIN/SODIUM CHLORIDE 60 MG/50ML PIGGYBACK 0.00000 0.31870 12/1/2012 TOBRAMYCIN/SODIUM CHLORIDE 80MG/100ML PIGGYBACK 0.00000 0.18270 12/1/2012 TOLAZAMIDE 250 MG TABLET 2.20070 2.22090 1/25/2013 TOLAZAMIDE 500 MG TABLET 1.52138 1.52140 1/25/2013 TOLBUTAMIDE 500 MG TABLET 0.73441 0.73440 1/25/2013 TOLMETIN SODIUM 200 MG TABLET 0.45500 0.52500 2/8/2013 TOLMETIN SODIUM 400 MG CAPSULE 0.00000 1.16584 12/1/2012 TOLMETIN SODIUM 600 MG TABLET 2.47646 2.47650 1/25/2013 TOLNAFTATE 1 % AERO POWD 0.00000 0.02769 12/1/2012 TOLNAFTATE 1 % CREAM (G) 0.00000 0.10090 12/1/2012 TOLNAFTATE 1 % POWDER 0.04743 0.04750 1/25/2013 TOLTERODINE TARTRATE 1 MG TABLET 1.10309 1.07090 1/25/2013 TOLTERODINE TARTRATE 2 MG TABLET 1.13203 1.09920 1/25/2013 TOPIRAMATE 100 MG TABLET 0.09527 0.09530 12/14/2012 Page 53 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 TOPIRAMATE 15 MG CAP SPRINK 0.50060 0.48588 2/22/2013 TOPIRAMATE 200 MG TABLET 0.11886 0.11890 12/14/2012 TOPIRAMATE 25 MG CAP SPRINK 0.55140 0.53905 2/22/2013 TOPIRAMATE 25 MG TABLET 0.03240 0.03243 2/15/2013 TOPIRAMATE 50 MG TABLET 0.06338 0.06340 12/14/2012 TOPOTECAN HCL 4 MG VIAL 148.61475 138.71330 1/25/2013 TOPOTECAN HCL 4 MG/4 ML VIAL 0.00000 124.05225 12/1/2012 TORSEMIDE 10 MG TABLET 0.12837 0.12840 12/14/2012 TORSEMIDE 100 MG TABLET 0.34679 0.34680 12/14/2012 TORSEMIDE 20 MG TABLET 0.00000 0.12020 12/1/2012 TORSEMIDE 20 MG/2 ML VIAL 0.00000 4.31340 12/1/2012 TORSEMIDE 5 MG TABLET 0.11120 0.12160 1/25/2013 TORSEMIDE 50 MG/5 ML VIAL 0.00000 2.34654 12/1/2012 TRAMADOL HCL 100 MG TAB ER 24H 2.39230 2.25486 2/22/2013 TRAMADOL HCL 100 MG TBMP 24HR 2.96215 1.86080 1/25/2013 TRAMADOL HCL 200 MG TAB ER 24H 4.20988 4.20960 1/25/2013 TRAMADOL HCL 200 MG TBMP 24HR 5.08217 2.95290 1/25/2013 TRAMADOL HCL 300 MG TAB ER 24H 0.00000 4.64707 12/1/2012 TRAMADOL HCL 300 MG TBMP 24HR 0.00000 3.77000 12/1/2012 TRAMADOL HCL 50 MG TABLET 0.02470 0.02466 2/8/2013 TRAMADOL HCL/ACETAMINOPHEN 37.5-325MG TABLET 0.18144 0.18140 12/14/2012 TRANDOLAPRIL 1 MG TABLET 0.27740 0.25060 1/25/2013 TRANDOLAPRIL 2 MG TABLET 0.27372 0.27370 12/14/2012 TRANDOLAPRIL 4 MG TABLET 0.27359 0.27360 12/14/2012 TRANEXAMIC ACID 1000 MG/10 AMPUL 0.00000 3.94380 12/1/2012 TRANEXAMIC ACID 1000 MG/10 VIAL 6.10796 6.09656 2/1/2013 TRANEXAMIC ACID 650 MG TABLET 0.00000 3.65202 1/25/2013 TRANYLCYPROMINE SULFATE 10 MG TABLET 0.00000 1.80076 12/1/2012 TRAZODONE HCL 100 MG TABLET 0.04703 0.04700 12/14/2012 TRAZODONE HCL 150 MG TABLET 0.10564 0.10560 12/14/2012 TRAZODONE HCL 300 MG TABLET 0.00000 3.39183 12/1/2012 TRAZODONE HCL 50 MG TABLET 0.02439 0.02440 12/14/2012 TRETINOIN 0.01 % GEL (GRAM) 0.85430 0.83881 2/22/2013 TRETINOIN 0.025 % CREAM (G) 0.65530 0.64325 2/22/2013 TRETINOIN 0.025 % GEL (GRAM) 0.98480 0.95540 1/25/2013 TRETINOIN 0.05 % CREAM (G) 1.06660 1.08430 1/25/2013 TRETINOIN 0.1 % CREAM (G) 1.08480 1.09426 2/22/2013 TRETINOIN 10 MG CAPSULE 0.00000 20.32926 12/1/2012 TRETINOIN/EMOLLIENT 0.05 % CREAM (G) 0.00000 2.30347 12/1/2012 TRIAMCINOLONE ACETONIDE 0.025 % CREAM (G) 0.09313 0.09310 12/14/2012 TRIAMCINOLONE ACETONIDE 0.025 % LOTION 0.44092 0.44090 12/14/2012 TRIAMCINOLONE ACETONIDE 0.025 % OINT. (G) 0.09313 0.09310 12/14/2012 TRIAMCINOLONE ACETONIDE 0.1 % CREAM (G) 0.14700 0.21180 2/1/2013 TRIAMCINOLONE ACETONIDE 0.1 % LOTION 0.38860 0.47245 2/22/2013 TRIAMCINOLONE ACETONIDE 0.1 % OINT. (G) 0.04860 0.04864 2/1/2013 TRIAMCINOLONE ACETONIDE 0.1 % PASTE (G) 8.19810 8.11257 2/22/2013 TRIAMCINOLONE ACETONIDE 0.5 % CREAM (G) 0.49690 0.47180 2/22/2013 TRIAMCINOLONE ACETONIDE 0.5 % OINT. (G) 0.40600 0.47130 2/1/2013 TRIAMCINOLONE ACETONIDE 55MCG SPRAY 5.20146 5.20150 1/25/2013 TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25 MG CAPSULE 0.06405 0.06410 12/14/2012 TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25 MG TABLET 0.19700 0.19698 2/15/2013 TRIAMTERENE/HYDROCHLOROTHIAZID 75 MG-50MG TABLET 0.21909 0.21910 12/14/2012 TRIAZOLAM 0.125 MG TABLET 0.23712 0.23710 12/14/2012 TRIAZOLAM 0.25 MG TABLET 0.00000 0.14740 12/1/2012 Page 54 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 TRICLOSAN CLEANSER 0.02152 0.00570 1/25/2013 TRIFLUOPERAZINE HCL 1 MG TABLET 0.00000 0.27066 12/1/2012 TRIFLUOPERAZINE HCL 10 MG TABLET 0.62890 0.61860 1/25/2013 TRIFLUOPERAZINE HCL 2 MG TABLET 0.56400 0.36440 2/15/2013 TRIFLUOPERAZINE HCL 5 MG TABLET 0.48480 0.48440 1/25/2013 TRIFLURIDINE 1 % DROPS 0.00000 16.63947 12/1/2012 TRIHEXYPHENIDYL HCL 2 MG TABLET 0.05414 0.05410 12/14/2012 TRIHEXYPHENIDYL HCL 2 MG/5 ML ELIXIR 0.03900 0.03920 2/8/2013 TRIHEXYPHENIDYL HCL 5 MG TABLET 0.11095 0.11100 12/14/2012 TRIMETHOBENZAMIDE HCL 100 MG/ML VIAL 4.10263 4.38990 1/25/2013 TRIMETHOBENZAMIDE HCL 300 MG CAPSULE 0.00000 1.49810 12/1/2012 TRIMETHOPRIM 100 MG TABLET 0.26280 0.26290 1/25/2013 TRIMIPRAMINE MALEATE 100 MG CAPSULE 0.00000 4.04880 12/1/2012 TRIMIPRAMINE MALEATE 25 MG CAPSULE 0.00000 1.70263 12/1/2012 TRIMIPRAMINE MALEATE 50 MG CAPSULE 0.00000 2.78507 12/1/2012 TROPICAMIDE 0.5 % DROPS 0.44030 0.64860 1/25/2013 TROPICAMIDE 1 % DROPS 0.59054 0.59050 12/14/2012 TROSPIUM CHLORIDE 20 MG TABLET 1.93053 1.92680 1/25/2013 TROSPIUM CHLORIDE 60 MG CAP ER 24H 0.00000 4.71567 12/1/2012 UREA 40 % LOTION 0.06888 0.06890 12/14/2012 UREA 40 % NL FM SUSP 0.00000 11.93033 12/1/2012 UREA 45 % GEL/PF APP 0.00000 5.82575 12/1/2012 UREA 45 % LOTION 0.00000 0.17003 12/1/2012 UREA/HYALURONATE SODIUM 40%-0.2% KIT 0.00000 282.72300 12/1/2012 URSODIOL 250 MG TABLET 0.00000 1.87768 12/1/2012 URSODIOL 300 MG CAPSULE 0.31021 0.31020 12/14/2012 URSODIOL 500 MG TABLET 0.00000 3.32738 12/1/2012 VALACYCLOVIR HCL 1000 MG TABLET 1.83944 1.79880 1/25/2013 VALACYCLOVIR HCL 500 MG TABLET 1.12372 1.11530 1/25/2013 VALPROATE SODIUM 100 % POWDER 3.65380 4.41000 2/22/2013 VALPROATE SODIUM 250 MG/5ML SOLUTION 0.01430 0.01447 2/22/2013 VALPROATE SODIUM 250 MG/CUP SOLUTION 0.19011 0.30250 12/21/2012 VALPROATE SODIUM 500MG/10ML SOLUTION 0.00000 0.07088 12/1/2012 VALPROIC ACID 250 MG CAPSULE 0.15804 0.15800 12/14/2012 VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5MG TABLET 2.99366 2.99470 1/25/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 160-25MG TABLET 3.39495 3.39510 1/25/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5MG TABLET 3.79280 3.79430 1/25/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG TABLET 4.30287 4.30410 1/25/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG TABLET 2.75113 2.74960 1/25/2013 VANCOMYCIN HCL 1 G VIAL 4.04719 4.04820 1/25/2013 VANCOMYCIN HCL 1 G VIAL PORT 5.65320 4.40160 2/15/2013 VANCOMYCIN HCL 10 G VIAL 53.87630 35.96050 2/22/2013 VANCOMYCIN HCL 125 MG CAPSULE 23.22800 21.92457 2/15/2013 VANCOMYCIN HCL 250 MG CAPSULE 40.40230 40.40120 1/25/2013 VANCOMYCIN HCL 5 G VIAL 0.00000 22.28100 12/1/2012 VANCOMYCIN HCL 500 MG VIAL 2.42580 2.11680 1/25/2013 VANCOMYCIN HCL 500 MG VIAL PORT 2.94840 2.74260 1/25/2013 VANCOMYCIN HCL 750 MG VIAL 6.84180 6.69900 1/25/2013 VANCOMYCIN HCL 750 MG VIAL PORT 0.00000 10.90110 12/1/2012 VANCOMYCIN HCL/D5W 1G/200ML FROZ.PIGGY 0.08114 0.29790 1/25/2013 VANCOMYCIN HCL/D5W 500MG/0.1L FROZ.PIGGY 0.00000 0.10933 12/1/2012 VANCOMYCIN IN DEXTROSE,ISO-OSM 750MG/.15L FROZ.PIGGY 0.00000 0.17722 12/1/2012 VASOPRESSIN 20 UNIT/ML VIAL 0.00000 1.97529 12/1/2012 VENLAFAXINE HCL 100 MG TABLET 0.36636 0.36640 12/14/2012 Page 55 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 VENLAFAXINE HCL 150 MG CAP ER 24H 0.28090 0.28086 2/8/2013 VENLAFAXINE HCL 150 MG TAB ER 24 0.00000 1.46640 12/1/2012 VENLAFAXINE HCL 225 MG TAB ER 24 10.26940 10.83870 1/25/2013 VENLAFAXINE HCL 25 MG TABLET 0.34038 0.34040 12/14/2012 VENLAFAXINE HCL 37.5 MG CAP ER 24H 0.16980 0.14767 2/15/2013 VENLAFAXINE HCL 37.5 MG TAB ER 24 0.00000 2.37658 12/1/2012 VENLAFAXINE HCL 37.5 MG TABLET 0.32468 0.32470 12/14/2012 VENLAFAXINE HCL 50 MG TABLET 0.00000 0.36760 12/1/2012 VENLAFAXINE HCL 75 MG CAP ER 24H 0.19323 0.19310 1/25/2013 VENLAFAXINE HCL 75 MG TAB ER 24 3.14490 3.24610 1/25/2013 VENLAFAXINE HCL 75 MG TABLET 0.33430 0.32590 1/25/2013 VERAPAMIL HCL 100 MG CAP24H PCT 0.00000 1.23213 12/1/2012 VERAPAMIL HCL 120 MG CAP24H PEL 0.41197 0.41200 12/14/2012 VERAPAMIL HCL 120 MG TABLET 0.06164 0.06160 12/14/2012 VERAPAMIL HCL 120 MG TABLET ER 0.29373 0.29370 12/14/2012 VERAPAMIL HCL 180 MG CAP24H PEL 0.42450 0.42650 1/25/2013 VERAPAMIL HCL 180 MG TABLET ER 0.16911 0.16910 12/14/2012 VERAPAMIL HCL 2.5 MG/ML AMPUL 1.56240 1.65480 1/25/2013 VERAPAMIL HCL 2.5 MG/ML DISP SYRIN 0.00000 4.46460 12/1/2012 VERAPAMIL HCL 2.5 MG/ML VIAL 1.94970 2.14400 1/25/2013 VERAPAMIL HCL 200 MG CAP24H PCT 0.00000 1.58723 12/1/2012 VERAPAMIL HCL 240 MG CAP24H PEL 0.49810 0.49820 1/25/2013 VERAPAMIL HCL 240 MG TABLET ER 0.14485 0.14490 12/14/2012 VERAPAMIL HCL 300 MG CAP24H PCT 2.27503 2.25220 1/25/2013 VERAPAMIL HCL 360 MG CAP24H PEL 0.00000 1.46958 12/1/2012 VERAPAMIL HCL 40 MG TABLET 0.17654 0.17650 12/14/2012 VERAPAMIL HCL 80 MG TABLET 0.05601 0.05600 12/14/2012 VINBLASTINE SULFATE 1 MG/ML VIAL 0.00000 2.22600 12/1/2012 VINBLASTINE SULFATE 10 MG VIAL 0.00000 1.81350 12/1/2012 VIT A,C & E/LUTEIN/MINERALS 1000-60-2 TABLET 0.06145 0.05410 1/25/2013 VIT A/VIT C/VIT E/ZINC/COPPER 14320-226 CAPSULE 0.16160 0.16420 1/25/2013 VIT A/VIT C/VIT E/ZINC/COPPER 7160-113 TABLET 0.07386 0.06620 1/25/2013 VIT B CMPLX 3/FA/VIT C/BIOTIN 1MG-60MG TABLET 0.12805 0.12810 12/14/2012 VIT B COMP/C/FA/IRON/VIT E 500-400-18 TABLET 0.00000 0.05547 12/1/2012 VIT B12/LMEFOLATE CA/VIT B6/B2 1-6-50-5MG TABLET 2.02075 1.43640 1/25/2013 VITAMIN A/VIT C/ZINC/PROPOLIS 15 MG LOZENGE 0.02095 0.02440 1/25/2013 VITAMIN B COMPLEX/LYSINE 790MG/15ML LIQUID 0.03536 0.03270 1/25/2013 VITAMIN E 100 UNIT CAPSULE 0.00000 0.02028 12/1/2012 VITAMIN E 1000 UNIT CAPSULE 0.00000 0.12857 12/1/2012 VITAMIN E 200 UNIT CAPSULE 0.02873 0.02860 1/25/2013 VITAMIN E 400 UNIT CAPSULE 0.05208 0.04540 1/25/2013 VITAMIN E 50 UNIT/ML DROPS 1.83322 1.89350 1/25/2013 VITAMIN E MIXED 400 UNIT CAPSULE 0.05369 0.05030 1/25/2013 VITAMINS B1,B2,B3,B5,& B6 100-2MG/ML VIAL 0.00000 1.31319 12/1/2012 VITS A & D/WHITE PET/LANOLIN OINT PACK 0.12202 0.03450 1/25/2013 VORICONAZOLE 200 MG TABLET 0.00000 26.29668 12/1/2012 VORICONAZOLE 200 MG VIAL 0.00000 87.18650 12/1/2012 VORICONAZOLE 50 MG TABLET 0.00000 7.61796 12/1/2012 WARFARIN SODIUM 1 MG TABLET 0.06472 0.06470 12/14/2012 WARFARIN SODIUM 10 MG TABLET 0.06673 0.06670 12/14/2012 WARFARIN SODIUM 2 MG TABLET 0.06472 0.06470 12/14/2012 WARFARIN SODIUM 2.5 MG TABLET 0.06472 0.06470 12/14/2012 WARFARIN SODIUM 3 MG TABLET 0.06472 0.06470 12/14/2012 WARFARIN SODIUM 4 MG TABLET 0.06472 0.06470 12/14/2012 Page 56 of 57 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 22, 2013 ‑ Version 2013.08 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 WARFARIN SODIUM 5 MG TABLET 0.06472 0.06470 1/25/2013 WARFARIN SODIUM 6 MG TABLET 0.06512 0.06510 12/14/2012 WARFARIN SODIUM 7.5 MG TABLET 0.06673 0.06670 12/14/2012 WATER LIQUID 0.00000 0.01291 12/1/2012 WATER FOR INJ.,BACTERIOSTATIC VIAL 0.01764 0.02210 1/25/2013 WATER FOR INJECTION,STERILE AMPUL 0.09072 0.08820 1/25/2013 WATER FOR INJECTION,STERILE IV SOLN 0.00214 0.00210 12/14/2012 WATER FOR INJECTION,STERILE VIAL 0.02640 0.03430 1/25/2013 WATER FOR IRRIGATION,STERILE IRRIG SOLN 0.00000 0.00580 12/1/2012 WATER/ME-PARABEN/PROPYLPARABEN VIAL 0.00000 0.10643 12/1/2012 WHEAT GERM OIL OIL 0.00000 0.26600 12/1/2012 WITCH HAZEL 50 % MED. PAD 0.00000 0.07611 12/1/2012 ZAFIRLUKAST 10 MG TABLET 0.00000 1.19188 12/1/2012 ZAFIRLUKAST 20 MG TABLET 0.00000 1.25253 12/1/2012 ZALEPLON 10 MG CAPSULE 0.21695 0.26180 1/25/2013 ZALEPLON 5 MG CAPSULE 0.23040 0.21208 2/22/2013 ZIDOVUDINE 10 MG/ML SYRUP 0.00000 0.13226 12/1/2012 ZIDOVUDINE 100 MG CAPSULE 0.00000 1.19166 12/1/2012 ZIDOVUDINE 300 MG TABLET 0.38950 0.39530 1/25/2013 ZINC CHLORIDE 1 MG/ML VIAL 0.17052 0.17050 1/25/2013 ZINC SULFATE 1 MG/ML VIAL 0.00000 0.21874 12/1/2012 ZINC SULFATE 5 MG/ML VIAL 0.00000 0.65343 12/1/2012 ZIPRASIDONE HCL 20 MG CAPSULE 2.81730 2.82114 2/22/2013 ZIPRASIDONE HCL 40 MG CAPSULE 2.81730 2.81951 2/22/2013 ZIPRASIDONE HCL 60 MG CAPSULE 0.00000 3.49354 12/1/2012 ZIPRASIDONE HCL 80 MG CAPSULE 3.49960 3.49530 2/22/2013 ZOLPIDEM TARTRATE 10 MG TABLET 0.02770 0.02730 1/25/2013 ZOLPIDEM TARTRATE 12.5 MG TAB MPHASE 1.59058 2.76720 1/11/2013 ZOLPIDEM TARTRATE 5 MG TABLET 0.02650 0.02600 1/25/2013 ZOLPIDEM TARTRATE 6.25 MG TAB MPHASE 1.59070 1.59071 2/15/2013 ZONISAMIDE 100 MG CAPSULE 0.14311 0.14310 1/25/2013 ZONISAMIDE 25 MG CAPSULE 0.11410 0.11658 2/22/2013 ZONISAMIDE 50 MG CAPSULE 0.11658 0.11660 12/14/2012

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