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West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 0.9 % CHLORIDE INJECTION VIAL (ML) 0.9 % 0.05712 08/12/2014 0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 0.9 0.00196 03/06/2015 0.00196 08/21/2015 % 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK WITH THREADED 0.03505 01/30/2015 0.03505 08/21/2015 PORT (ML) 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK WITH VIAL PORT 0.04175 07/18/2014 (NON-THREADED) ABACAVIR SULFATE ORAL TABLET 300 MG 1.77633 11/25/2017 0.36867 05/22/2020 ABIRATERONE ACETATE ORAL TABLET 250 MG 3.78000 02/21/2020 4.56040 02/24/2020 ACAMPROSATE ORAL TABLET, DELAYED RELEASE (ENTERIC 0.74145 04/09/2020 0.70192 06/19/2020 COATED) 333 MG ACARBOSE ORAL TABLET 100 MG 0.18990 03/02/2018 0.13000 11/16/2018 ACARBOSE ORAL TABLET 25 MG 0.23329 08/21/2015 0.13994 08/25/2017 ACARBOSE ORAL TABLET 50 MG 0.14640 05/25/2018 0.12500 11/16/2018 ACEBUTOLOL HCL ORAL CAPSULE 200 MG 0.60776 10/07/2019 0.55890 06/18/2021 ACEBUTOLOL HCL ORAL CAPSULE 400 MG 0.26000 08/21/2015 0.68650 05/11/2021 ACETAMINOPHEN ORAL CAPSULE 500 MG 0.01093 08/12/2014 ACETAMINOPHEN ORAL DROPS 80MG/0.8ML 0.17160 10/11/2013 0.17160 08/21/2015 ACETAMINOPHEN ORAL LIQUID (ML) 160 MG/5ML 0.00932 09/27/2013 0.00932 08/21/2015 ACETAMINOPHEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 160 0.02137 08/21/2015 0.02033 02/17/2017 MG/5ML ACETAMINOPHEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 160 0.01083 06/09/2017 0.02033 03/02/2018 MG/5ML ACETAMINOPHEN ORAL TABLET 325 MG 0.00830 06/20/2014 0.00830 08/21/2015 ACETAMINOPHEN ORAL TABLET 500 MG 0.01040 04/03/2015 0.01040 08/21/2015 ACETAMINOPHEN ORAL TABLET,CHEWABLE 80 MG 0.04651 04/03/2015 0.04651 08/21/2015 ACETAMINOPHEN ORAL TABLET,DISINTEGRATING 80 MG 0.05113 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 120 MG 0.20324 08/22/2014 0.20324 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 325 MG 0.46400 08/22/2014 0.46400 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 650 MG 0.21762 08/22/2014 0.21762 08/21/2015 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.01332 01/30/2015 0.01332 08/21/2015 120-12MG/5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.21394 03/27/2015 0.21394 08/21/2015 120-12MG/5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.10079 03/27/2015 0.10079 08/21/2015 300MG/12.5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.14344 09/19/2014 0.14344 08/21/2015 15MG ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.10480 10/20/2017 0.09167 12/22/2017 30MG ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.19101 05/20/2016 0.17150 08/17/2018 60MG ACETAMINOPHEN/DIPHENHYDRAMINE HCL ORAL TABLET 500MG-25MG 0.04047 04/24/2015 0.04047 08/21/2015 ACETAZOLAMIDE ORAL CAPSULE, EXTENDED RELEASE 500 MG 0.94140 09/22/2017 0.70000 11/16/2018 ACETAZOLAMIDE ORAL TABLET 125 MG 1.29790 11/16/2018 0.53466 05/21/2021 ACETAZOLAMIDE ORAL TABLET 250 MG 0.68040 09/25/2020 0.57850 12/25/2020 ACETIC IRRIGATION SOLUTION, IRRIGATION 0.25 % 0.00350 03/01/2013 ACETIC ACID OTIC SOLUTION, NON-ORAL 2 % 1.65333 02/21/2020 1.38600 09/25/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ACETIC ACID/ALUMINUM ACETATE DROPS 2 % 0.84000 01/25/2013 0.84000 08/21/2015 INTRAVENOUS VIAL (ML) 200 MG/ML 5.26400 03/06/2015 5.26400 08/21/2015 ACETYLCYSTEINE MISCELLANEOUS VIAL (ML) 100 MG/ML 0.45068 08/21/2015 0.35144 02/21/2020 ACETYLCYSTEINE MISCELLANEOUS VIAL (ML) 200 MG/ML 0.34100 03/27/2020 0.32978 08/28/2020 ACETYLCYSTEINE/MECOBALAMIN/LEVOMEFOLATE CALCIUM ORAL 1.89794 02/20/2015 1.89794 08/21/2015 TABLET 600-2-6 MG ACITRETIN ORAL CAPSULE 10 MG 9.53166 12/18/2017 6.66000 06/18/2021 ACITRETIN ORAL CAPSULE 17.5 MG 42.31920 03/21/2014 ACITRETIN ORAL CAPSULE 25 MG 9.33333 05/17/2019 6.57371 06/18/2021 ACYCLOVIR ORAL CAPSULE 200 MG 0.08844 08/21/2015 0.05480 09/22/2017 ACYCLOVIR ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200 MG/5ML 0.40698 01/19/2020 0.39070 08/28/2020 ACYCLOVIR ORAL TABLET 400 MG 0.06655 07/14/2017 0.05351 11/16/2018 ACYCLOVIR ORAL TABLET 800 MG 0.13520 12/22/2017 0.11600 08/16/2019 ACYCLOVIR SODIUM INTRAVENOUS VIAL (EA) 500 MG 31.20600 08/22/2014 31.20600 08/21/2015 ACYCLOVIR SODIUM INTRAVENOUS VIAL (ML) 50 MG/ML 1.40750 07/25/2014 ACYCLOVIR TOPICAL OINTMENT (GRAM) 5 % 1.94109 11/15/2019 0.89933 05/22/2020 ADAPALENE TOPICAL CREAM (GRAM) 0.1 % 3.31978 12/25/2020 3.31978 01/01/2021 ADAPALENE TOPICAL GEL (GRAM) 0.1 % 1.58578 11/15/2019 1.58578 01/01/2021 ADAPALENE TOPICAL GEL (GRAM) 0.3 % 3.41117 06/16/2017 3.41117 01/01/2021 ADAPALENE TOPICAL GEL WITH PUMP (GRAM) 0.3 % 4.61985 08/21/2015 4.61985 01/01/2021 ADEFOVIR DIPIVOXIL ORAL TABLET 10 MG 26.52627 09/27/2013 ALBUMIN HUMAN INTRAVENOUS INTRAVENOUS SOLUTION 25 % 1.51200 05/01/2015 1.51200 08/21/2015 ALBUMIN HUMAN INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.21588 09/19/2014 0.21588 08/21/2015 ALBUTEROL SULFATE INHALATION SOLUTION, NON-ORAL 5 MG/ML 1.45230 10/23/2017 2.12250 12/27/2019 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (EA) 2.5 MG/0.5 0.43876 08/01/2014 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 0.63MG/3ML 0.15441 11/16/2018 0.11333 11/15/2019 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 1.25MG/3ML 0.19073 06/21/2019 0.15240 12/20/2019 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 2.5 MG/3ML 0.05253 08/21/2015 0.03400 01/19/2018 ALBUTEROL SULFATE ORAL SYRUP 2 MG/5 ML 0.01277 08/21/2015 0.03571 08/28/2019 ALBUTEROL SULFATE ORAL TABLET 2 MG 4.56651 08/21/2015 4.05000 12/25/2015 ALBUTEROL SULFATE ORAL TABLET 4 MG 3.62765 12/25/2015 2.00000 06/18/2021 ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 4 MG 1.18451 04/25/2014 ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 8 MG 1.71821 04/05/2013 ALCLOMETASONE DIPROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.88300 08/16/2019 0.62717 03/20/2020 ALCLOMETASONE DIPROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 0.58692 06/28/2013 ALENDRONATE SODIUM ORAL SOLUTION, ORAL 70 MG/75ML 2.45700 09/27/2013 ALENDRONATE SODIUM ORAL TABLET 10 MG 0.18750 08/21/2015 0.13200 10/20/2017 ALENDRONATE SODIUM ORAL TABLET 35 MG 0.35333 08/17/2018 0.23750 05/17/2019 ALENDRONATE SODIUM ORAL TABLET 40 MG 2.80060 03/27/2015 ALENDRONATE SODIUM ORAL TABLET 5 MG 0.18110 08/12/2014 0.18110 08/21/2015 ALENDRONATE SODIUM ORAL TABLET 70 MG 0.23250 09/21/2018 0.20500 12/25/2020 ALFUZOSIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.11326 03/16/2018 0.05870 05/22/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ALLOPURINOL ORAL TABLET 100 MG 0.07267 11/16/2018 0.04709 01/25/2019 ALLOPURINOL ORAL TABLET 300 MG 0.09110 07/26/2019 0.05230 07/17/2020 ALMOTRIPTAN MALATE ORAL TABLET 12.5 MG 25.31000 08/25/2017 16.33370 10/19/2018 ALPHA ORAL CAPSULE 200 MG 0.12771 08/08/2014 0.12771 08/21/2015 ALPHA LIPOIC ACID ORAL CAPSULE 50 MG 0.10210 08/12/2014 0.10210 08/21/2015 ALPRAZOLAM ORAL TABLET 0.25 MG 0.01509 05/16/2014 0.01509 08/21/2015 ALPRAZOLAM ORAL TABLET 0.5 MG 0.01780 08/21/2015 0.01462 03/19/2021 ALPRAZOLAM ORAL TABLET 1 MG 0.01970 02/06/2015 0.01970 08/21/2015 ALPRAZOLAM ORAL TABLET 2 MG 0.07213 09/28/2015 0.04891 12/22/2017 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 0.5 MG 0.36136 08/21/2015 0.18083 09/22/2017 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 1 MG 0.21717 09/22/2017 0.16917 03/19/2021 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 0.40200 08/17/2018 0.37733 01/15/2021 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 3 MG 0.55483 11/20/2015 0.35500 09/22/2017 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 0.25 MG 1.36123 03/01/2013 1.36123 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 0.5 MG 1.51669 01/25/2013 1.51669 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 1 MG 2.02358 01/25/2013 2.02358 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 2 MG 3.00202 01/25/2013 3.00202 08/21/2015 ALUMINUM HYDROXIDE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.00813 08/21/2015 320 MG/5ML AMANTADINE HCL ORAL CAPSULE 100 MG 0.24644 08/17/2018 0.18726 12/25/2020 AMANTADINE HCL ORAL SOLUTION, ORAL 50 MG/5 ML 0.01733 04/03/2015 0.01733 08/21/2015 AMANTADINE HCL ORAL TABLET 100 MG 0.13100 08/16/2019 0.43980 06/09/2020 ORAL TABLET 10 MG 38.40000 02/21/2020 AMBRISENTAN ORAL TABLET 5 MG 38.40000 02/21/2020 AMCINONIDE TOPICAL CREAM (GRAM) 0.1 % 2.82140 08/12/2014 AMCINONIDE TOPICAL LOTION (ML) 0.1 % 1.90000 08/12/2014 AMCINONIDE TOPICAL OINTMENT (GRAM) 0.1 % 4.53600 08/30/2013 AMIKACIN SULFATE INJECTION VIAL (ML) 1000MG/4ML 3.14373 12/05/2014 3.14373 08/21/2015 AMIKACIN SULFATE INJECTION VIAL (ML) 500 MG/2ML 2.95555 12/05/2014 2.95555 08/21/2015 AMILORIDE HCL ORAL TABLET 5 MG 0.14880 11/15/2019 0.13230 05/22/2020 AMILORIDE HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5 MG-50 MG 0.42250 05/30/2014 0.42250 08/21/2015 AMINO ORAL POWDER (GRAM) 0.25540 08/12/2014 AMINOCAPROIC ACID INTRAVENOUS VIAL (ML) 250 MG/ML 0.08148 02/06/2015 0.08148 08/21/2015 AMINOCAPROIC ACID ORAL TABLET 1000 MG 18.30610 08/12/2014 18.30610 08/21/2015 AMINOCAPROIC ACID ORAL TABLET 500 MG 5.37896 10/11/2013 5.37896 08/21/2015 AMINOPHYLLINE INTRAVENOUS VIAL (ML) 250MG/10ML 0.30912 01/30/2015 0.30912 08/21/2015 AMINOPHYLLINE INTRAVENOUS VIAL (ML) 500MG/20ML 0.07270 08/12/2014 HCL INTRAVENOUS AMPUL (ML) 50 MG/ML 0.33600 01/25/2013 AMIODARONE HCL ORAL TABLET 100 MG 1.97100 03/20/2020 1.39967 10/23/2020 AMIODARONE HCL ORAL TABLET 200 MG 0.12724 09/30/2016 0.09890 11/16/2018 AMIODARONE HCL ORAL TABLET 400 MG 3.19526 08/22/2014 2.81936 12/02/2016 HCL ORAL TABLET 10 MG 0.05742 11/16/2018 0.03550 08/16/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date AMITRIPTYLINE HCL ORAL TABLET 100 MG 0.43230 08/13/2020 0.31750 11/20/2020 AMITRIPTYLINE HCL ORAL TABLET 150 MG 0.63350 01/24/2020 0.53600 06/19/2020 AMITRIPTYLINE HCL ORAL TABLET 25 MG 0.09537 11/16/2018 0.06874 05/22/2020 AMITRIPTYLINE HCL ORAL TABLET 50 MG 0.18572 03/20/2020 0.15000 06/19/2020 AMITRIPTYLINE HCL ORAL TABLET 75 MG 0.25740 11/15/2019 0.12500 04/17/2020 AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE ORAL TABLET 12.5MG-5MG 1.07296 08/01/2014 AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE ORAL TABLET 25 MG-10MG 1.51380 05/02/2014 BESYLATE ORAL TABLET 10 MG 0.02527 08/21/2015 0.01238 09/21/2018 AMLODIPINE BESYLATE ORAL TABLET 2.5 MG 0.01756 07/14/2017 0.01004 10/23/2020 AMLODIPINE BESYLATE ORAL TABLET 5 MG 0.01293 10/23/2020 0.01252 02/19/2021 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG- 3.63000 09/30/2016 1.46667 11/15/2019 10MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG- 3.93004 08/21/2015 2.41746 07/16/2021 20MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG- 3.69400 05/25/2018 2.50000 09/20/2019 40MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG- 6.55993 08/21/2015 5.53825 06/16/2017 80MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 2.5MG- 5.07347 08/12/2014 5.07347 08/21/2015 10MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 2.5MG- 3.01200 09/22/2017 2.46833 03/20/2020 20MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 2.5MG- 6.55993 08/21/2015 5.92000 09/30/2016 40MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG- 4.55853 08/21/2015 3.16379 06/16/2017 10 MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG- 3.93250 08/21/2015 2.74000 05/25/2018 20 MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG- 3.35767 09/22/2017 3.09133 02/21/2020 40 MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG- 5.92000 09/30/2016 3.28900 05/17/2019 80 MG AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 10 MG-20MG 0.22277 09/30/2016 0.10120 08/25/2017 AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 10 MG-40MG 0.14950 11/24/2017 0.09950 07/26/2019 AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 2.5MG-10MG 0.46372 03/25/2016 0.08560 09/22/2017 AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 5 MG-10 MG 0.14570 08/25/2017 0.07450 08/17/2018 AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 5 MG-20 MG 0.10380 09/22/2017 0.09650 06/18/2021 AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 5 MG-40 MG 0.17283 11/24/2017 0.09000 04/27/2018 AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 10 0.52000 11/24/2017 0.31333 11/15/2019 MG-20MG AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 10 0.69044 03/17/2017 0.49867 05/17/2019 MG-40MG AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 5 MG- 0.65033 10/20/2017 0.44433 12/22/2017 20 MG AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 5 MG- 0.72933 11/16/2018 0.35000 05/22/2020 40 MG AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 10MG-160MG 0.47493 04/22/2016 0.35000 03/15/2019 AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 10MG-320MG 0.53089 05/20/2016 0.43333 11/24/2017 AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 5 MG-160MG 0.42633 10/21/2019 0.33484 12/20/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 5 MG-320MG 0.45034 03/03/2017 0.37667 11/15/2019 AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL 4.40212 01/01/2017 0.91533 05/25/2018 TABLET 10-160-25 AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL 1.41000 05/25/2018 0.94467 05/17/2019 TABLET 10-320-25 AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL 4.40212 01/01/2017 1.15000 03/15/2019 TABLET 10MG-160MG AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL 3.88023 01/01/2017 1.74210 08/25/2017 TABLET 5-160-12.5 AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL 3.88023 01/01/2017 1.40400 06/18/2021 TABLET 5-160-25MG AMMONIUM CHLORIDE VIAL (ML) 5 MEQ/ML 0.42630 01/25/2013 AMMONIUM LACTATE TOPICAL CREAM (GRAM) 12 % 0.03021 04/26/2019 0.05714 06/05/2019 AMMONIUM LACTATE TOPICAL LOTION (GRAM) 12 % 0.01588 05/22/2020 0.06990 02/16/2021 AMOXAPINE ORAL TABLET 100 MG 1.16865 11/22/2013 AMOXAPINE ORAL TABLET 150 MG 1.28830 01/25/2013 AMOXAPINE ORAL TABLET 25 MG 0.27027 01/25/2013 AMOXAPINE ORAL TABLET 50 MG 0.69923 11/22/2013 AMOXICILLIN ORAL CAPSULE 250 MG 0.04730 08/21/2015 0.04589 05/21/2021 AMOXICILLIN ORAL CAPSULE 500 MG 0.05236 06/16/2017 0.05190 10/23/2020 AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 0.01420 04/24/2015 0.01420 08/21/2015 MG/5ML AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 0.05684 08/21/2015 0.02500 08/25/2017 MG/5ML AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 0.02291 10/20/2017 0.01825 07/26/2019 MG/5ML AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 400 0.01901 07/26/2019 0.01728 11/20/2020 MG/5ML AMOXICILLIN ORAL TABLET 500 MG 0.25550 08/17/2018 0.13125 05/17/2019 AMOXICILLIN ORAL TABLET 875 MG 0.12230 06/16/2017 0.08590 12/22/2017 AMOXICILLIN ORAL TABLET,CHEWABLE 125 MG 0.15067 01/25/2013 AMOXICILLIN ORAL TABLET,CHEWABLE 250 MG 0.26748 10/03/2014 0.26748 08/21/2015 AMOXICILLIN ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 11.26813 12/26/2014 11.26813 08/21/2015 775 MG AMOXICILLIN/ CLAVULANATE ORAL SUSPENSION, 0.11239 08/21/2015 0.03290 11/24/2017 RECONSTITUTED, ORAL (ML) 200-28.5/5 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, 0.55083 03/20/2020 0.30000 05/22/2020 RECONSTITUTED, ORAL (ML) 250-62.5/5 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, 0.08554 03/03/2017 0.06173 11/15/2019 RECONSTITUTED, ORAL (ML) 400-57MG/5 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, 0.08168 03/03/2017 0.06436 11/16/2018 RECONSTITUTED, ORAL (ML) 600-42.9/5 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET 250-125 MG 4.14283 08/21/2015 3.35700 08/17/2018 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET 500-125 MG 0.25000 09/21/2018 0.24500 06/18/2021 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET 875-125 MG 0.24750 09/21/2018 0.23428 01/24/2020 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET, EXTENDED 3.37383 10/31/2014 RELEASE 12 HR 1000-62.5 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET,CHEWABLE 200- 1.00222 03/01/2013 1.00222 08/21/2015 28.5MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET,CHEWABLE 400- 1.51840 08/22/2014 3.77335 04/22/2016 57MG AMPHETAMINE SULFATE ORAL TABLET 10 MG 3.68478 08/28/2020 AMPHETAMINE SULFATE ORAL TABLET 5 MG 3.68478 08/28/2020 AMPHOTERICIN B INJECTION VIAL (EA) 50 MG 20.87400 05/30/2014 AMPICILLIN SODIUM INJECTION VIAL (EA) 1 G 2.89120 01/25/2013 AMPICILLIN SODIUM INJECTION VIAL (EA) 10 G 36.92358 12/26/2014 36.92358 08/21/2015 AMPICILLIN SODIUM INJECTION VIAL (EA) 125 MG 3.50250 08/12/2014 AMPICILLIN SODIUM INJECTION VIAL (EA) 2 G 6.57000 11/08/2013 6.49900 05/17/2019 AMPICILLIN SODIUM INJECTION VIAL (EA) 250 MG 1.41638 01/25/2013 AMPICILLIN SODIUM INJECTION VIAL (EA) 500 MG 1.62006 01/25/2013 AMPICILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 12.17907 08/12/2014 G AMPICILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2 23.62640 01/25/2013 G AMPICILLIN SODIUM/SULBACTAM SODIUM INJECTION VIAL (EA) 1.5 G 2.57012 07/18/2014 2.57012 08/21/2015 AMPICILLIN SODIUM/SULBACTAM SODIUM INJECTION VIAL (EA) 15 G 20.70600 08/12/2014 20.70600 08/21/2015 AMPICILLIN SODIUM/SULBACTAM SODIUM INJECTION VIAL (EA) 3 G 6.47640 08/23/2013 6.47640 08/21/2015 AMPICILLIN SODIUM/SULBACTAM SODIUM INTRAVENOUS VIAL WITH 3.24240 01/25/2013 THREADED PORT (EA) 1.5 G AMPICILLIN SODIUM/SULBACTAM SODIUM INTRAVENOUS VIAL WITH 5.22060 01/25/2013 5.22060 08/21/2015 THREADED PORT (EA) 3 G AMPICILLIN TRIHYDRATE ORAL CAPSULE 250 MG 0.09000 08/12/2014 0.09000 08/21/2015 AMPICILLIN TRIHYDRATE ORAL CAPSULE 500 MG 0.14370 08/21/2015 0.46990 05/15/2020 AMPICILLIN TRIHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL 0.03950 02/08/2013 0.03950 08/21/2015 (ML) 125 MG/5ML AMPICILLIN TRIHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL 0.06860 02/08/2013 0.06860 08/21/2015 (ML) 250 MG/5ML ANAGRELIDE HCL ORAL CAPSULE 0.5 MG 0.60112 05/16/2014 ANAGRELIDE HCL ORAL CAPSULE 1 MG 1.29259 05/16/2014 ANASTROZOLE ORAL TABLET 1 MG 0.08533 06/16/2017 0.04100 08/16/2019 ANTIPYRINE/BENZOCAINE DROPS 5.4 %-1.4% 0.43271 02/06/2015 0.43271 08/21/2015 ANTIPYRINE/BENZOCAINE DROPS 5.5 %-1.4% 10.70600 12/26/2014 10.70600 08/21/2015 ANTIVENIN,LATRODECTUS MACTANS INJECTION VIAL (EA) 6000 UNIT 57.33000 12/12/2014 57.33000 08/21/2015 ANTIVENIN,MICRURUS FULVIUS INJECTION VIAL (EA) 1496.32000 01/25/2013 APRACLONIDINE HCL OPHTHALMIC DROPS 0.5 % 12.32550 08/21/2015 10.34900 08/16/2019 ARGATROBAN IN 0.9 % SODIUM CHLORIDE INTRAVENOUS VIAL (ML) 125 11.61817 01/25/2013 MG/125 ARGATROBAN IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS VIAL 3.85000 08/12/2014 (ML) 50 MG/50ML ARGATROBAN INTRAVENOUS VIAL (ML) 100 MG/ML 412.36020 05/01/2015 412.36020 08/21/2015 ARGININE HCL ORAL TABLET 1000 MG 0.14760 08/12/2014 ARGININE ORAL CAPSULE 500 MG 0.08386 08/12/2014 0.08386 08/21/2015 ARIPIPRAZOLE ORAL SOLUTION, ORAL 1 MG/ML 2.75841 04/21/2017 1.91233 09/25/2020 ARIPIPRAZOLE ORAL TABLET 10 MG 0.15550 05/22/2020 0.13171 05/21/2021 ARIPIPRAZOLE ORAL TABLET 15 MG 0.15833 12/25/2020 0.15039 05/21/2021 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ARIPIPRAZOLE ORAL TABLET 2 MG 0.18274 05/17/2019 0.06467 04/17/2020 ARIPIPRAZOLE ORAL TABLET 20 MG 0.26086 08/28/2020 0.20576 02/19/2021 ARIPIPRAZOLE ORAL TABLET 30 MG 0.22500 11/15/2019 0.16745 11/20/2020 ARIPIPRAZOLE ORAL TABLET 5 MG 0.14460 06/19/2020 0.08567 09/25/2020 ARMODAFINIL ORAL TABLET 150 MG 1.03341 08/01/2018 ARMODAFINIL ORAL TABLET 200 MG 1.37000 08/25/2017 1.27067 02/21/2020 ARMODAFINIL ORAL TABLET 250 MG 1.19665 08/01/2018 1.09333 01/25/2019 ASCORBIC ACID ORAL TABLET 1000 MG 0.05352 08/12/2014 0.05352 08/21/2015 ASCORBIC ACID ORAL TABLET 250 MG 0.01807 08/12/2014 0.01807 08/21/2015 ASCORBIC ACID ORAL TABLET 500 MG 0.02550 08/12/2014 0.02550 08/21/2015 ASCORBIC ACID ORAL TABLET, EXTENDED RELEASE 1000 MG 0.07311 08/12/2014 0.07311 08/21/2015 ASCORBIC ACID ORAL TABLET,CHEWABLE 250 MG 0.02510 01/25/2013 ASCORBIC ACID ORAL TABLET,CHEWABLE 500 MG 0.04768 08/12/2014 0.04768 08/21/2015 ASPIRIN ORAL TABLET 325 MG 0.00616 03/27/2015 0.00616 08/21/2015 ASPIRIN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 325 MG 0.00872 05/01/2015 0.00872 08/21/2015 ASPIRIN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 81 MG 0.00804 04/03/2015 0.00804 08/21/2015 ASPIRIN ORAL TABLET,CHEWABLE 81 MG 0.02048 05/01/2015 0.02048 08/21/2015 ASPIRIN/ACETAMINOPHEN/CAFFEINE ORAL TABLET 250-250-65 0.04476 04/24/2015 0.04476 08/21/2015 ASPIRIN/CALCIUM / ORAL TABLET 325 MG 0.02015 03/07/2014 0.02015 08/21/2015 ASPIRIN//CITRIC ACID ORAL TABLET, 0.09644 08/12/2014 0.09644 08/21/2015 EFFERVESCENT 325-1916MG ATAZANAVIR SULFATE ORAL CAPSULE 150 MG 4.58000 02/21/2020 ATAZANAVIR SULFATE ORAL CAPSULE 200 MG 4.48000 02/21/2020 ATAZANAVIR SULFATE ORAL CAPSULE 300 MG 6.89000 02/21/2020 ATENOLOL ORAL TABLET 100 MG 0.03400 08/21/2015 0.01518 09/22/2017 ATENOLOL ORAL TABLET 25 MG 0.02659 04/03/2015 0.02659 08/21/2015 ATENOLOL ORAL TABLET 50 MG 0.01640 04/17/2015 0.01640 08/21/2015 ATENOLOL/CHLORTHALIDONE ORAL TABLET 100MG-25MG 0.45970 11/24/2017 0.39948 03/02/2018 ATENOLOL/CHLORTHALIDONE ORAL TABLET 50 MG-25MG 0.35135 03/02/2018 0.32495 11/16/2018 ATOMOXETINE HCL ORAL CAPSULE 10 MG 1.79000 05/22/2020 1.36383 08/28/2020 ATOMOXETINE HCL ORAL CAPSULE 100 MG 2.81100 05/17/2019 2.47000 12/20/2019 ATOMOXETINE HCL ORAL CAPSULE 18 MG 1.62230 06/21/2020 1.15467 09/25/2020 ATOMOXETINE HCL ORAL CAPSULE 25 MG 1.41167 01/24/2020 1.98117 05/22/2020 ATOMOXETINE HCL ORAL CAPSULE 40 MG 1.64600 05/22/2020 1.23845 02/19/2021 ATOMOXETINE HCL ORAL CAPSULE 60 MG 1.98000 08/28/2020 1.86429 12/25/2020 ATOMOXETINE HCL ORAL CAPSULE 80 MG 1.96534 09/20/2019 1.66667 11/15/2019 ATORVASTATIN CALCIUM ORAL TABLET 10 MG 0.03668 09/25/2020 0.02891 03/19/2021 ATORVASTATIN CALCIUM ORAL TABLET 20 MG 0.04804 08/28/2020 0.04526 12/25/2020 ATORVASTATIN CALCIUM ORAL TABLET 40 MG 0.09629 10/25/2019 0.05800 04/17/2020 ATORVASTATIN CALCIUM ORAL TABLET 80 MG 0.10064 11/15/2019 0.09897 10/23/2020 ATOVAQUONE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 750 2.21000 12/21/2018 1.42857 11/15/2019 MG/5ML ATOVAQUONE/PROGUANIL HCL ORAL TABLET 250-100 MG 2.23250 05/17/2019 2.19550 11/15/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ATOVAQUONE/PROGUANIL HCL ORAL TABLET 62.5-25 MG 1.85045 06/06/2014 0.92151 01/13/2017 ATROPINE SULFATE INJECTION SYRINGE (ML) 0.05 MG/ML 2.23272 01/25/2013 ATROPINE SULFATE INJECTION SYRINGE (ML) 0.1 MG/ML 0.43014 01/25/2013 0.43014 08/21/2015 ATROPINE SULFATE INJECTION VIAL (ML) 0.4 MG/ML 0.85480 08/12/2014 0.85480 08/21/2015 ATROPINE SULFATE INJECTION VIAL (ML) 1 MG/ML 1.50320 08/12/2014 ATROPINE SULFATE OPHTHALMIC DROPS 1 % 8.17320 08/22/2015 9.81029 01/31/2020 ATROPINE SULFATE OPHTHALMIC OINTMENT (GRAM) 1 % 3.98000 02/08/2013 AZATHIOPRINE ORAL TABLET 50 MG 0.21600 04/26/2019 0.18135 11/15/2019 AZELASTINE HCL NASAL AEROSOL, SPRAY WITH PUMP (ML) 137 MCG 0.27345 07/26/2019 0.24233 07/16/2021 AZELASTINE HCL NASAL AEROSOL, SPRAY WITH PUMP (ML) 205.5 MCG 0.93000 09/25/2020 0.69133 11/20/2020 AZELASTINE HCL OPHTHALMIC DROPS 0.05 % 1.31000 12/21/2018 1.14932 05/21/2021 AZITHROMYCIN INTRAVENOUS VIAL (EA) 500 MG 3.77260 08/12/2014 3.77260 08/21/2015 AZITHROMYCIN INTRAVENOUS VIAL WITH THREADED PORT (EA) 500 MG 12.68820 01/25/2013 AZITHROMYCIN ORAL PACKET (EA) 1 G 20.29440 01/17/2014 20.29440 08/21/2015 AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100 0.58000 08/16/2019 0.42933 05/22/2020 MG/5ML AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 0.42067 11/20/2020 0.27533 05/21/2021 MG/5ML AZITHROMYCIN ORAL TABLET 250 MG 0.29000 10/20/2017 0.27106 01/19/2018 AZITHROMYCIN ORAL TABLET 500 MG 0.97640 03/03/2017 0.56111 06/16/2017 AZITHROMYCIN ORAL TABLET 600 MG 1.49833 05/17/2019 1.25500 09/20/2019 AZTREONAM INJECTION VIAL (EA) 1 G 27.67800 08/15/2014 AZTREONAM INJECTION VIAL (EA) 2 G 39.02640 01/30/2015 39.02640 08/21/2015 B-COMPLEX WITH C ORAL TABLET 0.02618 08/15/2014 0.02618 08/21/2015 BACITRACIN OPHTHALMIC OINTMENT (GRAM) 500 UNIT/G 13.86800 08/21/2015 27.98908 08/15/2018 BACITRACIN TOPICAL OINTMENT (GRAM) 500 UNIT/G 0.06722 04/19/2013 0.06722 08/21/2015 BACITRACIN TOPICAL OINTMENT (GRAM) 500 UNIT/G 0.10676 04/17/2015 0.10676 08/21/2015 BACITRACIN/POLYMYXIN B SULFATE OPHTHALMIC OINTMENT (GRAM) 2.05714 08/16/2019 2.05000 08/28/2020 500-10K/G BACITRACIN/POLYMYXIN B SULFATE TOPICAL OINTMENT (GRAM) 500- 0.27376 01/25/2013 0.27376 08/21/2015 10K/G BACLOFEN MISCELLANEOUS POWDER (GRAM) 100 % 2.61831 02/13/2015 2.61831 08/21/2015 BACLOFEN ORAL TABLET 10 MG 0.07070 01/25/2019 0.05757 01/24/2020 BACLOFEN ORAL TABLET 20 MG 0.14090 05/22/2020 0.11300 08/28/2020 BALSALAZIDE DISODIUM ORAL CAPSULE 750 MG 0.22496 03/02/2018 0.45520 05/24/2021 BCG LIVE INTRAVESICAL VIAL (EA) 50 MG 291.39600 01/25/2013 BENAZEPRIL HCL ORAL TABLET 10 MG 0.03800 10/20/2017 0.01900 11/16/2018 BENAZEPRIL HCL ORAL TABLET 20 MG 0.05197 08/21/2015 0.04190 09/25/2020 BENAZEPRIL HCL ORAL TABLET 40 MG 0.06427 08/25/2017 0.04368 10/20/2017 BENAZEPRIL HCL ORAL TABLET 5 MG 0.05199 08/21/2015 0.03583 11/16/2018 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.60520 12/22/2017 0.49990 08/28/2020 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20 MG-25MG 0.87187 03/03/2017 0.49535 06/16/2017 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG 0.68974 08/25/2018 0.59990 08/28/2020 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5-6.25MG 0.45890 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date BENZOCAINE/MENTHOL MUCOUS MEMBRANE LOZENGE 15MG-3.6MG 0.09806 02/13/2015 0.09806 08/21/2015 BENZONATATE ORAL CAPSULE 100 MG 0.09980 11/16/2018 0.08282 11/15/2019 BENZONATATE ORAL CAPSULE 200 MG 0.14064 09/30/2016 0.08920 08/16/2019 BENZOYL PEROXIDE TOPICAL CLEANSER (GRAM) 10 % 0.04197 05/01/2015 0.04197 08/21/2015 BENZOYL PEROXIDE TOPICAL CLEANSER (GRAM) 5 % 0.04075 08/09/2013 0.04075 08/21/2015 BENZOYL PEROXIDE TOPICAL FOAM (GRAM) 5.3% 2.00832 08/12/2014 BENZOYL PEROXIDE TOPICAL FOAM (GRAM) 9.8 % 1.60318 08/12/2014 BENZOYL PEROXIDE TOPICAL GEL (GRAM) 10 % 0.21574 03/20/2015 0.21574 08/21/2015 BENZOYL PEROXIDE TOPICAL GEL (GRAM) 2.5 % 0.23088 08/16/2013 BENZOYL PEROXIDE TOPICAL GEL (GRAM) 5 % 0.18789 02/27/2015 0.18789 08/21/2015 BENZPHETAMINE HCL ORAL TABLET 50 MG 0.43389 11/07/2014 0.43389 08/21/2015 BENZTROPINE MESYLATE INJECTION AMPUL (ML) 2 MG/2 ML 23.40625 08/12/2014 BENZTROPINE MESYLATE INJECTION VIAL (ML) 2 MG/2 ML 40.39560 01/25/2013 40.39560 08/21/2015 BENZTROPINE MESYLATE ORAL TABLET 0.5 MG 0.08100 09/22/2017 0.05221 07/26/2019 BENZTROPINE MESYLATE ORAL TABLET 1 MG 0.09106 08/25/2017 0.05550 09/21/2018 BENZTROPINE MESYLATE ORAL TABLET 2 MG 0.09210 02/22/2019 0.07071 08/16/2019 BETA-CAROTENE(A) W-C AND E/LUTEIN/ ORAL TABLET 1000- 0.06145 08/12/2014 0.06145 08/21/2015 60-2 BETA-CAROTENE/ASCORBIC ACID/VITE AC/ZINC OXIDE/CUPRIC OXIDE 0.16420 08/12/2014 0.16420 08/21/2015 ORAL CAPSULE 14320-226 BETA-CAROTENE/ASCORBIC ACID/VITE AC/ZINC OXIDE/CUPRIC OXIDE 0.06620 08/12/2014 ORAL TABLET 7160-113 BETAMETHASONE ACETATE/BETAMETHASONE SODIUM PHOSPHATE 5.60000 01/25/2013 5.60000 08/21/2015 INJECTION VIAL (ML) 6 MG/ML BETAMETHASONE DIPROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.88400 07/17/2020 1.06198 03/22/2021 BETAMETHASONE DIPROPIONATE TOPICAL GEL (GRAM) 0.05 % 1.21450 01/25/2013 BETAMETHASONE DIPROPIONATE TOPICAL LOTION (ML) 0.05 % 0.23117 08/16/2019 0.45600 02/07/2020 BETAMETHASONE DIPROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 1.57591 03/29/2013 1.57591 08/21/2015 BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL TOPICAL 0.34930 08/21/2015 0.17260 01/25/2019 CREAM (GRAM) 0.05 % BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL TOPICAL 1.77637 08/16/2013 LOTION (ML) 0.05 % BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL TOPICAL 1.66174 06/16/2017 0.86311 08/16/2019 OINTMENT (GRAM) 0.05 % BETAMETHASONE VALERATE TOPICAL CREAM (GRAM) 0.1 % 0.16667 02/21/2020 0.56973 07/01/2020 BETAMETHASONE VALERATE TOPICAL FOAM (GRAM) 0.12 % 3.31660 08/21/2015 2.50000 10/25/2019 BETAMETHASONE VALERATE TOPICAL LOTION (ML) 0.1 % 0.79430 03/29/2013 0.79430 08/21/2015 BETAMETHASONE VALERATE TOPICAL OINTMENT (GRAM) 0.1 % 0.69422 09/04/2018 0.56667 02/21/2020 BETAXOLOL HCL OPHTHALMIC DROPS 0.5 % 7.27680 01/25/2013 BETAXOLOL HCL ORAL TABLET 10 MG 0.51160 08/16/2019 BETHANECHOL CHLORIDE ORAL TABLET 10 MG 0.29680 08/25/2017 0.11950 05/17/2019 BETHANECHOL CHLORIDE ORAL TABLET 25 MG 0.27150 09/22/2017 0.17580 08/16/2019 BETHANECHOL CHLORIDE ORAL TABLET 5 MG 0.14400 09/22/2017 0.12190 11/15/2019 BETHANECHOL CHLORIDE ORAL TABLET 50 MG 0.28034 12/02/2016 0.25990 11/16/2018 BICALUTAMIDE ORAL TABLET 50 MG 0.21667 08/25/2017 0.10180 08/17/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date BIOFLAVONOID, LEMON/VITAMIN B COMP AND C ORAL TABLET 200-100 0.14285 05/03/2013 MG ORAL CAPSULE 2500 MCG 0.09390 08/12/2014 ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 5 MG 0.00996 01/16/2015 0.00996 08/21/2015 BISACODYL RECTAL SUPPOSITORY, RECTAL 10 MG 0.09491 08/12/2014 0.09491 08/21/2015 BISMUTH SUBSALICYLATE ORAL SUSPENSION, ORAL (FINAL DOSE 0.00732 03/20/2015 0.00732 08/21/2015 FORM) 262MG/15ML BISMUTH SUBSALICYLATE ORAL SUSPENSION, ORAL (FINAL DOSE 0.01095 04/24/2015 0.01095 08/21/2015 FORM) 525MG/15ML BISMUTH SUBSALICYLATE ORAL TABLET,CHEWABLE 262 MG 0.09120 08/21/2015 0.05733 01/25/2019 BISOPROLOL FUMARATE ORAL TABLET 10 MG 0.52457 03/24/2020 0.37525 11/20/2020 BISOPROLOL FUMARATE ORAL TABLET 5 MG 0.30530 07/17/2020 0.43143 08/24/2020 BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 10- 0.06432 04/17/2015 0.06432 08/21/2015 6.25MG BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 2.5- 0.04920 10/20/2017 0.03462 03/02/2018 6.25MG BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 5- 0.42720 10/25/2019 0.33813 02/21/2020 6.25MG BRIMONIDINE TARTRATE OPHTHALMIC DROPS 0.15 % 16.27762 08/21/2015 16.27762 04/22/2016 BRIMONIDINE TARTRATE OPHTHALMIC DROPS 0.2 % 0.51810 02/22/2019 0.42067 06/19/2020 BROMFENAC SODIUM OPHTHALMIC DROPS 0.09 % 39.30875 09/26/2014 39.30875 08/21/2015 BROMOCRIPTINE MESYLATE ORAL CAPSULE 5 MG 6.00042 03/25/2016 4.25000 10/19/2018 BROMOCRIPTINE MESYLATE ORAL TABLET 2.5 MG 2.15134 05/28/2019 1.06633 11/15/2019 BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL ORAL LIQUID (ML) 0.15294 01/25/2013 0.15294 08/21/2015 4-10MG/5ML BROMPHENIRAMINE MALEATE/PHENYLEPHRINE 0.11830 09/13/2013 0.11830 08/21/2015 HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 4-10-20/5 BROMPHENIRAMINE MALEATE/PHENYLEPHRINE 0.09960 12/12/2014 0.09960 08/21/2015 HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 4-7.5-15/5 BROMPHENIRAMINE MALEATE/PHENYLEPHRINE 0.01700 02/06/2015 0.01700 08/21/2015 HCL/DEXTROMETHORPHAN ORAL SOLUTION, ORAL 1-2.5-5/5 BROMPHENIRAMINE MALEATE/PSEUDOEPHEDRINE 0.01880 03/27/2015 HCL/DEXTROMETHORPHAN ORAL ELIXIR 1-15-5MG/5 BROMPHENIRAMINE MALEATE/PSEUDOEPHEDRINE 0.12883 09/20/2017 0.05776 11/16/2018 HCL/DEXTROMETHORPHAN ORAL SYRUP 2-30-10/5 BUDESONIDE INHALATION AMPUL FOR NEBULIZATION (ML) 0.25MG/2ML 0.77933 01/23/2021 0.64421 04/16/2021 BUDESONIDE INHALATION AMPUL FOR NEBULIZATION (ML) 0.5 MG/2ML 0.74983 01/01/2021 0.62792 05/21/2021 BUDESONIDE INHALATION AMPUL FOR NEBULIZATION (ML) 1 MG/2 ML 4.11367 06/19/2020 4.11367 01/01/2021 BUDESONIDE ORAL CAPSULE, DELAYED, AND EXTENDED RELEASE 3 0.89630 08/16/2019 0.48290 04/17/2020 MG BUMETANIDE INJECTION VIAL (ML) 0.25 MG/ML 0.26572 01/25/2013 0.26572 08/21/2015 BUMETANIDE ORAL TABLET 0.5 MG 0.15517 02/20/2015 0.15517 08/21/2015 BUMETANIDE ORAL TABLET 1 MG 0.27990 05/22/2020 0.27362 08/28/2020 BUMETANIDE ORAL TABLET 2 MG 0.64435 03/03/2017 0.58140 09/25/2020 BUPIVACAINE HCL INJECTION VIAL (ML) 2.5 MG/ML 0.04200 04/25/2014 BUPIVACAINE HCL INJECTION VIAL (ML) 5 MG/ML 0.05090 04/25/2014 0.05090 08/21/2015 BUPIVACAINE HCL/EPINEPHRINE BITARTRATE INJECTION CARTRIDGE 0.26130 08/12/2014 (ML) 0.5-1:200K BUPIVACAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 0.25-.0005 0.12253 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date BUPIVACAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 0.5-1:200K 0.11900 01/25/2013 BUPIVACAINE HCL/EPINEPHRINE/PF INJECTION VIAL (ML) 0.25-.0005 0.27733 01/25/2013 BUPIVACAINE HCL/EPINEPHRINE/PF INJECTION VIAL (ML) 0.5-1:200K 0.25992 01/25/2013 BUPIVACAINE HCL/PF INJECTION AMPUL (ML) 2.5 MG/ML 0.11790 08/12/2014 BUPIVACAINE HCL/PF INJECTION AMPUL (ML) 5 MG/ML 0.08690 08/12/2014 BUPIVACAINE HCL/PF INJECTION AMPUL (ML) 7.5 MG/ML 0.10478 01/25/2013 0.10478 08/21/2015 BUPIVACAINE HCL/PF INJECTION VIAL (ML) 2.5 MG/ML 0.06089 08/12/2014 BUPIVACAINE HCL/PF INJECTION VIAL (ML) 5 MG/ML 0.06736 08/12/2014 BUPIVACAINE HCL/PF INJECTION VIAL (ML) 7.5 MG/ML 0.13428 08/12/2014 BUPRENORPHINE HCL INJECTION CARTRIDGE (ML) 0.3 MG/ML 12.18000 01/25/2013 BUPRENORPHINE HCL SUBLINGUAL TABLET, SUBLINGUAL 2 MG 1.05933 06/16/2017 0.43600 09/22/2017 BUPRENORPHINE HCL SUBLINGUAL TABLET, SUBLINGUAL 8 MG 0.95666 06/25/2019 0.65800 09/20/2019 BUPRENORPHINE HCL/ HCL SUBLINGUAL TABLET, 2.60728 06/16/2017 1.19133 11/15/2019 SUBLINGUAL 2 MG-0.5MG BUPRENORPHINE HCL/NALOXONE HCL SUBLINGUAL TABLET, 1.18317 02/19/2021 1.03049 07/16/2021 SUBLINGUAL 8 MG-2 MG BUPROPION HCL ORAL TABLET 100 MG 0.18600 09/22/2017 0.11485 08/16/2019 BUPROPION HCL ORAL TABLET 75 MG 0.14167 11/15/2019 0.08950 05/22/2020 BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 12 HR 150 MG 0.44367 03/25/2016 0.20967 07/14/2017 BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 24 HR 150 MG 0.14598 06/19/2020 0.13146 09/25/2020 BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 0.19016 05/22/2020 0.14086 05/21/2021 BUPROPION HCL ORAL TABLET,SUSTAINED-RELEASE 12 HR 100 MG 0.12200 07/23/2018 0.10897 09/25/2020 BUPROPION HCL ORAL TABLET,SUSTAINED-RELEASE 12 HR 150 MG 0.07500 06/19/2020 0.05360 06/18/2021 BUPROPION HCL ORAL TABLET,SUSTAINED-RELEASE 12 HR 200 MG 0.19271 07/14/2017 0.08490 02/22/2019 BUSPIRONE HCL ORAL TABLET 10 MG 0.03737 09/25/2020 0.03497 04/16/2021 BUSPIRONE HCL ORAL TABLET 15 MG 0.05500 07/26/2019 0.04652 11/20/2020 BUSPIRONE HCL ORAL TABLET 30 MG 0.19998 07/17/2020 0.11717 11/20/2020 BUSPIRONE HCL ORAL TABLET 5 MG 0.02551 11/16/2018 0.01998 12/25/2020 BUSPIRONE HCL ORAL TABLET 7.5 MG 0.33000 11/15/2019 0.28190 11/20/2020 BUTALBITAL/ACETAMINOPHEN ORAL TABLET 50MG-325MG 0.86233 03/14/2014 1.09000 08/07/2015 BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL CAPSULE 50-300-40 2.36850 08/03/2018 1.86500 10/19/2018 BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL CAPSULE 50-325-40 1.35905 03/27/2015 BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL TABLET 50-325-40 0.22890 12/20/2019 0.15773 05/22/2020 BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE ORAL 4.30822 03/06/2015 CAPSULE 50-300-30 BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE ORAL 1.04965 08/21/2015 1.01795 03/02/2018 CAPSULE 50-325-30 BUTALBITAL/ASPIRIN/CAFFEINE ORAL CAPSULE 50-325-40 0.88420 01/24/2020 1.00000 05/04/2020 BUTALBITAL/ASPIRIN/CAFFEINE ORAL TABLET 50-325-40 0.29110 12/17/2018 BUTENAFINE HCL TOPICAL CREAM (GRAM) 1 % 0.40179 08/21/2015 0.40179 01/01/2019 BUTORPHANOL TARTRATE INJECTION VIAL (ML) 1 MG/ML 1.94300 01/25/2013 1.94300 08/21/2015 BUTORPHANOL TARTRATE INJECTION VIAL (ML) 2 MG/ML 1.94300 01/25/2013 1.94300 08/21/2015 BUTORPHANOL TARTRATE NASAL AEROSOL, SPRAY (ML) 10 MG/ML 16.32960 08/21/2015 12.19584 06/16/2017 CABERGOLINE ORAL TABLET 0.5 MG 2.93000 06/21/2019 2.12000 07/26/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CAFFEINE CITRATE INTRAVENOUS VIAL (ML) 60 MG/3 ML 3.35400 04/03/2015 3.35400 08/21/2015 CAFFEINE CITRATE ORAL SOLUTION, ORAL 60 MG/3 ML 6.70190 08/21/2015 6.66666 01/25/2019 CAFFEINE/ INJECTION VIAL (ML) 250 MG/ML 2.73000 01/25/2013 CALCIPOTRIENE TOPICAL CREAM (GRAM) 0.005 % 1.70100 04/26/2019 0.88683 01/24/2020 CALCIPOTRIENE TOPICAL OINTMENT (GRAM) 0.005 % 4.22790 08/12/2014 2.29000 12/25/2020 CALCIPOTRIENE TOPICAL SOLUTION, NON-ORAL 0.005 % 2.64568 06/16/2017 1.56000 05/25/2018 CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE TOPICAL OINTMENT 8.11932 06/16/2017 8.11932 01/01/2018 (GRAM) 0.005-.064 CALCITONIN,SALMON,SYNTHETIC NASAL AEROSOL, SPRAY WITH PUMP 10.40270 09/25/2015 9.78378 09/30/2016 (ML) 200/SPRAY CALCITRIOL INTRAVENOUS AMPUL (ML) 1 MCG/ML 4.68130 05/10/2013 CALCITRIOL ORAL CAPSULE 0.25 MCG 0.17150 11/16/2018 0.13009 08/16/2019 CALCITRIOL ORAL CAPSULE 0.5 MCG 0.50783 02/08/2018 0.20400 11/16/2018 CALCITRIOL ORAL SOLUTION, ORAL 1 MCG/ML 5.49667 08/26/2016 4.59200 08/16/2019 CALCITRIOL TOPICAL OINTMENT (GRAM) 3 MCG/G 6.43120 01/09/2015 6.43120 01/01/2018 CALCIUM ACETATE ORAL CAPSULE 667 MG 0.51577 03/31/2020 0.29233 07/17/2020 CALCIUM ACETATE ORAL TABLET 667 MG 0.36813 01/03/2014 0.30825 11/16/2018 CALCIUM ACETATE/ALUMINUM SULFATE TOPICAL POWDER IN PACKET 0.72740 01/25/2013 (EA) 952-1347MG ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.01799 01/25/2013 500 MG/5ML CALCIUM CARBONATE ORAL TABLET 500(1250) 0.01434 06/21/2013 0.01434 08/21/2015 CALCIUM CARBONATE ORAL TABLET 600 MG 0.02144 07/26/2013 0.02144 08/21/2015 CALCIUM CARBONATE ORAL TABLET,CHEWABLE 200(500)MG 0.01357 02/06/2015 0.01357 08/21/2015 CALCIUM CARBONATE ORAL TABLET,CHEWABLE 300MG(750) 0.02554 02/27/2015 0.02554 08/21/2015 CALCIUM CARBONATE ORAL TABLET,CHEWABLE 400(1000) 0.04240 08/21/2015 0.02986 08/17/2018 CALCIUM CARBONATE ORAL TABLET,CHEWABLE 500(1250) 0.03420 08/12/2014 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL 0.04855 08/12/2014 CAPSULE 600 MG-400 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.01032 01/25/2013 0.01032 08/21/2015 250 MG-125 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.02170 08/12/2014 0.02170 08/21/2015 250 MG-125 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.01599 08/12/2014 0.01599 08/21/2015 500 MG-200 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.03507 08/12/2014 0.03507 08/21/2015 500 MG-400 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.01899 01/25/2013 0.01899 08/21/2015 600 MG-200 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.01956 02/27/2015 0.01956 08/21/2015 600 MG-400 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.05873 02/13/2015 0.05873 08/21/2015 600 MG-800 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL 0.03420 08/21/2015 TABLET,CHEWABLE 500 MG-100 CALCIUM CARBONATE/ERGOCALCIFEROL (VITAMIN D2) TABLET 250 MG- 0.02170 08/12/2014 0.02170 08/21/2015 125 CALCIUM CARBONATE/ ORAL 0.01352 08/21/2015 TABLET,CHEWABLE 675-135 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CALCIUM CHLORIDE INTRAVENOUS SYRINGE (ML) 100 MG/ML 0.47124 08/12/2014 0.47124 08/21/2015 CALCIUM CHLORIDE INTRAVENOUS VIAL (ML) 100 MG/ML 0.17500 01/25/2013 CALCIUM CITRATE ORAL TABLET 200(950)MG 0.03070 08/12/2014 0.03070 08/21/2015 CALCIUM CITRATE ORAL TABLET 250 MG 0.05565 01/25/2013 CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.04005 08/12/2014 200MG-6.25 CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.05724 08/12/2014 0.05724 08/21/2015 315MG-5MCG CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.04615 11/21/2014 0.04615 08/21/2015 315MG-6.25 CALCIUM POLYCARBOPHIL ORAL TABLET 625 MG 0.06417 08/12/2014 0.06417 08/21/2015 CANDESARTAN CILEXETIL ORAL TABLET 16 MG 1.34663 05/17/2019 1.17100 11/15/2019 CANDESARTAN CILEXETIL ORAL TABLET 32 MG 1.54000 04/27/2018 1.06144 09/20/2019 CANDESARTAN CILEXETIL ORAL TABLET 4 MG 1.45322 11/15/2019 1.20000 02/21/2020 CANDESARTAN CILEXETIL ORAL TABLET 8 MG 1.45333 08/17/2018 1.25400 08/16/2019 CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE ORAL TABLET 16- 1.87708 11/07/2014 1.87708 08/21/2015 12.5MG CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE ORAL TABLET 32- 2.91948 01/25/2013 2.91948 08/21/2015 12.5MG CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE ORAL TABLET 3.15984 08/12/2014 3.15984 08/21/2015 32MG-25MG CAPECITABINE ORAL TABLET 150 MG 8.21479 08/21/2015 0.50000 10/23/2020 CAPECITABINE ORAL TABLET 500 MG 3.86667 11/15/2019 0.63775 10/23/2020 CAPSAICIN TOPICAL CREAM (GRAM) 0.025 % 0.06709 04/05/2013 0.06709 08/21/2015 CAPSAICIN TOPICAL CREAM (GRAM) 0.075 % 0.09338 08/12/2014 0.09338 08/21/2015 CAPSAICIN/METHYL SALICYLATE/MENTHOL TOPICAL LOTION (GRAM) 2.36327 01/25/2013 0.002%-20% CAPTOPRIL MISCELLANEOUS POWDER (GRAM) 100 % 56.85764 02/22/2013 56.85764 08/21/2015 CAPTOPRIL ORAL TABLET 100 MG 1.12780 05/09/2014 1.12780 08/21/2015 CAPTOPRIL ORAL TABLET 12.5 MG 0.46645 08/15/2014 0.46645 08/21/2015 CAPTOPRIL ORAL TABLET 25 MG 0.75000 08/25/2017 0.57400 05/21/2021 CAPTOPRIL ORAL TABLET 50 MG 0.99970 02/22/2019 0.77990 11/15/2019 CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-15MG 0.33384 12/27/2013 0.33384 08/21/2015 CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-25MG 1.10214 05/30/2014 1.10214 08/21/2015 CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG-15MG 1.89163 05/30/2014 1.89163 08/21/2015 CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG-25MG 1.89163 05/30/2014 1.89163 08/21/2015 ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 1.26909 06/06/2019 1.25017 03/20/2020 12HR 100 MG CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 1.25113 08/21/2015 12HR 200 MG CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 1.45789 05/22/2020 1.20983 02/19/2021 12HR 200 MG CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 1.32201 08/28/2020 1.27775 05/21/2021 12HR 300 MG CARBAMAZEPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 0.11631 07/18/2014 0.11631 01/01/2020 MG/5ML CARBAMAZEPINE ORAL TABLET 200 MG 0.32256 03/02/2020 0.17940 07/17/2020 CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 100 MG 0.62636 08/28/2020 0.55350 11/20/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 200 MG 0.88980 04/17/2020 1.06740 06/22/2020 CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 400 MG 1.93680 09/26/2020 1.69920 02/19/2021 CARBAMAZEPINE ORAL TABLET,CHEWABLE 100 MG 0.28300 02/24/2019 0.23768 09/20/2019 CARBAMIDE PEROXIDE OTIC DROPS 6.5 % 0.11614 08/21/2015 0.06800 08/25/2017 CARBIDOPA ORAL TABLET 25 MG 3.86500 01/25/2019 1.91063 12/25/2020 CARBIDOPA/LEVODOPA ORAL TABLET 10MG-100MG 0.09610 09/22/2017 0.06610 05/22/2020 CARBIDOPA/LEVODOPA ORAL TABLET 25MG-100MG 0.08025 03/16/2018 0.06590 07/17/2020 CARBIDOPA/LEVODOPA ORAL TABLET 25MG-250MG 0.12267 03/16/2018 0.09850 05/22/2020 CARBIDOPA/LEVODOPA ORAL TABLET, EXTENDED RELEASE 25MG- 0.18200 08/17/2018 0.11510 10/19/2018 100MG CARBIDOPA/LEVODOPA ORAL TABLET, EXTENDED RELEASE 50MG- 0.42000 09/11/2019 0.31670 05/22/2020 200MG CARBIDOPA/LEVODOPA ORAL TABLET,DISINTEGRATING 10MG-100MG 0.77305 01/25/2013 0.77305 08/21/2015 CARBIDOPA/LEVODOPA ORAL TABLET,DISINTEGRATING 25MG-100MG 0.94146 04/10/2015 0.94146 08/21/2015 CARBIDOPA/LEVODOPA ORAL TABLET,DISINTEGRATING 25MG-250MG 1.10100 01/25/2013 1.10100 08/21/2015 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 12.5-50 MG 2.13334 08/21/2015 2.13334 04/22/2016 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 18.75-75MG 2.62496 08/12/2014 2.62496 04/22/2016 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 25-100-200 1.37907 03/03/2017 0.83370 09/22/2017 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 31.25-125 2.62481 04/22/2016 1.13280 02/22/2019 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 37.5-150MG 0.84205 11/15/2019 0.62336 02/21/2020 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 50-200-200 0.83370 09/22/2017 0.54950 05/17/2019 CARBINOXAMINE MALEATE ORAL LIQUID (ML) 4 MG/5 ML 0.09112 03/15/2013 0.09112 08/21/2015 CARBINOXAMINE MALEATE ORAL TABLET 4 MG 0.49602 05/10/2013 0.49602 08/21/2015 CARBOXYMETHYLCELLULOSE SODIUM OPHTHALMIC DROPPERETTE, 0.32162 03/29/2013 GEL 1 % CARBOXYMETHYLCELLULOSE SODIUM OPHTHALMIC DROPPERETTE, 0.20828 08/12/2014 0.20828 08/21/2015 SINGLE-USE DROP DISPENSER 0.5 % CARBOXYMETHYLCELLULOSE SODIUM OPHTHALMIC DROPS 0.5 % 0.33524 08/12/2014 0.33524 08/21/2015 CARISOPRODOL ORAL TABLET 250 MG 2.31410 02/08/2013 1.93208 06/16/2017 CARISOPRODOL ORAL TABLET 350 MG 0.07909 08/21/2015 0.05359 07/14/2017 CARISOPRODOL/ASPIRIN ORAL TABLET 200-325 MG 1.52430 08/12/2014 1.52430 08/21/2015 CARISOPRODOL/ASPIRIN/CODEINE PHOSPHATE ORAL TABLET 200-325- 1.94250 01/25/2013 1.94250 08/21/2015 16 CARTEOLOL HCL OPHTHALMIC DROPS 1 % 1.17210 01/25/2013 ORAL TABLET 12.5 MG 0.04968 08/21/2015 0.01920 06/16/2017 CARVEDILOL ORAL TABLET 25 MG 0.03886 08/21/2015 0.02489 11/16/2018 CARVEDILOL ORAL TABLET 3.125 MG 0.03629 08/21/2015 0.02240 10/20/2017 CARVEDILOL ORAL TABLET 6.25 MG 0.01866 10/23/2020 0.01794 04/16/2021 CARVEDILOL PHOSPHATE ORAL CAPSULE,EXTENDED RELEASE 5.63500 10/23/2020 4.65700 02/19/2021 MULTIPHASE 24HR 20 MG ORAL OIL (ML) 0.05545 01/25/2013 CEFACLOR ORAL CAPSULE 250 MG 1.39260 02/01/2013 1.39260 08/21/2015 CEFACLOR ORAL CAPSULE 500 MG 1.61040 08/12/2014 1.61040 08/21/2015 CEFACLOR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 0.68231 01/25/2013 MG/5ML West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CEFACLOR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 1.36453 01/25/2013 1.36453 08/21/2015 MG/5ML CEFACLOR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 375 2.04680 01/25/2013 MG/5ML CEFACLOR ORAL TABLET, EXTENDED RELEASE 12 HR 500 MG 3.48600 01/25/2013 3.48600 08/21/2015 CEFADROXIL ORAL CAPSULE 500 MG 0.16550 03/16/2018 0.12410 02/22/2019 CEFADROXIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 0.36218 02/06/2015 0.20630 11/15/2019 MG/5ML CEFADROXIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 500 0.50605 02/06/2015 0.24250 11/16/2018 MG/5ML CEFADROXIL ORAL TABLET 1 G 2.32518 01/25/2013 CEFAZOLIN SODIUM INJECTION VIAL (EA) 1 G 5.80360 09/26/2014 5.80360 08/21/2015 CEFAZOLIN SODIUM INJECTION VIAL (EA) 10 G 6.55920 09/26/2014 6.55920 08/21/2015 CEFAZOLIN SODIUM INJECTION VIAL (EA) 500 MG 1.03662 01/25/2013 CEFAZOLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 4.26300 01/25/2013 G CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS 0.20427 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS 17.93574 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV 0.07526 07/18/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML CEFDINIR ORAL CAPSULE 300 MG 0.44750 11/05/2020 0.42058 05/21/2021 CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML 0.11329 05/22/2020 0.10693 09/25/2020 CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML 0.14058 12/23/2020 0.13050 04/16/2021 CEFDITOREN PIVOXIL ORAL TABLET 200 MG 10.31835 11/28/2014 10.31835 08/21/2015 CEFDITOREN PIVOXIL ORAL TABLET 400 MG 10.31835 11/28/2014 10.31835 08/21/2015 CEFEPIME HCL IN DEXTROSE 5 % IN INTRAVENOUS 0.55476 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFEPIME HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 14.59910 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFEPIME HCL IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV 1.09878 11/07/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML CEFEPIME HCL IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV 0.88078 07/25/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2 G/100 ML CEFEPIME HCL INJECTION VIAL (EA) 1 G 4.04600 08/16/2019 3.99900 03/20/2020 CEFEPIME HCL INJECTION VIAL (EA) 2 G 3.93300 03/02/2018 6.00500 06/20/2018 CEFIXIME ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100 MG/5ML 3.56300 05/01/2015 3.56300 08/21/2015 CEFIXIME ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 MG/5ML 7.12610 05/01/2015 7.12610 08/21/2015 CEFOTAXIME SODIUM INJECTION VIAL (EA) 1 G 2.12524 09/06/2013 2.12524 08/21/2015 CEFOTAXIME SODIUM INJECTION VIAL (EA) 10 G 18.35400 01/25/2013 CEFOTAXIME SODIUM INJECTION VIAL (EA) 2 G 4.12516 08/12/2014 4.12516 08/21/2015 CEFOTAXIME SODIUM INJECTION VIAL (EA) 500 MG 1.26000 10/04/2013 1.26000 08/21/2015 CEFOTETAN DISODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS 12.81880 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFOTETAN DISODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS 17.59800 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFOTETAN DISODIUM INJECTION VIAL (EA) 1 G 9.55920 01/25/2013 CEFOTETAN DISODIUM INJECTION VIAL (EA) 2 G 19.91500 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CEFOTETAN DISODIUM INTRAVENOUS VIAL (EA) 10 G 98.60200 01/25/2013 CEFOXITIN SODIUM INTRAVENOUS VIAL (EA) 1 G 4.45484 03/20/2015 4.45484 08/21/2015 CEFOXITIN SODIUM INTRAVENOUS VIAL (EA) 10 G 32.13068 01/25/2013 CEFOXITIN SODIUM INTRAVENOUS VIAL (EA) 2 G 7.94256 03/20/2015 7.94256 08/21/2015 CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS 0.45037 04/19/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS 0.92383 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFPODOXIME PROXETIL ORAL SUSPENSION, RECONSTITUTED, ORAL 1.14772 03/29/2013 (ML) 100 MG/5ML CEFPODOXIME PROXETIL ORAL SUSPENSION, RECONSTITUTED, ORAL 0.52444 08/12/2014 (ML) 50 MG/5 ML CEFPODOXIME PROXETIL ORAL TABLET 100 MG 3.61735 06/16/2017 1.77000 09/25/2020 CEFPODOXIME PROXETIL ORAL TABLET 200 MG 2.46500 10/19/2018 2.20000 05/22/2020 CEFPROZIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 0.29385 08/22/2014 0.14400 02/22/2019 MG/5ML CEFPROZIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 0.23730 09/22/2017 0.21875 11/16/2018 MG/5ML CEFPROZIL ORAL TABLET 250 MG 0.98670 08/21/2015 0.65800 06/16/2017 CEFPROZIL ORAL TABLET 500 MG 1.19535 06/16/2017 1.07200 02/21/2020 CEFTAZIDIME IN DEXTROSE 5% AND WATER INTRAVENOUS 9.03846 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFTAZIDIME IN DEXTROSE 5% AND WATER INTRAVENOUS 13.01154 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFTAZIDIME INJECTION VIAL (EA) 1 G 4.82560 11/08/2013 4.82560 08/21/2015 CEFTAZIDIME INJECTION VIAL (EA) 2 G 10.56045 11/01/2013 10.56045 08/21/2015 CEFTAZIDIME INJECTION VIAL (EA) 6 G 24.35825 08/12/2014 24.35825 08/21/2015 CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS 0.54291 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS 0.94697 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV 0.23839 07/18/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV 0.56464 04/04/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2 G/50 ML CEFTRIAXONE SODIUM INJECTION VIAL (EA) 1 G 1.40413 03/02/2018 0.92998 08/16/2019 CEFTRIAXONE SODIUM INJECTION VIAL (EA) 10 G 16.22880 08/21/2015 14.68000 08/17/2018 CEFTRIAXONE SODIUM INJECTION VIAL (EA) 2 G 2.30600 03/20/2020 0.21605 05/22/2020 CEFTRIAXONE SODIUM INJECTION VIAL (EA) 250 MG 0.63100 08/17/2018 0.12600 05/17/2019 CEFTRIAXONE SODIUM INJECTION VIAL (EA) 500 MG 1.32048 08/21/2015 0.85100 08/25/2017 CEFTRIAXONE SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 3.51120 02/15/2013 1 G CEFTRIAXONE SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 6.39660 01/25/2013 2 G CEFUROXIME AXETIL ORAL TABLET 250 MG 0.34339 08/16/2019 0.26250 05/22/2020 CEFUROXIME AXETIL ORAL TABLET 500 MG 0.42400 01/24/2020 0.38067 06/19/2020 CEFUROXIME SODIUM INJECTION VIAL (EA) 1.5 G 4.35422 08/12/2014 4.35422 08/21/2015 CEFUROXIME SODIUM INJECTION VIAL (EA) 750 MG 2.72428 11/14/2014 2.72428 08/21/2015 CEFUROXIME SODIUM INTRAVENOUS VIAL (EA) 1.5 G 4.35422 08/12/2014 4.35422 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CEFUROXIME SODIUM INTRAVENOUS VIAL (EA) 7.5 G 17.79645 08/12/2014 17.79645 08/21/2015 CELECOXIB ORAL CAPSULE 100 MG 0.15240 11/16/2018 0.12000 01/25/2019 CELECOXIB ORAL CAPSULE 200 MG 0.12861 05/22/2020 0.10406 01/15/2021 CELECOXIB ORAL CAPSULE 400 MG 1.25000 09/30/2016 0.71400 07/26/2019 CELECOXIB ORAL CAPSULE 50 MG 0.28033 10/20/2017 0.06583 05/17/2019 CEPHALEXIN ORAL CAPSULE 250 MG 0.07390 09/22/2017 0.06050 03/16/2018 CEPHALEXIN ORAL CAPSULE 500 MG 0.08687 12/22/2017 0.07836 03/19/2021 CEPHALEXIN ORAL CAPSULE 750 MG 6.15000 04/17/2019 5.49950 05/22/2020 CEPHALEXIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 0.14563 08/21/2015 0.09450 11/24/2017 MG/5ML CEPHALEXIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 0.08460 10/25/2019 0.06562 07/16/2021 MG/5ML CEPHALEXIN ORAL TABLET 250 MG 0.40092 01/25/2013 CEPHALEXIN ORAL TABLET 500 MG 0.80132 01/25/2013 CETIRIZINE HCL ORAL SOLUTION, ORAL 1 MG/ML 0.03306 08/21/2015 0.01500 12/21/2018 CETIRIZINE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.03306 07/07/2017 CETIRIZINE HCL ORAL TABLET 10 MG 0.04666 09/22/2017 0.03192 11/15/2019 CETIRIZINE HCL ORAL TABLET 5 MG 0.07567 08/21/2015 0.02870 11/15/2019 CETIRIZINE HCL ORAL TABLET,CHEWABLE 10 MG 1.66170 06/06/2014 1.66170 08/21/2015 CETIRIZINE HCL ORAL TABLET,CHEWABLE 5 MG 2.74179 08/21/2015 1.66166 01/25/2019 CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ORAL TABLET, EXTENDED 0.50458 01/25/2019 0.65776 03/05/2019 RELEASE 12 HR 5 MG-120MG CEVIMELINE HCL ORAL CAPSULE 30 MG 0.90460 03/20/2020 0.62670 05/21/2021 CHLORAMPHENICOL SOD SUCCINATE INTRAVENOUS VIAL (EA) 1 G 2.64689 01/25/2013 CHLORDIAZEPOXIDE HCL ORAL CAPSULE 10 MG 0.08863 08/21/2015 0.05930 12/22/2017 CHLORDIAZEPOXIDE HCL ORAL CAPSULE 25 MG 0.06297 03/02/2018 0.53060 11/17/2020 CHLORDIAZEPOXIDE HCL ORAL CAPSULE 5 MG 0.10875 08/15/2014 0.10875 08/21/2015 CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE ORAL CAPSULE 5 MG-2.5MG 0.27604 02/27/2015 0.27604 08/21/2015 CHLORHEXIDINE GLUCONATE MUCOUS MEMBRANE MOUTHWASH 0.12 0.00598 08/21/2015 0.00493 10/23/2020 % CHLOROQUINE PHOSPHATE ORAL TABLET 250 MG 0.86970 03/01/2013 0.86970 08/21/2015 CHLOROQUINE PHOSPHATE ORAL TABLET 500 MG 3.44058 08/12/2014 3.44058 08/21/2015 CHLOROTHIAZIDE ORAL TABLET 250 MG 0.15141 12/13/2013 0.15141 08/21/2015 CHLOROTHIAZIDE SODIUM INTRAVENOUS VIAL (EA) 500 MG 98.11300 04/17/2015 98.11300 08/21/2015 CHLORPHENIRAMINE MALEATE ORAL SYRUP 2 MG/5 ML 0.01798 01/25/2013 0.01798 08/21/2015 CHLORPHENIRAMINE MALEATE ORAL TABLET 4 MG 0.00634 02/06/2015 0.00634 08/21/2015 CHLORPHENIRAMINE MALEATE ORAL TABLET, EXTENDED RELEASE 12 0.34709 08/21/2015 MG CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE HCL ORAL LIQUID (ML) 0.02660 08/12/2014 4-10MG/5ML CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE 0.06860 08/12/2014 0.06860 08/21/2015 HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 2-5-15MG/5 CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE 0.04500 08/12/2014 HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 4-10-15/5 CHLORPHENIRAMINE MALEATE/PSEUDOEPHEDRINE HCL ORAL TABLET 0.05310 08/12/2014 4 MG-60 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CHLORPHENIRAMINE 0.01868 01/25/2013 0.01868 08/21/2015 MALEATE/PSEUDOEPHEDRINE/DEXTROMETHORPHAN ORAL LIQUID (ML) 1-15-5MG/5 HCL INJECTION AMPUL (ML) 25 MG/ML 18.81600 11/08/2013 CHLORPROMAZINE HCL ORAL TABLET 10 MG 2.65000 01/22/2016 1.55000 05/22/2020 CHLORPROMAZINE HCL ORAL TABLET 100 MG 5.06490 06/13/2019 3.69556 02/19/2021 CHLORPROMAZINE HCL ORAL TABLET 200 MG 6.39990 07/17/2020 5.77080 12/25/2020 CHLORPROMAZINE HCL ORAL TABLET 25 MG 2.39250 05/17/2019 1.85000 02/21/2020 CHLORPROMAZINE HCL ORAL TABLET 50 MG 2.95200 04/26/2019 2.49667 03/19/2021 CHLORPROPAMIDE TABLET 100 MG 0.84154 06/27/2014 0.84154 08/21/2015 CHLORPROPAMIDE TABLET 250 MG 0.85230 08/12/2014 CHLORTHALIDONE ORAL TABLET 25 MG 0.21557 05/22/2020 0.14890 11/20/2020 CHLORTHALIDONE ORAL TABLET 50 MG 0.35950 08/16/2019 0.24788 05/21/2021 CHLORZOXAZONE ORAL TABLET 500 MG 0.23400 04/10/2015 0.23400 08/21/2015 CHOLECALCIFEROL (VIT D3)/FOLIC ACID ORAL CAPSULE 94.38MCG-1 15.16153 05/01/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 10 MCG 0.03240 05/01/2015 0.03240 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 100 MCG 0.06993 02/08/2013 CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 1250 MCG 0.14700 09/26/2014 CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 250 MCG 0.64783 12/26/2014 0.64783 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL DROPS 125 MCG/ML 0.07303 08/12/2014 CHOLECALCIFEROL (VITAMIN D3) ORAL LIQUID (ML) 10MCG/5ML 0.02914 01/25/2013 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 10 MCG 0.01786 04/17/2015 0.01786 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 125 MCG 0.05258 05/01/2015 0.05258 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 25 MCG 0.01997 08/12/2014 0.01997 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 50 MCG 0.02861 12/05/2014 0.02861 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 75 MCG 0.05516 01/25/2013 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET,CHEWABLE 10 MCG 0.02509 01/25/2013 0.02509 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET,CHEWABLE 25 MCG 0.06098 08/12/2014 0.06098 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) SUBLINGUAL SPRAY, SUSPENSION 0.30847 01/25/2013 (ML) 25MCG/SPRY CHOLESTYRAMINE (WITH SUGAR) ORAL POWDER (GRAM) 4 G 0.17550 07/26/2019 0.14794 10/25/2019 CHOLESTYRAMINE (WITH SUGAR) ORAL POWDER IN PACKET (EA) 4 G 1.21063 02/21/2020 0.97100 10/23/2020 CHOLESTYRAMINE/ASPARTAME ORAL POWDER (GRAM) 4 G 0.23748 04/22/2019 0.19459 06/19/2020 CHOLESTYRAMINE/ASPARTAME ORAL POWDER IN PACKET (EA) 4 G 1.58483 02/22/2019 1.30321 11/15/2019 SALICYLATE/MAGNESIUM SALICYLATE ORAL LIQUID (ML) 500 0.12848 01/25/2013 MG/5ML CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR VIAL (EA) 10000 184.04000 07/12/2013 UNIT CICLOPIROX OLAMINE TOPICAL CREAM (GRAM) 0.77 % 0.14964 08/12/2014 0.10611 01/24/2020 CICLOPIROX OLAMINE TOPICAL SUSPENSION, TOPICAL (ML) 0.77 % 0.37748 01/25/2013 CICLOPIROX TOPICAL GEL (GRAM) 0.77 % 1.12739 06/16/2017 0.89877 11/15/2019 CICLOPIROX TOPICAL SHAMPOO 1 % 0.39030 05/25/2018 0.24717 11/15/2019 CICLOPIROX TOPICAL SOLUTION, NON-ORAL 8 % 1.45000 05/22/2020 1.40714 03/19/2021 CICLOPIROX/UREA/CAMPHOR/MENTHOL/EUCALYPTOL TOPICAL 266.99400 01/25/2013 SOLUTION, NON-ORAL 8 % West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CIDOFOVIR INTRAVENOUS VIAL (ML) 75 MG/ML 118.10400 08/12/2014 CILOSTAZOL ORAL TABLET 100 MG 0.11183 03/02/2018 0.08000 02/22/2019 CILOSTAZOL ORAL TABLET 50 MG 0.08083 04/17/2020 0.07725 08/28/2020 CIMETIDINE HCL ORAL SOLUTION, ORAL 300 MG/5ML 0.06283 05/17/2013 0.06283 08/21/2015 CIMETIDINE ORAL TABLET 200 MG 0.23684 08/21/2015 0.19530 06/19/2020 CIMETIDINE ORAL TABLET 300 MG 0.26286 08/21/2015 0.22900 08/25/2017 CIMETIDINE ORAL TABLET 400 MG 0.31057 08/21/2015 0.44250 08/24/2016 CIMETIDINE ORAL TABLET 800 MG 1.28479 08/21/2015 0.74363 06/16/2017 CINACALCET HCL ORAL TABLET 30 MG 5.76000 02/21/2020 CINACALCET HCL ORAL TABLET 60 MG 11.16000 02/21/2020 CINACALCET HCL ORAL TABLET 90 MG 13.00000 02/21/2020 CIPROFLOXACIN HCL OPHTHALMIC DROPS 0.3 % 0.56000 10/19/2018 2.30160 06/06/2019 CIPROFLOXACIN HCL ORAL TABLET 100 MG 10.65167 09/26/2014 CIPROFLOXACIN HCL ORAL TABLET 250 MG 0.09120 08/17/2018 0.08880 04/16/2021 CIPROFLOXACIN HCL ORAL TABLET 500 MG 0.09234 06/16/2017 0.07880 07/17/2020 CIPROFLOXACIN HCL ORAL TABLET 750 MG 0.34599 08/21/2015 0.23220 08/17/2018 CIPROFLOXACIN HCL OTIC DROPPERETTE, SINGLE-USE DROP 12.61951 08/01/2014 DISPENSER 0.2 % CIPROFLOXACIN LACTATE VIAL (ML) 200MG/20ML 0.08890 01/25/2013 CIPROFLOXACIN LACTATE VIAL (ML) 400MG/40ML 0.06320 08/12/2014 CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.01697 01/25/2013 0.01697 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 200MG/0.1L CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.01204 03/01/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 400MG/0.2L CIPROFLOXACIN ORAL SUSPENSION, MICROCAPSULE RECONSTITUTED 0.85323 08/22/2014 250 MG/5ML CIPROFLOXACIN ORAL SUSPENSION, MICROCAPSULE RECONSTITUTED 0.99890 08/22/2014 500 MG/5ML CIPROFLOXACIN/CIPROFLOXACIN HCL TABLET,EXTENDED RELEASE 7.79233 01/25/2013 7.79233 08/21/2015 MULTIPHASE 24 HR 1000 MG CIPROFLOXACIN/CIPROFLOXACIN HCL TABLET,EXTENDED RELEASE 6.85916 01/25/2013 6.85916 08/21/2015 MULTIPHASE 24 HR 500 MG CISATRACURIUM BESYLATE INTRAVENOUS VIAL (ML) 10 MG/ML 11.95425 01/16/2015 11.95425 08/21/2015 CISATRACURIUM BESYLATE INTRAVENOUS VIAL (ML) 2 MG/ML 2.36880 08/12/2014 2.36880 08/21/2015 CITALOPRAM HYDROBROMIDE ORAL SOLUTION, ORAL 10 MG/5 ML 0.24500 01/25/2019 0.20829 07/17/2020 CITALOPRAM HYDROBROMIDE ORAL TABLET 10 MG 0.02661 05/01/2015 0.02661 08/21/2015 CITALOPRAM HYDROBROMIDE ORAL TABLET 20 MG 0.03382 08/21/2015 0.02364 01/19/2018 CITALOPRAM HYDROBROMIDE ORAL TABLET 40 MG 0.04139 08/21/2015 0.02900 11/16/2018 CITRATE PHOSPHATE DEXTROS SOLN MISCELLANEOUS SOLUTION, 0.08318 01/25/2013 NON-ORAL 2.63 G/100 CITRIC ACID/SODIUM CITRATE ORAL SOLUTION, ORAL 334-500MG 0.02013 11/14/2014 0.02013 08/21/2015 CLARITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 0.36569 05/17/2013 MG/5ML CLARITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 1.14740 12/11/2017 1.22798 04/16/2018 MG/5ML CLARITHROMYCIN ORAL TABLET 250 MG 2.64794 08/21/2015 0.34333 06/16/2017 CLARITHROMYCIN ORAL TABLET 500 MG 0.45686 03/03/2017 0.40642 05/22/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CLARITHROMYCIN ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 3.50443 08/21/2015 3.18447 06/16/2017 HCL ORAL CAPSULE 150 MG 0.08641 08/21/2015 0.07460 09/21/2018 CLINDAMYCIN HCL ORAL CAPSULE 300 MG 0.19938 03/03/2017 0.19264 08/28/2020 CLINDAMYCIN HCL ORAL CAPSULE 75 MG 0.41720 01/25/2013 CLINDAMYCIN PALMITATE HCL ORAL SOLUTION, RECONSTITUTED, 0.24990 08/13/2020 0.18495 04/16/2021 ORAL 75 MG/5 ML CLINDAMYCIN PHOSPHATE INJECTION VIAL (ML) 150 MG/ML 0.35600 08/12/2014 CLINDAMYCIN PHOSPHATE TOPICAL FOAM (GRAM) 1 % 3.71476 08/21/2015 3.56290 11/15/2019 CLINDAMYCIN PHOSPHATE TOPICAL GEL (GRAM) 1 % 0.87733 05/22/2020 0.86167 07/17/2020 CLINDAMYCIN PHOSPHATE TOPICAL LOTION (ML) 1 % 0.89300 05/22/2020 0.76650 09/25/2020 CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION, NON-ORAL 1 % 0.31316 06/16/2017 0.20259 02/22/2019 CLINDAMYCIN PHOSPHATE TOPICAL SWAB, MEDICATED 1 % 0.32269 03/19/2019 0.29097 11/15/2019 CLINDAMYCIN PHOSPHATE VAGINAL CREAM WITH APPLICATOR 2 % 1.71925 08/23/2019 1.62938 08/28/2020 CLINDAMYCIN PHOSPHATE VIAL WITH THREADED PORT (ML) 300 2.99418 01/25/2013 MG/2ML CLINDAMYCIN PHOSPHATE VIAL WITH THREADED PORT (ML) 600 1.60881 01/25/2013 MG/4ML CLINDAMYCIN PHOSPHATE VIAL WITH THREADED PORT (ML) 1.51899 01/25/2013 900MG/6ML CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE TOPICAL GEL (GRAM) 1 2.44740 02/22/2019 1.52390 03/20/2020 %-5 % CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE TOPICAL GEL (GRAM) 3.16462 08/12/2014 1.13000 08/16/2019 1.2(1)%-5% CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.11749 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 300MG/50ML CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.16505 11/07/2014 0.16505 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 600MG/50ML CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.21492 10/24/2014 0.21492 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 900MG/50ML CLOBAZAM ORAL TABLET 20 MG 0.80000 04/17/2020 CLOBETASOL PROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.63767 05/22/2020 0.62635 08/28/2020 CLOBETASOL PROPIONATE TOPICAL FOAM (GRAM) 0.05 % 1.24600 03/20/2020 1.03090 05/22/2020 CLOBETASOL PROPIONATE TOPICAL GEL (GRAM) 0.05 % 2.30000 05/25/2018 1.25150 08/16/2019 CLOBETASOL PROPIONATE TOPICAL LOTION (ML) 0.05 % 1.57000 12/21/2018 0.67797 11/15/2019 CLOBETASOL PROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 0.39284 01/24/2020 0.20242 06/19/2020 CLOBETASOL PROPIONATE TOPICAL SHAMPOO 0.05 % 1.53000 05/26/2018 1.47407 11/15/2019 CLOBETASOL PROPIONATE TOPICAL SOLUTION, NON-ORAL 0.05 % 0.63510 10/25/2019 0.51260 06/19/2020 CLOBETASOL PROPIONATE TOPICAL SPRAY, NON-AEROSOL (ML) 0.05 % 4.33264 03/06/2015 0.42972 06/18/2021 CLOBETASOL PROPIONATE/EMOLLIENT TOPICAL CREAM (GRAM) 1.20000 12/20/2019 0.66483 03/20/2020 0.05 % CLOBETASOL PROPIONATE/EMOLLIENT BASE TOPICAL FOAM (GRAM) 3.64100 08/12/2014 3.64100 08/21/2015 0.05 % CLOCORTOLONE PIVALATE TOPICAL CREAM (GRAM) 0.1 % 5.01620 03/07/2014 CLOMIPHENE CITRATE ORAL TABLET 50 MG 1.01394 08/21/2015 0.58467 09/22/2017 CLOMIPRAMINE HCL ORAL CAPSULE 25 MG 2.85000 02/21/2020 2.00045 03/19/2021 CLOMIPRAMINE HCL ORAL CAPSULE 50 MG 3.40000 01/25/2019 1.98650 10/25/2019 CLOMIPRAMINE HCL ORAL CAPSULE 75 MG 2.72010 02/22/2019 1.58230 11/15/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CLONAZEPAM ORAL TABLET 0.5 MG 0.01635 12/12/2014 0.01635 08/21/2015 CLONAZEPAM ORAL TABLET 1 MG 0.02613 08/21/2015 0.01922 10/23/2020 CLONAZEPAM ORAL TABLET 2 MG 0.04039 08/21/2015 0.02645 11/16/2018 CLONAZEPAM ORAL TABLET,DISINTEGRATING 0.125 MG 0.72847 09/19/2014 0.70200 11/15/2019 CLONAZEPAM ORAL TABLET,DISINTEGRATING 0.25 MG 0.62800 09/22/2017 0.51183 11/15/2019 CLONAZEPAM ORAL TABLET,DISINTEGRATING 0.5 MG 0.51100 11/15/2019 0.54183 03/02/2020 CLONAZEPAM ORAL TABLET,DISINTEGRATING 1 MG 0.74870 03/18/2020 0.53817 04/16/2021 CLONAZEPAM ORAL TABLET,DISINTEGRATING 2 MG 1.09330 01/25/2013 CLONIDINE HCL ORAL TABLET 0.1 MG 0.01272 09/21/2018 0.02400 03/15/2021 CLONIDINE HCL ORAL TABLET 0.2 MG 0.05338 08/21/2015 0.02868 08/25/2017 CLONIDINE HCL ORAL TABLET 0.3 MG 0.04301 08/21/2015 0.02763 04/27/2018 CLONIDINE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 0.1 MG 0.88817 07/26/2019 0.69150 05/22/2020 CLONIDINE HCL/PF EPIDURAL VIAL (ML) 1000MCG/10 2.29944 08/12/2014 CLONIDINE HCL/PF EPIDURAL VIAL (ML) 5000MCG/10 10.09700 08/12/2014 10.09700 08/21/2015 CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 8.79250 11/15/2019 4.99750 05/22/2020 0.1MG/24HR CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 14.26950 11/15/2019 12.69000 12/20/2019 0.2MG/24HR CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 21.24500 11/15/2019 18.23000 12/20/2019 0.3MG/24HR CLOPIDOGREL BISULFATE ORAL TABLET 300 MG 14.71960 04/17/2015 14.71960 08/21/2015 CLOPIDOGREL BISULFATE ORAL TABLET 75 MG 0.05800 06/16/2017 0.05198 10/25/2019 CLORAZEPATE DIPOTASSIUM ORAL TABLET 15 MG 0.26100 08/21/2015 2.39650 09/19/2016 CLORAZEPATE DIPOTASSIUM ORAL TABLET 3.75 MG 0.19698 08/15/2014 0.19698 08/21/2015 CLORAZEPATE DIPOTASSIUM ORAL TABLET 7.5 MG 0.30128 08/01/2014 0.30128 08/21/2015 MUCOUS MEMBRANE TROCHE 10 MG 0.97392 03/27/2015 CLOTRIMAZOLE TOPICAL CREAM (GRAM) 1 % 0.10907 08/21/2015 0.07533 06/19/2020 CLOTRIMAZOLE TOPICAL SOLUTION, NON-ORAL 1 % 0.32656 01/25/2013 CLOTRIMAZOLE VAGINAL CREAM WITH APPLICATOR 1 % 0.07865 03/01/2013 0.07865 08/21/2015 CLOTRIMAZOLE VAGINAL CREAM WITH APPLICATOR 2 % 0.32760 08/12/2014 0.32760 08/21/2015 CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE TOPICAL CREAM 0.20951 02/22/2019 0.19625 05/22/2020 (GRAM) 1 %-0.05 % CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE TOPICAL LOTION 3.46640 05/31/2013 (ML) 1 %-0.05 % CLOZAPINE ORAL TABLET 100 MG 0.55898 09/22/2020 0.50038 05/21/2021 CLOZAPINE ORAL TABLET 200 MG 1.33800 09/25/2020 1.19690 07/16/2021 CLOZAPINE ORAL TABLET 25 MG 0.28170 01/06/2020 0.18130 05/22/2020 CLOZAPINE ORAL TABLET 50 MG 0.46890 06/19/2020 0.45830 08/28/2020 CLOZAPINE ORAL TABLET,DISINTEGRATING 100 MG 4.61480 08/17/2018 4.51730 08/16/2019 CLOZAPINE ORAL TABLET,DISINTEGRATING 12.5 MG 1.55925 01/25/2013 CLOZAPINE ORAL TABLET,DISINTEGRATING 25 MG 2.09823 01/25/2013 COAL TAR TOPICAL SHAMPOO 1 % 0.03020 08/12/2014 COCAINE HCL SOLUTION, NON-ORAL 4 % 15.19980 01/25/2013 CODEINE PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE ORAL CAPSULE 1.89262 08/21/2015 1.23660 09/22/2017 30-50-325 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CODEINE PHOSPHATE/GUAIFENESIN ORAL LIQUID (ML) 10-100MG/5 0.05079 08/21/2015 0.02594 08/25/2017 CODEINE PHOSPHATE/GUAIFENESIN ORAL LIQUID (ML) 6.3-100/5 0.03518 08/12/2014 CODEINE PHOSPHATE/GUAIFENESIN ORAL LIQUID (ML) 7.5-225/5 0.04970 08/12/2014 CODEINE SULFATE ORAL TABLET 15 MG 0.36736 03/01/2013 CODEINE SULFATE ORAL TABLET 30 MG 0.44059 09/19/2014 0.44059 08/21/2015 CODEINE SULFATE ORAL TABLET 60 MG 0.79681 09/19/2014 0.79681 08/21/2015 COLCHICINE ORAL CAPSULE 0.6 MG 4.16383 05/17/2019 3.83870 07/26/2019 COLCHICINE ORAL TABLET 0.6 MG 2.97767 09/25/2020 2.97767 01/01/2021 COLESTIPOL HCL ORAL GRANULES (GRAM) 5 G 0.20871 01/25/2013 COLESTIPOL HCL ORAL PACKET (EA) 5 G 2.75100 01/16/2015 COLESTIPOL HCL ORAL TABLET 1 G 0.57208 05/22/2020 0.62492 03/25/2021 COLISTIN (AS COLISTIMETHATE SODIUM) INJECTION VIAL (EA) 150 MG 22.52000 10/25/2019 16.54000 03/19/2021 CORTISONE ACETATE TABLET 25 MG 3.04785 02/20/2015 3.04785 08/21/2015 COSYNTROPIN INJECTION VIAL (EA) 0.25 MG 64.39973 04/19/2013 64.39973 08/21/2015 COSYNTROPIN VIAL (ML) 0.25 MG/ML 151.55280 01/25/2013 CROMOLYN SODIUM INHALATION AMPUL FOR NEBULIZATION (ML) 20 1.16380 10/03/2014 MG/2 ML CROMOLYN SODIUM NASAL AEROSOL, SPRAY WITH PUMP (ML) 5.2 MG 0.33554 01/25/2013 0.33554 08/21/2015 CROMOLYN SODIUM OPHTHALMIC DROPS 4 % 0.46600 09/30/2016 0.73652 05/15/2021 CROMOLYN SODIUM ORAL CONCENTRATE, ORAL 20 MG/ML 0.87906 08/21/2015 0.25000 03/15/2019 CUPRIC CHLORIDE INTRAVENOUS VIAL (ML) 0.4 MG/ML 0.15460 08/12/2014 (VITAMIN B-12) ORAL TABLET 100 MCG 0.01365 02/13/2015 0.01365 08/21/2015 CYANOCOBALAMIN (VITAMIN B-12) ORAL TABLET 500 MCG 0.02101 02/13/2015 0.02101 08/21/2015 CYANOCOBALAMIN (VITAMIN B-12) ORAL TABLET, EXTENDED RELEASE 0.03872 08/12/2014 0.03872 08/21/2015 1000 MCG CYANOCOBALAMIN (VITAMIN B-12) SUBLINGUAL TABLET, SUBLINGUAL 0.05332 08/12/2014 0.05332 08/21/2015 1000 MCG CYANOCOBALAMIN (VITAMIN B-12) SUBLINGUAL TABLET, SUBLINGUAL 0.10737 03/08/2013 5000 MCG CYANOCOBALAMIN/FOLIC ACID ORAL TABLET 0.5 MG-1MG 0.12600 01/25/2013 CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE ORAL TABLET 2-2.5-25MG 0.43177 03/20/2015 0.43177 08/21/2015 CYANOCOBALAMIN/LEVOMEFOLATE CALCIUM/PYRIDOXINE/RIBOFLAVIN 2.02075 02/20/2015 2.02075 08/21/2015 ORAL TABLET 1-6-50-5MG CYANOCOBALAMIN/LEVOMEFOLATE CALCIUM/VIT B6 ORAL TABLET 2- 0.89950 07/18/2014 1.13-25 CYCLOBENZAPRINE HCL ORAL TABLET 10 MG 0.02680 08/21/2015 0.01476 11/16/2018 CYCLOBENZAPRINE HCL ORAL TABLET 5 MG 0.02130 01/24/2020 0.01860 04/16/2021 CYCLOBENZAPRINE HCL ORAL TABLET 7.5 MG 1.79990 05/17/2019 1.36560 02/19/2021 CYCLOPENTOLATE HCL OPHTHALMIC DROPS 1 % 1.65266 05/10/2013 1.65266 08/21/2015 CYCLOPENTOLATE HCL OPHTHALMIC DROPS 2 % 3.33840 02/08/2013 INTRAVENOUS VIAL (EA) 1 G 432.93460 12/12/2014 CYCLOPHOSPHAMIDE INTRAVENOUS VIAL (EA) 2 G 1063.88300 12/12/2014 1063.88300 08/21/2015 CYCLOPHOSPHAMIDE INTRAVENOUS VIAL (EA) 500 MG 266.22500 12/12/2014 266.22500 08/21/2015 CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG 8.29164 09/05/2014 5.41000 09/21/2018 CYCLOSPORINE ORAL CAPSULE 100 MG 8.83300 07/08/2020 6.95353 12/25/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CYCLOSPORINE ORAL CAPSULE 25 MG 3.39817 09/27/2018 1.82000 01/25/2019 CYCLOSPORINE, MODIFIED ORAL CAPSULE 100 MG 2.20106 02/27/2015 1.21667 03/03/2017 CYCLOSPORINE, MODIFIED ORAL CAPSULE 25 MG 0.51042 05/20/2016 0.23923 03/03/2017 CYCLOSPORINE, MODIFIED ORAL CAPSULE 50 MG 1.20163 07/25/2014 CYCLOSPORINE, MODIFIED ORAL SOLUTION, ORAL 100 MG/ML 2.00000 09/22/2017 1.76740 02/22/2019 CYPROHEPTADINE HCL ORAL SYRUP 2 MG/5 ML 0.06816 03/02/2018 0.05256 08/28/2020 CYPROHEPTADINE HCL ORAL TABLET 4 MG 0.14405 11/15/2019 0.10337 05/21/2021 CYTARABINE INJECTION VIAL (ML) 20 MG/ML 0.40080 08/12/2014 0.40080 08/21/2015 CYTARABINE/PF INJECTION VIAL (ML) 100 MG/5ML 1.97106 01/25/2013 1.97106 08/21/2015 CYTARABINE/PF INJECTION VIAL (ML) 2 G/20 ML 0.82997 08/12/2014 0.82997 08/21/2015 CYTARABINE/PF INJECTION VIAL (ML) 20 MG/ML 0.76440 01/16/2015 0.76440 08/21/2015 DACARBAZINE INTRAVENOUS VIAL (EA) 100 MG 7.93800 01/25/2013 DANAZOL ORAL CAPSULE 100 MG 3.38527 02/13/2015 DANAZOL ORAL CAPSULE 200 MG 4.80198 03/20/2015 4.80198 08/21/2015 DANAZOL ORAL CAPSULE 50 MG 2.25628 02/13/2015 DANTROLENE SODIUM INTRAVENOUS VIAL (EA) 20 MG 68.04000 01/25/2013 DANTROLENE SODIUM ORAL CAPSULE 100 MG 1.51750 02/08/2013 0.82590 03/20/2020 DANTROLENE SODIUM ORAL CAPSULE 25 MG 0.60000 08/30/2018 0.35000 11/16/2018 DANTROLENE SODIUM ORAL CAPSULE 50 MG 1.21009 03/22/2013 0.63900 05/25/2018 DAPSONE ORAL TABLET 100 MG 1.25033 01/25/2019 1.17600 03/20/2020 DARIFENACIN HYDROBROMIDE ORAL TABLET, EXTENDED RELEASE 24 2.60744 11/15/2019 2.41867 02/21/2020 HR 7.5 MG DAUNORUBICIN HCL INTRAVENOUS VIAL (ML) 5 MG/ML 18.76077 08/12/2014 18.76077 08/21/2015 DECITABINE INTRAVENOUS VIAL (EA) 50 MG 1375.39150 12/12/2014 1375.39150 08/21/2015 MESYLATE INJECTION VIAL (EA) 2 G 26.33481 01/25/2013 26.33481 08/21/2015 DEMECLOCYCLINE HCL ORAL TABLET 150 MG 2.95730 03/16/2018 2.71000 11/16/2018 DEMECLOCYCLINE HCL ORAL TABLET 300 MG 7.13944 02/27/2015 7.13944 08/21/2015 DESIPRAMINE HCL ORAL TABLET 10 MG 0.71980 05/17/2019 0.57533 11/15/2019 DESIPRAMINE HCL ORAL TABLET 100 MG 2.97528 08/21/2015 1.78620 03/20/2020 DESIPRAMINE HCL ORAL TABLET 150 MG 4.38839 08/12/2014 2.86792 10/23/2020 DESIPRAMINE HCL ORAL TABLET 25 MG 0.96739 08/21/2015 0.42950 01/24/2020 DESIPRAMINE HCL ORAL TABLET 50 MG 1.31850 05/25/2018 1.28040 10/23/2020 DESIPRAMINE HCL ORAL TABLET 75 MG 2.22992 08/12/2014 1.19400 09/22/2017 DESLORATADINE ORAL TABLET 5 MG 0.33544 11/24/2017 0.25470 10/25/2019 DESLORATADINE ORAL TABLET,DISINTEGRATING 2.5 MG 10.07649 01/24/2014 10.07649 08/21/2015 DESLORATADINE ORAL TABLET,DISINTEGRATING 5 MG 4.07750 01/25/2013 4.07750 08/21/2015 DESMOPRESSIN ACETATE (NON-REFRIGERATED) NASAL AEROSOL, 13.10000 02/21/2020 10.55833 07/16/2021 SPRAY WITH PUMP (ML) 10/SPRAY DESMOPRESSIN ACETATE INJECTION AMPUL (ML) 4 MCG/ML 16.22800 08/30/2013 DESMOPRESSIN ACETATE INJECTION VIAL (ML) 4 MCG/ML 8.62810 05/16/2014 26.82700 05/18/2021 DESMOPRESSIN ACETATE NASAL AEROSOL, SPRAY WITH PUMP (ML) 28.62300 02/06/2015 10/SPRAY DESMOPRESSIN ACETATE NASAL SOLUTION, NON-ORAL 0.1 MG/ML 25.31760 03/08/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DESMOPRESSIN ACETATE ORAL TABLET 0.1 MG 0.41720 11/15/2019 0.23400 06/19/2020 DESMOPRESSIN ACETATE ORAL TABLET 0.2 MG 0.50930 10/25/2019 0.44210 03/20/2020 DESOGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.15-0.03 0.21696 03/02/2018 0.10127 03/20/2020 DESOGESTREL-ETHINYL ESTRADIOL ORAL TABLET 7 DAYS X 3 0.81931 08/21/2015 0.52119 06/16/2017 DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL ORAL 0.37988 03/02/2018 0.33000 04/16/2021 TABLET 21-5 (28) DESONIDE TOPICAL CREAM (GRAM) 0.05 % 0.91650 03/20/2020 0.77367 04/16/2021 DESONIDE TOPICAL LOTION (ML) 0.05 % 1.83560 12/05/2014 1.66017 11/15/2019 DESONIDE TOPICAL OINTMENT (GRAM) 0.05 % 1.28900 08/16/2019 0.70000 10/25/2019 DESOXIMETASONE TOPICAL CREAM (GRAM) 0.05 % 3.19548 02/07/2014 DESOXIMETASONE TOPICAL CREAM (GRAM) 0.25 % 0.73085 06/16/2017 0.57933 03/20/2020 DESOXIMETASONE TOPICAL GEL (GRAM) 0.05 % 2.73169 01/25/2013 DESOXIMETASONE TOPICAL OINTMENT (GRAM) 0.05 % 5.41981 08/21/2015 2.58526 06/18/2021 DESOXIMETASONE TOPICAL OINTMENT (GRAM) 0.25 % 3.72602 06/16/2017 0.79000 12/20/2019 DESVENLAFAXINE FUMARATE TABLET, EXTENDED RELEASE 24 HR 100 4.64370 04/04/2014 MG DESVENLAFAXINE FUMARATE TABLET, EXTENDED RELEASE 24 HR 50 4.64370 04/04/2014 MG DESVENLAFAXINE SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 0.77253 02/06/2020 0.64700 02/19/2021 HR 100 MG DESVENLAFAXINE SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 0.82000 04/27/2018 0.76900 08/16/2019 HR 25 MG DESVENLAFAXINE SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 0.71833 05/17/2019 0.58611 05/21/2021 HR 50 MG ORAL ELIXIR 0.5 MG/5ML 0.14107 04/21/2017 0.06692 09/22/2017 DEXAMETHASONE ORAL SOLUTION, ORAL 0.5 MG/5ML 0.03446 08/22/2014 DEXAMETHASONE ORAL TABLET 1.5 MG 0.09841 02/07/2014 0.09841 08/21/2015 DEXAMETHASONE ORAL TABLET 4 MG 0.34200 04/06/2018 0.93000 05/28/2019 DEXAMETHASONE SODIUM PHOSPHATE INJECTION VIAL (ML) 10 MG/ML 0.80490 08/12/2014 0.80490 08/21/2015 DEXAMETHASONE SODIUM PHOSPHATE INJECTION VIAL (ML) 4 MG/ML 0.28517 08/12/2014 0.28517 08/21/2015 DEXAMETHASONE SODIUM PHOSPHATE OPHTHALMIC DROPS 0.1 % 3.31265 08/21/2015 9.46200 04/16/2018 DEXAMETHASONE SODIUM PHOSPHATE/PF INJECTION VIAL (ML) 10 6.35376 01/25/2013 MG/ML DEXCHLORPHENIRAMINE 0.08050 08/12/2014 MALEATE/PSEUDOEPHEDRINE/CHLOPHEDIANOL ORAL LIQUID (ML) 1-30- 12.5 DEXMETHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 6.50059 03/27/2015 5.84742 12/02/2016 BIPHASIC 50-50 10 MG DEXMETHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 5.46315 03/27/2015 BIPHASIC 50-50 5 MG DEXMETHYLPHENIDATE HCL ORAL TABLET 10 MG 0.41200 08/16/2019 0.39990 10/25/2019 DEXMETHYLPHENIDATE HCL ORAL TABLET 2.5 MG 0.47427 12/02/2016 0.19260 09/22/2017 DEXMETHYLPHENIDATE HCL ORAL TABLET 5 MG 0.31590 11/15/2019 0.20000 01/24/2020 HCL INTRAVENOUS VIAL (EA) 250 MG 165.25050 01/16/2015 DEXRAZOXANE HCL INTRAVENOUS VIAL (EA) 500 MG 286.43625 01/16/2015 DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 1.42000 01/23/2020 1.60104 07/09/2020 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 10 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 1.69990 05/22/2020 1.60113 08/28/2020 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 15 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.70200 07/17/2020 0.89428 01/05/2021 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 20 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 1.89020 11/15/2019 1.89020 01/22/2020 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 25 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 1.51574 11/15/2019 1.51574 01/22/2020 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 30 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 2.02485 03/20/2020 0.81560 11/20/2020 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 5 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.33058 11/15/2019 0.20740 07/16/2021 ASPARTATE ORAL TABLET 10 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.23110 09/22/2017 0.52690 01/08/2018 ASPARTATE ORAL TABLET 12.5 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.37100 09/20/2019 0.33810 10/23/2020 ASPARTATE ORAL TABLET 15 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.30766 05/21/2021 0.29148 07/16/2021 ASPARTATE ORAL TABLET 20 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.30526 05/21/2021 0.35855 07/13/2021 ASPARTATE ORAL TABLET 30 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.40500 06/22/2018 0.25450 11/16/2018 ASPARTATE ORAL TABLET 5 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.69359 12/02/2016 0.54333 03/03/2017 ASPARTATE ORAL TABLET 7.5 MG DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 0.46820 03/20/2020 1.19950 04/17/2020 10 MG DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 1.85122 11/14/2017 0.88868 09/21/2018 15 MG DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 2.62825 01/01/2017 2.06516 06/16/2017 5 MG DEXTROAMPHETAMINE SULFATE ORAL SOLUTION, ORAL 5 MG/5 ML 1.27716 01/24/2014 1.27716 08/21/2015 DEXTROAMPHETAMINE SULFATE ORAL TABLET 10 MG 0.42930 01/24/2020 0.40200 03/20/2020 DEXTROAMPHETAMINE SULFATE ORAL TABLET 5 MG 0.64600 03/22/2019 0.34350 05/17/2019 DEXTROMETHORPHAN HBR/ACETAMINOPHEN/DOXYLAMINE ORAL 0.01469 08/22/2014 0.01469 08/21/2015 LIQUID (ML) 15-325/15 DEXTROMETHORPHAN HBR/PHENYLEPHRINE 0.05168 08/12/2014 0.05168 08/21/2015 HCL/DEXBROMPHENIRAMINE ORAL SYRUP 20-10-2/5 DEXTROMETHORPHAN POLISTIREX ORAL SUSPENSION, EXTENDED 0.08530 03/20/2015 0.08530 08/21/2015 RELEASE 12 HR 30 MG/5 ML DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS DEHP- 0.04179 01/25/2013 FREE BAG, INJECTION (ML) 10 %-0.2 % DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS 0.03704 01/25/2013 INTRAVENOUS SOLUTION 10 %-0.2 % DEXTROSE 10 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.01077 01/25/2013 INTRAVENOUS SOLUTION 10%-0.45% DEXTROSE 10 % IN WATER INTRAVENOUS DEHP-FREE BAG, INJECTION 0.00819 01/25/2013 (ML) 10 % DEXTROSE 10 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 10 0.00207 04/05/2013 % DEXTROSE 2.5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.00250 08/12/2014 0.00250 08/21/2015 INTRAVENOUS SOLUTION 2.5%-0.45% DEXTROSE 20 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 20 0.00864 01/25/2013 % DEXTROSE 25 % IN WATER INTRAVENOUS SYRINGE (ML) 25 % 0.38140 08/12/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DEXTROSE 30 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 30 0.00877 01/25/2013 0.00877 08/21/2015 % DEXTROSE 40 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 40 0.00870 08/12/2014 % DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS 0.00228 01/25/2013 INTRAVENOUS SOLUTION 5 %-0.2 % DEXTROSE 5 % AND 0.3 % SODIUM CHLORIDE INTRAVENOUS 0.00230 01/25/2013 INTRAVENOUS SOLUTION 5 %-0.3 % DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.00181 08/22/2014 0.00181 08/21/2015 INTRAVENOUS SOLUTION 5 %-0.45 % DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS 0.00274 01/09/2015 0.00274 08/21/2015 INTRAVENOUS SOLUTION 5 %-0.9 % DEXTROSE 5 % IN LACTATED RINGERS INTRAVENOUS INTRAVENOUS 0.00214 01/25/2013 SOLUTION 5 % DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.00275 07/25/2014 0.00275 08/21/2015 DEXTROSE 5 % IN WATER INTRAVENOUS PIGGYBACK WITH THREADED 0.02997 01/30/2015 0.02997 08/21/2015 PORT (ML) DEXTROSE 5 % IN WATER INTRAVENOUS PIGGYBACK WITH VIAL PORT 0.07096 01/25/2013 (NON-THREADED) DEXTROSE 5 % IN WATER INTRAVENOUS VIAL (ML) 5 % 0.53214 01/25/2013 DEXTROSE 50 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 50 0.00630 01/25/2013 0.00630 08/21/2015 % DEXTROSE 50 % IN WATER INTRAVENOUS SYRINGE (ML) 50 % 0.09475 04/05/2013 0.09475 08/21/2015 DEXTROSE 50 % IN WATER INTRAVENOUS VIAL (ML) 50 % 0.02540 08/12/2014 DEXTROSE 70 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 70 0.00532 04/19/2013 0.00532 08/21/2015 % DEXTROSE ORAL SOLUTION, ORAL 5 % 0.01679 01/16/2015 0.01679 08/21/2015 DIAZEPAM INJECTION SYRINGE (ML) 5 MG/ML 3.71280 01/25/2013 DIAZEPAM INJECTION VIAL (ML) 5 MG/ML 1.36920 07/12/2013 DIAZEPAM ORAL CONCENTRATE, ORAL 5 MG/ML 1.83609 01/16/2015 DIAZEPAM ORAL SOLUTION, ORAL 5 MG/5 ML 0.10010 05/09/2014 DIAZEPAM ORAL TABLET 10 MG 0.02396 09/19/2014 0.02396 08/21/2015 DIAZEPAM ORAL TABLET 2 MG 0.02372 08/21/2015 0.02133 05/21/2021 DIAZEPAM ORAL TABLET 5 MG 0.02230 01/23/2015 0.02230 08/21/2015 DIAZEPAM RECTAL KIT 12.5-15-20 234.84300 04/01/2019 232.00000 10/25/2019 DIAZEPAM RECTAL KIT 2.5 MG 197.11300 08/22/2014 197.11300 04/01/2019 DIAZEPAM RECTAL KIT 5-7.5-10MG 245.00000 10/25/2019 234.39000 11/15/2019 DICLOFENAC POTASSIUM ORAL TABLET 50 MG 0.99990 07/16/2020 0.56726 04/16/2021 DICLOFENAC SODIUM OPHTHALMIC DROPS 0.1 % 1.02376 05/02/2014 1.02376 08/21/2015 DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.99526 03/28/2014 COATED) 25 MG DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.09565 03/03/2017 0.08500 01/24/2020 COATED) 50 MG DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.08230 01/24/2020 0.07730 01/15/2021 COATED) 75 MG DICLOFENAC SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 100 0.66130 12/19/2018 1.60000 06/04/2019 MG DICLOFENAC SODIUM TOPICAL DROPS 1.5 % 0.90000 04/27/2018 0.11873 11/15/2019 DICLOFENAC SODIUM TOPICAL GEL (GRAM) 1 % 0.17595 11/15/2019 0.14776 05/22/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DICLOFENAC SODIUM TOPICAL GEL (GRAM) 3 % 0.68850 03/20/2020 0.37480 07/16/2021 DICLOFENAC SODIUM/MISOPROSTOL ORAL TABLET,IMMEDIATE,DELAY 2.34693 08/21/2015 1.56576 06/16/2017 RELEASE,BIPHASE 50 MG-200 DICLOFENAC SODIUM/MISOPROSTOL ORAL TABLET,IMMEDIATE,DELAY 1.94983 03/03/2017 1.59850 05/22/2020 RELEASE,BIPHASE 75 MG-200 SODIUM ORAL CAPSULE 250 MG 0.33183 09/26/2014 0.33183 08/21/2015 DICLOXACILLIN SODIUM ORAL CAPSULE 500 MG 0.67080 09/26/2014 0.67080 08/21/2015 DICYCLOMINE HCL ORAL CAPSULE 10 MG 0.14349 11/15/2019 0.11241 04/17/2020 DICYCLOMINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.21028 04/03/2015 DICYCLOMINE HCL ORAL TABLET 20 MG 0.18270 10/04/2019 0.14990 07/17/2020 DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.70223 01/25/2013 125 MG DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 4.32270 02/08/2013 200 MG DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 5.50853 01/25/2013 250 MG DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 8.60350 02/08/2013 400 MG DIETHYLPROPION HCL ORAL TABLET 25 MG 0.23090 08/21/2015 0.18070 11/24/2017 DIETHYLPROPION HCL ORAL TABLET, EXTENDED RELEASE 75 MG 0.88524 08/22/2014 0.88524 08/21/2015 DIFLORASONE DIACETATE TOPICAL CREAM (GRAM) 0.05 % 3.29067 08/21/2015 DIFLORASONE DIACETATE TOPICAL OINTMENT (GRAM) 0.05 % 2.47670 08/12/2014 2.47670 08/21/2015 DIFLUNISAL ORAL TABLET 500 MG 1.18611 05/17/2013 1.18611 08/21/2015 DIGOXIN INJECTION SYRINGE (ML) 250 MCG/ML 1.58760 01/25/2013 DIGOXIN ORAL SOLUTION, ORAL 50 MCG/ML 0.56138 04/17/2015 0.68654 08/24/2017 DIGOXIN ORAL TABLET 125 MCG 0.24247 05/17/2019 0.21936 03/20/2020 DIGOXIN ORAL TABLET 250 MCG 0.29347 08/16/2019 0.17780 10/25/2019 DIHYDROERGOTAMINE MESYLATE INJECTION AMPUL (ML) 1 MG/ML 104.81800 03/13/2015 DIHYDROERGOTAMINE MESYLATE INJECTION VIAL (ML) 1 MG/ML 37.55430 01/25/2013 DIHYDROERGOTAMINE MESYLATE NASAL AEROSOL, SPRAY WITH 296.65500 07/05/2017 324.99800 09/24/2019 PUMP (ML) 0.5MG/SPRY DILTIAZEM HCL INTRAVENOUS VIAL WITH THREADED PORT (EA) 100 MG 14.71680 01/25/2013 DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 120 MG 0.18874 10/19/2018 0.13167 05/17/2019 DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 180 MG 0.16256 10/25/2019 0.12444 04/17/2020 DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 240 MG 0.25000 04/27/2018 0.23078 02/22/2019 DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 300 MG 0.41122 10/20/2017 0.28339 11/16/2018 DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 360 MG 4.13262 01/07/2019 2.89000 10/25/2019 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 60 MG 1.97040 04/10/2015 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 90 MG 1.05763 05/16/2014 2.33360 07/24/2018 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 120 MG 0.31426 08/21/2015 0.23822 03/02/2018 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 180 MG 0.32000 03/02/2018 0.26189 08/17/2018 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 240 MG 0.51111 07/14/2017 0.41667 11/24/2017 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 300 MG 0.64937 07/14/2017 0.33644 05/22/2020 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 360 MG 0.39467 02/22/2019 0.35344 11/15/2019 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 420 MG 1.49711 09/30/2016 1.16224 06/16/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DILTIAZEM HCL ORAL CAPSULE,EXTENDED-RELEASE 24HR 0.44907 09/30/2016 0.35690 09/22/2017 DEGRADABLE 120 MG DILTIAZEM HCL ORAL CAPSULE,EXTENDED-RELEASE 24HR 0.58869 08/21/2015 0.41490 03/17/2017 DEGRADABLE 180 MG DILTIAZEM HCL ORAL CAPSULE,EXTENDED-RELEASE 24HR 0.45397 03/02/2018 0.42815 03/16/2018 DEGRADABLE 240 MG DILTIAZEM HCL ORAL TABLET 120 MG 0.28520 11/16/2018 0.26220 02/22/2019 DILTIAZEM HCL ORAL TABLET 30 MG 0.09900 08/21/2015 0.07598 09/22/2017 DILTIAZEM HCL ORAL TABLET 60 MG 0.21057 04/28/2016 0.14363 07/14/2017 DILTIAZEM HCL ORAL TABLET 90 MG 0.24125 09/22/2017 0.22950 05/22/2020 DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 180 MG 2.04560 08/21/2015 1.63333 05/17/2019 DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 240 MG 2.33427 08/21/2015 1.94733 03/20/2020 DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 2.97603 12/19/2014 2.97603 08/21/2015 DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 360 MG 2.40333 11/16/2018 2.18554 06/21/2019 DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 420 MG 3.54216 03/21/2014 3.13330 06/16/2017 DILUENT FOR EPOPROSTENOL SODIUM () INTRAVENOUS VIAL 0.14700 01/25/2013 (ML) DIMENHYDRINATE INJECTION VIAL (ML) 50 MG/ML 4.98960 01/25/2013 DIMENHYDRINATE ORAL TABLET 50 MG 0.01809 01/25/2013 0.01809 08/21/2015 DIMETHICONE TOPICAL CREAM (ML) 5 % 0.03918 04/10/2015 0.03918 08/21/2015 DIMETHICONE TOPICAL SPRAY, NON-AEROSOL (ML) 2 % 0.03000 08/12/2014 DIPHENHYDRAMINE HCL INJECTION VIAL (ML) 50 MG/ML 0.59000 08/16/2019 DIPHENHYDRAMINE HCL ORAL CAPSULE 25 MG 0.03163 08/21/2015 0.02020 10/20/2017 DIPHENHYDRAMINE HCL ORAL CAPSULE 50 MG 0.01743 08/12/2014 0.01743 08/21/2015 DIPHENHYDRAMINE HCL ORAL CAPSULE 50 MG 0.17282 08/21/2015 0.01743 11/17/2017 DIPHENHYDRAMINE HCL ORAL ELIXIR 12.5MG/5ML 0.00512 01/25/2013 0.00512 08/21/2015 DIPHENHYDRAMINE HCL ORAL LIQUID (ML) 12.5MG/5ML 0.00578 01/16/2015 0.00578 08/21/2015 DIPHENHYDRAMINE HCL ORAL SYRUP 12.5MG/5ML 0.01260 08/12/2014 DIPHENHYDRAMINE HCL ORAL TABLET 25 MG 0.02104 02/06/2015 0.02104 08/21/2015 DIPHENOXYLATE HCL/ATROPINE SULFATE ORAL LIQUID (ML) 2.5-.025/5 0.10803 01/25/2013 DIPHENOXYLATE HCL/ATROPINE SULFATE ORAL TABLET 2.5-.025MG 0.29000 02/22/2019 0.21900 11/15/2019 DIPYRIDAMOLE ORAL TABLET 25 MG 0.05708 02/13/2015 0.05708 08/21/2015 DIPYRIDAMOLE ORAL TABLET 50 MG 0.10810 08/21/2015 1.44930 07/20/2021 DIPYRIDAMOLE ORAL TABLET 75 MG 0.13680 08/12/2014 0.13680 08/21/2015 DISOPYRAMIDE PHOSPHATE ORAL CAPSULE 100 MG 0.34801 05/01/2015 0.34801 08/21/2015 DISOPYRAMIDE PHOSPHATE ORAL CAPSULE 150 MG 0.35458 08/21/2015 DISULFIRAM ORAL TABLET 250 MG 0.78000 01/25/2019 1.50849 04/09/2019 DISULFIRAM ORAL TABLET 500 MG 0.87360 03/02/2018 1.64030 06/15/2021 DIVALPROEX SODIUM ORAL CAPSULE, DELAYED RELEASE SPRINKLE 0.29874 03/20/2020 0.23220 06/19/2020 125 MG DIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.05896 08/21/2015 0.04414 03/02/2018 COATED) 125 MG DIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.10366 08/21/2015 0.06000 08/25/2017 COATED) 250 MG DIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.10326 01/19/2018 0.07662 12/20/2019 COATED) 500 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DIVALPROEX SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 250 0.14808 06/19/2020 0.11640 03/19/2021 MG DIVALPROEX SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 500 0.25350 08/31/2020 0.22640 03/19/2021 MG DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.08730 08/12/2014 INTRAVENOUS SOLUTION 1000MG/250 DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.04960 08/12/2014 INTRAVENOUS SOLUTION 250 MG/250 DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.02810 08/12/2014 INTRAVENOUS SOLUTION 500 MG/500 DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.05620 08/12/2014 INTRAVENOUS SOLUTION 500MG/250 DOBUTAMINE HCL INTRAVENOUS VIAL (ML) 250MG/20ML 0.15780 08/12/2014 DOBUTAMINE HCL INTRAVENOUS VIAL (ML) 500MG/40ML 0.15830 08/12/2014 INTRAVENOUS VIAL (ML) 140 MG/7ML 43.50599 01/23/2015 43.50599 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 160 MG/8ML 675.67500 08/12/2014 DOCETAXEL INTRAVENOUS VIAL (ML) 160MG/16ML 67.85567 08/12/2014 67.85567 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 20 MG/2 ML 60.99275 08/12/2014 60.99275 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 200MG/20ML 42.61540 05/01/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 20MG/ML(1) 53.07450 02/27/2015 53.07450 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 80 MG/4 ML 50.41463 02/27/2015 50.41463 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 80 MG/8 ML 61.30313 08/12/2014 61.30313 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) FNL 20MG/2 148.61475 01/25/2013 148.61475 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) FNL 80MG/8 297.22950 01/25/2013 297.22950 08/21/2015 CALCIUM ORAL CAPSULE 240 MG 0.05135 08/12/2014 0.05135 08/21/2015 DOCUSATE SODIUM ORAL CAPSULE 100 MG 0.01474 01/30/2015 0.01474 08/21/2015 DOCUSATE SODIUM ORAL CAPSULE 250 MG 0.04068 03/27/2015 0.04068 08/21/2015 DOCUSATE SODIUM ORAL LIQUID (ML) 50 MG/5 ML 0.00902 08/12/2014 0.00902 08/21/2015 DOCUSATE SODIUM ORAL SYRUP 60 MG/15ML 0.00788 08/12/2014 0.00788 08/21/2015 DOCUSATE SODIUM ORAL TABLET 100 MG 0.02938 08/21/2015 0.01740 08/17/2018 DOCUSATE SODIUM RECTAL (ML) 283 MG/5ML 3.28266 08/21/2015 DOCUSATE SODIUM/BENZOCAINE RECTAL ENEMA (ML) 283-20MG/5 2.68029 08/21/2015 DOFETILIDE ORAL CAPSULE 125 MCG 3.55783 09/22/2017 0.93398 07/16/2021 DOFETILIDE ORAL CAPSULE 500 MCG 2.61000 10/25/2019 1.71667 03/20/2020 DONEPEZIL HCL ORAL TABLET 10 MG 0.05607 08/25/2017 0.03508 09/22/2017 DONEPEZIL HCL ORAL TABLET 23 MG 0.76656 08/16/2019 0.24733 02/21/2020 DONEPEZIL HCL ORAL TABLET 5 MG 0.04100 07/26/2019 0.03500 10/25/2019 DONEPEZIL HCL ORAL TABLET,DISINTEGRATING 10 MG 0.27257 01/30/2015 DONEPEZIL HCL ORAL TABLET,DISINTEGRATING 5 MG 0.37252 08/21/2015 0.22000 03/20/2020 DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC 0.02960 08/12/2014 BAG, INJECTION (ML) 200MG/.25L DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC 0.03690 08/12/2014 BAG, INJECTION (ML) 400MG/.25L DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC 0.04060 08/12/2014 BAG, INJECTION (ML) 400MG/0.5L DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC 0.08010 08/12/2014 BAG, INJECTION (ML) 800MG/.25L West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC 0.05100 08/12/2014 BAG, INJECTION (ML) 800MG/0.5L DOPAMINE HCL INTRAVENOUS VIAL (ML) 400 MG/5ML 0.50263 01/25/2013 DOPAMINE HCL INTRAVENOUS VIAL (ML) 400MG/10ML 0.07980 01/25/2013 DOPAMINE HCL INTRAVENOUS VIAL (ML) 800MG/10ML 0.20101 01/25/2013 DOPAMINE HCL INTRAVENOUS VIAL (ML) 800MG/5ML 0.62837 01/25/2013 DORZOLAMIDE HCL OPHTHALMIC DROPS 2 % 0.81880 08/25/2017 0.78900 12/20/2019 DORZOLAMIDE HCL/TIMOLOL MALEATE OPHTHALMIC DROPS 22.3-6.8/1 1.53356 12/25/2020 1.50800 05/21/2021 DOXAZOSIN MESYLATE ORAL TABLET 1 MG 0.13300 09/22/2017 0.05640 09/20/2019 DOXAZOSIN MESYLATE ORAL TABLET 2 MG 0.09930 11/24/2017 0.05640 01/24/2020 DOXAZOSIN MESYLATE ORAL TABLET 4 MG 0.18871 08/01/2019 0.08960 01/24/2020 DOXAZOSIN MESYLATE ORAL TABLET 8 MG 0.10930 11/24/2017 0.08800 06/19/2020 DOXEPIN HCL ORAL CAPSULE 10 MG 0.22778 05/17/2019 0.17825 09/25/2020 DOXEPIN HCL ORAL CAPSULE 100 MG 0.48440 10/23/2020 0.40835 02/19/2021 DOXEPIN HCL ORAL CAPSULE 150 MG 0.92954 03/20/2015 DOXEPIN HCL ORAL CAPSULE 25 MG 0.36040 08/25/2017 0.24400 06/19/2020 DOXEPIN HCL ORAL CAPSULE 50 MG 0.58570 08/06/2019 0.35900 05/21/2021 DOXEPIN HCL ORAL CAPSULE 75 MG 0.65458 05/17/2019 0.78555 10/29/2020 DOXEPIN HCL ORAL CONCENTRATE, ORAL 10 MG/ML 0.05720 08/12/2014 DOXERCALCIFEROL ORAL CAPSULE 0.5 MCG 11.21120 01/01/2017 11.21120 01/02/2017 DOXERCALCIFEROL ORAL CAPSULE 1 MCG 22.42149 01/01/2017 22.42149 01/02/2017 DOXERCALCIFEROL ORAL CAPSULE 2.5 MCG 25.97343 01/01/2017 25.97343 01/02/2017 DOXORUBICIN HCL INTRAVENOUS VIAL (EA) 10 MG 40.96400 08/08/2014 40.96400 08/21/2015 DOXORUBICIN HCL INTRAVENOUS VIAL (EA) 50 MG 29.40000 03/07/2014 29.40000 08/21/2015 DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS VIAL (ML) 2 80.99070 04/05/2013 MG/ML DOXYCYCLINE HYCLATE INTRAVENOUS VIAL (EA) 100 MG 13.86000 11/14/2014 13.86000 08/21/2015 DOXYCYCLINE HYCLATE ORAL CAPSULE 100 MG 0.13096 05/22/2020 0.10060 07/17/2020 DOXYCYCLINE HYCLATE ORAL CAPSULE 50 MG 0.21890 11/15/2019 0.16100 05/21/2021 DOXYCYCLINE HYCLATE ORAL TABLET 100 MG 0.12565 08/16/2019 0.09980 04/17/2020 DOXYCYCLINE HYCLATE ORAL TABLET 20 MG 0.20961 07/08/2016 0.18620 05/21/2021 DOXYCYCLINE HYCLATE ORAL TABLET, DELAYED RELEASE (ENTERIC 9.19320 08/17/2018 5.36500 10/19/2018 COATED) 100 MG DOXYCYCLINE HYCLATE ORAL TABLET, DELAYED RELEASE (ENTERIC 8.72316 04/24/2015 5.65000 06/21/2019 COATED) 150 MG DOXYCYCLINE HYCLATE ORAL TABLET, DELAYED RELEASE (ENTERIC 7.15693 08/12/2014 COATED) 75 MG DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 100 MG 0.16447 11/16/2018 0.14700 01/24/2020 DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 150 MG 17.25512 01/25/2013 DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 50 MG 0.20460 08/17/2018 0.12490 10/25/2019 DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 75 MG 11.72204 01/30/2015 11.72204 08/21/2015 DOXYCYCLINE MONOHYDRATE ORAL SUSPENSION, RECONSTITUTED, 0.26565 03/20/2015 0.23433 05/17/2019 ORAL (ML) 25 MG/5 ML DOXYCYCLINE MONOHYDRATE ORAL TABLET 100 MG 0.56939 06/16/2017 0.22315 03/20/2020 DOXYCYCLINE MONOHYDRATE ORAL TABLET 150 MG 4.39361 01/25/2013 4.39361 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DOXYCYCLINE MONOHYDRATE ORAL TABLET 50 MG 0.65088 06/16/2017 0.32590 09/22/2017 DOXYCYCLINE MONOHYDRATE ORAL TABLET 75 MG 0.73370 08/12/2014 0.73370 08/21/2015 DOXYLAMINE SUCCINATE ORAL TABLET 25 MG 0.20563 08/21/2015 DRONABINOL ORAL CAPSULE 10 MG 7.63483 09/22/2017 3.32307 12/25/2020 DRONABINOL ORAL CAPSULE 2.5 MG 1.56000 12/21/2018 1.49667 11/15/2019 DRONABINOL ORAL CAPSULE 5 MG 3.24900 11/15/2019 2.50000 03/20/2020 DROPERIDOL INJECTION AMPUL (ML) 2.5 MG/ML 0.84840 01/25/2013 DROPERIDOL INJECTION VIAL (ML) 2.5 MG/ML 1.48750 01/25/2013 DROSPIRENONE ORAL TABLET 4 MG (28) 6.72216 06/04/2021 DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM ORAL 3.80020 02/26/2019 3.28512 11/15/2019 TABLET 3-0.02(24) DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM ORAL 3.96298 06/04/2021 TABLET 3-0.03(21) HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.13200 08/28/2020 0.09200 07/16/2021 COATED) 20 MG DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.09361 09/25/2020 0.07333 01/15/2021 COATED) 30 MG DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 2.98102 04/23/2019 2.25600 02/21/2020 COATED) 40 MG DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.11663 08/16/2019 0.10200 06/19/2020 COATED) 60 MG DUTASTERIDE ORAL CAPSULE 0.5 MG 0.13530 08/16/2019 0.11478 07/17/2020 DUTASTERIDE/TAMSULOSIN HCL ORAL CAPSULE,EXTENDED RELEASE 2.40833 11/16/2018 2.18600 08/16/2019 MULTIPHASE 24HR 0.5-0.4 MG ECONAZOLE NITRATE TOPICAL CREAM (GRAM) 1 % 0.44717 11/15/2019 0.24988 05/22/2020 ELECTROLYTE-48 SOLUTION/DEXTROSE 5 % IN WATER INTRAVENOUS 0.00430 08/12/2014 INTRAVENOUS SOLUTION 5 % ELECTROLYTES/DEXTROSE ORAL SOLUTION, ORAL 0.00517 02/27/2015 0.00517 08/21/2015 ELETRIPTAN HYDROBROMIDE ORAL TABLET 20 MG 5.01000 12/20/2019 3.56000 03/19/2021 ELETRIPTAN HYDROBROMIDE ORAL TABLET 40 MG 3.67667 09/20/2019 3.10833 11/20/2020 EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION (GRAM) 0.44835 01/25/2013 0.44835 08/21/2015 EMOLLIENT COMBINATION NO.32 TOPICAL EMULSION (GRAM) 0.72194 08/29/2014 0.72194 08/21/2015 EMOLLIENT COMBINATION NO.44 TOPICAL FOAM (GRAM) 0.90811 01/25/2013 EMOLLIENT COMBINATION NO.53 TOPICAL CREAM (GRAM) 0.49685 08/12/2014 EMOLLIENT COMBINATION NO.53 TOPICAL FOAM (GRAM) 1.01001 01/25/2013 ENALAPRIL MALEATE MISCELLANEOUS POWDER (GRAM) 100 % 3.35240 08/12/2014 3.35240 08/21/2015 ENALAPRIL MALEATE ORAL TABLET 10 MG 0.07090 09/20/2019 0.05510 11/15/2019 ENALAPRIL MALEATE ORAL TABLET 2.5 MG 0.06000 08/25/2017 0.05650 07/26/2019 ENALAPRIL MALEATE ORAL TABLET 20 MG 0.11706 11/16/2018 0.07320 01/24/2020 ENALAPRIL MALEATE ORAL TABLET 5 MG 0.13023 08/25/2017 0.07035 11/16/2018 ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE ORAL TABLET 10 MG- 0.14036 08/21/2015 0.09050 06/16/2017 25MG ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE ORAL TABLET 5MG- 0.08740 05/31/2013 0.08740 08/21/2015 12.5MG ENALAPRILAT DIHYDRATE INTRAVENOUS VIAL (ML) 1.25 MG/ML 1.78220 09/12/2014 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 100 MG/ML 9.69900 07/17/2020 9.09933 08/28/2020 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 120MG/.8ML 17.76502 04/21/2017 14.62375 08/28/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 150 MG/ML 12.95000 09/21/2018 11.45550 11/15/2019 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 30MG/0.3ML 10.59000 08/22/2019 8.99667 03/20/2020 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 40MG/0.4ML 9.89679 11/20/2020 11.91250 04/09/2021 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 60MG/0.6ML 10.60666 06/19/2020 10.19300 12/25/2020 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 80MG/0.8ML 8.92000 05/22/2020 8.66188 11/20/2020 ENOXAPARIN SODIUM SUBCUTANEOUS VIAL (ML) 300MG/3ML 59.20133 08/21/2015 10.59000 11/20/2020 ENTACAPONE ORAL TABLET 200 MG 0.63276 12/27/2019 0.72238 08/07/2020 ENTECAVIR ORAL TABLET 0.5 MG 1.70800 05/17/2019 0.69967 11/15/2019 ENTECAVIR ORAL TABLET 1 MG 5.88033 09/22/2017 5.88030 09/23/2017 ,DIGESTIVE ORAL CAPSULE 0.05940 08/12/2014 0.05940 08/21/2015 EPHEDRINE SULFATE VIAL (ML) 50 MG/ML 4.10130 01/25/2013 4.10130 08/21/2015 EPINASTINE HCL OPHTHALMIC DROPS 0.05 % 9.27130 08/21/2015 5.46126 06/16/2017 EPINEPHRINE HCL/PF INJECTION AMPUL (ML) 1 MG/ML(1) 682.71000 02/20/2015 EPINEPHRINE INJECTION SYRINGE (ML) 0.1 MG/ML 0.47910 08/12/2014 0.47910 08/21/2015 EPINEPHRINE INJECTION VIAL (ML) 1 MG/ML 0.20160 08/12/2014 0.20160 08/21/2015 EPIRUBICIN HCL INTRAVENOUS VIAL (EA) 200 MG 1992.09500 01/25/2013 EPLERENONE ORAL TABLET 25 MG 0.72583 09/25/2020 0.48748 07/16/2021 EPLERENONE ORAL TABLET 50 MG 0.98300 08/16/2019 1.31207 10/07/2020 EPOPROSTENOL SODIUM (GLYCINE) INTRAVENOUS VIAL (EA) 0.5 MG 12.85200 01/25/2013 EPOPROSTENOL SODIUM (GLYCINE) INTRAVENOUS VIAL (EA) 1.5 MG 24.45100 01/25/2013 EPROSARTAN MESYLATE ORAL TABLET 600 MG 2.39820 01/25/2013 ERGOCALCIFEROL (VITAMIN D2) ORAL CAPSULE 1250 MCG 0.09770 09/22/2017 0.08700 04/16/2021 ERGOCALCIFEROL (VITAMIN D2) ORAL TABLET 10 MCG 0.02380 02/08/2013 ERGOCALCIFEROL (VITAMIN D2) ORAL TABLET 50 MCG 0.05446 01/25/2013 ERGOLOID MESYLATES ORAL TABLET 1 MG 5.67287 02/06/2015 ERLOTINIB HCL ORAL TABLET 100 MG 12.50000 02/21/2020 ERLOTINIB HCL ORAL TABLET 150 MG 12.93000 02/21/2020 ERLOTINIB HCL ORAL TABLET 25 MG 9.50000 02/21/2020 BASE IN ETHANOL TOPICAL GEL (GRAM) 2 % 2.23000 01/25/2019 1.68000 07/26/2019 ERYTHROMYCIN BASE IN ETHANOL TOPICAL SOLUTION, NON-ORAL 2 % 0.42017 06/21/2019 0.32978 11/15/2019 ERYTHROMYCIN BASE IN ETHANOL TOPICAL SWAB, MEDICATED 2 % 1.10370 02/08/2013 ERYTHROMYCIN BASE OPHTHALMIC OINTMENT (GRAM) 5 MG/GRAM 1.68401 06/16/2017 1.63247 02/22/2019 ERYTHROMYCIN BASE ORAL CAPSULE,DELAYED RELEASE (ENTERIC 2.41500 08/21/2015 4.82650 07/19/2019 COATED) 250 MG ERYTHROMYCIN BASE ORAL TABLET 250 MG 7.81000 06/21/2019 6.78000 07/16/2021 ERYTHROMYCIN BASE ORAL TABLET 500 MG 9.78572 08/21/2015 12.26652 05/16/2016 ERYTHROMYCIN BASE/BENZOYL PEROXIDE TOPICAL GEL (GRAM) 3 %-5 1.97425 03/20/2020 1.97425 01/01/2021 % ESCITALOPRAM OXALATE ORAL SOLUTION, ORAL 5 MG/5 ML 0.36009 02/26/2016 0.14983 04/26/2019 ESCITALOPRAM OXALATE ORAL TABLET 10 MG 0.04554 09/22/2017 0.04156 12/25/2020 ESCITALOPRAM OXALATE ORAL TABLET 20 MG 0.05913 02/22/2019 0.03570 10/25/2019 ESCITALOPRAM OXALATE ORAL TABLET 5 MG 0.03320 10/20/2017 0.03020 01/15/2021 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ESOMEPRAZOLE MAGNESIUM ORAL CAPSULE,DELAYED RELEASE 0.19700 08/16/2019 0.18285 08/28/2020 (ENTERIC COATED) 20 MG ESOMEPRAZOLE MAGNESIUM ORAL CAPSULE,DELAYED RELEASE 0.15306 04/17/2020 0.12056 01/15/2021 (ENTERIC COATED) 40 MG ESOMEPRAZOLE SODIUM INTRAVENOUS VIAL (EA) 20 MG 9.22875 04/24/2015 9.22875 08/21/2015 ESOMEPRAZOLE SODIUM INTRAVENOUS VIAL (EA) 40 MG 10.43250 04/24/2015 10.43250 08/21/2015 ESTAZOLAM ORAL TABLET 1 MG 0.26770 08/12/2014 ESTAZOLAM ORAL TABLET 2 MG 0.29330 08/12/2014 0.29330 08/21/2015 ESTRADIOL ORAL TABLET 0.5 MG 0.10410 08/25/2017 0.06180 09/22/2017 ESTRADIOL ORAL TABLET 1 MG 0.11270 07/14/2017 0.07130 05/22/2020 ESTRADIOL ORAL TABLET 2 MG 0.13700 06/16/2017 0.11000 10/20/2017 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 7.60625 07/26/2019 6.32117 12/25/2020 .025MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 7.27000 10/19/2018 6.67875 05/17/2019 .0375MG/24 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 6.63000 06/22/2018 5.61875 08/16/2019 .075MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 6.69750 01/15/2021 6.30625 05/21/2021 0.05MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 7.76750 05/29/2020 7.20375 12/25/2020 0.1MG/24HR ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 13.00000 03/03/2017 10.76000 11/20/2020 .025MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 12.39250 12/22/2017 11.07000 01/24/2020 .0375MG/24 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 10.55000 05/02/2014 .075MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 11.97900 12/25/2020 11.12819 02/19/2021 0.05MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 12.05375 06/16/2017 9.29050 02/19/2021 0.06MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 14.16352 12/25/2015 12.42131 06/16/2017 0.1MG/24HR ESTRADIOL VAGINAL TABLET 10 MCG 7.73889 07/17/2020 8.90125 08/10/2020 ESTRADIOL VALERATE/DIENOGEST ORAL TABLET 3-2-1(28) 7.65819 06/04/2021 ESTRADIOL/NORETHINDRONE ACETATE ORAL TABLET 0.5-0.1 MG 1.73571 03/15/2019 2.26160 04/13/2020 ESTRADIOL/NORETHINDRONE ACETATE ORAL TABLET 1 MG-0.5MG 2.29848 06/16/2017 1.95614 02/19/2021 ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE ORAL TABLET 0.625- 1.58654 08/12/2014 1.58654 08/21/2015 1.25 ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE ORAL TABLET 1.25- 1.74068 08/12/2014 1.74068 08/21/2015 2.5MG ESTROPIPATE TABLET 0.75 MG 0.36322 04/25/2014 0.36322 08/21/2015 ESTROPIPATE TABLET 1.5 MG 0.50765 04/25/2014 ESTROPIPATE TABLET 3 MG 0.70270 08/12/2014 ESZOPICLONE ORAL TABLET 1 MG 0.29577 09/22/2017 0.26290 05/17/2019 ESZOPICLONE ORAL TABLET 2 MG 0.19400 09/22/2017 0.17820 11/16/2018 ESZOPICLONE ORAL TABLET 3 MG 0.34539 03/03/2017 0.20747 08/25/2017 ETHACRYNIC ACID ORAL TABLET 25 MG 5.52000 08/16/2019 3.91330 07/16/2021 ETHAMBUTOL HCL ORAL TABLET 100 MG 0.28000 11/24/2017 0.16920 08/17/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ETHINYL ESTRADIOL/DROSPIRENONE ORAL TABLET 0.02-3(28) 0.36702 08/16/2019 0.34500 05/21/2021 ETHINYL ESTRADIOL/DROSPIRENONE ORAL TABLET 0.03MG-3MG 0.39301 08/17/2018 0.24209 07/17/2020 ETHOSUXIMIDE ORAL CAPSULE 250 MG 0.70270 02/22/2019 0.45000 07/16/2021 ETHOSUXIMIDE ORAL SOLUTION, ORAL 250 MG/5ML 0.27221 01/25/2019 0.15389 06/19/2020 ETHYL ALCOHOL INJECTION AMPUL (ML) 98 % 7.48300 12/12/2014 7.48300 08/21/2015 ETHYL ALCOHOL INJECTION VIAL (ML) 98 % 12.09096 08/12/2014 ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL ORAL TABLET 1 MG- 0.70226 03/03/2017 0.58262 11/24/2017 35MCG ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL ORAL TABLET 1 MG- 0.65000 06/04/2021 50MCG ETIDRONATE DISODIUM ORAL TABLET 200 MG 3.02458 01/24/2014 ETIDRONATE DISODIUM ORAL TABLET 400 MG 6.04777 11/22/2013 6.04777 08/21/2015 ETODOLAC ORAL CAPSULE 200 MG 0.89280 01/13/2017 0.84280 11/24/2017 ETODOLAC ORAL CAPSULE 300 MG 1.02950 11/24/2017 0.70490 03/02/2018 ETODOLAC ORAL TABLET 400 MG 0.42692 08/17/2018 0.34640 11/16/2018 ETODOLAC ORAL TABLET 500 MG 0.49930 08/25/2017 0.26330 11/15/2019 ETODOLAC ORAL TABLET, EXTENDED RELEASE 24 HR 400 MG 2.03084 08/21/2015 1.21731 06/16/2017 ETODOLAC ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.96565 06/16/2017 0.16333 11/15/2019 ETODOLAC ORAL TABLET, EXTENDED RELEASE 24 HR 600 MG 2.29187 08/21/2015 1.36061 06/16/2017 ETONOGESTREL/ETHINYL ESTRADIOL VAGINAL RING, VAGINAL .12 108.55500 12/25/2020 102.92500 07/16/2021 -.015MG ETOPOSIDE ORAL CAPSULE 50 MG 56.82120 02/15/2013 EXEMESTANE ORAL TABLET 25 MG 2.18833 07/25/2019 1.29833 11/15/2019 EZETIMIBE ORAL TABLET 10 MG 0.13771 01/15/2020 0.07384 04/17/2020 EZETIMIBE/ ORAL TABLET 10 MG-10MG 2.62000 04/27/2018 2.37300 11/16/2018 EZETIMIBE/SIMVASTATIN ORAL TABLET 10 MG-20MG 1.90000 06/21/2019 EZETIMIBE/SIMVASTATIN ORAL TABLET 10 MG-40MG 0.77689 03/20/2020 0.71933 05/22/2020 EZETIMIBE/SIMVASTATIN ORAL TABLET 10 MG-80MG 1.85700 10/02/2019 2.09682 11/26/2019 FAMCICLOVIR ORAL TABLET 125 MG 0.46454 08/21/2015 0.35833 11/16/2018 FAMCICLOVIR ORAL TABLET 250 MG 0.68028 08/21/2015 0.28887 06/16/2017 FAMCICLOVIR ORAL TABLET 500 MG 0.51583 11/16/2018 0.49467 11/15/2019 FAMOTIDINE IN SODIUM CHLORIDE, ISO-OSMOTIC/PF INTRAVENOUS 0.13650 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 20 MG/50ML FAMOTIDINE INTRAVENOUS VIAL (ML) 10 MG/ML 0.26572 01/09/2015 0.26572 08/21/2015 FAMOTIDINE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 1.99680 05/18/2020 2.67480 08/26/2020 40MG/5ML FAMOTIDINE ORAL TABLET 10 MG 0.08920 03/27/2015 0.08920 08/21/2015 FAMOTIDINE ORAL TABLET 20 MG 0.09562 02/19/2021 0.05344 04/16/2021 FAMOTIDINE ORAL TABLET 40 MG 0.10778 02/19/2021 0.06520 06/18/2021 FAMOTIDINE/PF INTRAVENOUS VIAL (ML) 20 MG/2 ML 0.37429 08/12/2014 0.37429 08/21/2015 FEBUXOSTAT ORAL TABLET 40 MG 2.11167 08/28/2020 1.36433 06/18/2021 FEBUXOSTAT ORAL TABLET 80 MG 2.43327 08/28/2020 1.16900 07/16/2021 FELBAMATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 600 MG/5ML 1.58070 12/02/2016 1.10721 05/22/2020 FELBAMATE ORAL TABLET 400 MG 0.86430 08/16/2019 2.05645 03/23/2021 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date FELBAMATE ORAL TABLET 600 MG 1.48180 02/22/2019 1.41430 03/20/2020 ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.34000 05/20/2016 0.09000 11/24/2017 FELODIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 2.5 MG 0.54257 08/21/2015 0.14760 09/22/2017 FELODIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 5 MG 0.19800 07/14/2017 0.07260 11/24/2017 FENOFIBRATE NANOCRYSTALLIZED ORAL TABLET 145 MG 0.16870 08/16/2019 0.15547 06/19/2020 FENOFIBRATE NANOCRYSTALLIZED ORAL TABLET 48 MG 0.10550 11/15/2019 0.06544 09/25/2020 FENOFIBRATE ORAL CAPSULE 150 MG 5.00920 01/23/2017 5.55870 09/05/2017 FENOFIBRATE ORAL CAPSULE 50 MG 1.73180 08/01/2014 FENOFIBRATE ORAL TABLET 160 MG 0.19590 04/17/2020 0.17144 04/16/2021 FENOFIBRATE ORAL TABLET 54 MG 0.16656 11/15/2019 0.13503 11/20/2020 FENOFIBRATE,MICRONIZED ORAL CAPSULE 130 MG 1.89200 10/19/2018 1.08800 12/25/2020 FENOFIBRATE,MICRONIZED ORAL CAPSULE 134 MG 0.19433 11/15/2019 0.14630 04/17/2020 FENOFIBRATE,MICRONIZED ORAL CAPSULE 200 MG 0.55315 08/16/2019 0.43290 09/25/2020 FENOFIBRATE,MICRONIZED ORAL CAPSULE 43 MG 1.64500 08/21/2015 0.58033 09/22/2017 FENOFIBRATE,MICRONIZED ORAL CAPSULE 67 MG 0.39699 08/24/2019 0.11000 11/15/2019 FENOFIBRIC ACID (CHOLINE) ORAL CAPSULE,DELAYED RELEASE 1.21444 08/01/2018 0.84544 02/22/2019 (ENTERIC COATED) 135 MG FENOFIBRIC ACID (CHOLINE) ORAL CAPSULE,DELAYED RELEASE 0.41211 09/22/2017 0.37988 01/25/2019 (ENTERIC COATED) 45 MG FENOFIBRIC ACID ORAL TABLET 105 MG 2.10232 05/30/2014 2.03967 08/25/2017 FENOFIBRIC ACID ORAL TABLET 35 MG 0.70070 08/12/2014 FENOPROFEN CALCIUM ORAL TABLET 600 MG 1.53587 02/07/2014 1.53587 08/21/2015 CITRATE BUCCAL LOZENGE ON A HANDLE 1200 MCG 31.46500 01/25/2013 FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 1600 MCG 38.80683 01/25/2013 FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 200 MCG 13.16280 01/25/2013 7.47933 09/22/2017 FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 400 MCG 16.67657 01/25/2013 FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 600 MCG 20.42600 01/25/2013 FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 800 MCG 24.20180 10/25/2013 FENTANYL CITRATE/PF INTRAVENOUS SYRINGE (ML) 100MCG/2ML 0.65520 01/25/2013 0.65520 08/21/2015 FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 100 7.70600 08/17/2018 6.41480 02/22/2019 MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 12 7.50908 03/20/2021 5.49925 07/16/2021 MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 25 2.22000 10/25/2019 2.16000 05/22/2020 MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 42.45400 05/01/2015 39.39600 06/18/2021 37.5MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 4.31360 11/20/2020 3.85840 05/21/2021 50MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 61.68800 05/01/2015 62.5MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 7.43407 02/12/2020 5.99600 05/21/2021 75MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 83.99000 05/01/2015 87.5MCG/HR FERROUS FUMARATE/ASCORBIC ACID/B12-IF/FOLIC ACID ORAL 0.18226 08/30/2013 CAPSULE 110-0.5MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date FERROUS GLUCONATE ORAL TABLET 240(27)MG 0.03859 08/12/2014 FERROUS SULFATE ORAL DROPS 15 MG/ML 0.06072 03/06/2015 0.06072 08/21/2015 FERROUS SULFATE ORAL SOLUTION, ORAL 220 (44)/5 0.00626 04/10/2015 0.00626 08/21/2015 FERROUS SULFATE ORAL TABLET 325(65) MG 0.00838 04/10/2015 0.00838 08/21/2015 FEXOFENADINE HCL ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 30 0.05664 02/27/2015 MG/5 ML FEXOFENADINE HCL ORAL TABLET 180 MG 0.19000 11/16/2018 0.15500 08/16/2019 FEXOFENADINE HCL ORAL TABLET 60 MG 0.31707 08/21/2015 0.24340 08/16/2019 FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL ORAL TABLET, 0.66733 08/21/2015 EXTENDED RELEASE 12 HR 60MG-120MG FINASTERIDE ORAL TABLET 1 MG 0.31250 03/25/2016 0.09000 08/25/2017 FINASTERIDE ORAL TABLET 5 MG 0.13871 03/03/2017 0.05049 09/22/2017 /BORAGE OIL/FLAXSEED OIL/OMEGA 3,6,9 COMBINATION NO1 0.06168 08/12/2014 ORAL CAPSULE 400-400 MG FISH OIL/DOCOSAHEXAENOIC ACID/EICOSAPENTAENOIC ACID ORAL 0.01579 01/25/2013 CAPSULE 1200-144MG FLAVOXATE HCL ORAL TABLET 100 MG 0.80990 08/21/2015 0.45341 06/16/2017 FLECAINIDE ACETATE ORAL TABLET 100 MG 0.20830 11/16/2018 0.17710 08/16/2019 FLECAINIDE ACETATE ORAL TABLET 150 MG 0.37675 01/08/2021 0.24953 07/16/2021 FLECAINIDE ACETATE ORAL TABLET 50 MG 0.13700 01/24/2020 0.06080 09/25/2020 FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS SOLUTION, 0.09824 04/24/2015 0.09824 08/21/2015 PIGGYBACK (ML) 200MG/0.1L FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS SOLUTION, 0.05315 04/24/2015 0.05315 08/21/2015 PIGGYBACK (ML) 400MG/0.2L FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS 0.01660 08/25/2017 0.03849 03/27/2020 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 200MG/0.1L FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS 0.03369 04/24/2015 0.03369 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 400MG/0.2L FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS IV 0.05285 03/06/2015 0.05285 08/21/2015 SOLUTION, PIGGYBACK, BOTTLE (ML) 200MG/0.1L FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS IV 0.09450 01/25/2013 0.09450 08/21/2015 SOLUTION, PIGGYBACK, BOTTLE (ML) 400MG/0.2L FLUCONAZOLE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 10 0.32278 08/21/2015 0.23000 09/22/2017 MG/ML FLUCONAZOLE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 40 0.49314 09/22/2017 0.47400 10/25/2019 MG/ML FLUCONAZOLE ORAL TABLET 100 MG 0.44833 09/25/2020 0.25161 01/15/2021 FLUCONAZOLE ORAL TABLET 150 MG 0.72107 02/22/2019 0.62917 06/19/2020 FLUCONAZOLE ORAL TABLET 200 MG 0.55972 11/16/2018 0.48000 06/19/2020 FLUCONAZOLE ORAL TABLET 50 MG 0.53200 06/16/2017 0.19000 10/23/2020 FLUCYTOSINE ORAL CAPSULE 250 MG 57.44830 11/21/2014 57.44830 08/21/2015 FLUCYTOSINE ORAL CAPSULE 500 MG 111.16350 11/21/2014 111.16350 08/21/2015 FLUDROCORTISONE ACETATE ORAL TABLET 0.1 MG 0.37080 12/06/2016 0.30660 10/20/2017 FLUNISOLIDE NASAL AEROSOL, SPRAY (ML) 25 MCG 1.92500 03/13/2015 1.92500 08/21/2015 FLUOCINOLONE ACETONIDE OIL OTIC DROPS 0.01 % 4.81200 12/21/2018 1.46265 06/18/2021 FLUOCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.01 % 1.82185 08/12/2014 1.82185 08/21/2015 FLUOCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.025 % 1.39143 08/21/2015 1.29967 02/21/2020 FLUOCINOLONE ACETONIDE TOPICAL OIL (ML) 0.01 % 0.55000 02/22/2019 0.55000 01/01/2021 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date FLUOCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.025 % 1.18650 08/22/2014 FLUOCINOLONE ACETONIDE TOPICAL SOLUTION, NON-ORAL 0.01 % 1.56983 08/16/2019 0.90000 11/15/2019 FLUOCINOLONE ACETONIDE/SHOWER CAP TOPICAL OIL (ML) 0.01 % 0.33818 09/25/2020 0.33818 01/01/2021 FLUOCINONIDE TOPICAL CREAM (GRAM) 0.05 % 0.79753 11/24/2017 0.53592 10/25/2019 FLUOCINONIDE TOPICAL CREAM (GRAM) 0.1 % 11.07021 12/02/2016 0.81117 06/18/2021 FLUOCINONIDE TOPICAL GEL (GRAM) 0.05 % 1.04867 01/24/2020 1.50566 03/04/2020 FLUOCINONIDE TOPICAL OINTMENT (GRAM) 0.05 % 0.78790 08/30/2013 0.42932 07/08/2016 FLUOCINONIDE TOPICAL SOLUTION, NON-ORAL 0.05 % 0.79333 02/21/2020 0.62225 03/19/2021 FLUOCINONIDE/EMOLLIENT BASE TOPICAL CREAM (GRAM) 0.05 % 0.25684 06/07/2013 0.25684 08/21/2015 FLUORIDE (SODIUM) DENTAL CREAM (GRAM) 1.1 % 0.08013 08/21/2015 0.06294 10/25/2019 FLUORIDE (SODIUM) DENTAL GEL (GRAM) 1.1 % 0.06890 09/27/2013 0.06890 08/21/2015 FLUORIDE (SODIUM) ORAL DROPS 0.5 MG/ML 0.17316 08/21/2015 0.10320 11/24/2017 FLUORIDE (SODIUM) ORAL TABLET,CHEWABLE 0.25(0.55) 0.03738 03/01/2013 0.03738 08/21/2015 FLUORIDE (SODIUM) ORAL TABLET,CHEWABLE 0.5(1.1)MG 0.03740 02/22/2013 0.03740 08/21/2015 FLUORIDE (SODIUM) ORAL TABLET,CHEWABLE 1MG(2.2MG) 0.03852 04/19/2013 0.03852 08/21/2015 OPHTHALMIC SUSPENSION, DROPS(FINAL 10.37820 02/20/2015 12.54792 04/27/2019 DOSAGE FORM)(ML) 0.1 % FLUOROURACIL INTRAVENOUS VIAL (ML) 1 G/20 ML 0.25200 03/27/2015 0.25200 08/21/2015 FLUOROURACIL INTRAVENOUS VIAL (ML) 2.5 G/50ML 0.19859 03/27/2015 FLUOROURACIL INTRAVENOUS VIAL (ML) 5 G/100 ML 0.12840 09/22/2017 0.11050 03/20/2020 FLUOROURACIL INTRAVENOUS VIAL (ML) 500MG/10ML 0.25200 03/27/2015 0.25200 08/21/2015 FLUOROURACIL TOPICAL CREAM (GRAM) 0.5 % 41.44770 12/26/2014 FLUOROURACIL TOPICAL CREAM (GRAM) 5 % 4.05885 08/21/2015 4.05885 04/15/2016 FLUOROURACIL TOPICAL SOLUTION, NON-ORAL 2 % 4.95080 08/12/2014 FLUOROURACIL TOPICAL SOLUTION, NON-ORAL 5 % 7.93170 05/17/2013 FLUOXETINE HCL ORAL CAPSULE 10 MG 0.02814 05/01/2015 0.02814 08/21/2015 FLUOXETINE HCL ORAL CAPSULE 20 MG 0.02676 09/25/2020 0.02323 01/15/2021 FLUOXETINE HCL ORAL CAPSULE 40 MG 0.06800 01/25/2019 0.05020 10/23/2020 FLUOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 29.33500 02/21/2014 29.33500 08/21/2015 COATED) 90 MG FLUOXETINE HCL ORAL SOLUTION, ORAL 20 MG/5 ML 0.49922 04/23/2020 0.46677 08/28/2020 FLUOXETINE HCL ORAL TABLET 10 MG 0.05507 03/20/2015 0.05507 08/21/2015 FLUOXETINE HCL ORAL TABLET 20 MG 0.67167 07/26/2019 0.56167 11/15/2019 FLUOXETINE HCL ORAL TABLET 60 MG 2.97158 07/05/2013 FLUPHENAZINE DECANOATE INJECTION VIAL (ML) 25 MG/ML 15.27632 08/28/2020 12.95867 02/19/2021 FLUPHENAZINE HCL INJECTION VIAL (ML) 2.5 MG/ML 10.58000 03/01/2013 FLUPHENAZINE HCL ORAL CONCENTRATE, ORAL 5 MG/ML 0.81136 01/25/2013 FLUPHENAZINE HCL ORAL ELIXIR 2.5 MG/5ML 0.26710 01/25/2013 FLUPHENAZINE HCL ORAL TABLET 1 MG 3.20310 03/11/2019 2.52000 02/21/2020 FLUPHENAZINE HCL ORAL TABLET 10 MG 7.36791 01/06/2020 6.63180 06/19/2020 FLUPHENAZINE HCL ORAL TABLET 2.5 MG 0.47850 06/12/2018 3.16710 08/23/2019 FLUPHENAZINE HCL ORAL TABLET 5 MG 2.92200 08/17/2018 6.89950 11/27/2018 FLURAZEPAM HCL ORAL CAPSULE 15 MG 0.19583 08/22/2014 0.19583 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date FLURAZEPAM HCL ORAL CAPSULE 30 MG 0.35100 08/22/2014 0.35100 08/21/2015 FLURBIPROFEN ORAL TABLET 100 MG 0.36823 02/20/2015 0.36823 08/21/2015 FLURBIPROFEN ORAL TABLET 50 MG 0.22113 09/19/2014 0.22113 08/21/2015 FLURBIPROFEN SODIUM OPHTHALMIC DROPS 0.03 % 1.57114 08/21/2015 1.14467 06/16/2017 FLUTAMIDE ORAL CAPSULE 125 MG 0.63643 08/21/2015 0.49639 11/24/2017 FLUTICASONE PROPIONATE NASAL SPRAY, SUSPENSION 50 MCG 0.32375 12/02/2016 0.15892 01/27/2017 FLUTICASONE PROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.23000 08/25/2017 0.18317 08/16/2019 FLUTICASONE PROPIONATE TOPICAL LOTION (ML) 0.05 % 4.54942 08/30/2013 4.54942 08/21/2015 FLUTICASONE PROPIONATE TOPICAL OINTMENT (GRAM) 0.005 % 0.48681 03/01/2013 FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE INHALATION 2.46034 10/23/2020 2.46034 01/01/2021 BLISTER, WITH INHALATION DEVICE 250-50 MCG FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE INHALATION 2.91650 09/25/2020 2.91650 01/01/2021 BLISTER, WITH INHALATION DEVICE 500-50 MCG FLUVASTATIN SODIUM ORAL CAPSULE 20 MG 2.64600 03/27/2015 2.64600 04/22/2016 FLUVASTATIN SODIUM ORAL CAPSULE 40 MG 2.64297 08/23/2013 2.64297 04/22/2016 FLUVOXAMINE MALEATE ORAL CAPSULE, EXT RELEASE 24 HR 100 MG 7.12857 10/10/2014 FLUVOXAMINE MALEATE ORAL CAPSULE, EXT RELEASE 24 HR 150 MG 7.65030 10/10/2014 FLUVOXAMINE MALEATE ORAL TABLET 100 MG 0.42234 07/13/2020 0.28839 09/25/2020 FLUVOXAMINE MALEATE ORAL TABLET 25 MG 0.23769 08/21/2015 0.16767 08/25/2017 FLUVOXAMINE MALEATE ORAL TABLET 50 MG 0.23950 11/15/2019 0.43131 08/28/2020 FOLIC ACID INJECTION VIAL (ML) 5 MG/ML 1.79410 02/15/2013 FOLIC ACID ORAL TABLET 0.4 MG 0.01380 02/06/2015 0.01380 08/21/2015 FOLIC ACID ORAL TABLET 1 MG 0.02320 08/21/2015 0.00800 03/02/2018 FOLIC ACID/ARGININE HCL/CYANOCOBALAMIN/VIT B6/BLACK PEPPER 0.56210 01/25/2013 TABLET 2-500-500 FOLIC ACID/MULTIVIT WITH MINERALS/LUTEIN ORAL TABLET 0.4MG-250 0.03600 01/25/2013 FOLIC ACID/PYRIDOXINE HCL/CA PHOS DIBASIC & TRIBASIC/GINGER 0.72360 01/25/2013 0.72360 08/21/2015 ORAL TABLET 1.2-40-100 FOLIC ACID/VITAMIN B COMPLEX AND ORAL TABLET 0.8 MG 0.09960 08/12/2014 0.09960 08/21/2015 FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 10MG/0.8ML 94.71000 01/09/2015 94.71000 08/21/2015 FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 2.5 MG/0.5 83.02000 08/21/2015 28.20200 02/21/2020 FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 5MG/0.4ML 110.40650 01/09/2015 110.40650 08/21/2015 FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 7.5MG/0.6 129.37800 01/09/2015 129.37800 08/21/2015 FORMALDEHYDE SOLUTION WITH APPLICATOR (ML) 10 % 0.36953 01/25/2013 FOSCARNET SODIUM INTRAVENOUS INFUSION BOTTLE (ML) 24 MG/ML 0.25326 01/30/2015 0.25326 08/21/2015 FOSINOPRIL SODIUM ORAL TABLET 10 MG 0.15448 08/21/2015 0.11000 12/21/2018 FOSINOPRIL SODIUM ORAL TABLET 20 MG 0.14428 08/21/2015 0.09833 02/22/2019 FOSINOPRIL SODIUM ORAL TABLET 40 MG 0.19096 08/21/2015 0.14144 02/22/2019 FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.74360 08/12/2014 0.74360 08/21/2015 FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 1.06964 08/12/2014 1.06964 08/21/2015 MG FOSPHENYTOIN SODIUM INJECTION VIAL (ML) 100MG PE/2 0.91763 01/30/2015 0.91763 08/21/2015 FOSPHENYTOIN SODIUM INJECTION VIAL (ML) 500 PE/10 0.75985 01/30/2015 0.75985 08/21/2015 FUROSEMIDE INJECTION VIAL (ML) 10 MG/ML 0.40508 08/21/2015 0.36590 08/16/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date FUROSEMIDE ORAL SOLUTION, ORAL 10 MG/ML 0.11127 05/17/2013 FUROSEMIDE ORAL SOLUTION, ORAL 40MG/5ML 0.14150 01/25/2013 FUROSEMIDE ORAL TABLET 20 MG 0.01363 04/24/2015 0.01363 08/21/2015 FUROSEMIDE ORAL TABLET 40 MG 0.02141 04/24/2015 0.02141 08/21/2015 FUROSEMIDE ORAL TABLET 80 MG 0.03476 08/21/2015 0.02408 10/20/2017 MISCELLANEOUS POWDER (GRAM) 100 % 1.14400 08/21/2015 GABAPENTIN ORAL CAPSULE 100 MG 0.02447 10/20/2017 0.02238 03/19/2021 GABAPENTIN ORAL CAPSULE 300 MG 0.03986 12/25/2020 0.03899 04/16/2021 GABAPENTIN ORAL CAPSULE 400 MG 0.04698 04/17/2020 0.04861 07/14/2020 GABAPENTIN ORAL SOLUTION, ORAL 250 MG/5ML 0.29166 01/25/2013 GABAPENTIN ORAL SOLUTION, ORAL 250 MG/5ML 0.15513 03/29/2019 0.11517 08/16/2019 GABAPENTIN ORAL SOLUTION, ORAL 300 MG/6ML 0.29164 01/25/2013 GABAPENTIN ORAL TABLET 600 MG 0.08738 01/27/2017 0.06198 04/17/2020 GABAPENTIN ORAL TABLET 800 MG 0.09060 11/20/2020 0.13021 05/01/2021 GALANTAMINE HBR ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 1.31666 08/16/2019 1.18400 09/20/2019 HR 16 MG GALANTAMINE HBR ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 2.00142 06/16/2017 0.83300 03/02/2018 HR 24 MG GALANTAMINE HBR ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 1.22142 09/21/2018 0.43700 08/16/2019 HR 8 MG GALANTAMINE HBR ORAL SOLUTION, ORAL 4 MG/ML 2.95575 01/25/2013 2.95575 08/21/2015 GALANTAMINE HBR ORAL TABLET 12 MG 0.65067 09/22/2017 0.15067 08/16/2019 GALANTAMINE HBR ORAL TABLET 4 MG 0.89375 03/02/2018 0.76000 11/15/2019 GALANTAMINE HBR ORAL TABLET 8 MG 0.60633 03/16/2018 0.40533 02/19/2021 GANCICLOVIR SODIUM INTRAVENOUS VIAL (EA) 500 MG 62.00208 02/27/2015 GANIRELIX ACETATE SUBCUTANEOUS SYRINGE (ML) 250MCG/0.5 243.87300 01/25/2013 GATIFLOXACIN OPHTHALMIC DROPS 0.5 % 20.80000 10/19/2018 12.24211 07/16/2021 GEMCITABINE HCL INTRAVENOUS VIAL (EA) 1 G 39.64700 01/23/2015 39.64700 08/21/2015 GEMCITABINE HCL INTRAVENOUS VIAL (EA) 2 G 96.93425 08/08/2014 96.93425 08/21/2015 GEMCITABINE HCL INTRAVENOUS VIAL (EA) 200 MG 9.28800 01/23/2015 9.28800 08/21/2015 GEMCITABINE HCL INTRAVENOUS VIAL (ML) 1 G/26.3ML 2.87559 08/12/2014 GEMCITABINE HCL INTRAVENOUS VIAL (ML) 2 G/52.6ML 3.25580 08/12/2014 GEMCITABINE HCL INTRAVENOUS VIAL (ML) 200MG/5.26 3.55320 08/12/2014 GEMFIBROZIL ORAL TABLET 600 MG 0.07726 06/16/2017 0.06021 12/22/2017 GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC 0.13213 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 100MG/50ML GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC 0.06630 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 120MG/0.1L GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC 0.15469 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 70 MG/50ML GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC 0.07491 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 90MG/100ML GENTAMICIN SULFATE INJECTION VIAL (ML) 20 MG/2 ML 1.45158 01/25/2013 GENTAMICIN SULFATE INJECTION VIAL (ML) 40 MG/ML 0.51161 08/12/2014 1.35660 01/16/2017 GENTAMICIN SULFATE OPHTHALMIC DROPS 0.3 % 0.68286 11/24/2017 0.62300 06/21/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date GENTAMICIN SULFATE OPHTHALMIC OINTMENT (GRAM) 0.3 % 3.99600 08/21/2015 8.10000 10/23/2019 GENTAMICIN SULFATE TOPICAL CREAM (GRAM) 0.1 % 1.86566 07/18/2018 1.44078 05/21/2021 GENTAMICIN SULFATE TOPICAL OINTMENT (GRAM) 0.1 % 2.02650 03/20/2020 1.66667 11/20/2020 GENTAMICIN SULFATE/PF INJECTION VIAL (ML) 20 MG/2 ML 1.09954 08/12/2014 GENTAMICIN SULFATE/PF INTRAVENOUS VIAL WITH THREADED PORT 0.29434 01/25/2013 (ML) 100MG/10ML GENTAMICIN SULFATE/PF INTRAVENOUS VIAL WITH THREADED PORT 0.39255 01/25/2013 (ML) 60 MG/6 ML GLIMEPIRIDE ORAL TABLET 1 MG 0.03490 12/22/2017 0.01800 01/25/2019 GLIMEPIRIDE ORAL TABLET 2 MG 0.06095 09/22/2017 0.03695 12/22/2017 GLIMEPIRIDE ORAL TABLET 4 MG 0.08041 03/03/2017 0.04760 09/22/2017 GLIPIZIDE ORAL TABLET 10 MG 0.05265 08/21/2015 0.02000 08/25/2017 GLIPIZIDE ORAL TABLET 5 MG 0.03000 08/21/2015 0.01935 10/20/2017 GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.14525 12/20/2019 0.10929 11/20/2020 GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 2.5 MG 0.15400 12/22/2017 0.10667 03/15/2019 GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 5 MG 0.10660 03/16/2018 0.07990 10/25/2019 GLIPIZIDE/ HCL ORAL TABLET 2.5-250 MG 0.34151 11/08/2013 0.34151 08/21/2015 GLIPIZIDE/METFORMIN HCL ORAL TABLET 2.5-500 MG 0.43480 05/20/2016 0.23690 05/17/2019 GLIPIZIDE/METFORMIN HCL ORAL TABLET 5 MG-500MG 0.24565 11/24/2017 0.21777 11/16/2018 SULFATE ORAL TABLET 750 MG 0.33095 01/25/2013 GLUCOSAMINE SULFATE/CHONDROITIN 1.20120 01/25/2013 SULFATE/METHYLSULFONYLMETHAN ORAL TABLET 500-200 MG GLYBURIDE ORAL TABLET 1.25 MG 0.07710 03/02/2018 0.06020 02/22/2019 GLYBURIDE ORAL TABLET 2.5 MG 0.13169 08/21/2015 0.03220 09/22/2017 GLYBURIDE ORAL TABLET 5 MG 0.04420 09/22/2017 0.03258 06/18/2021 GLYBURIDE,MICRONIZED ORAL TABLET 1.5 MG 0.02590 08/12/2014 0.02590 08/21/2015 GLYBURIDE,MICRONIZED ORAL TABLET 3 MG 0.02840 08/12/2014 0.02840 08/21/2015 GLYBURIDE,MICRONIZED ORAL TABLET 6 MG 0.09900 05/17/2013 0.09900 08/21/2015 GLYBURIDE/METFORMIN HCL ORAL TABLET 1.25-250MG 0.09353 08/21/2015 0.03860 11/16/2018 GLYBURIDE/METFORMIN HCL ORAL TABLET 2.5-500 MG 0.08911 08/21/2015 0.05000 08/25/2017 GLYBURIDE/METFORMIN HCL ORAL TABLET 5 MG-500MG 0.04340 08/25/2017 0.02658 02/22/2019 GLYCINE ORAL POWDER (GRAM) 0.21190 08/12/2014 GLYCINE UROLOGIC SOLUTION IRRIGATION SOLUTION, IRRIGATION 1.5 0.00291 08/12/2014 % GLYCOPYRROLATE INJECTION VIAL (ML) 0.2 MG/ML 0.22100 08/21/2015 GLYCOPYRROLATE ORAL TABLET 1 MG 0.11360 05/17/2019 0.06940 03/20/2020 GLYCOPYRROLATE ORAL TABLET 2 MG 0.26900 09/22/2017 0.17170 03/02/2018 GRANISETRON HCL INTRAVENOUS VIAL (ML) 1 MG/ML 4.71250 01/25/2013 4.71250 08/21/2015 GRANISETRON HCL INTRAVENOUS VIAL (ML) 1 MG/ML(1) 7.21995 01/25/2013 6.71000 05/17/2019 GRANISETRON HCL ORAL TABLET 1 MG 1.52404 02/27/2015 1.52404 08/21/2015 GRANISETRON HCL/PF INTRAVENOUS VIAL (ML) 100 MCG/ML 3.21880 08/12/2014 ULTRAMICROSIZE ORAL TABLET 125 MG 3.68837 10/17/2014 3.68837 08/21/2015 GRISEOFULVIN ULTRAMICROSIZE ORAL TABLET 250 MG 4.28393 08/21/2015 2.81345 06/16/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date GRISEOFULVIN, MICROSIZE ORAL SUSPENSION, ORAL (FINAL DOSE 0.12406 01/31/2014 0.12406 08/21/2015 FORM) 125 MG/5ML GRISEOFULVIN, MICROSIZE ORAL TABLET 500 MG 5.95588 12/05/2014 GUAIFENESIN ORAL LIQUID (ML) 100 MG/5ML 0.00603 09/19/2014 0.00603 08/21/2015 GUAIFENESIN ORAL TABLET 200 MG 0.04248 10/31/2014 0.04248 08/21/2015 GUAIFENESIN ORAL TABLET 400 MG 0.05655 08/12/2014 0.05655 08/21/2015 GUAIFENESIN ORAL TABLET, EXTENDED RELEASE 12 HR 600 MG 0.31161 08/21/2015 GUAIFENESIN/DEXTROMETHORPHAN HBR ORAL LIQUID (ML) 100- 0.01776 11/07/2014 0.01776 08/21/2015 10MG/5 GUAIFENESIN/DEXTROMETHORPHAN HBR ORAL SYRUP 100-10MG/5 0.00801 08/12/2014 0.00801 08/21/2015 GUAIFENESIN/DEXTROMETHORPHAN HBR ORAL TABLET 400MG-20MG 0.07778 08/21/2015 GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.15389 10/10/2014 DROPS 5-2.5MG/ML GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.01987 04/24/2015 0.01987 08/21/2015 LIQUID (ML) 100-10-5MG GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.03941 08/12/2014 0.03941 08/21/2015 LIQUID (ML) 100-15-5/5 GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.02590 08/12/2014 LIQUID (ML) 200-10-5/5 GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.07980 08/12/2014 0.07980 08/21/2015 LIQUID (ML) 200-20-10 GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.47192 12/12/2014 0.47192 08/21/2015 TABLET 380-15-10 GUAIFENESIN/PHENYLEPHRINE HCL ORAL TABLET 380MG-10MG 0.43170 08/12/2014 GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1 MG 0.29290 12/20/2019 0.24130 09/25/2020 GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 0.31610 07/26/2019 0.24000 11/15/2019 GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 3 MG 0.58000 08/25/2017 0.36520 01/25/2019 GUANIDINE HCL TABLET 125 MG 0.17724 01/25/2013 HALOBETASOL PROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.92200 08/16/2019 0.79908 11/15/2019 HALOBETASOL PROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 2.05920 06/16/2017 1.65860 03/20/2020 HALOPERIDOL DECANOATE INTRAMUSCULAR AMPUL (ML) 100 MG/ML 33.55200 12/25/2020 29.94700 03/19/2021 HALOPERIDOL DECANOATE INTRAMUSCULAR AMPUL (ML) 50 MG/ML 18.82000 08/28/2020 18.51333 02/19/2021 HALOPERIDOL DECANOATE INTRAMUSCULAR VIAL (ML) 100 MG/ML 37.96000 08/28/2020 28.39850 12/25/2020 HALOPERIDOL DECANOATE INTRAMUSCULAR VIAL (ML) 50 MG/ML 19.26333 12/25/2020 19.01360 02/19/2021 HALOPERIDOL LACTATE INJECTION AMPUL (ML) 5 MG/ML 5.15760 01/25/2013 HALOPERIDOL LACTATE INJECTION VIAL (ML) 5 MG/ML 1.02376 08/21/2015 0.63747 08/17/2018 HALOPERIDOL LACTATE ORAL CONCENTRATE, ORAL 2 MG/ML 0.03924 08/17/2018 0.06721 05/23/2019 HALOPERIDOL ORAL TABLET 0.5 MG 0.21117 10/11/2013 0.15250 08/25/2017 HALOPERIDOL ORAL TABLET 1 MG 0.33160 02/22/2018 0.28000 05/25/2018 HALOPERIDOL ORAL TABLET 10 MG 0.68650 03/20/2020 0.57540 03/19/2021 HALOPERIDOL ORAL TABLET 2 MG 0.50550 06/04/2020 0.45190 05/21/2021 HALOPERIDOL ORAL TABLET 20 MG 1.18740 03/02/2018 0.95065 08/16/2019 HALOPERIDOL ORAL TABLET 5 MG 0.46260 05/13/2019 0.44668 11/15/2019 HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.04754 04/10/2015 0.04754 08/21/2015 INTRAVENOUS SOLUTION 12500/250 HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.02356 04/10/2015 0.02356 08/21/2015 INTRAVENOUS SOLUTION 25000/250 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.01978 04/10/2015 0.01978 08/21/2015 INTRAVENOUS SOLUTION 25000/500 HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM CHLORIDE/PF 0.00720 01/25/2013 0.00720 08/21/2015 INTRAVENOUS INTRAVENOUS SOLUTION 1000/500ML HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM CHLORIDE/PF 0.00440 08/12/2014 0.00440 08/21/2015 INTRAVENOUS INTRAVENOUS SOLUTION 2K/1000ML HEPARIN SODIUM,PORCINE INJECTION CARTRIDGE (ML) 5000/ML(1) 3.65400 01/25/2013 HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 1000/ML 0.20739 11/28/2014 0.20739 08/21/2015 HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 10000/ML 2.31659 05/01/2015 2.31659 08/21/2015 HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 20000/ML 8.04388 04/03/2015 HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 5000/ML 1.04000 08/25/2017 0.70240 08/16/2019 HEPARIN SODIUM,PORCINE INTRAVENOUS SYRINGE (ML) 500/5 ML 0.32928 11/15/2013 HEPARIN SODIUM,PORCINE INTRAVENOUS VIAL (ML) 100/ML 0.03983 04/05/2013 0.03983 08/21/2015 HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.05431 04/24/2015 0.05431 08/21/2015 INTRAVENOUS SOLUTION 12500/250 HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.01097 04/17/2015 0.01097 08/21/2015 INTRAVENOUS SOLUTION 20K/500ML HEPARIN SODIUM,PORCINE/PF INJECTION CARTRIDGE (ML) 5000/0.5ML 3.99840 05/01/2015 3.99840 08/21/2015 HEPARIN SODIUM,PORCINE/PF INJECTION VIAL (ML) 1000/ML 3.64676 08/12/2014 HEPARIN SODIUM,PORCINE/PF INJECTION VIAL (ML) 5000/0.5ML 9.36923 01/25/2013 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 1 UNIT/ML 0.53235 05/31/2013 0.53235 08/21/2015 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 10 UNIT/ML 0.15678 05/31/2013 0.15678 08/21/2015 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 100/ML (1) 0.14740 05/31/2013 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 1000/10 ML 0.14740 05/31/2013 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 200/2 ML 0.14740 05/31/2013 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 300/3 ML 0.15513 07/25/2014 0.15513 08/21/2015 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 500/5 ML 0.09299 03/07/2014 0.09299 08/21/2015 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS VIAL (ML) 10 UNIT/ML 1.27250 08/12/2014 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS VIAL (ML) 100/ML (1) 1.63384 01/25/2013 HYDRALAZINE HCL INJECTION VIAL (ML) 20 MG/ML 4.60408 07/19/2013 HYDRALAZINE HCL ORAL TABLET 10 MG 0.03468 08/25/2017 0.03226 12/25/2020 HYDRALAZINE HCL ORAL TABLET 100 MG 0.06535 09/30/2016 0.06483 05/21/2021 HYDRALAZINE HCL ORAL TABLET 25 MG 0.05000 03/17/2017 0.03020 09/22/2017 HYDRALAZINE HCL ORAL TABLET 50 MG 0.05113 09/22/2017 0.03105 12/22/2017 HYDROCHLOROTHIAZIDE ORAL CAPSULE 12.5 MG 0.05352 08/21/2015 0.02000 08/25/2017 HYDROCHLOROTHIAZIDE ORAL TABLET 12.5 MG 0.08000 08/25/2017 0.05327 11/15/2019 HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG 0.02250 08/21/2015 0.00892 10/20/2017 HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG 0.04931 08/21/2015 0.01144 08/25/2017 HYDROCODONE BITARTRATE MISCELLANEOUS POWDER (GRAM) 100 % 7.56450 08/21/2015 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 0.56630 05/30/2014 2.5-108/5 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 0.47191 01/25/2013 2.5-167/5 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 0.59709 08/01/2014 5-217MG/10 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 0.16755 08/12/2014 7.5-325/15 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 0.07831 07/11/2017 0.04658 11/24/2017 7.5-325/15 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 10MG- 1.78019 10/17/2014 0.60510 09/22/2017 300MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 10MG- 0.10886 06/16/2017 0.09900 04/16/2021 325MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 2.5-325 0.69069 04/03/2015 MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 5 MG- 0.65450 09/22/2017 0.32970 05/22/2020 300MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 5 MG- 0.14569 03/03/2017 0.06500 08/25/2017 325MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 7.5-300 1.07550 06/16/2017 0.70230 09/22/2017 MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 7.5-325 0.09087 01/25/2019 0.07087 08/16/2019 MG HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE ORAL 0.52500 01/25/2013 SYRUP 5-1.5 MG/5 HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE ORAL 0.06580 08/12/2014 SYRUP 5-1.5 MG/5 HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE ORAL 0.71674 01/30/2015 0.71674 08/21/2015 TABLET 5 MG-1.5MG HYDROCODONE POLISTIREX/CHLORPHENIRAMINE POLISTIREX ORAL 0.40047 11/24/2017 0.38226 10/19/2018 SUSPENSION, EXTENDED RELEASE 12 HR 10-8MG/5ML HYDROCODONE/IBUPROFEN ORAL TABLET 10MG-200MG 3.99069 04/10/2015 3.99069 08/21/2015 HYDROCODONE/IBUPROFEN ORAL TABLET 2.5-200 MG 2.04491 01/25/2013 2.04491 08/21/2015 HYDROCODONE/IBUPROFEN ORAL TABLET 5MG-200MG 2.49634 08/21/2015 2.23740 09/22/2017 HYDROCODONE/IBUPROFEN ORAL TABLET 7.5-200 MG 0.25323 05/20/2016 0.15400 07/14/2017 HYDROCORTISONE ACETATE MISCELLANEOUS POWDER (GRAM) 3.23180 01/25/2013 3.23180 08/21/2015 HYDROCORTISONE ACETATE RECTAL SUPPOSITORY, RECTAL 25 MG 2.93375 08/16/2019 2.38958 03/20/2020 HYDROCORTISONE ACETATE RECTAL SUPPOSITORY, RECTAL 30 MG 3.95180 08/12/2014 HYDROCORTISONE ACETATE/ HCL/ALOE VERA RECTAL KIT 251.09000 07/18/2014 2.5-3%(7G) HYDROCORTISONE ACETATE/PRAMOXINE HCL TOPICAL CREAM (GRAM) 1.29675 05/01/2015 1.29675 08/21/2015 2.5 %-1 % HYDROCORTISONE BUTYRATE TOPICAL CREAM (GRAM) 0.1 % 1.02530 02/15/2013 1.02530 08/21/2015 HYDROCORTISONE BUTYRATE TOPICAL OINTMENT (GRAM) 0.1 % 1.88020 05/09/2014 1.88020 08/21/2015 HYDROCORTISONE BUTYRATE TOPICAL SOLUTION, NON-ORAL 0.1 % 0.21870 07/25/2014 0.21870 08/21/2015 HYDROCORTISONE BUTYRATE/EMOLLIENT BASE TOPICAL CREAM 6.29588 12/27/2013 2.47703 06/18/2021 (GRAM) 0.1 % HYDROCORTISONE MISCELLANEOUS POWDER (GRAM) 2.18774 08/12/2014 2.18774 08/21/2015 HYDROCORTISONE ORAL TABLET 10 MG 0.21970 09/22/2017 0.42893 02/25/2021 HYDROCORTISONE ORAL TABLET 20 MG 0.45000 11/24/2017 0.13960 08/17/2018 HYDROCORTISONE ORAL TABLET 5 MG 0.16140 09/22/2017 0.15020 11/16/2018 HYDROCORTISONE RECTAL ENEMA (ML) 100MG/60ML 0.06885 12/05/2014 0.06885 08/21/2015 HYDROCORTISONE TOPICAL CREAM (GRAM) 0.5 % 0.08224 04/05/2013 0.08224 08/21/2015 HYDROCORTISONE TOPICAL CREAM (GRAM) 1 % 0.05060 01/30/2015 0.05060 08/21/2015 HYDROCORTISONE TOPICAL CREAM (GRAM) 2.5 % 0.08792 10/25/2019 0.07675 05/22/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date HYDROCORTISONE TOPICAL CREAM WITH PERINEAL APPLICATOR 1 % 0.66820 01/25/2013 HYDROCORTISONE TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 0.42190 12/23/2019 0.34234 05/22/2020 % HYDROCORTISONE TOPICAL LOTION (GRAM) 1 % 0.04414 08/12/2014 HYDROCORTISONE TOPICAL LOTION (ML) 1 % 0.03153 08/12/2014 0.03153 08/21/2015 HYDROCORTISONE TOPICAL LOTION (ML) 2.5 % 0.23863 04/12/2013 HYDROCORTISONE TOPICAL OINTMENT (GRAM) 1 % 0.10490 01/30/2015 0.10490 08/21/2015 HYDROCORTISONE TOPICAL OINTMENT (GRAM) 2.5 % 0.11200 08/12/2014 0.11200 08/21/2015 HYDROCORTISONE VALERATE TOPICAL CREAM (GRAM) 0.2 % 1.43182 11/15/2019 1.04733 05/22/2020 HYDROCORTISONE VALERATE TOPICAL OINTMENT (GRAM) 0.2 % 4.59200 08/21/2015 3.09378 07/16/2021 HYDROCORTISONE/ACETIC ACID OTIC DROPS 1 %-2 % 9.82215 08/21/2015 8.85454 01/13/2017 HYDROCORTISONE/ALOE VERA TOPICAL CREAM (GRAM) 1 % 0.08883 08/21/2015 0.04374 01/25/2019 HYDROCORTISONE/IODOQUINOL TOPICAL CREAM (GRAM) 1 %-1 % 0.43200 08/12/2014 HYDROCORTISONE/ OIL/PETROLATUM,WHITE OINTMENT 0.12564 01/25/2013 (GRAM) 1 % HYDROMORPHONE HCL INJECTION AMPUL (ML) 1 MG/ML 0.87360 01/25/2013 HYDROMORPHONE HCL INJECTION AMPUL (ML) 4 MG/ML 1.33560 01/25/2013 HYDROMORPHONE HCL INJECTION SYRINGE (ML) 0.5MG/.5ML 8.44200 06/21/2013 HYDROMORPHONE HCL INJECTION SYRINGE (ML) 1 MG/ML 3.90600 01/25/2013 HYDROMORPHONE HCL INJECTION SYRINGE (ML) 2 MG/ML 1.88160 12/26/2014 HYDROMORPHONE HCL INJECTION SYRINGE (ML) 4 MG/ML 3.78000 01/25/2013 HYDROMORPHONE HCL INJECTION VIAL (ML) 2 MG/ML 0.87780 08/12/2014 HYDROMORPHONE HCL ORAL LIQUID (ML) 1 MG/ML 0.27988 01/25/2013 HYDROMORPHONE HCL ORAL TABLET 2 MG 0.07780 08/25/2017 0.05790 05/22/2020 HYDROMORPHONE HCL ORAL TABLET 4 MG 0.08770 09/22/2017 0.07870 07/26/2019 HYDROMORPHONE HCL ORAL TABLET 8 MG 0.21960 02/22/2019 0.20310 03/20/2020 HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 12 14.29670 08/01/2014 14.29670 08/21/2015 MG HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 16 19.06219 08/21/2015 15.75000 05/25/2018 MG HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 32 37.91137 08/01/2014 MG HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 8 9.53110 08/01/2014 9.53110 08/21/2015 MG HYDROMORPHONE HCL RECTAL SUPPOSITORY, RECTAL 3 MG 8.58670 02/01/2013 HYDROMORPHONE HCL/PF INJECTION AMPUL (ML) 1 MG/ML 0.87360 01/25/2013 HYDROMORPHONE HCL/PF INJECTION AMPUL (ML) 2 MG/ML 0.94080 01/25/2013 HYDROMORPHONE HCL/PF INJECTION AMPUL (ML) 4 MG/ML 1.33560 01/25/2013 HYDROMORPHONE HCL/PF INJECTION SYRINGE (ML) 4 MG/ML 3.78000 01/25/2013 HYDROMORPHONE HCL/PF INJECTION VIAL (ML) 10 MG/ML 1.90750 01/30/2015 1.61638 12/02/2016 HYDROQUINONE MICROSPHERES CREAM, EXTENDED RELEASE (GRAM) 2.49387 01/25/2013 4 % HYDROQUINONE TOPICAL CREAM (GRAM) 4 % 2.30566 08/21/2015 0.83056 11/15/2019 HYDROXOCOBALAMIN INTRAMUSCULAR VIAL (ML) 1000MCG/ML 0.89273 01/25/2013 HYDROXYUREA ORAL CAPSULE 500 MG 0.21423 11/24/2017 0.18352 03/02/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date HYDROXYZINE HCL INTRAMUSCULAR VIAL (ML) 50 MG/ML 1.75000 01/25/2013 1.75000 08/21/2015 HYDROXYZINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.05916 08/21/2015 0.03692 03/02/2018 HYDROXYZINE HCL ORAL TABLET 10 MG 0.03772 09/22/2017 0.02288 04/16/2021 HYDROXYZINE HCL ORAL TABLET 25 MG 0.04000 08/25/2017 0.04986 06/06/2019 HYDROXYZINE HCL ORAL TABLET 50 MG 0.08702 10/03/2019 0.04500 06/19/2020 HYDROXYZINE PAMOATE ORAL CAPSULE 100 MG 0.52378 08/15/2014 0.52378 08/21/2015 HYDROXYZINE PAMOATE ORAL CAPSULE 25 MG 0.08300 02/25/2019 0.06010 10/25/2019 HYDROXYZINE PAMOATE ORAL CAPSULE 50 MG 0.08144 09/03/2019 0.06434 11/15/2019 HYOSCYAMINE SULFATE ORAL DROPS 0.125MG/ML 1.29622 04/24/2015 1.29622 08/21/2015 HYOSCYAMINE SULFATE ORAL ELIXIR 125MCG/5ML 0.04790 12/26/2014 HYOSCYAMINE SULFATE ORAL TABLET 0.125 MG 0.13030 09/22/2017 0.11025 08/16/2019 HYOSCYAMINE SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 0.60697 07/18/2014 0.60697 08/21/2015 0.375 MG HYOSCYAMINE SULFATE ORAL TABLET,DISINTEGRATING 0.125 MG 0.18450 03/16/2018 0.12900 05/17/2019 HYOSCYAMINE SULFATE SUBLINGUAL TABLET, SUBLINGUAL 0.125 MG 0.19432 12/25/2015 0.07000 07/14/2017 HYPROMELLOSE OPHTHALMIC DROPS 0.3 % 0.35978 08/12/2014 HYPROMELLOSE OPHTHALMIC DROPS 0.4 % 0.17850 01/25/2013 IBANDRONATE SODIUM INTRAVENOUS SYRINGE (ML) 3 MG/3 ML 74.36375 11/14/2014 IBANDRONATE SODIUM ORAL TABLET 150 MG 4.66000 06/22/2018 4.34278 11/15/2019 IBUPROFEN ORAL CAPSULE 200 MG 0.10261 04/10/2015 0.10261 08/21/2015 IBUPROFEN ORAL SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 50 0.22167 01/30/2015 0.22167 08/21/2015 MG/1.25 IBUPROFEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 MG/5ML 0.02262 04/17/2015 0.02262 08/21/2015 IBUPROFEN ORAL TABLET 200 MG 0.01635 01/16/2015 0.01635 08/21/2015 IBUPROFEN ORAL TABLET 400 MG 0.04002 08/25/2017 0.03780 05/21/2021 IBUPROFEN ORAL TABLET 600 MG 0.06700 08/21/2015 0.03420 07/14/2017 IBUPROFEN ORAL TABLET 800 MG 0.08189 11/20/2020 0.07580 03/19/2021 IBUPROFEN ORAL TABLET,CHEWABLE 100 MG 0.12702 08/21/2015 0.12802 05/03/2019 IBUPROFEN/OXYCODONE HCL TABLET 400 MG-5MG 1.03130 08/12/2014 1.03130 08/21/2015 IFOSFAMIDE INTRAVENOUS VIAL (EA) 3 G 88.61300 01/25/2013 IFOSFAMIDE INTRAVENOUS VIAL (ML) 1 G/20 ML 2.09300 02/27/2015 2.09300 08/21/2015 IFOSFAMIDE INTRAVENOUS VIAL (ML) 3 G/60 ML 1.93007 10/17/2014 1.93007 08/21/2015 IFOSFAMIDE/MESNA KIT 3G-1G 281.14725 01/25/2013 IMIPENEM/CILASTATIN SODIUM INTRAVENOUS VIAL (EA) 250 MG 4.41000 08/12/2014 4.41000 08/21/2015 IMIPENEM/CILASTATIN SODIUM INTRAVENOUS VIAL (EA) 500 MG 8.82000 04/18/2014 8.82000 08/21/2015 IMIPRAMINE HCL ORAL TABLET 10 MG 0.10780 08/25/2017 0.06140 11/24/2017 IMIPRAMINE HCL ORAL TABLET 25 MG 0.10686 03/03/2017 0.06370 11/24/2017 IMIPRAMINE HCL ORAL TABLET 50 MG 0.13870 03/20/2020 0.10530 05/22/2020 IMIPRAMINE PAMOATE ORAL CAPSULE 100 MG 5.97100 03/07/2014 IMIPRAMINE PAMOATE ORAL CAPSULE 125 MG 8.87087 04/10/2015 IMIPRAMINE PAMOATE ORAL CAPSULE 150 MG 11.22875 04/10/2015 IMIPRAMINE PAMOATE ORAL CAPSULE 75 MG 7.95000 12/27/2013 IMIQUIMOD TOPICAL CREAM IN PACKET (EA) 5 % 1.89000 12/20/2019 1.08750 09/25/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date INDAPAMIDE ORAL TABLET 1.25 MG 0.17220 09/22/2017 0.09380 09/25/2020 INDAPAMIDE ORAL TABLET 2.5 MG 0.17880 09/22/2017 0.14820 01/24/2020 INDOMETHACIN ORAL CAPSULE 25 MG 0.07340 12/22/2017 0.02910 11/16/2018 INDOMETHACIN ORAL CAPSULE 50 MG 0.09440 03/02/2018 0.07690 09/21/2018 INDOMETHACIN ORAL CAPSULE, EXTENDED RELEASE 75 MG 0.32783 07/14/2017 0.27750 03/02/2018 INDOMETHACIN SODIUM INTRAVENOUS VIAL (EA) 1 MG 365.86025 08/12/2014 IPRATROPIUM BROMIDE INHALATION SOLUTION, NON-ORAL 0.2 MG/ML 0.06013 08/21/2015 0.03720 07/26/2019 IPRATROPIUM BROMIDE NASAL AEROSOL, SPRAY (ML) 21 MCG 0.62500 12/25/2015 0.59969 04/21/2017 IPRATROPIUM BROMIDE NASAL AEROSOL, SPRAY (ML) 42 MCG 2.39930 05/03/2019 1.51067 07/17/2020 IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION AMPUL FOR 0.04815 07/26/2019 0.04222 01/15/2021 NEBULIZATION (ML) 0.5-3MG/3 IRBESARTAN ORAL TABLET 150 MG 0.13666 08/25/2017 0.11244 10/20/2017 IRBESARTAN ORAL TABLET 75 MG 0.14563 08/21/2015 0.08700 09/22/2017 IRBESARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 150-12.5MG 0.18022 03/02/2018 0.15667 08/17/2018 IRBESARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 300-12.5MG 0.19011 09/22/2017 0.17176 11/16/2018 CARBONYL,GLUC/FOLIC ACID/VIT B12/VIT C/DOCUSATE SODIUM 0.78945 08/21/2015 2.02566 12/13/2018 TABLET 90-1-50 MG IRON POLYSACCHAR COMPLX/IRON POLYPEPTIDE/FOLIC 2.61148 01/25/2013 2.61148 08/21/2015 ACID/B12 TABLET 22-6-1-25 IRON POLYSACCHARIDE COMPLEX ORAL CAPSULE 150 MG 0.12990 08/16/2013 0.12990 08/21/2015 IRON POLYSACCHARIDE COMPLEX/CYANOCOBALAMIN/FOLIC ACID 0.19524 02/20/2015 0.19524 08/21/2015 ORAL CAPSULE 150-25-1 IRON POLYSACCHARIDE COMPLEX/IRON HEME POLYPEPTIDE ORAL 0.37090 08/12/2014 TABLET 28 MG IRON,CARBONYL ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.12650 08/12/2014 15MG/1.25 IRON,CARBONYL/ASCORBIC ACID/CYANOCOBALAMIN/FOLIC ACID ORAL 0.80738 08/12/2014 TABLET 100-250-1 IRON,CARBONYL/DOCUSATE SODIUM/B12-IF/FOLIC ACID/MULTIVIT-MIN 0.47055 01/25/2013 TABLET, EXTENDED RELEASE 24 HR 150-50-1MG IRON,CARBONYL/METHYLFOLATE/VIT C/VIT E/VIT B12/BIOTIN/ 0.47055 01/25/2013 ORAL TABLET, EXTENDED RELEASE 24 HR 150-50-1MG ISOMETHEPTENE MUCATE/DICHLORALPHENAZONE/ACETAMINOPHEN 4.71877 09/19/2014 4.71877 08/21/2015 CAPSULE 65-100-325 ISONIAZID INJECTION VIAL (ML) 100 MG/ML 63.03150 01/25/2013 ISONIAZID ORAL SOLUTION, ORAL 50 MG/5 ML 0.09983 01/25/2013 ISONIAZID ORAL TABLET 100 MG 0.04221 12/13/2013 0.04221 08/21/2015 ISONIAZID ORAL TABLET 300 MG 0.06993 11/28/2014 0.06993 08/21/2015 ISOPROPYL ALCOHOL IN GLYCERIN OTIC DROPS 95 %-5 % 0.07020 08/12/2014 0.07020 08/21/2015 ISOSORBIDE DINITRATE ORAL TABLET 10 MG 0.68863 08/21/2015 0.22376 09/30/2016 ISOSORBIDE DINITRATE ORAL TABLET 20 MG 0.41250 03/02/2018 0.18870 09/21/2018 ISOSORBIDE DINITRATE ORAL TABLET 30 MG 0.60040 09/25/2020 0.48530 11/20/2020 ISOSORBIDE DINITRATE ORAL TABLET 5 MG 0.09160 02/21/2020 0.38911 08/06/2020 ISOSORBIDE DINITRATE ORAL TABLET, EXTENDED RELEASE 40 MG 1.24501 12/05/2014 1.24501 08/21/2015 ISOSORBIDE MONONITRATE ORAL TABLET 10 MG 0.19730 01/25/2013 0.19730 08/21/2015 ISOSORBIDE MONONITRATE ORAL TABLET 20 MG 0.12251 10/11/2013 0.09070 01/19/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.31550 09/22/2017 0.24000 11/24/2017 120 MG ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.07058 05/17/2019 0.06600 09/25/2020 30 MG ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.08680 01/24/2020 0.06790 03/20/2020 60 MG ISOSULFAN BLUE SUBCUTANEOUS VIAL (ML) 1 % 110.57218 04/03/2015 110.57218 08/21/2015 ISOTRETINOIN ORAL CAPSULE 10 MG 3.70100 10/19/2018 2.38573 10/23/2020 ISOTRETINOIN ORAL CAPSULE 20 MG 1.92767 08/16/2019 3.46933 02/07/2020 ISOTRETINOIN ORAL CAPSULE 30 MG 5.11994 04/08/2020 3.79000 10/23/2020 ISOTRETINOIN ORAL CAPSULE 40 MG 2.13833 01/24/2020 2.12667 08/28/2020 ISOXSUPRINE HCL ORAL TABLET 10 MG 0.80892 04/03/2015 0.80892 08/21/2015 ISRADIPINE ORAL CAPSULE 2.5 MG 0.95543 02/13/2015 0.95543 08/21/2015 ISRADIPINE ORAL CAPSULE 5 MG 1.39713 03/27/2015 1.39713 08/21/2015 ITRACONAZOLE ORAL CAPSULE 100 MG 1.62600 09/20/2019 1.09133 11/15/2019 IVERMECTIN ORAL TABLET 3 MG 7.57155 01/16/2015 ORAL TABLET 200 MG 0.98460 12/22/2017 0.93167 03/02/2018 KETOCONAZOLE TOPICAL CREAM (GRAM) 2 % 0.46671 02/21/2020 0.36634 07/17/2020 KETOCONAZOLE TOPICAL SHAMPOO 2 % 0.05789 08/25/2017 0.11250 10/02/2020 KETOPROFEN ORAL CAPSULE 75 MG 0.40169 03/06/2015 0.40169 08/21/2015 KETOPROFEN ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 5.64648 03/13/2015 5.64648 08/21/2015 200 MG KETOROLAC TROMETHAMINE INJECTION SYRINGE (ML) 30 MG/ML 1.81000 04/25/2014 KETOROLAC TROMETHAMINE INJECTION VIAL (ML) 15 MG/ML 1.01304 02/13/2015 1.01304 08/21/2015 KETOROLAC TROMETHAMINE INJECTION VIAL (ML) 30 MG/ML 1.31943 01/25/2013 KETOROLAC TROMETHAMINE INJECTION VIAL (ML) 30MG/ML(1) 1.08696 02/13/2015 1.08696 08/21/2015 KETOROLAC TROMETHAMINE INTRAMUSCULAR VIAL (ML) 60 MG/2 ML 0.97981 02/13/2015 0.97981 08/21/2015 KETOROLAC TROMETHAMINE OPHTHALMIC DROPS 0.4 % 7.81600 03/27/2015 7.81600 08/21/2015 KETOROLAC TROMETHAMINE OPHTHALMIC DROPS 0.5 % 1.13433 08/25/2017 1.03900 06/18/2021 KETOROLAC TROMETHAMINE ORAL TABLET 10 MG 0.69950 11/16/2018 0.58960 05/22/2020 KETOTIFEN FUMARATE OPHTHALMIC DROPS 0.025 % 0.92080 08/21/2015 0.92080 12/31/2020 LABETALOL HCL INTRAVENOUS SYRINGE (ML) 20 MG/4 ML 0.65310 01/25/2013 0.65310 08/21/2015 LABETALOL HCL ORAL TABLET 100 MG 0.10450 09/20/2019 0.09052 01/15/2021 LABETALOL HCL ORAL TABLET 200 MG 0.12920 07/26/2019 0.11565 09/25/2020 LABETALOL HCL ORAL TABLET 300 MG 0.27700 11/24/2017 0.18370 09/20/2019 LACTIC ACID CREAM (GRAM) 10 % 0.08303 01/25/2013 LACTIC ACID LOTION (ML) 10 % 0.04280 08/12/2014 ORAL SOLUTION, ORAL 10 G/15 ML 0.03407 04/03/2015 LACTULOSE ORAL SOLUTION, ORAL 10 G/15 ML 0.01396 04/24/2015 0.00994 10/23/2020 LACTULOSE ORAL SOLUTION, ORAL 10 G/15 ML 0.01301 08/21/2015 0.01296 02/19/2021 LACTULOSE ORAL SOLUTION, ORAL 20 G/30 ML 0.02205 02/07/2014 0.02205 08/21/2015 LAMIVUDINE ORAL SOLUTION, ORAL 10 MG/ML 0.34922 03/13/2015 0.27563 11/24/2017 LAMIVUDINE ORAL TABLET 150 MG 1.72083 03/17/2017 0.65500 11/15/2019 LAMIVUDINE ORAL TABLET 300 MG 1.31000 11/15/2019 1.11217 11/20/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LAMIVUDINE/ZIDOVUDINE ORAL TABLET 150-300 MG 0.91667 09/22/2017 0.33467 05/22/2020 ORAL TABLET 100 MG 0.05167 08/25/2017 0.03960 12/22/2017 LAMOTRIGINE ORAL TABLET 150 MG 0.06512 08/25/2017 0.05278 08/28/2020 LAMOTRIGINE ORAL TABLET 200 MG 0.08236 08/21/2015 0.06122 08/25/2017 LAMOTRIGINE ORAL TABLET 25 MG 0.02605 07/26/2019 0.02380 09/25/2020 LAMOTRIGINE ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG 0.13440 02/21/2020 0.20031 04/08/2020 LAMOTRIGINE ORAL TABLET, CHEWABLE DISPERSIBLE 5 MG 0.08870 02/22/2019 0.17130 05/21/2019 LAMOTRIGINE ORAL TABLET, DOSE PACK 25MG (35) 2.90500 01/25/2013 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG 1.92966 01/25/2019 1.72650 06/21/2019 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 200 MG 2.01533 03/20/2020 1.62533 07/17/2020 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 25 MG 1.75000 06/22/2018 1.55055 06/21/2019 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 250 MG 8.57000 12/20/2018 6.25000 03/19/2021 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 2.83067 10/25/2019 2.28741 09/25/2020 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 50 MG 1.94367 11/15/2019 1.60000 05/22/2020 LAMOTRIGINE ORAL TABLET,DISINTEGRATING 100 MG 3.93467 05/22/2020 4.78611 12/30/2020 LAMOTRIGINE ORAL TABLET,DISINTEGRATING 200 MG 23.77830 08/21/2015 6.30000 03/15/2019 LAMOTRIGINE ORAL TABLET,DISINTEGRATING 25 MG 5.75000 08/17/2018 4.72000 01/25/2019 LAMOTRIGINE ORAL TABLET,DISINTEGRATING 50 MG 18.68721 08/21/2015 3.33933 11/24/2017 LANOLIN//PETROLATUM,WHITE OPHTHALMIC OINTMENT 0.91000 01/25/2013 0.91000 08/21/2015 (GRAM) LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.28500 06/16/2017 0.13167 05/17/2019 COATED) 15 MG LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.15656 07/14/2017 0.08467 03/15/2019 COATED) 30 MG LANSOPRAZOLE/AMOXICILLIN TRIHYDRATE/CLARITHROMYCIN ORAL 3.59300 03/20/2015 COMBINATION PACKAGE (EA) 30-500-500 LATANOPROST OPHTHALMIC DROPS 0.005 % 1.62800 04/17/2020 1.32000 01/15/2021 LEFLUNOMIDE ORAL TABLET 10 MG 0.76500 02/22/2019 0.66667 05/17/2019 LEFLUNOMIDE ORAL TABLET 20 MG 1.03800 03/20/2020 0.52533 08/28/2020 LETROZOLE ORAL TABLET 2.5 MG 0.10433 07/14/2017 0.08978 04/17/2020 LEUCOVORIN CALCIUM INJECTION VIAL (EA) 200 MG 16.25400 08/12/2014 16.25400 08/21/2015 LEUCOVORIN CALCIUM INJECTION VIAL (EA) 50 MG 5.85200 08/12/2014 5.85200 08/21/2015 LEUCOVORIN CALCIUM INJECTION VIAL (EA) 500 MG 99.22500 01/25/2013 LEUCOVORIN CALCIUM INJECTION VIAL (ML) 10 MG/ML 0.29460 08/12/2014 0.29460 08/21/2015 LEUCOVORIN CALCIUM ORAL TABLET 10 MG 5.25150 08/12/2014 LEUCOVORIN CALCIUM ORAL TABLET 15 MG 5.85368 01/25/2013 LEUCOVORIN CALCIUM ORAL TABLET 25 MG 7.83744 05/17/2013 4.84400 03/02/2018 LEUCOVORIN CALCIUM ORAL TABLET 5 MG 0.64904 12/02/2016 0.60030 08/17/2018 LEUPROLIDE ACETATE SUBCUTANEOUS KIT 1 MG/0.2ML 129.30375 03/13/2015 129.30375 08/21/2015 LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (EA) 1.25MG/0.5 4.52639 12/26/2014 4.52639 08/21/2015 LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (ML) 0.31MG/3ML 0.54096 03/17/2017 0.44401 05/21/2021 LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (ML) 0.63MG/3ML 0.30400 05/17/2019 0.25156 11/15/2019 LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (ML) 1.25MG/3ML 0.38012 03/02/2018 0.29673 08/17/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS 0.59877 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 1000MG/100 LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS 0.77967 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 1500MG/100 LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS 0.36284 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 500MG/0.1L LEVETIRACETAM INTRAVENOUS VIAL (ML) 500 MG/5ML 1.29524 08/12/2014 1.29524 08/21/2015 LEVETIRACETAM ORAL SOLUTION, ORAL 100 MG/ML 0.03332 10/20/2017 0.03150 11/20/2020 LEVETIRACETAM ORAL SOLUTION, ORAL 500 MG/5ML 1.06824 08/21/2015 0.05210 09/30/2016 LEVETIRACETAM ORAL TABLET 1000 MG 0.21650 07/26/2019 0.19483 07/17/2020 LEVETIRACETAM ORAL TABLET 250 MG 0.07448 08/21/2015 0.06112 05/22/2020 LEVETIRACETAM ORAL TABLET 500 MG 0.10089 05/19/2017 0.07706 08/01/2018 LEVETIRACETAM ORAL TABLET 750 MG 0.16433 03/04/2019 0.12917 07/26/2019 LEVETIRACETAM ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.74117 06/29/2020 0.16667 11/20/2020 LEVETIRACETAM ORAL TABLET, EXTENDED RELEASE 24 HR 750 MG 0.27750 05/17/2019 0.21650 05/22/2020 LEVOBUNOLOL HCL OPHTHALMIC DROPS 0.5 % 2.15200 09/30/2016 0.58000 12/21/2018 LEVOCARNITINE (WITH SUGAR) ORAL SOLUTION, ORAL 100 MG/ML 0.27042 06/22/2018 0.19661 11/15/2019 LEVOCARNITINE ORAL TABLET 330 MG 0.72599 05/25/2018 0.87770 06/25/2021 LEVOCARNITINE ORAL TABLET 500 MG 0.24450 10/24/2014 0.24450 08/21/2015 LEVOCETIRIZINE DIHYDROCHLORIDE ORAL SOLUTION, ORAL 2.5 0.43651 08/12/2014 0.43651 08/21/2015 MG/5ML LEVOCETIRIZINE DIHYDROCHLORIDE ORAL TABLET 5 MG 0.07215 11/16/2018 0.06111 04/26/2019 LEVOFLOXACIN INTRAVENOUS VIAL (ML) 25 MG/ML 0.55298 08/12/2014 LEVOFLOXACIN OPHTHALMIC DROPS 0.5 % 7.88880 01/25/2013 LEVOFLOXACIN ORAL SOLUTION, ORAL 250MG/10ML 0.88900 08/12/2014 LEVOFLOXACIN ORAL TABLET 250 MG 0.14767 08/21/2015 0.05240 03/15/2019 LEVOFLOXACIN ORAL TABLET 500 MG 0.12400 11/16/2018 0.10300 07/26/2019 LEVOFLOXACIN ORAL TABLET 750 MG 0.24150 03/02/2018 0.22400 04/26/2019 LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS 0.11258 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 250MG/50ML LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS 0.06601 08/12/2014 0.02228 11/24/2017 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 500MG/0.1L LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS 0.05357 08/12/2014 0.01569 11/24/2017 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 750MG/.15L LEVOMEFOLATE CALCIUM ORAL TABLET 15 MG 2.04831 01/23/2015 2.04831 08/21/2015 LEVOMEFOLATE CALCIUM ORAL TABLET 7.5 MG 2.05620 02/20/2015 2.05620 08/21/2015 LEVONORGESTREL ORAL TABLET 0.75 MG 12.79600 01/25/2013 12.79600 08/21/2015 LEVONORGESTREL ORAL TABLET 1.5 MG 10.22000 05/17/2019 8.50000 12/20/2019 LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL 3.65296 06/04/2021 ORAL TABLET, DOSE PACK, 3 MONTHS 0.15MG(84) LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL 0.99800 12/21/2018 0.41879 01/25/2019 ORAL TABLET, DOSE PACK, 3 MONTHS 100-20(84) LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL 0.31610 03/20/2020 0.56003 05/12/2020 ORAL TABLET, DOSE PACK, 3 MONTHS 150-30(84) LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET 0.1-0.02MG 0.21078 03/15/2019 0.09595 07/17/2020 LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET 0.15-0.03 0.19619 09/30/2016 0.11607 03/02/2018 LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET 6-5-10 0.68718 08/12/2014 0.18904 07/08/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET 90-20 MCG 1.48500 04/24/2015 LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET, DOSE PACK, 3 0.32100 11/16/2018 0.19314 02/19/2021 MONTHS 0.15-0.03 TARTRATE ORAL TABLET 2 MG 1.12600 08/12/2014 1.12600 08/21/2015 SODIUM INTRAVENOUS VIAL (EA) 100 MCG 77.11900 11/07/2014 77.11900 08/21/2015 LEVOTHYROXINE SODIUM INTRAVENOUS VIAL (EA) 500 MCG 44.60050 08/21/2015 482.92000 02/10/2021 LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG 0.30251 08/28/2020 0.19055 03/19/2021 LEVOTHYROXINE SODIUM ORAL TABLET 112 MCG 0.28570 03/19/2021 0.18832 06/18/2021 LEVOTHYROXINE SODIUM ORAL TABLET 125 MCG 0.33660 07/17/2020 0.25572 05/21/2021 LEVOTHYROXINE SODIUM ORAL TABLET 137 MCG 0.32780 08/28/2020 0.29570 01/15/2021 LEVOTHYROXINE SODIUM ORAL TABLET 150 MCG 0.24822 02/19/2021 0.19980 07/16/2021 LEVOTHYROXINE SODIUM ORAL TABLET 175 MCG 0.37844 05/22/2020 0.35941 08/28/2020 LEVOTHYROXINE SODIUM ORAL TABLET 200 MCG 0.33885 07/14/2017 0.33506 01/15/2021 LEVOTHYROXINE SODIUM ORAL TABLET 25 MCG 0.17105 04/17/2020 0.11477 03/19/2021 LEVOTHYROXINE SODIUM ORAL TABLET 300 MCG 0.59100 03/30/2019 0.55480 05/22/2020 LEVOTHYROXINE SODIUM ORAL TABLET 50 MCG 0.20082 12/20/2019 0.19857 07/16/2021 LEVOTHYROXINE SODIUM ORAL TABLET 75 MCG 0.30045 07/14/2017 0.22038 04/17/2020 LEVOTHYROXINE SODIUM ORAL TABLET 88 MCG 0.26722 07/14/2017 0.23539 04/17/2020 LIDOCAINE HCL IN DEXTROSE 5% IN WATER/PF INTRAVENOUS 0.01280 08/12/2014 INTRAVENOUS SOLUTION 4 MG/ML LIDOCAINE HCL IN DEXTROSE 5% IN WATER/PF INTRAVENOUS 0.02029 01/25/2013 INTRAVENOUS SOLUTION 8 MG/ML LIDOCAINE HCL IN DEXTROSE 7.5 % IN WATER/PF INTRATHECAL AMPUL 6.05930 08/12/2014 (ML) 5 % LIDOCAINE HCL INJECTION VIAL (ML) 10 MG/ML 0.05802 02/07/2014 0.05802 08/21/2015 LIDOCAINE HCL INJECTION VIAL (ML) 20 MG/ML 0.06084 01/25/2013 LIDOCAINE HCL MUCOUS MEMBRANE JELLY (ML) 2 % 0.27545 08/21/2015 2.46660 03/12/2021 LIDOCAINE HCL MUCOUS MEMBRANE JELLY WITH PREFILLED 0.34943 12/12/2014 0.34943 08/21/2015 APPLICATOR (ML) 2 % LIDOCAINE HCL MUCOUS MEMBRANE SOLUTION, NON-ORAL 40 MG/ML 0.06266 08/12/2014 0.06266 08/21/2015 LIDOCAINE HCL MUCOUS MEMBRANE SOLUTION, ORAL 2 % 0.07917 05/21/2018 0.07115 09/25/2020 LIDOCAINE HCL TOPICAL CREAM (GRAM) 3 % 1.03527 07/17/2020 LIDOCAINE HCL TOPICAL SOLUTION, ORAL 4 % 1.05248 01/25/2013 LIDOCAINE HCL/EPINEPHRINE BITARTRATE INJECTION CARTRIDGE (ML) 0.14933 01/25/2013 2 %-1:100K LIDOCAINE HCL/EPINEPHRINE BITARTRATE INJECTION CARTRIDGE (ML) 0.14933 01/25/2013 2%-1:50000 LIDOCAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 1%-1:100K 0.06995 01/25/2013 0.06995 08/21/2015 LIDOCAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 2 %-1:100K 0.07910 08/12/2014 0.07910 08/21/2015 LIDOCAINE HCL/EPINEPHRINE/PF INJECTION VIAL (ML) 2%-1:200K 0.35740 08/12/2014 0.35740 08/21/2015 LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL CREAM (GRAM) 3 1.78500 03/13/2015 %-0.5 % LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL CREAM WITH 1.37036 02/06/2015 1.37036 08/21/2015 APPLICATOR 3 %-0.5 % LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL CREAM WITH 251.09000 01/25/2013 APPLICATOR 3%-1%(7 G) West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL GEL WITH 251.09000 01/25/2013 APPLICATOR (GRAM) 3-2.5%(7G) LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL KIT 3 %-0.5 % 7.69340 08/21/2015 LIDOCAINE HCL/PF INJECTION AMPUL (ML) 10 MG/ML 0.35751 12/20/2013 0.35751 08/21/2015 LIDOCAINE HCL/PF INJECTION AMPUL (ML) 15 MG/ML 0.66715 01/25/2013 LIDOCAINE HCL/PF INJECTION AMPUL (ML) 20 MG/ML 1.01535 12/27/2013 LIDOCAINE HCL/PF INJECTION AMPUL (ML) 40 MG/ML 0.56780 08/12/2014 LIDOCAINE HCL/PF INJECTION VIAL (ML) 20 MG/ML 0.48516 08/12/2014 LIDOCAINE HCL/PF INJECTION VIAL (ML) 5 MG/ML 0.11002 01/25/2013 LIDOCAINE HCL/PF INTRAVENOUS SYRINGE (ML) 100 MG/5ML 0.66080 01/25/2013 0.66080 08/21/2015 LIDOCAINE HCL/PF INTRAVENOUS SYRINGE (ML) 50 MG/5 ML 0.88790 08/12/2014 LIDOCAINE HCL/PF INTRAVENOUS VIAL (ML) 20 MG/ML 0.28224 01/25/2013 LIDOCAINE MISCELLANEOUS POWDER (GRAM) 0.19471 08/21/2015 LIDOCAINE TOPICAL ADHESIVE PATCH, MEDICATED 5 % 2.05929 11/20/2020 1.96922 07/16/2021 LIDOCAINE TOPICAL CREAM (GRAM) 4 % 0.79667 08/16/2019 0.31433 02/21/2020 LIDOCAINE TOPICAL CREAM (GRAM) 5 % 1.05645 12/26/2014 1.05645 08/21/2015 LIDOCAINE TOPICAL OINTMENT (GRAM) 5 % 0.22550 01/24/2020 0.20580 07/17/2020 LIDOCAINE/PRILOCAINE TOPICAL CREAM (GRAM) 2.5 %-2.5% 0.19392 11/15/2019 0.17500 05/22/2020 LIDOCAINE/PRILOCAINE TOPICAL KIT 2.5 %-2.5% 1.40764 01/25/2013 1.40764 08/21/2015 LINDANE TOPICAL LOTION (ML) 1 % 1.59670 02/08/2013 1.59670 08/21/2015 LINDANE TOPICAL SHAMPOO 1 % 1.59670 02/08/2013 1.59670 08/21/2015 LINEZOLID IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS 0.50400 03/13/2015 0.50400 08/21/2015 SOLUTION, PIGGYBACK (ML) 600MG/300 LINEZOLID ORAL TABLET 600 MG 1.17500 08/28/2020 2.17277 12/04/2020 LIOTHYRONINE SODIUM ORAL TABLET 25 MCG 0.65000 03/17/2017 0.42480 07/14/2017 LIOTHYRONINE SODIUM ORAL TABLET 5 MCG 0.29155 07/14/2017 0.26940 07/16/2021 LIOTHYRONINE SODIUM ORAL TABLET 50 MCG 1.01491 04/24/2015 0.47406 03/03/2017 LISINOPRIL ORAL TABLET 10 MG 0.02112 08/21/2015 0.01302 09/25/2020 LISINOPRIL ORAL TABLET 2.5 MG 0.01635 05/01/2015 0.01635 08/21/2015 LISINOPRIL ORAL TABLET 20 MG 0.02569 04/06/2020 0.02264 09/25/2020 LISINOPRIL ORAL TABLET 30 MG 0.07504 08/21/2015 0.03142 06/16/2017 LISINOPRIL ORAL TABLET 40 MG 0.02100 08/25/2017 0.02610 07/25/2019 LISINOPRIL ORAL TABLET 5 MG 0.01809 08/21/2015 0.00832 10/20/2017 LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.02693 08/21/2015 0.02360 05/21/2021 LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 20 MG-25MG 0.05186 08/21/2015 0.02920 10/20/2017 LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG 0.04063 08/21/2015 0.02670 04/27/2018 LITHIUM CARBONATE ORAL CAPSULE 150 MG 0.06052 08/21/2015 0.05345 03/19/2021 LITHIUM CARBONATE ORAL CAPSULE 300 MG 0.03114 04/24/2015 0.03114 08/21/2015 LITHIUM CARBONATE ORAL CAPSULE 600 MG 0.14351 08/21/2015 0.08414 07/14/2017 LITHIUM CARBONATE ORAL TABLET 300 MG 0.14961 04/17/2015 0.14961 08/21/2015 LITHIUM CARBONATE ORAL TABLET, EXTENDED RELEASE 300 MG 0.12000 09/21/2018 0.09970 07/17/2020 LITHIUM CARBONATE ORAL TABLET, EXTENDED RELEASE 450 MG 0.17713 02/22/2019 0.10100 05/17/2019 LITHIUM CITRATE SOLUTION, ORAL 8 MEQ/5 ML 0.03921 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LOPERAMIDE HCL ORAL CAPSULE 2 MG 0.28182 03/10/2019 0.22363 11/15/2019 LOPERAMIDE HCL ORAL LIQUID (ML) 1MG/7.5ML 0.03361 08/12/2014 0.03361 08/21/2015 LOPERAMIDE HCL ORAL TABLET 2 MG 0.08953 08/12/2014 0.08953 08/21/2015 ORAL SOLUTION, ORAL 5 MG/5 ML 0.04500 08/21/2015 0.03325 11/16/2018 LORATADINE ORAL TABLET 10 MG 0.05136 08/21/2015 0.03157 10/20/2017 LORATADINE ORAL TABLET,DISINTEGRATING 10 MG 0.38100 02/01/2013 0.38100 08/21/2015 LORATADINE/PSEUDOEPHEDRINE SULFATE ORAL TABLET, EXTENDED 0.58500 04/07/2017 0.75400 07/16/2018 RELEASE 12 HR 5 MG-120MG LORATADINE/PSEUDOEPHEDRINE SULFATE ORAL TABLET, EXTENDED 0.36808 11/16/2018 0.30533 05/22/2020 RELEASE 24 HR 10MG-240MG LORAZEPAM INJECTION SYRINGE (ML) 2 MG/ML 1.76400 02/15/2013 1.76400 08/21/2015 LORAZEPAM INJECTION SYRINGE (ML) 4 MG/ML 2.46960 01/25/2013 LORAZEPAM INJECTION VIAL (ML) 2 MG/ML 0.59480 03/02/2018 0.46840 11/15/2019 LORAZEPAM INJECTION VIAL (ML) 4 MG/ML 1.14324 01/25/2013 LORAZEPAM ORAL CONCENTRATE, ORAL 2 MG/ML 0.29067 09/21/2018 0.26900 11/15/2019 LORAZEPAM ORAL TABLET 0.5 MG 0.03047 08/21/2015 0.02030 10/20/2017 LORAZEPAM ORAL TABLET 1 MG 0.03287 08/21/2015 0.01735 12/22/2017 LORAZEPAM ORAL TABLET 2 MG 0.05247 08/21/2015 0.03950 08/17/2018 LOSARTAN POTASSIUM ORAL TABLET 100 MG 0.06386 06/16/2017 0.04114 10/20/2017 LOSARTAN POTASSIUM ORAL TABLET 25 MG 0.03245 10/20/2017 0.02177 10/25/2019 LOSARTAN POTASSIUM ORAL TABLET 50 MG 0.09600 02/21/2020 0.08833 03/19/2021 LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 100- 0.08772 08/25/2017 0.07169 12/22/2017 12.5MG LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 100MG- 0.06639 04/27/2018 0.19126 03/16/2020 25MG LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 50-12.5 0.05099 11/16/2018 0.19909 06/30/2020 MG ORAL TABLET 10 MG 0.05820 09/22/2017 0.04733 05/22/2020 LOVASTATIN ORAL TABLET 20 MG 0.05223 06/16/2017 0.03900 10/20/2017 LOVASTATIN ORAL TABLET 40 MG 0.04717 09/22/2017 0.01901 11/16/2018 LOXAPINE SUCCINATE ORAL CAPSULE 10 MG 0.26000 03/02/2018 0.66531 06/03/2019 LOXAPINE SUCCINATE ORAL CAPSULE 25 MG 0.76809 08/21/2015 0.56280 08/25/2017 LOXAPINE SUCCINATE ORAL CAPSULE 5 MG 0.37172 08/21/2015 0.28570 03/02/2018 LOXAPINE SUCCINATE ORAL CAPSULE 50 MG 0.66820 08/17/2018 0.62000 08/16/2019 MAGNESIUM CARBONATE/ALUMINUM HYDROXIDE/ALGINIC ACID ORAL 0.01253 01/25/2013 SUSPENSION, ORAL (FINAL DOSE FORM) 358-95/15 ORAL TABLET, EXTENDED RELEASE 64 MG 0.08364 01/25/2013 MAGNESIUM HYDROXIDE ORAL SUSPENSION, ORAL (FINAL DOSE 0.00419 08/12/2014 0.00419 08/21/2015 FORM) 400 MG/5ML MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ORAL 0.00592 09/19/2014 0.00592 08/21/2015 SUSPENSION, ORAL (FINAL DOSE FORM) 200-200-20 MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ORAL 0.00967 12/26/2014 0.00967 08/21/2015 SUSPENSION, ORAL (FINAL DOSE FORM) 400-400-40 MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ORAL 0.03062 08/12/2014 0.03062 08/21/2015 TABLET,CHEWABLE 200-200-25 ORAL CAPSULE 400 MG 0.08450 08/12/2014 MAGNESIUM OXIDE ORAL TABLET 400 MG 0.02077 02/06/2015 0.02077 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date IN STERILE WATER INTRAVENOUS 0.01970 08/12/2014 INTRAVENOUS SOLUTION 20 G/500ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS 0.01440 08/12/2014 INTRAVENOUS SOLUTION 40G/1000ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS 0.24560 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 2 G/50 ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS 0.13419 07/25/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 4 G/100 ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS 0.23100 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 4 G/50 ML MAGNESIUM SULFATE INJECTION SYRINGE (ML) 4 MEQ/ML 0.63168 01/25/2013 MAGNESIUM SULFATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.11630 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 1 G/100 ML MALATHION TOPICAL LOTION (ML) 0.5 % 2.54547 08/21/2015 3.71143 08/12/2019 CHLORIDE INTRAVENOUS VIAL (ML) 0.1 MG/ML 0.17390 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 10 % 0.01620 08/12/2014 MANNITOL INTRAVENOUS INTRAVENOUS SOLUTION 20 % 0.03980 01/25/2013 MANNITOL INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.00866 01/25/2013 MANNITOL/ SOLUTION URETHRAL SOLUTION, IRRIGATION 0.00569 01/25/2013 0.54G-2.7G MAPROTILINE HCL ORAL TABLET 25 MG 0.59890 08/12/2014 MAPROTILINE HCL ORAL TABLET 50 MG 0.93980 02/08/2013 MAPROTILINE HCL ORAL TABLET 75 MG 1.28950 08/12/2014 HCL ORAL TABLET 12.5 MG 0.03685 02/27/2015 0.03685 08/21/2015 MECLIZINE HCL ORAL TABLET 25 MG 0.12062 03/03/2017 0.04200 11/15/2019 MECLOFENAMATE SODIUM ORAL CAPSULE 100 MG 3.34760 08/12/2014 3.34760 08/21/2015 MECLOFENAMATE SODIUM ORAL CAPSULE 50 MG 1.91160 08/12/2014 MECOBALAMIN/LEVOMEFOLATE CALCIUM/ 0.88358 03/27/2015 0.88358 08/21/2015 ORAL TABLET 2-3-35 MG MEDROXYPROGESTERONE ACETATE INTRAMUSCULAR VIAL (ML) 150 35.40500 05/22/2020 30.38788 03/19/2021 MG/ML MEDROXYPROGESTERONE ACETATE ORAL TABLET 10 MG 0.12690 08/21/2015 0.09842 07/14/2017 MEDROXYPROGESTERONE ACETATE ORAL TABLET 2.5 MG 0.10570 08/25/2017 0.07140 03/20/2020 MEDROXYPROGESTERONE ACETATE ORAL TABLET 5 MG 0.21370 05/19/2017 0.11870 03/02/2018 MEFENAMIC ACID ORAL CAPSULE 250 MG 6.03867 08/17/2018 1.46000 10/19/2018 MEFLOQUINE HCL ORAL TABLET 250 MG 3.74400 04/05/2013 3.74400 08/21/2015 MEGESTROL ACETATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.29429 08/08/2014 0.29429 08/21/2015 400MG/10ML MEGESTROL ACETATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.08725 08/07/2020 0.08253 05/21/2021 400MG/10ML MEGESTROL ACETATE ORAL TABLET 20 MG 0.11377 06/27/2014 MEGESTROL ACETATE ORAL TABLET 40 MG 0.14931 07/14/2017 0.10500 08/16/2019 ORAL TABLET, EXTENDED RELEASE 3 MG 0.06370 01/25/2013 MELATONIN/TRYPTOPHAN ORAL CAPSULE 3 MG-100MG 5.05750 01/31/2014 MELOXICAM ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 7.5 MG/5ML 1.33161 02/21/2014 MELOXICAM ORAL TABLET 15 MG 0.01655 08/17/2018 0.01631 11/20/2020 MELOXICAM ORAL TABLET 7.5 MG 0.02466 08/21/2015 0.01550 08/28/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date MEMANTINE HCL ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 2.50450 08/16/2019 2.41733 05/22/2020 HR 21 MG MEMANTINE HCL ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 1.93938 11/15/2019 0.97767 06/19/2020 HR 28 MG MEMANTINE HCL ORAL TABLET 10 MG 0.08633 11/16/2018 0.06912 12/20/2019 MEMANTINE HCL ORAL TABLET 5 MG 0.09917 09/22/2017 0.07933 05/21/2021 MENTHOL MUCOUS MEMBRANE LOZENGE 8 MG 0.06420 08/12/2014 MENTHOL TOPICAL GEL (GRAM) 10 % 0.11397 01/25/2013 MEPERIDINE HCL INJECTION CARTRIDGE (ML) 10 MG/ML 0.49911 01/25/2013 MEPERIDINE HCL ORAL SOLUTION, ORAL 50 MG/5 ML 0.14191 01/25/2013 MEPERIDINE HCL ORAL TABLET 100 MG 0.32670 03/06/2015 MEPERIDINE HCL ORAL TABLET 50 MG 1.31433 08/21/2015 0.41454 06/16/2017 MEPERIDINE HCL/PF INJECTION VIAL (ML) 100 MG/ML 2.35200 01/25/2013 MEPERIDINE HCL/PF INJECTION VIAL (ML) 25 MG/ML 2.12100 01/25/2013 MEPERIDINE HCL/PF INJECTION VIAL (ML) 50 MG/ML 0.94080 01/25/2013 MEPIVACAINE HCL/PF INJECTION CARTRIDGE (ML) 30 MG/ML 0.17730 08/12/2014 MEPROBAMATE ORAL TABLET 200 MG 4.81285 10/17/2014 4.81285 08/21/2015 MEPROBAMATE ORAL TABLET 400 MG 0.98070 01/25/2013 0.98070 08/21/2015 MERCAPTOPURINE ORAL TABLET 50 MG 0.88334 09/22/2017 0.76000 05/17/2019 MEROPENEM INTRAVENOUS VIAL (EA) 1 G 11.34682 08/21/2015 16.85013 01/23/2017 MEROPENEM INTRAVENOUS VIAL (EA) 500 MG 4.50240 12/26/2014 4.50240 08/21/2015 MESALAMINE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 1.2 3.19075 01/29/2020 2.22400 04/17/2020 G MESALAMINE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 4.25000 11/15/2019 4.25000 01/01/2020 800 MG MESALAMINE RECTAL ENEMA (ML) 4 G/60 ML 0.19094 04/21/2017 0.16262 03/02/2018 MESALAMINE WITH CLEANSING WIPES RECTAL ENEMA KIT 4 G/60 ML 119.73500 12/26/2014 110.04250 06/16/2017 METAPROTERENOL SULFATE ORAL SYRUP 10 MG/5 ML 0.02460 08/12/2014 0.02460 08/21/2015 METAPROTERENOL SULFATE ORAL TABLET 10 MG 0.69965 01/25/2013 0.69965 08/21/2015 METAPROTERENOL SULFATE ORAL TABLET 20 MG 0.97496 01/25/2013 0.97496 08/21/2015 METAXALONE ORAL TABLET 800 MG 0.52160 04/26/2019 0.45990 05/22/2020 METFORMIN HCL ORAL TABLET 1000 MG 0.02404 09/25/2020 0.02247 11/20/2020 METFORMIN HCL ORAL TABLET 500 MG 0.01435 07/26/2019 0.01367 02/19/2021 METFORMIN HCL ORAL TABLET 850 MG 0.02986 08/21/2015 0.02315 08/28/2020 METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1000 MG 2.82733 10/23/2020 2.47866 03/19/2021 METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 3.60978 12/26/2014 3.41667 11/24/2017 METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.04020 08/21/2015 0.02600 01/25/2019 METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 750 MG 0.06915 08/17/2018 0.04510 04/17/2020 HCL INJECTION VIAL (ML) 10 MG/ML 6.01720 01/25/2013 METHADONE HCL ORAL CONCENTRATE, ORAL 10 MG/ML 0.62300 02/01/2013 METHADONE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.09670 07/18/2014 METHADONE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.12491 01/25/2013 METHADONE HCL ORAL TABLET 10 MG 0.10562 05/19/2017 0.08790 11/16/2018 METHADONE HCL ORAL TABLET 5 MG 0.11840 10/25/2019 0.10660 01/24/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date METHADONE HCL ORAL TABLET, SOLUBLE 40 MG 0.22381 01/25/2013 0.22381 08/21/2015 METHAMPHETAMINE HCL ORAL TABLET 5 MG 4.11749 05/01/2015 4.11749 08/21/2015 METHAZOLAMIDE ORAL TABLET 25 MG 2.68163 03/13/2015 METHAZOLAMIDE ORAL TABLET 50 MG 2.59840 12/05/2014 METHENAMINE HIPPURATE ORAL TABLET 1 G 0.88680 09/25/2020 0.83487 06/18/2021 METHENAMINE MANDELATE ORAL TABLET 500 MG 0.62041 01/25/2013 METHENAMINE/METHYLENE BLUE/SOD 1.80978 03/06/2015 1.80978 08/21/2015 PHOS/P.SALICYLATE/HYOSCYAMINE ORAL CAPSULE 118-10-36 METHENAMINE/METHYLENE BLUE/SOD 4.27272 03/06/2015 4.27272 08/21/2015 PHOS/P.SALICYLATE/HYOSCYAMINE ORAL TABLET 81-0.12MG METHENAMINE/METHYLENE BLUE/SOD 0.91000 09/12/2014 PHOS/P.SALICYLATE/HYOSCYAMINE ORAL TABLET 81.6-10.8 METHENAMINE/SOD PHOSPH,MONOBASIC/METHYLENE 2.26793 03/06/2015 BLUE/HYOSCYAMINE ORAL TABLET 81.6-.12MG METHIMAZOLE ORAL TABLET 10 MG 0.15839 08/21/2015 0.09155 03/03/2017 METHIMAZOLE ORAL TABLET 5 MG 0.08482 02/27/2015 0.04940 09/22/2017 METHOCARBAMOL INJECTION VIAL (ML) 100 MG/ML 4.14861 02/13/2015 METHOCARBAMOL ORAL TABLET 500 MG 0.05895 08/25/2017 0.03100 11/16/2018 METHOCARBAMOL ORAL TABLET 750 MG 0.08070 12/25/2020 0.07330 04/16/2021 METHOTREXATE SODIUM INJECTION VIAL (ML) 25 MG/ML 3.00720 01/30/2015 METHOTREXATE SODIUM ORAL TABLET 2.5 MG 0.35990 06/19/2020 0.25322 04/16/2021 METHOTREXATE SODIUM/PF INJECTION VIAL (ML) 25 MG/ML 2.87500 10/02/2019 1.82394 12/25/2020 METHOXSALEN ORAL CAPSULE, LIQUID-FILLED, RAPID RELEASE 10 MG 66.75860 09/05/2014 METHSCOPOLAMINE BROMIDE ORAL TABLET 2.5 MG 1.53056 08/21/2015 0.31450 08/17/2018 METHSCOPOLAMINE BROMIDE ORAL TABLET 5 MG 2.17750 05/20/2016 0.86350 09/22/2017 METHYCLOTHIAZIDE TABLET 5 MG 1.21660 01/25/2013 METHYL SALICYLATE MISCELLANEOUS OIL (ML) 0.47540 08/12/2014 METHYLDOPA ORAL TABLET 250 MG 0.12359 07/14/2017 0.06990 03/02/2018 METHYLDOPA ORAL TABLET 500 MG 0.32656 08/21/2015 0.16892 05/19/2017 METHYLDOPA/HYDROCHLOROTHIAZIDE ORAL TABLET 250MG-15MG 0.67180 08/12/2014 METHYLDOPA/HYDROCHLOROTHIAZIDE ORAL TABLET 250MG-25MG 1.51046 12/26/2014 METHYLERGONOVINE MALEATE INJECTION AMPUL (ML) .2MG/ML(1) 4.75860 08/12/2014 METHYLERGONOVINE MALEATE INJECTION VIAL (ML) .2MG/ML(1) 6.39450 01/25/2013 METHYLERGONOVINE MALEATE ORAL TABLET 0.2 MG 53.75250 01/25/2019 27.26667 05/22/2020 METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 4.03956 12/09/2017 2.29720 07/26/2019 BIPHASIC 30-70 10 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 2.94350 12/08/2017 2.94350 12/09/2017 BIPHASIC 30-70 20 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 2.96640 12/09/2017 3.27270 05/16/2018 BIPHASIC 30-70 30 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 4.30300 12/08/2017 4.30300 12/09/2017 BIPHASIC 30-70 40 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 4.55740 12/09/2017 4.24000 07/26/2019 BIPHASIC 30-70 50 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 6.76633 12/08/2017 6.76633 12/09/2017 BIPHASIC 30-70 60 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 3.59850 05/17/2019 2.04020 06/18/2021 BIPHASIC 50-50 20 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 3.78000 07/26/2019 2.44420 08/28/2020 BIPHASIC 50-50 30 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 4.27230 11/24/2017 3.85000 06/22/2018 BIPHASIC 50-50 40 MG METHYLPHENIDATE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.90135 04/10/2015 METHYLPHENIDATE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.73600 03/02/2016 0.73600 01/01/2021 METHYLPHENIDATE HCL ORAL TABLET 10 MG 0.15585 07/17/2020 0.11087 07/16/2021 METHYLPHENIDATE HCL ORAL TABLET 20 MG 0.23660 10/23/2020 0.16635 07/16/2021 METHYLPHENIDATE HCL ORAL TABLET 5 MG 0.17340 08/17/2018 0.15000 01/25/2019 METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 10 MG 1.67990 08/16/2019 1.14450 02/19/2021 METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 20 MG 2.23490 03/16/2018 1.70023 08/17/2018 METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 18 7.32227 01/05/2018 4.56290 11/15/2019 MG METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 27 6.98215 01/05/2018 5.31480 11/15/2019 MG METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 36 6.58990 07/09/2019 6.27617 11/15/2019 MG METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 54 4.40970 11/15/2019 5.65671 12/05/2019 MG ACETATE INJECTION VIAL (ML) 40 MG/ML 3.47672 08/12/2014 3.47672 08/21/2015 METHYLPREDNISOLONE ACETATE INJECTION VIAL (ML) 80 MG/ML 7.07957 08/12/2014 7.07957 08/21/2015 METHYLPREDNISOLONE ORAL TABLET 16 MG 2.47842 04/03/2015 1.95015 06/16/2017 METHYLPREDNISOLONE ORAL TABLET 32 MG 3.62572 04/03/2015 METHYLPREDNISOLONE ORAL TABLET 4 MG 0.31030 01/19/2018 0.21648 05/17/2019 METHYLPREDNISOLONE ORAL TABLET 8 MG 1.15600 11/24/2017 1.09220 11/15/2019 METHYLPREDNISOLONE ORAL TABLET, DOSE PACK 4 MG 0.22143 04/09/2021 0.17735 07/16/2021 METHYLPREDNISOLONE SODIUM SUCCINATE INJECTION VIAL (EA) 125 4.08408 01/25/2013 MG METHYLPREDNISOLONE SODIUM SUCCINATE INJECTION VIAL (EA) 40 3.53132 01/25/2013 MG METHYLPREDNISOLONE SODIUM SUCCINATE INTRAVENOUS VIAL (EA) 17.05200 01/25/2013 1000 MG METIPRANOLOL OPHTHALMIC DROPS 0.3 % 2.91720 01/25/2013 METOCLOPRAMIDE HCL INJECTION SYRINGE (ML) 10 MG/2 ML 0.66573 05/24/2013 0.66573 08/21/2015 METOCLOPRAMIDE HCL INJECTION VIAL (ML) 5 MG/ML 0.37728 02/13/2015 0.37728 08/21/2015 METOCLOPRAMIDE HCL ORAL SOLUTION, ORAL 10 MG/10ML 0.04456 08/09/2013 0.04456 08/21/2015 METOCLOPRAMIDE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.01217 08/21/2015 0.03870 07/16/2018 METOCLOPRAMIDE HCL ORAL TABLET 10 MG 0.04069 08/21/2015 0.02797 11/16/2018 METOCLOPRAMIDE HCL ORAL TABLET 5 MG 0.04126 08/21/2015 0.02200 09/22/2017 METOLAZONE ORAL TABLET 10 MG 0.84230 05/17/2013 METOLAZONE ORAL TABLET 2.5 MG 1.17600 06/06/2020 1.02540 10/23/2020 METOLAZONE ORAL TABLET 5 MG 0.88200 08/28/2020 0.72220 05/21/2021 METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.20520 09/21/2018 0.17251 05/22/2020 100 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.32643 02/21/2020 0.26240 05/21/2021 200 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.06050 07/17/2020 0.04444 06/18/2021 25 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.18560 06/16/2017 0.09250 09/21/2018 50 MG METOPROLOL TARTRATE INTRAVENOUS AMPUL (ML) 5 MG/5 ML 0.23020 08/12/2014 0.23020 08/21/2015 METOPROLOL TARTRATE INTRAVENOUS SYRINGE (ML) 5 MG/5 ML 0.70560 01/25/2013 METOPROLOL TARTRATE ORAL TABLET 100 MG 0.03114 08/21/2015 0.02070 05/22/2020 METOPROLOL TARTRATE ORAL TABLET 25 MG 0.01899 09/25/2020 0.01561 12/25/2020 METOPROLOL TARTRATE ORAL TABLET 50 MG 0.01697 09/25/2020 0.01390 12/25/2020 METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE ORAL TABLET 0.84850 06/16/2017 0.63568 06/21/2019 100MG-25MG METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE ORAL TABLET 1.53410 02/08/2013 100MG-50MG METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE ORAL TABLET 50 0.70970 11/24/2017 0.67570 03/02/2018 MG-25MG METRONIDAZOLE IN SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS 0.01400 04/05/2013 0.01400 08/21/2015 SOLUTION, PIGGYBACK (ML) 500MG/0.1L METRONIDAZOLE ORAL CAPSULE 375 MG 3.91048 01/31/2014 3.91048 08/21/2015 METRONIDAZOLE ORAL TABLET 250 MG 0.17910 12/22/2017 0.07480 08/16/2019 METRONIDAZOLE ORAL TABLET 500 MG 0.14590 09/22/2017 0.11483 11/16/2018 METRONIDAZOLE TOPICAL CREAM (GRAM) 0.75 % 0.88756 05/22/2020 1.05589 10/31/2020 METRONIDAZOLE TOPICAL GEL (GRAM) 0.75 % 1.23346 06/16/2017 0.81000 12/21/2018 METRONIDAZOLE TOPICAL LOTION (ML) 0.75 % 2.93220 01/17/2014 2.39124 06/16/2017 METRONIDAZOLE VAGINAL GEL WITH APPLICATOR (GRAM) 0.75 % 0.75276 11/20/2020 0.56929 02/19/2021 HCL ORAL CAPSULE 150 MG 0.55042 08/21/2015 0.53950 06/18/2021 MEXILETINE HCL ORAL CAPSULE 200 MG 0.70746 10/03/2014 MEXILETINE HCL ORAL CAPSULE 250 MG 0.48191 08/09/2013 MICONAZOLE NITRATE TOPICAL CREAM (GRAM) 2 % 0.05700 03/07/2014 0.05700 08/21/2015 MICONAZOLE NITRATE TOPICAL OINTMENT (GRAM) 2 % 0.08500 08/12/2014 MICONAZOLE NITRATE TOPICAL TINCTURE 2 % 0.39340 08/12/2014 MICONAZOLE NITRATE VAGINAL CREAM WITH APPLICATOR 2 % 0.09470 04/24/2015 0.09470 08/21/2015 MICONAZOLE NITRATE VAGINAL KIT 200 MG-2 % 7.83470 08/21/2015 7.64000 01/25/2019 MICONAZOLE NITRATE VAGINAL SUPPOSITORY, VAGINAL 100 MG 0.44030 01/25/2013 0.44030 08/21/2015 MICONAZOLE NITRATE VAGINAL SUPPOSITORY, VAGINAL 200 MG 12.26633 01/25/2013 MIDODRINE HCL ORAL TABLET 10 MG 0.55753 02/21/2020 0.51220 08/28/2020 MIDODRINE HCL ORAL TABLET 2.5 MG 0.28820 11/15/2019 0.22990 08/28/2020 MIDODRINE HCL ORAL TABLET 5 MG 0.31930 10/25/2019 0.25346 12/25/2020 MILRINONE LACTATE INTRAVENOUS VIAL (ML) 1 MG/ML 0.29545 08/25/2017 0.27241 05/22/2020 MILRINONE LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.13280 08/12/2014 0.13280 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 20MG/100ML MILRINONE LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.16676 10/03/2014 0.16676 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 40MG/200ML MINERAL OIL RECTAL ENEMA (ML) 0.01182 08/21/2015 MINERAL OIL TOPICAL LOTION (ML) 0.01828 08/12/2014 MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT (GRAM) 15 0.81740 08/12/2014 %-83 % West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT (GRAM) 1.90107 01/16/2015 1.90107 08/21/2015 15%-85% MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT (GRAM) 3 4.48140 08/21/2015 %-94 % MINOCYCLINE HCL ORAL CAPSULE 100 MG 0.30445 04/17/2015 0.30445 08/21/2015 MINOCYCLINE HCL ORAL CAPSULE 50 MG 0.19068 03/03/2017 0.13650 03/15/2019 MINOCYCLINE HCL ORAL CAPSULE 75 MG 0.35403 08/12/2014 MINOCYCLINE HCL ORAL TABLET 100 MG 2.20000 05/25/2018 1.80620 11/16/2018 MINOCYCLINE HCL ORAL TABLET 50 MG 1.14200 09/22/2017 1.03750 11/15/2019 MINOCYCLINE HCL ORAL TABLET 75 MG 1.69228 01/25/2013 1.69228 08/21/2015 MINOCYCLINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 135 MG 3.56811 01/25/2013 3.56811 08/21/2015 MINOCYCLINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 45 MG 3.56811 01/25/2013 3.56811 08/21/2015 MINOCYCLINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 90 MG 3.56811 01/25/2013 3.56811 08/21/2015 MINOXIDIL ORAL TABLET 10 MG 0.20050 11/24/2017 0.12250 11/16/2018 MINOXIDIL ORAL TABLET 2.5 MG 0.01538 08/25/2017 0.04230 09/05/2019 MIRTAZAPINE ORAL TABLET 15 MG 0.06475 11/15/2019 0.05000 07/17/2020 MIRTAZAPINE ORAL TABLET 30 MG 0.13332 05/19/2017 0.07067 06/16/2017 MIRTAZAPINE ORAL TABLET 45 MG 0.07467 05/22/2020 0.05908 07/16/2021 MIRTAZAPINE ORAL TABLET 7.5 MG 0.70950 02/21/2020 0.66000 04/17/2020 MIRTAZAPINE ORAL TABLET,DISINTEGRATING 15 MG 0.58000 08/25/2017 0.47533 11/24/2017 MIRTAZAPINE ORAL TABLET,DISINTEGRATING 30 MG 0.65247 03/03/2017 0.53400 09/22/2017 MIRTAZAPINE ORAL TABLET,DISINTEGRATING 45 MG 0.92063 06/03/2019 0.76367 11/15/2019 MISOPROSTOL ORAL TABLET 100 MCG 0.42254 09/19/2014 0.42254 08/21/2015 MISOPROSTOL ORAL TABLET 200 MCG 0.77996 07/29/2016 0.69441 03/03/2017 MITOMYCIN INTRAVENOUS VIAL (EA) 40 MG 256.23975 08/21/2015 990.94800 11/05/2015 MODAFINIL ORAL TABLET 100 MG 1.82967 03/02/2018 0.49100 10/19/2018 MODAFINIL ORAL TABLET 200 MG 0.35717 11/15/2019 0.63463 11/29/2019 MOEXIPRIL HCL ORAL TABLET 15 MG 0.37580 02/08/2013 0.37580 08/21/2015 MOEXIPRIL HCL ORAL TABLET 7.5 MG 0.37580 08/12/2014 0.37580 08/21/2015 MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE TABLET 15-12.5MG 0.51310 08/12/2014 MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE TABLET 15-25MG 0.37076 01/25/2013 0.37076 08/21/2015 MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE TABLET 7.5-12.5MG 0.50960 01/25/2013 0.50960 08/21/2015 (AMMONIUM MOLYBDATE) VIAL (ML) 25 MCG/ML 0.32672 01/25/2013 MOMETASONE FUROATE NASAL AEROSOL, SPRAY WITH PUMP (GRAM) 2.32029 02/21/2020 2.29942 08/28/2020 50 MCG MOMETASONE FUROATE TOPICAL CREAM (GRAM) 0.1 % 0.18611 08/16/2019 0.37303 08/27/2020 MOMETASONE FUROATE TOPICAL OINTMENT (GRAM) 0.1 % 0.20169 11/15/2019 0.18244 03/20/2020 MOMETASONE FUROATE TOPICAL SOLUTION, NON-ORAL 0.1 % 0.30258 10/16/2019 0.22200 04/16/2021 MONTELUKAST SODIUM ORAL GRANULES IN PACKET (EA) 4 MG 2.29967 10/19/2018 1.78811 02/22/2019 MONTELUKAST SODIUM ORAL TABLET 10 MG 0.05967 06/16/2017 0.05171 02/19/2021 MONTELUKAST SODIUM ORAL TABLET,CHEWABLE 4 MG 0.10275 08/17/2018 0.08729 05/21/2021 MONTELUKAST SODIUM ORAL TABLET,CHEWABLE 5 MG 0.06795 06/19/2020 0.05211 04/16/2021 MORPHINE SULFATE INJECTION SYRINGE (ML) 10 MG/ML 1.83954 05/23/2014 1.83954 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date MORPHINE SULFATE INJECTION SYRINGE (ML) 2 MG/ML 1.83954 04/25/2014 1.83954 08/21/2015 MORPHINE SULFATE INJECTION SYRINGE (ML) 4 MG/ML 1.83954 05/23/2014 1.83954 08/21/2015 MORPHINE SULFATE INJECTION SYRINGE (ML) 5 MG/ML 1.83954 05/23/2014 MORPHINE SULFATE INJECTION SYRINGE (ML) 8 MG/ML 1.83954 05/23/2014 1.83954 08/21/2015 MORPHINE SULFATE INJECTION VIAL (ML) 10 MG/ML 0.74480 01/25/2013 MORPHINE SULFATE INJECTION VIAL (ML) 15 MG/ML 0.69440 01/25/2013 MORPHINE SULFATE INJECTION VIAL (ML) 5 MG/ML 0.83160 01/25/2013 MORPHINE SULFATE INJECTION VIAL (ML) 8 MG/ML 0.94080 01/25/2013 MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 10 MG/ML 3.25500 01/25/2013 MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 15 MG/ML 3.25500 01/25/2013 MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 2 MG/ML 3.25500 01/25/2013 MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 4 MG/ML 3.25500 01/25/2013 MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 8 MG/ML 2.98200 01/25/2013 MORPHINE SULFATE INTRAVENOUS PATIENT CONTROLLED ANALGESIA 0.33600 11/08/2013 0.33600 08/21/2015 SYRINGE 30 MG/30ML MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 10 MG/ML 1.80600 12/26/2014 MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 2 MG/ML 1.80600 03/28/2014 MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 4 MG/ML 1.80600 03/28/2014 MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 8 MG/ML 1.80600 12/26/2014 MORPHINE SULFATE INTRAVENOUS VIAL (ML) 25 MG/ML 1.33770 07/26/2013 MORPHINE SULFATE INTRAVENOUS VIAL (ML) 50 MG/ML 1.03719 06/27/2014 MORPHINE SULFATE INTRAVENOUS VIAL WITH THREADED PORT (ML) 4.96650 01/25/2013 100 MG/4ML MORPHINE SULFATE INTRAVENOUS VIAL WITH THREADED PORT (ML) 1.99080 01/25/2013 250MG/10ML MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 10 2.38833 09/22/2017 2.16080 11/24/2017 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 12.63000 08/21/2015 11.91976 12/02/2016 100 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 20 2.41414 06/16/2017 1.25730 09/22/2017 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 30 3.44336 06/16/2017 1.18850 11/15/2019 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 50 4.71535 06/16/2017 2.79941 07/16/2021 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 60 7.95944 08/21/2015 5.37753 01/27/2017 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 80 10.60675 08/21/2015 8.45051 06/16/2017 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 13.81709 02/21/2014 24HR 120 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 4.01072 02/21/2014 24HR 30 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 5.94685 02/21/2014 24HR 45 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 7.78841 02/21/2014 24HR 60 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 9.91130 02/21/2014 24HR 75 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 11.71044 02/21/2014 24HR 90 MG MORPHINE SULFATE ORAL SOLUTION, ORAL 10 MG/5 ML 0.05473 08/21/2015 0.04420 08/17/2018 MORPHINE SULFATE ORAL SOLUTION, ORAL 100 MG/5ML 0.23910 09/30/2016 0.22056 08/16/2019 MORPHINE SULFATE ORAL SOLUTION, ORAL 20 MG/5 ML 0.08307 01/16/2015 0.08307 08/21/2015 MORPHINE SULFATE ORAL TABLET 15 MG 0.11466 04/03/2015 MORPHINE SULFATE ORAL TABLET 30 MG 0.49746 11/05/2018 0.33520 07/16/2021 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 100 MG 1.07226 04/09/2018 0.90900 04/16/2021 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 15 MG 0.18007 09/25/2020 0.15530 04/16/2021 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 200 MG 2.23770 03/02/2018 1.86820 01/24/2020 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 30 MG 0.35780 05/21/2020 0.30890 04/16/2021 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 60 MG 0.68500 07/31/2020 0.60280 07/16/2021 MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 10 MG 3.85880 08/12/2014 MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 20 MG 5.25000 01/25/2013 MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 30 MG 6.56250 01/25/2013 MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 5 MG 3.50000 01/25/2013 MORPHINE SULFATE/PF INJECTION AMPUL (ML) 0.5 MG/ML 2.23713 01/25/2013 MORPHINE SULFATE/PF INJECTION AMPUL (ML) 1 MG/ML 3.80940 01/25/2013 MORPHINE SULFATE/PF INJECTION VIAL (ML) 0.5 MG/ML 0.42080 08/12/2014 MORPHINE SULFATE/PF INJECTION VIAL (ML) 1 MG/ML 0.41240 08/12/2014 MORPHINE SULFATE/PF INTRAVENOUS PATIENT CONTROLLED 0.61320 01/25/2013 ANALGESIA VIAL 150MG/30ML MORPHINE SULFATE/PF INTRAVENOUS PATIENT CONTROLLED 0.50469 01/25/2013 ANALGESIA VIAL 30 MG/30ML MOXIFLOXACIN HCL ORAL TABLET 400 MG 1.78867 03/15/2019 1.33333 11/15/2019 multivit no.49/ferrous fumarate/folic acid/levomefolate/dha CAPSULE 27-1.13 1.81370 01/25/2013 1.81370 08/21/2015 MG comb no.48/ferrous fumarate/folic acid/dha CAPSULE 28-1-250MG 3.34740 09/26/2014 MULTIVITAMIN COMBINATION NO.47/FERROUS FUM/ NO.1/DHA 1.43085 04/24/2015 0.81153 06/16/2017 ORAL CAPSULE 27-1-300MG multivitamin combination no.50/iron ps complex/folic acid CAPSULE 155 MG- 0.20689 01/25/2013 1MG MULTIVITAMIN COMBINATION NO.51/FERROUS FUMARATE/FOLIC ACID 0.60753 01/23/2015 0.60753 08/21/2015 ORAL CAPSULE 106.5-1MG multivitamin combo no.52/iron/iron asparto gly/folic/omega-3 CAPSULE 27-1- 0.98583 12/26/2014 0.98583 08/21/2015 330MG MULTIVITAMIN ORAL TABLET 0.01441 02/20/2015 0.01441 08/21/2015 MULTIVITAMIN WITH IRON ORAL TABLET 0.01954 08/12/2014 0.01954 08/21/2015 MULTIVITAMIN WITH MINERALS NO.69/IRON,CARBONYL/FOLIC ACID 1.05126 04/19/2013 ORAL TABLET 50-1.25 MG MULTIVITAMIN WITH MINERALS NO.7/FOLIC ACID ORAL CAPSULE 1 MG 0.17550 02/15/2013 MULTIVITAMIN WITH MINERALS/FERROUS GLUCONATE ORAL LIQUID 0.01674 08/12/2014 0.01674 08/21/2015 (ML) 9 MG/15 ML MULTIVITAMIN WITH MINERALS/FOLIC ACID ORAL TABLET 0.4 MG 0.80780 08/12/2014 0.80780 08/21/2015 MULTIVITAMIN WITH MINERALS/FOLIC ACID//LUTEIN ORAL 0.04317 03/27/2015 0.04317 08/21/2015 TABLET .4-300-250 MULTIVITAMIN WITH MINERALS/FOLIC ACID/LYCOPENE/LUTEIN ORAL 0.05011 08/12/2014 TABLET 500-300MCG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date MULTIVITAMIN WITH MINERALS/LUTEIN ORAL TABLET 0.04780 08/12/2014 0.04780 08/21/2015 MULTIVITAMIN,STRESS FORMULA/ZINC ORAL TABLET 0.04810 05/02/2014 0.04810 08/21/2015 MULTIVITAMIN,THERAPEUTIC ORAL TABLET 0.02440 08/12/2014 MULTIVITAMIN-MINERALS NO.71/IRON FUMARAT/FOLIC ACID NO.1/DHA 1.28123 10/10/2014 ORAL CAPSULE 28-1-300MG MULTIVITS WITH CALCIUM AND MINERALS/IRON FUMARATE/FOLIC ACID 0.03495 08/12/2014 ORAL TABLET 9MG-400MCG MUPIROCIN CALCIUM TOPICAL CREAM (GRAM) 2 % 2.58284 02/06/2015 2.58284 08/21/2015 MUPIROCIN TOPICAL OINTMENT (GRAM) 2 % 0.16642 11/20/2020 0.15204 04/16/2021 MV-MIN 75/FERROUS FUM/IRON PS CPLX/FOLIC AC/OMEGA-3/DHA/EPA 0.74013 04/10/2015 ORAL CAPSULE 35-1-200MG MV-MINS NO.74/FERROUS FUMARATE/IRON PS CPLX/FOLIC ACID ORAL 1.15359 01/25/2013 CAPSULE 85 MG-1 MG MYCOPHENOLATE MOFETIL ORAL CAPSULE 250 MG 0.19250 11/24/2017 0.12520 01/19/2018 MYCOPHENOLATE MOFETIL ORAL SUSPENSION, RECONSTITUTED, 4.24000 07/26/2019 5.06388 03/31/2020 ORAL (ML) 200 MG/ML MYCOPHENOLATE MOFETIL ORAL TABLET 500 MG 0.20142 03/03/2017 0.16100 06/21/2019 MYCOPHENOLATE SODIUM ORAL TABLET, DELAYED RELEASE 1.39966 03/03/2017 0.82950 11/16/2018 (ENTERIC COATED) 180 MG MYCOPHENOLATE SODIUM ORAL TABLET, DELAYED RELEASE 2.80967 09/20/2019 2.01000 10/23/2020 (ENTERIC COATED) 360 MG NABUMETONE ORAL TABLET 500 MG 0.14920 08/01/2018 0.12800 05/22/2020 NABUMETONE ORAL TABLET 750 MG 0.20923 05/19/2017 0.15891 09/22/2017 NADOLOL ORAL TABLET 20 MG 1.25218 01/08/2018 0.29000 11/15/2019 NADOLOL ORAL TABLET 40 MG 0.80040 01/01/2018 0.44895 06/19/2020 NADOLOL ORAL TABLET 80 MG 3.31195 12/02/2016 3.31195 01/01/2018 NADOLOL/BENDROFLUMETHIAZIDE ORAL TABLET 40 MG-5 MG 1.72368 01/25/2013 NADOLOL/BENDROFLUMETHIAZIDE ORAL TABLET 80 MG-5 MG 2.25914 01/25/2013 IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV SOLUTION, 0.25511 01/25/2013 PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML NAFCILLIN IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV SOLUTION, 0.53762 07/25/2014 PIGGYBACK PREMIX FROZEN(ML) 2 G/100 ML NAFCILLIN SODIUM INJECTION VIAL (EA) 1 G 11.78070 01/16/2015 NAFCILLIN SODIUM INJECTION VIAL (EA) 10 G 69.68850 03/06/2015 NAFCILLIN SODIUM INJECTION VIAL (EA) 2 G 11.96470 03/06/2015 11.96470 08/21/2015 NAFCILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 G 12.56750 08/12/2014 NAFCILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2 G 26.14500 03/29/2013 NALBUPHINE HCL INJECTION AMPUL (ML) 20 MG/ML 3.45670 01/25/2013 NALBUPHINE HCL INJECTION VIAL (ML) 10 MG/ML 1.19280 01/25/2013 1.19280 08/21/2015 NALBUPHINE HCL INJECTION VIAL (ML) 20 MG/ML 1.70020 08/12/2014 NALOXONE HCL INJECTION SYRINGE (ML) 0.4 MG/ML 3.15000 01/25/2013 NALOXONE HCL INJECTION SYRINGE (ML) 1 MG/ML 7.11900 11/15/2013 7.11900 08/21/2015 NALTREXONE HCL ORAL TABLET 50 MG 0.66875 11/15/2019 0.61843 08/28/2020 NAPHAZOLINE HCL DROPS 0.1 % 0.11787 01/25/2013 0.11787 08/21/2015 NAPHAZOLINE HCL/GLYCERIN OPHTHALMIC DROPS 0.012-0.25 0.13090 04/03/2015 NAPROXEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 125 MG/5ML 0.81200 05/04/2018 0.85722 08/24/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date NAPROXEN ORAL TABLET 250 MG 0.04181 08/12/2014 0.04181 08/21/2015 NAPROXEN ORAL TABLET 375 MG 0.05065 08/21/2015 0.04691 05/21/2021 NAPROXEN ORAL TABLET 500 MG 0.06330 08/21/2015 0.04180 10/20/2017 NAPROXEN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 375 0.12990 12/22/2017 0.11150 11/15/2019 MG NAPROXEN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 500 0.17979 08/21/2015 0.13450 03/15/2019 MG NAPROXEN SODIUM ORAL TABLET 220 MG 0.04739 04/03/2015 0.04739 08/21/2015 NAPROXEN SODIUM ORAL TABLET 275 MG 1.20510 08/01/2018 0.99950 11/16/2018 NAPROXEN SODIUM ORAL TABLET 550 MG 0.46647 11/15/2019 0.32180 05/22/2020 NARATRIPTAN HCL ORAL TABLET 1 MG 3.92785 06/16/2017 2.79000 12/25/2020 NARATRIPTAN HCL ORAL TABLET 2.5 MG 1.70222 09/25/2020 1.10278 11/20/2020 NATEGLINIDE ORAL TABLET 120 MG 0.36656 08/16/2019 0.14756 02/21/2020 NATEGLINIDE ORAL TABLET 60 MG 0.28945 08/16/2019 0.26967 05/22/2020 HCL ORAL TABLET 100 MG 1.09937 10/03/2014 1.09937 08/21/2015 NEFAZODONE HCL ORAL TABLET 150 MG 1.18018 02/13/2015 1.18018 08/21/2015 NEFAZODONE HCL ORAL TABLET 200 MG 1.18438 10/17/2014 1.18438 08/21/2015 NEFAZODONE HCL ORAL TABLET 250 MG 0.66582 08/23/2013 NEFAZODONE HCL ORAL TABLET 50 MG 0.56680 08/12/2014 NEOMYCIN SULF/BACITRACIN ZINC/POLYMYXIN B SULF/PRAMOXINE 0.16974 08/21/2015 0.07183 08/17/2018 HCL TOPICAL OINTMENT (GRAM) 3.5-10K-10 NEOMYCIN SULFATE ORAL TABLET 500 MG 0.50000 11/24/2017 0.61422 08/18/2018 NEOMYCIN SULFATE/BACITRACIN ZINC/POLYMYXIN B TOPICAL 0.08442 02/13/2015 0.08442 08/21/2015 OINTMENT (GRAM) 3.5-400-5K NEOMYCIN SULFATE/BACITRACIN ZINC/POLYMYXIN 12.81263 08/21/2015 12.16571 03/02/2018 B/HYDROCORTISONE OPHTHALMIC OINTMENT (GRAM) 3.5-10K-1 NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B OPHTHALMIC 8.09100 08/21/2015 3.90000 02/22/2019 OINTMENT (GRAM) 3.5MG-400 NEOMYCIN SULFATE/POLYMYXIN B SULFATE IRRIGATION AMPUL (ML) 7.53960 04/12/2013 40-200K/ML NEOMYCIN SULFATE/POLYMYXIN B SULFATE IRRIGATION VIAL (ML) 40- 5.02645 01/25/2013 200K/ML NEOMYCIN SULFATE/POLYMYXIN B SULFATE/GRAMICIDIN D 4.33580 05/24/2013 4.33580 08/21/2015 OPHTHALMIC DROPS 1.75MG-10K NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE 13.05287 03/08/2013 OPHTHALMIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 3.5-10K- 10 NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE OTIC 7.04760 09/22/2015 5.61033 11/20/2020 SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 3.5-10K-1 NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE OPHTHALMIC 2.52857 08/16/2019 1.53143 09/20/2019 OINTMENT (GRAM) 3.5-10K-.1 NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE OPHTHALMIC 2.60900 06/22/2018 2.47400 07/17/2020 SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 0.1 % ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 50 MG/5 ML 0.40225 01/25/2013 NEVIRAPINE ORAL TABLET 200 MG 0.19200 08/21/2015 0.10617 09/22/2017 NEVIRAPINE ORAL TABLET, EXTENDED RELEASE 24 HR 400 MG 15.82373 08/21/2015 3.59633 11/24/2017 NIACIN (INOSITOL NIACINATE) ORAL TABLET 500 MG 0.02737 08/21/2015 NIACIN ORAL CAPSULE, EXTENDED RELEASE 250 MG 0.04147 02/01/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date NIACIN ORAL CAPSULE, EXTENDED RELEASE 500 MG 0.04930 08/12/2014 NIACIN ORAL TABLET 100 MG 0.01270 08/12/2014 0.01270 08/21/2015 NIACIN ORAL TABLET 50 MG 0.01274 01/25/2013 NIACIN ORAL TABLET 500 MG 0.02000 08/12/2014 0.02000 08/21/2015 NIACIN ORAL TABLET, EXTENDED RELEASE 1000 MG 0.05775 01/25/2013 NIACIN ORAL TABLET, EXTENDED RELEASE 24 HR 1000 MG 1.24189 10/20/2017 0.81100 11/15/2019 NIACIN ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.33656 07/26/2019 0.08178 11/15/2019 NIACIN ORAL TABLET, EXTENDED RELEASE 250 MG 0.03662 02/08/2013 NIACIN ORAL TABLET, EXTENDED RELEASE 500 MG 0.03081 08/12/2014 0.03081 08/21/2015 NIACIN ORAL TABLET, EXTENDED RELEASE 750 MG 0.05020 08/12/2014 NIACINAMIDE ORAL TABLET 500 MG 0.02737 04/05/2013 HCL ORAL CAPSULE 20 MG 0.34500 02/08/2013 NICARDIPINE HCL ORAL CAPSULE 30 MG 0.35170 08/12/2014 POLACRILEX BUCCAL GUM 2 MG 0.17264 11/16/2018 0.20629 04/02/2019 NICOTINE POLACRILEX BUCCAL GUM 4 MG 0.14927 01/19/2018 0.21527 05/15/2019 NICOTINE POLACRILEX BUCCAL LOZENGE 2 MG 0.36791 08/21/2015 NICOTINE POLACRILEX BUCCAL LOZENGE 4 MG 0.33277 05/26/2017 0.29250 08/16/2019 NICOTINE POLACRILEX BUCCAL MINI LOZENGE 4 MG 0.38277 05/26/2017 NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 1.16303 02/21/2020 1.66904 07/31/2020 14MG/24HR NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 21 1.36143 11/16/2018 1.30714 02/22/2019 MG/24HR NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 7MG/24HR 1.46910 06/21/2019 1.29714 11/15/2019 MISCELLANEOUS POWDER (GRAM) 2.02800 08/21/2015 NIFEDIPINE ORAL CAPSULE 10 MG 0.40990 02/22/2019 0.39940 08/28/2020 NIFEDIPINE ORAL CAPSULE 20 MG 1.61182 08/21/2015 1.31822 06/16/2017 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 30 MG 0.16274 08/17/2018 0.10000 12/20/2019 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 60 MG 0.20292 08/17/2018 0.15000 07/17/2020 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 90 MG 0.34796 03/19/2019 0.28610 10/25/2019 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 30 MG 0.13326 08/25/2017 0.11185 11/16/2018 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 60 MG 0.30939 02/22/2019 0.16950 05/17/2019 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 90 MG 0.39300 05/17/2019 0.20555 08/16/2019 NIMODIPINE ORAL CAPSULE 30 MG 13.27890 08/21/2015 2.09000 05/17/2019 ORAL TABLET, EXTENDED RELEASE 24 HR 17 MG 4.66057 04/22/2016 3.86000 05/20/2016 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 20 MG 10.97514 03/13/2015 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 25.5 MG 5.87636 01/25/2013 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 30 MG 7.05270 02/08/2013 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 34 MG 5.87636 01/25/2013 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 40 MG 6.65350 01/25/2013 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 8.5MG 3.94911 12/02/2016 3.89950 11/16/2018 NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE 100 MG 0.91780 07/14/2017 0.74480 03/02/2018 NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE 50 MG 0.47000 10/25/2019 0.39193 02/21/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS ORAL CAPSULE 0.52928 04/17/2020 0.46800 05/22/2020 100 MG NITROFURANTOIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 25 1.31539 03/02/2018 9.40983 04/23/2019 MG/5 ML NITROGLYCERIN IN 5 % DEXTROSE IN WATER INTRAVENOUS INFUSION 0.01110 08/12/2014 BOTTLE (ML) 200MG/500 NITROGLYCERIN IN 5 % DEXTROSE IN WATER INTRAVENOUS INFUSION 0.02260 08/12/2014 BOTTLE (ML) 50MG/500ML NITROGLYCERIN INTRAVENOUS VIAL (ML) 50 MG/10ML 0.47040 01/25/2013 NITROGLYCERIN ORAL CAPSULE, EXTENDED RELEASE 2.5 MG 0.33267 05/17/2013 0.33267 08/21/2015 NITROGLYCERIN ORAL CAPSULE, EXTENDED RELEASE 6.5 MG 0.32960 02/15/2013 0.32960 08/21/2015 NITROGLYCERIN ORAL CAPSULE, EXTENDED RELEASE 9 MG 0.17330 08/12/2014 0.17330 08/21/2015 NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.69594 08/21/2015 0.52033 08/16/2019 0.1MG/HR NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.43967 03/03/2017 0.35275 11/24/2017 0.2MG/HR NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.43334 09/30/2016 0.39678 02/22/2019 0.4MG/HR NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.97601 08/21/2015 0.54533 10/20/2017 0.6MG/HR NITROGLYCERIN TRANSLINGUAL AEROSOL, SPRAY (GRAM) 27.46701 01/25/2013 400MCG/SPR NITROGLYCERIN TRANSLINGUAL SPRAY, NON-AEROSOL (GRAM) 17.75102 03/19/2021 16.00667 06/18/2021 400MCG/SPR NIZATIDINE ORAL CAPSULE 150 MG 0.26336 08/21/2015 0.18833 08/25/2017 NIZATIDINE ORAL CAPSULE 300 MG 0.56236 08/21/2015 0.36667 11/16/2018 NIZATIDINE ORAL SOLUTION, ORAL 150MG/10ML 0.49300 08/21/2015 1.00143 10/26/2019 /ETHINYL ESTRADIOL TRANSDERMAL PATCH, 39.00000 06/04/2021 TRANSDERMAL WEEKLY 150-35/24H NORETHINDRONE ACETATE ORAL TABLET 5 MG 0.65960 06/21/2019 0.99460 08/08/2019 NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 0.5MG- 2.00956 04/27/2018 2.5 NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1.5- 0.57873 09/22/2017 0.42460 05/22/2020 0.03MG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1MG- 0.20508 01/24/2020 0.13889 05/22/2020 20MCG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1MG- 1.65878 04/03/2019 1.33988 05/17/2019 5MCG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 0.16679 11/15/2019 0.15557 05/22/2020 ORAL TABLET 1.5-30(21) NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 5.33565 06/04/2021 ORAL TABLET 1MG-10(24) NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 0.19802 02/22/2019 0.14387 06/21/2019 ORAL TABLET 1MG-20(21) NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 0.73809 01/25/2019 0.69405 11/20/2020 ORAL TABLET 1MG-20(24) NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 1.42880 08/21/2015 0.91503 06/16/2017 ORAL TABLET 5-7-9-7 NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 1.88500 04/17/2020 1.78571 11/20/2020 ORAL TABLET,CHEWABLE 1MG-20(24) NORETHINDRONE ORAL TABLET 0.35 MG 0.10917 03/16/2018 0.07500 11/15/2019 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 0.4-0.035 0.39583 06/16/2017 0.24429 02/21/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 0.5-0.035 0.70263 02/26/2016 0.66000 04/27/2018 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 1 MG-35MCG 0.28925 06/16/2017 0.21179 07/16/2021 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 7 DAYS X 3 0.37448 06/16/2017 0.15179 11/15/2019 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 7-9-5 0.98375 01/25/2013 0.59237 06/16/2017 NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE ORAL 1.86241 08/21/2015 1.46607 10/20/2017 TABLET,CHEWABLE 0.4-35(21) NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE ORAL 1.60596 04/27/2018 TABLET,CHEWABLE 0.8-25(24) NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 0.25-0.035 0.21536 11/16/2018 0.12787 03/15/2019 NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 7DAYSX3 28 0.19123 11/16/2018 0.10250 03/15/2019 NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 7DAYSX3 LO 0.17845 01/24/2020 0.15456 06/19/2020 NORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.3-0.03MG 0.26161 11/16/2018 0.41660 06/18/2020 HCL ORAL CAPSULE 10 MG 0.07000 08/25/2017 0.05556 10/25/2019 NORTRIPTYLINE HCL ORAL CAPSULE 25 MG 0.06686 11/16/2018 0.05334 11/15/2019 NORTRIPTYLINE HCL ORAL CAPSULE 50 MG 0.11622 06/16/2017 0.07750 05/22/2020 NORTRIPTYLINE HCL ORAL CAPSULE 75 MG 0.15800 08/25/2017 0.12989 09/22/2017 NORTRIPTYLINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.26055 02/27/2015 0.26055 08/21/2015 NYSTATIN MISCELLANEOUS POWDER (EA) 10B UNIT 17265.36000 01/25/2013 NYSTATIN MISCELLANEOUS POWDER (EA) 150MM UNIT 98.76650 01/25/2013 NYSTATIN MISCELLANEOUS POWDER (EA) 1B UNIT 404.56500 01/25/2013 NYSTATIN MISCELLANEOUS POWDER (EA) 2B UNIT 459.38450 01/25/2013 NYSTATIN MISCELLANEOUS POWDER (EA) 500MM UNIT 156.49700 01/25/2013 156.49700 08/21/2015 NYSTATIN MISCELLANEOUS POWDER (EA) 50MM UNIT 47.31300 01/25/2013 47.31300 08/21/2015 NYSTATIN MISCELLANEOUS POWDER (EA) 5B UNIT 742.07950 01/25/2013 NYSTATIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100000/ML 0.06036 06/16/2017 0.04816 08/17/2018 NYSTATIN ORAL TABLET 500K UNIT 0.40617 05/19/2017 0.34870 08/17/2018 NYSTATIN TOPICAL CREAM (GRAM) 100000/G 0.17875 11/15/2019 0.16033 01/24/2020 NYSTATIN TOPICAL OINTMENT (GRAM) 100000/G 0.32875 11/16/2018 0.28593 06/21/2019 NYSTATIN TOPICAL POWDER (GRAM) 100000/G 0.29656 07/26/2019 0.26384 11/15/2019 NYSTATIN/TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.95666 04/26/2019 0.38408 02/21/2020 100000-0.1 NYSTATIN/TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.55533 02/22/2019 0.18333 09/20/2019 100000-0.1 OCTREOTIDE ACETATE INJECTION AMPUL (ML) 100 MCG/ML 4.02220 03/07/2014 OCTREOTIDE ACETATE INJECTION AMPUL (ML) 50 MCG/ML 2.84310 01/25/2013 OCTREOTIDE ACETATE INJECTION AMPUL (ML) 500 MCG/ML 21.50330 12/26/2014 OCTREOTIDE ACETATE INJECTION SYRINGE (ML) 100 MCG/ML 15.96000 03/21/2014 OCTREOTIDE ACETATE INJECTION SYRINGE (ML) 50 MCG/ML 5.98920 01/25/2013 OCTREOTIDE ACETATE INJECTION SYRINGE (ML) 500 MCG/ML 45.22560 01/25/2013 OCTREOTIDE ACETATE INJECTION VIAL (ML) 100 MCG/ML 5.15580 05/01/2015 5.15580 08/21/2015 OCTREOTIDE ACETATE INJECTION VIAL (ML) 1000MCG/ML 34.03343 02/27/2015 34.03343 08/21/2015 OCTREOTIDE ACETATE INJECTION VIAL (ML) 200 MCG/ML 8.03760 08/12/2014 8.03760 08/21/2015 OCTREOTIDE ACETATE INJECTION VIAL (ML) 50 MCG/ML 2.83010 09/05/2014 2.83010 08/21/2015 OCTREOTIDE ACETATE INJECTION VIAL (ML) 500 MCG/ML 20.95800 05/01/2015 20.95800 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date OFLOXACIN OPHTHALMIC DROPS 0.3 % 1.83240 11/15/2019 1.48200 01/15/2021 OFLOXACIN OTIC DROPS 0.3 % 3.89183 07/02/2020 2.16133 02/19/2021 OLANZAPINE INTRAMUSCULAR VIAL (EA) 10 MG 29.05000 02/01/2013 OLANZAPINE ORAL TABLET 10 MG 0.12030 08/10/2020 0.10867 03/19/2021 OLANZAPINE ORAL TABLET 15 MG 0.15220 09/22/2017 0.11167 04/17/2020 OLANZAPINE ORAL TABLET 2.5 MG 0.10093 08/25/2017 0.07267 03/02/2018 OLANZAPINE ORAL TABLET 20 MG 0.16876 11/15/2019 0.10000 01/24/2020 OLANZAPINE ORAL TABLET 5 MG 0.09611 08/25/2017 0.07497 08/16/2019 OLANZAPINE ORAL TABLET 7.5 MG 0.10995 05/17/2019 0.08533 08/16/2019 OLANZAPINE ORAL TABLET,DISINTEGRATING 10 MG 0.76425 03/19/2020 0.35333 11/20/2020 OLANZAPINE ORAL TABLET,DISINTEGRATING 15 MG 0.57400 05/17/2019 0.55533 05/22/2020 OLANZAPINE ORAL TABLET,DISINTEGRATING 20 MG 0.61067 11/24/2017 0.41667 11/20/2020 OLANZAPINE ORAL TABLET,DISINTEGRATING 5 MG 0.72000 03/04/2019 0.18167 03/20/2020 OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 12MG-25MG 15.27470 08/15/2014 OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 12MG-50MG 15.27773 08/12/2014 OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 3 MG-25 MG 7.51917 11/14/2014 7.51917 08/21/2015 OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 6MG-25MG 10.13740 08/21/2015 6.50000 06/18/2021 OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 6MG-50MG 10.13740 08/01/2014 7.04000 01/25/2019 OLMESARTAN MEDOXOMIL ORAL TABLET 20 MG 0.10100 04/27/2018 0.08956 06/19/2020 OLMESARTAN MEDOXOMIL ORAL TABLET 40 MG 0.16863 04/27/2018 0.14348 06/18/2021 OLMESARTAN MEDOXOMIL ORAL TABLET 5 MG 0.08550 11/16/2018 0.05067 07/26/2019 OLMESARTAN MEDOXOMIL/AMLODIPINE 1.37855 11/15/2019 1.37855 01/01/2020 BESYLATE/HYDROCHLOROTHIAZIDE ORAL TABLET 20-5-12.5 OLMESARTAN MEDOXOMIL/AMLODIPINE 1.82389 11/15/2019 1.82389 01/01/2020 BESYLATE/HYDROCHLOROTHIAZIDE ORAL TABLET 40-10-12.5 OLMESARTAN MEDOXOMIL/AMLODIPINE 1.61800 11/16/2018 1.61800 01/01/2020 BESYLATE/HYDROCHLOROTHIAZIDE ORAL TABLET 40-10-25MG OLMESARTAN MEDOXOMIL/AMLODIPINE 1.00133 05/17/2019 1.00133 01/01/2020 BESYLATE/HYDROCHLOROTHIAZIDE ORAL TABLET 40-5-12.5 OLMESARTAN MEDOXOMIL/AMLODIPINE 1.71000 11/16/2018 1.71000 01/01/2020 BESYLATE/HYDROCHLOROTHIAZIDE ORAL TABLET 40-5-25 MG OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE ORAL TABLET 20- 0.13000 08/17/2018 0.08333 03/15/2019 12.5 MG OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE ORAL TABLET 40 0.20000 04/27/2018 0.17600 02/22/2019 MG-25MG OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE ORAL TABLET 40- 0.12000 04/27/2018 12.5 MG OLOPATADINE HCL NASAL AEROSOL, SPRAY WITH PUMP (GRAM) 0.6 % 2.15000 06/21/2019 2.35611 06/24/2019 OLOPATADINE HCL OPHTHALMIC DROPS 0.1 % 2.10667 08/28/2020 1.87900 02/19/2021 OMEGA-3 ACID ETHYL ESTERS ORAL CAPSULE 1 G 0.21378 01/01/2019 0.18871 05/22/2020 OMEGA-3 FATTY ACIDS/DOCOSAHEXAENOIC ACID/EPA/FISH OIL ORAL 0.05283 08/12/2014 CAPSULE 1000 MG ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.11633 08/25/2017 0.02056 08/17/2018 10 MG OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.03862 07/14/2017 0.02840 09/25/2020 20 MG OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.04480 01/24/2020 0.04334 01/15/2021 40 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date OMEPRAZOLE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 20 0.47857 08/25/2017 0.19321 02/21/2020 MG OMEPRAZOLE/SODIUM BICARBONATE ORAL CAPSULE 20MG-1.1G 6.58183 09/22/2017 1.95000 10/25/2019 OMEPRAZOLE/SODIUM BICARBONATE ORAL CAPSULE 40MG-1.1G 1.85000 10/25/2019 1.28050 11/15/2019 ONDANSETRON HCL INTRAVENOUS VIAL (ML) 2 MG/ML 0.07865 01/16/2015 0.07865 08/21/2015 ONDANSETRON HCL ORAL SOLUTION, ORAL 4 MG/5 ML 0.23744 11/15/2019 0.18500 09/25/2020 ONDANSETRON HCL ORAL TABLET 4 MG 0.05643 05/22/2020 0.05333 06/18/2021 ONDANSETRON HCL ORAL TABLET 8 MG 0.12277 11/16/2018 0.09415 05/22/2020 ONDANSETRON HCL/PF INJECTION AMPUL (ML) 4 MG/2 ML 8.31950 01/25/2013 ONDANSETRON HCL/PF INJECTION SYRINGE (ML) 4 MG/2 ML 0.93551 05/01/2015 0.93551 08/21/2015 ONDANSETRON HCL/PF INJECTION VIAL (ML) 4 MG/2 ML 0.25000 11/16/2018 0.14720 03/20/2020 ONDANSETRON ORAL TABLET,DISINTEGRATING 4 MG 0.16667 07/17/2020 0.14295 05/21/2021 ONDANSETRON ORAL TABLET,DISINTEGRATING 8 MG 0.22773 11/15/2019 0.21807 04/16/2021 OPIUM TINCTURE ORAL TINCTURE 10 MG/ML 3.65310 08/02/2013 2.38890 03/02/2018 OPIUM/BELLADONNA ALKALOIDS RECTAL SUPPOSITORY, RECTAL 30- 19.61500 07/18/2014 16.2 MG OPIUM/BELLADONNA ALKALOIDS RECTAL SUPPOSITORY, RECTAL 60- 23.41675 10/24/2014 16.2 MG ORPHENADRINE CITRATE ORAL TABLET, EXTENDED RELEASE 100 MG 0.18230 09/22/2017 0.14850 11/16/2018 OSELTAMIVIR PHOSPHATE ORAL CAPSULE 30 MG 5.33000 01/25/2019 OSELTAMIVIR PHOSPHATE ORAL CAPSULE 45 MG 5.55000 01/25/2019 OSELTAMIVIR PHOSPHATE ORAL CAPSULE 75 MG 2.92000 03/20/2020 1.84057 05/22/2020 OSELTAMIVIR PHOSPHATE ORAL SUSPENSION, RECONSTITUTED, ORAL 1.02317 11/15/2019 0.63350 05/22/2020 (ML) 6 MG/ML OXACILLIN SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV 0.25790 01/25/2013 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML OXACILLIN SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV 0.23003 09/26/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2 G/50 ML OXACILLIN SODIUM INJECTION VIAL (EA) 1 G 8.82240 08/22/2014 8.82240 08/21/2015 OXACILLIN SODIUM INJECTION VIAL (EA) 10 G 86.55715 08/22/2014 OXACILLIN SODIUM INJECTION VIAL (EA) 2 G 15.23550 08/22/2014 15.23550 08/21/2015 OXACILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 G 0.86301 01/25/2013 OXACILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2 G 2.23201 01/25/2013 OXANDROLONE ORAL TABLET 10 MG 9.27840 01/25/2013 9.27840 08/21/2015 OXANDROLONE ORAL TABLET 2.5 MG 3.00096 08/12/2014 3.00096 08/21/2015 OXAPROZIN ORAL TABLET 600 MG 0.89000 10/19/2018 0.76500 03/20/2020 OXAZEPAM ORAL CAPSULE 10 MG 0.56183 01/13/2017 0.51416 01/27/2017 OXAZEPAM ORAL CAPSULE 15 MG 0.77475 12/02/2016 0.74047 04/21/2017 OXAZEPAM ORAL CAPSULE 30 MG 1.11314 04/24/2015 ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 300 0.31168 01/07/2019 0.28028 03/19/2021 MG/5ML OXCARBAZEPINE ORAL TABLET 150 MG 0.09147 08/17/2018 0.07880 07/26/2019 OXCARBAZEPINE ORAL TABLET 300 MG 0.14390 11/16/2018 0.12910 07/26/2019 OXCARBAZEPINE ORAL TABLET 600 MG 0.30876 05/19/2017 0.27511 08/25/2017 OXYBUTYNIN CHLORIDE ORAL SYRUP 5 MG/5 ML 0.02124 05/17/2013 0.02124 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date OXYBUTYNIN CHLORIDE ORAL TABLET 5 MG 0.11303 06/21/2019 0.07000 05/22/2020 OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 10 0.21015 01/15/2021 0.19402 05/21/2021 MG OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 15 0.20670 05/22/2020 0.15440 07/17/2020 MG OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 5 0.18040 01/24/2020 0.17300 10/23/2020 MG OXYCODONE HCL ORAL CAPSULE 5 MG 1.29200 08/21/2015 0.41790 06/16/2017 OXYCODONE HCL ORAL CONCENTRATE, ORAL 20 MG/ML 3.73320 09/30/2016 2.80000 05/25/2018 OXYCODONE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.15271 09/20/2019 0.09998 11/15/2019 OXYCODONE HCL ORAL TABLET 10 MG 0.13000 03/02/2018 0.11250 06/18/2021 OXYCODONE HCL ORAL TABLET 15 MG 0.14173 03/03/2017 0.11260 03/02/2018 OXYCODONE HCL ORAL TABLET 20 MG 0.24678 01/27/2017 0.19825 08/25/2017 OXYCODONE HCL ORAL TABLET 30 MG 0.19490 03/20/2020 0.24570 08/27/2020 OXYCODONE HCL ORAL TABLET 5 MG 0.07130 08/25/2017 0.06998 12/25/2020 OXYCODONE HCL ORAL TABLET,ORAL ONLY,EXTENDED RELEASE 12 5.78530 03/03/2017 5.78530 03/04/2017 HR 40 MG OXYCODONE HCL ORAL TABLET,ORAL ONLY,EXTENDED RELEASE 12 9.41957 03/03/2017 9.41957 03/04/2017 HR 80 MG OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 10MG-325MG 0.27202 07/17/2019 0.25078 08/16/2019 OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 2.5-325 MG 1.43437 05/01/2015 1.24120 11/24/2017 OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 5 MG-325MG 0.09991 03/03/2017 0.06530 09/21/2018 OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 7.5-325 MG 0.22515 05/17/2019 0.16020 11/15/2019 OXYCODONE HCL/ASPIRIN ORAL TABLET 4.8355-325 0.40759 11/07/2014 0.40759 08/21/2015 OXYMORPHONE HCL ORAL TABLET 10 MG 2.46947 07/14/2017 1.92770 11/24/2017 OXYMORPHONE HCL ORAL TABLET 5 MG 1.64692 08/21/2015 1.36790 11/24/2017 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 10 MG 2.43642 08/21/2015 2.81100 01/29/2018 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 15 MG 3.54294 04/03/2015 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 20 MG 5.11420 07/10/2017 5.38900 05/17/2018 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 30 MG 6.21979 08/21/2015 6.32123 07/13/2017 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 40 MG 8.11845 05/16/2014 8.11845 08/21/2015 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 5 MG 1.26886 05/16/2014 1.26886 08/21/2015 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 7.5 MG 1.91827 05/16/2014 PALIPERIDONE ORAL TABLET, EXTENDED RELEASE 24 HR 6 MG 17.55344 01/03/2017 8.99000 06/21/2019 PALIPERIDONE ORAL TABLET, EXTENDED RELEASE 24 HR 9 MG 9.85456 11/20/2020 7.68075 02/19/2021 PAMIDRONATE DISODIUM INTRAVENOUS VIAL (EA) 30 MG 10.37300 02/27/2015 10.37300 08/21/2015 PAMIDRONATE DISODIUM INTRAVENOUS VIAL (EA) 90 MG 26.85500 02/27/2015 26.85500 08/21/2015 PAMIDRONATE DISODIUM INTRAVENOUS VIAL (ML) 30MG/10ML 1.47400 08/12/2014 1.47400 08/21/2015 PAMIDRONATE DISODIUM INTRAVENOUS VIAL (ML) 60 MG/10ML 4.62000 01/25/2013 PAMIDRONATE DISODIUM INTRAVENOUS VIAL (ML) 90 MG/10ML 4.54740 08/08/2014 4.54740 08/21/2015 PANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.05756 12/22/2017 0.04411 01/19/2018 COATED) 20 MG PANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.05189 06/16/2017 0.04867 10/23/2020 COATED) 40 MG PAREGORIC LIQUID (ML) 2 MG/5 ML 0.46388 04/26/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PARICALCITOL INJECTION VIAL (ML) 2 MCG/ML 3.52800 03/27/2015 PARICALCITOL INJECTION VIAL (ML) 5 MCG/ML 8.82000 01/30/2015 PARICALCITOL ORAL CAPSULE 1 MCG 2.80000 05/25/2018 0.94067 08/17/2018 PARICALCITOL ORAL CAPSULE 2 MCG 15.52623 07/04/2014 8.23334 03/03/2017 PARICALCITOL ORAL CAPSULE 4 MCG 31.05270 07/04/2014 PAROMOMYCIN SULFATE ORAL CAPSULE 250 MG 2.95152 06/14/2013 PAROXETINE HCL ORAL TABLET 10 MG 0.05431 12/22/2017 0.04078 11/16/2018 PAROXETINE HCL ORAL TABLET 20 MG 0.05879 07/14/2017 0.04100 09/22/2017 PAROXETINE HCL ORAL TABLET 30 MG 0.14156 08/21/2015 0.08967 09/22/2017 PAROXETINE HCL ORAL TABLET 40 MG 0.17420 08/21/2015 0.07622 07/14/2017 PAROXETINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 25 MG 1.44307 05/17/2019 1.27800 03/20/2020 PEANUT OIL MISCELLANEOUS OIL (ML) 0.09990 08/12/2014 0.09990 08/21/2015 PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM 0.00288 12/05/2014 CHLORIDE ORAL SOLUTION, RECONSTITUTED, ORAL 236-22.74G PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM 0.00219 08/22/2014 0.00219 08/21/2015 CHLORIDE ORAL SOLUTION, RECONSTITUTED, ORAL 240-22.72G PENICILLIN G POTASSIUM INJECTION VIAL (EA) 20MM UNIT 24.80100 08/12/2014 PENICILLIN G POTASSIUM INJECTION VIAL (EA) 5MM UNIT 26.68167 04/17/2015 26.68167 08/21/2015 PENICILLIN G POTASSIUM/DEXTROSE-WATER INTRAVENOUS IV 0.19490 01/25/2013 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1MM/50ML PENICILLIN G POTASSIUM/DEXTROSE-WATER INTRAVENOUS IV 0.21880 01/25/2013 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2MM/50ML PENICILLIN G POTASSIUM/DEXTROSE-WATER INTRAVENOUS IV 0.13440 01/25/2013 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 3MM/50ML PENICILLIN G PROCAINE INTRAMUSCULAR SYRINGE (ML) 1.2MM/2 ML 11.84540 01/25/2013 11.84540 08/21/2015 PENICILLIN G PROCAINE INTRAMUSCULAR SYRINGE (ML) 600000/ML 13.05360 01/25/2013 PENICILLIN G SODIUM INJECTION VIAL (EA) 5MM UNIT 40.12055 08/09/2013 PENICILLIN V POTASSIUM ORAL SOLUTION, RECONSTITUTED, ORAL 125 0.02349 04/05/2013 MG/5ML PENICILLIN V POTASSIUM ORAL SOLUTION, RECONSTITUTED, ORAL 250 0.05111 04/03/2015 MG/5ML PENICILLIN V POTASSIUM ORAL TABLET 250 MG 0.17072 08/21/2015 0.07000 11/24/2017 PENICILLIN V POTASSIUM ORAL TABLET 500 MG 0.07250 11/15/2019 0.05740 01/24/2020 PENTAZOCINE HCL/NALOXONE HCL ORAL TABLET 50MG-0.5MG 2.10324 04/03/2015 2.10324 08/21/2015 ORAL TABLET, EXTENDED RELEASE 400 MG 0.14637 08/25/2017 0.12795 11/16/2018 PERINDOPRIL ERBUMINE ORAL TABLET 2 MG 0.85163 01/25/2013 PERINDOPRIL ERBUMINE ORAL TABLET 4 MG 0.61627 08/21/2015 0.58980 11/15/2019 PERINDOPRIL ERBUMINE ORAL TABLET 8 MG 0.70278 08/29/2014 0.70278 08/21/2015 TOPICAL CREAM (GRAM) 5 % 0.45460 03/20/2019 0.29678 02/21/2020 PERMETHRIN TOPICAL LIQUID (ML) 1 % 0.04372 12/13/2013 0.04372 08/21/2015 PERPHENAZINE ORAL TABLET 16 MG 1.67330 10/24/2014 1.53480 09/22/2017 PERPHENAZINE ORAL TABLET 2 MG 0.45370 03/16/2018 0.31250 01/25/2019 PERPHENAZINE ORAL TABLET 4 MG 0.46600 01/25/2019 0.34360 02/22/2019 PERPHENAZINE ORAL TABLET 8 MG 0.29300 03/20/2020 0.47317 06/16/2020 PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 2 MG-10 MG 0.85974 03/13/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 2 MG-25 MG 1.09466 04/03/2015 PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 4 MG-25 MG 1.19224 03/13/2015 PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 4 MG-50 MG 1.96854 03/13/2015 2.47290 03/06/2018 PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 4MG-10MG 0.47570 08/12/2014 PETROLATUM,WHITE TOPICAL OINTMENT IN PACKET (GRAM) 13.09140 08/21/2015 PETROLATUM,WHITE/WATER TOPICAL LOTION (ML) 0.00860 08/12/2014 PHENAZOPYRIDINE HCL ORAL TABLET 100 MG 0.51200 11/24/2017 0.26500 06/21/2019 PHENAZOPYRIDINE HCL ORAL TABLET 200 MG 0.68905 11/16/2018 0.40000 05/22/2020 PHENDIMETRAZINE TARTRATE ORAL TABLET 35 MG 0.13406 08/12/2014 0.13406 08/21/2015 PHENELZINE SULFATE ORAL TABLET 15 MG 0.58450 01/25/2013 0.44016 09/30/2016 ORAL ELIXIR 20 MG/5 ML 0.11000 07/26/2019 0.10937 11/20/2020 PHENOBARBITAL ORAL TABLET 100 MG 0.22053 04/19/2013 PHENOBARBITAL ORAL TABLET 15 MG 0.11231 04/12/2013 PHENOBARBITAL ORAL TABLET 16.2 MG 0.16065 08/21/2015 0.37408 09/23/2015 PHENOBARBITAL ORAL TABLET 30 MG 0.12320 08/29/2014 PHENOBARBITAL ORAL TABLET 32.4 MG 0.50000 08/25/2017 0.36000 11/16/2018 PHENOBARBITAL ORAL TABLET 64.8 MG 0.58906 05/06/2019 0.49250 08/16/2019 PHENOBARBITAL ORAL TABLET 97.2MG 0.90673 03/01/2018 0.85000 05/25/2018 PHENOBARBITAL SODIUM INJECTION VIAL (ML) 130MG/ML 13.60800 01/25/2013 PHENOBARBITAL SODIUM INJECTION VIAL (ML) 65 MG/ML 10.58400 07/26/2013 PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE SULF/SCOPOLAMINE 0.11741 08/21/2015 HB ORAL ELIXIR 16.2MG/5ML PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE SULF/SCOPOLAMINE 0.02701 08/21/2015 HB ORAL TABLET 16.2 MG PHENTERMINE HCL ORAL CAPSULE 15 MG 0.76603 08/21/2015 0.16000 09/22/2017 PHENTERMINE HCL ORAL CAPSULE 30 MG 0.19443 08/21/2015 0.14830 08/25/2017 PHENTERMINE HCL ORAL CAPSULE 37.5 MG 0.32924 08/21/2015 0.10540 09/22/2017 PHENTERMINE HCL ORAL TABLET 37.5 MG 0.08429 08/21/2015 0.06571 04/26/2019 PHENYLEPHRINE HCL OPHTHALMIC DROPS 10 % 6.86000 02/27/2015 6.86000 08/21/2015 PHENYLEPHRINE HCL OPHTHALMIC DROPS 2.5 % 6.61924 02/27/2015 6.61924 08/21/2015 PHENYLEPHRINE HCL ORAL SOLUTION, ORAL 2.5 MG/5ML 0.04150 08/12/2014 PHENYLEPHRINE HCL ORAL TABLET 10 MG 0.04135 09/19/2014 0.04135 08/21/2015 PHENYLEPHRINE HCL/PROMETHAZINE HCL ORAL SYRUP 5-6.25MG/5 0.23791 10/31/2014 0.23791 08/21/2015 ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 MG/4ML 0.27300 08/12/2014 PHENYTOIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 125 MG/5ML 0.08026 03/17/2017 0.06283 08/17/2018 PHENYTOIN ORAL TABLET,CHEWABLE 50 MG 0.19360 08/17/2018 0.29720 12/18/2019 PHENYTOIN SODIUM EXTENDED ORAL CAPSULE 100 MG 0.17390 03/15/2019 0.16530 10/25/2019 PHENYTOIN SODIUM EXTENDED ORAL CAPSULE 200 MG 0.55990 08/12/2014 PHENYTOIN SODIUM INTRAVENOUS AMPUL (ML) 50 MG/ML 0.57670 08/12/2014 PHENYTOIN SODIUM INTRAVENOUS SYRINGE (ML) 50 MG/ML 0.68460 01/25/2013 PHENYTOIN SODIUM INTRAVENOUS VIAL (ML) 50 MG/ML 0.37563 08/12/2014 PHOSPHORATED CARBOHYDRATE (DEXTROSE AND FRUCTOSE) ORAL 0.03038 08/12/2014 SOLUTION, ORAL West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PHYTONADIONE (VIT K1) INJECTION AMPUL (ML) 10 MG/ML 26.38440 08/22/2014 PHYTONADIONE (VIT K1) ORAL TABLET 100 MCG 0.02140 08/12/2014 0.02140 08/21/2015 PHYTONADIONE (VIT K1) ORAL TABLET 5 MG 44.17600 08/16/2019 38.95000 06/18/2021 PILOCARPINE HCL OPHTHALMIC DROPS 1 % 4.34000 04/26/2013 4.34000 08/21/2015 PILOCARPINE HCL OPHTHALMIC DROPS 2 % 4.43940 08/21/2015 4.22200 05/22/2020 PILOCARPINE HCL OPHTHALMIC DROPS 4 % 4.65220 08/21/2015 4.14400 02/21/2020 PILOCARPINE HCL ORAL TABLET 5 MG 0.74470 02/22/2019 0.28990 11/15/2019 PILOCARPINE HCL ORAL TABLET 7.5 MG 1.15570 05/20/2016 1.04620 11/16/2018 PINDOLOL ORAL TABLET 10 MG 0.97925 06/16/2017 0.79990 02/22/2019 PINDOLOL ORAL TABLET 5 MG 0.85750 03/02/2018 0.65800 01/25/2019 PIOGLITAZONE HCL ORAL TABLET 15 MG 0.05857 11/16/2018 0.05734 06/18/2021 PIOGLITAZONE HCL ORAL TABLET 30 MG 0.12456 08/25/2017 0.07133 11/16/2018 PIOGLITAZONE HCL ORAL TABLET 45 MG 0.14678 03/16/2018 0.03389 11/16/2018 PIOGLITAZONE HCL/GLIMEPIRIDE ORAL TABLET 30 MG-2 MG 21.94569 03/01/2013 6.57850 06/16/2017 PIOGLITAZONE HCL/GLIMEPIRIDE ORAL TABLET 30 MG-4 MG 21.94569 03/01/2013 10.75527 06/16/2017 PIOGLITAZONE HCL/METFORMIN HCL ORAL TABLET 15MG-500MG 1.12650 08/17/2018 1.11033 03/20/2020 PIOGLITAZONE HCL/METFORMIN HCL ORAL TABLET 15MG-850MG 1.02022 11/24/2017 0.61100 02/21/2020 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 3.74530 08/21/2015 4.62000 10/05/2016 2.25 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 11.98000 08/21/2015 3.25000 05/22/2020 3.375 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 15.01360 07/19/2013 4.35700 05/22/2020 4.5 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 95.66330 08/21/2015 72.90000 01/25/2019 40.5 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL WITH 8.32230 01/25/2013 THREADED PORT (EA) 2.25 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL WITH 12.66720 01/31/2014 THREADED PORT (EA) 3.375 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL WITH 15.73320 01/25/2013 THREADED PORT (EA) 4.5 G PIPERONYL BUTOXIDE/PYRETHRINS TOPICAL SHAMPOO 4%-0.33% 0.03613 05/03/2013 0.03613 08/21/2015 PIROXICAM ORAL CAPSULE 10 MG 0.53490 11/24/2017 0.44020 03/15/2019 PIROXICAM ORAL CAPSULE 20 MG 0.57000 10/19/2018 0.23350 11/16/2018 PODOFILOX TOPICAL SOLUTION, NON-ORAL 0.5 % 16.47695 04/22/2016 12.20500 09/30/2016 POLYDIMETHYLSILOXANES/SILICON DIOXIDE TOPICAL GEL (GRAM) 3.96690 04/03/2015 3350 ORAL POWDER (GRAM) 17 G/DOSE 0.02099 05/19/2017 0.01945 05/21/2021 POLYETHYLENE GLYCOL 3350 ORAL POWDER IN PACKET (EA) 17 G 1.46800 07/14/2020 1.46800 04/23/2021 POLYETHYLENE GLYCOL 400/HYPROMELLOSE/GLYCERIN OPHTHALMIC 0.06720 01/25/2013 DROPS 1-0.2-0.2% POLYMYXIN B SULFATE/TRIMETHOPRIM OPHTHALMIC DROPS 10000- 0.41400 12/22/2017 0.38700 09/20/2019 1/ML POLYVINYL ALCOHOL OPHTHALMIC DROPS 1.4 % 0.13400 01/25/2013 0.13400 08/21/2015 POTASSIUM ALUM/SALICYLIC ACID//BENTONITE TOPICAL POWDER 0.06740 08/12/2014 (GRAM) POTASSIUM ALUM/TALC/BENTONITE TOPICAL POWDER (GRAM) 0.07530 08/12/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date POTASSIUM BICARBONATE/CITRIC ACID ORAL TABLET, EFFERVESCENT 0.21200 05/01/2015 0.18200 08/17/2018 25 MEQ POTASSIUM CHLORIDE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.00410 08/12/2014 INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS 0.00283 04/19/2013 INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS 0.00510 01/25/2013 INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER INTRAVENOUS 0.00310 08/12/2014 INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER INTRAVENOUS 0.00266 01/25/2013 INTRAVENOUS SOLUTION 30 MEQ/L POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER INTRAVENOUS 0.00209 01/25/2013 0.00209 08/21/2015 INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE 0.00320 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE 0.00540 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE 0.00234 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 10 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE 0.00322 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE 0.00200 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 30 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE 0.00227 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE 0.00320 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 10 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE 0.00230 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE 0.00236 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 30 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE 0.00228 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5% AND 0.3 % SODIUM CHLORIDE 0.00322 01/25/2013 0.00322 08/21/2015 INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN LACTATED RINGERS AND 5 % DEXTROSE 0.00610 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN LACTATED RINGERS AND 5 % DEXTROSE 0.00403 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE 0.02218 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 10MEQ/0.1L POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE 0.06570 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 10MEQ/50ML POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE 0.02180 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 20MEQ/0.1L POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE 0.10610 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 20MEQ/50ML POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE 0.04528 01/25/2013 0.04528 08/21/2015 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 30MEQ/0.1L POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE 0.04897 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 40MEQ/0.1L POTASSIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 2 0.02779 08/22/2014 MEQ/ML POTASSIUM CHLORIDE INTRAVENOUS VIAL (ML) 2 MEQ/ML 0.02303 04/19/2013 0.02303 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date POTASSIUM CHLORIDE ORAL CAPSULE, EXTENDED RELEASE 10 MEQ 0.27000 08/25/2017 0.09794 09/22/2017 POTASSIUM CHLORIDE ORAL CAPSULE, EXTENDED RELEASE 8 MEQ 0.41723 02/26/2016 0.15000 08/16/2019 POTASSIUM CHLORIDE ORAL LIQUID (ML) 20MEQ/15ML 0.28252 12/09/2019 0.17876 12/25/2020 POTASSIUM CHLORIDE ORAL LIQUID (ML) 40MEQ/15ML 0.38055 11/16/2018 0.56550 07/10/2020 POTASSIUM CHLORIDE ORAL PACKET (EA) 20 MEQ 4.93300 01/13/2020 3.59811 09/25/2020 POTASSIUM CHLORIDE ORAL TABLET, EXT RELEASE, 0.19245 11/16/2018 0.16745 08/16/2019 PARTICLES/ 10 MEQ POTASSIUM CHLORIDE ORAL TABLET, EXT RELEASE, 0.18056 10/25/2019 0.17111 12/25/2020 PARTICLES/CRYSTALS 20 MEQ POTASSIUM CHLORIDE ORAL TABLET, EXTENDED RELEASE 10 MEQ 0.13899 07/26/2019 0.11950 09/25/2020 POTASSIUM CHLORIDE ORAL TABLET, EXTENDED RELEASE 8 MEQ 0.35868 08/21/2015 0.15500 08/25/2017 POTASSIUM CHLORIDE/POTASSIUM BICARBONATE/CITRIC ACID 0.68997 01/25/2013 TABLET, EFFERVESCENT 25 MEQ POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 10 MEQ 0.52180 07/26/2019 0.40707 11/20/2020 POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 15 MEQ 1.06610 03/20/2020 0.99990 10/23/2020 POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 5 MEQ 0.92685 09/30/2016 0.52180 11/15/2019 POVIDONE- TOPICAL OINTMENT (GRAM) 10 % 0.06258 01/25/2013 0.06258 08/21/2015 POVIDONE-IODINE TOPICAL SOLUTION, NON-ORAL 10 % 0.00639 04/17/2015 0.00639 08/21/2015 POVIDONE-IODINE TOPICAL SWAB, MEDICATED 10 % 0.15276 08/12/2014 POVIDONE-IODINE VAGINAL SOLUTION, NON-ORAL 0.3 % 0.00990 08/12/2014 PRAMIPEXOLE DI-HCL ORAL TABLET 0.125 MG 0.03978 09/22/2017 0.03356 06/18/2021 PRAMIPEXOLE DI-HCL ORAL TABLET 0.25 MG 0.04338 07/14/2017 0.03074 11/16/2018 PRAMIPEXOLE DI-HCL ORAL TABLET 0.5 MG 0.04834 08/25/2017 0.02844 12/20/2019 PRAMIPEXOLE DI-HCL ORAL TABLET 0.75 MG 0.09654 08/21/2015 0.05479 03/19/2021 PRAMIPEXOLE DI-HCL ORAL TABLET 1 MG 0.04395 08/25/2017 0.03333 05/22/2020 PRAMIPEXOLE DI-HCL ORAL TABLET 1.5 MG 0.06322 09/22/2017 0.04000 04/27/2018 PRAMIPEXOLE DI-HCL ORAL TABLET, EXTENDED RELEASE 24 HR 0.375 11.95470 05/01/2015 MG PRAMIPEXOLE DI-HCL ORAL TABLET, EXTENDED RELEASE 24 HR 0.75 11.29637 04/24/2015 MG PRAMIPEXOLE DI-HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1.5 MG 11.29637 04/24/2015 PRAMOXINE HCL TOPICAL TOWELETTE (EA) 1 % 0.35233 01/25/2013 PRASUGREL HCL ORAL TABLET 10 MG 0.41000 04/17/2020 0.27733 05/22/2020 PRASUGREL HCL ORAL TABLET 5 MG 0.21000 01/25/2019 0.69533 04/06/2020 PRAVASTATIN SODIUM ORAL TABLET 10 MG 0.06264 09/20/2019 0.04363 03/20/2020 PRAVASTATIN SODIUM ORAL TABLET 20 MG 0.06396 05/22/2020 0.03656 01/15/2021 PRAVASTATIN SODIUM ORAL TABLET 40 MG 0.14067 09/22/2017 0.06651 01/19/2018 PRAVASTATIN SODIUM ORAL TABLET 80 MG 0.21211 09/22/2017 0.11322 12/22/2017 PRAZOSIN HCL ORAL CAPSULE 1 MG 0.22789 05/22/2020 0.18267 06/18/2021 PRAZOSIN HCL ORAL CAPSULE 2 MG 0.44780 11/23/2019 0.27003 02/21/2020 PRAZOSIN HCL ORAL CAPSULE 5 MG 0.60000 11/15/2019 0.36400 04/17/2020 PREDNICARBATE TOPICAL CREAM (GRAM) 0.1 % 1.10483 12/26/2014 1.10483 08/21/2015 PREDNICARBATE TOPICAL OINTMENT (GRAM) 0.1 % 1.13044 04/24/2015 1.13044 08/21/2015 ACETATE OPHTHALMIC SUSPENSION, DROPS(FINAL 5.78800 12/25/2020 5.55546 05/21/2021 DOSAGE FORM)(ML) 1 % West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PREDNISOLONE ORAL SOLUTION, ORAL 15 MG/5 ML 0.03992 08/30/2013 0.03992 08/21/2015 PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC DROPS 1 % 4.19720 02/08/2013 4.19720 08/21/2015 PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION, ORAL 15 MG/5 0.08044 12/26/2014 0.08044 08/21/2015 ML PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION, ORAL 25 MG/5 1.48119 12/05/2014 ML PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION, ORAL 5 MG/5 0.57224 02/21/2014 0.57224 08/21/2015 ML PREDNISOLONE SODIUM PHOSPHATE ORAL TABLET,DISINTEGRATING 10.06877 02/13/2015 10.06877 08/21/2015 10 MG PREDNISOLONE SODIUM PHOSPHATE ORAL TABLET,DISINTEGRATING 16.78133 02/13/2015 15 MG PREDNISOLONE SODIUM PHOSPHATE ORAL TABLET,DISINTEGRATING 21.57604 02/13/2015 30 MG PREDNISONE ORAL SOLUTION, ORAL 5 MG/5 ML 0.25220 02/07/2018 0.58034 07/03/2018 PREDNISONE ORAL TABLET 1 MG 0.09709 09/30/2016 0.08132 09/25/2020 PREDNISONE ORAL TABLET 10 MG 0.11202 08/25/2017 0.07950 09/22/2017 PREDNISONE ORAL TABLET 2.5 MG 0.10130 11/15/2019 0.08693 08/28/2020 PREDNISONE ORAL TABLET 20 MG 0.11890 01/19/2018 0.07974 09/21/2018 PREDNISONE ORAL TABLET 5 MG 0.05260 09/22/2017 0.04580 10/25/2019 PREDNISONE ORAL TABLET 50 MG 0.28608 08/12/2014 0.25110 08/28/2020 PREDNISONE ORAL TABLET, DOSE PACK 10 MG 0.78000 02/06/2015 0.78000 08/21/2015 PREDNISONE ORAL TABLET, DOSE PACK 5 MG 0.45000 10/24/2014 0.45000 08/21/2015 ORAL CAPSULE 100 MG 0.15800 02/21/2020 PREGABALIN ORAL CAPSULE 150 MG 0.16000 04/01/2020 0.08611 04/16/2021 PREGABALIN ORAL CAPSULE 200 MG 0.17000 02/21/2020 PREGABALIN ORAL CAPSULE 225 MG 0.17000 02/21/2020 PREGABALIN ORAL CAPSULE 25 MG 0.11111 11/15/2019 PREGABALIN ORAL CAPSULE 300 MG 0.28689 11/15/2019 0.17767 04/01/2020 PREGABALIN ORAL CAPSULE 50 MG 0.11222 04/01/2020 0.10200 12/25/2020 PREGABALIN ORAL CAPSULE 75 MG 0.11233 05/22/2020 0.09333 12/25/2020 PRENATAL VIT 17/IRON/FOLIC ACID/FISH OIL/DHA/OMEGA 3,6 NO.1 1.61980 01/25/2013 1.61980 08/21/2015 CAPSULE 35-5-1.2MG PRENATAL VIT NO.21/IRON POLYSACCH,HEME POLYPEP/FOLIC ACID 1.47032 08/12/2014 TABLET 28-6-1 MG PRENATAL VIT NO.22/IRON CBN,GLUCON/FOLIC ACID/DOCUSATE/DHA 0.63047 07/05/2013 0.63047 08/21/2015 COMBINATION PACKAGE (EA) 27-1-50 MG PRENATAL VIT NO.81/SOD.FEREDETATE-IRON PS/FOLIC ACID/OMEGA-3 0.86509 01/25/2013 ORAL COMBINATION PACKAGE, TABLET AND DR CAP 27-1-430MG PRENATAL VIT WITH CALCIUM 15/IRON/FOLIC ACID/DOCUSATE SODIUM 0.11873 08/29/2014 0.11873 08/21/2015 TABLET 90-1-50 MG PRENATAL VIT WITH CALCIUM 16/IRON/FOLIC ACID/DOCUSATE SODIUM 0.13967 08/29/2014 0.13967 08/21/2015 TABLET 90-1-50 MG PRENATAL VIT WITH CALCIUM 18/IRON/FOLIC ACID/DOCUSATE SODIUM 0.08180 08/12/2014 0.08180 08/21/2015 TABLET 90-1-50 MG PRENATAL VIT WITH CALCIUM 53/IRON BIS,S-P/FOLIC ACID/OMEGA-3 0.43260 01/25/2013 ORAL COMBINATION PACKAGE (EA) 29-1-400MG PRENATAL VIT WITH CALCIUM 95/FERROUS FUMARATE/FOLIC ACID/DHA 0.10500 04/19/2013 ORAL COMBINATION PACKAGE (EA) 28-800-200 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PRENATAL VIT WITH CALCIUM NO.126/FERROUS FUMARATE/FOLIC ACID 0.04810 01/25/2016 ORAL TABLET 28MG-0.8MG PRENATAL VIT WITH CALCIUM NO.128/FERROUS FUMARATE/FOLIC ACID 0.04207 01/25/2016 TABLET 28MG-0.8MG PRENATAL VIT WITH CALCIUM NO.129/FERROUS FUMARATE/FOLIC ACID 0.04257 01/25/2016 ORAL TABLET 27MG-0.8MG PRENATAL VIT WITH CALCIUM NO.130/FERROUS FUMARATE/FOLIC ACID 0.04207 01/25/2016 ORAL TABLET 27MG-0.8MG PRENATAL VIT WITH CALCIUM NO.131/FERROUS FUMARATE/FOLIC ACID 0.04810 01/25/2016 TABLET 28MG-0.8MG PRENATAL VIT WITH CALCIUM NO.40/IRON FUMARATE/FOLATE NO.1 1.33925 05/02/2014 ORAL TABLET 27 MG-1 MG PRENATAL VIT WITH CALCIUM NO.69/IRON/FOLIC ACID/DOCUSATE/DHA 1.38343 01/31/2014 CAPSULE 28-1-50 MG PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS FUMARATE/FOLIC 0.20146 05/17/2013 ACID ORAL TABLET 60 MG-1 MG PRENATAL VITAMIN CALCIUM,IRON,FOLIC ACID (LESS THAN 1 MG) ORAL 0.04207 04/05/2013 0.04207 08/21/2015 TABLET PRENATAL VITAMIN COMBO NO.22/IRON/FOLIC ACID/OMEGA-3/DHA 0.62446 08/12/2014 COMBINATION PACKAGE (EA) 28-6-1-203 PRENATAL VITAMIN NO.19/IRON POLYSAC,IRON HEME/FOLIC ACID/DHA 2.08973 05/03/2013 2.08973 08/21/2015 CAPSULE 22-6-1-200 PRENATAL VITAMIN NO.52/IRON/FOLIC ACID/OMEGA-3/DHA ORAL 0.36225 01/25/2013 COMBINATION PACKAGE (EA) 29-1-200MG PRENATAL VITAMIN NO.59/IRON CARB,FUM/FOLIC ACID/DOCUSATE/DHA 4.46109 12/12/2014 CAPSULE 27-1-50 MG PRENATAL VITAMIN NO.86/IRON BIS-GLYCINATE/FOLIC ACID ORAL 0.83875 09/05/2014 0.83875 08/21/2015 TABLET 32 MG-1 MG PRENATAL VITAMIN WITH CALCIUM NO.76/IRON,CARBONYL/FOLIC ACID 0.22547 08/12/2014 0.22547 08/21/2015 ORAL TABLET 29 MG-1 MG PRENATAL NO.11/FERROUS FUMARATE/FOLIC ACID/OMEGA-3 2.01177 04/03/2015 ORAL CAPSULE 28-1-200MG PRENATAL VITAMINS NO.119/IRON FUMARATE/FOLIC ACID ORAL 0.44586 01/31/2014 0.44586 08/21/2015 TABLET 29-1-25 MG PRENATAL VITAMINS NO.25/FERROUS FUMARATE/FOLIC ACID/DHA 0.55977 04/19/2013 CAPSULE 30-975-200 PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID 0.04257 04/12/2013 0.04257 08/21/2015 ORAL TABLET 27MG-0.8MG PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID 0.04810 08/12/2014 0.04810 08/21/2015 ORAL TABLET 28MG-0.8MG PRENATAL VITS NO.115/IRON FUMARATE/FOLIC ACID/DOCUSATE SOD. 0.61940 04/04/2014 0.61940 08/21/2015 TABLET 29-1-25 MG PRENATAL VITS NO.119/IRON FUMARATE/FOLIC ACID/DOCUSATE SOD. 0.44586 01/31/2014 0.44586 08/21/2015 TABLET 29-1-25 MG PRENATAL VITS NO.151/IRON FUM/FOLIC ACID/OMEGA3/DHA/EPA/FISH 0.11428 08/12/2014 ORAL CAPSULE 27-800-228 PRENATAL VITS NO.24/IRON AMINO ACID CHELATE/FOLIC ACID/DHA 0.41988 04/19/2013 COMBINATION PACKAGE (EA) 30-975-300 PRENATAL VITS NO.34/IRON,CARB/FOLIC ACID/DOCUSATE SODIUM/DHA 1.58305 01/25/2013 1.58305 08/21/2015 CAPSULE 30-1-50 MG PRENATAL VITS WITH CALCIUM 118/FERROUS FUMARATE/FOLIC ACID 0.60102 11/08/2013 0.60102 08/21/2015 ORAL TABLET,CHEWABLE 29 MG-1 MG PRENATAL VITS WITH CALCIUM 95/FERROUS FUMARATE/FOLIC ACID 0.05924 12/19/2014 0.05924 08/21/2015 ORAL TABLET 28MG-0.8MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PRENATAL VITS WITH CALCIUM NO.21/FERROUS FUMARATE/FOLIC ACID 0.06411 01/25/2013 ORAL TABLET 14 MG-400 PRENATAL VITS WITH CALCIUM NO.72/FERROUS FUMARATE/FOLIC ACID 0.06606 03/13/2015 0.06606 08/21/2015 ORAL TABLET 27 MG-1 MG PRENATAL VITS WITH CALCIUM NO.73/FERROUS FUMARATE/FOLIC ACID 0.26832 08/29/2014 0.26832 08/21/2015 ORAL TABLET 28 MG-1 MG PRENATAL VITS WITH CALCIUM NO.74/FERROUS FUMARATE/FOLIC ACID 0.02170 08/21/2015 ORAL TABLET 27 MG-1 MG PRENATAL VITS WITH CALCIUM NO.80/IRON FUM/FOLIC ACID/DSS/DHA 1.98769 01/25/2013 1.98769 08/21/2015 CAPSULE 29-1.25-55 PRENATAL VITS WITH CALCIUM NO.87/IRON BISGLY/FOLIC ACID/DHA 0.59733 01/17/2014 0.59733 08/21/2015 ORAL COMBINATION PACKAGE (EA) 32-1-230MG PRENATAL VITS WITH CALCIUM NO.90/FERROUS FUMARATE/FOLIC ACID 0.08394 01/25/2013 TABLET 9 MG-0.5MG PRENATAL VITS WITH CALCIUM NO.93/FERROUS FUMARATE/FOLIC ACID 0.05495 04/19/2013 ORAL TABLET 9MG-267MCG PRENATAL VITS WITH CALCIUM NO.96/FERROUS FUMARATE/FOLIC ACID 0.06924 08/12/2014 ORAL TABLET 27MG-0.8MG PRENATAL VITS, CALCIUM NO.91/FERROUS FUMARATE/FOLIC ACID/DHA 0.16328 04/19/2013 ORAL COMBINATION PACKAGE (EA) 28-975-200 PRENATAL VITS,CALCIUM NO.66/IRON FUM/FOLIC ACID/DOCUSATE/DHA 1.21550 08/29/2014 1.21550 08/21/2015 CAPSULE 26-1.2-55 PRENATAL VITS,CALCIUM NO.66/IRON FUM/FOLIC ACID/DOCUSATE/DHA 0.45240 09/26/2014 0.45240 08/21/2015 CAPSULE 27-1.25-55 PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG 1.17327 11/07/2014 1.17327 08/21/2015 PRIMIDONE ORAL TABLET 250 MG 0.16411 08/21/2015 0.14150 08/25/2017 PRIMIDONE ORAL TABLET 50 MG 0.08737 08/21/2015 0.06000 08/25/2017 PROBENECID ORAL TABLET 500 MG 0.51720 08/21/2015 0.79640 07/18/2019 PROBENECID/COLCHICINE ORAL TABLET 500-0.5 MG 0.67760 10/10/2014 PROCAINAMIDE HCL INJECTION VIAL (ML) 100 MG/ML 1.98490 08/12/2014 PROCAINAMIDE HCL INJECTION VIAL (ML) 500 MG/ML 8.23200 01/25/2013 PROCHLORPERAZINE EDISYLATE INJECTION VIAL (ML) 10 MG/2 ML 2.63900 01/17/2014 2.63900 08/21/2015 PROCHLORPERAZINE EDISYLATE INJECTION VIAL (ML) 5 MG/ML 1.68000 01/25/2013 PROCHLORPERAZINE MALEATE ORAL TABLET 10 MG 0.05210 10/20/2017 0.34730 12/05/2019 PROCHLORPERAZINE MALEATE ORAL TABLET 5 MG 0.24370 07/05/2019 0.18950 11/15/2019 PROCHLORPERAZINE RECTAL SUPPOSITORY, RECTAL 25 MG 8.90000 08/08/2014 8.90000 08/21/2015 INTRAMUSCULAR VIAL (ML) 50 MG/ML 2.02150 01/25/2013 1.55900 03/02/2018 PROGESTERONE MISCELLANEOUS POWDER (GRAM) 100 % 0.47840 08/21/2015 PROGESTERONE, MICRONIZED MISCELLANEOUS POWDER (GRAM) 100 0.37440 08/21/2015 % PROGESTERONE, MICRONIZED ORAL CAPSULE 100 MG 0.24402 06/21/2019 0.19990 03/20/2020 PROGESTERONE, MICRONIZED ORAL CAPSULE 200 MG 0.71130 09/20/2019 0.37030 07/16/2021 PROMETHAZINE HCL INJECTION AMPUL (ML) 25 MG/ML 1.67584 10/24/2014 PROMETHAZINE HCL INJECTION AMPUL (ML) 50 MG/ML 1.79970 08/12/2014 PROMETHAZINE HCL INJECTION VIAL (ML) 25 MG/ML 0.76113 11/22/2013 0.76113 08/21/2015 PROMETHAZINE HCL INJECTION VIAL (ML) 50 MG/ML 1.91280 08/12/2014 PROMETHAZINE HCL ORAL SYRUP 6.25MG/5ML 0.01454 02/27/2015 0.01454 08/21/2015 PROMETHAZINE HCL ORAL TABLET 12.5 MG 0.05630 09/22/2017 0.04160 12/22/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PROMETHAZINE HCL ORAL TABLET 25 MG 0.09320 08/21/2015 0.03140 07/14/2017 PROMETHAZINE HCL ORAL TABLET 50 MG 0.14740 08/21/2015 0.10467 04/21/2017 PROMETHAZINE HCL RECTAL SUPPOSITORY, RECTAL 12.5 MG 7.87258 06/16/2017 5.57000 10/23/2020 PROMETHAZINE HCL RECTAL SUPPOSITORY, RECTAL 25 MG 5.28542 12/24/2020 3.57167 03/19/2021 PROMETHAZINE HCL RECTAL SUPPOSITORY, RECTAL 50 MG 25.03550 10/17/2014 PROMETHAZINE HCL/CODEINE ORAL SYRUP 6.25-10/5 0.01528 01/25/2013 0.01528 08/21/2015 PROMETHAZINE HCL/DEXTROMETHORPHAN HBR ORAL SYRUP 6.25-15/5 0.01170 12/25/2020 0.06537 01/04/2021 PROMETHAZINE/PHENYLEPHRINE HCL/CODEINE ORAL SYRUP 6.25-5-10 0.08490 08/21/2015 0.01101 11/24/2017 PROPAFENONE HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 225 3.07683 03/20/2020 1.88000 05/22/2020 MG PROPAFENONE HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 325 5.37947 04/21/2017 3.30000 12/20/2019 MG PROPAFENONE HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 425 5.15292 06/16/2017 2.72034 07/16/2021 MG PROPAFENONE HCL ORAL TABLET 150 MG 0.21963 08/21/2015 0.11450 08/25/2017 PROPAFENONE HCL ORAL TABLET 225 MG 0.29990 03/02/2018 0.19070 02/22/2019 PROPAFENONE HCL ORAL TABLET 300 MG 0.95600 07/29/2016 0.45365 06/16/2017 PROPANTHELINE BROMIDE TABLET 15 MG 0.59475 03/20/2015 0.59475 08/21/2015 PROPARACAINE HCL OPHTHALMIC DROPS 0.5 % 0.81433 04/05/2013 0.81433 08/21/2015 PROPRANOLOL HCL MISCELLANEOUS POWDER (GRAM) 17.22364 08/23/2013 17.22364 08/21/2015 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 120 MG 0.48840 03/20/2020 0.40220 10/23/2020 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 160 MG 0.79800 12/21/2018 0.59990 09/25/2020 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 60 MG 0.25580 09/25/2020 0.24880 06/18/2021 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 80 MG 0.49490 02/26/2020 0.45000 08/28/2020 PROPRANOLOL HCL ORAL SOLUTION, ORAL 20 MG/5 ML 0.15914 07/18/2014 PROPRANOLOL HCL ORAL SOLUTION, ORAL 40MG/5ML 0.20614 03/15/2013 PROPRANOLOL HCL ORAL TABLET 10 MG 0.07170 04/26/2019 0.04726 03/19/2021 PROPRANOLOL HCL ORAL TABLET 20 MG 0.12333 11/16/2018 0.08990 09/20/2019 PROPRANOLOL HCL ORAL TABLET 40 MG 0.14630 02/22/2019 0.08100 09/25/2020 PROPRANOLOL HCL ORAL TABLET 60 MG 0.60253 01/13/2017 0.55290 03/02/2018 PROPRANOLOL HCL ORAL TABLET 80 MG 0.17910 01/24/2020 0.16090 07/16/2021 PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 40 MG- 0.71600 08/12/2014 25MG PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 80 MG- 0.87940 08/12/2014 25MG PROTAMINE SULFATE INTRAVENOUS VIAL (ML) 10 MG/ML 1.17782 08/12/2014 PROTECTIVES COMBINATION NO.2/CERAMIDES 1,3,6-II TOPICAL CREAM 1.87360 08/12/2014 (GRAM) PROTRIPTYLINE HCL ORAL TABLET 10 MG 1.94520 08/21/2015 1.23085 06/16/2017 PROTRIPTYLINE HCL ORAL TABLET 5 MG 1.43575 07/29/2016 1.10701 12/02/2016 PSEUDOEPHEDRINE HCL ORAL TABLET 30 MG 0.02680 11/21/2014 0.02680 08/21/2015 PSEUDOEPHEDRINE HCL ORAL TABLET 60 MG 0.02105 08/12/2014 0.02105 08/21/2015 PSEUDOEPHEDRINE HCL/CHLOPHEDIANOL HCL/GUAIFENESIN ORAL 0.08600 08/12/2014 LIQUID (ML) 30-12.5/5 PSEUDOEPHEDRINE HCL/CODEINE PHOSPHATE/GUAIFENESIN ORAL 0.15863 01/30/2015 0.15863 08/21/2015 SYRUP 30-10-100 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PSYLLIUM HUSK (WITH SUGAR) ORAL POWDER (GRAM) 3.4 G/7 G 0.01464 12/26/2014 0.01464 08/21/2015 PSYLLIUM SEED (WITH SUGAR) ORAL POWDER (GRAM) 0.00920 08/12/2014 0.00920 08/21/2015 PSYLLIUM SEED ORAL POWDER (GRAM) 0.01780 01/25/2013 0.01780 08/21/2015 PYRANTEL PAMOATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 50 0.16310 01/25/2013 MG/ML PYRAZINAMIDE ORAL TABLET 500 MG 1.88174 07/25/2014 PYRIDOSTIGMINE BROMIDE ORAL TABLET 60 MG 0.34550 02/17/2020 0.24830 08/28/2020 PYRIDOXINE HCL (VITAMIN B6) INJECTION VIAL (ML) 100 MG/ML 7.86632 01/25/2013 PYRIDOXINE HCL (VITAMIN B6) ORAL TABLET 100 MG 0.02559 08/12/2014 0.02559 08/21/2015 PYRIDOXINE HCL (VITAMIN B6) ORAL TABLET 25 MG 0.02190 08/12/2014 PYRIDOXINE HCL (VITAMIN B6) ORAL TABLET 50 MG 0.01407 09/27/2013 0.01407 08/21/2015 QUETIAPINE FUMARATE ORAL TABLET 100 MG 0.03670 09/21/2018 0.03110 07/26/2019 QUETIAPINE FUMARATE ORAL TABLET 200 MG 0.08270 06/16/2017 0.06540 06/19/2020 QUETIAPINE FUMARATE ORAL TABLET 25 MG 0.03890 09/22/2017 0.02259 03/16/2018 QUETIAPINE FUMARATE ORAL TABLET 300 MG 0.13924 03/03/2017 0.12517 09/21/2018 QUETIAPINE FUMARATE ORAL TABLET 400 MG 0.27326 01/13/2017 0.09749 01/27/2017 QUETIAPINE FUMARATE ORAL TABLET 50 MG 0.04017 08/28/2020 0.03800 04/16/2021 QUETIAPINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 HR 150 0.32842 11/15/2019 0.10817 03/20/2020 MG QUETIAPINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 HR 200 0.46666 01/25/2019 0.25400 11/15/2019 MG QUETIAPINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 HR 300 0.46206 11/15/2019 0.28000 11/20/2020 MG QUETIAPINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 HR 400 0.65533 04/11/2019 0.46000 06/21/2019 MG QUETIAPINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 HR 50 0.28000 11/16/2018 0.11959 05/17/2019 MG QUINAPRIL HCL ORAL TABLET 10 MG 0.13756 12/22/2017 0.09914 11/20/2020 QUINAPRIL HCL ORAL TABLET 20 MG 0.08945 08/25/2017 0.07100 11/15/2019 QUINAPRIL HCL ORAL TABLET 40 MG 0.12089 10/20/2017 0.07200 08/17/2018 QUINAPRIL HCL ORAL TABLET 5 MG 0.14511 06/16/2017 0.09400 09/22/2017 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.56012 07/04/2014 0.56012 08/21/2015 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20 MG-25MG 0.49945 08/21/2015 0.35755 11/16/2018 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG 0.42731 08/21/2015 0.36578 11/16/2018 QUINIDINE GLUCONATE ORAL TABLET, EXTENDED RELEASE 324 MG 0.84810 08/12/2014 0.84810 08/21/2015 QUINIDINE GLUCONATE VIAL (ML) 80 MG/ML 3.64770 01/25/2013 QUINIDINE SULFATE ORAL TABLET 200 MG 0.09930 01/25/2013 QUINIDINE SULFATE ORAL TABLET 300 MG 0.18360 08/12/2014 QUINIDINE SULFATE ORAL TABLET, EXTENDED RELEASE 300 MG 0.67330 08/12/2014 QUININE SULFATE ORAL CAPSULE 324 MG 3.07125 08/21/2015 1.83367 09/22/2017 RABEPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.31567 10/20/2017 0.19089 03/20/2020 COATED) 20 MG RALOXIFENE HCL ORAL TABLET 60 MG 0.32133 05/17/2019 0.27733 07/17/2020 RAMELTEON ORAL TABLET 8 MG 3.03167 01/01/2020 2.79767 05/22/2020 RAMIPRIL ORAL CAPSULE 1.25 MG 0.12030 12/21/2018 0.09855 11/15/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date RAMIPRIL ORAL CAPSULE 10 MG 0.05856 08/21/2015 0.03852 10/20/2017 RAMIPRIL ORAL CAPSULE 2.5 MG 0.09500 08/21/2015 0.04723 11/24/2017 RAMIPRIL ORAL CAPSULE 5 MG 0.06081 11/16/2018 0.02720 07/26/2019 RANITIDINE HCL CAPSULE 150 MG 0.31000 06/21/2019 0.41255 10/11/2019 RANITIDINE HCL CAPSULE 300 MG 1.03000 10/19/2018 0.81033 11/16/2018 RANITIDINE HCL SYRUP 15 MG/ML 0.03000 06/21/2019 0.05891 12/17/2019 RANITIDINE HCL TABLET 150 MG 0.04560 05/01/2015 0.04560 08/21/2015 RANITIDINE HCL TABLET 300 MG 0.10192 10/20/2017 0.08896 10/25/2019 RANITIDINE HCL TABLET 75 MG 0.09782 08/21/2015 0.05750 11/24/2017 RANITIDINE HCL VIAL (ML) 25 MG/ML 1.01383 02/20/2015 1.01383 08/21/2015 RANOLAZINE ORAL TABLET, EXTENDED RELEASE 12 HR 1000 MG 0.71411 01/24/2020 RANOLAZINE ORAL TABLET, EXTENDED RELEASE 12 HR 500 MG 0.34100 11/20/2020 0.27383 07/16/2021 MESYLATE ORAL TABLET 1 MG 5.08438 11/27/2019 4.40000 11/20/2020 REPAGLINIDE ORAL TABLET 0.5 MG 0.17060 11/24/2017 0.08777 11/16/2018 REPAGLINIDE ORAL TABLET 1 MG 0.13355 11/16/2018 0.11823 05/22/2020 REPAGLINIDE ORAL TABLET 2 MG 0.18605 12/22/2017 0.10198 08/17/2018 RIBAVIRIN ORAL CAPSULE 200 MG 0.79060 03/13/2015 0.79060 08/21/2015 RIBAVIRIN ORAL TABLET 200 MG 0.72584 08/21/2015 0.61089 10/23/2015 RIBOFLAVIN (VITAMIN B2) ORAL TABLET 25 MG 0.02310 08/12/2014 RIFABUTIN ORAL CAPSULE 150 MG 12.24594 08/12/2014 RIFAMPIN ORAL CAPSULE 150 MG 1.02820 12/13/2013 0.91689 11/20/2015 RIFAMPIN ORAL CAPSULE 300 MG 0.48100 11/24/2017 0.47600 07/26/2019 RILUZOLE ORAL TABLET 50 MG 0.28500 04/17/2020 0.62321 03/11/2021 RIMANTADINE HCL ORAL TABLET 100 MG 1.70880 08/12/2014 1.70880 08/21/2015 RINGER'S SOLUTION INTRAVENOUS INTRAVENOUS SOLUTION 0.00250 08/12/2014 RINGER'S SOLUTION IRRIGATION SOLUTION, IRRIGATION 0.00710 08/12/2014 RINGER'S SOLUTION,LACTATED INTRAVENOUS INTRAVENOUS 0.03400 08/21/2015 0.00364 04/21/2017 SOLUTION RINGER'S SOLUTION,LACTATED IRRIGATION SOLUTION, IRRIGATION 0.00220 01/25/2013 RISEDRONATE SODIUM ORAL TABLET 150 MG 28.95000 06/21/2019 27.16000 05/21/2021 RISEDRONATE SODIUM ORAL TABLET 30 MG 29.56000 03/25/2016 RISEDRONATE SODIUM ORAL TABLET 35 MG 4.77875 10/23/2020 3.44000 05/21/2021 RISEDRONATE SODIUM ORAL TABLET 5 MG 3.95000 01/25/2019 2.33300 04/17/2020 RISPERIDONE ORAL SOLUTION, ORAL 1 MG/ML 0.21474 11/15/2019 0.16267 06/19/2020 RISPERIDONE ORAL TABLET 0.25 MG 0.04949 08/25/2017 0.02047 03/20/2020 RISPERIDONE ORAL TABLET 0.5 MG 0.04150 10/20/2017 0.02083 01/24/2020 RISPERIDONE ORAL TABLET 1 MG 0.06372 08/25/2017 0.03897 09/22/2017 RISPERIDONE ORAL TABLET 2 MG 0.05984 05/14/2019 0.04430 11/15/2019 RISPERIDONE ORAL TABLET 3 MG 0.06627 08/25/2017 0.04333 12/22/2017 RISPERIDONE ORAL TABLET 4 MG 0.07709 09/22/2017 0.06578 05/22/2020 RISPERIDONE ORAL TABLET,DISINTEGRATING 0.25 MG 5.90310 03/22/2013 RISPERIDONE ORAL TABLET,DISINTEGRATING 0.5 MG 0.67437 06/16/2017 0.50000 04/27/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date RISPERIDONE ORAL TABLET,DISINTEGRATING 1 MG 0.93124 01/27/2017 0.48786 03/02/2018 RISPERIDONE ORAL TABLET,DISINTEGRATING 2 MG 1.77337 12/25/2015 0.97357 03/17/2017 RISPERIDONE ORAL TABLET,DISINTEGRATING 3 MG 1.24500 11/16/2018 1.15500 11/15/2019 RISPERIDONE ORAL TABLET,DISINTEGRATING 4 MG 6.09630 02/06/2015 3.22000 06/18/2021 RIVASTIGMINE TARTRATE ORAL CAPSULE 1.5 MG 0.15325 11/16/2018 0.11583 05/17/2019 RIVASTIGMINE TARTRATE ORAL CAPSULE 3 MG 0.20075 11/16/2018 0.11583 05/17/2019 RIVASTIGMINE TARTRATE ORAL CAPSULE 4.5 MG 0.26333 09/22/2017 0.11583 05/17/2019 RIVASTIGMINE TARTRATE ORAL CAPSULE 6 MG 0.45891 09/22/2017 0.10250 08/16/2019 RIVASTIGMINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 3.66667 03/20/2020 2.78575 02/19/2021 13.3MG/24H RIVASTIGMINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 3.44000 12/20/2019 2.53000 02/21/2020 4.6MG/24HR RIVASTIGMINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 3.57000 02/21/2020 2.99456 11/20/2020 9.5MG/24HR RIZATRIPTAN BENZOATE ORAL TABLET 10 MG 0.37778 07/26/2019 0.23278 07/16/2021 RIZATRIPTAN BENZOATE ORAL TABLET 5 MG 0.57750 03/20/2020 0.43333 04/17/2020 RIZATRIPTAN BENZOATE ORAL TABLET,DISINTEGRATING 10 MG 0.83889 09/22/2017 0.49000 12/21/2018 RIZATRIPTAN BENZOATE ORAL TABLET,DISINTEGRATING 5 MG 0.85000 09/21/2018 0.55500 08/16/2019 ROPINIROLE HCL ORAL TABLET 0.25 MG 0.06306 07/14/2017 0.05500 09/25/2020 ROPINIROLE HCL ORAL TABLET 0.5 MG 0.05230 03/16/2018 0.04000 12/20/2019 ROPINIROLE HCL ORAL TABLET 1 MG 0.05854 07/14/2017 0.04490 04/27/2018 ROPINIROLE HCL ORAL TABLET 2 MG 0.13261 08/21/2015 0.05812 07/14/2017 ROPINIROLE HCL ORAL TABLET 3 MG 0.06620 05/22/2020 0.05493 08/28/2020 ROPINIROLE HCL ORAL TABLET 4 MG 0.08150 10/20/2017 0.06920 01/19/2018 ROPINIROLE HCL ORAL TABLET 5 MG 0.14000 01/25/2019 0.08350 08/16/2019 ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 12 MG 7.95362 08/21/2015 4.25900 08/17/2018 ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 1.09254 08/21/2015 0.74883 11/15/2019 ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 4 MG 1.15000 06/22/2018 0.40520 10/19/2018 ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 6 MG 4.97944 08/21/2015 1.06633 09/22/2017 ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 8 MG 3.22530 08/12/2014 3.22530 08/21/2015 ROPIVACAINE HCL/PF INJECTION VIAL (ML) 10 MG/ML 0.49701 10/17/2014 0.49701 08/21/2015 ROPIVACAINE HCL/PF INJECTION VIAL (ML) 2 MG/ML 0.23912 12/05/2014 ROPIVACAINE HCL/PF INJECTION VIAL (ML) 5 MG/ML 0.29748 10/17/2014 ROPIVACAINE HCL/PF INJECTION VIAL (ML) 7.5 MG/ML 0.42672 12/05/2014 ROSUVASTATIN CALCIUM ORAL TABLET 10 MG 0.06033 09/21/2018 0.04500 10/23/2020 ROSUVASTATIN CALCIUM ORAL TABLET 20 MG 0.12200 10/20/2017 0.06520 12/21/2018 ROSUVASTATIN CALCIUM ORAL TABLET 40 MG 0.10000 12/21/2018 0.09033 10/23/2020 ROSUVASTATIN CALCIUM ORAL TABLET 5 MG 0.06722 11/15/2019 0.05389 04/17/2020 SACCHAROMYCES BOULARDII ORAL CAPSULE 250 MG 0.55650 10/10/2014 SALICYLIC ACID TOPICAL FILM-FORMING LIQUID WITH APPLICATOR 27.5 7.24360 01/31/2014 % SALICYLIC ACID TOPICAL LIQUID (ML) 26 % 6.03610 01/25/2013 SALICYLIC ACID/COAL TAR/ SHAMPOO 2 %-1 %-2% 0.20597 01/25/2013 SALSALATE ORAL TABLET 500 MG 0.24147 11/07/2014 0.24147 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date SALSALATE ORAL TABLET 750 MG 1.38136 06/16/2017 0.60680 05/25/2018 SCOPOLAMINE HYDROBROMIDE VIAL (ML) 0.4 MG/ML 3.78000 01/25/2013 HCL ORAL CAPSULE 5 MG 1.61219 08/21/2015 0.94567 05/21/2021 SELEGILINE HCL ORAL TABLET 5 MG 1.25290 11/28/2014 1.25290 08/21/2015 INTRAVENOUS VIAL (ML) 40 MCG/ML 0.24063 01/25/2013 SELENIUM ORAL TABLET 200 MCG 0.05669 08/12/2014 0.05669 08/21/2015 SELENIUM SULFIDE TOPICAL SHAMPOO 2.5 % 0.07952 09/19/2014 0.07952 08/21/2015 SENNOSIDES ORAL SYRUP 8.8MG/5ML 0.04146 08/12/2014 0.04146 08/21/2015 SENNOSIDES ORAL TABLET 8.6 MG 0.00978 05/01/2015 0.00978 08/21/2015 SENNOSIDES/DOCUSATE SODIUM ORAL TABLET 8.6MG-50MG 0.01946 11/07/2014 0.01946 08/21/2015 SERTRALINE HCL ORAL CONCENTRATE, ORAL 20 MG/ML 0.68521 05/19/2017 0.65250 08/16/2019 SERTRALINE HCL ORAL TABLET 100 MG 0.07310 08/21/2015 0.04255 10/20/2017 SERTRALINE HCL ORAL TABLET 25 MG 0.03430 10/20/2017 0.02144 01/25/2019 SERTRALINE HCL ORAL TABLET 50 MG 0.05250 08/21/2015 0.03376 06/16/2017 SEVELAMER CARBONATE ORAL TABLET 800 MG 0.26393 10/23/2020 0.31508 10/30/2020 SILDENAFIL CITRATE ORAL TABLET 20 MG 0.10600 03/20/2020 0.07400 07/17/2020 SILVER NITRATE TOPICAL SOLUTION, NON-ORAL 0.5 % 0.03476 01/25/2013 SILVER SULFADIAZINE TOPICAL CREAM (GRAM) 1 % 0.08520 03/15/2019 0.07140 12/20/2019 SILVER TOPICAL GEL, EXTENDED RELEASE (ML) 48.44700 01/25/2013 SIMETHICONE ORAL CAPSULE 125 MG 0.08754 03/13/2015 0.08754 08/21/2015 SIMETHICONE ORAL CAPSULE 180 MG 0.07370 08/21/2015 0.03333 03/02/2018 SIMETHICONE ORAL SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 0.08040 08/21/2015 0.05634 11/16/2018 40MG/0.6ML SIMETHICONE ORAL TABLET,CHEWABLE 125 MG 0.07236 02/06/2015 0.07236 08/21/2015 SIMETHICONE ORAL TABLET,CHEWABLE 80 MG 0.02452 11/21/2014 0.02452 08/21/2015 SIMVASTATIN ORAL TABLET 10 MG 0.03578 08/21/2015 0.02311 10/20/2017 SIMVASTATIN ORAL TABLET 20 MG 0.04000 08/21/2015 0.01895 09/22/2017 SIMVASTATIN ORAL TABLET 40 MG 0.03117 06/16/2017 0.02766 05/21/2021 SIMVASTATIN ORAL TABLET 5 MG 0.02917 11/24/2017 0.02656 04/16/2021 SIMVASTATIN ORAL TABLET 80 MG 0.09991 08/21/2015 0.05544 11/24/2017 ORAL TABLET 0.5 MG 5.70661 11/21/2019 3.99000 06/18/2021 SIROLIMUS ORAL TABLET 1 MG 7.77140 01/21/2020 7.28433 10/23/2020 SIROLIMUS ORAL TABLET 2 MG 22.65484 12/08/2017 16.95000 09/21/2018 SODIUM BENZOATE MISCELLANEOUS POWDER (GRAM) 0.04664 01/25/2013 0.04664 08/21/2015 SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 0.5MEQ/ML 0.44100 01/25/2013 SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 0.9MEQ/ML 0.12734 01/25/2013 SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 1 MEQ/ML 0.09770 08/12/2014 0.09770 08/21/2015 SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 10MEQ/10ML 0.74256 01/25/2013 SODIUM BICARBONATE INTRAVENOUS VIAL (ML) 0.5MEQ/ML 0.42840 03/01/2013 SODIUM BICARBONATE INTRAVENOUS VIAL (ML) 1 MEQ/ML 0.13238 11/07/2014 SODIUM BICARBONATE ORAL TABLET 325 MG 0.02155 01/25/2013 0.02155 08/21/2015 SODIUM BICARBONATE ORAL TABLET 650 MG 0.00953 03/22/2013 0.00953 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date SODIUM CHLORIDE 0.45 % INTRAVENOUS INTRAVENOUS SOLUTION 0.45 0.00260 03/07/2014 % SODIUM CHLORIDE 0.45 % INTRAVENOUS PIGGYBACK WITH THREADED 0.04345 01/30/2015 0.04345 08/21/2015 PORT (ML) SODIUM CHLORIDE 3 % INTRAVENOUS INTRAVENOUS SOLUTION 3 % 0.00878 04/19/2013 SODIUM CHLORIDE 5 % INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.00770 08/12/2014 SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 0.05389 03/06/2015 0.05389 08/21/2015 0.9 % SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 0.04183 03/01/2013 10 % SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 0.04633 04/03/2015 0.04980 03/28/2018 3 % SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 0.07000 11/01/2013 7 % SODIUM CHLORIDE INTRAVENOUS VIAL (ML) 2.5 MEQ/ML 0.02780 04/05/2013 0.02780 08/21/2015 SODIUM CHLORIDE INTRAVENOUS VIAL (ML) 4 MEQ/ML 0.03239 11/22/2013 SODIUM CHLORIDE IRRIGATING SOLUTION IRRIGATION SOLUTION, 0.00764 08/12/2014 0.00764 08/21/2015 IRRIGATION 0.9 % SODIUM CHLORIDE MISCELLANEOUS TABLET, SOLUBLE 1000 MG 0.09895 12/26/2014 SODIUM CHLORIDE NASAL AEROSOL, SPRAY (ML) 0.65 % 0.02561 02/13/2015 0.02561 08/21/2015 SODIUM CHLORIDE OPHTHALMIC OINTMENT (GRAM) 5 % 2.49240 08/12/2014 1.85007 06/16/2017 SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM CHLORIDE/PEG 0.00401 08/21/2015 0.00353 12/25/2020 ORAL SOLUTION, RECONSTITUTED, ORAL 420G SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INTRAVENOUS 5.15944 05/01/2015 5.15944 08/21/2015 VIAL (ML) 62.5MG/5ML SODIUM HYPOCHLORITE MISCELLANEOUS SOLUTION, NON-ORAL 0.125 9.54390 08/12/2014 % SODIUM HYPOCHLORITE MISCELLANEOUS SOLUTION, NON-ORAL 0.25 0.04024 01/25/2013 % SODIUM HYPOCHLORITE MISCELLANEOUS SOLUTION, NON-ORAL 0.5 % 0.04024 01/25/2013 SODIUM LACTATE VIAL (ML) 5 MEQ/ML 0.39992 01/25/2013 SODIUM MORRHUATE VIAL (ML) 50 MG/ML 1.96000 01/25/2013 SODIUM PHOSPHATE,MONOBASIC/SODIUM PHOSPHATE,DIBASIC 0.00578 08/12/2014 0.00578 08/21/2015 RECTAL ENEMA (ML) 19G-7G/118 SODIUM POLYSTYRENE SULFONATE ENEMA (ML) 30 G/120ML 0.25725 07/26/2013 SODIUM POLYSTYRENE SULFONATE ENEMA (ML) 50 G/200ML 0.15435 07/26/2013 SODIUM POLYSTYRENE SULFONATE ORAL POWDER (GRAM) 0.19415 08/21/2015 0.08976 02/22/2019 SODIUM POLYSTYRENE SULFONATE ORAL SUSPENSION, ORAL (FINAL 0.11988 10/10/2014 DOSE FORM) 15 G/60 ML SODIUM/POTASSIUM/POTASSIUM CITRATE/SODIUM CITRATE/CIT AC 0.02493 01/23/2015 0.02493 08/21/2015 ORAL SOLUTION, ORAL 500-550/5 SOLIFENACIN SUCCINATE ORAL TABLET 10 MG 0.15733 06/19/2020 0.14333 04/16/2021 SORBITOL SOLUTION IRRIGATION SOLUTION, IRRIGATION 3 % 0.00351 01/25/2013 SORBITOL SOLUTION IRRIGATION SOLUTION, IRRIGATION 3.3 % 0.00332 01/25/2013 SOTALOL HCL INTRAVENOUS VIAL (ML) 150MG/10ML 5.68750 01/25/2013 SOTALOL HCL ORAL TABLET 120 MG 0.09290 11/15/2019 0.07900 01/24/2020 SOTALOL HCL ORAL TABLET 160 MG 0.20247 08/12/2014 0.20247 08/21/2015 SOTALOL HCL ORAL TABLET 240 MG 0.35321 03/29/2013 0.35321 08/21/2015 SOTALOL HCL ORAL TABLET 80 MG 0.06730 09/22/2017 0.05260 12/22/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date SPINOSAD TOPICAL SUSPENSION, TOPICAL (ML) 0.9 % 1.59301 08/18/2017 1.59301 01/01/2018 MISCELLANEOUS POWDER (GRAM) 100 % 4.24580 08/12/2014 4.24580 08/21/2015 SPIRONOLACTONE ORAL TABLET 100 MG 0.23410 08/16/2019 0.16950 09/20/2019 SPIRONOLACTONE ORAL TABLET 25 MG 0.04580 11/16/2018 0.04436 06/18/2021 SPIRONOLACTONE ORAL TABLET 50 MG 0.11380 12/25/2020 0.09186 07/16/2021 SPIRONOLACTONE, MICRONIZED MISCELLANEOUS POWDER (GRAM) 9.66880 08/12/2014 100 % SPIRONOLACTONE/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-25MG 0.90011 03/29/2018 0.72980 08/17/2018 STAVUDINE ORAL CAPSULE 15 MG 1.32500 08/12/2014 STAVUDINE ORAL CAPSULE 20 MG 1.31140 08/12/2014 STAVUDINE ORAL CAPSULE 30 MG 1.09200 09/27/2013 STAVUDINE ORAL CAPSULE 40 MG 0.98233 02/26/2016 0.91833 11/24/2017 STAVUDINE ORAL SOLUTION, RECONSTITUTED, ORAL 1 MG/ML 0.27563 01/25/2013 STREPTOMYCIN SULFATE INTRAMUSCULAR VIAL (EA) 1 G 11.16500 01/25/2013 SUCRALFATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 1 G/10 ML 0.34210 09/25/2020 0.31664 02/19/2021 SUCRALFATE ORAL TABLET 1 G 0.19994 01/04/2018 0.15950 05/22/2020 SULFACETAMIDE SODIUM OPHTHALMIC DROPS 10 % 2.74986 08/21/2015 1.92000 12/21/2018 SULFACETAMIDE SODIUM OPHTHALMIC OINTMENT (GRAM) 10 % 13.17200 05/23/2014 13.17200 08/21/2015 SULFACETAMIDE SODIUM TOPICAL CLEANSER (ML) 10 % 0.37761 08/12/2014 0.37761 08/21/2015 SULFACETAMIDE SODIUM TOPICAL CLEANSER, GEL (ML) 10 % 1.02906 02/13/2015 SULFACETAMIDE SODIUM TOPICAL CLEANSER, GEL EXTENDED 0.85753 10/25/2013 RELEASE 10 % SULFACETAMIDE SODIUM TOPICAL SUSPENSION, TOPICAL (ML) 10 % 0.61247 01/25/2013 0.61247 08/21/2015 SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE 2.56476 02/15/2013 2.56476 08/21/2015 OPHTHALMIC DROPS 10 %-0.23% SULFACETAMIDE SODIUM/SULFUR TOPICAL CLEANSER (GRAM) 10- 0.07523 02/20/2015 0.07523 08/21/2015 5%(W/W) SULFACETAMIDE SODIUM/SULFUR TOPICAL CLEANSER (GRAM) 9 %-4.5 0.26751 08/21/2015 0.09064 11/15/2019 % SULFACETAMIDE SODIUM/SULFUR TOPICAL CLEANSER (ML) 9 %-4 % 0.22315 01/25/2013 SULFACETAMIDE SODIUM/SULFUR TOPICAL CREAM (GRAM) 10-5%(W/W) 4.86785 08/22/2014 4.86785 08/21/2015 SULFACETAMIDE SODIUM/SULFUR TOPICAL PADS, MEDICATED (EA) 10 4.47784 03/20/2015 4.47784 08/21/2015 %-5 % SULFACETAMIDE SODIUM/SULFUR TOPICAL SUSPENSION, TOPICAL 1.58340 05/02/2014 (GRAM) 10-5%(W/W) SULFACETAMIDE SODIUM/SULFUR TOPICAL SUSPENSION, TOPICAL 0.20782 08/12/2014 (ML) 8 %-4 % SULFACETAMIDE SODIUM/SULFUR/AVOBENZONE/OCTINOXATE/OCTYL 0.47020 11/21/2014 SAL TOPICAL COMBINATION PACKAGE, CLEANSER AND CREAM 9 %-4.5 % SULFACETAMIDE SODIUM/SULFUR/UREA TOPICAL CLEANSER (ML) 10%- 0.49178 01/25/2013 5%-10% SULFADIAZINE ORAL TABLET 500 MG 3.21496 12/05/2014 3.21496 08/21/2015 SULFAMETHOXAZOLE/TRIMETHOPRIM INTRAVENOUS VIAL (ML) 80- 0.78029 11/07/2014 16MG/ML SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL SUSPENSION, ORAL (FINAL 0.13732 11/16/2018 0.12203 07/26/2019 DOSE FORM) 200-40MG/5 SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL TABLET 400MG-80MG 0.06393 08/17/2018 0.04490 08/16/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL TABLET 800-160 MG 0.07643 08/25/2017 0.04090 12/22/2017 SULFASALAZINE ORAL TABLET 500 MG 0.15600 02/27/2015 0.15600 08/21/2015 SULFASALAZINE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 0.22563 09/30/2016 0.12670 08/25/2017 500 MG SULINDAC ORAL TABLET 150 MG 0.15930 08/21/2015 0.12100 09/22/2017 SULINDAC ORAL TABLET 200 MG 0.19673 03/02/2018 0.13438 08/17/2018 SUMATRIPTAN NASAL SPRAY, NON-AEROSOL (EA) 20 MG 40.67000 06/22/2018 35.13238 07/16/2021 SUMATRIPTAN NASAL SPRAY, NON-AEROSOL (EA) 5 MG 41.62195 03/19/2021 38.32500 07/16/2021 SUMATRIPTAN SUCCINATE ORAL TABLET 100 MG 0.44444 06/16/2017 0.36778 03/02/2018 SUMATRIPTAN SUCCINATE ORAL TABLET 25 MG 0.46722 11/15/2019 0.37556 03/20/2020 SUMATRIPTAN SUCCINATE ORAL TABLET 50 MG 0.36556 11/16/2018 0.33111 10/23/2020 SUMATRIPTAN SUCCINATE SUBCUTANEOUS CARTRIDGE (ML) 6 129.12200 01/25/2013 129.12200 08/21/2015 MG/0.5ML SUMATRIPTAN SUCCINATE SUBCUTANEOUS PEN INJECTOR (ML) 6 86.52000 06/21/2019 69.87308 12/25/2020 MG/0.5ML SUMATRIPTAN SUCCINATE SUBCUTANEOUS VIAL (ML) 6 MG/0.5ML 32.50000 01/25/2019 23.01000 03/19/2021 ORAL CAPSULE 0.5 MG 0.08055 08/17/2018 0.79745 08/18/2020 TACROLIMUS ORAL CAPSULE 1 MG 0.13478 11/16/2018 0.49990 12/02/2020 TACROLIMUS ORAL CAPSULE 5 MG 5.46000 01/17/2020 1.35000 07/16/2021 TACROLIMUS TOPICAL OINTMENT (GRAM) 0.03 % 5.17608 11/24/2017 4.11000 12/20/2019 TACROLIMUS TOPICAL OINTMENT (GRAM) 0.1 % 4.83523 11/24/2017 3.49000 05/22/2020 TADALAFIL ORAL TABLET 10 MG 1.05000 06/21/2019 0.54643 11/20/2020 TADALAFIL ORAL TABLET 20 MG 1.05000 06/21/2019 0.42967 08/16/2019 TADALAFIL ORAL TABLET 20 MG 0.73000 08/28/2020 TADALAFIL ORAL TABLET 5 MG 0.24689 08/28/2020 0.19220 05/21/2021 TAMOXIFEN CITRATE ORAL TABLET 10 MG 0.24955 08/21/2015 0.15000 11/24/2017 TAMOXIFEN CITRATE ORAL TABLET 20 MG 0.46024 05/13/2020 0.38084 02/19/2021 TAMSULOSIN HCL ORAL CAPSULE 0.4 MG 0.04990 11/20/2020 0.04014 06/18/2021 TEA TREE OIL TOPICAL OIL (ML) 100 % 0.25509 08/12/2014 ORAL TABLET 20 MG 0.70000 01/01/2017 0.13809 06/16/2017 TELMISARTAN ORAL TABLET 40 MG 0.26333 09/22/2017 0.12822 11/16/2018 TELMISARTAN ORAL TABLET 80 MG 0.28902 06/16/2017 0.26433 08/17/2018 TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 40 MG-10MG 3.87707 08/21/2015 3.87707 01/01/2020 TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 40 MG-5 MG 3.87707 10/03/2014 3.87707 08/21/2015 TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 80 MG-10MG 3.87707 08/21/2015 3.87707 01/01/2020 TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 80 MG-5 MG 3.87707 08/21/2015 3.87707 01/01/2020 TELMISARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 40-12.5 MG 2.39935 06/16/2017 0.73000 05/25/2018 TELMISARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 80 MG-25MG 1.23867 08/17/2018 0.56667 11/15/2019 TELMISARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 80-12.5MG 1.28950 09/21/2018 1.17000 02/22/2019 TEMAZEPAM ORAL CAPSULE 15 MG 0.06445 08/21/2015 0.04590 03/02/2018 TEMAZEPAM ORAL CAPSULE 22.5 MG 4.17825 06/16/2017 3.96400 04/17/2020 TEMAZEPAM ORAL CAPSULE 30 MG 0.08040 03/06/2015 0.08040 08/21/2015 TEMAZEPAM ORAL CAPSULE 7.5 MG 3.36810 06/16/2017 1.55470 09/22/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date TEMOZOLOMIDE ORAL CAPSULE 100 MG 33.73950 04/16/2021 19.52800 06/18/2021 TEMOZOLOMIDE ORAL CAPSULE 140 MG 128.55828 07/29/2016 TEMOZOLOMIDE ORAL CAPSULE 180 MG 60.22000 05/22/2020 42.50000 04/16/2021 TEMOZOLOMIDE ORAL CAPSULE 20 MG 21.53000 07/29/2016 TEMOZOLOMIDE ORAL CAPSULE 250 MG 241.19000 07/29/2016 69.13100 04/16/2021 TEMOZOLOMIDE ORAL CAPSULE 5 MG 8.05000 07/29/2016 TENIPOSIDE INTRAVENOUS AMPUL (ML) 50 MG/5 ML 56.11060 08/16/2013 56.11060 08/21/2015 TERAZOSIN HCL ORAL CAPSULE 1 MG 0.05574 08/29/2014 0.05574 08/21/2015 TERAZOSIN HCL ORAL CAPSULE 10 MG 0.06888 08/21/2015 0.04130 08/25/2017 TERAZOSIN HCL ORAL CAPSULE 2 MG 0.05574 08/12/2014 0.05574 08/21/2015 TERAZOSIN HCL ORAL CAPSULE 5 MG 0.06266 08/21/2015 0.05040 12/22/2017 TERBINAFINE HCL ORAL TABLET 250 MG 0.10367 08/25/2017 0.08000 12/20/2019 TERBINAFINE HCL TOPICAL CREAM (GRAM) 1 % 0.39135 04/10/2015 0.39135 08/21/2015 TERBUTALINE SULFATE ORAL TABLET 2.5 MG 0.27990 12/26/2014 1.26973 10/01/2015 VAGINAL CREAM WITH APPLICATOR 0.4 % 0.48888 03/03/2017 0.71068 01/16/2020 TERCONAZOLE VAGINAL CREAM WITH APPLICATOR 0.8 % 1.43255 07/05/2013 1.43255 08/21/2015 TERCONAZOLE VAGINAL SUPPOSITORY, VAGINAL 80 MG 22.83867 04/12/2013 22.83867 08/21/2015 TESTOSTERONE CYPIONATE INTRAMUSCULAR VIAL (ML) 100 MG/ML 4.13840 08/12/2014 TESTOSTERONE CYPIONATE INTRAMUSCULAR VIAL (ML) 200 MG/ML 16.21857 04/24/2020 12.63000 02/19/2021 TESTOSTERONE ENANTHATE INTRAMUSCULAR VIAL (ML) 200 MG/ML 11.89300 04/19/2013 11.89300 08/21/2015 TESTOSTERONE MISCELLANEOUS POWDER (GRAM) 0.19136 08/21/2015 TESTOSTERONE PROPIONATE MISCELLANEOUS POWDER (GRAM) 1.55480 08/21/2015 TESTOSTERONE TRANSDERMAL GEL (GRAM) 50 MG (1%) 1.92771 04/22/2016 1.28256 06/16/2017 TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG 13.97550 11/14/2014 4.85000 10/25/2019 (2%) TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 1.92710 03/06/2015 1.92710 08/21/2015 12.5/1.25G TESTOSTERONE TRANSDERMAL GEL IN PACKET (GRAM) 25MG(1%) 4.08296 03/06/2015 TESTOSTERONE TRANSDERMAL GEL IN PACKET (GRAM) 50 MG (1%) 1.98413 01/01/2017 1.98413 01/03/2017 TETANUS AND DIPHTHERIA TOXOIDS, ADULT INTRAMUSCULAR VIAL 30.27570 01/25/2013 30.27570 08/21/2015 (ML) 2-2 LF/0.5 TETANUS,DIPHTHERIA TOXOID PED/PF INTRAMUSCULAR VIAL (ML) 5- 150.18360 11/07/2014 150.18360 08/21/2015 25/0.5ML TETRACAINE HCL OPHTHALMIC DROPS 0.5 % 0.49187 01/25/2013 0.49187 08/21/2015 TETRACAINE HCL/PF OPHTHALMIC DROPS 0.5 % 8.12960 08/12/2014 HCL MISCELLANEOUS POWDER (GRAM) 0.66757 05/01/2015 0.66757 08/21/2015 TETRACYCLINE HCL ORAL CAPSULE 250 MG 3.20000 09/21/2018 1.20000 07/16/2021 TETRACYCLINE HCL ORAL CAPSULE 500 MG 3.86019 09/21/2018 2.19010 11/15/2019 THEOPHYLLINE ANHYDROUS ORAL ELIXIR 80 MG/15ML 0.58429 07/05/2013 0.58429 08/21/2015 THEOPHYLLINE ANHYDROUS ORAL SOLUTION, ORAL 80 MG/15ML 0.15122 08/12/2014 0.15122 08/21/2015 THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 0.31010 01/30/2015 0.31010 08/21/2015 100 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 0.39893 01/30/2015 0.39893 08/21/2015 200 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 2.59756 03/14/2018 2.59756 06/08/2018 300 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 2.63490 07/12/2017 4.55210 01/11/2018 450 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 400 0.95030 02/01/2013 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 600 1.37320 02/01/2013 MG THEOPHYLLINE IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.03335 01/25/2013 INTRAVENOUS SOLUTION 200MG/0.1L THEOPHYLLINE IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.09490 08/12/2014 INTRAVENOUS SOLUTION 200MG/50ML THEOPHYLLINE IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.01852 01/25/2013 INTRAVENOUS SOLUTION 400MG/.25L THEOPHYLLINE IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.00730 01/25/2013 INTRAVENOUS SOLUTION 400MG/0.5L THEOPHYLLINE IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.01890 08/12/2014 INTRAVENOUS SOLUTION 800MG/.25L THIAMINE HCL INJECTION VIAL (ML) 100 MG/ML 3.68193 08/12/2014 THIAMINE HCL ORAL TABLET 100 MG 0.01375 08/12/2014 0.01375 08/21/2015 THIAMINE HCL ORAL TABLET 50 MG 0.01586 01/25/2013 THIAMINE HCL/RIBOFLAVIN/NIACINAMIDE/DEXPANTHENOL/PYRIDOXINE 1.31319 01/25/2013 INJECTION VIAL (ML) 100-2MG/ML THIAMINE MONONITRATE (VIT B1) ORAL TABLET 100 MG 0.02524 04/24/2015 0.02524 08/21/2015 THIORIDAZINE HCL ORAL TABLET 10 MG 0.35490 05/30/2014 THIORIDAZINE HCL ORAL TABLET 100 MG 0.79650 07/21/2016 0.83510 01/20/2017 THIORIDAZINE HCL ORAL TABLET 25 MG 0.24040 02/15/2013 THIORIDAZINE HCL ORAL TABLET 50 MG 0.59970 05/19/2017 0.56010 11/16/2018 THIOTHIXENE ORAL CAPSULE 1 MG 0.44352 12/26/2014 0.44352 08/21/2015 THIOTHIXENE ORAL CAPSULE 10 MG 1.88013 04/10/2015 1.88013 08/21/2015 THIOTHIXENE ORAL CAPSULE 2 MG 0.85163 03/13/2015 0.85163 08/21/2015 THIOTHIXENE ORAL CAPSULE 5 MG 1.29668 08/21/2015 1.90520 01/02/2020 TIAGABINE HCL ORAL TABLET 2 MG 4.68720 03/27/2015 4.68720 08/21/2015 TIAGABINE HCL ORAL TABLET 4 MG 4.68720 03/27/2015 4.68720 08/21/2015 TICLOPIDINE HCL TABLET 250 MG 1.31502 11/14/2014 1.31502 08/21/2015 TIMOLOL MALEATE OPHTHALMIC DROPS 0.25 % 0.45600 11/24/2017 0.42400 02/22/2019 TIMOLOL MALEATE OPHTHALMIC DROPS 0.5 % 0.56636 02/22/2019 0.51000 04/26/2019 TIMOLOL MALEATE OPHTHALMIC GEL-FORMING SOLUTION 0.25 % 19.30600 06/27/2014 TIMOLOL MALEATE OPHTHALMIC GEL-FORMING SOLUTION 0.5 % 19.15060 07/18/2014 TIMOLOL MALEATE ORAL TABLET 10 MG 0.99344 06/06/2014 TIMOLOL MALEATE ORAL TABLET 20 MG 1.83281 06/06/2014 TIMOLOL MALEATE ORAL TABLET 5 MG 0.44560 08/12/2014 TINIDAZOLE ORAL TABLET 250 MG 0.87620 08/22/2014 0.87620 01/01/2017 TINIDAZOLE ORAL TABLET 500 MG 2.65000 06/22/2018 1.67000 06/21/2019 TIZANIDINE HCL ORAL CAPSULE 2 MG 0.60000 12/21/2018 0.29733 02/21/2020 TIZANIDINE HCL ORAL CAPSULE 4 MG 0.78350 06/16/2017 0.40807 02/21/2020 TIZANIDINE HCL ORAL CAPSULE 6 MG 1.53533 12/22/2017 0.26287 07/16/2021 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date TIZANIDINE HCL ORAL TABLET 2 MG 0.07180 04/07/2020 0.04067 10/23/2020 TIZANIDINE HCL ORAL TABLET 4 MG 0.04641 08/28/2020 0.03761 12/25/2020 TOBRAMYCIN OPHTHALMIC DROPS 0.3 % 1.09667 06/16/2017 0.82800 11/24/2017 TOBRAMYCIN SULFATE INJECTION VIAL (EA) 1.2 G 67.77984 08/01/2014 TOBRAMYCIN SULFATE INJECTION VIAL (ML) 10 MG/ML 1.10250 01/25/2013 TOBRAMYCIN SULFATE INJECTION VIAL (ML) 40 MG/ML 0.57335 10/03/2014 0.57335 08/21/2015 TOBRAMYCIN SULFATE/SODIUM CHLORIDE INTRAVENOUS 0.31870 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 60 MG/50ML TOBRAMYCIN SULFATE/SODIUM CHLORIDE INTRAVENOUS 0.18270 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 80MG/100ML TOBRAMYCIN/DEXAMETHASONE OPHTHALMIC SUSPENSION, DROPS 12.90400 08/25/2017 12.90400 01/01/2018 (FINAL DOSAGE FORM)(ML) 0.3 %-0.1% TOLAZAMIDE TABLET 250 MG 2.22090 08/12/2014 2.22090 08/21/2015 TOLAZAMIDE TABLET 500 MG 1.52140 08/12/2014 TOLBUTAMIDE TABLET 500 MG 0.73440 08/12/2014 TOLMETIN SODIUM ORAL CAPSULE 400 MG 1.16584 01/25/2013 1.16584 08/21/2015 TOLMETIN SODIUM ORAL TABLET 200 MG 0.52500 02/08/2013 TOLMETIN SODIUM ORAL TABLET 600 MG 2.47650 08/12/2014 2.47650 08/21/2015 TOPICAL AEROSOL, POWDER (GRAM) 1 % 0.04750 08/21/2015 TOLNAFTATE TOPICAL CREAM (GRAM) 1 % 0.11078 01/09/2015 0.11078 08/21/2015 TOLNAFTATE TOPICAL POWDER (GRAM) 1 % 0.04750 08/12/2014 0.04750 08/21/2015 TOLTERODINE TARTRATE ORAL CAPSULE, EXT RELEASE 24 HR 2 MG 1.23116 03/20/2020 1.12933 07/17/2020 TOLTERODINE TARTRATE ORAL CAPSULE, EXT RELEASE 24 HR 4 MG 1.12667 05/17/2019 0.90000 05/22/2020 TOLTERODINE TARTRATE ORAL TABLET 1 MG 0.72917 11/16/2018 0.43100 11/15/2019 TOLTERODINE TARTRATE ORAL TABLET 2 MG 0.58475 05/17/2019 0.38750 05/22/2020 TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 12.64551 09/19/2014 16.13817 04/05/2019 100 MG TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 15.54000 09/19/2014 16.10700 05/21/2018 150 MG TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 20.06300 05/09/2019 22.09013 03/07/2020 200 MG TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 25 4.87551 09/19/2014 5.74233 09/12/2018 MG TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 50 6.72182 04/20/2018 7.40912 09/12/2018 MG TOPIRAMATE ORAL CAPSULE, SPRINKLE 15 MG 0.23103 04/21/2017 0.48250 03/10/2020 TOPIRAMATE ORAL CAPSULE, SPRINKLE 25 MG 0.46055 09/30/2016 0.44733 08/17/2018 TOPIRAMATE ORAL TABLET 100 MG 0.06500 08/25/2017 0.03583 02/22/2019 TOPIRAMATE ORAL TABLET 200 MG 0.09788 03/03/2017 0.08528 11/16/2018 TOPIRAMATE ORAL TABLET 25 MG 0.02497 11/20/2020 0.02180 06/18/2021 TOPIRAMATE ORAL TABLET 50 MG 0.03750 09/22/2017 0.02333 05/22/2020 TOPOTECAN HCL INTRAVENOUS VIAL (EA) 4 MG 81.26200 01/23/2015 81.26200 08/21/2015 TOPOTECAN HCL INTRAVENOUS VIAL (ML) 4 MG/4 ML 30.38490 01/09/2015 30.38490 08/21/2015 TORSEMIDE ORAL TABLET 10 MG 0.06650 10/20/2017 0.04670 11/15/2019 TORSEMIDE ORAL TABLET 100 MG 0.25220 03/02/2018 0.12655 11/16/2018 TORSEMIDE ORAL TABLET 20 MG 0.07950 07/14/2017 0.06643 11/16/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date TORSEMIDE ORAL TABLET 5 MG 0.09400 09/22/2017 0.05660 11/16/2018 TORSEMIDE VIAL (ML) 20 MG/2 ML 4.31340 01/25/2013 TORSEMIDE VIAL (ML) 50 MG/5 ML 2.34654 01/25/2013 HCL ORAL TABLET 50 MG 0.01510 04/27/2018 0.01627 09/18/2018 TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG 1.49967 03/20/2020 1.24734 02/19/2021 TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 200 MG 1.99330 07/15/2020 1.99330 04/23/2021 TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 3.23534 06/16/2017 2.64123 10/23/2020 TRAMADOL HCL ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 1.86080 08/12/2014 1.86080 08/21/2015 100 MG TRAMADOL HCL ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 5.44880 08/15/2014 5.44880 08/21/2015 200 MG TRAMADOL HCL ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 3.77000 01/25/2013 3.77000 08/21/2015 300 MG TRAMADOL HCL/ACETAMINOPHEN ORAL TABLET 37.5-325MG 0.21668 08/21/2015 0.08010 09/22/2017 TRANDOLAPRIL ORAL TABLET 1 MG 0.25064 08/21/2015 0.21120 08/25/2017 TRANDOLAPRIL ORAL TABLET 2 MG 0.27372 08/21/2015 0.23910 06/16/2017 TRANDOLAPRIL ORAL TABLET 4 MG 0.25133 08/12/2014 0.25133 08/21/2015 TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND 3.70321 05/01/2015 REL BIPHASE 24HR 1MG-240 MG TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND 3.70321 05/01/2015 REL BIPHASE 24HR 2 MG-180MG TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND 3.70321 05/01/2015 REL BIPHASE 24HR 2MG-240 MG TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND 3.70321 05/01/2015 REL BIPHASE 24HR 4MG-240 MG TRANEXAMIC ACID INTRAVENOUS AMPUL (ML) 1000 MG/10 4.94036 04/10/2015 4.94036 08/21/2015 TRANEXAMIC ACID INTRAVENOUS VIAL (ML) 1000 MG/10 4.18675 02/13/2015 4.18675 08/21/2015 TRANEXAMIC ACID ORAL TABLET 650 MG 1.07400 05/17/2019 1.81496 05/09/2020 TRANYLCYPROMINE SULFATE ORAL TABLET 10 MG 1.49220 03/02/2018 1.01000 10/25/2019 TRAVOPROST (BENZALKONIUM) DROPS 0.004 % 29.13400 05/03/2013 TRAVOPROST OPHTHALMIC DROPS 0.004 % 46.20000 07/17/2020 TRAZODONE HCL ORAL TABLET 100 MG 0.10300 04/20/2016 0.06178 07/14/2017 TRAZODONE HCL ORAL TABLET 150 MG 0.08990 03/20/2020 0.08180 01/15/2021 TRAZODONE HCL ORAL TABLET 300 MG 2.19000 10/19/2018 1.89000 02/19/2021 TRAZODONE HCL ORAL TABLET 50 MG 0.03200 08/25/2017 0.03199 11/20/2020 TRETINOIN ORAL CAPSULE 10 MG 18.81170 12/05/2014 TRETINOIN TOPICAL CREAM (GRAM) 0.025 % 2.01003 08/28/2020 2.01003 01/01/2021 TRETINOIN TOPICAL CREAM (GRAM) 0.05 % 3.13550 10/20/2020 3.13550 01/01/2021 TRETINOIN TOPICAL CREAM (GRAM) 0.1 % 3.50800 12/25/2020 3.50800 01/01/2021 TRETINOIN TOPICAL GEL (GRAM) 0.01 % 3.47467 08/28/2020 3.47467 01/01/2021 TRETINOIN TOPICAL GEL (GRAM) 0.025 % 2.89600 03/20/2020 2.89600 01/01/2021 TRIAMCINOLONE ACETONIDE DENTAL PASTE (GRAM) 0.1 % 5.58000 12/21/2018 5.19600 03/20/2020 TRIAMCINOLONE ACETONIDE INJECTION VIAL (ML) 10 MG/ML 1.52320 08/01/2014 1.52320 08/21/2015 TRIAMCINOLONE ACETONIDE INJECTION VIAL (ML) 40 MG/ML 2.89400 08/01/2014 2.89400 08/21/2015 TRIAMCINOLONE ACETONIDE NASAL AEROSOL, SPRAY (GRAM) 55 MCG 4.71467 03/27/2015 4.71467 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date TRIAMCINOLONE ACETONIDE TOPICAL AEROSOL (GRAM) 0.147MG/G 2.72467 05/01/2015 2.64159 03/20/2020 TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.025 % 0.09310 08/12/2014 0.09310 08/21/2015 TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.1 % 0.04281 01/25/2019 0.03227 01/15/2021 TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.5 % 0.31333 10/25/2019 0.24200 07/17/2020 TRIAMCINOLONE ACETONIDE TOPICAL LOTION (ML) 0.025 % 0.76647 08/12/2014 0.41583 02/19/2021 TRIAMCINOLONE ACETONIDE TOPICAL LOTION (ML) 0.1 % 0.40833 11/24/2017 0.38000 11/15/2019 TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.025 % 0.28560 08/21/2015 0.13286 08/16/2019 TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.1 % 0.11910 08/21/2015 0.11162 08/28/2020 TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.5 % 0.35000 03/20/2020 0.19933 07/17/2020 TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL CAPSULE 37.5-25 MG 0.11056 03/03/2017 0.04697 12/22/2017 TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL TABLET 37.5-25 MG 0.15561 05/19/2017 0.07000 08/25/2017 TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL TABLET 75 MG-50MG 0.18148 08/21/2015 0.05500 09/22/2017 TRIAZOLAM ORAL TABLET 0.125 MG 0.20980 03/01/2013 0.20980 08/21/2015 TRIAZOLAM ORAL TABLET 0.25 MG 0.86737 02/13/2015 0.86737 08/21/2015 TRIFLUOPERAZINE HCL ORAL TABLET 1 MG 0.61215 04/24/2015 0.55090 11/24/2017 TRIFLUOPERAZINE HCL ORAL TABLET 10 MG 1.67825 04/24/2015 1.46378 06/21/2019 TRIFLUOPERAZINE HCL ORAL TABLET 2 MG 0.72000 08/17/2018 0.69000 11/16/2018 TRIFLUOPERAZINE HCL ORAL TABLET 5 MG 0.97490 01/19/2018 0.95030 03/02/2018 TRIFLURIDINE OPHTHALMIC DROPS 1 % 21.91752 04/15/2019 22.80000 06/17/2020 TRIHEXYPHENIDYL HCL ORAL ELIXIR 2 MG/5 ML 0.06175 02/13/2015 TRIHEXYPHENIDYL HCL ORAL TABLET 2 MG 0.05735 11/22/2013 TRIHEXYPHENIDYL HCL ORAL TABLET 5 MG 0.09110 08/25/2017 0.06878 01/19/2018 TRIMETHOBENZAMIDE HCL ORAL CAPSULE 300 MG 1.14618 04/12/2013 TRIMETHOPRIM ORAL TABLET 100 MG 0.27023 02/13/2015 0.16520 09/22/2017 TRIPROLIDINE HCL/PSEUDOEPHEDRINE HCL ORAL LIQUID (ML) 0.938- 1.59900 08/12/2014 1.59900 08/21/2015 10/1 TRIPROLIDINE HCL/PSEUDOEPHEDRINE HCL ORAL SYRUP 1.25-30/5 0.05830 08/12/2014 TRIPROLIDINE HCL/PSEUDOEPHEDRINE HCL ORAL TABLET 2.5MG-60MG 0.05247 01/25/2013 0.05247 08/21/2015 TROPICAMIDE OPHTHALMIC DROPS 0.5 % 0.64860 08/12/2014 TROPICAMIDE OPHTHALMIC DROPS 1 % 0.52737 08/12/2014 0.34733 11/24/2017 TROSPIUM CHLORIDE ORAL CAPSULE, EXT RELEASE 24 HR 60 MG 4.06176 12/02/2016 3.77843 06/16/2017 TROSPIUM CHLORIDE ORAL TABLET 20 MG 0.37433 09/22/2017 0.25217 05/17/2019 ULIPRISTAL ACETATE ORAL TABLET 30 MG 34.53250 06/04/2021 UREA TOPICAL CREAM (GRAM) 40 % 0.16364 08/21/2015 1.75937 03/06/2019 UREA TOPICAL FOAM (GRAM) 35 % 0.88531 09/05/2014 UREA TOPICAL GEL WITH PREFILLED APPLICATOR (ML) 45 % 5.82575 01/25/2013 UREA TOPICAL KIT 40%-0.2% 282.72300 01/25/2013 UREA TOPICAL LOTION (GRAM) 45 % 0.17003 01/25/2013 0.17003 08/21/2015 UREA TOPICAL LOTION (ML) 40 % 0.07492 09/26/2014 0.07492 08/21/2015 UREA TOPICAL NAIL FILM SUSPENSION (ML) 40 % 11.93033 02/14/2014 UREA/HYALURONATE SODIUM KIT 40%-0.2% 282.72300 01/25/2013 URSODIOL MISCELLANEOUS POWDER (GRAM) 100 % 1.52880 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date URSODIOL ORAL CAPSULE 300 MG 0.79510 09/20/2019 0.42870 09/25/2020 URSODIOL ORAL TABLET 250 MG 0.71540 01/24/2020 0.65730 04/16/2021 URSODIOL ORAL TABLET 500 MG 1.05000 11/24/2017 0.63240 05/17/2019 VALACYCLOVIR HCL ORAL TABLET 1000 MG 0.37833 01/19/2018 0.34233 09/21/2018 VALACYCLOVIR HCL ORAL TABLET 500 MG 0.21606 06/21/2019 0.18200 07/26/2019 VALGANCICLOVIR HCL ORAL TABLET 450 MG 5.24417 11/15/2019 4.48050 11/20/2020 VALPROIC ACID (AS SODIUM ) ( SODIUM) 0.69225 08/12/2014 MISCELLANEOUS POWDER (GRAM) 100 % VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) ORAL 0.15149 05/01/2015 0.15149 08/21/2015 SOLUTION, ORAL 250 MG/5ML VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) ORAL 0.01897 02/14/2020 0.01788 08/28/2020 SOLUTION, ORAL 250 MG/5ML VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) ORAL 0.08532 08/12/2014 SOLUTION, ORAL 500MG/10ML VALPROIC ACID ORAL CAPSULE 250 MG 0.22504 04/12/2018 0.14010 02/22/2019 VALSARTAN ORAL TABLET 160 MG 0.32845 05/22/2020 0.27578 06/18/2021 VALSARTAN ORAL TABLET 320 MG 0.48608 10/02/2019 0.40033 04/17/2020 VALSARTAN ORAL TABLET 40 MG 0.05556 11/24/2017 0.18770 10/02/2019 VALSARTAN ORAL TABLET 80 MG 0.12753 05/19/2017 0.07372 03/02/2018 VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 160-12.5MG 0.11778 03/16/2018 0.66866 03/14/2020 VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 160MG-25MG 0.20035 03/03/2017 0.14689 03/16/2018 VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 320-12.5MG 0.25178 03/03/2017 0.20556 08/17/2018 VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 320MG-25MG 0.43524 12/19/2019 0.32422 05/22/2020 VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 80-12.5MG 0.21031 03/03/2017 0.13678 08/25/2017 VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 1 G 3.85000 05/17/2019 2.93100 03/20/2020 VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 10 G 41.89000 09/16/2016 40.99000 08/17/2018 VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 5 G 21.82000 07/04/2016 21.43000 08/17/2018 VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 500 MG 2.11680 08/12/2014 2.11680 08/21/2015 VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 750 MG 6.69900 01/25/2013 VANCOMYCIN HCL INTRAVENOUS VIAL WITH THREADED PORT (EA) 750 10.90110 01/25/2013 MG VANCOMYCIN HCL ORAL CAPSULE 125 MG 2.10033 02/21/2020 1.76030 09/25/2020 VANCOMYCIN HCL ORAL CAPSULE 250 MG 6.49950 05/17/2019 3.03556 12/25/2020 VANCOMYCIN IN 5 % DEXTROSE IN WATER INTRAVENOUS IV SOLUTION, 0.29786 07/25/2014 PIGGYBACK PREMIX FROZEN(ML) 1G/200ML VANCOMYCIN IN 5 % DEXTROSE IN WATER INTRAVENOUS IV SOLUTION, 0.18969 11/07/2014 PIGGYBACK PREMIX FROZEN(ML) 500MG/0.1L VANCOMYCIN IN 5 % DEXTROSE IN WATER INTRAVENOUS IV SOLUTION, 0.17722 07/25/2014 PIGGYBACK PREMIX FROZEN(ML) 750MG/.15L VASOPRESSIN VIAL (ML) 20 UNIT/ML 3.14184 08/12/2014 3.14184 08/21/2015 VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 150 MG 0.14250 07/26/2019 0.13922 06/18/2021 VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 37.5 MG 0.10578 01/19/2018 0.09175 05/22/2020 VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 75 MG 0.15843 11/15/2019 0.09733 04/17/2020 VENLAFAXINE HCL ORAL TABLET 100 MG 0.09980 08/16/2019 0.05010 06/19/2020 VENLAFAXINE HCL ORAL TABLET 25 MG 0.19030 08/25/2017 0.11520 11/16/2018 VENLAFAXINE HCL ORAL TABLET 37.5 MG 0.11380 07/26/2019 0.07010 07/17/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date VENLAFAXINE HCL ORAL TABLET 50 MG 0.23880 09/22/2017 0.14160 08/17/2018 VENLAFAXINE HCL ORAL TABLET 75 MG 0.09780 12/22/2017 0.04630 05/22/2020 VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 150 MG 2.62298 12/02/2016 2.46167 02/19/2021 VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 225 MG 5.09967 10/23/2020 3.59542 07/16/2021 VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 37.5 MG 3.22698 03/27/2015 VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 75 MG 4.74492 12/31/2019 3.57383 10/23/2020 VERAPAMIL HCL INTRAVENOUS AMPUL (ML) 2.5 MG/ML 1.65480 01/25/2013 VERAPAMIL HCL INTRAVENOUS SYRINGE (ML) 2.5 MG/ML 4.46460 01/25/2013 VERAPAMIL HCL INTRAVENOUS VIAL (ML) 2.5 MG/ML 2.14400 01/25/2013 2.14400 08/21/2015 VERAPAMIL HCL MISCELLANEOUS POWDER (GRAM) 100 % 0.53976 08/21/2015 VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 1.35700 09/21/2016 0.86929 06/16/2017 120 MG VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.70015 04/10/2015 0.70015 08/21/2015 180 MG VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.89550 05/15/2015 0.89550 08/21/2015 240 MG VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 2.54807 04/10/2015 2.54807 08/21/2015 360 MG VERAPAMIL HCL ORAL CAPSULE,24HR EXTENDED RELEASE PELLET CT 1.23210 08/12/2014 1.23210 08/21/2015 100 MG VERAPAMIL HCL ORAL CAPSULE,24HR EXTENDED RELEASE PELLET CT 1.58723 01/25/2013 1.58723 08/21/2015 200 MG VERAPAMIL HCL ORAL CAPSULE,24HR EXTENDED RELEASE PELLET CT 2.09080 02/27/2015 2.09080 08/21/2015 300 MG VERAPAMIL HCL ORAL TABLET 120 MG 0.06180 09/22/2017 0.04790 10/25/2019 VERAPAMIL HCL ORAL TABLET 40 MG 0.18824 05/30/2014 VERAPAMIL HCL ORAL TABLET 80 MG 0.05600 08/21/2015 0.04430 10/23/2020 VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 120 MG 0.16750 03/16/2018 0.11030 08/17/2018 VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 180 MG 0.16830 08/21/2015 0.10355 09/22/2017 VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 240 MG 0.12965 10/20/2017 0.07657 03/02/2018 VINBLASTINE SULFATE INTRAVENOUS VIAL (ML) 1 MG/ML 2.22600 01/25/2013 VIT B COMPLEX/VIT C/FOLIC ACID/FERROUS FUMARATE/VIT E ACET 0.05547 01/25/2013 ORAL TABLET 500-400-18 /ASCORBIC ACID/ZINC/PROPOLIS (BEE GLUE) ORAL LOZENGE 0.02440 08/12/2014 15 MG VITAMIN B COMPLEX AND VITAMIN C NO.20/FOLIC ACID ORAL CAPSULE 0.16037 08/21/2015 0.09490 11/24/2017 1 MG VITAMIN B COMPLEX NO.3/FOLIC ACID/ASCORBIC ACID(VITC)/BIOTIN 0.12810 08/12/2014 0.12810 08/21/2015 ORAL TABLET 1MG-60MG VITAMIN B COMPLEX/ ORAL LIQUID (ML) 790MG/15ML 0.03270 01/25/2013 (DL-ALPHA TOCOPHERYL ACETATE) ORAL CAPSULE 180 MG 0.04540 08/21/2015 VITAMIN E MIXED ORAL CAPSULE 400 UNIT 0.05369 08/12/2014 0.05369 08/21/2015 VITAMIN E ORAL CAPSULE 100 UNIT 0.02028 01/25/2013 0.02028 08/21/2015 VITAMIN E ORAL CAPSULE 1000 UNIT 0.12857 01/25/2013 0.12857 08/21/2015 VITAMIN E ORAL CAPSULE 200 UNIT 0.02860 08/12/2014 VITAMIN E ORAL CAPSULE 400 UNIT 0.04540 08/12/2014 0.04540 08/21/2015 VITAMIN E ORAL DROPS 50 UNIT/ML 0.94477 01/31/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date VITAMINS A AND D/WHITE PETROLATUM/LANOLIN TOPICAL OINTMENT 0.03450 08/12/2014 IN PACKET (GRAM) VORICONAZOLE INTRAVENOUS VIAL (EA) 200 MG 44.58750 08/12/2014 23.95000 03/19/2021 VORICONAZOLE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 9.84947 12/27/2013 MG/5ML VORICONAZOLE ORAL TABLET 200 MG 5.00600 08/17/2018 3.00000 05/17/2019 VORICONAZOLE ORAL TABLET 50 MG 5.86000 07/08/2016 4.93290 09/21/2018 WARFARIN SODIUM ORAL TABLET 1 MG 0.14230 01/19/2018 0.09226 08/16/2019 WARFARIN SODIUM ORAL TABLET 10 MG 0.21998 08/21/2015 0.12355 08/16/2019 WARFARIN SODIUM ORAL TABLET 2 MG 0.11277 08/16/2019 0.07090 05/22/2020 WARFARIN SODIUM ORAL TABLET 2.5 MG 0.20194 08/21/2015 0.06420 08/16/2019 WARFARIN SODIUM ORAL TABLET 3 MG 0.20206 08/21/2015 0.10730 07/26/2019 WARFARIN SODIUM ORAL TABLET 4 MG 0.10000 08/16/2019 0.08291 05/22/2020 WARFARIN SODIUM ORAL TABLET 5 MG 0.08184 06/21/2019 0.07560 07/26/2019 WARFARIN SODIUM ORAL TABLET 6 MG 0.23115 08/21/2015 0.07290 08/16/2019 WARFARIN SODIUM ORAL TABLET 7.5 MG 0.17462 08/21/2015 0.06695 08/16/2019 WATER FOR INJ.,BACTERIOSTATIC INJECTION VIAL (ML) 0.02828 03/20/2015 0.02828 08/21/2015 WATER FOR INJECTION,STERILE INJECTION AMPUL (ML) 0.08820 01/25/2013 0.08820 08/21/2015 WATER FOR INJECTION,STERILE INJECTION VIAL (ML) 0.07489 08/21/2015 0.05462 02/22/2019 WATER FOR INJECTION,STERILE INTRAVENOUS INTRAVENOUS 0.00226 05/01/2015 0.00226 08/21/2015 SOLUTION WATER FOR IRRIGATION,STERILE IRRIGATION SOLUTION, IRRIGATION 0.00545 08/12/2014 0.00545 08/21/2015 WATER ORAL LIQUID (ML) 0.01165 01/16/2015 0.01165 08/21/2015 WITCH HAZEL TOPICAL PADS, MEDICATED (EA) 50 % 0.07692 08/12/2014 0.07692 08/21/2015 ORAL TABLET 10 MG 1.19188 01/25/2013 1.19188 01/01/2017 ZAFIRLUKAST ORAL TABLET 20 MG 1.11667 02/21/2020 0.82500 04/17/2020 ZALEPLON ORAL CAPSULE 10 MG 0.21311 08/21/2015 0.13820 09/22/2017 ZALEPLON ORAL CAPSULE 5 MG 0.21208 08/21/2015 0.17120 08/17/2018 ZIDOVUDINE ORAL CAPSULE 100 MG 0.82839 11/08/2013 0.82839 08/21/2015 ZIDOVUDINE ORAL SYRUP 10 MG/ML 0.12787 05/10/2013 0.09521 11/24/2017 ZIDOVUDINE ORAL TABLET 300 MG 0.37007 08/21/2015 0.30183 11/24/2017 ZINC CHLORIDE INTRAVENOUS VIAL (ML) 1 MG/ML 0.17050 08/12/2014 ZINC SULFATE INTRAVENOUS VIAL (ML) 1 MG/ML 0.21874 01/25/2013 ZINC SULFATE INTRAVENOUS VIAL (ML) 5 MG/ML 0.65343 01/25/2013 ZIPRASIDONE HCL ORAL CAPSULE 20 MG 0.22400 12/20/2019 0.19433 05/22/2020 ZIPRASIDONE HCL ORAL CAPSULE 40 MG 0.41667 08/14/2020 0.28333 09/25/2020 ZIPRASIDONE HCL ORAL CAPSULE 60 MG 0.43250 06/22/2018 0.24917 05/17/2019 ZIPRASIDONE HCL ORAL CAPSULE 80 MG 0.27250 07/29/2020 0.41615 12/01/2020 ZOLEDRONIC ACID IN MANNITOL AND 0.9 % SODIUM CHLORIDE 10.14930 08/16/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 4 MG/100ML ZOLEDRONIC ACID IN MANNITOL AND WATER FOR INJECTION 8.37592 10/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 5 MG/100ML ZOLMITRIPTAN ORAL TABLET 2.5 MG 5.62000 06/16/2017 0.96500 09/21/2018 ZOLMITRIPTAN ORAL TABLET 5 MG 2.88000 02/21/2020 2.65000 04/17/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 7/30/2021 Disclaimer: Price listing does not guarantee coverage

Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ZOLMITRIPTAN ORAL TABLET,DISINTEGRATING 2.5 MG 5.64000 06/22/2018 2.64387 06/18/2021 ZOLMITRIPTAN ORAL TABLET,DISINTEGRATING 5 MG 5.50481 06/16/2017 3.89667 09/22/2017 ZOLPIDEM TARTRATE ORAL TABLET 10 MG 0.02680 08/21/2015 0.02236 10/23/2020 ZOLPIDEM TARTRATE ORAL TABLET 5 MG 0.02680 08/21/2015 0.01954 05/21/2021 ZOLPIDEM TARTRATE ORAL TABLET, EXTENDED RELEASE MULTIPHASE 0.52530 12/22/2017 0.48879 03/16/2018 12.5 MG ZOLPIDEM TARTRATE ORAL TABLET, EXTENDED RELEASE MULTIPHASE 0.38000 10/19/2018 0.18852 06/21/2019 6.25 MG ZONISAMIDE ORAL CAPSULE 100 MG 0.10150 03/20/2020 0.09160 04/16/2021 ZONISAMIDE ORAL CAPSULE 25 MG 0.12974 04/21/2017 0.07950 07/14/2017 ZONISAMIDE ORAL CAPSULE 50 MG 0.15682 04/28/2016 0.12410 08/25/2017