West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 0.9 % SODIUM 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 11/24/2017 1.77633 11/25/2017 ABIRATERONE ACETATE ORAL TABLET 250 MG 3.78000 02/21/2020 4.56040 02/24/2020 ACAMPROSATE CALCIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.67426 02/21/2020 0.74145 04/09/2020 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 0.40001 06/04/2019 0.60776 10/07/2019 ACEBUTOLOL HCL ORAL CAPSULE 400 MG 0.26000 03/27/2015 0.26000 08/21/2015 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 1.52593 08/21/2015 1.29790 11/16/2018 ACETAZOLAMIDE ORAL TABLET 250 MG 1.02880 02/22/2019 0.69948 05/17/2019 ACETIC ACID IRRIGATION SOLUTION, IRRIGATION 0.25 % 0.00350 03/01/2013 ACETIC ACID OTIC SOLUTION, NON-ORAL 2 % 1.81591 08/21/2015 1.65333 02/21/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 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 ACETYLCYSTEINE 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 0.19900 02/21/2020 0.34100 03/27/2020 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 6.66667 11/24/2017 9.53166 12/18/2017 ACITRETIN ORAL CAPSULE 17.5 MG 42.31920 03/21/2014 ACITRETIN ORAL CAPSULE 25 MG 12.56000 01/25/2019 9.33333 05/17/2019 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 0.37206 11/16/2018 0.40698 01/19/2020 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 % 6.90000 05/26/2018 1.94109 11/15/2019 ADAPALENE TOPICAL CREAM (GRAM) 0.1 % 3.51289 04/26/2013 ADAPALENE TOPICAL GEL (GRAM) 0.1 % 1.82556 06/22/2018 1.58578 11/15/2019 ADAPALENE TOPICAL GEL (GRAM) 0.3 % 4.68580 08/21/2015 3.41117 06/16/2017 ADAPALENE TOPICAL GEL WITH PUMP (GRAM) 0.3 % 4.61985 04/10/2015 4.61985 08/21/2015 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 4.11250 08/21/2015 3.62765 12/25/2015 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 0.27875 10/20/2017 0.23250 09/21/2018 ALFUZOSIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.13697 08/21/2015 0.11326 03/16/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 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 0.11998 10/19/2018 0.09110 07/26/2019 ALMOTRIPTAN MALATE ORAL TABLET 12.5 MG 25.31000 08/25/2017 16.33370 10/19/2018 ALPHA LIPOIC ACID 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 04/17/2015 0.01780 08/21/2015 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 0.44913 08/21/2015 0.21717 09/22/2017 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 0.41600 08/21/2015 0.40200 08/17/2018 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 0.43730 12/22/2017 0.24644 08/17/2018 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 1.07830 09/21/2018 0.13100 08/16/2019 AMBRISENTAN 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 0.20030 11/16/2018 0.14880 11/15/2019 AMILORIDE HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5 MG-50 MG 0.42250 05/30/2014 0.42250 08/21/2015 AMINO ACIDS 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 AMIODARONE HCL INTRAVENOUS AMPUL (ML) 50 MG/ML 0.33600 01/25/2013 AMIODARONE HCL ORAL TABLET 100 MG 2.16500 11/24/2017 1.97100 03/20/2020 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 AMITRIPTYLINE 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 5/1/2020 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 0.34700 08/16/2019 0.38720 09/13/2019 AMITRIPTYLINE HCL ORAL TABLET 150 MG 0.67500 11/27/2019 0.63350 01/24/2020 AMITRIPTYLINE HCL ORAL TABLET 25 MG 0.17140 09/22/2017 0.09537 11/16/2018 AMITRIPTYLINE HCL ORAL TABLET 50 MG 0.23130 08/02/2019 0.18572 03/20/2020 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 AMLODIPINE BESYLATE ORAL TABLET 10 MG 0.02527 08/21/2015 0.01238 09/21/2018 AMLODIPINE BESYLATE ORAL TABLET 2.5 MG 0.05960 08/21/2015 0.01756 07/14/2017 AMLODIPINE BESYLATE ORAL TABLET 5 MG 0.06240 08/21/2015 0.01300 08/25/2017 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 04/10/2015 3.93004 08/21/2015 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-10 4.55853 08/21/2015 3.16379 06/16/2017 MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG-20 3.93250 08/21/2015 2.74000 05/25/2018 MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG-40 3.35767 09/22/2017 3.09133 02/21/2020 MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG-80 5.92000 09/30/2016 3.28900 05/17/2019 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 0.17815 08/25/2017 0.10380 09/22/2017 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- 0.88000 11/24/2017 0.72933 11/16/2018 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 5/1/2020 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 08/21/2015 3.88023 01/01/2017 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 % 0.02596 08/21/2015 0.07500 03/25/2016 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 04/10/2015 0.04730 08/21/2015 AMOXICILLIN ORAL CAPSULE 500 MG 0.06941 08/21/2015 0.05236 06/16/2017 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 0.02680 08/21/2015 0.01901 07/26/2019 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 775 11.26813 12/26/2014 11.26813 08/21/2015 MG AMOXICILLIN/POTASSIUM 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, 0.58748 08/16/2019 0.55083 03/20/2020 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 0.26356 11/24/2017 0.25000 09/21/2018 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 5/1/2020 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 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 01/25/2013 0.14370 08/21/2015 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 2.79055 03/17/2017 2.75841 04/21/2017 ARIPIPRAZOLE ORAL TABLET 10 MG 0.20064 11/15/2019 0.17992 03/20/2020 ARIPIPRAZOLE ORAL TABLET 15 MG 0.27900 04/26/2019 0.18774 11/15/2019 ARIPIPRAZOLE ORAL TABLET 2 MG 0.18274 05/17/2019 0.06467 04/17/2020 ARIPIPRAZOLE ORAL TABLET 20 MG 0.30522 06/21/2019 0.27600 09/20/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ARIPIPRAZOLE ORAL TABLET 30 MG 0.26417 05/17/2019 0.22500 11/15/2019 ARIPIPRAZOLE ORAL TABLET 5 MG 0.32114 11/16/2018 0.19485 05/17/2019 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 CARBONATE/MAGNESIUM ORAL TABLET 325 MG 0.02015 03/07/2014 0.02015 08/21/2015 ASPIRIN/SODIUM BICARBONATE/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 1.99000 05/25/2018 2.33485 10/24/2019 ATOMOXETINE HCL ORAL CAPSULE 100 MG 2.81100 05/17/2019 2.47000 12/20/2019 ATOMOXETINE HCL ORAL CAPSULE 18 MG 1.80600 11/15/2019 1.62233 02/21/2020 ATOMOXETINE HCL ORAL CAPSULE 25 MG 2.21236 10/14/2019 1.41167 01/24/2020 ATOMOXETINE HCL ORAL CAPSULE 40 MG 2.28518 11/22/2019 1.70867 03/20/2020 ATOMOXETINE HCL ORAL CAPSULE 60 MG 1.95000 06/21/2019 2.41600 07/17/2019 ATOMOXETINE HCL ORAL CAPSULE 80 MG 1.96534 09/20/2019 1.66667 11/15/2019 ATORVASTATIN CALCIUM ORAL TABLET 10 MG 0.05920 08/17/2018 0.04039 11/15/2019 ATORVASTATIN CALCIUM ORAL TABLET 20 MG 0.06926 02/22/2019 0.06114 07/26/2019 ATORVASTATIN CALCIUM ORAL TABLET 40 MG 0.09629 10/25/2019 0.05800 04/17/2020 ATORVASTATIN CALCIUM ORAL TABLET 80 MG 0.11409 10/20/2017 0.10064 11/15/2019 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.33442 11/16/2018 0.27345 07/26/2019 AZELASTINE HCL NASAL AEROSOL, SPRAY WITH PUMP (ML) 205.5 MCG 1.16607 08/16/2019 1.02000 02/21/2020 AZELASTINE HCL OPHTHALMIC DROPS 0.05 % 2.20055 11/24/2017 1.31000 12/21/2018 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 0.61680 11/16/2018 0.58000 08/16/2019 MG/5ML AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 0.56816 02/21/2020 0.55000 04/17/2020 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 VITAMIN 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 ZINC TOPICAL OINTMENT (GRAM) 500 UNIT/G 0.10676 04/17/2015 0.10676 08/21/2015 BACITRACIN/POLYMYXIN B SULFATE OPHTHALMIC OINTMENT (GRAM) 2.81450 08/21/2015 2.05714 08/16/2019 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 0.11300 01/24/2020 0.19580 02/04/2020 BALSALAZIDE DISODIUM ORAL CAPSULE 750 MG 0.35921 09/22/2017 0.22496 03/02/2018 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 03/27/2015 0.05197 08/21/2015 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 0.63132 06/16/2017 0.60520 12/22/2017 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 0.19990 08/17/2018 0.68974 08/25/2018 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5-6.25MG 0.45890 08/21/2015 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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/MINERALS ORAL TABLET 1000-60 0.06145 08/12/2014 0.06145 08/21/2015 -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 % 1.24034 08/16/2019 1.08858 11/15/2019 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 % 0.56720 07/08/2016 0.16667 02/21/2020 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 BIOFLAVONOID, LEMON/VITAMIN B COMP AND C ORAL TABLET 200-100 0.14285 05/03/2013 MG BIOTIN ORAL CAPSULE 2500 MCG 0.09390 08/12/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date BISACODYL 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 0.42566 11/15/2019 0.52457 03/24/2020 BISOPROLOL FUMARATE ORAL TABLET 5 MG 0.56161 10/24/2019 0.38074 02/21/2020 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 % 0.53640 08/25/2017 0.51810 02/22/2019 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 2.80662 12/02/2016 0.51467 11/15/2019 BUDESONIDE INHALATION AMPUL FOR NEBULIZATION (ML) 0.5 MG/2ML 0.93000 06/21/2019 0.74983 11/15/2019 BUDESONIDE INHALATION AMPUL FOR NEBULIZATION (ML) 1 MG/2 ML 9.16650 03/04/2018 4.43100 11/15/2019 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 0.42694 03/05/2019 0.37153 05/17/2019 BUMETANIDE ORAL TABLET 2 MG 0.99030 05/24/2016 0.64435 03/03/2017 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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/NALOXONE HCL SUBLINGUAL TABLET, 2.60728 06/16/2017 1.19133 11/15/2019 SUBLINGUAL 2 MG-0.5MG BUPRENORPHINE HCL/NALOXONE HCL SUBLINGUAL TABLET, 2.31650 09/21/2018 1.75693 11/15/2019 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 0.17010 08/21/2019 0.14167 11/15/2019 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 0.17667 04/26/2019 0.15723 11/15/2019 BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 0.32086 03/03/2017 0.22833 01/25/2019 BUPROPION HCL ORAL TABLET,SUSTAINED-RELEASE 12 HR 100 MG 0.07644 03/02/2018 0.12200 07/23/2018 BUPROPION HCL ORAL TABLET,SUSTAINED-RELEASE 12 HR 150 MG 0.13512 03/03/2017 0.09350 06/16/2017 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 0.03984 10/20/2017 0.04536 11/29/2018 BUSPIRONE HCL ORAL TABLET 15 MG 0.06612 11/14/2018 0.05500 07/26/2019 BUSPIRONE HCL ORAL TABLET 30 MG 0.26383 05/17/2019 0.21300 07/26/2019 BUSPIRONE HCL ORAL TABLET 5 MG 0.04020 08/21/2015 0.02551 11/16/2018 BUSPIRONE HCL ORAL TABLET 7.5 MG 0.35967 05/17/2019 0.33000 11/15/2019 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 0.24309 11/15/2019 0.22890 12/20/2019 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 0.89900 11/15/2019 0.88420 01/24/2020 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CAFFEINE/SODIUM BENZOATE 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 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 0.09543 08/16/2019 0.51577 03/31/2020 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 CALCIUM CARBONATE 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 CAPSULE 0.04855 08/12/2014 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/MAGNESIUM HYDROXIDE ORAL 0.01352 08/21/2015 TABLET,CHEWABLE 675-135 MG 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 200 0.04005 08/12/2014 MG-250 CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 315 0.05724 08/12/2014 0.05724 08/21/2015 MG-200 CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 315 0.04615 11/21/2014 0.04615 08/21/2015 MG-250 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 04/24/2015 8.21479 08/21/2015 CAPECITABINE ORAL TABLET 500 MG 5.07000 11/24/2017 3.86667 11/15/2019 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 0.99791 08/21/2015 0.75000 08/25/2017 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 CARBAMAZEPINE 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 0.95851 05/07/2019 1.55500 10/17/2019 12HR 200 MG CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 0.93459 11/15/2019 1.46300 11/16/2019 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 0.22000 12/20/2019 0.32256 03/02/2020 CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 100 MG 0.49080 11/15/2019 0.63951 01/21/2020 CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 200 MG 0.90340 11/15/2019 0.88980 04/17/2020 CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 400 MG 1.58000 12/20/2019 2.17370 02/03/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 5.19620 10/19/2018 3.86500 01/25/2019 CARBIDOPA/LEVODOPA ORAL TABLET 10MG-100MG 0.14258 08/21/2015 0.09610 09/22/2017 CARBIDOPA/LEVODOPA ORAL TABLET 25MG-100MG 0.09799 07/14/2017 0.08025 03/16/2018 CARBIDOPA/LEVODOPA ORAL TABLET 25MG-250MG 0.15020 11/24/2017 0.12267 03/16/2018 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- 0.18000 11/16/2018 0.42000 09/11/2019 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 CARVEDILOL 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 0.04950 08/21/2015 0.02150 07/14/2017 CASTOR OIL 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 G 4.26300 01/25/2013 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 0.40142 08/17/2018 0.33556 11/16/2018 CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML 0.20459 12/22/2017 0.12375 11/16/2018 CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML 0.12749 05/17/2019 0.08000 12/20/2019 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 WATER 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 4.71590 05/03/2013 3.61735 06/16/2017 CEFPODOXIME PROXETIL ORAL TABLET 200 MG 5.14200 03/16/2018 2.46500 10/19/2018 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 2.36530 02/22/2019 2.30600 03/20/2020 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 0.41395 07/26/2019 0.34339 08/16/2019 CEFUROXIME AXETIL ORAL TABLET 500 MG 0.44732 08/16/2019 0.42400 01/24/2020 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 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 0.18600 02/22/2019 0.15090 06/21/2019 CELECOXIB ORAL CAPSULE 400 MG 1.25000 09/30/2016 0.71400 07/26/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.10023 08/21/2015 0.08687 12/22/2017 CEPHALEXIN ORAL CAPSULE 750 MG 5.35900 09/22/2017 6.15000 04/17/2019 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 0.09433 11/16/2018 0.08460 10/25/2019 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 0.98965 12/10/2019 0.90460 03/20/2020 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 0.08949 08/21/2015 0.06297 03/02/2018 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 03/13/2015 0.00598 08/21/2015 % 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 CHLORPHENIRAMINE 0.01868 01/25/2013 0.01868 08/21/2015 MALEATE/PSEUDOEPHEDRINE/DEXTROMETHORPHAN ORAL LIQUID (ML) 1-15-5MG/5 CHLORPROMAZINE HCL INJECTION AMPUL (ML) 25 MG/ML 18.81600 11/08/2013 CHLORPROMAZINE HCL ORAL TABLET 10 MG 2.65000 01/22/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CHLORPROMAZINE HCL ORAL TABLET 100 MG 3.26785 05/17/2019 5.06490 06/13/2019 CHLORPROMAZINE HCL ORAL TABLET 200 MG 6.35000 10/25/2019 7.16716 12/16/2019 CHLORPROMAZINE HCL ORAL TABLET 25 MG 2.39250 05/17/2019 1.85000 02/21/2020 CHLORPROMAZINE HCL ORAL TABLET 50 MG 4.07080 11/16/2018 2.95200 04/26/2019 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 0.36824 08/16/2019 0.32970 01/24/2020 CHLORTHALIDONE ORAL TABLET 50 MG 0.59540 01/25/2019 0.35950 08/16/2019 CHLORZOXAZONE ORAL TABLET 500 MG 0.23400 04/10/2015 0.23400 08/21/2015 CHOLECALCIFEROL (VIT D3)/FOLIC ACID ORAL CAPSULE 3775 UNIT 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 1.33367 08/25/2017 1.21063 02/21/2020 CHOLESTYRAMINE/ASPARTAME ORAL POWDER (GRAM) 4 G 0.16658 11/16/2018 0.23748 04/22/2019 CHOLESTYRAMINE/ASPARTAME ORAL POWDER IN PACKET (EA) 4 G 1.58483 02/22/2019 1.30321 11/15/2019 CHOLINE 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 % 2.02083 02/22/2019 1.49242 04/26/2019 CICLOPIROX/UREA/CAMPHOR/MENTHOL/EUCALYPTOL TOPICAL 266.99400 01/25/2013 SOLUTION, NON-ORAL 8 % 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 0.10087 11/16/2018 0.08083 04/17/2020 CIMETIDINE HCL ORAL SOLUTION, ORAL 300 MG/5ML 0.06283 05/17/2013 0.06283 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CIMETIDINE ORAL TABLET 200 MG 0.23684 08/12/2014 0.23684 08/21/2015 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 0.10750 07/14/2017 0.09120 08/17/2018 CIPROFLOXACIN HCL ORAL TABLET 500 MG 0.20001 03/03/2017 0.09234 06/16/2017 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 0.42456 04/12/2018 0.24500 01/25/2019 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 0.87519 01/13/2017 0.45686 03/03/2017 CLARITHROMYCIN ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 3.50443 08/21/2015 3.18447 06/16/2017 CLINDAMYCIN HCL ORAL CAPSULE 150 MG 0.08641 08/21/2015 0.07460 09/21/2018 CLINDAMYCIN HCL ORAL CAPSULE 300 MG 0.25661 08/21/2015 0.19938 03/03/2017 CLINDAMYCIN HCL ORAL CAPSULE 75 MG 0.41720 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CLINDAMYCIN PALMITATE HCL ORAL SOLUTION, RECONSTITUTED, ORAL 0.19640 09/22/2017 0.23180 02/15/2018 75 MG/5 ML CLINDAMYCIN PHOSPHATE INJECTION VIAL (ML) 150 MG/ML 0.35600 08/12/2014 CLINDAMYCIN PHOSPHATE INTRAVENOUS VIAL WITH THREADED PORT 2.99418 01/25/2013 (ML) 300 MG/2ML CLINDAMYCIN PHOSPHATE INTRAVENOUS VIAL WITH THREADED PORT 1.60881 01/25/2013 (ML) 600 MG/4ML CLINDAMYCIN PHOSPHATE INTRAVENOUS VIAL WITH THREADED PORT 1.51899 01/25/2013 (ML) 900MG/6ML CLINDAMYCIN PHOSPHATE TOPICAL FOAM (GRAM) 1 % 3.71476 08/21/2015 3.56290 11/15/2019 CLINDAMYCIN PHOSPHATE TOPICAL GEL (GRAM) 1 % 0.99800 11/19/2019 1.04700 01/11/2020 CLINDAMYCIN PHOSPHATE TOPICAL LOTION (ML) 1 % 1.15406 11/18/2019 1.00375 03/20/2020 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 % 1.37550 08/16/2019 1.71925 08/23/2019 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 % 0.59872 11/15/2019 0.89179 02/13/2020 CLOBETASOL PROPIONATE TOPICAL FOAM (GRAM) 0.05 % 1.97900 02/22/2019 1.24600 03/20/2020 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 % 0.49209 07/26/2019 0.39284 01/24/2020 CLOBETASOL PROPIONATE TOPICAL SHAMPOO 0.05 % 1.53000 05/26/2018 1.47407 11/15/2019 CLOBETASOL PROPIONATE TOPICAL SOLUTION, NON-ORAL 0.05 % 0.67960 07/26/2019 0.63510 10/25/2019 CLOBETASOL PROPIONATE TOPICAL SPRAY, NON-AEROSOL (ML) 0.05 % 4.33264 03/06/2015 CLOBETASOL PROPIONATE/EMOLLIENT BASE 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 3.50000 02/22/2019 2.85000 02/21/2020 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 CLONAZEPAM ORAL TABLET 0.5 MG 0.01635 12/12/2014 0.01635 08/21/2015 CLONAZEPAM ORAL TABLET 1 MG 0.02613 02/06/2015 0.02613 08/21/2015 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.58810 03/16/2018 0.74870 03/18/2020 CLONAZEPAM ORAL TABLET,DISINTEGRATING 2 MG 1.09330 01/25/2013 CLONIDINE HCL ORAL TABLET 0.1 MG 0.02704 08/21/2015 0.01272 09/21/2018 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 1.44083 02/22/2019 0.88817 07/26/2019 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 0.1MG/24HR 17.56000 07/08/2016 8.79250 11/15/2019 CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.2MG/24HR 14.26950 11/15/2019 12.69000 12/20/2019 CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.3MG/24HR 21.24500 11/15/2019 18.23000 12/20/2019 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 CLOTRIMAZOLE MUCOUS MEMBRANE TROCHE 10 MG 0.97392 03/27/2015 CLOTRIMAZOLE TOPICAL CREAM (GRAM) 1 % 0.10907 03/20/2015 0.10907 08/21/2015 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 0.30408 03/03/2017 0.20951 02/22/2019 (GRAM) 1 %-0.05 % CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE TOPICAL LOTION 3.46640 05/31/2013 (ML) 1 %-0.05 % CLOZAPINE ORAL TABLET 100 MG 0.25570 11/15/2019 0.32882 03/03/2020 CLOZAPINE ORAL TABLET 200 MG 1.04025 08/16/2019 0.93590 02/21/2020 CLOZAPINE ORAL TABLET 25 MG 0.17340 10/25/2019 0.28170 01/06/2020 CLOZAPINE ORAL TABLET 50 MG 0.42855 02/21/2020 0.59637 02/26/2020 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 5.20633 07/16/2019 5.02150 03/20/2020 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 0.49028 11/15/2019 0.66658 02/25/2020 COLISTIN (AS COLISTIMETHATE SODIUM) INJECTION VIAL (EA) 150 MG 26.57000 06/24/2019 22.52000 10/25/2019 CORTISONE ACETATE ORAL 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 % 0.67817 08/21/2015 0.46600 09/30/2016 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 CYANOCOBALAMIN (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 HCL (B6) 0.89950 07/18/2014 ORAL TABLET 2-1.13-25 CYANOCOBALAMIN/LEVOMEFOLATE CALCIUM/PYRIDOXINE/RIBOFLAVIN 2.02075 02/20/2015 2.02075 08/21/2015 ORAL TABLET 1-6-50-5MG CYCLOBENZAPRINE HCL ORAL TABLET 10 MG 0.02680 08/21/2015 0.01476 11/16/2018 CYCLOBENZAPRINE HCL ORAL TABLET 5 MG 0.03457 10/20/2017 0.02130 01/24/2020 CYCLOBENZAPRINE HCL ORAL TABLET 7.5 MG 3.36504 08/21/2015 1.79990 05/17/2019 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 CYCLOPHOSPHAMIDE 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 5.25882 05/23/2014 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CYPROHEPTADINE HCL ORAL SYRUP 2 MG/5 ML 0.08798 02/27/2015 0.06816 03/02/2018 CYPROHEPTADINE HCL ORAL TABLET 4 MG 0.23460 08/16/2019 0.14405 11/15/2019 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 DEFEROXAMINE 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 DESIPRAMINE HCL ORAL TABLET 25 MG 0.96739 08/21/2015 0.42950 01/24/2020 DESIPRAMINE HCL ORAL TABLET 50 MG 1.74170 02/21/2018 1.31850 05/25/2018 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, 14.44800 04/26/2019 13.10000 02/21/2020 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 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 DESMOPRESSIN ACETATE ORAL TABLET 0.1 MG 0.54370 09/20/2019 0.41720 11/15/2019 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 TABLET 0.46310 03/03/2017 0.37988 03/02/2018 21-5 (28) West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DESONIDE TOPICAL CREAM (GRAM) 0.05 % 1.15112 06/21/2019 0.91650 03/20/2020 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 02/07/2014 5.41981 08/21/2015 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 0.50550 11/15/2019 0.77253 02/06/2020 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 0.75488 01/25/2019 0.71833 05/17/2019 HR 50 MG DEXAMETHASONE 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 DEXRAZOXANE 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 01/22/2020 1.42000 01/23/2020 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 10 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 1.80000 07/26/2019 1.80000 01/22/2020 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 15 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.95660 01/22/2020 1.57007 01/28/2020 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 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- 3.82332 01/22/2020 2.02485 03/20/2020 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 5 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.42600 06/25/2019 0.33058 11/15/2019 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- 0.50545 03/16/2019 0.37100 09/20/2019 ASPARTATE ORAL TABLET 15 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.56320 03/08/2019 0.37150 09/20/2019 ASPARTATE ORAL TABLET 20 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.36280 01/25/2019 0.21010 03/20/2020 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 1.31280 01/24/2020 0.46820 03/20/2020 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 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 % West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 04/17/2015 0.02372 08/21/2015 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 0.42767 03/16/2018 0.25630 11/16/2018 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 0.09565 07/14/2017 0.08230 01/24/2020 COATED) 75 MG DICLOFENAC SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG 0.66130 12/19/2018 1.60000 06/04/2019 DICLOFENAC SODIUM TOPICAL DROPS 1.5 % 0.90000 04/27/2018 0.11873 11/15/2019 DICLOFENAC SODIUM TOPICAL GEL (GRAM) 1 % 0.20653 08/17/2019 0.17595 11/15/2019 DICLOFENAC SODIUM TOPICAL GEL (GRAM) 3 % 1.49000 05/25/2018 0.68850 03/20/2020 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 2.34698 08/21/2015 1.94983 03/03/2017 RELEASE,BIPHASE 75 MG-200 DICLOXACILLIN 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DICYCLOMINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.21028 04/03/2015 DICYCLOMINE HCL ORAL TABLET 20 MG 0.14933 09/20/2019 0.18270 10/04/2019 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 PUMP 296.65500 07/05/2017 324.99800 09/24/2019 (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 0.89878 12/02/2016 0.64937 07/14/2017 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DILTIAZEM HCL ORAL TABLET 90 MG 0.26263 08/21/2015 0.24125 09/22/2017 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 (GLYCINE) 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 08/12/2014 0.10810 08/21/2015 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 3.76000 01/08/2018 0.87360 03/02/2018 DIVALPROEX SODIUM ORAL CAPSULE, DELAYED RELEASE SPRINKLE 0.34270 08/27/2019 0.29874 03/20/2020 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 DIVALPROEX SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 250 MG 0.15500 02/22/2019 0.28108 04/01/2020 DIVALPROEX SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.20742 12/20/2019 0.14998 04/17/2020 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 DOCETAXEL 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 DOCUSATE 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 ENEMA (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 4.55000 08/25/2017 3.55783 09/22/2017 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 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 0.78900 09/20/2019 1.73621 01/29/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.33396 07/08/2016 0.10930 11/24/2017 DOXEPIN HCL ORAL CAPSULE 10 MG 0.37514 08/21/2015 0.22778 05/17/2019 DOXEPIN HCL ORAL CAPSULE 100 MG 0.90989 04/03/2019 0.96692 09/30/2019 DOXEPIN HCL ORAL CAPSULE 150 MG 0.92954 03/20/2015 DOXEPIN HCL ORAL CAPSULE 25 MG 0.49387 08/21/2015 0.36040 08/25/2017 DOXEPIN HCL ORAL CAPSULE 50 MG 0.45428 05/17/2019 0.58570 08/06/2019 DOXEPIN HCL ORAL CAPSULE 75 MG 1.19520 09/18/2016 0.65458 05/17/2019 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 0.31458 03/02/2018 0.16900 12/21/2018 DOXYCYCLINE HYCLATE ORAL CAPSULE 50 MG 0.28216 04/08/2019 0.21890 11/15/2019 DOXYCYCLINE HYCLATE ORAL TABLET 100 MG 0.12565 08/16/2019 0.09980 04/17/2020 DOXYCYCLINE HYCLATE ORAL TABLET 20 MG 0.62690 08/21/2015 0.20961 07/08/2016 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 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 9.55706 12/02/2016 7.63483 09/22/2017 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DROPERIDOL INJECTION VIAL (ML) 2.5 MG/ML 1.48750 01/25/2013 DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM ORAL 3.80020 02/26/2019 3.28512 11/15/2019 TABLET 3-0.02(24) DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.19211 11/16/2018 0.15437 08/16/2019 COATED) 20 MG DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.15200 12/21/2018 0.10633 12/20/2019 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 0.14504 07/26/2019 0.11663 08/16/2019 COATED) 60 MG DUTASTERIDE ORAL CAPSULE 0.5 MG 0.17067 09/21/2018 0.13530 08/16/2019 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 % 0.54333 02/22/2019 0.44717 11/15/2019 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 9.80000 04/27/2018 5.01000 12/20/2019 ELETRIPTAN HYDROBROMIDE ORAL TABLET 40 MG 5.31750 05/17/2019 3.67667 09/20/2019 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 13.03766 04/21/2017 10.08000 08/01/2018 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 120MG/.8ML 19.56825 02/26/2016 17.76502 04/21/2017 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 9.96000 08/01/2018 9.79500 02/21/2020 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 60MG/0.6ML 12.50000 01/27/2017 11.40870 03/17/2017 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 80MG/0.8ML 8.71125 11/15/2019 9.16000 12/27/2019 ENOXAPARIN SODIUM SUBCUTANEOUS VIAL (ML) 300MG/3ML 59.20133 03/06/2015 59.20133 08/21/2015 ENTACAPONE ORAL TABLET 200 MG 0.33480 11/15/2019 0.63276 12/27/2019 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ENZYMES,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 1.11944 11/15/2019 0.94433 01/24/2020 EPLERENONE ORAL TABLET 50 MG 1.26499 06/16/2017 0.98300 08/16/2019 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 0.16000 06/16/2017 0.09770 09/22/2017 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 ERYTHROMYCIN 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 9.39950 01/25/2019 7.81000 06/21/2019 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 2.91330 08/27/2019 1.97425 03/20/2020 % 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 0.06080 06/16/2017 0.04554 09/22/2017 ESCITALOPRAM OXALATE ORAL TABLET 20 MG 0.05913 02/22/2019 0.03570 10/25/2019 ESCITALOPRAM OXALATE ORAL TABLET 5 MG 0.06264 08/25/2017 0.03320 10/20/2017 ESOMEPRAZOLE MAGNESIUM ORAL CAPSULE,DELAYED RELEASE 0.23553 05/17/2019 0.19700 08/16/2019 (ENTERIC COATED) 20 MG ESOMEPRAZOLE MAGNESIUM ORAL CAPSULE,DELAYED RELEASE 0.22614 08/16/2019 0.15306 04/17/2020 (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 0.16296 08/21/2015 0.11270 07/14/2017 ESTRADIOL ORAL TABLET 2 MG 0.13700 06/16/2017 0.11000 10/20/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 8.45640 06/16/2017 7.60625 07/26/2019 .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 6.18000 12/21/2018 8.09043 11/26/2019 0.05MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 7.14500 08/17/2018 5.94125 05/17/2019 0.1MG/24HR ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY .025MG/24H 15.92223 09/20/2013 13.00000 03/03/2017 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY .0375MG/24 12.39250 12/22/2017 11.07000 01/24/2020 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY .075MG/24H 10.55000 05/02/2014 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.05MG/24H 9.98000 05/17/2019 13.11750 11/06/2019 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.06MG/24H 15.47000 04/25/2014 12.05375 06/16/2017 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 14.16352 12/25/2015 12.42131 06/16/2017 0.1MG/24HR ESTRADIOL VAGINAL TABLET 10 MCG 12.49875 09/20/2019 9.30000 12/20/2019 ESTRADIOL/NORETHINDRONE ACETATE ORAL TABLET 0.5-0.1 MG 1.85000 12/21/2018 1.73571 03/15/2019 ESTRADIOL/NORETHINDRONE ACETATE ORAL TABLET 1 MG-0.5MG 2.83847 03/25/2016 2.29848 06/16/2017 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 ETHAMBUTOL HCL ORAL TABLET 100 MG 0.28000 11/24/2017 0.16920 08/17/2018 ETHAMBUTOL HCL ORAL TABLET 400 MG 0.71366 06/16/2017 0.36260 09/22/2017 ETHINYL ESTRADIOL/DROSPIRENONE ORAL TABLET 0.02-3(28) 0.49000 03/15/2019 0.36702 08/16/2019 ETHINYL ESTRADIOL/DROSPIRENONE ORAL TABLET 0.03MG-3MG 0.49000 04/27/2018 0.39301 08/17/2018 ETHOSUXIMIDE ORAL CAPSULE 250 MG 1.08530 03/02/2018 0.70270 02/22/2019 ETHOSUXIMIDE ORAL SOLUTION, ORAL 250 MG/5ML 0.28869 04/21/2017 0.27221 01/25/2019 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 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/SIMVASTATIN 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 1.17650 11/15/2019 0.77689 03/20/2020 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, ORAL (FINAL DOSE FORM) 40MG/5ML 0.77031 08/09/2019 1.14744 03/03/2020 FAMOTIDINE ORAL TABLET 10 MG 0.08920 03/27/2015 0.08920 08/21/2015 FAMOTIDINE ORAL TABLET 20 MG 0.02905 10/25/2019 0.19960 04/13/2020 FAMOTIDINE ORAL TABLET 40 MG 0.08659 08/21/2015 0.05563 03/02/2018 FAMOTIDINE/PF INTRAVENOUS VIAL (ML) 20 MG/2 ML 0.37429 08/12/2014 0.37429 08/21/2015 FEBUXOSTAT ORAL TABLET 40 MG 4.80000 02/21/2020 FEBUXOSTAT ORAL TABLET 80 MG 4.97000 02/21/2020 FELBAMATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 600 MG/5ML 1.87137 04/22/2016 1.58070 12/02/2016 FELBAMATE ORAL TABLET 400 MG 1.34690 10/20/2017 0.86430 08/16/2019 FELBAMATE ORAL TABLET 600 MG 1.48180 02/22/2019 1.41430 03/20/2020 FELODIPINE 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 0.20622 11/16/2018 0.16870 08/16/2019 FENOFIBRATE NANOCRYSTALLIZED ORAL TABLET 48 MG 0.14196 05/17/2019 0.10550 11/15/2019 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 0.29844 02/11/2020 0.19590 04/17/2020 FENOFIBRATE ORAL TABLET 54 MG 0.18444 11/16/2018 0.16656 11/15/2019 FENOFIBRATE,MICRONIZED ORAL CAPSULE 130 MG 2.43400 08/17/2018 1.89200 10/19/2018 FENOFIBRATE,MICRONIZED ORAL CAPSULE 134 MG 0.19433 11/15/2019 0.14630 04/17/2020 FENOFIBRATE,MICRONIZED ORAL CAPSULE 200 MG 0.73900 02/14/2019 0.55315 08/16/2019 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 FENTANYL 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 7.16254 01/13/2020 7.60912 02/20/2020 MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 25 2.55100 02/22/2019 2.22000 10/25/2019 MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 42.45400 05/01/2015 37.5MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 50MCG/HR 3.05057 11/15/2019 2.49800 01/24/2020 FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 61.68800 05/01/2015 62.5MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 75MCG/HR 4.63650 11/15/2019 7.43407 02/12/2020 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 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, EXTENDED 0.66733 08/21/2015 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 FISH OIL/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 0.58174 08/21/2015 0.19130 08/17/2018 FLECAINIDE ACETATE ORAL TABLET 50 MG 0.14900 07/26/2019 0.13700 01/24/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.54328 11/16/2018 0.46613 11/15/2019 FLUCONAZOLE ORAL TABLET 150 MG 0.80333 08/01/2018 0.72107 02/22/2019 FLUCONAZOLE ORAL TABLET 200 MG 1.12014 05/29/2018 0.55972 11/16/2018 FLUCONAZOLE ORAL TABLET 50 MG 0.89200 08/21/2015 0.53200 06/16/2017 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 % 6.56750 10/19/2018 4.81200 12/21/2018 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 % 1.30643 08/21/2015 0.55000 02/22/2019 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 % 1.31863 08/21/2015 0.50719 03/20/2020 FLUOCINONIDE TOPICAL CREAM (GRAM) 0.05 % 0.79753 11/24/2017 0.53592 10/25/2019 FLUOCINONIDE TOPICAL CREAM (GRAM) 0.1 % 13.23945 02/27/2015 11.07021 12/02/2016 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 % 1.13388 05/02/2014 0.79333 02/21/2020 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 FLUOROMETHOLONE 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.02988 05/01/2015 0.02988 08/21/2015 FLUOXETINE HCL ORAL CAPSULE 40 MG 0.10783 02/01/2018 0.06800 01/25/2019 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 0.41658 07/27/2019 0.49922 04/23/2020 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 13.83300 08/17/2018 16.70660 11/06/2019 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 6.23852 08/16/2019 7.36791 01/06/2020 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 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 2.45000 04/17/2020 BLISTER, WITH INHALATION DEVICE 250-50 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 0.42683 08/16/2019 0.33360 02/21/2020 FLUVOXAMINE MALEATE ORAL TABLET 25 MG 0.23769 08/21/2015 0.16767 08/25/2017 FLUVOXAMINE MALEATE ORAL TABLET 50 MG 0.31590 08/16/2019 0.23950 11/15/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 VITAMIN C 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 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 GABAPENTIN MISCELLANEOUS POWDER (GRAM) 100 % 1.14400 08/21/2015 GABAPENTIN ORAL CAPSULE 100 MG 0.03654 08/21/2015 0.02447 10/20/2017 GABAPENTIN ORAL CAPSULE 300 MG 0.05614 04/18/2019 0.04300 06/21/2019 GABAPENTIN ORAL CAPSULE 400 MG 0.06516 12/06/2019 0.04698 04/17/2020 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 0.12078 07/14/2017 0.10138 12/22/2017 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.69000 04/22/2016 0.60633 03/16/2018 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 % 24.56800 05/25/2018 20.80000 10/19/2018 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 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 GENTAMICIN SULFATE TOPICAL OINTMENT (GRAM) 0.1 % 2.52733 02/07/2019 2.02650 03/20/2020 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 0.19510 07/26/2019 0.14525 12/20/2019 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/METFORMIN 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 GLUCOSAMINE SULFATE ORAL TABLET 750 MG 0.33095 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.11240 08/25/2017 0.04420 09/22/2017 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 GRISEOFULVIN 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1 MG 0.32400 07/26/2019 0.29290 12/20/2019 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 ORAL 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 43.21000 04/15/2019 35.04600 05/17/2019 HALOPERIDOL DECANOATE INTRAMUSCULAR AMPUL (ML) 50 MG/ML 21.74667 01/25/2013 HALOPERIDOL DECANOATE INTRAMUSCULAR VIAL (ML) 100 MG/ML 43.24600 10/13/2015 38.75000 12/21/2018 HALOPERIDOL DECANOATE INTRAMUSCULAR VIAL (ML) 50 MG/ML 22.14000 08/21/2015 22.00000 01/25/2019 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 0.72503 01/04/2020 0.68650 03/20/2020 HALOPERIDOL ORAL TABLET 2 MG 0.19690 11/24/2017 0.31198 12/28/2017 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.05309 08/21/2015 0.03468 08/25/2017 HYDRALAZINE HCL ORAL TABLET 100 MG 0.11896 05/20/2016 0.06535 09/30/2016 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 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- 0.16477 05/19/2017 0.10886 06/16/2017 325MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 2.5-325 0.69069 04/03/2015 MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 5 MG- 1.21000 08/25/2017 0.65450 09/22/2017 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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/LIDOCAINE 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 (GRAM) 0.1 % HYDROCORTISONE MISCELLANEOUS POWDER (GRAM) 2.18774 08/12/2014 2.18774 08/21/2015 HYDROCORTISONE ORAL TABLET 10 MG 0.28362 05/20/2016 0.21970 09/22/2017 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 % 0.09447 08/21/2015 0.08792 10/25/2019 HYDROCORTISONE TOPICAL CREAM WITH PERINEAL APPLICATOR 1 % 0.66820 01/25/2013 HYDROCORTISONE TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 0.33678 08/16/2019 0.42190 12/23/2019 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 % 1.51000 08/16/2019 1.43182 11/15/2019 HYDROCORTISONE VALERATE TOPICAL OINTMENT (GRAM) 0.2 % 4.59200 07/25/2014 4.59200 08/21/2015 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/MINERAL OIL/PETROLATUM,WHITE TOPICAL 0.12564 01/25/2013 OINTMENT (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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date HYDROMORPHONE HCL ORAL LIQUID (ML) 1 MG/ML 0.27988 01/25/2013 HYDROMORPHONE HCL ORAL TABLET 2 MG 0.09250 08/21/2015 0.07780 08/25/2017 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 MG 9.53110 08/01/2014 9.53110 08/21/2015 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 TOPICAL CREAM, EXTENDED 2.49387 01/25/2013 RELEASE (GRAM) 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 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 0.07338 08/21/2015 0.03772 09/22/2017 HYDROXYZINE HCL ORAL TABLET 25 MG 0.04000 08/25/2017 0.04986 06/06/2019 HYDROXYZINE HCL ORAL TABLET 50 MG 0.08070 04/26/2019 0.08702 10/03/2019 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date IBUPROFEN ORAL TABLET 200 MG 0.01635 01/16/2015 0.01635 08/21/2015 IBUPROFEN ORAL TABLET 400 MG 0.06240 08/21/2015 0.04002 08/25/2017 IBUPROFEN ORAL TABLET 600 MG 0.06700 08/21/2015 0.03420 07/14/2017 IBUPROFEN ORAL TABLET 800 MG 0.07263 08/21/2015 0.03474 07/14/2017 IBUPROFEN ORAL TABLET,CHEWABLE 100 MG 0.12702 08/21/2015 0.12802 05/03/2019 IBUPROFEN/OXYCODONE HCL ORAL 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 0.15140 08/25/2017 0.13870 03/20/2020 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 % 2.07408 06/16/2017 1.89000 12/20/2019 INDAPAMIDE ORAL TABLET 1.25 MG 0.30448 08/01/2014 0.17220 09/22/2017 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 1.17400 03/03/2017 2.39930 05/03/2019 IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION AMPUL FOR 0.05553 03/03/2017 0.04815 07/26/2019 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 IRON CARBONYL,GLUC/FOLIC ACID/VIT B12/VIT C/DOCUSATE SODIUM 0.78945 08/21/2015 2.02566 12/13/2018 ORAL TABLET 90-1-50 MG IRON POLYSACCHAR COMPLX/IRON HEME POLYPEPTIDE/FOLIC 2.61148 01/25/2013 2.61148 08/21/2015 ACID/B12 ORAL 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 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 0.83200 10/10/2014 0.83200 08/21/2015 ISOSORBIDE DINITRATE ORAL TABLET 5 MG 0.39000 12/21/2018 0.09160 02/21/2020 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 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 0.10900 11/16/2018 0.07058 05/17/2019 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 6.52054 01/22/2016 3.70100 10/19/2018 ISOTRETINOIN ORAL CAPSULE 20 MG 1.92767 08/16/2019 3.46933 02/07/2020 ISOTRETINOIN ORAL CAPSULE 30 MG 5.43200 07/18/2019 3.55000 12/20/2019 ISOTRETINOIN ORAL CAPSULE 40 MG 3.19000 10/25/2019 2.13833 01/24/2020 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 KETOCONAZOLE ORAL TABLET 200 MG 0.98460 12/22/2017 0.93167 03/02/2018 KETOCONAZOLE TOPICAL CREAM (GRAM) 2 % 0.55784 11/15/2019 0.46671 02/21/2020 KETOCONAZOLE TOPICAL SHAMPOO 2 % 0.07500 03/17/2017 0.05789 08/25/2017 KETOPROFEN ORAL CAPSULE 75 MG 0.40169 03/06/2015 0.40169 08/21/2015 KETOPROFEN ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 200 5.64648 03/13/2015 5.64648 08/21/2015 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 % 1.29534 08/21/2015 1.13433 08/25/2017 KETOROLAC TROMETHAMINE ORAL TABLET 10 MG 0.83500 04/23/2016 0.69950 11/16/2018 KETOTIFEN FUMARATE OPHTHALMIC DROPS 0.025 % 0.92080 03/27/2015 0.92080 08/21/2015 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 0.14153 05/17/2019 0.10450 09/20/2019 LABETALOL HCL ORAL TABLET 200 MG 0.18547 12/22/2017 0.12920 07/26/2019 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 LACTULOSE 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 LACTULOSE ORAL SOLUTION, ORAL 10 G/15 ML 0.01301 11/21/2014 0.01301 08/21/2015 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 1.61000 11/24/2017 1.31000 11/15/2019 LAMIVUDINE/ZIDOVUDINE ORAL TABLET 150-300 MG 2.21434 03/17/2017 0.91667 09/22/2017 LAMOTRIGINE ORAL TABLET 100 MG 0.05167 08/25/2017 0.03960 12/22/2017 LAMOTRIGINE ORAL TABLET 150 MG 0.10385 08/21/2015 0.06512 08/25/2017 LAMOTRIGINE ORAL TABLET 200 MG 0.08236 08/21/2015 0.06122 08/25/2017 LAMOTRIGINE ORAL TABLET 25 MG 0.03110 07/14/2017 0.02605 07/26/2019 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 2.06266 01/25/2019 2.01533 03/20/2020 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 7.24667 11/16/2018 8.57000 12/20/2018 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 4.42467 06/22/2018 2.83067 10/25/2019 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 50 MG 3.07133 08/25/2017 1.94367 11/15/2019 LAMOTRIGINE ORAL TABLET,DISINTEGRATING 100 MG 10.52000 07/08/2016 5.81000 08/17/2018 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/MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT 0.91000 01/25/2013 0.91000 08/21/2015 (GRAM) LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.28500 06/16/2017 0.13167 05/17/2019 15 MG LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.15656 07/14/2017 0.08467 03/15/2019 30 MG LANSOPRAZOLE/AMOXICILLIN TRIHYDRATE/CLARITHROMYCIN ORAL 3.59300 03/20/2015 COMBINATION PACKAGE (EA) 30-500-500 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LATANOPROST OPHTHALMIC DROPS 0.005 % 1.67400 10/19/2018 1.62800 04/17/2020 LEFLUNOMIDE ORAL TABLET 10 MG 0.76500 02/22/2019 0.66667 05/17/2019 LEFLUNOMIDE ORAL TABLET 20 MG 1.34389 08/16/2019 1.03800 03/20/2020 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 0.78893 08/21/2015 0.54096 03/17/2017 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 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 0.04966 08/21/2015 0.03332 10/20/2017 LEVETIRACETAM ORAL SOLUTION, ORAL 500 MG/5ML 1.06824 08/21/2015 0.05210 09/30/2016 LEVETIRACETAM ORAL TABLET 1000 MG 0.22030 03/22/2019 0.21650 07/26/2019 LEVETIRACETAM ORAL TABLET 250 MG 0.07448 02/20/2015 0.07448 08/21/2015 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 0.23278 11/16/2018 0.16667 07/26/2019 LEVETIRACETAM ORAL TABLET, EXTENDED RELEASE 24 HR 750 MG 0.35000 12/21/2018 0.27750 05/17/2019 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 0.53495 04/24/2015 0.72599 05/25/2018 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LEVOFLOXACIN ORAL TABLET 750 MG 0.24150 03/02/2018 0.22400 04/26/2019 LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS 0.11258 08/12/2014 SOLUTION, PIGGYBACK (ML) 250MG/50ML LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS 0.06601 08/12/2014 0.02228 11/24/2017 SOLUTION, PIGGYBACK (ML) 500MG/0.1L LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS 0.05357 08/12/2014 0.01569 11/24/2017 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 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 0.75200 01/25/2019 0.31610 03/20/2020 ORAL TABLET, DOSE PACK, 3 MONTHS 150-30(84) LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET 0.1-0.02MG 0.27345 08/17/2018 0.21078 03/15/2019 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 LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET 90-20 MCG 1.48500 04/24/2015 LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET, DOSE PACK, 3 0.40699 05/23/2018 0.32100 11/16/2018 MONTHS 0.15-0.03 LEVORPHANOL TARTRATE ORAL TABLET 2 MG 1.12600 08/12/2014 1.12600 08/21/2015 LEVOTHYROXINE 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 01/25/2013 44.60050 08/21/2015 LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG 0.20882 07/14/2017 0.32886 03/17/2020 LEVOTHYROXINE SODIUM ORAL TABLET 112 MCG 0.37767 10/19/2018 0.31907 06/21/2019 LEVOTHYROXINE SODIUM ORAL TABLET 125 MCG 0.34227 11/16/2018 0.39235 06/14/2019 LEVOTHYROXINE SODIUM ORAL TABLET 137 MCG 0.40522 05/19/2017 0.35260 10/20/2017 LEVOTHYROXINE SODIUM ORAL TABLET 150 MCG 0.38550 02/22/2019 0.24822 01/24/2020 LEVOTHYROXINE SODIUM ORAL TABLET 175 MCG 0.43757 11/24/2017 0.42570 12/20/2019 LEVOTHYROXINE SODIUM ORAL TABLET 200 MCG 0.49196 01/27/2017 0.33885 07/14/2017 LEVOTHYROXINE SODIUM ORAL TABLET 25 MCG 0.22294 11/16/2018 0.17105 04/17/2020 LEVOTHYROXINE SODIUM ORAL TABLET 300 MCG 0.39278 11/16/2018 0.59100 03/30/2019 LEVOTHYROXINE SODIUM ORAL TABLET 50 MCG 0.27192 07/14/2017 0.20082 12/20/2019 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 02/14/2014 0.27545 08/21/2015 LIDOCAINE HCL MUCOUS MEMBRANE JELLY WITH PREFILLED 0.34943 12/12/2014 0.34943 08/21/2015 APPLICATOR (ML) 2 % West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 % 0.02375 08/21/2015 0.07917 05/21/2018 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) 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 % 2.24989 11/15/2019 2.15204 02/21/2020 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 % 0.26639 11/15/2019 0.22550 01/24/2020 LIDOCAINE/PRILOCAINE TOPICAL CREAM (GRAM) 2.5 %-2.5% 0.27834 07/26/2019 0.19392 11/15/2019 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 1.51000 02/21/2020 2.34734 03/04/2020 LIOTHYRONINE SODIUM ORAL TABLET 25 MCG 0.65000 03/17/2017 0.42480 07/14/2017 LIOTHYRONINE SODIUM ORAL TABLET 5 MCG 0.32485 05/19/2017 0.29155 07/14/2017 LIOTHYRONINE SODIUM ORAL TABLET 50 MCG 1.01491 04/24/2015 0.47406 03/03/2017 LISINOPRIL ORAL TABLET 10 MG 0.02112 04/17/2015 0.02112 08/21/2015 LISINOPRIL ORAL TABLET 2.5 MG 0.01635 05/01/2015 0.01635 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LISINOPRIL ORAL TABLET 20 MG 0.02086 10/20/2017 0.02569 04/06/2020 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 03/06/2015 0.02693 08/21/2015 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 02/13/2015 0.06052 08/21/2015 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 0.14970 03/03/2017 0.12000 09/21/2018 LITHIUM CARBONATE ORAL TABLET, EXTENDED RELEASE 450 MG 0.17713 02/22/2019 0.10100 05/17/2019 LITHIUM CITRATE ORAL SOLUTION, ORAL 8 MEQ/5 ML 0.03921 01/25/2013 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 LORATADINE 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 0.57203 08/21/2015 0.36808 11/16/2018 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 0.42866 09/04/2019 0.09600 02/21/2020 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 0.07450 08/21/2015 0.05099 11/16/2018 MG LOVASTATIN ORAL TABLET 10 MG 0.07840 01/27/2016 0.05820 09/22/2017 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 MAGNESIUM CHLORIDE 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 MAGNESIUM OXIDE 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 MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS INTRAVENOUS 0.01970 08/12/2014 SOLUTION 20 G/500ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS INTRAVENOUS 0.01440 08/12/2014 SOLUTION 40G/1000ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS INTRAVENOUS 0.24560 08/12/2014 SOLUTION, PIGGYBACK (ML) 2 G/50 ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS INTRAVENOUS 0.13419 07/25/2014 SOLUTION, PIGGYBACK (ML) 4 G/100 ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS INTRAVENOUS 0.23100 08/12/2014 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 MANGANESE CHLORIDE INTRAVENOUS VIAL (ML) 0.1 MG/ML 0.17390 08/12/2014 MANNITOL 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/SORBITOL 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 MECLIZINE 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/PYRIDOXAL PHOSPHATE 0.88358 03/27/2015 0.88358 08/21/2015 ORAL TABLET 2-3-35 MG MEDROXYPROGESTERONE ACETATE INTRAMUSCULAR VIAL (ML) 150 36.18000 09/20/2019 42.38726 11/13/2019 MG/ML MEDROXYPROGESTERONE ACETATE ORAL TABLET 10 MG 0.12690 08/21/2015 0.09842 07/14/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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) 0.08856 11/19/2019 0.07566 03/20/2020 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 MELATONIN 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 0.03190 08/21/2015 0.01655 08/17/2018 MELOXICAM ORAL TABLET 7.5 MG 0.02466 05/01/2015 0.02466 08/21/2015 MEMANTINE HCL ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 2.50450 08/16/2019 21 MG MEMANTINE HCL ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 2.33692 05/17/2019 1.93938 11/15/2019 28 MG MEMANTINE HCL ORAL TABLET 10 MG 0.08633 11/16/2018 0.06912 12/20/2019 MEMANTINE HCL ORAL TABLET 5 MG 0.18583 08/25/2017 0.09917 09/22/2017 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) 800 4.25000 11/15/2019 4.25000 01/01/2020 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date METAXALONE ORAL TABLET 800 MG 0.99990 02/22/2019 0.52160 04/26/2019 METFORMIN HCL ORAL TABLET 1000 MG 0.03664 08/21/2015 0.02659 10/20/2017 METFORMIN HCL ORAL TABLET 500 MG 0.01932 08/21/2015 0.01435 07/26/2019 METFORMIN HCL ORAL TABLET 850 MG 0.02986 05/01/2015 0.02986 08/21/2015 METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1000 MG 3.80000 05/17/2019 3.67350 11/15/2019 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 METHADONE 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 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 0.63990 01/24/2020 0.59990 03/20/2020 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 0.05730 12/22/2017 0.10932 08/23/2019 METHOTREXATE SODIUM INJECTION VIAL (ML) 25 MG/ML 3.00720 01/30/2015 METHOTREXATE SODIUM ORAL TABLET 2.5 MG 0.42453 08/16/2019 0.38159 11/15/2019 METHOTREXATE SODIUM/PF INJECTION VIAL (ML) 25 MG/ML 0.58357 08/21/2015 2.87500 10/02/2019 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 62.25000 04/04/2018 53.75250 01/25/2019 METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 4.03956 12/09/2017 2.29720 07/26/2019 30-70 10 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 2.94350 12/08/2017 2.94350 12/09/2017 30-70 20 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 2.96640 12/09/2017 3.27270 05/16/2018 30-70 30 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 4.30300 12/08/2017 4.30300 12/09/2017 30-70 40 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 4.55740 12/09/2017 4.24000 07/26/2019 30-70 50 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 6.76633 12/08/2017 6.76633 12/09/2017 30-70 60 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 3.68500 10/19/2018 3.59850 05/17/2019 50-50 20 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 4.36506 04/25/2014 3.78000 07/26/2019 50-50 30 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 4.27230 11/24/2017 3.85000 06/22/2018 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 02/27/2015 0.73600 03/02/2016 METHYLPHENIDATE HCL ORAL TABLET 10 MG 0.27063 08/17/2018 0.18500 01/25/2019 METHYLPHENIDATE HCL ORAL TABLET 20 MG 0.23000 01/25/2019 0.27814 04/18/2019 METHYLPHENIDATE HCL ORAL TABLET 5 MG 0.17340 08/17/2018 0.15000 01/25/2019 METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 10 MG 2.31000 05/25/2018 1.67990 08/16/2019 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 METHYLPREDNISOLONE 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 0.21667 02/22/2019 0.20571 04/17/2020 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.81350 02/22/2019 0.89960 05/08/2019 METOLAZONE ORAL TABLET 5 MG 0.68220 01/24/2020 1.11320 02/25/2020 METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.25564 01/19/2018 0.20520 09/21/2018 100 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.43860 12/20/2019 0.32643 02/21/2020 200 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 25 0.15329 11/24/2017 0.10200 06/21/2019 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 50 0.18560 06/16/2017 0.09250 09/21/2018 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 05/01/2015 0.03114 08/21/2015 METOPROLOL TARTRATE ORAL TABLET 25 MG 0.02399 05/01/2015 0.02399 08/21/2015 METOPROLOL TARTRATE ORAL TABLET 50 MG 0.02097 12/26/2014 0.02097 08/21/2015 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 % 1.11140 09/03/2019 1.18465 10/07/2019 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 % 0.62043 04/26/2019 0.72500 06/26/2019 MEXILETINE HCL ORAL CAPSULE 150 MG 0.55042 01/30/2015 0.55042 08/21/2015 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.71570 08/05/2019 0.55753 02/21/2020 MIDODRINE HCL ORAL TABLET 2.5 MG 0.31350 12/04/2018 0.28820 11/15/2019 MIDODRINE HCL ORAL TABLET 5 MG 0.35870 08/16/2019 0.31930 10/25/2019 MILRINONE LACTATE INTRAVENOUS VIAL (ML) 1 MG/ML 0.38297 08/21/2015 0.29545 08/25/2017 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 % 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 0.08134 06/16/2017 0.06475 11/15/2019 MIRTAZAPINE ORAL TABLET 30 MG 0.13332 05/19/2017 0.07067 06/16/2017 MIRTAZAPINE ORAL TABLET 45 MG 0.14417 11/16/2018 0.11133 11/15/2019 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 MOLYBDENUM (AMMONIUM MOLYBDATE) VIAL (ML) 25 MCG/ML 0.32672 01/25/2013 MOMETASONE FUROATE NASAL AEROSOL, SPRAY WITH PUMP (GRAM) 2.67456 08/16/2019 2.32029 02/21/2020 50 MCG MOMETASONE FUROATE TOPICAL CREAM (GRAM) 0.1 % 0.49044 06/25/2019 0.18611 08/16/2019 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 % 0.22914 08/21/2015 0.30258 10/16/2019 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 0.12093 03/03/2017 0.05967 06/16/2017 MONTELUKAST SODIUM ORAL TABLET,CHEWABLE 4 MG 0.12956 03/02/2018 0.10275 08/17/2018 MONTELUKAST SODIUM ORAL TABLET,CHEWABLE 5 MG 0.09067 09/22/2017 0.08100 06/21/2019 MORPHINE SULFATE INJECTION SYRINGE (ML) 10 MG/ML 1.83954 05/23/2014 1.83954 08/21/2015 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 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 PELLETS 50 6.65266 08/21/2015 4.71535 06/16/2017 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 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 0.17240 04/11/2014 0.49746 11/05/2018 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 100 MG 0.98200 11/24/2017 1.07226 04/09/2018 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 15 MG 0.15750 04/27/2018 0.21670 03/07/2020 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 0.30890 07/26/2019 0.23720 04/17/2020 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 60 MG 0.63607 09/22/2017 0.54275 11/16/2018 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 multivitamin comb no.48/ferrous fumarate/folic acid/dha CAPSULE 28-1-250MG 3.34740 09/26/2014 MULTIVITAMIN COMBINATION NO.47/FERROUS FUM/FOLATE 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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/LYCOPENE/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 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 % 0.20477 11/24/2017 0.17500 12/21/2018 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 (ENTERIC 1.39966 03/03/2017 0.82950 11/16/2018 COATED) 180 MG MYCOPHENOLATE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 2.89000 03/15/2019 2.80967 09/20/2019 COATED) 360 MG NABUMETONE ORAL TABLET 500 MG 0.16887 08/25/2017 0.14920 08/01/2018 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 09/22/2017 0.80040 01/01/2018 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 NAFCILLIN 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.71722 10/25/2019 0.66875 11/15/2019 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 NAPROXEN ORAL TABLET 250 MG 0.04181 08/12/2014 0.04181 08/21/2015 NAPROXEN ORAL TABLET 375 MG 0.05065 11/21/2014 0.05065 08/21/2015 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 0.61812 01/04/2019 0.46647 11/15/2019 NARATRIPTAN HCL ORAL TABLET 1 MG 4.82300 09/30/2016 3.92785 06/16/2017 NARATRIPTAN HCL ORAL TABLET 2.5 MG 2.25096 07/27/2019 1.10278 11/15/2019 NATEGLINIDE ORAL TABLET 120 MG 0.36656 08/16/2019 0.14756 02/21/2020 NATEGLINIDE ORAL TABLET 60 MG 0.37877 09/22/2017 0.28945 08/16/2019 NEFAZODONE 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) 40- 7.53960 04/12/2013 200K/ML NEOMYCIN SULFATE/POLYMYXIN B SULFATE IRRIGATION VIAL (ML) 40- 5.02645 01/25/2013 200K/ML West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 2.05680 08/21/2015 7.04760 09/22/2015 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 2.83000 03/03/2017 2.60900 06/22/2018 SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 0.1 % NEVIRAPINE 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 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 NICARDIPINE HCL ORAL CAPSULE 20 MG 0.34500 02/08/2013 NICARDIPINE HCL ORAL CAPSULE 30 MG 0.35170 08/12/2014 NICOTINE 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 14MG/24HR 1.24071 08/16/2019 1.16303 02/21/2020 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 NIFEDIPINE MISCELLANEOUS POWDER (GRAM) 2.02800 08/21/2015 NIFEDIPINE ORAL CAPSULE 10 MG 0.43570 11/24/2017 0.40990 02/22/2019 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 0.23630 12/22/2017 0.20292 08/17/2018 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 NISOLDIPINE 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 NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS ORAL CAPSULE 0.58062 11/16/2018 0.52928 04/17/2020 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) 31.99165 01/05/2018 23.27500 01/25/2019 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 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- 0.74511 06/16/2017 0.57873 09/22/2017 0.03MG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1MG- 0.22238 08/16/2019 0.20508 01/24/2020 20MCG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1MG- 1.65878 04/03/2019 1.33988 05/17/2019 5MCG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 0.22024 05/17/2019 0.16679 11/15/2019 ORAL TABLET 1.5-30(21) 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 1.05273 11/24/2017 0.73809 01/25/2019 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 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 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 0.60029 03/25/2016 0.28925 06/16/2017 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 0.20000 04/27/2018 0.17845 01/24/2020 NORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.3-0.03MG 0.41253 10/20/2017 0.26161 11/16/2018 NORTRIPTYLINE 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 0.21011 12/02/2016 0.11622 06/16/2017 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) 100000 0.95666 04/26/2019 0.38408 02/21/2020 -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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 OFLOXACIN OPHTHALMIC DROPS 0.3 % 2.10000 02/22/2019 1.83240 11/15/2019 OFLOXACIN OTIC DROPS 0.3 % 2.58116 10/10/2014 14.24520 06/04/2015 OLANZAPINE INTRAMUSCULAR VIAL (EA) 10 MG 29.05000 02/01/2013 OLANZAPINE ORAL TABLET 10 MG 0.13334 11/16/2018 0.10867 04/17/2020 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 0.35333 11/16/2018 0.76425 03/19/2020 OLANZAPINE ORAL TABLET,DISINTEGRATING 15 MG 0.60733 11/16/2018 0.57400 05/17/2019 OLANZAPINE ORAL TABLET,DISINTEGRATING 20 MG 3.18610 08/21/2015 0.61067 11/24/2017 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 08/01/2014 10.13740 08/21/2015 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 OLMESARTAN MEDOXOMIL ORAL TABLET 40 MG 0.16863 04/27/2018 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 % 3.27200 10/16/2019 2.57629 11/15/2019 OMEGA-3 ACID ETHYL ESTERS ORAL CAPSULE 1 G 0.21378 11/16/2018 0.21378 01/01/2019 OMEGA-3 FATTY ACIDS/DOCOSAHEXAENOIC ACID/EPA/FISH OIL ORAL 0.05283 08/12/2014 CAPSULE 1000 MG OMEPRAZOLE 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) 0.08682 08/21/2015 0.03862 07/14/2017 20 MG OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.05675 04/26/2019 0.04480 01/24/2020 40 MG 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 0.25940 07/26/2019 0.23744 11/15/2019 ONDANSETRON HCL ORAL TABLET 4 MG 0.10433 06/16/2017 0.07664 11/16/2018 ONDANSETRON HCL ORAL TABLET 8 MG 0.18887 04/10/2018 0.12277 11/16/2018 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 0.24667 10/19/2018 0.22616 11/15/2019 ONDANSETRON ORAL TABLET,DISINTEGRATING 8 MG 0.24400 07/26/2019 0.22773 11/15/2019 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 3.20000 06/21/2019 2.92000 03/20/2020 OSELTAMIVIR PHOSPHATE ORAL SUSPENSION, RECONSTITUTED, ORAL 1.18238 03/13/2019 1.02317 11/15/2019 (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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 OXCARBAZEPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 300 0.25400 12/21/2018 0.31168 01/07/2019 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 OXYBUTYNIN CHLORIDE ORAL TABLET 5 MG 0.16233 05/17/2019 0.11303 06/21/2019 OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 10 0.25538 02/22/2019 0.22747 11/15/2019 MG OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 15 0.33005 11/16/2018 0.28120 05/17/2019 MG OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 5 0.31306 11/15/2019 0.18040 01/24/2020 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 0.15800 07/14/2017 0.13000 03/02/2018 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 0.25736 03/15/2019 0.19490 03/20/2020 OXYCODONE HCL ORAL TABLET 5 MG 0.09012 03/03/2017 0.07130 08/25/2017 OXYCODONE HCL ORAL TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 5.78530 03/03/2017 5.78530 03/04/2017 40 MG OXYCODONE HCL ORAL TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 9.41957 03/03/2017 9.41957 03/04/2017 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PALIPERIDONE ORAL TABLET, EXTENDED RELEASE 24 HR 9 MG 13.28867 12/27/2019 12.64833 02/21/2020 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 0.11779 08/21/2015 0.05189 06/16/2017 COATED) 40 MG PAREGORIC LIQUID (ML) 2 MG/5 ML 0.46388 04/26/2013 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 PENTOXIFYLLINE ORAL TABLET, EXTENDED RELEASE 400 MG 0.14637 08/25/2017 0.12795 11/16/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 PERMETHRIN 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 0.52100 07/26/2019 0.29300 03/20/2020 PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 2 MG-10 MG 0.85974 03/13/2015 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 1.16476 08/29/2018 0.68905 11/16/2018 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 PHENOBARBITAL ORAL ELIXIR 20 MG/5 ML 0.12828 01/30/2015 0.11000 07/26/2019 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PHENYTOIN 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 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 PILOCARPINE HCL OPHTHALMIC DROPS 1 % 4.34000 04/26/2013 4.34000 08/21/2015 PILOCARPINE HCL OPHTHALMIC DROPS 2 % 4.43940 04/26/2013 4.43940 08/21/2015 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 0.07000 08/25/2017 0.05857 11/16/2018 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 05/01/2015 11.98000 08/21/2015 3.375 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 15.01360 07/19/2013 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date POLYETHYLENE GLYCOL 3350 ORAL POWDER (GRAM) 17G/DOSE 0.04100 08/21/2015 0.02099 05/19/2017 POLYETHYLENE GLYCOL 3350 ORAL POWDER IN PACKET (EA) 17G 0.89286 02/21/2020 1.48370 03/04/2020 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/TALC/BENTONITE TOPICAL POWDER 0.06740 08/12/2014 (GRAM) POTASSIUM ALUM/TALC/BENTONITE TOPICAL POWDER (GRAM) 0.07530 08/12/2014 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 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 0.23230 10/25/2019 0.28252 12/09/2019 POTASSIUM CHLORIDE ORAL LIQUID (ML) 40MEQ/15ML 0.83849 07/19/2017 0.38055 11/16/2018 POTASSIUM CHLORIDE ORAL PACKET (EA) 20 MEQ 4.03333 11/15/2019 4.93300 01/13/2020 POTASSIUM CHLORIDE ORAL TABLET, EXT RELEASE, 0.19245 11/16/2018 0.16745 08/16/2019 PARTICLES/CRYSTALS 10 MEQ POTASSIUM CHLORIDE ORAL TABLET, EXT RELEASE, 0.18912 02/22/2019 0.18056 10/25/2019 PARTICLES/CRYSTALS 20 MEQ POTASSIUM CHLORIDE ORAL TABLET, EXTENDED RELEASE 10 MEQ 0.14650 12/21/2018 0.13899 07/26/2019 POTASSIUM CHLORIDE ORAL TABLET, EXTENDED RELEASE 8 MEQ 0.35868 08/21/2015 0.15500 08/25/2017 POTASSIUM CHLORIDE/POTASSIUM BICARBONATE/CITRIC ACID TABLET, 0.68997 01/25/2013 EFFERVESCENT 25 MEQ POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 10 MEQ 0.65371 04/25/2019 0.52180 07/26/2019 POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 15 MEQ 1.19990 09/20/2019 1.06610 03/20/2020 POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 5 MEQ 0.92685 09/30/2016 0.52180 11/15/2019 POVIDONE-IODINE 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 0.06600 08/25/2017 0.03978 09/22/2017 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 02/06/2015 0.09654 08/21/2015 PRAMIPEXOLE DI-HCL ORAL TABLET 1 MG 0.09671 09/30/2016 0.04395 08/25/2017 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 0.49333 05/17/2019 0.41000 04/17/2020 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 0.16635 03/03/2017 0.08000 08/25/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.30846 08/02/2019 0.25364 11/15/2019 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 PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION, DROPS(FINAL 6.15000 12/20/2019 5.55440 02/21/2020 DOSAGE FORM)(ML) 1 % 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 ML 0.57224 02/21/2014 0.57224 08/21/2015 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 0.19015 03/27/2015 0.09709 09/30/2016 PREDNISONE ORAL TABLET 10 MG 0.11202 08/25/2017 0.07950 09/22/2017 PREDNISONE ORAL TABLET 2.5 MG 0.14040 08/21/2015 0.10130 11/15/2019 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 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 PREGABALIN ORAL CAPSULE 100 MG 0.15800 02/21/2020 PREGABALIN ORAL CAPSULE 150 MG 0.19717 11/15/2019 0.16000 04/01/2020 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 0.41000 11/15/2019 0.11222 04/01/2020 PREGABALIN ORAL CAPSULE 75 MG 0.23485 11/15/2019 0.16844 04/01/2020 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.2/IRON BG CHEL,SUCC-PROT/FOLIC ACID/OMEGA-3 0.36225 01/25/2013 ORAL COMBINATION PACKAGE (EA) 29-1-250MG 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 ORAL 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 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 ORAL CAPSULE 28-1-50 MG PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID 0.20146 05/17/2013 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.59/IRON CARB,FUM/FOLIC ACID/DOCUSATE/DHA 4.46109 12/12/2014 ORAL 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 VITAMINS NO.11/FERROUS FUMARATE/FOLIC ACID/OMEGA-3 2.01177 04/03/2015 ORAL CAPSULE 28-1-200MG 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 ORAL 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 ORAL 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 ORAL 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 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 ORAL 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 ORAL 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 ORAL 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 PROGESTERONE 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 0.96465 08/16/2019 0.71130 09/20/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 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 8.24914 01/13/2017 7.87258 06/16/2017 PROMETHAZINE HCL RECTAL SUPPOSITORY, RECTAL 25 MG 5.81666 02/01/2018 5.25000 02/21/2020 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 0.04860 10/21/2019 0.06227 12/11/2019 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 3.45893 06/16/2017 3.07683 03/20/2020 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 6.99942 10/31/2014 5.15292 06/16/2017 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 ORAL 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 0.54990 01/24/2020 0.48840 03/20/2020 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 160 MG 1.30000 11/16/2018 0.79800 12/21/2018 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 60 MG 0.32273 08/16/2019 0.24880 10/25/2019 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 80 MG 0.27910 09/20/2019 0.49490 02/26/2020 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 0.10768 01/24/2019 0.07170 04/26/2019 PROPRANOLOL HCL ORAL TABLET 20 MG 0.12333 11/16/2018 0.08990 09/20/2019 PROPRANOLOL HCL ORAL TABLET 40 MG 0.21556 03/03/2017 0.14630 02/22/2019 PROPRANOLOL HCL ORAL TABLET 60 MG 0.60253 01/13/2017 0.55290 03/02/2018 PROPRANOLOL HCL ORAL TABLET 80 MG 0.27250 11/16/2018 0.17910 01/24/2020 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 1,3,6-11 TOPICAL CREAM 1.87360 08/12/2014 (GRAM) PROTRIPTYLINE HCL ORAL TABLET 10 MG 1.94520 08/21/2015 1.23085 06/16/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 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 0.24830 01/24/2020 0.34550 02/17/2020 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 0.13073 01/27/2017 0.08270 06/16/2017 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 0.08886 03/03/2017 0.06000 11/24/2017 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 0.53330 07/26/2019 0.46206 11/15/2019 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 0.15690 08/21/2015 0.13756 12/22/2017 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.54147 11/16/2018 0.32133 05/17/2019 RAMELTEON ORAL TABLET 8 MG 3.03167 11/15/2019 3.03167 01/01/2020 RAMIPRIL ORAL CAPSULE 1.25 MG 0.12030 12/21/2018 0.09855 11/15/2019 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 0.37763 01/24/2020 RASAGILINE MESYLATE ORAL TABLET 1 MG 4.40000 11/15/2019 5.08438 11/27/2019 REPAGLINIDE ORAL TABLET 0.5 MG 0.17060 11/24/2017 0.08777 11/16/2018 REPAGLINIDE ORAL TABLET 1 MG 0.15930 12/22/2017 0.13355 11/16/2018 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 0.85000 09/21/2018 0.28500 04/17/2020 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 31.25000 03/15/2019 28.95000 06/21/2019 RISEDRONATE SODIUM ORAL TABLET 30 MG 29.56000 03/25/2016 RISEDRONATE SODIUM ORAL TABLET 35 MG 5.21000 03/15/2019 5.21000 10/25/2019 RISEDRONATE SODIUM ORAL TABLET 5 MG 3.95000 01/25/2019 2.33300 04/17/2020 RISPERIDONE ORAL SOLUTION, ORAL 1 MG/ML 0.36455 08/12/2019 0.21474 11/15/2019 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 0.11650 08/25/2017 0.07709 09/22/2017 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 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 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 3.94122 08/16/2019 3.66667 03/20/2020 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 3.99967 11/15/2019 3.57000 02/21/2020 9.5MG/24HR RIZATRIPTAN BENZOATE ORAL TABLET 10 MG 0.51667 03/15/2019 0.37778 07/26/2019 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 0.10162 08/21/2015 0.06306 07/14/2017 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 0.13603 08/21/2015 0.08220 08/25/2017 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 0.08622 03/16/2018 0.06033 09/21/2018 ROSUVASTATIN CALCIUM ORAL TABLET 20 MG 0.12200 10/20/2017 0.06520 12/21/2018 ROSUVASTATIN CALCIUM ORAL TABLET 40 MG 0.12344 09/21/2018 0.10000 12/21/2018 ROSUVASTATIN CALCIUM ORAL TABLET 5 MG 0.06722 11/15/2019 0.05389 04/17/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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/SULFUR SHAMPOO 2 %-1 %-2% 0.20597 01/25/2013 SALSALATE ORAL TABLET 500 MG 0.24147 11/07/2014 0.24147 08/21/2015 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 SELEGILINE HCL ORAL CAPSULE 5 MG 1.61219 08/12/2014 1.61219 08/21/2015 SELEGILINE HCL ORAL TABLET 5 MG 1.25290 11/28/2014 1.25290 08/21/2015 SELENIUM 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 SILDENAFIL CITRATE ORAL TABLET 20 MG 0.18128 01/24/2020 0.10600 03/20/2020 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 0.06240 08/21/2015 0.03117 06/16/2017 SIMVASTATIN ORAL TABLET 5 MG 0.05868 08/21/2015 0.02917 11/24/2017 SIMVASTATIN ORAL TABLET 80 MG 0.09991 08/21/2015 0.05544 11/24/2017 SIROLIMUS ORAL TABLET 0.5 MG 3.99000 09/21/2018 5.70661 11/21/2019 SIROLIMUS ORAL TABLET 1 MG 7.15000 12/20/2019 7.77140 01/21/2020 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 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 06/27/2014 0.00401 08/21/2015 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,DIBASIC/POT PHOS,MONOB/SOD PHOSPHATE 0.21890 11/24/2017 0.16750 03/20/2020 MONO ORAL TABLET 250 MG 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 0.30000 04/17/2020 SORBITOL SOLUTION IRRIGATION SOLUTION, IRRIGATION 3 % 0.00351 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 SPINOSAD TOPICAL SUSPENSION, TOPICAL (ML) 0.9 % 1.59301 08/18/2017 1.59301 01/01/2018 SPIRONOLACTONE 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 0.06122 08/21/2015 0.04580 11/16/2018 SPIRONOLACTONE ORAL TABLET 50 MG 0.14490 08/25/2017 0.12350 10/25/2019 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 0.40574 03/04/2020 0.42860 04/06/2020 SUCRALFATE ORAL TABLET 1 G 0.14615 01/13/2017 0.19994 01/04/2018 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 (ML) 0.20782 08/12/2014 8 %-4 % SULFACETAMIDE SODIUM/SULFUR/AVOBENZONE/OCTINOXATE/OCTYL 0.47020 11/21/2014 SAL TOPICAL COMBINATION PACKAGE, CLEANSER AND CREAM 9 %-4.5 % West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 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 45.17086 06/16/2017 40.67000 06/22/2018 SUMATRIPTAN NASAL SPRAY, NON-AEROSOL (EA) 5 MG 42.56000 09/21/2018 46.82000 04/05/2019 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 0.46667 07/14/2017 0.36556 11/16/2018 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 91.25000 01/25/2019 86.52000 06/21/2019 MG/0.5ML SUMATRIPTAN SUCCINATE SUBCUTANEOUS VIAL (ML) 6 MG/0.5ML 39.30000 10/19/2018 32.50000 01/25/2019 TACROLIMUS ORAL CAPSULE 0.5 MG 0.11703 03/03/2017 0.08055 08/17/2018 TACROLIMUS ORAL CAPSULE 1 MG 0.18660 03/03/2017 0.13478 11/16/2018 TACROLIMUS ORAL CAPSULE 5 MG 0.39610 09/21/2018 5.46000 01/17/2020 TACROLIMUS TOPICAL OINTMENT (GRAM) 0.03 % 5.17608 11/24/2017 4.11000 12/20/2019 TACROLIMUS TOPICAL OINTMENT (GRAM) 0.1 % 4.83523 06/16/2017 4.83523 11/24/2017 TADALAFIL ORAL TABLET 10 MG 1.05000 06/21/2019 TADALAFIL ORAL TABLET 20 MG 1.05000 06/21/2019 0.42967 08/16/2019 TADALAFIL ORAL TABLET 5 MG 0.43700 08/16/2019 0.28400 01/24/2020 TAMOXIFEN CITRATE ORAL TABLET 10 MG 0.24955 08/21/2015 0.15000 11/24/2017 TAMOXIFEN CITRATE ORAL TABLET 20 MG 0.29980 12/20/2019 0.24500 04/17/2020 TAMSULOSIN HCL ORAL CAPSULE 0.4 MG 0.09815 11/24/2017 0.06065 11/16/2018 TEA TREE OIL TOPICAL OIL (ML) 100 % 0.25509 08/12/2014 TELMISARTAN 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 TEMOZOLOMIDE ORAL CAPSULE 100 MG 96.94428 10/28/2016 42.23000 09/21/2018 TEMOZOLOMIDE ORAL CAPSULE 140 MG 128.55828 07/29/2016 TEMOZOLOMIDE ORAL CAPSULE 180 MG 139.03357 07/29/2016 127.00000 09/22/2017 TEMOZOLOMIDE ORAL CAPSULE 20 MG 21.53000 07/29/2016 TEMOZOLOMIDE ORAL CAPSULE 250 MG 241.19000 07/29/2016 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 TERCONAZOLE 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 14.40000 11/20/2019 15.27368 01/22/2020 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 (ML) 30.27570 01/25/2013 30.27570 08/21/2015 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 TETRACYCLINE HCL MISCELLANEOUS POWDER (GRAM) 0.66757 05/01/2015 0.66757 08/21/2015 TETRACYCLINE HCL ORAL CAPSULE 250 MG 4.62950 08/21/2015 3.20000 09/21/2018 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 2.02220 05/20/2016 1.53533 12/22/2017 TIZANIDINE HCL ORAL TABLET 2 MG 0.02233 11/16/2018 0.07180 04/07/2020 TIZANIDINE HCL ORAL TABLET 4 MG 0.06003 08/21/2015 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 TOLNAFTATE 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 1.42833 09/20/2019 1.23116 03/20/2020 TOLTERODINE TARTRATE ORAL CAPSULE, EXT RELEASE 24 HR 4 MG 1.60520 10/19/2018 1.12667 05/17/2019 TOLTERODINE TARTRATE ORAL TABLET 1 MG 0.72917 11/16/2018 0.43100 11/15/2019 TOLTERODINE TARTRATE ORAL TABLET 2 MG 0.65000 08/25/2017 0.58475 05/17/2019 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 0.04470 08/21/2015 0.02750 06/16/2017 TOPIRAMATE ORAL TABLET 50 MG 0.05968 08/21/2015 0.03750 09/22/2017 TOPOTECAN HCL INTRAVENOUS VIAL (EA) 4 MG 81.26200 01/23/2015 81.26200 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 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 TRAMADOL 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 1.65067 05/25/2018 1.49967 03/20/2020 TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 200 MG 4.20992 08/21/2015 1.30933 09/22/2017 TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 4.04500 09/30/2016 3.23534 06/16/2017 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 REL 3.70321 05/01/2015 BIPHASE 24HR 1MG-240 MG TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND REL 3.70321 05/01/2015 BIPHASE 24HR 2 MG-180MG TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND REL 3.70321 05/01/2015 BIPHASE 24HR 2MG-240 MG TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND REL 3.70321 05/01/2015 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 1.72100 02/22/2019 1.07400 05/17/2019 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 TRAZODONE HCL ORAL TABLET 100 MG 0.10300 04/20/2016 0.06178 07/14/2017 TRAZODONE HCL ORAL TABLET 150 MG 0.13590 02/22/2019 0.08990 03/20/2020 TRAZODONE HCL ORAL TABLET 300 MG 2.76314 08/21/2015 2.19000 10/19/2018 TRAZODONE HCL ORAL TABLET 50 MG 0.08541 10/02/2015 0.03200 08/25/2017 TRETINOIN ORAL CAPSULE 10 MG 18.81170 12/05/2014 TRETINOIN TOPICAL CREAM (GRAM) 0.025 % 2.08949 03/20/2020 2.39910 03/30/2020 TRETINOIN TOPICAL CREAM (GRAM) 0.05 % 3.20000 10/25/2019 3.60262 03/23/2020 TRETINOIN TOPICAL CREAM (GRAM) 0.1 % 4.55930 04/01/2019 3.89489 07/26/2019 TRETINOIN TOPICAL GEL (GRAM) 0.01 % 1.51858 04/01/2019 3.77480 10/08/2019 TRETINOIN TOPICAL GEL (GRAM) 0.025 % 3.33916 08/19/2019 2.89600 03/20/2020 TRIAMCINOLONE ACETONIDE DENTAL PASTE (GRAM) 0.1 % 5.58000 12/21/2018 5.19600 03/20/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 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 % 0.05888 06/16/2017 0.04281 01/25/2019 TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.5 % 0.33419 07/14/2017 0.31333 10/25/2019 TRIAMCINOLONE ACETONIDE TOPICAL LOTION (ML) 0.025 % 0.76647 08/12/2014 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 02/20/2015 0.11910 08/21/2015 TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.5 % 0.38333 06/21/2019 0.35000 03/20/2020 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 % 21.31330 07/09/2018 21.91752 04/15/2019 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 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date UREA/HYALURONATE SODIUM KIT 40%-0.2% 282.72300 01/25/2013 URSODIOL MISCELLANEOUS POWDER (GRAM) 100 % 1.52880 08/21/2015 URSODIOL ORAL CAPSULE 300 MG 1.28215 08/16/2019 0.79510 09/20/2019 URSODIOL ORAL TABLET 250 MG 0.89760 10/15/2018 0.71540 01/24/2020 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 19.10000 09/22/2017 5.24417 11/15/2019 VALPROIC ACID (AS SODIUM SALT) (VALPROATE 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 0.01420 05/17/2013 0.01897 02/14/2020 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 0.57111 09/03/2019 0.46207 11/15/2019 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 160-25MG 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 0.20933 12/22/2017 0.43524 12/19/2019 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 2.25000 11/16/2018 2.10033 02/21/2020 VANCOMYCIN HCL ORAL CAPSULE 250 MG 7.23600 11/24/2017 6.49950 05/17/2019 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 0.14709 03/02/2018 0.14250 07/26/2019 VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 37.5 MG 0.11800 10/20/2017 0.10578 01/19/2018 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 0.21218 08/17/2018 0.09980 08/16/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 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 25 MG 0.19030 08/25/2017 0.11520 11/16/2018 VENLAFAXINE HCL ORAL TABLET 37.5 MG 0.14520 08/17/2018 0.11380 07/26/2019 VENLAFAXINE HCL ORAL TABLET 50 MG 0.23880 09/22/2017 0.14160 08/17/2018 VENLAFAXINE HCL ORAL TABLET 75 MG 0.12000 07/14/2017 0.09780 12/22/2017 VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 150 MG 3.19458 08/21/2015 2.62298 12/02/2016 VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 225 MG 5.77550 01/09/2015 7.38620 12/11/2018 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 3.51130 03/27/2015 4.74492 12/31/2019 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 08/12/2014 0.05600 08/21/2015 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 VITAMIN A/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/LYSINE ORAL LIQUID (ML) 790MG/15ML 0.03270 01/25/2013 VITAMIN E (DL-ALPHA TOCOPHERYL ACETATE) ORAL CAPSULE 400 UNIT 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 VITAMINS A AND D/WHITE PETROLATUM/LANOLIN TOPICAL OINTMENT IN 0.03450 08/12/2014 PACKET (GRAM) VORICONAZOLE INTRAVENOUS VIAL (EA) 200 MG 44.58750 08/12/2014 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 0.13000 01/19/2018 0.11277 08/16/2019 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 0.20206 08/21/2015 0.10000 08/16/2019 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 ZAFIRLUKAST 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 0.24250 10/25/2019 0.22400 12/20/2019 ZIPRASIDONE HCL ORAL CAPSULE 40 MG 0.39000 11/16/2018 0.26000 12/21/2018 ZIPRASIDONE HCL ORAL CAPSULE 60 MG 0.43250 06/22/2018 0.24917 05/17/2019 ZIPRASIDONE HCL ORAL CAPSULE 80 MG 0.37425 09/20/2019 0.28483 03/20/2020 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 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 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 ZOLMITRIPTAN ORAL TABLET,DISINTEGRATING 2.5 MG 7.56000 06/16/2017 5.64000 06/22/2018 ZOLMITRIPTAN ORAL TABLET,DISINTEGRATING 5 MG 5.50481 06/16/2017 3.89667 09/22/2017 ZOLPIDEM TARTRATE ORAL TABLET 10 MG 0.02680 03/27/2015 0.02680 08/21/2015 ZOLPIDEM TARTRATE ORAL TABLET 5 MG 0.02680 03/13/2015 0.02680 08/21/2015 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 0.14126 04/05/2019 0.10150 03/20/2020 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