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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.
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    DUAVEE® (Conjugated Estrogens-Bazedoxifene) Oral Tablet

    PHARMACY COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 11/17/2016 SECTION: DRUGS LAST REVIEW DATE: 11/19/2020 LAST CRITERIA REVISION DATE: 11/19/2020 ARCHIVE DATE: DUAVEE® (conjugated estrogens-bazedoxifene) oral tablet Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. This Pharmacy Coverage Guideline provides information related to coverage determinations only and does not imply that a service or treatment is clinically appropriate or inappropriate. The provider and the member are responsible for all decisions regarding the appropriateness of care. Providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines. The section identified as “Description” defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as “Criteria” defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Pharmacy Coverage Guidelines are subject to change as new information becomes available. For purposes of this Pharmacy Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable.
  • Bioidentical Hormones: an Evidence-Based Review for Primary Care Providers

    Bioidentical Hormones: an Evidence-Based Review for Primary Care Providers

    REVIEW Bioidentical Hormones: An Evidence-Based Review for Primary Care Providers Eileen Conaway, DO Context: Since 2002, when the US Food and Drug Adminis - combination with estrogen for the management of vasomotor tration (FDA) placed a black box warning on women’s hor - symptoms. Dehydroepiandrosterone is not FDA approved, mone replacement products, women and their providers but small-scale studies indicate it may improve bone min - have been struggling with whether to proceed with hormone eral density. Data are conflicting about efficacy in improving replacement therapy. Out of the controversy has grown a sexual dysfunction. There is an abundance of misleading popular movement promoting the use of bioidentical hor - information available in the media and on the Internet for mones. Many providers are still unsure if they want to rec - our patients. Compounded bioidenticals and salivary hor - ommend these products and, if so, how to use them appro - mone testing are unnecessary, are not standardized, and priately. should be avoided. Objective: To inform primary care providers (eg, physicians, Conclusion: Bioidentical hormones that are approved by the physician assistants, nurse practitioners) about current data on FDA may be preferred over standard hormone replacement the safety and efficacy of bioidentical hormone replacement because of their physiologic benefits and safety profile. therapy and to provide a context for patient perceptions. J Am Osteopath Assoc . 2011;111(3):153-164 Methods: Literature published between 1999 and 2009 was reviewed through MD Consult’s Medline and Ovid search n the aftermath of the unexpected adverse results of the engines. A Google search of popular media was also per - IWomen’s Health Initiative (WHI) trial 1 in 2002, women formed using the same terms.
  • Recent Advances in the Analysis of Steroid Hormones and Related Drugs

    Recent Advances in the Analysis of Steroid Hormones and Related Drugs

    ANALYTICAL SCIENCES MAY 2004, VOL. 20 767 2004 © The Japan Society for Analytical Chemistry Reviews Recent Advances in the Analysis of Steroid Hormones and Related Drugs Sándor GÖRÖG Gedeon Richter Ltd., P.O.B. 27, H-1475 Budapest, Hungary The development during the last 15 years and the state-of-the-art in the analysis of bulk steroid hormone drugs and hormone-like structures and pharmaceutical formulations made thereof are summarized. Other steroids (sterols, bile acids, cardiac glycosides, vitamins D) as well as biological-clinical aspects and pharmacokinetic and metabolic studies are excluded from this review. The state-of-the-art is summarized based on comparisons of monographs in the latest editions of the European Pharmacopoeia, United States Pharmacopoeia and the Japanese Pharmacopoeia. This is followed by sections dealing with new developments in the methodology for the fields of spectroscopic and spectrophotometric, chromatographic, electrophoretic and hyphenated techniques as well electroanalytical methods. The review is terminated by two problem-oriented sections: examples on impurity and degradation profiling as well as enantiomeric analysis. (Received January 14, 2004; Accepted February 2, 2004) 1 Introduction 767 4·3 Supercritical fluid chromatography (SFC) 2 Steroid Hormone Drugs in Pharmacopoeias 768 4·4 High-performance liquid chromatography 2·1 Assay of bulk drug materials (HPLC) and HPLC-MS 2·2 Related impurities test of bulk drug materials 5 Electrophoretic and Related Methods 776 2·3 Assay of steroid hormone formulations