Dear Provider,

Washington Apple Health (Medicaid), administered by the Health Care Authority (agency), will implement the following changes to the State Maximum Allowable Costs (SMAC) list for the fee-for-service (FFS) Prescription Drug Program:

MAC Additions MAC Generic Name Strength Form Effective 01/01/2019 DEXMETHYLPHENIDATE HCL 5 MG CAP ER 24 HR $3.77590 DEXMETHYLPHENIDATE HCL 10 MG CAP ER 24 HR $5.49370 DEXMETHYLPHENIDATE HCL 20 MG CAP ER 24 HR $5.30870 LEVETIRACETAM 250 MG TABLET $0.09508 LEVETIRACETAM 500 MG TABLET $0.10483 LEVETIRACETAM 750 MG TABLET $0.18100 MAC Adjustments MAC Generic Name Strength Form Effective 01/01/2019 AMOXICILLIN & K CLAVULANATE 400-57 MG CHEW TAB $2.99600 AMOXICILLIN & K CLAVULANATE 500-125 MG TABLET $0.40250 AMOXICILLIN & K CLAVULANATE 875-125 MG TABLET $0.38950 AMOXICILLIN & K CLAVULANATE 200-28.5 MG/5ML SUSP RECON $0.11930 AMOXICILLIN & K CLAVULANATE 250-62.5 MG/5ML SUSP RECON $0.46250 AMOXICILLIN & K CLAVULANATE 400-57 MG/5ML SUSP RECON $0.10840 AMOXICILLIN & K CLAVULANATE 600-42.9 MG/5ML SUSP RECON $0.11040 AMPHETAMINE-DEXTROAMPHETAMINE 5 MG TABLET $0.55650 AMPHETAMINE-DEXTROAMPHETAMINE 7.5 MG TABLET $0.99100 AMPHETAMINE-DEXTROAMPHETAMINE 10 MG TABLET $0.47210 AMPHETAMINE-DEXTROAMPHETAMINE 12.5 MG TABLET $0.99100 AMPHETAMINE-DEXTROAMPHETAMINE 15 MG TABLET $0.62100 AMPHETAMINE-DEXTROAMPHETAMINE 20 MG TABLET $0.55650 AMPHETAMINE-DEXTROAMPHETAMINE 30 MG TABLET $0.55650 CHLORHEXIDINE GLUCONATE 0.12% SOLUTION $0.01052 CLONIDINE HCL 0.1 MG TABLET $0.04000 CLONIDINE HCL 0.2 MG TABLET $0.05000 CLONIDINE HCL 0.3 MG TABLET $0.08180 CLONIDINE TD 0.1 MG/24HR PATCH WEEKLY $14.61730 CLONIDINE TD 0.2 MG/24HR PATCH WEEKLY $17.27510 CLONIDINE TD 0.3 MG/24HR PATCH WEEKLY $21.31500 CYCLOSPORINE (OPHTH) 0.05% EMULSION $8.45490

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DEXMETHYLPHENIDATE HCL 15 MG CAP ER 24 HR $4.27280 DEXMETHYLPHENIDATE HCL 25 MG CAP ER 24 HR $3.38330 DEXMETHYLPHENIDATE HCL 30 MG CAP ER 24 HR $4.94350 DEXMETHYLPHENIDATE HCL 35 MG CAP ER 24 HR $3.90310 DEXMETHYLPHENIDATE HCL 40 MG CAP ER 24 HR $5.88770 DEXMETHYLPHENIDATE HCL 2.5 MG TABLET $0.45130 DEXMETHYLPHENIDATE HCL 5 MG TABLET $0.56330 DEXMETHYLPHENIDATE HCL 10 MG TABLET $0.86940 HYDROCODONE-ACETAMINOPHEN 10-325 MG TABLET $0.14520 IPRATROPIUM-ALBUTEROL 0.5-2.5(3) MG/3ML NEBU SOLUTION $0.05944 KETOTIFEN FUMARATE 0.025% OPHTH SOLN $1.49800 LACTIC ACID (AMMONIUM LACTATE) 12% CREAM $0.04835 LACTIC ACID (AMMONIUM LACTATE) 12% LOTION $0.04828 LAMOTRIGINE 200 MG TABLET $0.08450 LEVETIRACETAM 1000 MG TABLET $0.32050 LEVETIRACETAM 500 MG TAB ER 24HR $0.36233 LEVETIRACETAM 750 MG TAB ER 24HR $0.65750 VANCOMYCIN HCL 125 MG CAPSULE $4.51550 VANCOMYCIN HCL 250 MG CAPSULE $6.79720

The full SMAC list can be found on the agency’s Provider billing guides and fee schedules website under the Prescription Drug Program and applies to claims billed FFS.

Thank you.

Medicaid Program Health Care Authority

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