West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 0.9 % SODIUM CHLORIDE PGY VL PRT 0.07096 0.07291 2/22/2013 0.9 % SODIUM CHLORIDE 0.9 % IV SOLN 0.00141 0.00165 12/27/2013 0.9 % SODIUM CHLORIDE 0.9 % VIAL 0.04800 0.05830 1/25/2013 ABACAVIR SULFATE 300 MG TABLET 6.27295 6.21453 9/6/2013 ACARBOSE 100 MG TABLET 0.50679 0.40200 7/12/2013 ACARBOSE 25 MG TABLET 0.46270 0.26023 1/3/2014 ACARBOSE 50 MG TABLET 0.35054 0.33353 1/3/2014 ACEBUTOLOL HCL 200 MG CAPSULE 0.21353 0.21350 12/14/2012 ACETAMINOPHEN 100 MG/ML DROPS 0.15340 0.11667 4/12/2013 ACETAMINOPHEN 120 MG SUPP.RECT 0.16289 0.19717 11/22/2013 ACETAMINOPHEN 160 MG/5ML ELIXIR 0.01968 0.01083 9/27/2013 ACETAMINOPHEN 160 MG/5ML LIQUID 0.01297 0.00932 9/27/2013 ACETAMINOPHEN 160 MG/5ML ORAL SUSP 0.02397 0.02412 5/24/2013 ACETAMINOPHEN 325 MG SUPP.RECT 0.00000 0.45850 12/1/2012 ACETAMINOPHEN 325 MG TABLET 0.00616 0.00830 1/25/2013 ACETAMINOPHEN 500 MG CAPSULE 0.02940 0.01093 5/17/2013 ACETAMINOPHEN 500 MG TABLET 0.00951 0.01093 5/17/2013 ACETAMINOPHEN 650 MG SUPP.RECT 0.21683 0.21680 12/14/2012 ACETAMINOPHEN 80 MG TAB CHEW 0.04850 0.04450 3/1/2013 ACETAMINOPHEN 80MG/0.8ML DROPS 0.27720 0.17160 4/19/2013 ACETAMINOPHEN WITH CODEINE 120-12MG/5 (5 ML) SOLUTION 0.00000 0.15890 12/1/2012 ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION 0.01490 0.01485 4/26/2013 ACETAMINOPHEN WITH CODEINE 300MG-15MG TABLET 0.14200 0.13111 1/10/2014 ACETAMINOPHEN WITH CODEINE 300MG-30MG TABLET 0.10638 0.10461 12/27/2013 ACETAMINOPHEN WITH CODEINE 300MG-60MG TABLET 0.22732 0.21863 1/24/2014 ACETAMINOPHEN WITH CODEINE 300MG/12.5 SOLUTION 0.04760 0.07496 3/1/2013 ACETAMINOPHEN/DIPHENHYDRAMINE 325-12.5MG TABLET 0.15370 0.15400 1/25/2013 ACETAMINOPHEN/DIPHENHYDRAMINE 500MG-25MG TABLET 0.03653 0.04181 9/6/2013 ACETAZOLAMIDE 125 MG TABLET 0.58123 1.52593 1/24/2014 ACETAZOLAMIDE 250 MG TABLET 1.55955 2.16264 1/24/2014 ACETAZOLAMIDE 500 MG CAPSULE ER 3.00454 3.00400 1/25/2013 ACETIC ACID 0.25 % IRRIG SOLN 0.00270 0.00350 3/1/2013 ACETIC ACID 2 % SOLUTION 1.75603 1.81591 6/28/2013 ACETIC ACID/ALUMINUM ACETATE 2 % DROPS 0.00000 0.84000 12/1/2012 ACETIC ACID/HYDROCORTISONE 2 %-1 % DROPS 0.00000 9.82215 12/1/2012 ACETYL/METHYL-B12/LMEFOLATE CA 600-2-6 MG TABLET 1.86527 1.23520 1/25/2013 ACETYLCYSTEINE 100 MG/ML VIAL 0.45068 0.35253 8/9/2013 ACETYLCYSTEINE 200 MG/ML VIAL 0.00000 5.26400 12/1/2012 ACITRETIN 10 MG CAPSULE 0.00000 21.82892 8/2/2013 ACITRETIN 17.5 MG CAPSULE 0.00000 26.92153 8/2/2013 ACITRETIN 25 MG CAPSULE 26.90660 23.63130 11/8/2013 ACYCLOVIR 200 MG CAPSULE 0.09460 0.09058 8/16/2013 ACYCLOVIR 200 MG/5ML ORAL SUSP 0.16775 0.16913 5/31/2013 ACYCLOVIR 400 MG TABLET 0.00000 0.11107 1/17/2014 ACYCLOVIR 5 % OINT. (G) 18.13435 18.17113 12/13/2013 ACYCLOVIR 800 MG TABLET 0.25266 0.24713 1/31/2014 ACYCLOVIR SODIUM 1000 MG VIAL 7.68600 9.04800 1/25/2013 ACYCLOVIR SODIUM 50 MG/ML VIAL 0.00000 2.85501 12/1/2012 ADAPALENE 0.1 % CREAM (G) 3.66909 3.51289 4/26/2013 ADAPALENE 0.1 % GEL (GRAM) 0.00000 3.05760 12/1/2012 ADEFOVIR DIPIVOXIL 10 MG TABLET 0.00000 26.52627 9/27/2013 ALBUMIN HUMAN 25 % IV SOLN 0.90300 0.91240 1/25/2013 ALBUMIN HUMAN 25 % VIAL 1.54350 1.51200 7/26/2013 ALBUMIN HUMAN 5 % IV SOLN 0.21150 0.21000 1/17/2014 ALBUTEROL SULFATE 0.63MG/3ML VIAL-NEB 0.00000 0.37527 12/1/2012 ALBUTEROL SULFATE 1.25MG/3ML VIAL-NEB 0.37674 0.37242 11/15/2013 ALBUTEROL SULFATE 2 MG TABLET 0.14470 4.56651 5/3/2013

Page 1 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 ALBUTEROL SULFATE 2 MG/5 ML SYRUP 0.01260 0.01277 5/24/2013 ALBUTEROL SULFATE 2.5 MG/0.5 VIAL-NEB 0.63406 0.64655 11/22/2013 ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB 0.05117 0.05506 1/17/2014 ALBUTEROL SULFATE 4 MG TAB ER 12H 0.98160 1.04048 7/26/2013 ALBUTEROL SULFATE 4 MG TABLET 0.21051 4.56651 5/3/2013 ALBUTEROL SULFATE 5 MG/ML SOLUTION 0.58175 0.72066 10/18/2013 ALBUTEROL SULFATE 8 MG TAB ER 12H 1.84058 1.71821 4/5/2013 ALCLOMETASONE DIPROPIONATE 0.05 % CREAM (G) 0.56410 1.30908 6/21/2013 ALCLOMETASONE DIPROPIONATE 0.05 % OINT. (G) 0.58690 0.58692 6/28/2013 ALENDRONATE SODIUM 10 MG TABLET 0.18747 0.18750 12/14/2012 ALENDRONATE SODIUM 35 MG TABLET 0.64320 0.63650 1/24/2014 ALENDRONATE SODIUM 40 MG TABLET 6.63531 6.63530 12/14/2012 ALENDRONATE SODIUM 5 MG TABLET 0.18150 0.18110 1/25/2013 ALENDRONATE SODIUM 70 MG TABLET 0.71360 0.69010 1/25/2013 ALENDRONATE SODIUM 70 MG/75ML SOLUTION 0.00000 2.45700 9/27/2013 ALFUZOSIN HCL 10 MG TAB ER 24H 0.21554 0.22634 6/21/2013 ALLOPURINOL 100 MG TABLET 0.03688 0.03388 8/23/2013 ALLOPURINOL 300 MG TABLET 0.06151 0.05850 10/11/2013 ALPHA LIPOIC ACID 200 MG CAPSULE 0.10000 0.09998 8/2/2013 ALPHA LIPOIC ACID 50 MG CAPSULE 0.04900 0.10210 1/25/2013 ALPRAZOLAM 0.25 MG TAB RAPDIS 1.28921 1.36123 3/1/2013 ALPRAZOLAM 0.25 MG TABLET 0.01540 0.01509 6/14/2013 ALPRAZOLAM 0.5 MG TAB ER 24H 0.33260 0.57218 6/28/2013 ALPRAZOLAM 0.5 MG TAB RAPDIS 0.00000 1.51669 12/1/2012 ALPRAZOLAM 0.5 MG TABLET 0.01814 0.01777 6/14/2013 ALPRAZOLAM 1 MG TAB ER 24H 0.43080 0.44913 6/28/2013 ALPRAZOLAM 1 MG TAB RAPDIS 0.00000 2.02358 12/1/2012 ALPRAZOLAM 1 MG TABLET 0.02010 0.01970 6/14/2013 ALPRAZOLAM 2 MG TAB ER 24H 0.57960 0.41600 6/28/2013 ALPRAZOLAM 2 MG TAB RAPDIS 0.00000 3.00202 12/1/2012 ALPRAZOLAM 2 MG TABLET 0.04087 0.04007 6/14/2013 ALPRAZOLAM 3 MG TAB ER 24H 0.79700 0.79340 1/25/2013 ALUM/SALICYLIC ACID/TALC/BENT POWDER 0.06733 0.06740 1/25/2013 AMANTADINE HCL 100 MG CAPSULE 0.00000 1.36390 12/1/2012 AMANTADINE HCL 100 MG TABLET 1.45925 1.59829 4/12/2013 AMANTADINE HCL 50 MG/5 ML SYRUP 0.01740 0.01970 1/25/2013 AMCINONIDE 0.1 % CREAM (G) 3.29673 2.82140 1/25/2013 AMCINONIDE 0.1 % LOTION 3.80018 1.90000 1/25/2013 AMCINONIDE 0.1 % OINT. (G) 2.26800 4.53600 8/30/2013 AMIKACIN SULFATE 1000MG/4ML VIAL 2.74505 3.26100 11/15/2013 AMIKACIN SULFATE 500 MG/2ML VIAL 1.62705 2.81400 7/5/2013 AMILORIDE HCL 5 MG TABLET 0.60351 0.54422 12/20/2013 AMILORIDE/HYDROCHLOROTHIAZIDE 5MG-50MG TABLET 0.24680 0.25763 3/1/2013 AMINO ACIDS POWDER 0.53784 0.25540 1/25/2013 AMINOCAPROIC ACID 1000 MG TABLET 16.95015 18.30610 12/21/2012 AMINOCAPROIC ACID 250 MG/ML SOLUTION 1.24998 2.81233 6/14/2013 AMINOCAPROIC ACID 250 MG/ML VIAL 0.00000 0.08148 8/16/2013 AMINOCAPROIC ACID 500 MG TABLET 2.10790 5.37896 10/11/2013 AMINOPHYLLINE 250MG/10ML AMPUL 0.05712 0.05540 1/25/2013 AMINOPHYLLINE 250MG/10ML VIAL 0.10836 0.10840 1/25/2013 AMINOPHYLLINE 500MG/20ML VIAL 0.07266 0.07270 1/25/2013 AMIODARONE HCL 100 MG TABLET 0.00000 5.20077 8/16/2013 AMIODARONE HCL 200 MG TABLET 0.16280 0.15276 8/16/2013 AMIODARONE HCL 400 MG TABLET 3.85907 3.56070 8/30/2013 AMIODARONE HCL 50 MG/ML AMPUL 0.27720 0.33600 1/25/2013 AMITRIP HCL/CHLORDIAZEPOXIDE 12.5MG-5MG TABLET 0.77870 0.82537 1/3/2014 AMITRIP HCL/CHLORDIAZEPOXIDE 25 MG-10MG TABLET 1.09858 1.16452 8/2/2013

Page 2 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 AMITRIPTYLINE HCL 10 MG TABLET 0.01919 0.01972 4/26/2013 AMITRIPTYLINE HCL 100 MG TABLET 0.05051 0.05278 5/10/2013 AMITRIPTYLINE HCL 150 MG TABLET 0.10760 0.10451 4/19/2013 AMITRIPTYLINE HCL 25 MG TABLET 0.02023 0.01946 12/13/2013 AMITRIPTYLINE HCL 50 MG TABLET 0.02396 0.02578 4/26/2013 AMITRIPTYLINE HCL 75 MG TABLET 0.04341 0.04596 3/29/2013 AMLODIPINE BESYLATE 10 MG TABLET 0.02533 0.02526 5/31/2013 AMLODIPINE BESYLATE 2.5 MG TABLET 0.01983 0.05960 11/8/2013 AMLODIPINE BESYLATE 5 MG TABLET 0.02125 0.06240 11/8/2013 AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-20MG CAPSULE 0.84835 0.48320 1/17/2014 AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-40MG CAPSULE 0.98222 0.97472 1/3/2014 AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG CAPSULE 1.14784 0.80360 12/27/2013 AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-10 MG CAPSULE 0.81700 0.47840 1/17/2014 AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-20 MG CAPSULE 0.82477 0.49990 1/24/2014 AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-40 MG CAPSULE 0.00000 0.80695 12/1/2012 AMLODIPINE/ATORVASTATIN 10 MG-10MG TABLET 3.52613 4.42173 12/6/2013 AMLODIPINE/ATORVASTATIN 10 MG-20MG TABLET 6.09134 6.55993 1/31/2014 AMLODIPINE/ATORVASTATIN 10 MG-40MG TABLET 6.09134 6.55993 1/31/2014 AMLODIPINE/ATORVASTATIN 10 MG-80MG TABLET 6.09134 6.55993 1/31/2014 AMLODIPINE/ATORVASTATIN 2.5MG-10MG TABLET 3.52621 3.52616 2/22/2013 AMLODIPINE/ATORVASTATIN 2.5MG-20MG TABLET 4.82421 4.82420 2/22/2013 AMLODIPINE/ATORVASTATIN 2.5MG-40MG TABLET 4.82417 4.82420 1/25/2013 AMLODIPINE/ATORVASTATIN 5 MG-10 MG TABLET 0.00000 3.52617 12/1/2012 AMLODIPINE/ATORVASTATIN 5 MG-20 MG TABLET 5.75881 6.09134 12/6/2013 AMLODIPINE/ATORVASTATIN 5 MG-40 MG TABLET 6.09134 6.55993 1/31/2014 AMLODIPINE/ATORVASTATIN 5 MG-80 MG TABLET 6.09134 6.55993 1/31/2014 AMMONIUM ALUM/TALC/BENTONITE POWDER 0.07538 0.07530 1/25/2013 AMMONIUM CHLORIDE 5 MEQ/ML VIAL 0.28522 0.42630 1/25/2013 AMMONIUM LACTATE 12 % CREAM (G) 0.03670 0.04307 10/25/2013 AMMONIUM LACTATE 12 % LOTION 0.01942 0.02596 11/8/2013 AMOXAPINE 100 MG TABLET 0.72280 1.16865 11/22/2013 AMOXAPINE 150 MG TABLET 0.00000 1.28830 12/1/2012 AMOXAPINE 25 MG TABLET 0.00000 0.27027 12/1/2012 AMOXAPINE 50 MG TABLET 0.40850 0.69923 11/22/2013 AMOXICILLIN 125 MG TAB CHEW 0.00000 0.15067 12/1/2012 AMOXICILLIN 125 MG/5ML SUSP RECON 0.01843 0.01662 8/16/2013 AMOXICILLIN 200 MG/5ML SUSP RECON 0.02734 0.05684 11/22/2013 AMOXICILLIN 250 MG CAPSULE 0.05826 0.05499 7/12/2013 AMOXICILLIN 250 MG/5ML SUSP RECON 0.02171 0.02144 11/29/2013 AMOXICILLIN 400 MG/5ML SUSP RECON 0.02841 0.02693 8/16/2013 AMOXICILLIN 500 MG CAPSULE 0.08911 0.08769 12/13/2013 AMOXICILLIN 500 MG TABLET 0.00000 0.28243 12/1/2012 AMOXICILLIN 875MG TABLET 0.18412 0.13400 7/12/2013 AMOXICILLIN/POTASSIUM CLAV 1000-62.5 TAB ER 12H 2.58600 2.71530 2/8/2013 AMOXICILLIN/POTASSIUM CLAV 200-28.5/5 SUSP RECON 0.10748 0.10111 11/29/2013 AMOXICILLIN/POTASSIUM CLAV 200-28.5MG TAB CHEW 0.96700 1.00222 3/1/2013 AMOXICILLIN/POTASSIUM CLAV 400-57MG TAB CHEW 1.40043 1.40040 12/14/2012 AMOXICILLIN/POTASSIUM CLAV 400-57MG/5 SUSP RECON 0.15756 0.15075 8/30/2013 AMOXICILLIN/POTASSIUM CLAV 500-125 MG TABLET 0.91520 0.97150 10/11/2013 AMOXICILLIN/POTASSIUM CLAV 600-42.9/5 SUSP RECON 0.00000 0.21300 12/1/2012 AMOXICILLIN/POTASSIUM CLAV 875-125 MG TABLET 1.03113 0.90030 5/10/2013 AMPHOTERICIN B 50 MG VIAL 12.76000 15.22500 8/2/2013 AMPICILLIN SODIUM 1 G VIAL 0.00000 2.89120 12/1/2012 AMPICILLIN SODIUM 1 G VIAL PORT 12.52460 12.17907 8/9/2013 AMPICILLIN SODIUM 10 G VIAL 0.00000 40.47315 12/1/2012 AMPICILLIN SODIUM 125 MG VIAL 3.65400 3.50250 1/25/2013 AMPICILLIN SODIUM 2 G VIAL 4.95820 6.57000 11/8/2013

Page 3 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 AMPICILLIN SODIUM 2 G VIAL PORT 0.00000 23.62640 12/1/2012 AMPICILLIN SODIUM 250 MG VIAL 0.00000 1.41638 12/1/2012 AMPICILLIN SODIUM 500 MG VIAL 0.00000 1.62006 12/1/2012 AMPICILLIN SODIUM/SULBACTAM NA 1.5 G VIAL 2.56744 3.10147 8/9/2013 AMPICILLIN SODIUM/SULBACTAM NA 1.5 G VIAL PORT 0.00000 3.24240 1/11/2013 AMPICILLIN SODIUM/SULBACTAM NA 15 G VIAL 21.31500 20.70600 4/5/2013 AMPICILLIN SODIUM/SULBACTAM NA 3 G VIAL 4.27310 6.47640 8/9/2013 AMPICILLIN SODIUM/SULBACTAM NA 3 G VIAL PORT 0.00000 5.22060 1/11/2013 AMPICILLIN TRIHYDRATE 125 MG/5ML SUSP RECON 0.03530 0.03950 2/8/2013 AMPICILLIN TRIHYDRATE 250 MG CAPSULE 0.08999 0.09000 12/14/2012 AMPICILLIN TRIHYDRATE 250 MG/5ML SUSP RECON 0.05200 0.06860 2/8/2013 AMPICILLIN TRIHYDRATE 500 MG CAPSULE 0.00000 0.14370 12/1/2012 ANAGRELIDE HCL 0.5 MG CAPSULE 0.00000 0.22620 12/1/2012 ANAGRELIDE HCL 1 MG CAPSULE 0.43732 0.43730 12/14/2012 ANASTROZOLE 1 MG TABLET 0.15142 0.15140 12/14/2012 ANTIPYRINE/BENZOCAINE 5.5 %-1.4% DROPS 0.00000 10.43970 5/24/2013 ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4 %-1.4% DROPS 0.56723 0.53842 12/20/2013 ANTIVENIN,LATRODECTUS MACTANS COMBO. PKG 0.00000 28.66500 12/1/2012 ANTIVENIN,MICRURUS FULVIUS COMBO. PKG 0.00000 1,496.32000 12/1/2012 APRACLONIDINE HCL 0.5 % DROPS 0.00000 12.32550 12/1/2012 ARGATROBAN 100 MG/ML VIAL 1,319.78700 1,124.62000 1/25/2013 ARGATROBAN IN 0.9 % SOD CHLOR 125 MG/125 VIAL 0.00000 11.61817 12/1/2012 ARGATROBAN IN NACL,ISO-OSMOTIC 50 MG/50ML VIAL 6.73915 3.85000 10/4/2013 ARGININE 500 MG CAPSULE 0.08060 0.08386 3/8/2013 ARGININE HCL 1000 MG TABLET 0.13360 0.14760 4/26/2013 ASCORBIC ACID 1000 MG TABLET 0.04930 0.04855 5/24/2013 ASCORBIC ACID 1000 MG TABLET ER 0.07153 0.07311 4/5/2013 ASCORBIC ACID 250 MG TAB CHEW 0.02522 0.02510 1/25/2013 ASCORBIC ACID 250 MG TABLET 0.01670 0.01807 6/21/2013 ASCORBIC ACID 500 MG TAB CHEW 0.04453 0.04768 11/1/2013 ASCORBIC ACID 500 MG TABLET 0.02280 0.02550 5/17/2013 ASPIRIN 325 MG TABLET 0.00800 0.00804 3/22/2013 ASPIRIN 325 MG TABLET DR 0.00858 0.01214 5/17/2013 ASPIRIN 81 MG TAB CHEW 0.02198 0.02502 11/1/2013 ASPIRIN 81 MG TABLET DR 0.00981 0.01026 12/13/2013 ASPIRIN/ACETAMINOPHEN/CAFFEINE 250-250-65 TABLET 0.07609 0.04476 11/8/2013 ASPIRIN/SOD BICARB/CITRIC ACID 325-1916MG TABLET EFF 0.07967 0.09644 3/8/2013 ATENOLOL 100 MG TABLET 0.00000 0.03400 12/1/2012 ATENOLOL 25 MG TABLET 0.01321 0.01323 1/24/2014 ATENOLOL 50 MG TABLET 0.01514 0.01640 3/15/2013 ATENOLOL/CHLORTHALIDONE 100MG-25MG TABLET 0.16727 0.16099 5/31/2013 ATENOLOL/CHLORTHALIDONE 50 MG-25MG TABLET 0.10422 0.10097 7/12/2013 ATORVASTATIN CALCIUM 10 MG TABLET 0.00000 0.55680 12/1/2012 ATORVASTATIN CALCIUM 20 MG TABLET 0.00000 0.79430 12/1/2012 ATORVASTATIN CALCIUM 40 MG TABLET 0.00000 0.79430 12/1/2012 ATORVASTATIN CALCIUM 80 MG TABLET 0.00000 0.95320 12/1/2012 ATOVAQUONE/PROGUANIL HCL 250-100 MG TABLET 5.00297 5.06839 6/7/2013 ATOVAQUONE/PROGUANIL HCL 62.5-25 MG TABLET 0.00000 1.85045 12/1/2012 ATROPINE SULFATE 0.05MG/ML SYRINGE 0.00000 2.23272 12/1/2012 ATROPINE SULFATE 0.1 MG/ML SYRINGE 0.00000 0.43014 12/1/2012 ATROPINE SULFATE 0.4 MG/ML VIAL 1.02665 0.85480 1/25/2013 ATROPINE SULFATE 1 % DROPS 1.39710 1.76890 2/1/2013 ATROPINE SULFATE 1 % OINT. (G) 3.06200 3.98000 2/8/2013 ATROPINE SULFATE 1 MG/ML VIAL 1.48447 1.50320 1/25/2013 AZATHIOPRINE 50 MG TABLET 0.15392 0.32500 9/27/2013 AZATHIOPRINE SODIUM 100 MG VIAL 8.98980 10.56045 12/14/2012 AZELASTINE HCL 0.05 % DROPS 7.75667 8.70000 11/22/2013

Page 4 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 AZELASTINE HCL 137 MCG SPRAY/PUMP 2.45540 2.02162 9/20/2013 AZITHROMYCIN 1 G PACKET 13.46450 20.29440 1/17/2014 AZITHROMYCIN 100 MG/5ML SUSP RECON 0.83153 0.82854 10/18/2013 AZITHROMYCIN 200 MG/5ML SUSP RECON 0.00000 0.71130 1/25/2012 AZITHROMYCIN 250 MG TABLET 0.61198 0.61194 11/29/2013 AZITHROMYCIN 500 MG TABLET 1.78220 3.15413 8/30/2013 AZITHROMYCIN 500 MG VIAL 3.97150 4.90100 9/20/2013 AZITHROMYCIN 500 MG VIAL PORT 0.00000 12.68820 12/1/2012 AZITHROMYCIN 600 MG TABLET 3.25870 3.26560 5/17/2013 AZTREONAM 1 G VIAL 0.00000 27.67800 12/1/2012 AZTREONAM 2 G VIAL 0.00000 56.23800 12/1/2012 B COMPLEX WITH VITAMIN C TABLET 0.00000 0.02613 12/1/2012 B12/LEVOMEFOLATE CALCIUM/B-6 2-1.13-25 TABLET 0.00000 0.89950 9/27/2013 BACITRACIN 500 UNIT/G OINT. (G) OPHTHALMIC 0.00000 13.86800 12/1/2012 BACITRACIN 500 UNIT/G OINT. (G) TOPICAL 0.06785 0.06722 4/19/2013 BACITRACIN ZINC 500 UNIT/G OINT. (G) 0.00000 0.10720 12/1/2012 BACITRACIN/POLYMYXIN B SULFATE 500-10K/G OINT. (G) OPHTHALMIC 3.92600 5.41640 9/27/2013 BACITRACIN/POLYMYXIN B SULFATE 500-10K/G OINT. (G) TOPICAL 0.00000 0.27376 12/1/2012 BACLOFEN 10 MG TABLET 0.04451 0.04241 8/30/2013 BACLOFEN 100 % POWDER 2.85072 2.60135 10/25/2013 BACLOFEN 20 MG TABLET 0.08194 0.07625 8/16/2013 BALSALAZIDE DISODIUM 750 MG CAPSULE 0.23182 0.21733 11/29/2013 BCG LIVE 50 MG VIAL 0.00000 291.39600 12/1/2012 BENAZEPRIL HCL 10 MG TABLET 0.05028 0.04409 11/22/2013 BENAZEPRIL HCL 20 MG TABLET 0.05510 0.05507 4/19/2013 BENAZEPRIL HCL 40 MG TABLET 0.06940 0.06941 8/30/2013 BENAZEPRIL HCL 5 MG TABLET 0.04904 0.04900 12/14/2012 BENAZEPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.43692 1.44718 9/20/2013 BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.43705 1.44718 9/27/2013 BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.44373 1.44718 9/27/2013 BENZOCAINE/MENTHOL 15MG-3.6MG LOZENGE 0.09813 0.10645 4/19/2013 BENZONATATE 100 MG CAPSULE 0.09072 0.08915 1/31/2014 BENZONATATE 200 MG CAPSULE 0.00000 0.13306 12/1/2012 BENZOYL PEROXIDE 10 % CLEANSER 0.04190 0.04239 4/5/2013 BENZOYL PEROXIDE 10 % GEL (GRAM) 0.16212 0.19383 1/31/2014 BENZOYL PEROXIDE 2.5 % GEL (GRAM) 0.00000 0.23088 8/16/2013 BENZOYL PEROXIDE 5 % CLEANSER 0.04451 0.04075 8/9/2013 BENZOYL PEROXIDE 5 % GEL (GRAM) 0.18364 0.18360 12/14/2012 BENZOYL PEROXIDE 5.3% FOAM 0.00000 2.02384 12/1/2012 BENZOYL PEROXIDE 9.8 % FOAM 1.61098 1.60318 11/22/2013 BENZPHETAMINE HCL 50 MG TABLET 0.00000 0.47918 12/1/2012 BENZTROPINE MESYLATE 0.5 MG TABLET 0.15752 0.16160 9/27/2013 BENZTROPINE MESYLATE 1 MG TABLET 0.17702 0.16026 8/23/2013 BENZTROPINE MESYLATE 2 MG TABLET 0.22580 0.18065 8/23/2013 BENZTROPINE MESYLATE 2 MG/2 ML AMPUL 20.56250 23.40625 12/20/2013 BENZTROPINE MESYLATE 2 MG/2 ML VIAL 0.00000 40.39560 12/1/2012 BETAMET ACET/BETAMET NA PH 6 MG/ML VIAL 0.00000 5.60000 12/1/2012 BETAMETHASONE DIPROPIONATE 0.05 % CREAM (G) 1.51061 1.52911 1/24/2014 BETAMETHASONE DIPROPIONATE 0.05 % GEL (GRAM) 1.59404 1.21450 1/25/2013 BETAMETHASONE DIPROPIONATE 0.05 % LOTION 0.54284 0.53761 5/3/2013 BETAMETHASONE DIPROPIONATE 0.05 % OINT. (G) 1.63323 1.57591 3/29/2013 BETAMETHASONE VALERATE 0.1 % CREAM (G) 0.70387 0.78990 1/24/2014 BETAMETHASONE VALERATE 0.1 % LOTION 0.35000 0.79430 3/29/2013 BETAMETHASONE VALERATE 0.12 % FOAM 0.00000 2.71317 1/25/2013 BETAMETHASONE/PROPYLENE GLYC 0.05 % CREAM (G) 0.37466 0.31088 9/13/2013 BETAMETHASONE/PROPYLENE GLYC 0.05 % LOTION 0.70578 1.77637 8/16/2013 BETAXOLOL HCL 0.5 % DROPS 0.00000 7.27680 12/1/2012

Page 5 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 BETHANECHOL CHLORIDE 10 MG TABLET 0.42702 0.14220 12/27/2013 BETHANECHOL CHLORIDE 25 MG TABLET 0.16130 0.15650 4/12/2013 BETHANECHOL CHLORIDE 5 MG TABLET 0.24132 0.10666 1/24/2014 BETHANECHOL CHLORIDE 50 MG TABLET 0.32150 0.45410 2/8/2013 BICALUTAMIDE 50 MG TABLET 0.32321 0.30016 6/14/2013 BIOFLAV,LEMON/VIT BCOMP&C 200-100 MG TABLET 0.00000 0.14285 12/1/2012 BIOTIN 2500 MCG CAPSULE 0.08104 0.09390 1/25/2013 BISACODYL 10 MG SUPP.RECT 0.09487 0.09491 7/5/2013 BISACODYL 5 MG TABLET DR 0.00947 0.00996 6/21/2013 BISMUTH SUBSALICYLATE 262 MG TAB CHEW 0.06890 0.04558 5/3/2013 BISMUTH SUBSALICYLATE 262MG/15ML ORAL SUSP 0.00737 0.00882 6/21/2013 BISMUTH SUBSALICYLATE 525MG/15ML ORAL SUSP 0.01099 0.01100 6/14/2013 BISOPROLOL FUMARATE 10 MG TABLET 0.29168 0.64320 6/14/2013 BISOPROLOL FUMARATE 5 MG TABLET 0.29922 0.29172 4/12/2013 BISOPROLOL FUMARATE/HCTZ 10-6.25MG TABLET 0.06340 0.06060 1/25/2013 BISOPROLOL FUMARATE/HCTZ 2.5-6.25MG TABLET 0.05910 0.05829 4/19/2013 BISOPROLOL FUMARATE/HCTZ 5-6.25MG TABLET 0.00000 0.37000 12/1/2012 BRIMONIDINE TARTRATE 0.15 % DROPS 12.45300 13.44910 1/25/2013 BRIMONIDINE TARTRATE 0.2 % DROPS 0.58424 0.58420 12/14/2012 BROMFENAC SODIUM 0.09% DROPS 40.47120 42.65845 1/10/2014 BROMOCRIPTINE MESYLATE 2.5 MG TABLET 0.00000 1.07776 12/1/2012 BROMOCRIPTINE MESYLATE 5 MG CAPSULE 3.90067 6.51728 7/12/2013 BROMPHENIRAM/PHENYLEPHRINE/DM 1-2.5-5/5 SOLUTION 0.00000 0.02385 12/1/2012 BROMPHENIRAM/PHENYLEPHRINE/DM 4-10-20/5 LIQUID 0.00000 0.11830 12/1/2012 BROMPHENIRAM/PHENYLEPHRINE/DM 4-7.5-15/5 LIQUID 0.08550 0.09255 4/26/2013 BUDESONIDE 0.25MG/2ML AMPUL-NEB 3.02400 3.29490 2/22/2013 BUDESONIDE 0.5 MG/2ML AMPUL-NEB 3.55640 3.87765 2/22/2013 BUDESONIDE 3 MG CAPDR & ER 11.98525 11.98500 1/25/2013 BUMETANIDE 0.25 MG/ML VIAL 0.00000 0.26572 12/1/2012 BUMETANIDE 0.5 MG TABLET 0.08817 0.10865 5/17/2013 BUMETANIDE 1 MG TABLET 0.12197 0.12248 8/16/2013 BUMETANIDE 2 MG TABLET 0.09836 0.15169 6/7/2013 BUPIVACAINE HCL 2.5 MG/ML VIAL 0.04183 0.04200 1/25/2013 BUPIVACAINE HCL 5 MG/ML VIAL 0.00000 0.05090 12/1/2012 BUPIVACAINE HCL/EPINEPHRINE 0.25-.0005 VIAL 0.00000 0.12253 12/1/2012 BUPIVACAINE HCL/EPINEPHRINE 0.5-1:200K VIAL 0.00000 0.11900 12/1/2012 BUPIVACAINE HCL/EPINEPHRINE BI 0.5-1:200K CARTRIDGE 0.27533 0.26130 1/25/2013 BUPIVACAINE HCL/EPINEPHRINE/PF 0.25-.0005 VIAL 0.00000 0.27733 12/1/2012 BUPIVACAINE HCL/EPINEPHRINE/PF 0.5-1:200K VIAL 0.00000 0.25992 12/1/2012 BUPIVACAINE HCL/PF 2.5 MG/ML AMPUL 0.11788 0.11790 1/25/2013 BUPIVACAINE HCL/PF 2.5 MG/ML VIAL 0.06646 0.06390 1/24/2014 BUPIVACAINE HCL/PF 5 MG/ML AMPUL 0.08685 0.08690 1/25/2013 BUPIVACAINE HCL/PF 5 MG/ML VIAL 0.05100 0.06736 1/24/2014 BUPIVACAINE HCL/PF 7.5 MG/ML AMPUL 0.00000 0.10478 12/1/2012 BUPIVACAINE HCL/PF 7.5 MG/ML VIAL 0.14727 0.13428 1/24/2014 BUPRENORPHINE HCL 0.3 MG/ML SYRINGE 8.12070 12.18000 1/25/2013 BUPRENORPHINE HCL 2 MG TAB SUBL 1.64269 1.32704 1/24/2014 BUPRENORPHINE HCL 8 MG TAB SUBL 2.50094 2.48526 12/27/2013 BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG TAB SUBL 4.07645 4.07493 10/25/2013 BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG TAB SUBL 7.30150 7.30180 10/25/2013 BUPROPION HCL 100 MG TABLET 0.42760 0.34760 2/22/2013 BUPROPION HCL 100 MG TABLET ER 0.24656 0.24660 12/14/2012 BUPROPION HCL 150 MG TAB ER 24H 0.80110 0.64762 2/22/2013 BUPROPION HCL 150 MG TABLET ER (ANTIDEPRESSANTS) 0.28247 0.28186 5/3/2013 BUPROPION HCL 150 MG TABLET ER (SMOKING DETERRENT) 0.56248 0.58090 3/1/2013 BUPROPION HCL 200 MG TABLET ER 0.50360 0.48799 6/14/2013 BUPROPION HCL 300 MG TAB ER 24H 0.72940 0.71229 12/13/2013

Page 6 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 BUPROPION HCL 75 MG TABLET 0.00000 0.40820 12/1/2012 BUSPIRONE HCL 10 MG TABLET 0.07642 0.07584 9/13/2013 BUSPIRONE HCL 15 MG TABLET 0.09945 0.10768 6/14/2013 BUSPIRONE HCL 30 MG TABLET 0.54820 0.76395 7/12/2013 BUSPIRONE HCL 5 MG TABLET 0.04585 0.04543 11/8/2013 BUSPIRONE HCL 7.5 MG TABLET 1.84460 1.10621 8/16/2013 BUTALB/ACETAMINOPHEN/CAFFEINE 50-300-40 CAPSULE 1.71612 1.93130 1/31/2014 BUTALB/ACETAMINOPHEN/CAFFEINE 50-325-40 TABLET 0.00000 0.05990 12/1/2012 BUTALBIT/ACETAMIN/CAFF/CODEINE 50-300-30 CAPSULE 0.00000 3.59100 10/18/2013 BUTALBIT/ACETAMIN/CAFF/CODEINE 50-325-30 CAPSULE 0.28609 0.28610 12/14/2012 BUTALBITAL/ACETAMINOPHEN 50MG-325MG TABLET 0.26453 0.32318 1/31/2014 BUTALBITAL/ASPIRIN/CAFFEINE 50-325-40 CAPSULE 0.39703 0.43081 11/29/2013 BUTENAFINE HCL 1 % CREAM (G) 0.00000 0.40179 12/1/2012 BUTORPHANOL TARTRATE 1 MG/ML VIAL 0.00000 1.94300 12/1/2012 BUTORPHANOL TARTRATE 10 MG/ML SPRAY 4.68429 4.68430 12/14/2012 BUTORPHANOL TARTRATE 2 MG/ML VIAL 0.00000 1.94300 12/1/2012 CABERGOLINE 0.5 MG TABLET 13.28292 11.90184 11/29/2013 CAFFEINE CITRATED 60 MG/3 ML SOLUTION 4.81689 6.70190 1/25/2013 CAFFEINE CITRATED 60 MG/3 ML VIAL 0.00000 4.29429 12/1/2012 CAFFEINE/SODIUM BENZOATE 250 MG/ML VIAL 3.77000 2.73000 1/25/2013 CALCIPOTRIENE 0.005 % CREAM (G) 5.04887 5.15468 1/31/2014 CALCIPOTRIENE 0.005 % OINT. (G) 4.22205 4.22790 8/30/2013 CALCIPOTRIENE 0.005 % SOLUTION 2.72662 3.36520 11/15/2013 CALCITONIN,SALMON,SYNTHETIC 200/DOSE SPRAY/PUMP 12.62800 12.21825 9/13/2013 CALCITRIOL 0.25 MCG CAPSULE 0.52970 0.52974 6/7/2013 CALCITRIOL 0.5 MCG CAPSULE 1.17680 1.17683 6/7/2013 CALCITRIOL 1 MCG/ML AMPUL 0.00000 4.68130 12/1/2012 CALCITRIOL 1 MCG/ML SOLUTION 6.96810 7.01272 7/5/2013 CALCITRIOL 3 MCG/G OINT. (G) 0.00000 10.42220 12/1/2012 CALCIUM ACETATE 667 MG CAPSULE 0.00000 0.60520 12/1/2012 CALCIUM ACETATE 667 MG TABLET 0.39117 0.36813 8/2/2013 CALCIUM ACETATE/ALUMINUM SULF 839-1191MG POWD PACK 0.00000 0.50621 12/1/2012 CALCIUM ACETATE/ALUMINUM SULF 952-1347MG POWD PACK 0.67677 0.72740 1/25/2013 CALCIUM CARBONATE 200(500)MG TAB CHEW 0.01317 0.01394 7/5/2013 CALCIUM CARBONATE 300MG(750) TAB CHEW 0.02330 0.02844 8/23/2013 CALCIUM CARBONATE 500 MG/5ML ORAL SUSP 0.00000 0.01799 12/1/2012 CALCIUM CARBONATE 500(1250) TAB CHEW 0.04429 0.03420 1/25/2013 CALCIUM CARBONATE 500(1250) TABLET 0.01430 0.01434 5/24/2013 CALCIUM CARBONATE 600 MG TABLET 0.00000 0.02144 12/1/2012 CALCIUM CARBONATE/VITAMIN D2 250 MG-125 TABLET 0.01841 0.02170 1/25/2013 CALCIUM CARBONATE/VITAMIN D3 250 MG-125 TABLET 0.00000 0.01032 12/1/2012 CALCIUM CARBONATE/VITAMIN D3 500 MG-200 TABLET 0.01273 0.01599 6/28/2013 CALCIUM CARBONATE/VITAMIN D3 500 MG-400 TABLET 0.03049 0.03179 8/16/2013 CALCIUM CARBONATE/VITAMIN D3 600 MG-200 TABLET 0.00000 0.01899 12/1/2012 CALCIUM CARBONATE/VITAMIN D3 600 MG-400 CAPSULE 0.04580 0.04855 7/5/2013 CALCIUM CARBONATE/VITAMIN D3 600 MG-400 TABLET 0.01956 0.01914 9/20/2013 CALCIUM CARBONATE/VITAMIN D3 600 MG-800 TABLET 0.06880 0.06272 9/20/2013 CALCIUM CHLORIDE 100 MG/ML SYRINGE 0.50020 0.47124 2/1/2013 CALCIUM CHLORIDE 100 MG/ML VIAL 0.00000 0.17500 12/1/2012 CALCIUM CITRATE 200(950)MG TABLET 0.05593 0.03070 1/25/2013 CALCIUM CITRATE 250 MG TABLET 0.00000 0.05565 12/1/2012 CALCIUM CITRATE/VITAMIN D3 200 MG-250 TABLET 0.04220 0.04005 11/8/2013 CALCIUM CITRATE/VITAMIN D3 315 MG-200 TABLET 0.04370 0.05724 5/3/2013 CALCIUM CITRATE/VITAMIN D3 315 MG-250 TABLET 0.04584 0.04701 10/18/2013 CALCIUM POLYCARBOPHIL 625 MG TABLET 0.05896 0.07532 8/16/2013 CANDESARTAN CILEXETIL 16 MG TABLET 2.28281 1.61728 1/24/2014 CANDESARTAN CILEXETIL 32 MG TABLET 3.09074 2.19844 1/24/2014

Page 7 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CANDESARTAN CILEXETIL 4 MG TABLET 2.26738 1.62543 1/24/2014 CANDESARTAN CILEXETIL 8 MG TABLET 2.26738 1.61850 1/24/2014 CANDESARTAN/HYDROCHLOROTHIAZID 16-12.5MG TABLET 0.00000 2.86251 12/14/2012 CANDESARTAN/HYDROCHLOROTHIAZID 32-12.5MG TABLET 0.00000 2.91948 12/14/2012 CANDESARTAN/HYDROCHLOROTHIAZID 32MG-25MG TABLET 3.15928 3.15984 6/14/2013 CAPSAICIN 0.025 % CREAM (G) 0.06590 0.06709 4/5/2013 CAPSAICIN 0.075 % CREAM (G) 0.00000 0.08472 12/1/2012 CAPSAICIN/ME-SALICYLATE/MENTH 0.002%-20% LOTION 0.00000 2.36327 12/1/2012 CAPTOPRIL 100 % POWDER 33.69341 56.85764 2/22/2013 CAPTOPRIL 100 MG TABLET 0.39797 1.06383 10/4/2013 CAPTOPRIL 12.5 MG TABLET 0.01313 0.01310 12/14/2012 CAPTOPRIL 25 MG TABLET 0.01943 0.01940 1/25/2013 CAPTOPRIL 50 MG TABLET 0.02948 0.03203 12/27/2013 CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-15MG TABLET 0.29705 0.33384 12/27/2013 CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-25MG TABLET 0.29710 0.31499 7/12/2013 CAPTOPRIL/HYDROCHLOROTHIAZIDE 50 MG-15MG TABLET 0.86296 0.86300 12/14/2012 CAPTOPRIL/HYDROCHLOROTHIAZIDE 50 MG-25MG TABLET 0.00000 0.57278 12/27/2013 CARBAMAZEPINE 100 MG CPMP 12HR 1.27108 1.26436 8/16/2013 CARBAMAZEPINE 100 MG TAB CHEW 0.05700 0.05701 5/24/2013 CARBAMAZEPINE 200 MG CPMP 12HR 1.27160 1.25110 2/8/2013 CARBAMAZEPINE 200 MG TAB ER 12H 0.97210 0.97960 6/14/2013 CARBAMAZEPINE 200 MG TABLET 0.04569 0.04386 9/13/2013 CARBAMAZEPINE 300 MG CPMP 12HR 1.25110 1.25113 5/3/2013 CARBAMAZEPINE 400 MG TAB ER 12H 1.38250 1.95783 7/12/2013 CARBAMIDE PEROXIDE 6.5 % DROPS 0.12690 0.12686 5/24/2013 CARBIDOPA/LEVODOPA 10MG-100MG TAB RAPDIS 0.00000 0.77305 12/1/2012 CARBIDOPA/LEVODOPA 10MG-100MG TABLET 0.14690 0.14258 11/8/2013 CARBIDOPA/LEVODOPA 25MG-100MG TAB RAPDIS 0.87334 0.86710 1/25/2013 CARBIDOPA/LEVODOPA 25MG-100MG TABLET 0.13178 0.13139 6/14/2013 CARBIDOPA/LEVODOPA 25MG-100MG TABLET ER 0.36195 0.31555 1/3/2014 CARBIDOPA/LEVODOPA 25MG-250MG TAB RAPDIS 1.11111 1.10100 1/25/2013 CARBIDOPA/LEVODOPA 25MG-250MG TABLET 0.17529 0.18023 11/8/2013 CARBIDOPA/LEVODOPA 50MG-200MG TABLET ER 0.00000 0.72000 11/1/2012 CARBIDOPA/LEVODOPA/ENTACAPONE 12.5-50 MG TABLET 0.00000 2.62406 12/1/2012 CARBIDOPA/LEVODOPA/ENTACAPONE 18.75-75MG TABLET 2.62406 2.62456 11/8/2013 CARBIDOPA/LEVODOPA/ENTACAPONE 25-100-200 TABLET 2.62406 2.62456 11/8/2013 CARBIDOPA/LEVODOPA/ENTACAPONE 31.25-125 TABLET 2.62406 2.62456 11/8/2013 CARBIDOPA/LEVODOPA/ENTACAPONE 37.5-150MG TABLET 2.62406 2.62456 11/8/2013 CARBIDOPA/LEVODOPA/ENTACAPONE 50-200-200 TABLET 2.62406 2.62456 11/8/2013 CARBINOXAMINE MALEATE 4 MG TABLET 0.00000 0.49602 12/1/2012 CARBINOXAMINE MALEATE 4 MG/5 ML LIQUID 0.00000 0.09112 12/1/2012 CARBOXYMETHYLCELLULOSE SODIUM 0.5 % DROPERETTE 0.22027 0.20329 6/21/2013 CARBOXYMETHYLCELLULOSE SODIUM 0.5 % DROPS 0.32289 0.32765 5/17/2013 CARBOXYMETHYLCELLULOSE SODIUM 1 % DROPER GEL 0.00000 0.32162 3/29/2013 CARISOPRODOL 250 MG TABLET 2.22150 2.31410 2/8/2013 CARISOPRODOL 350 MG TABLET 0.06350 0.06352 2/1/2013 CARISOPRODOL/ASPIRIN 200-325 MG TABLET 1.66120 1.52430 1/25/2013 CARTEOLOL HCL 1 % DROPS 0.00000 1.17210 12/1/2012 CARVEDILOL 12.5 MG TABLET 0.03819 0.03779 12/27/2013 CARVEDILOL 25 MG TABLET 0.04824 0.03886 1/17/2014 CARVEDILOL 3.125 MG TABLET 0.03819 0.03779 12/27/2013 CARVEDILOL 6.25 MG TABLET 0.03739 0.03578 11/1/2013 CASTOR OIL OIL 0.00000 0.05545 12/1/2012 CEFACLOR 125 MG/5ML SUSP RECON 0.00000 0.68231 12/1/2012 CEFACLOR 250 MG CAPSULE 0.00000 1.39260 12/1/2012 CEFACLOR 250 MG/5ML SUSP RECON 0.00000 1.36453 12/1/2012 CEFACLOR 375 MG/5ML SUSP RECON 0.00000 2.04680 12/1/2012

Page 8 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CEFACLOR 500 MG CAPSULE 1.61041 1.61040 12/14/2012 CEFACLOR 500 MG TAB ER 12H 0.00000 3.48600 12/1/2012 CEFADROXIL HYDRATE 1 G TABLET 0.00000 2.32518 12/1/2012 CEFADROXIL HYDRATE 250 MG/5ML SUSP RECON 0.00000 0.36218 12/1/2012 CEFADROXIL HYDRATE 500 MG CAPSULE 0.33686 0.33735 5/31/2013 CEFADROXIL HYDRATE 500 MG/5ML SUSP RECON 0.49266 0.50605 8/30/2013 CEFAZOLIN SODIUM 1 G VIAL 0.87320 0.90290 1/25/2013 CEFAZOLIN SODIUM 1 G VIAL PORT 0.00000 4.26300 12/1/2012 CEFAZOLIN SODIUM 10 G VIAL 6.63040 7.56397 11/1/2013 CEFAZOLIN SODIUM 500 MG VIAL 0.00000 1.03662 12/1/2012 CEFAZOLIN SODIUM/DEXTROSE,ISO 1 G/50 ML FROZ.PIGGY 0.12224 0.23170 1/25/2013 CEFAZOLIN SODIUM/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.00000 0.20427 12/1/2012 CEFAZOLIN SODIUM/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 17.93574 12/1/2012 CEFDINIR 125 MG/5ML SUSP RECON 0.46900 0.52740 12/14/2012 CEFDINIR 250 MG/5ML SUSP RECON 0.91321 0.98740 12/14/2012 CEFDINIR 300 MG CAPSULE 1.61135 1.60220 7/12/2013 CEFEPIME HCL 1 G VIAL 4.97640 4.48630 9/27/2013 CEFEPIME HCL 2 G VIAL 8.69760 8.31600 8/9/2013 CEFEPIME HCL/D5W 1 G/50 ML PIGGYBACK 0.00000 0.55476 12/1/2012 CEFEPIME HCL/D5W 2 G/50 ML PIGGYBACK 0.85405 14.59910 1/25/2013 CEFEPIME HCL/DEXTROSE, ISO-OSM 1 G/50 ML FROZ.PIGGY 0.00000 1.09878 12/1/2012 CEFEPIME HCL/DEXTROSE, ISO-OSM 2 G/100 ML FROZ.PIGGY 0.00000 0.88078 12/1/2012 CEFOTAXIME SODIUM 1 G VIAL 1.38268 2.12524 9/6/2013 CEFOTAXIME SODIUM 10 G VIAL 0.00000 18.35400 12/1/2012 CEFOTAXIME SODIUM 2 G VIAL 4.12516 4.80340 10/4/2013 CEFOTAXIME SODIUM 500 MG VIAL 1.31950 1.26000 10/4/2013 CEFOTETAN DISOD/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 12.30600 12.81880 1/25/2013 CEFOTETAN DISOD/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 17.59800 12/1/2012 CEFOTETAN DISODIUM 1 G VIAL 0.00000 9.55920 12/1/2012 CEFOTETAN DISODIUM 10 G VIAL 0.00000 98.60200 12/1/2012 CEFOTETAN DISODIUM 2 G VIAL 19.11840 19.91500 1/25/2013 CEFOXITIN SODIUM 1 G VIAL 0.00000 4.45380 12/1/2012 CEFOXITIN SODIUM 10 G VIAL 0.00000 32.13068 12/1/2012 CEFOXITIN SODIUM 2 G VIAL 0.00000 8.21424 12/1/2012 CEFOXITIN SODIUM/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.50369 0.45037 4/19/2013 CEFOXITIN SODIUM/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 0.92383 12/1/2012 CEFPODOXIME PROXETIL 100 MG TABLET 4.34499 4.71590 5/3/2013 CEFPODOXIME PROXETIL 100 MG/5ML SUSP RECON 1.03385 1.14772 3/29/2013 CEFPODOXIME PROXETIL 50 MG/5 ML SUSP RECON 0.48050 0.52444 3/15/2013 CEFPROZIL 125 MG/5ML SUSP RECON 0.29300 0.29320 1/25/2013 CEFPROZIL 250 MG TABLET 1.99325 0.98696 6/28/2013 CEFPROZIL 250 MG/5ML SUSP RECON 0.00000 0.54020 12/1/2012 CEFPROZIL 500 MG TABLET 5.09799 1.55100 12/27/2013 CEFTAZIDIME PENTAHYDRATE 1 G VIAL 5.26390 4.82560 11/8/2013 CEFTAZIDIME PENTAHYDRATE 2 G VIAL 7.32917 10.56045 11/1/2013 CEFTAZIDIME PENTAHYDRATE 6G VIAL 21.52150 24.35825 8/9/2013 CEFTAZIDIME PENTAHYDRATE/D5W 1 G/50 ML PIGGYBACK 0.00000 9.03846 12/1/2012 CEFTAZIDIME PENTAHYDRATE/D5W 2 G/50 ML PIGGYBACK 0.00000 13.01154 12/1/2012 CEFTRIAXONE NA/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.00000 0.54291 12/1/2012 CEFTRIAXONE NA/DEXTROSE,ISO 2 G/50 ML FROZ.PIGGY 3.69970 3.11476 7/26/2013 CEFTRIAXONE NA/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 0.94697 12/1/2012 CEFTRIAXONE SODIUM 1 G VIAL 1.60666 2.25000 6/14/2013 CEFTRIAXONE SODIUM 1 G VIAL PORT 4.62840 3.51120 2/15/2013 CEFTRIAXONE SODIUM 10 G VIAL 13.90900 16.22880 1/24/2014 CEFTRIAXONE SODIUM 2 G VIAL 0.00000 3.43070 12/1/2012 CEFTRIAXONE SODIUM 2 G VIAL PORT 8.30760 6.39660 1/25/2013 CEFTRIAXONE SODIUM 250 MG VIAL 1.03050 1.09880 12/6/2013

Page 9 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CEFTRIAXONE SODIUM 500 MG VIAL 1.21810 1.21806 5/10/2013 CEFUROXIME AXETIL 250 MG TABLET 0.45566 0.45830 8/30/2013 CEFUROXIME AXETIL 500 MG TABLET 0.00000 0.73340 12/1/2012 CEFUROXIME SODIUM 1.5 G VIAL 4.33520 4.35422 9/6/2013 CEFUROXIME SODIUM 7.5G VIAL 19.28430 17.79645 4/19/2013 CEFUROXIME SODIUM 750 MG VIAL 0.00000 2.24102 12/1/2012 CEFUROXIME SODIUM/DEXTROSE,ISO 1.5G/50ML PIGGYBACK 0.00000 0.53477 12/1/2012 CEFUROXIME SODIUM/DEXTROSE,ISO 750MG/50ML PIGGYBACK 0.00000 0.42827 12/1/2012 CELLULOSE 80 % POWDER 0.00000 0.03535 12/1/2012 CEPHALEXIN 125 MG/5ML SUSP RECON 0.05280 0.06486 11/15/2013 CEPHALEXIN 250 MG CAPSULE 0.07772 0.13145 12/13/2013 CEPHALEXIN 250 MG TABLET 0.00000 0.40092 12/1/2012 CEPHALEXIN 250 MG/5ML SUSP RECON 0.06727 0.07129 11/15/2013 CEPHALEXIN 500 MG CAPSULE 0.08887 0.10023 5/17/2013 CEPHALEXIN 500 MG TABLET 0.00000 0.80132 12/1/2012 CEPHALEXIN 750 MG CAPSULE 0.00000 5.38300 6/7/2013 CETIRIZINE HCL 1 MG/ML SOLUTION 0.02961 0.02747 9/6/2013 CETIRIZINE HCL 10 MG TAB CHEW 1.93954 1.66170 10/18/2013 CETIRIZINE HCL 10 MG TABLET 0.05347 0.10500 12/6/2013 CETIRIZINE HCL 5 MG TAB CHEW 1.35807 1.95217 8/9/2013 CETIRIZINE HCL 5 MG TABLET 0.08420 0.08360 3/1/2013 CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H 0.67289 0.68411 11/29/2013 CEVIMELINE HCL 30 MG CAPSULE 2.35746 2.33208 8/16/2013 CHLOPHEDIANOL HCL/GUAIFENESIN 25-200MG/5 LIQUID 0.09157 0.08650 1/25/2013 CHLORAMPHENICOL SOD SUCC 1 G VIAL 0.00000 2.64689 12/1/2012 CHLORDIAZEPOXIDE HCL 10 MG CAPSULE 0.07238 0.07240 12/14/2012 CHLORDIAZEPOXIDE HCL 25 MG CAPSULE 0.08947 0.08950 12/14/2012 CHLORDIAZEPOXIDE HCL 5 MG CAPSULE 0.10604 0.10600 12/14/2012 CHLORDIAZEPOXIDE/CLIDINIUM BR 5 MG-2.5MG CAPSULE 0.00000 0.28408 12/1/2012 CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH 0.00580 0.00581 3/22/2013 CHLOROPROCAINE HCL/PF 20 MG/ML VIAL 0.55650 0.49140 1/25/2013 CHLOROQUINE PHOSPHATE 250 MG TABLET 1.16780 0.86970 3/1/2013 CHLOROQUINE PHOSPHATE 500 MG TABLET 2.61400 3.44058 6/28/2013 CHLOROTHIAZIDE 250 MG TABLET 0.00000 0.15141 12/13/2013 CHLOROTHIAZIDE SODIUM 500 MG VIAL 0.00000 222.92725 12/1/2012 CHLORPHENIRAMINE MALEATE 12 MG TABLET ER 0.29912 0.34710 12/21/2012 CHLORPHENIRAMINE MALEATE 2 MG/5 ML SYRUP 0.00000 0.01798 12/1/2012 CHLORPHENIRAMINE MALEATE 4 MG TABLET 0.00557 0.00571 6/28/2013 CHLORPROMAZINE HCL 25 MG/ML AMPUL 8.27700 18.81600 11/8/2013 CHLORPROPAMIDE 100 MG TABLET 0.33400 0.34550 1/25/2013 CHLORPROPAMIDE 250 MG TABLET 0.81158 0.85230 1/25/2013 CHLORTHALIDONE 25 MG TABLET 0.00000 0.34700 12/1/2012 CHLORTHALIDONE 50 MG TABLET 0.44933 0.47630 1/25/2013 CHLORZOXAZONE 500 MG TABLET 0.24258 0.24242 1/10/2014 CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT TAB CHEW 0.07209 0.07210 1/25/2013 CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT TABLET 0.01994 0.01997 8/9/2013 CHOLECALCIFEROL (VITAMIN D3) 1000/SPRAY SPRAY SUSP 0.00000 0.30847 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT CAPSULE 1.07310 0.76007 6/7/2013 CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT TABLET 0.02924 0.02970 12/27/2013 CHOLECALCIFEROL (VITAMIN D3) 3000 UNIT TABLET 0.00000 0.05516 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT CAPSULE 0.01948 0.02548 7/26/2013 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TAB CHEW 0.00000 0.02509 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TABLET 0.01698 0.01694 11/15/2013 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/5 LIQUID 0.00000 0.02914 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 4000 UNIT CAPSULE 0.00000 0.06993 12/1/2012 CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT TABLET 0.05126 0.05313 7/12/2013 CHOLECALCIFEROL (VITAMIN D3) 5000/ML DROPS 0.00000 0.07973 12/1/2012

Page 10 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT CAPSULE 0.27670 0.14700 11/22/2013 CHOLESTYRAMINE (WITH SUGAR) 4 G POWD PACK 0.86151 1.99770 12/13/2013 CHOLESTYRAMINE (WITH SUGAR) 4 G POWDER 0.21462 0.21802 11/29/2013 CHOLESTYRAMINE/ASPARTAME 4 G POWD PACK 0.43400 1.09344 8/30/2013 CHOLESTYRAMINE/ASPARTAME 4 G POWDER 0.14980 0.29520 12/13/2013 CHOLINE SAL/MAG SALICYLATE 500 MG/5ML LIQUID 0.00000 0.12848 12/1/2012 CHORIONIC GONADOTROPIN, HUMAN 10000 UNIT VIAL 18.69945 184.04000 7/12/2013 CICLOPIROX 0.77 % GEL (GRAM) 1.48043 1.36830 1/25/2013 CICLOPIROX 1 % SHAMPOO 0.61126 0.57510 12/21/2012 CICLOPIROX 8 % SOLUTION 5.30497 3.47658 10/25/2013 CICLOPIROX OLAMINE 0.77 % CREAM (G) 0.14968 0.14517 5/24/2013 CICLOPIROX OLAMINE 0.77 % SUSPENSION 0.00000 0.37748 12/1/2012 CICLOPIROX/URE/CAMPH/MENTH/EUC 8 % SOLUTION 0.00000 266.99400 12/1/2012 CIDOFOVIR 75 MG/ML VIAL 87.02400 118.10400 3/15/2013 CILOSTAZOL 100 MG TABLET 0.13494 0.13490 12/14/2012 CILOSTAZOL 50 MG TABLET 0.15283 0.14589 9/20/2013 CIMETIDINE 200 MG TABLET 0.18930 0.23684 3/29/2013 CIMETIDINE 300 MG TABLET 0.15126 0.14778 1/3/2014 CIMETIDINE 400 MG TABLET 0.06357 0.24350 8/16/2013 CIMETIDINE 800 MG TABLET 0.31785 0.53313 5/10/2013 CIMETIDINE HCL 300 MG/5ML SOLUTION 0.03350 0.06283 5/17/2013 CIPROFLOXACIN HCL 0.2 % DROPERETTE 0.00000 5.25900 12/1/2012 CIPROFLOXACIN HCL 0.3 % DROPS 0.66062 0.73968 5/17/2013 CIPROFLOXACIN HCL 100 MG TABLET 0.00000 2.35900 12/1/2012 CIPROFLOXACIN HCL 250 MG TABLET 0.14941 0.14271 1/31/2014 CIPROFLOXACIN HCL 500 MG TABLET 0.16804 0.16211 12/13/2013 CIPROFLOXACIN HCL 750 MG TABLET 0.27860 0.27859 3/1/2013 CIPROFLOXACIN LACTATE 200MG/20ML VIAL 0.00000 0.08890 12/1/2012 CIPROFLOXACIN LACTATE 400MG/40ML VIAL 0.06318 0.06320 1/25/2013 CIPROFLOXACIN LACTATE/D5W 200MG/0.1L PIGGYBACK 0.00000 0.01697 12/1/2012 CIPROFLOXACIN LACTATE/D5W 400MG/0.2L PIGGYBACK 0.01250 0.01204 3/1/2013 CIPROFLOXACIN/CIPROFLOXA HCL 1000 MG TBMP 24HR 0.00000 7.79233 12/1/2012 CIPROFLOXACIN/CIPROFLOXA HCL 500 MG TBMP 24HR 0.00000 6.85916 12/1/2012 CISATRACURIUM BESYLATE 10 MG/ML VIAL 0.00000 10.93957 12/1/2012 CISATRACURIUM BESYLATE 2 MG/ML VIAL 2.13996 2.16839 8/2/2013 CITALOPRAM HYDROBROMIDE 10 MG TABLET 0.02921 0.02581 11/8/2013 CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION 0.00000 0.18230 1/25/2012 CITALOPRAM HYDROBROMIDE 20 MG TABLET 0.03560 0.03685 5/17/2013 CITALOPRAM HYDROBROMIDE 40 MG TABLET 0.04791 0.04887 5/17/2013 CITRATE PHOSPHATE DEXTROS SOLN 2.63 G/100 SOLUTION 0.00000 0.08318 12/1/2012 CITRIC ACID/SODIUM CITRATE 334-500MG SOLUTION 0.01450 0.00980 8/30/2013 CLARITHROMYCIN 125 MG/5ML SUSP RECON 0.34465 0.36569 5/17/2013 CLARITHROMYCIN 250 MG TABLET 3.54661 3.43704 1/24/2014 CLARITHROMYCIN 500 MG TAB ER 24H 3.47640 2.91103 1/10/2014 CLARITHROMYCIN 500 MG TABLET 2.89315 2.89310 5/17/2013 CLEMASTINE FUMARATE 0.67MG/5ML SYRUP 0.00000 0.12454 3/22/2013 CLEMASTINE FUMARATE 1.34 MG TABLET 0.12753 0.12750 12/14/2012 CLINDAMYCIN HCL 150 MG CAPSULE 0.08790 0.08796 5/31/2013 CLINDAMYCIN HCL 300 MG CAPSULE 0.28640 0.28636 3/22/2013 CLINDAMYCIN HCL 75 MG CAPSULE 0.00000 0.41720 12/1/2012 CLINDAMYCIN PALMITATE HCL 75 MG/5 ML SOLN RECON 0.43421 0.42156 11/22/2013 CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GEL (GRAM) 3.76642 3.76643 6/21/2013 CLINDAMYCIN PHOS/BENZOYL PEROX 1.2(1)%-5% GEL ER (G) 3.16403 3.16110 1/25/2013 CLINDAMYCIN PHOSPHATE 1 % FOAM 2.14418 2.52647 6/7/2013 CLINDAMYCIN PHOSPHATE 1 % LOTION 1.11980 1.11977 3/15/2013 CLINDAMYCIN PHOSPHATE 1 % MED. SWAB 0.40374 0.40378 6/28/2013 CLINDAMYCIN PHOSPHATE 1 % SOLUTION 0.91410 0.91409 9/20/2013

Page 11 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 CLINDAMYCIN PHOSPHATE 150 MG/ML VIAL 0.30610 0.35600 12/21/2012 CLINDAMYCIN PHOSPHATE 2 % CREAM/APPL 1.57590 1.57588 8/23/2013 CLINDAMYCIN PHOSPHATE 300 MG/2ML VIAL PORT 0.00000 2.99418 12/1/2012 CLINDAMYCIN PHOSPHATE 600 MG/4ML VIAL PORT 0.00000 1.60881 12/1/2012 CLINDAMYCIN PHOSPHATE 900MG/6ML VIAL PORT 0.00000 1.51899 12/1/2012 CLINDAMYCIN PHOSPHATE/D5W 300MG/50ML PIGGYBACK 0.13773 0.10737 6/7/2013 CLINDAMYCIN PHOSPHATE/D5W 600MG/50ML PIGGYBACK 0.20775 0.16162 6/7/2013 CLINDAMYCIN PHOSPHATE/D5W 900MG/50ML PIGGYBACK 0.25374 0.19421 6/7/2013 CLOBETASOL PROPIONATE 0.05 % CREAM (G) 0.31910 0.32189 8/16/2013 CLOBETASOL PROPIONATE 0.05 % FOAM 3.07550 4.69223 12/27/2013 CLOBETASOL PROPIONATE 0.05 % GEL (GRAM) 0.36716 0.36720 12/14/2012 CLOBETASOL PROPIONATE 0.05 % LOTION 0.00000 3.23864 12/1/2012 CLOBETASOL PROPIONATE 0.05 % OINT. (G) 0.11460 0.23120 12/21/2012 CLOBETASOL PROPIONATE 0.05 % SHAMPOO 2.38350 2.31009 11/29/2013 CLOBETASOL PROPIONATE 0.05 % SOLUTION 0.29874 0.30766 5/17/2013 CLOBETASOL PROPIONATE/EMOLL 0.05 % CREAM (G) 0.29210 0.36716 5/17/2013 CLOBETASOL PROPIONATE/EMOLL 0.05 % FOAM 3.08826 3.51120 11/1/2013 CLOMIPHENE CITRATE 50 MG TABLET 0.00000 1.01304 12/1/2012 CLOMIPRAMINE HCL 25 MG CAPSULE 7.75151 7.86937 11/1/2013 CLOMIPRAMINE HCL 50 MG CAPSULE 7.33797 7.86937 8/2/2013 CLOMIPRAMINE HCL 75 MG CAPSULE 0.48094 7.86940 12/20/2013 CLONAZEPAM 0.125 MG TAB RAPDIS 0.73796 0.74721 1/31/2014 CLONAZEPAM 0.25 MG TAB RAPDIS 0.75950 0.76775 1/31/2014 CLONAZEPAM 0.5 MG TAB RAPDIS 0.78857 0.76348 11/29/2013 CLONAZEPAM 0.5 MG TABLET 0.01650 0.01648 3/22/2013 CLONAZEPAM 1 MG TAB RAPDIS 0.90253 0.79763 5/31/2013 CLONAZEPAM 1 MG TABLET 0.02610 0.02613 2/8/2013 CLONAZEPAM 2 MG TAB RAPDIS 0.00000 1.09330 12/1/2012 CLONAZEPAM 2 MG TABLET 0.04230 0.04234 11/8/2013 CLONIDINE 0.1MG/24HR PATCH TDWK 23.20687 20.99175 11/29/2013 CLONIDINE 0.2MG/24HR PATCH TDWK 39.07252 37.99719 1/31/2014 CLONIDINE 0.3MG/24HR PATCH TDWK 53.52290 54.05954 1/31/2014 CLONIDINE HCL 0.1 MG TAB ER 12H 0.00000 3.14977 10/25/2013 CLONIDINE HCL 0.1 MG TABLET 0.03020 0.03015 2/8/2013 CLONIDINE HCL 0.2 MG TABLET 0.04301 0.04261 9/13/2013 CLONIDINE HCL 0.3 MG TABLET 0.05390 0.05387 3/22/2013 CLONIDINE HCL/PF 1000MCG/10 VIAL 0.00000 2.18075 12/1/2012 CLONIDINE HCL/PF 5000MCG/10 VIAL 10.09700 8.35920 1/25/2013 CLOPIDOGREL BISULFATE 300 MG TABLET 18.92559 15.16650 1/25/2013 CLOPIDOGREL BISULFATE 75 MG TABLET 0.00000 0.35570 12/1/2012 CLORAZEPATE DIPOTASSIUM 15 MG TABLET 0.23750 0.26100 3/22/2013 CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET 0.19092 0.19685 11/29/2013 CLORAZEPATE DIPOTASSIUM 7.5 MG TABLET 0.16321 0.15830 5/10/2013 CLOTRIMAZOLE 1 % CREAM (G) 0.07540 0.07548 7/26/2013 CLOTRIMAZOLE 1 % CREAM/APPL 0.07790 0.07865 3/1/2013 CLOTRIMAZOLE 1 % SOLUTION 0.00000 0.32656 12/1/2012 CLOTRIMAZOLE 10 MG TROCHE 0.35770 0.36150 1/25/2013 CLOTRIMAZOLE 2 % CREAM/APPL 0.33420 0.32760 6/28/2013 CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % CREAM (G) 1.27401 1.26762 1/31/2014 CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % LOTION 3.60074 3.46640 5/31/2013 CLOZAPINE 100 MG TAB RAPDIS 5.72241 5.72222 2/15/2013 CLOZAPINE 100 MG TABLET 0.00000 1.62860 9/27/2012 CLOZAPINE 12.5 MG TAB RAPDIS 0.00000 1.55925 12/1/2012 CLOZAPINE 200 MG TABLET 4.37050 4.37030 1/25/2013 CLOZAPINE 25 MG TAB RAPDIS 0.00000 2.09823 12/1/2012 CLOZAPINE 25 MG TABLET 0.90840 0.90848 7/26/2013 CLOZAPINE 50 MG TABLET 0.00000 1.15500 12/1/2012

Page 12 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 COAL TAR 1 % SHAMPOO 0.03451 0.03020 1/25/2013 COCAINE HCL 4 % SOLUTION 17.36630 15.19980 1/25/2013 CODEINE SULFATE 15 MG TABLET 0.30360 0.36736 3/1/2013 CODEINE SULFATE 30 MG TABLET 0.39550 0.40417 4/5/2013 CODEINE SULFATE 30 MG/5 ML SOLUTION 0.50492 0.17982 3/8/2013 CODEINE SULFATE 60 MG TABLET 0.65850 0.72436 2/15/2013 CODEINE/BUTALBITAL/ASA/CAFFEIN 30-50-325 CAPSULE 0.66287 0.59335 4/26/2013 CODEINE/CARISOPRODOL/ASPIRIN 16-200-325 TABLET 0.00000 1.94250 12/1/2012 COLCHICINE/PROBENECID 0.5-500MG TABLET 0.00000 0.67760 12/1/2012 COLESTIPOL HCL 1 G TABLET 0.57812 0.65477 1/17/2014 COLESTIPOL HCL 5 G GRANULES 0.00000 0.20871 12/1/2012 COLESTIPOL HCL 5 G PACKET 0.00000 3.51494 12/1/2012 COLISTIN (COLISTIMETHATE NA) 150 MG VIAL 1.59621 19.47030 12/14/2012 CORTISONE ACETATE 25 MG TABLET 0.00000 0.75600 12/1/2012 COSYNTROPIN 0.25 MG VIAL 0.00000 64.39973 12/1/2012 COSYNTROPIN 0.25 MG/ML VIAL 0.00000 151.55280 12/1/2012 CROMOLYN SODIUM 20 MG/2 ML AMPUL-NEB 0.58770 0.64353 5/17/2013 CROMOLYN SODIUM 20 MG/ML SOLUTION 0.87924 0.87900 1/25/2013 CROMOLYN SODIUM 4 % DROPS 0.69948 0.69950 12/14/2012 CROMOLYN SODIUM 5.2 MG SPRAY/PUMP 0.00000 0.33554 12/1/2012 CUPRIC CHLORIDE 0.4 MG/ML VIAL 0.12348 0.15460 1/25/2013 CUPRIC SULFATE 0.4 MG/ML VIAL 0.00000 0.12958 12/1/2012 CYANOCOBALAMIN (VITAMIN B-12) 100 MCG TABLET 0.00000 0.01242 12/1/2012 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TAB SUBL 0.05840 0.05332 7/12/2013 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TABLET ER 0.04583 0.04152 3/15/2013 CYANOCOBALAMIN (VITAMIN B-12) 500 MCG TABLET 0.00000 0.01867 12/1/2012 CYANOCOBALAMIN (VITAMIN B-12) 5000 MCG TAB SUBL 0.00000 0.10737 3/8/2013 CYANOCOBALAMIN/FA/PYRIDOXINE 2-2.5-25MG TABLET 0.63825 0.63880 1/25/2013 CYANOCOBALAMIN/FOLIC ACID 0.5 MG-1MG TABLET 0.00000 0.12600 12/1/2012 CYCLOBENZAPRINE HCL 10 MG TABLET 0.02850 0.03018 11/1/2013 CYCLOBENZAPRINE HCL 5 MG TABLET 0.05842 0.05052 12/13/2013 CYCLOBENZAPRINE HCL 7.5 MG TABLET 0.00000 3.36504 5/3/2013 CYCLOPENTOLATE HCL 1 % DROPS 1.18990 1.65266 5/10/2013 CYCLOPENTOLATE HCL 2 % DROPS 1.73600 3.33840 2/8/2013 CYCLOPHOSPHAMIDE 1 G VIAL 289.48850 432.93460 6/28/2013 CYCLOPHOSPHAMIDE 2 G VIAL 742.15400 578.96300 1/25/2013 CYCLOPHOSPHAMIDE 25 MG TABLET 1.41297 1.55428 3/15/2013 CYCLOPHOSPHAMIDE 50 MG TABLET 2.59285 2.85220 3/15/2013 CYCLOPHOSPHAMIDE 500 MG VIAL 144.74250 237.49600 8/2/2013 CYCLOSPORINE 100 MG CAPSULE 5.81067 6.45710 8/2/2013 CYCLOSPORINE 25 MG CAPSULE 1.62657 1.65663 1/31/2014 CYCLOSPORINE 250 MG/5ML VIAL 0.00000 7.95732 12/1/2012 CYCLOSPORINE, MODIFIED 100 MG CAPSULE 3.84740 3.84735 11/29/2013 CYCLOSPORINE, MODIFIED 100 MG/ML SOLUTION 2.76371 2.88899 6/28/2013 CYCLOSPORINE, MODIFIED 25 MG CAPSULE 0.96260 0.96270 1/25/2013 CYCLOSPORINE, MODIFIED 50 MG CAPSULE 0.00000 1.91683 12/1/2012 CYPROHEPTADINE HCL 2 MG/5 ML SYRUP 0.07420 0.09530 2/1/2013 CYPROHEPTADINE HCL 4 MG TABLET 0.10997 0.11890 5/17/2013 CYTARABINE 20 MG/ML VIAL 0.39573 0.40080 1/25/2013 CYTARABINE/PF 1 G VIAL 0.00000 40.61400 12/1/2012 CYTARABINE/PF 100 MG VIAL 0.00000 7.10640 12/1/2012 CYTARABINE/PF 100 MG/5ML VIAL 0.00000 1.97106 12/1/2012 CYTARABINE/PF 2 G/20 ML VIAL 0.00000 0.87780 12/1/2012 CYTARABINE/PF 20 MG/ML VIAL 0.00000 0.75096 12/1/2012 D-CHLORPHENIRA/PSE/CHLOPHEDIAN 1-30-12.5 LIQUID 0.08693 0.08050 1/25/2013 D-METHORPHAN HB/P-EPD HCL/BPM 10-30-2/5 SYRUP 0.13310 0.13311 3/1/2013 D-METHORPHAN HB/P-EPD HCL/BPM 20-20-4/5 LIQUID 0.21004 0.21000 1/25/2013

Page 13 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 D-METHORPHAN HB/P-EPD HCL/BPM 30-50-3MG LIQUID 0.07317 0.06910 1/25/2013 D-METHORPHAN HB/P-EPD HCL/BPM 5-15-1MG/5 ELIXIR 0.01845 0.01127 8/30/2013 D-METHORPHAN HB/P-EPHED HCL/CP 15-15-2/5 SYRUP 0.00000 0.04846 12/1/2012 D-METHORPHAN HB/P-EPHED HCL/CP 5-15-1MG/5 LIQUID 0.00000 0.01868 12/1/2012 D-METHORPHAN HB/PROMETH HCL 15-6.25/5 SYRUP 0.01349 0.01365 1/24/2014 D-METHORPHAN/ACETAMIN/DOXYLAMN 15-325/15 LIQUID 0.01474 0.01469 4/19/2013 D-METHORPHAN/PE/DEXBROMPHENIR 20-10-2/5 SYRUP 0.06080 0.05168 2/22/2013 DACARBAZINE 100 MG VIAL 0.00000 7.93800 12/1/2012 DACTINOMYCIN 0.5 MG VIAL 1,065.68700 493.92000 11/29/2013 DANAZOL 100 MG CAPSULE 0.00000 2.00515 12/1/2012 DANAZOL 200 MG CAPSULE 3.37123 3.34131 4/26/2013 DANAZOL 50 MG CAPSULE 1.33637 1.26890 1/25/2013 DANTROLENE SODIUM 100 MG CAPSULE 1.39490 1.51750 2/8/2013 DANTROLENE SODIUM 20 MG VIAL 0.00000 68.04000 12/1/2012 DANTROLENE SODIUM 25 MG CAPSULE 0.00000 0.74851 12/1/2012 DANTROLENE SODIUM 50 MG CAPSULE 0.00000 1.21009 12/1/2012 DAPSONE 100 MG TABLET 0.00000 0.91000 12/1/2012 DAPSONE 25 MG TABLET 0.00000 0.74200 12/1/2012 DAUNORUBICIN HCL 5 MG/ML VIAL 14.20913 14.58975 12/14/2012 DECITABINE 50 MG VIAL 0.00000 1,365.37800 8/2/2013 DEFEROXAMINE MESYLATE 2 G VIAL 0.00000 26.33481 12/1/2012 DEFEROXAMINE MESYLATE 500 MG VIAL 8.40600 10.56850 12/27/2013 DEMECLOCYCLINE HCL 300 MG TABLET 3.66519 10.99400 7/12/2013 DESIPRAMINE HCL 10 MG TABLET 0.81680 0.81200 3/1/2013 DESIPRAMINE HCL 100 MG TABLET 2.88720 3.05540 1/25/2013 DESIPRAMINE HCL 150 MG TABLET 4.37997 4.40910 4/12/2013 DESIPRAMINE HCL 25 MG TABLET 0.96960 0.98480 2/8/2013 DESIPRAMINE HCL 75 MG TABLET 2.20052 2.17445 5/31/2013 DESLORATADINE 2.5 MG TAB RAPDIS 11.92731 10.07649 1/24/2014 DESLORATADINE 5 MG TAB RAPDIS 0.00000 4.07750 1/25/2013 DESLORATADINE 5 MG TABLET 0.00000 1.03622 12/1/2012 DESMOPRESSIN ACETATE 0.1 MG TABLET 1.17268 1.16461 12/13/2013 DESMOPRESSIN ACETATE 0.1 MG/ML SOLUTION 25.20840 25.31760 3/8/2013 DESMOPRESSIN ACETATE 0.2 MG TABLET 1.27244 1.19698 12/13/2013 DESMOPRESSIN ACETATE 10/SPRAY SPRAY/PUMP 33.88710 27.59120 8/2/2013 DESMOPRESSIN ACETATE 4MCG/ML AMPUL 7.12530 16.22800 8/30/2013 DESMOPRESSIN ACETATE 4MCG/ML VIAL 13.84457 8.62810 4/12/2013 DESOG-ET ESTRA/ETHIN ESTRA 21-5 TABLET 1.46998 1.49950 1/10/2014 DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.03 TABLET 0.65333 0.62830 5/17/2013 DESOGESTREL-ETHINYL ESTRADIOL 7 DAYS X 3 TABLET 0.00000 0.83100 12/1/2012 DESONIDE 0.05 % CREAM (G) 0.48267 4.07913 9/27/2013 DESONIDE 0.05 % LOTION 0.00000 1.83560 12/1/2012 DESONIDE 0.05 % OINT. (G) 0.66374 2.80467 7/26/2013 DESOXIMETASONE 0.05 % GEL (GRAM) 0.00000 2.73169 12/1/2012 DESOXIMETASONE 0.25 % OINT. (G) 4.15372 3.83684 10/18/2013 DEXAMETHASONE 0.5 MG/5ML ELIXIR 0.18009 0.18810 6/28/2013 DEXAMETHASONE 0.5 MG/5ML SOLUTION 0.11180 0.08588 11/22/2013 DEXAMETHASONE SOD PHOSPHATE 0.1 % DROPS 2.96250 3.31265 11/1/2013 DEXAMETHASONE SOD PHOSPHATE 10 MG/ML VIAL 0.66970 0.33586 9/6/2013 DEXAMETHASONE SOD PHOSPHATE 4 MG/ML VIAL 0.19600 0.23878 4/5/2013 DEXAMETHASONE SOD PHOSPHATE/PF 10 MG/ML VIAL 0.00000 6.35376 12/1/2012 DEXMETHYLPHENIDATE HCL 10 MG TABLET 1.92570 0.98000 10/4/2013 DEXMETHYLPHENIDATE HCL 2.5 MG TABLET 0.96705 0.94880 1/25/2013 DEXMETHYLPHENIDATE HCL 5 MG TABLET 0.00000 1.37844 12/1/2012 DEXPANTHENOL 250 MG/ML VIAL 1.36500 1.42180 1/25/2013 DEXTROAMPHETAMINE SULFATE 10 MG TABLET 0.00000 1.74148 3/8/2013 DEXTROAMPHETAMINE SULFATE 5 MG/5 ML SOLUTION 0.89328 1.27716 1/17/2014

Page 14 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 DEXTROAMPHETAMINE/AMPHETAMINE 10 MG CAP ER 24H 4.66703 4.59654 1/31/2014 DEXTROAMPHETAMINE/AMPHETAMINE 10 MG TABLET 1.20884 1.21525 1/31/2014 DEXTROAMPHETAMINE/AMPHETAMINE 15 MG TABLET 0.00000 1.02700 1/17/2014 DEXTROAMPHETAMINE/AMPHETAMINE 20 MG CAP ER 24H 0.00000 4.56096 1/17/2014 DEXTROAMPHETAMINE/AMPHETAMINE 20 MG TABLET 0.00000 1.19314 1/17/2014 DEXTROAMPHETAMINE/AMPHETAMINE 30 MG CAP ER 24H 0.00000 4.53046 1/17/2014 DEXTROAMPHETAMINE/AMPHETAMINE 30 MG TABLET 0.00000 1.21525 1/17/2014 DEXTROAMPHETAMINE/AMPHETAMINE 5 MG TABLET 0.00000 1.19584 1/17/2014 DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML SUS ER 12H 0.06322 0.08530 1/25/2013 DEXTROSE 10 % AND 0.2 % NACL 10 %-0.2 % DEHP FR BG 0.00000 0.04179 12/1/2012 DEXTROSE 10 % AND 0.2 % NACL 10 %-0.2 % IV SOLN 0.00000 0.03704 12/1/2012 DEXTROSE 10 % AND 0.45 % NACL 10%-0.45% IV SOLN 0.00000 0.01077 12/1/2012 DEXTROSE 10 % IN WATER 10 % DEHP FR BG 0.00000 0.00819 12/1/2012 DEXTROSE 10 % IN WATER 10 % IV SOLN 0.00281 0.00207 4/5/2013 DEXTROSE 2.5 % AND 0.45 % NACL 2.5%-0.45% IV SOLN 0.00252 0.00250 1/25/2013 DEXTROSE 20 % IN WATER 20 % IV SOLN 0.00000 0.00864 12/1/2012 DEXTROSE 25 % IN WATER 25 % SYRINGE 0.42672 0.38140 1/25/2013 DEXTROSE 30 % IN WATER 30 % IV SOLN 0.00000 0.00877 12/1/2012 DEXTROSE 40 % IN WATER 40 % IV SOLN 0.01091 0.00870 1/25/2013 DEXTROSE 5 % AND 0.3 % NACL 5 %-0.3 % IV SOLN 0.00213 0.00230 1/25/2013 DEXTROSE 5 % AND 0.9 % NACL 5 %-0.9 % IV SOLN 0.00000 0.00201 12/1/2012 DEXTROSE 5 % IN WATER PGGYBK PRT 0.04099 0.03320 1/25/2013 DEXTROSE 5 % IN WATER PGY VL PRT 0.00000 0.07096 12/1/2012 DEXTROSE 5 % IN WATER 5 % IV SOLN 0.00174 0.00158 4/19/2013 DEXTROSE 5 % IN WATER 5 % VIAL 0.00000 0.53214 12/1/2012 DEXTROSE 5 % SOLUTION 0.01868 0.01680 1/25/2013 DEXTROSE 5 %-0.2 % NACL 5 %-0.2 % IV SOLN 0.00000 0.00228 12/1/2012 DEXTROSE 5 %-0.45 % NACL 5 %-0.45 % IV SOLN 0.00145 0.00144 3/15/2013 DEXTROSE 5%-LACTATED RINGERS 5 % IV SOLN 0.00000 0.00214 12/1/2012 DEXTROSE 50 % IN WATER 50 % IV SOLN 0.00000 0.00630 12/1/2012 DEXTROSE 50 % IN WATER 50 % SYRINGE 0.12516 0.09475 4/5/2013 DEXTROSE 50 % IN WATER 50 % VIAL 0.02537 0.02540 1/25/2013 DEXTROSE 70 % IN WATER 70 % IV SOLN 0.00540 0.00532 4/19/2013 DIAZEPAM 10 MG TABLET 0.02395 0.02441 1/24/2014 DIAZEPAM 12.5-15-20 KIT 123.17425 123.06000 8/30/2013 DIAZEPAM 2 MG TABLET 0.02431 0.02396 7/19/2013 DIAZEPAM 2.5 MG KIT 103.82225 129.16538 11/22/2013 DIAZEPAM 5 MG TABLET 0.02230 0.02222 6/14/2013 DIAZEPAM 5 MG/5 ML SOLUTION 0.16829 0.18514 3/15/2013 DIAZEPAM 5 MG/ML ORAL CONC 1.54209 1.69680 3/15/2013 DIAZEPAM 5 MG/ML SYRINGE 3.37260 3.71280 1/25/2013 DIAZEPAM 5 MG/ML VIAL 1.17516 1.36920 7/12/2013 DIAZEPAM 5-7.5-10MG KIT 252.35700 233.82800 7/5/2013 DICLOFENAC POTASSIUM 50 MG TABLET 0.20414 0.43017 9/20/2013 DICLOFENAC SODIUM 0.1 % DROPS 1.02380 1.02376 10/18/2013 DICLOFENAC SODIUM 100 MG TAB ER 24H 0.51520 0.51523 3/15/2013 DICLOFENAC SODIUM 25 MG TABLET DR 0.99526 0.99530 12/14/2012 DICLOFENAC SODIUM 3 % GEL (GRAM) 0.00000 7.92596 12/13/2013 DICLOFENAC SODIUM 50 MG TABLET DR 0.35590 0.30726 12/13/2013 DICLOFENAC SODIUM 75 MG TABLET DR 0.36542 0.27766 8/30/2013 DICLOFENAC SODIUM/MISOPROSTOL 50 MG-200 TAB IR DR 0.00000 2.34693 12/1/2012 DICLOFENAC SODIUM/MISOPROSTOL 75 MG-200 TAB IR DR 0.00000 2.34697 12/1/2012 DICLOXACILLIN SODIUM 250 MG CAPSULE 0.23840 0.24669 3/1/2013 DICLOXACILLIN SODIUM 500 MG CAPSULE 0.47650 0.47953 3/1/2013 DICYCLOMINE HCL 10 MG CAPSULE 0.04234 0.04275 10/18/2013 DICYCLOMINE HCL 10 MG/5 ML SOLUTION 0.16100 0.33172 7/26/2013 DICYCLOMINE HCL 20 MG TABLET 0.09093 0.09068 10/18/2013

Page 15 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 DIDANOSINE 125 MG CAPSULE DR 0.00000 2.70223 12/1/2012 DIDANOSINE 200 MG CAPSULE DR 4.25300 4.32270 2/8/2013 DIDANOSINE 250 MG CAPSULE DR 0.00000 5.50853 12/1/2012 DIDANOSINE 400 MG CAPSULE DR 8.39520 8.60350 2/8/2013 DIETHYLPROPION HCL 25 MG TABLET 0.23594 0.23090 1/25/2013 DIETHYLPROPION HCL 75 MG TABLET ER 0.85826 0.80950 1/25/2013 DIFLORASONE DIACETATE 0.05 % OINT. (G) 2.91054 2.47670 1/25/2013 DIFLUNISAL 500 MG TABLET 1.13677 1.18611 5/17/2013 DIGOXIN 250 MCG/ML SYRINGE 0.00000 1.58760 12/1/2012 DIGOXIN 50 MCG/ML SOLUTION 0.49117 0.49985 1/31/2014 DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP 124.20538 136.62600 10/4/2013 DIHYDROERGOTAMINE MESYLATE 1 MG/ML AMPUL 53.12400 54.10623 2/22/2013 DIHYDROERGOTAMINE MESYLATE 1 MG/ML VIAL 0.00000 37.55430 12/1/2012 DILTIAZEM HCL 100 MG VIAL PORT 15.81300 14.71680 1/25/2013 DILTIAZEM HCL 120 MG CAP ER 24H 0.48939 0.41789 7/26/2013 DILTIAZEM HCL 120 MG CAP ER DEG 0.55012 0.55010 12/14/2012 DILTIAZEM HCL 120 MG CAPSULE ER 0.53252 0.58334 10/25/2013 DILTIAZEM HCL 120 MG TABLET 0.13822 0.19596 10/18/2013 DILTIAZEM HCL 180 MG CAP ER 24H 0.48052 0.48047 5/24/2013 DILTIAZEM HCL 180 MG CAP ER DEG 0.62752 0.62750 12/14/2012 DILTIAZEM HCL 180 MG CAPSULE ER 0.77988 0.55237 1/24/2014 DILTIAZEM HCL 180 MG TAB ER 24H 0.00000 2.08282 12/1/2012 DILTIAZEM HCL 240 MG CAP ER 24H 0.67400 0.66950 12/21/2012 DILTIAZEM HCL 240 MG CAP ER DEG 0.70396 0.67140 9/20/2013 DILTIAZEM HCL 240 MG CAPSULE ER 0.94974 0.99100 11/29/2013 DILTIAZEM HCL 240 MG TAB ER 24H 2.33435 2.33440 1/25/2013 DILTIAZEM HCL 30 MG TABLET 0.03320 0.06084 9/20/2013 DILTIAZEM HCL 300 MG CAP ER 24H 0.61600 0.71100 12/21/2012 DILTIAZEM HCL 300 MG CAPSULE ER 1.20200 1.39010 2/22/2013 DILTIAZEM HCL 300 MG TAB ER 24H 3.03668 3.03690 1/25/2013 DILTIAZEM HCL 360 MG CAP ER 24H 6.87758 7.16419 1/3/2014 DILTIAZEM HCL 360 MG CAPSULE ER 1.27911 1.22907 12/13/2013 DILTIAZEM HCL 360 MG TAB ER 24H 3.26731 3.26730 1/25/2013 DILTIAZEM HCL 420MG CAPSULE ER 0.00000 1.72005 12/1/2012 DILTIAZEM HCL 420MG TAB ER 24H 0.00000 3.54216 12/1/2012 DILTIAZEM HCL 60 MG CAP ER 12H 0.86790 0.91994 7/26/2013 DILTIAZEM HCL 60 MG TABLET 0.06177 0.10434 9/20/2013 DILTIAZEM HCL 90 MG TABLET 0.11968 0.13998 10/18/2013 DIMENHYDRINATE 50 MG TABLET 0.00000 0.01809 12/1/2012 DIMENHYDRINATE 50 MG/ML VIAL 0.00000 4.98960 12/1/2012 DIMETHICONE 1 % CREAM(ML) 0.05662 0.06020 1/25/2013 DIMETHICONE 2 % SPRAY 0.02996 0.03000 1/25/2013 DIMETHICONE 5 % CREAM(ML) 0.03770 0.03810 1/25/2013 DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR 0.00000 0.00512 1/11/2013 DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID 0.01039 0.00592 8/30/2013 DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP 0.01259 0.01260 1/25/2013 DIPHENHYDRAMINE HCL 25 MG CAPSULE 0.01635 0.01633 4/26/2013 DIPHENHYDRAMINE HCL 25 MG TABLET 0.02104 0.05025 7/19/2013 DIPHENHYDRAMINE HCL 50 MG CAPSULE 0.01742 0.01770 10/18/2013 DIPHENOXYLATE HCL/ATROPINE 2.5-.025/5 LIQUID 0.00000 0.10803 12/1/2012 DIPHENOXYLATE HCL/ATROPINE 2.5-.025MG TABLET 0.12154 0.12598 5/10/2013 DIPYRIDAMOLE 25 MG TABLET 0.06874 0.06870 12/14/2012 DIPYRIDAMOLE 50 MG TABLET 0.10814 0.10810 12/14/2012 DIPYRIDAMOLE 75 MG TABLET 0.13681 0.13680 12/14/2012 DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE 0.30511 0.30510 12/14/2012 DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE 0.35458 0.35460 12/14/2012 DISULFIRAM 250 MG TABLET 2.72263 2.44805 9/6/2013

Page 16 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 DISULFIRAM 500 MG TABLET 4.54673 4.53960 1/25/2013 DIVALPROEX SODIUM 125 MG CAP SPRINK 0.49677 0.49955 6/28/2013 DIVALPROEX SODIUM 125 MG TABLET DR 0.05186 0.05190 12/14/2012 DIVALPROEX SODIUM 250 MG TAB ER 24H 0.20690 1.71836 12/27/2013 DIVALPROEX SODIUM 250 MG TABLET DR 0.09070 0.08831 12/27/2013 DIVALPROEX SODIUM 500 MG TAB ER 24H 0.39704 2.85243 12/27/2013 DIVALPROEX SODIUM 500 MG TABLET DR 0.15812 0.15477 12/27/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 15-10-4/5 LIQUID 0.04836 0.04500 1/25/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 15-5-2MG/5 LIQUID 0.04477 0.06860 1/25/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 3-2-1MG/ML DROPS 0.55499 0.55500 1/25/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 3-3.5-1/ML DROPS 0.00000 1.37627 12/1/2012 DOBUTAMINE HCL 250MG/20ML VIAL 0.14557 0.15780 1/25/2013 DOBUTAMINE HCL 500MG/40ML VIAL 0.15834 0.15830 1/25/2013 DOBUTAMINE HCL/D5W 1000MG/250 IV SOLN 0.06402 0.08730 1/25/2013 DOBUTAMINE HCL/D5W 250MG/250 IV SOLN 0.03994 0.04960 1/25/2013 DOBUTAMINE HCL/D5W 500 MG/500 IV SOLN 0.02779 0.02810 1/25/2013 DOBUTAMINE HCL/D5W 500MG/250 IV SOLN 0.05540 0.05620 1/25/2013 DOCETAXEL 140 MG/7ML VIAL 0.00000 156.00000 8/2/2013 DOCETAXEL 160 MG/8ML VIAL 255.60500 675.67500 6/28/2013 DOCETAXEL 160MG/16ML VIAL 0.00000 159.40890 12/1/2012 DOCETAXEL 20 MG/2 ML VIAL 0.00000 150.34425 12/1/2012 DOCETAXEL 20MG/ML(1) VIAL 274.18067 247.63550 7/26/2013 DOCETAXEL 80 MG/4 ML VIAL 274.17833 247.63375 7/26/2013 DOCETAXEL 80 MG/8 ML VIAL 0.00000 150.33770 12/1/2012 DOCETAXEL FNL 20MG/2 VIAL 0.00000 148.61475 12/1/2012 DOCETAXEL FNL 80MG/8 VIAL 0.00000 297.22950 12/1/2012 DOCOSAHEXANOIC ACID 200 MG CAPSULE 0.18670 0.19600 3/15/2013 DOCUSATE CALCIUM 240 MG CAPSULE 0.05132 0.05135 5/24/2013 DOCUSATE SODIUM 100 MG CAPSULE 0.01506 0.01743 5/17/2013 DOCUSATE SODIUM 100 MG TABLET 0.00000 0.03068 12/1/2012 DOCUSATE SODIUM 250 MG CAPSULE 0.03978 0.04368 6/21/2013 DOCUSATE SODIUM 50 MG/5 ML LIQUID 0.02005 0.00902 11/22/2013 DOCUSATE SODIUM 60 MG/15ML SYRUP 0.00657 0.00788 11/8/2013 DONEPEZIL HCL 10 MG TAB RAPDIS 0.27260 0.27257 3/15/2013 DONEPEZIL HCL 10 MG TABLET 0.06827 0.15286 10/4/2013 DONEPEZIL HCL 23 MG TABLET 0.00000 7.94987 8/16/2013 DONEPEZIL HCL 5 MG TAB RAPDIS 0.27260 0.27257 3/15/2013 DONEPEZIL HCL 5 MG TABLET 0.07736 0.11410 10/4/2013 DOPAMINE HCL 400 MG/5ML VIAL 0.00000 0.50263 12/1/2012 DOPAMINE HCL 400MG/10ML VIAL 0.07476 0.07980 1/25/2013 DOPAMINE HCL 800MG/10ML VIAL 0.00000 0.20101 12/1/2012 DOPAMINE HCL 800MG/5ML VIAL 0.00000 0.62837 12/1/2012 DOPAMINE HCL/D5W 200MG/.25L PLAST. BAG 0.03060 0.02960 1/25/2013 DOPAMINE HCL/D5W 400MG/.25L PLAST. BAG 0.03721 0.03690 1/25/2013 DOPAMINE HCL/D5W 400MG/0.5L PLAST. BAG 0.04374 0.04060 1/25/2013 DOPAMINE HCL/D5W 800MG/.25L PLAST. BAG 0.05361 0.08010 1/25/2013 DOPAMINE HCL/D5W 800MG/0.5L PLAST. BAG 0.06031 0.05100 1/25/2013 DORZOLAMIDE HCL 2 % DROPS 1.36928 1.45792 10/25/2013 DORZOLAMIDE HCL/TIMOLOL MALEAT 2 %-0.5 % DROPS 1.83714 1.87466 1/31/2014 DOXAZOSIN MESYLATE 1 MG TABLET 0.64990 0.63623 11/8/2013 DOXAZOSIN MESYLATE 2 MG TABLET 0.69868 0.67992 11/8/2013 DOXAZOSIN MESYLATE 4 MG TABLET 0.44316 0.73338 9/27/2013 DOXAZOSIN MESYLATE 8 MG TABLET 0.54947 0.77023 9/27/2013 DOXEPIN HCL 10 MG CAPSULE 0.15811 0.16753 8/16/2013 DOXEPIN HCL 10 MG/ML ORAL CONC 0.05716 0.05720 12/14/2012 DOXEPIN HCL 100 MG CAPSULE 0.50570 0.53599 8/16/2013 DOXEPIN HCL 150 MG CAPSULE 0.00000 0.50211 12/1/2012

Page 17 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 DOXEPIN HCL 25 MG CAPSULE 0.21073 0.22344 8/16/2013 DOXEPIN HCL 50 MG CAPSULE 0.28019 0.29702 8/16/2013 DOXORUBICIN HCL PEG-LIPOSOMAL 2 MG/ML VIAL 80.58400 80.99070 4/5/2013 DOXYCYCLINE HYCLATE 100 MG CAPSULE 3.80692 3.27445 1/31/2014 DOXYCYCLINE HYCLATE 100 MG TABLET 3.77012 2.29740 8/9/2013 DOXYCYCLINE HYCLATE 100 MG TABLET DR 19.21626 9.20381 4/19/2013 DOXYCYCLINE HYCLATE 100 MG VIAL 12.55800 13.37070 1/25/2013 DOXYCYCLINE HYCLATE 150 MG TABLET DR 25.72164 12.31958 6/21/2013 DOXYCYCLINE HYCLATE 20 MG TABLET 0.77623 0.49892 4/19/2013 DOXYCYCLINE HYCLATE 50 MG CAPSULE 0.07660 1.57724 6/28/2013 DOXYCYCLINE HYCLATE 75 MG TABLET DR 7.15692 7.15693 10/18/2013 DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE 0.00000 0.41162 12/1/2012 DOXYCYCLINE MONOHYDRATE 100 MG TABLET 0.95110 0.95020 1/25/2013 DOXYCYCLINE MONOHYDRATE 150 MG CAPSULE 0.00000 17.25512 12/1/2012 DOXYCYCLINE MONOHYDRATE 150 MG TABLET 0.00000 4.39361 12/1/2012 DOXYCYCLINE MONOHYDRATE 25 MG/5 ML SUSP RECON 0.00000 0.26565 6/21/2013 DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE 0.21255 0.19253 3/1/2013 DOXYCYCLINE MONOHYDRATE 50 MG TABLET 1.35064 1.35060 12/14/2012 DOXYCYCLINE MONOHYDRATE 75 MG CAPSULE 0.00000 9.06192 12/1/2012 DOXYCYCLINE MONOHYDRATE 75 MG TABLET 0.86431 0.73370 1/25/2013 DRONABINOL 10 MG CAPSULE 0.00000 12.58532 12/1/2012 DRONABINOL 2.5 MG CAPSULE 3.54706 3.46778 1/24/2014 DRONABINOL 5 MG CAPSULE 7.34911 7.47720 11/29/2013 DROPERIDOL 2.5 MG/ML AMPUL 0.50820 0.84840 1/25/2013 DROPERIDOL 2.5 MG/ML VIAL 1.42800 1.48750 1/25/2013 ECONAZOLE NITRATE 1 % CREAM (G) 0.16333 0.22015 8/23/2013 ELECTROLYTE,ORAL SOLUTION 0.00409 0.00414 7/26/2013 ELECTROLYTE-48 SOLUTION/D5W 5 % IV SOLN 0.00433 0.00430 1/25/2013 EMOLLIENT COMBINATION NO.10 EMULSN(G) 0.00000 0.44835 12/1/2012 EMOLLIENT COMBINATION NO.32 EMULSN(G) 0.00000 0.61081 12/1/2012 EMOLLIENT COMBINATION NO.44 FOAM 0.00000 0.90811 12/1/2012 EMOLLIENT COMBINATION NO.53 CREAM (G) 0.00000 0.51341 12/1/2012 EMOLLIENT COMBINATION NO.53 FOAM 0.00000 1.01001 12/1/2012 ENALAPRIL MALEATE 10 MG TABLET 0.02967 0.14807 8/16/2013 ENALAPRIL MALEATE 100 % POWDER 8.58004 3.35240 1/25/2013 ENALAPRIL MALEATE 2.5 MG TABLET 0.02439 0.11109 8/16/2013 ENALAPRIL MALEATE 20 MG TABLET 0.04476 0.21065 8/16/2013 ENALAPRIL MALEATE 5 MG TABLET 0.02827 0.14097 8/16/2013 ENALAPRIL/HYDROCHLOROTHIAZIDE 10MG-25MG TABLET 0.10967 0.11725 5/17/2013 ENALAPRIL/HYDROCHLOROTHIAZIDE 5MG-12.5MG TABLET 0.07030 0.08740 5/31/2013 ENALAPRILAT DIHYDRATE 1.25MG/ML VIAL 1.81436 1.71820 1/25/2013 ENOXAPARIN SODIUM 100 MG/ML SYRINGE 24.98475 61.85070 7/19/2013 ENOXAPARIN SODIUM 120MG/.8ML SYRINGE 36.57456 67.48480 7/19/2013 ENOXAPARIN SODIUM 150 MG/ML SYRINGE 36.62633 67.48810 7/19/2013 ENOXAPARIN SODIUM 300MG/3ML VIAL 67.48810 69.34808 9/27/2013 ENOXAPARIN SODIUM 30MG/0.3ML SYRINGE 44.91890 41.91890 9/20/2013 ENOXAPARIN SODIUM 40MG/0.4ML SYRINGE 24.88500 42.00000 7/19/2013 ENOXAPARIN SODIUM 60MG/0.6ML SYRINGE 43.65600 46.65600 9/20/2013 ENOXAPARIN SODIUM 80MG/0.8ML SYRINGE 25.02281 45.50740 7/19/2013 ENTACAPONE 200 MG TABLET 0.00000 2.76836 12/1/2012 ENZYMES,DIGESTIVE CAPSULE 0.04515 0.05940 1/25/2013 EPHEDRINE SULFATE 50 MG/ML VIAL 4.92170 4.10130 1/25/2013 EPINASTINE HCL 0.05 % DROPS 10.45350 9.27130 11/22/2013 EPINEPHRINE 0.1 MG/ML SYRINGE 0.52584 0.47910 1/25/2013 EPINEPHRINE 1 MG/ML VIAL 0.00000 0.18800 12/1/2012 EPIRUBICIN HCL 200 MG VIAL 0.00000 1,992.09500 12/1/2012 EPIRUBICIN HCL 50 MG VIAL 0.00000 76.67100 12/1/2012

Page 18 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 EPLERENONE 25 MG TABLET 2.32284 2.30663 9/13/2013 EPLERENONE 50 MG TABLET 2.33800 2.29862 11/22/2013 EPOPROSTENOL SODIUM (GLYCINE) 0.5 MG VIAL 10.12200 12.85200 1/25/2013 EPOPROSTENOL SODIUM (GLYCINE) 1.5 MG VIAL 0.00000 24.45100 12/1/2012 EPROSARTAN MESYLATE 600 MG TABLET 0.00000 2.39820 12/1/2012 ERGOCALCIFEROL (VITAMIN D2) 2000 UNIT TABLET 0.00000 0.05446 12/1/2012 ERGOCALCIFEROL (VITAMIN D2) 400 UNIT TABLET 0.02270 0.02380 2/8/2013 ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT CAPSULE 0.25326 0.27818 1/17/2014 ERGOLOID MESYLATES 1 MG TABLET 3.91391 5.67287 4/26/2013 ERY E-SUCC/SULFISOXAZOLE 200-600/5 SUSP RECON 0.18300 0.19120 2/8/2013 ERYTHROMYCIN BASE 250 MG CAPSULE DR 2.65410 2.65405 7/5/2013 ERYTHROMYCIN BASE 250 MG TABLET 2.37790 2.97234 12/20/2013 ERYTHROMYCIN BASE 5 MG/G OINT. (G) 2.91200 2.90875 6/21/2013 ERYTHROMYCIN BASE 500 MG TABLET 2.79500 3.50999 1/31/2014 ERYTHROMYCIN BASE/ETHANOL 2 % MED. SWAB 1.04870 1.10370 2/8/2013 ERYTHROMYCIN/BENZOYL PEROXIDE 3 %-5 % GEL (GRAM) 1.07403 1.08783 1/24/2014 ESCITALOPRAM OXALATE 10 MG TABLET 0.00000 0.16950 2/1/2013 ESCITALOPRAM OXALATE 20 MG TABLET 0.16723 0.19890 2/8/2013 ESCITALOPRAM OXALATE 5 MG TABLET 0.11350 0.15950 2/8/2013 ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION 0.00000 0.55475 12/1/2012 ESOMEPRAZOLE SODIUM 20 MG VIAL 0.00000 73.28790 1/31/2014 ESOMEPRAZOLE SODIUM 40 MG VIAL 0.00000 73.28790 1/31/2014 ESTAZOLAM 1 MG TABLET 0.26774 0.26770 1/25/2013 ESTAZOLAM 2 MG TABLET 0.29328 0.29330 1/25/2013 ESTRADIOL .025MG/24H PATCH TDWK 11.57200 15.92223 9/20/2013 ESTRADIOL .0375MG/24 PATCH TDWK 13.63578 10.74000 8/23/2013 ESTRADIOL .075MG/24H PATCH TDWK 14.03856 10.55000 8/23/2013 ESTRADIOL 0.05MG/24H PATCH TDWK 11.57200 10.57875 4/19/2013 ESTRADIOL 0.06MG/24H PATCH TDWK 12.98050 11.48275 8/2/2013 ESTRADIOL 0.1MG/24HR PATCH TDWK 15.83261 15.63612 1/31/2014 ESTRADIOL 0.5 MG TABLET 0.07584 0.06790 5/17/2013 ESTRADIOL 1 MG TABLET 0.05120 0.08683 2/22/2013 ESTRADIOL 2 MG TABLET 0.11216 0.12047 5/17/2013 ESTRADIOL/NORETHINDRONE ACET 0.5-0.1MG TABLET 5.28900 6.39301 12/27/2013 ESTRADIOL/NORETHINDRONE ACET 1 MG-0.5MG TABLET 2.71944 2.68822 9/27/2013 ESTROGEN,ESTER/ME-TESTOSTERONE 0.625-1.25 TABLET 0.00000 0.54404 12/1/2012 ESTROGEN,ESTER/ME-TESTOSTERONE 1.25-2.5MG TABLET 0.00000 0.54404 12/1/2012 ESTROPIPATE 0.75 MG TABLET 0.23634 0.23630 12/14/2012 ESTROPIPATE 1.5 MG TABLET 0.33059 0.33060 12/14/2012 ESTROPIPATE 3 MG TABLET 0.70273 0.70270 12/14/2012 ETHAMBUTOL HCL 100 MG TABLET 0.30650 0.38773 8/2/2013 ETHAMBUTOL HCL 400 MG TABLET 0.62310 1.17404 8/2/2013 ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) TABLET 0.00000 1.77025 12/1/2012 ETHINYL ESTRADIOL/DROSPIRENONE 0.03-3MG TABLET 2.02110 2.83232 5/10/2013 ETHOSUXIMIDE 250 MG CAPSULE 0.82792 0.75335 8/9/2013 ETHOSUXIMIDE 250 MG/5ML SOLUTION 0.15604 0.18022 10/11/2013 ETHYL ALCOHOL 98 % AMPUL 6.26450 6.94000 3/1/2013 ETHYL ALCOHOL 98 % VIAL 12.10060 12.09096 3/29/2013 ETHYNODIOL D-ETHINYL ESTRADIOL 1 MG-35MCG TABLET 0.74020 0.74700 2/8/2013 ETIDRONATE DISODIUM 200 MG TABLET 2.85340 3.02458 1/24/2014 ETIDRONATE DISODIUM 400 MG TABLET 5.70550 6.04777 11/22/2013 ETODOLAC 200 MG CAPSULE 0.40000 0.92480 1/25/2013 ETODOLAC 300 MG CAPSULE 1.13180 1.13176 6/14/2013 ETODOLAC 400 MG TAB ER 24H 0.70968 2.03084 9/20/2013 ETODOLAC 400 MG TABLET 0.00000 1.05900 11/15/2013 ETODOLAC 500 MG TAB ER 24H 0.85649 2.15747 9/20/2013 ETODOLAC 500 MG TABLET 0.25986 0.23740 5/17/2013

Page 19 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 ETODOLAC 600 MG TAB ER 24H 1.55061 2.29187 9/20/2013 ETOPOSIDE 50 MG CAPSULE 46.79400 56.82120 2/15/2013 EXEMESTANE 25 MG TABLET 4.73060 5.12530 8/2/2013 FA/ARGININE HCL/B12/B6/PEP EX 2-500-500 TABLET 0.00000 0.56210 12/1/2012 FAMCICLOVIR 125 MG TABLET 1.06080 1.08160 3/22/2013 FAMCICLOVIR 250 MG TABLET 1.21270 1.08272 7/26/2013 FAMCICLOVIR 500 MG TABLET 2.43522 2.04591 7/26/2013 FAMOTIDINE 10 MG TABLET 0.08310 0.08308 4/12/2013 FAMOTIDINE 10 MG/ML VIAL 0.00000 0.27792 12/1/2012 FAMOTIDINE 20 MG TABLET 0.03788 0.03792 10/18/2013 FAMOTIDINE 40 MG TABLET 0.06941 0.07370 11/15/2013 FAMOTIDINE 40MG/5ML ORAL SUSP 0.00000 1.73584 12/1/2012 FAMOTIDINE IN NACL,ISO-OSM/PF 20 MG/50ML PIGGYBACK 0.00000 0.13650 12/1/2012 FAMOTIDINE/PF 20 MG/2 ML VIAL 0.37429 0.37780 1/25/2013 FE FUMARATE/VIT C/B12-IF/FA 110-0.5MG CAPSULE 0.40083 0.18226 8/30/2013 FELBAMATE 400 MG TABLET 0.00000 3.64207 12/1/2012 FELBAMATE 600 MG TABLET 0.00000 4.17758 12/1/2012 FELBAMATE 600MG/5ML ORAL SUSP 0.00000 1.87137 12/1/2012 FELODIPINE 10 MG TAB ER 24H 0.81547 0.76431 8/16/2013 FELODIPINE 2.5 MG TAB ER 24H 0.65459 0.64253 1/10/2014 FELODIPINE 5 MG TAB ER 24H 0.54377 0.54417 1/10/2014 FENOFIBRATE 160 MG TABLET 1.36605 1.33971 12/13/2013 FENOFIBRATE 54 MG TABLET 0.00000 0.55448 12/1/2012 FENOFIBRATE NANOCRYSTALLIZED 145MG TABLET 3.96421 3.82670 2/22/2013 FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET 1.07677 1.33480 8/16/2013 FENOFIBRATE,MICRONIZED 130 MG CAPSULE 0.00000 4.84307 3/15/2013 FENOFIBRATE,MICRONIZED 200 MG CAPSULE 0.00000 2.31300 12/1/2012 FENOFIBRATE,MICRONIZED 43 MG CAPSULE 0.00000 1.64500 3/15/2013 FENOFIBRATE,MICRONIZED 67 MG CAPSULE 0.73960 0.73955 3/1/2013 FENOFIBRIC ACID (CHOLINE) 135 MG CAPSULE DR 3.11212 4.19665 11/8/2013 FENOFIBRIC ACID (CHOLINE) 45 MG CAPSULE DR 0.00000 1.10787 8/16/2013 FENOFIBRIC ACID 105 MG TABLET 0.00000 3.96959 12/1/2012 FENOFIBRIC ACID 35 MG TABLET 0.00000 1.32159 12/1/2012 FENTANYL 100 MCG/HR PATCH TD72 0.00000 21.12400 12/20/2013 FENTANYL 25MCG/HR PATCH TD72 3.64000 4.61000 1/3/2014 FENTANYL 50MCG/HR PATCH TD72 6.54560 9.08500 2/8/2013 FENTANYL 75MCG/HR PATCH TD72 11.08370 13.25120 2/22/2013 FENTANYL CITRATE 1200 MCG LOZENGE HD 0.00000 31.46500 12/1/2012 FENTANYL CITRATE 1600 MCG LOZENGE HD 0.00000 38.80683 12/1/2012 FENTANYL CITRATE 200 MCG LOZENGE HD 0.00000 13.16280 12/1/2012 FENTANYL CITRATE 400 MCG LOZENGE HD 0.00000 16.67657 12/1/2012 FENTANYL CITRATE 600 MCG LOZENGE HD 0.00000 20.42600 12/1/2012 FENTANYL CITRATE 800 MCG LOZENGE HD 0.00000 24.20180 12/1/2012 FENTANYL CITRATE/PF 100MCG/2ML SYRINGE 0.59640 0.65520 1/25/2013 FERROUS GLUCONATE 240(27)MG TABLET 0.04165 0.05160 1/25/2013 FERROUS GLUCONATE 256(28)MG TABLET 0.00000 0.04946 4/19/2013 FERROUS SULFATE 15 MG/ML DROPS 0.07558 0.06191 9/27/2013 FERROUS SULFATE 220(44)/5 SOLUTION 0.00000 0.00697 12/1/2012 FERROUS SULFATE 325(65) MG TABLET 0.00830 0.00831 2/1/2013 FEXOFENADINE HCL 180 MG TABLET 0.37342 0.36687 9/20/2013 FEXOFENADINE HCL 30 MG TABLET 0.00000 0.71400 12/1/2012 FEXOFENADINE HCL 60 MG TABLET 0.55637 0.55639 12/27/2013 FEXOFENADINE/PSEUDOEPHEDRINE 180-240MG TAB ER 24H 0.00000 0.96973 12/1/2012 FINASTERIDE 5 MG TABLET 0.17866 0.17822 10/11/2013 FISH OIL/BORAGE/FLAX/OM3,6,9#1 400-400 MG CAPSULE 0.06490 0.06168 3/8/2013 FISH OIL/DHA/EPA 1200-144MG CAPSULE 0.00000 0.01579 12/1/2012 FLAVOXATE HCL 100 MG TABLET 0.95488 0.84201 5/17/2013

Page 20 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 FLECAINIDE ACETATE 100 MG TABLET 0.27700 0.27770 1/25/2013 FLECAINIDE ACETATE 150 MG TABLET 0.54565 0.54570 12/14/2012 FLECAINIDE ACETATE 50 MG TABLET 0.19060 0.19187 3/1/2013 FLUCONAZOLE 10 MG/ML SUSP RECON 0.26780 0.26688 5/3/2013 FLUCONAZOLE 100 MG TABLET 1.38741 1.39986 9/20/2013 FLUCONAZOLE 150 MG TABLET 0.72806 2.46133 8/30/2013 FLUCONAZOLE 200 MG TABLET 1.30286 2.07230 10/18/2013 FLUCONAZOLE 40 MG/ML SUSP RECON 0.64574 0.64570 12/14/2012 FLUCONAZOLE 50 MG TABLET 0.71847 0.43043 11/29/2013 FLUCONAZOLE IN DEXTROSE,ISO-OS 200MG/0.1L PIGGYBACK 0.09490 0.09492 4/12/2013 FLUCONAZOLE IN DEXTROSE,ISO-OS 400MG/0.2L PIGGYBACK 0.05300 0.05296 4/12/2013 FLUCONAZOLE IN NACL,ISO-OSM 100MG/50ML PGGYBK BTL 0.00000 0.25410 12/1/2012 FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L PGGYBK BTL 0.00000 0.12676 12/1/2012 FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L PIGGYBACK 0.05186 0.05182 4/26/2013 FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L PGGYBK BTL 0.00000 0.09450 12/1/2012 FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L PIGGYBACK 0.03268 0.03369 4/26/2013 FLUCYTOSINE 250 MG CAPSULE 0.00000 16.21200 12/1/2012 FLUCYTOSINE 500 MG CAPSULE 0.00000 31.37400 12/1/2012 FLUDROCORTISONE ACETATE 0.1 MG TABLET 0.51920 0.50277 4/12/2013 FLUNISOLIDE 25 MCG SPRAY 0.00000 1.92500 12/1/2012 FLUOCINOLONE ACETONIDE 0.01 % OIL 0.21619 0.27073 8/30/2013 FLUOCINOLONE ACETONIDE 0.01 % SOLUTION 0.00000 2.10000 12/1/2012 FLUOCINOLONE ACETONIDE 0.025 % CREAM (G) 1.18223 1.39143 1/10/2014 FLUOCINOLONE ACETONIDE 0.025 % OINT. (G) 1.32643 1.58340 3/29/2013 FLUOCINOLONE ACETONIDE OIL 0.01 % DROPS 1.50345 7.64750 10/11/2013 FLUOCINOLONE/SHOWER CAP 0.01 % OIL 0.28958 1.31845 10/11/2013 FLUOCINONIDE 0.05 % CREAM (G) 0.35081 0.40558 5/17/2013 FLUOCINONIDE 0.05 % GEL (GRAM) 0.80260 0.84670 1/25/2013 FLUOCINONIDE 0.05 % OINT. (G) 0.00000 0.78790 12/1/2012 FLUOCINONIDE 0.05 % SOLUTION 0.00000 1.20370 12/1/2012 FLUOCINONIDE 0.1 % CREAM (G) 0.00000 10.51620 1/31/2014 FLUOCINONIDE/EMOLLIENT BASE 0.05 % CREAM (G) 0.20660 0.25684 6/7/2013 FLUOROMETHOLONE 0.1 % DROPS SUSP 1.29450 1.62760 12/6/2013 FLUOROURACIL 1 G/20 ML VIAL 0.00000 0.49482 12/1/2012 FLUOROURACIL 2 % SOLUTION 5.29235 4.95080 1/25/2013 FLUOROURACIL 2.5 G/50ML VIAL 0.21580 0.21630 1/25/2013 FLUOROURACIL 5 % CREAM (G) 5.07677 4.05885 1/24/2014 FLUOROURACIL 5 % SOLUTION 5.44195 7.93170 5/17/2013 FLUOROURACIL 5 G/100 ML VIAL 0.21320 0.29560 2/1/2013 FLUOROURACIL 500MG/10ML VIAL 0.25082 0.24490 3/29/2013 FLUOXETINE HCL 10 MG CAPSULE 0.03034 0.03211 11/1/2013 FLUOXETINE HCL 10 MG TABLET 0.05200 0.05126 1/3/2014 FLUOXETINE HCL 20 MG CAPSULE 0.02479 0.02474 5/3/2013 FLUOXETINE HCL 20 MG TABLET 0.60474 0.59372 1/3/2014 FLUOXETINE HCL 20 MG/5 ML SOLUTION 0.03440 0.03527 7/5/2013 FLUOXETINE HCL 40 MG CAPSULE 0.21370 0.21373 3/22/2013 FLUOXETINE HCL 60 MG TABLET 2.21760 2.97158 7/5/2013 FLUOXETINE HCL 90 MG CAPSULE DR 0.00000 25.89300 12/1/2012 FLUPHENAZINE DECANOATE 25 MG/ML VIAL 17.59500 22.97610 4/12/2013 FLUPHENAZINE HCL 1 MG TABLET 0.11230 0.12779 5/17/2013 FLUPHENAZINE HCL 10 MG TABLET 0.16540 0.22160 1/25/2013 FLUPHENAZINE HCL 2.5 MG TABLET 0.19820 0.18330 1/25/2013 FLUPHENAZINE HCL 2.5 MG/5ML ELIXIR 0.00000 0.26710 12/1/2012 FLUPHENAZINE HCL 2.5 MG/ML VIAL 8.55120 10.58000 3/1/2013 FLUPHENAZINE HCL 5 MG TABLET 0.21690 0.22020 1/25/2013 FLUPHENAZINE HCL 5 MG/ML ORAL CONC 0.00000 0.81136 12/1/2012 FLURAZEPAM HCL 15 MG CAPSULE 0.06291 0.06290 12/14/2012

Page 21 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 FLURAZEPAM HCL 30 MG CAPSULE 0.06950 0.07260 12/14/2012 FLURBIPROFEN 100 MG TABLET 0.25139 0.25782 11/29/2013 FLURBIPROFEN 50 MG TABLET 0.11570 0.22100 4/19/2013 FLURBIPROFEN SODIUM 0.03 % DROPS 2.32417 1.57114 8/30/2013 FLUTAMIDE 125 MG CAPSULE 0.71030 0.63643 11/22/2013 FLUTICASONE PROPIONATE 0.005 % OINT. (G) 0.49070 0.48681 3/1/2013 FLUTICASONE PROPIONATE 0.05 % CREAM (G) 0.00000 0.55080 12/1/2012 FLUTICASONE PROPIONATE 0.05 % LOTION 0.00000 4.54942 12/1/2012 FLUTICASONE PROPIONATE 50 MCG SPRAY SUSP 0.76967 0.58542 1/31/2014 FLUVASTATIN SODIUM 20 MG CAPSULE 2.64297 3.18873 8/23/2013 FLUVASTATIN SODIUM 40 MG CAPSULE 2.64300 2.64297 8/23/2013 FLUVOXAMINE MALEATE 100 MG CAP ER 24H 18.53529 7.12857 5/31/2013 FLUVOXAMINE MALEATE 100 MG TABLET 0.28391 0.28246 11/29/2013 FLUVOXAMINE MALEATE 150 MG CAP ER 24H 19.89189 7.65030 5/3/2013 FLUVOXAMINE MALEATE 25 MG TABLET 0.29467 0.21544 1/3/2014 FLUVOXAMINE MALEATE 50 MG TABLET 0.38900 0.31115 9/20/2013 FOLIC ACID 0.4 MG TABLET 0.00000 0.01005 12/1/2012 FOLIC ACID 1 MG TABLET 0.00000 0.02320 12/1/2012 FOLIC ACID 5 MG/ML VIAL 1.49520 1.79410 2/15/2013 FOLIC ACID/MULTIVITS-MIN 0.4 MG TABLET 0.70885 0.80780 1/25/2013 FOLIC ACID/MULTIVITS-MIN/LUT 0.4MG-250 TABLET 0.04845 0.03600 1/25/2013 FOLIC ACID/VITAMIN B COMP W-C 0.8 MG TABLET 0.09958 0.09960 12/14/2012 FOLIC ACID/VITAMIN B COMP W-C 1 MG CAPSULE 0.11915 0.12301 11/15/2013 FONDAPARINUX SODIUM 10MG/0.8ML SYRINGE 0.00000 94.71000 1/25/2012 FONDAPARINUX SODIUM 2.5 MG/0.5 SYRINGE 36.82120 83.02000 9/13/2013 FONDAPARINUX SODIUM 5MG/0.4ML SYRINGE 176.97650 180.51275 10/25/2013 FONDAPARINUX SODIUM 7.5MG/0.6 SYRINGE 147.48213 132.73867 11/29/2013 FORMALDEHYDE 10 % SOL W/APPL 0.00000 0.36953 12/1/2012 FOSINOPRIL SODIUM 10 MG TABLET 0.17904 0.13400 11/29/2013 FOSINOPRIL SODIUM 20 MG TABLET 0.13924 0.18515 6/7/2013 FOSINOPRIL SODIUM 40 MG TABLET 0.17840 0.18330 9/20/2013 FOSINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 1.08073 0.97530 1/25/2013 FOSINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 1.00740 0.97530 1/25/2013 FOSPHENYTOIN SODIUM 100MG PE/2 VIAL 0.84210 0.95795 8/16/2013 FOSPHENYTOIN SODIUM 500 PE/10 VIAL 0.62205 0.69594 11/8/2013 FUROSEMIDE 10 MG/ML SOLUTION 0.11441 0.11127 5/17/2013 FUROSEMIDE 10 MG/ML VIAL 0.09070 0.19752 7/5/2013 FUROSEMIDE 20 MG TABLET 0.01053 0.01001 1/17/2014 FUROSEMIDE 40 MG TABLET 0.01167 0.01100 1/17/2014 FUROSEMIDE 40MG/5ML SOLUTION 0.00000 0.14150 12/1/2012 FUROSEMIDE 80 MG TABLET 0.02707 0.02701 4/26/2013 GABAPENTIN 100 MG CAPSULE 0.04090 0.04221 9/20/2013 GABAPENTIN 250 MG/5ML SOLUTION 0.12820 0.13253 1/17/2014 GABAPENTIN 250 MG/5ML SOLUTION (U-D) 0.00000 0.29166 12/1/2012 GABAPENTIN 300 MG CAPSULE 0.06928 0.06598 12/20/2013 GABAPENTIN 300 MG/6ML SOLUTION 0.00000 0.29164 12/1/2012 GABAPENTIN 400 MG CAPSULE 0.09903 0.09715 9/13/2013 GABAPENTIN 600 MG TABLET 0.23316 0.27550 3/15/2013 GABAPENTIN 800 MG TABLET 0.00000 0.42880 12/1/2012 GALANTAMINE HBR 12 MG TABLET 1.78863 1.85858 5/24/2013 GALANTAMINE HBR 16 MG CAP24H PEL 2.23110 2.15874 3/22/2013 GALANTAMINE HBR 24 MG CAP24H PEL 2.45528 2.45490 1/25/2013 GALANTAMINE HBR 4 MG TABLET 0.00000 1.78863 12/1/2012 GALANTAMINE HBR 4 MG/ML SOLUTION 0.00000 2.95575 12/1/2012 GALANTAMINE HBR 8 MG CAP24H PEL 2.36510 2.18150 1/25/2013 GALANTAMINE HBR 8 MG TABLET 1.78863 1.87242 5/17/2013 GANCICLOVIR SODIUM 500 MG VIAL 9.30936 9.65940 1/25/2013

Page 22 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 GANIRELIX ACETATE 250MCG/0.5 SYRINGE 221.90700 243.87300 1/25/2013 GATIFLOXACIN 0.5 % DROPS 0.00000 33.08480 10/25/2013 GEMCITABINE HCL 1 G VIAL 0.00000 39.63675 12/1/2012 GEMCITABINE HCL 1 G/26.3ML VIAL 0.00000 3.16329 12/1/2012 GEMCITABINE HCL 2 G VIAL 0.00000 92.63950 12/1/2012 GEMCITABINE HCL 2 G/52.6ML VIAL 0.00000 3.58109 12/1/2012 GEMCITABINE HCL 200 MG VIAL 0.00000 9.28800 12/1/2012 GEMCITABINE HCL 200MG/5.26 VIAL 0.00000 3.79680 12/1/2012 GEMFIBROZIL 600 MG TABLET 0.14583 0.17900 10/25/2013 GENTAMICIN IN NACL, ISO-OSM 100MG/50ML PIGGYBACK 0.00000 0.13213 12/1/2012 GENTAMICIN IN NACL, ISO-OSM 120MG/0.1L PIGGYBACK 0.00000 0.06630 12/1/2012 GENTAMICIN IN NACL, ISO-OSM 70 MG/50ML PIGGYBACK 0.00000 0.15469 12/1/2012 GENTAMICIN IN NACL, ISO-OSM 90MG/100ML PIGGYBACK 0.00000 0.07491 12/1/2012 GENTAMICIN SULFATE 0.3 % DROPS 1.24084 0.90852 6/14/2013 GENTAMICIN SULFATE 0.3 % OINT. (G) 2.66640 2.57725 12/27/2013 GENTAMICIN SULFATE 20 MG/2 ML VIAL 0.00000 1.45158 12/1/2012 GENTAMICIN SULFATE 40 MG/ML VIAL 0.60046 0.51161 1/17/2014 GENTAMICIN SULFATE/PF 100MG/10ML VIAL PORT 0.00000 0.29434 12/1/2012 GENTAMICIN SULFATE/PF 20 MG/2 ML VIAL 1.25658 1.09954 1/17/2014 GENTAMICIN SULFATE/PF 60 MG/6 ML VIAL PORT 0.00000 0.39255 12/1/2012 GENTAMICIN SULFATE/PF 80 MG/8 ML VIAL PORT 0.00000 0.34262 12/1/2012 GLIMEPIRIDE 1 MG TABLET 0.02910 0.02908 3/29/2013 GLIMEPIRIDE 2 MG TABLET 0.05347 0.04315 1/24/2014 GLIMEPIRIDE 4 MG TABLET 0.06860 0.06861 2/22/2013 GLIPIZIDE 10 MG TAB ER 24 0.00000 0.40120 12/1/2012 GLIPIZIDE 10 MG TABLET 0.03948 0.05265 11/8/2013 GLIPIZIDE 2.5 MG TAB ER 24 0.28467 0.21363 9/20/2013 GLIPIZIDE 5 MG TAB ER 24 0.00000 0.18940 12/1/2012 GLIPIZIDE 5 MG TABLET 0.01970 0.03000 1/25/2013 GLIPIZIDE/METFORMIN HCL 2.5-250 MG TABLET 0.00000 0.34151 12/1/2012 GLIPIZIDE/METFORMIN HCL 2.5-500 MG TABLET 0.00000 0.39585 12/1/2012 GLIPIZIDE/METFORMIN HCL 5 MG-500MG TABLET 0.39585 0.39607 8/2/2013 GLUCOSAMINE SULF/CHONDROITIN A 250-200 MG CAPSULE 0.12690 0.10590 1/25/2013 GLUCOSAMINE SULFATE 750 MG TABLET 0.00000 0.33095 12/1/2012 GLUCOSAMINE/CHONDROITIN A/MSM 500-200 MG TABLET 0.00000 1.20120 12/1/2012 GLYBURIDE 1.25 MG TABLET 0.11200 0.12103 11/8/2013 GLYBURIDE 2.5 MG TABLET 0.13308 0.14767 5/17/2013 GLYBURIDE 5 MG TABLET 0.20127 0.18706 11/15/2013 GLYBURIDE,MICRONIZED 1.5 MG TABLET 0.02587 0.02590 12/14/2012 GLYBURIDE,MICRONIZED 3 MG TABLET 0.02841 0.02840 12/14/2012 GLYBURIDE,MICRONIZED 6 MG TABLET 0.05510 0.09900 5/17/2013 GLYBURIDE/METFORMIN HCL 1.25-250MG TABLET 0.10184 0.10934 8/23/2013 GLYBURIDE/METFORMIN HCL 2.5-500 MG TABLET 0.09380 0.08911 7/26/2013 GLYBURIDE/METFORMIN HCL 5 MG-500MG TABLET 0.09517 0.08785 4/26/2013 GLYCINE POWDER 0.20644 0.21190 1/25/2013 GLYCINE 1.5 % IRRIG SOLN 0.00000 0.00300 12/1/2012 GLYCINE/SOD/WATER/SOD HYDROX VIAL 0.00000 0.14700 12/1/2012 GLYCOPYRROLATE 1 MG TABLET 0.23370 0.38840 4/12/2013 GLYCOPYRROLATE 2 MG TABLET 0.31946 0.68691 5/27/2013 GRANISETRON HCL 1 MG/ML VIAL 0.00000 4.71250 12/1/2012 GRANISETRON HCL 1 MG/ML(1) VIAL 0.00000 7.21995 12/1/2012 GRANISETRON HCL/PF 1 MG/ML(1) VIAL 9.00000 6.14680 8/30/2013 GRANISETRON HCL/PF 100 MCG/ML VIAL 2.49240 3.21880 8/30/2013 GRISEOFULVIN ULTRAMICROSIZE 125 MG TABLET 3.68837 3.68840 1/25/2013 GRISEOFULVIN ULTRAMICROSIZE 250 MG TABLET 4.71086 4.71090 1/25/2013 GRISEOFULVIN,MICROSIZE 125 MG/5ML ORAL SUSP 0.16187 0.12406 1/31/2014 GRISEOFULVIN,MICROSIZE 500 MG TABLET 0.00000 5.40337 12/14/2012

Page 23 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 GUAIFENESIN 100 MG/5ML LIQUID 0.00628 0.00603 8/30/2013 GUAIFENESIN 200 MG TABLET 0.05376 0.05110 12/14/2012 GUAIFENESIN 400 MG TABLET 0.10180 0.05655 6/7/2013 GUAIFENESIN 600 MG TABLET ER 0.31792 0.32897 11/1/2013 GUAIFENESIN/CODEINE PHOSPHATE 100-10MG/5 LIQUID 0.01567 0.02044 10/11/2013 GUAIFENESIN/CODEINE PHOSPHATE 100-6.3/5 LIQUID 0.06360 0.03518 11/22/2013 GUAIFENESIN/CODEINE PHOSPHATE 225-7.5/5 LIQUID 0.04710 0.04970 1/25/2013 GUAIFENESIN/D-METHORPHAN HB/PE 100-10-5MG LIQUID 0.00000 0.01943 12/1/2012 GUAIFENESIN/D-METHORPHAN HB/PE 100-15-5/5 LIQUID 0.08670 0.03941 10/11/2013 GUAIFENESIN/D-METHORPHAN HB/PE 200-10-5/5 LIQUID 0.02586 0.02590 4/19/2013 GUAIFENESIN/D-METHORPHAN HB/PE 200-20-10 LIQUID 0.08187 0.07980 1/25/2013 GUAIFENESIN/D-METHORPHAN HB/PE 380-15-10 TABLET 0.47192 0.43610 1/25/2013 GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 LIQUID 0.03762 0.03157 12/6/2013 GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 SYRUP 0.01352 0.00801 9/13/2013 GUAIFENESIN/DEXTROMETHORPHAN 400-20MG/5 LIQUID 0.07583 0.06510 2/22/2013 GUAIFENESIN/PHENYLEPHRINE HCL 380MG-10MG TABLET 0.46550 0.43170 1/25/2013 GUANFACINE HCL 1 MG TABLET 0.07990 0.07973 5/3/2013 GUANFACINE HCL 2 MG TABLET 0.11360 0.11553 3/1/2013 GUANIDINE HCL 125 MG TABLET 0.00000 0.17724 12/1/2012 HALOBETASOL PROPIONATE 0.05 % CREAM (G) 2.94003 2.67890 6/21/2013 HALOBETASOL PROPIONATE 0.05 % OINT. (G) 2.87200 2.83923 1/31/2014 HALOPERIDOL 0.5 MG TABLET 0.21377 0.21117 10/11/2013 HALOPERIDOL 1 MG TABLET 0.31078 0.35311 10/11/2013 HALOPERIDOL 10 MG TABLET 1.07036 1.07290 10/11/2013 HALOPERIDOL 2 MG TABLET 0.05077 0.44240 11/15/2013 HALOPERIDOL 20 MG TABLET 2.13551 2.13980 10/11/2013 HALOPERIDOL 5 MG TABLET 0.14260 0.67517 10/11/2013 HALOPERIDOL DECANOATE 100 MG/ML AMPUL 37.65030 41.45400 8/30/2013 HALOPERIDOL DECANOATE 100 MG/ML VIAL 31.87372 33.27379 8/2/2013 HALOPERIDOL DECANOATE 50 MG/ML AMPUL 0.00000 21.74667 12/1/2012 HALOPERIDOL DECANOATE 50 MG/ML VIAL 15.60005 22.14000 8/23/2013 HALOPERIDOL LACTATE 2 MG/ML ORAL CONC 0.04030 0.05316 5/17/2013 HALOPERIDOL LACTATE 5 MG/ML AMPUL 0.00000 5.15760 12/1/2012 HALOPERIDOL LACTATE 5 MG/ML VIAL 1.14838 1.14840 12/14/2012 HC/MINERAL OIL/PETROLAT,WHT 1 % OINT. (G) 0.00000 0.12564 12/1/2012 HEPARIN SOD,PORK IN 0.45% NACL 12500/250 IV SOLN 0.03562 0.03400 1/25/2013 HEPARIN SOD,PORK IN 0.45% NACL 25000/250 IV SOLN 0.00000 0.02288 12/1/2012 HEPARIN SOD,PORK IN 0.45% NACL 25000/500 IV SOLN 0.00000 0.01749 12/1/2012 HEPARIN SODIUM,PORCINE 10 UNIT/ML SYRINGE 0.64407 0.65250 1/25/2013 HEPARIN SODIUM,PORCINE 100/ML (1) SYRINGE 0.00000 1.26000 11/15/2013 HEPARIN SODIUM,PORCINE 100/ML VIAL 0.03720 0.03983 4/5/2013 HEPARIN SODIUM,PORCINE 1000/ML VIAL 0.21199 0.20726 9/13/2013 HEPARIN SODIUM,PORCINE 10000/ML VIAL 2.33150 2.33147 6/21/2013 HEPARIN SODIUM,PORCINE 200/2 ML SYRINGE 0.00000 0.64680 11/15/2013 HEPARIN SODIUM,PORCINE 20000/ML VIAL 9.83545 8.04232 5/31/2013 HEPARIN SODIUM,PORCINE 300/3 ML SYRINGE 0.00000 0.50680 11/15/2013 HEPARIN SODIUM,PORCINE 500/5 ML SYRINGE 0.00000 0.32928 11/15/2013 HEPARIN SODIUM,PORCINE 5000/ML VIAL 0.72530 0.72537 6/21/2013 HEPARIN SODIUM,PORCINE 5000/ML(1) CARTRIDGE 0.00000 3.65400 12/1/2012 HEPARIN SODIUM,PORCINE/D5W 12500/250 IV SOLN 0.04076 0.03780 1/25/2013 HEPARIN SODIUM,PORCINE/D5W 20K/500ML IV SOLN 0.01172 0.00870 1/25/2013 HEPARIN SODIUM,PORCINE/NS/PF 1000/500ML IV SOLN 0.00579 0.00720 1/25/2013 HEPARIN SODIUM,PORCINE/NS/PF 2K/1000ML IV SOLN 0.00370 0.00440 1/25/2013 HEPARIN SODIUM,PORCINE/PF 1 UNIT/ML SYRINGE 0.00000 0.53235 5/31/2013 HEPARIN SODIUM,PORCINE/PF 10 UNIT/ML SYRINGE 0.00000 0.15678 5/31/2013 HEPARIN SODIUM,PORCINE/PF 10 UNIT/ML VIAL 1.27811 1.27250 1/25/2013 HEPARIN SODIUM,PORCINE/PF 100/ML (1) SYRINGE 0.00000 0.14740 5/31/2013

Page 24 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 HEPARIN SODIUM,PORCINE/PF 100/ML (1) VIAL 0.00000 1.63384 12/1/2012 HEPARIN SODIUM,PORCINE/PF 1000/10 ML SYRINGE 0.00000 0.14740 5/31/2013 HEPARIN SODIUM,PORCINE/PF 1000/ML VIAL 4.02116 3.64416 6/21/2013 HEPARIN SODIUM,PORCINE/PF 200/2 ML SYRINGE 0.00000 0.14740 5/31/2013 HEPARIN SODIUM,PORCINE/PF 300/3 ML SYRINGE 0.14740 0.25350 11/8/2013 HEPARIN SODIUM,PORCINE/PF 500/5 ML SYRINGE 0.00000 0.14740 5/31/2013 HEPARIN SODIUM,PORCINE/PF 5000/0.5ML SYRINGE 0.00000 7.45725 12/1/2012 HEPARIN SODIUM,PORCINE/PF 5000/0.5ML VIAL 0.00000 9.36923 12/1/2012 HYDRALAZINE HCL 10 MG TABLET 0.05641 0.05708 11/8/2013 HYDRALAZINE HCL 100 MG TABLET 0.16320 0.18850 1/25/2013 HYDRALAZINE HCL 20 MG/ML VIAL 0.00000 4.60408 12/1/2012 HYDRALAZINE HCL 25 MG TABLET 0.05900 0.05896 3/8/2013 HYDRALAZINE HCL 50 MG TABLET 0.06526 0.06346 1/31/2014 HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE 0.03870 0.03846 9/20/2013 HYDROCHLOROTHIAZIDE 12.5 MG TABLET 0.22571 0.25380 11/1/2013 HYDROCHLOROTHIAZIDE 25 MG TABLET 0.01024 0.02250 10/4/2013 HYDROCHLOROTHIAZIDE 50 MG TABLET 0.02747 0.04003 10/4/2013 HYDROCODONE BIT/HOMATROP ME-BR 5 MG-1.5MG TABLET 0.00000 0.42566 12/1/2012 HYDROCODONE BIT/HOMATROP ME-BR 5-1.5 MG/5 SYRUP 0.12020 0.06580 1/25/2013 HYDROCODONE BIT/HOMATROP ME-BR 5-1.5 MG/5 SYRUP ( U-D CUPS) 0.00000 0.52500 12/1/2012 HYDROCODONE/ACETAMINOPHEN 10MG-325MG TABLET 0.12006 0.13226 1/17/2014 HYDROCODONE/ACETAMINOPHEN 2.5-108/5 SOLUTION 0.00000 0.56630 9/27/2013 HYDROCODONE/ACETAMINOPHEN 2.5-167/5 SOLUTION 0.00000 0.47191 12/1/2012 HYDROCODONE/ACETAMINOPHEN 5-217MG/10 SOLUTION 0.00000 0.32085 9/27/2013 HYDROCODONE/ACETAMINOPHEN 5MG-325MG TABLET 0.14156 0.12792 8/2/2013 HYDROCODONE/ACETAMINOPHEN 7.5-300MG TABLET 1.29819 1.28474 6/14/2013 HYDROCODONE/ACETAMINOPHEN 7.5-325MG TABLET 0.17298 0.15919 1/31/2014 HYDROCODONE/ACETAMINOPHEN 7.5-500/15 SOLUTION (Bottle; Hospital) 0.08700 0.06365 11/15/2013 HYDROCODONE/ACETAMINOPHEN 7.5-500/15 SOLUTION (U-D) 0.15120 0.17666 9/13/2013 HYDROCODONE/CHLORPHEN POLIS 10-8MG/5ML SUS ER 12H 0.00000 0.46202 12/1/2012 HYDROCODONE/IBUPROFEN 10MG-200MG TABLET 0.00000 2.86300 12/1/2012 HYDROCODONE/IBUPROFEN 2.5-200MG TABLET 0.00000 2.04491 12/1/2012 HYDROCODONE/IBUPROFEN 5MG-200MG TABLET 0.96333 2.17077 8/2/2013 HYDROCODONE/IBUPROFEN 7.5-200 MG TABLET 0.23919 0.23195 7/26/2013 HYDROCORTISONE POWDER 2.52898 2.18774 5/3/2013 HYDROCORTISONE 0.5 % CREAM (G) 0.08089 0.08224 4/5/2013 HYDROCORTISONE 1 % CREAM (G) RECTAL 0.00000 0.66820 12/1/2012 HYDROCORTISONE 1 % CREAM (G) TOPICAL 0.04382 0.04378 4/26/2013 HYDROCORTISONE 1 % LOTION (G) 0.03143 0.04428 8/23/2013 HYDROCORTISONE 1 % LOTION (ML) 0.03143 0.03153 5/3/2013 HYDROCORTISONE 1 % OINT. (G) 0.06810 0.10490 1/25/2013 HYDROCORTISONE 10 MG TABLET 0.31148 0.41100 6/14/2013 HYDROCORTISONE 100MG/60ML ENEMA 0.08251 0.06583 1/31/2014 HYDROCORTISONE 2.5 % CREAM (G) TOPICAL 0.10280 0.10318 12/20/2013 HYDROCORTISONE 2.5 % LOTION 0.23713 0.23863 4/12/2013 HYDROCORTISONE 2.5 % OINT. (G) 0.00000 0.11200 12/1/2012 HYDROCORTISONE 20 MG TABLET 0.70055 0.64071 12/13/2013 HYDROCORTISONE 5 MG TABLET 0.00000 0.23730 12/1/2012 HYDROCORTISONE AC/LIDOCAINE 0.5 %-3 % CREAM/APPL 0.00000 1.78500 12/1/2012 HYDROCORTISONE AC/LIDOCAINE 1%-3%(7G) CREAM/APPL 0.00000 251.09000 12/1/2012 HYDROCORTISONE AC/LIDOCAINE 2.5-3%(7G) GEL W/APPL 0.00000 251.09000 12/1/2012 HYDROCORTISONE ACETATE POWDER 0.00000 3.23180 12/1/2012 HYDROCORTISONE ACETATE 25 MG SUPP.RECT 1.70599 3.64114 11/15/2013 HYDROCORTISONE ACETATE 30 MG SUPP.RECT 4.26360 3.95180 1/25/2013 HYDROCORTISONE BUTYRATE 0.1 % CREAM (G) 0.99540 1.02530 2/15/2013 HYDROCORTISONE BUTYRATE 0.1 % OINT. (G) 1.05690 0.85571 4/12/2013 HYDROCORTISONE BUTYRATE 0.1 % SOLUTION 0.30030 0.29238 6/14/2013

Page 25 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 HYDROCORTISONE BUTYRATE/EMOLL 0.1 % CREAM (G) 0.00000 6.29588 12/27/2013 HYDROCORTISONE VALERATE 0.2 % CREAM (G) 2.26433 2.28761 1/24/2014 HYDROCORTISONE/IODOQUINOL 1 %-1 % CREAM (G) 0.43203 0.43200 12/14/2012 HYDROCORTISONE/LIDOCAINE/ALOE 2.5-3%(7G) KIT 0.00000 3.05119 12/1/2012 HYDROCORTISONE/PRAMOXINE 2.5 %-1 % CREAM (G) 0.00000 1.30835 12/1/2012 HYDROMORPHONE HCL 0.5MG/.5ML SYRINGE 0.00000 8.44200 6/21/2013 HYDROMORPHONE HCL 1 MG/ML LIQUID 0.00000 0.27988 12/1/2012 HYDROMORPHONE HCL 1 MG/ML SYRINGE 3.54900 3.90600 1/25/2013 HYDROMORPHONE HCL 2 MG TABLET 0.09310 0.09250 3/22/2013 HYDROMORPHONE HCL 2 MG/ML SYRINGE 3.79050 4.17900 1/25/2013 HYDROMORPHONE HCL 2 MG/ML VIAL 1.74300 0.87780 6/7/2013 HYDROMORPHONE HCL 3 MG SUPP.RECT 7.77580 8.58670 2/1/2013 HYDROMORPHONE HCL 4 MG TABLET 0.11086 0.11269 5/24/2013 HYDROMORPHONE HCL 4 MG/ML SYRINGE 3.42300 3.78000 1/25/2013 HYDROMORPHONE HCL 8 MG TABLET 0.28810 0.42855 10/25/2013 HYDROMORPHONE HCL/PF 1 MG/ML AMPUL 0.84000 0.87360 1/25/2013 HYDROMORPHONE HCL/PF 10 MG/ML VIAL 1.87600 1.83561 1/24/2014 HYDROMORPHONE HCL/PF 2 MG/ML AMPUL 0.86520 0.94080 1/25/2013 HYDROMORPHONE HCL/PF 4 MG/ML AMPUL 1.27680 1.33560 1/25/2013 HYDROQUINONE 4 % CREAM (G) 0.00000 0.35360 12/1/2012 HYDROQUINONE MICROSPHERES 4 % CRM ER (G) 0.00000 2.49387 12/1/2012 HYDROXOCOBALAMIN 1000MCG/ML VIAL 0.00000 0.89273 12/1/2012 HYDROXYCHLOROQUINE SULFATE 200 MG TABLET 0.00000 0.10720 12/1/2012 HYDROXYUREA 500 MG CAPSULE 0.35210 0.35730 5/17/2013 HYDROXYZINE HCL 10 MG TABLET 0.07343 0.07338 9/27/2013 HYDROXYZINE HCL 10 MG/5 ML SYRUP 0.05914 0.06066 12/27/2013 HYDROXYZINE HCL 25 MG TABLET 0.08630 0.08632 5/31/2013 HYDROXYZINE HCL 25 MG/ML VIAL 0.51630 2.62500 1/31/2014 HYDROXYZINE HCL 50 MG TABLET 0.11020 0.11015 3/1/2013 HYDROXYZINE HCL 50 MG/ML VIAL 0.00000 1.75000 12/1/2012 HYDROXYZINE PAMOATE 100 MG CAPSULE 0.31486 0.29887 11/29/2013 HYDROXYZINE PAMOATE 25 MG CAPSULE 0.00000 0.06620 12/1/2012 HYDROXYZINE PAMOATE 50 MG CAPSULE 0.00000 0.08680 12/1/2012 HYOSCYAMINE SULFATE 0.125 MG TAB RAPDIS 0.46127 0.27859 8/30/2013 HYOSCYAMINE SULFATE 0.125 MG TAB SUBL 0.22713 0.44000 1/11/2013 HYOSCYAMINE SULFATE 0.125 MG TABLET 0.43797 0.44950 1/24/2014 HYOSCYAMINE SULFATE 0.125MG/ML DROPS 1.92046 1.05770 8/30/2013 HYOSCYAMINE SULFATE 0.375 MG TAB ER 12H 0.42399 0.60697 3/15/2013 HYOSCYAMINE SULFATE 125MCG/5ML ELIXIR 0.05400 0.04790 1/25/2013 HYPROMELLOSE 0.3 % DROPS 0.33450 0.35978 5/3/2013 HYPROMELLOSE 0.4 % DROPS 0.00000 0.17850 12/1/2012 IBANDRONATE SODIUM 150 MG TABLET 97.13590 51.87650 11/8/2013 IBUPROFEN 100 MG/5ML ORAL SUSP 0.02337 0.02262 9/13/2013 IBUPROFEN 200 MG CAPSULE 0.00000 0.05530 12/1/2012 IBUPROFEN 200 MG TABLET 0.01469 0.01635 6/14/2013 IBUPROFEN 400 MG TABLET 0.03564 0.06240 1/17/2014 IBUPROFEN 50 MG/1.25 DROPS SUSP 0.27347 0.22657 12/20/2013 IBUPROFEN 600 MG TABLET 0.04556 0.06164 1/17/2014 IBUPROFEN 800 MG TABLET 0.05515 0.06968 1/17/2014 IBUPROFEN/OXYCODONE HCL 400MG-5MG TABLET 1.03152 1.03130 1/25/2013 IFOSFAMIDE 1 G/20 ML VIAL 5.07623 1.87005 8/23/2013 IFOSFAMIDE 3 G VIAL 0.00000 88.61300 12/1/2012 IFOSFAMIDE 3G/60ML VIAL 3.11430 1.92790 8/23/2013 IFOSFAMIDE/MESNA 3G-1G KIT 0.00000 281.14725 12/1/2012 IMIPENEM/CILASTATIN SODIUM 250 MG VIAL 6.52680 5.23320 3/29/2013 IMIPENEM/CILASTATIN SODIUM 500 MG VIAL 9.87840 8.82000 8/9/2013 IMIPRAMINE HCL 10 MG TABLET 0.12569 0.13202 4/12/2013

Page 26 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 IMIPRAMINE HCL 25 MG TABLET 0.16254 0.16830 4/12/2013 IMIPRAMINE HCL 50 MG TABLET 0.23249 0.22962 5/24/2013 IMIPRAMINE PAMOATE 100 MG CAPSULE 7.71290 11.65038 6/14/2013 IMIPRAMINE PAMOATE 125 MG CAPSULE 0.00000 11.40705 12/1/2012 IMIPRAMINE PAMOATE 150 MG CAPSULE 11.40705 10.62040 1/25/2013 IMIPRAMINE PAMOATE 75 MG CAPSULE 9.55543 7.95000 12/27/2013 IMIQUIMOD 5 % CREAM PACK 10.97052 16.23000 12/13/2013 INDAPAMIDE 1.25 MG TABLET 0.10850 0.07660 1/25/2013 INDAPAMIDE 2.5 MG TABLET 0.11850 0.08740 1/25/2013 INDOMETHACIN 25 MG CAPSULE 0.12284 0.12869 12/27/2013 INDOMETHACIN 50 MG CAPSULE 0.16656 0.16305 8/16/2013 INDOMETHACIN 75 MG CAPSULE ER 1.19716 1.29820 4/19/2013 INDOMETHACIN SODIUM 1 MG VIAL 409.47900 376.93367 12/6/2013 IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION 0.06128 0.06181 1/17/2014 IPRATROPIUM BROMIDE 21 MCG SPRAY 0.19067 0.21840 5/17/2013 IPRATROPIUM BROMIDE 42MCG SPRAY 0.38870 0.43680 5/17/2013 IPRATROPIUM/ALBUTEROL SULFATE 0.5-3MG/3 AMPUL-NEB 0.09619 0.09305 10/11/2013 IRBESARTAN 150 MG TABLET 0.19252 0.19296 10/25/2013 IRBESARTAN 300 MG TABLET 0.31847 0.31320 5/31/2013 IRBESARTAN 75 MG TABLET 0.14564 0.14563 5/3/2013 IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG TABLET 0.19206 0.19177 11/15/2013 IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG TABLET 0.31951 0.66610 4/5/2013 IRON FUMARATE/VIT C/VIT B12/FA 460-60MG CAPSULE 0.00000 0.43155 12/1/2012 IRON POLYSACCH/IRON HEME POLYP 28 MG TABLET 0.39748 0.37090 1/25/2013 IRON POLYSACCHARIDES COMPLEX 150 MG CAPSULE 0.18890 0.12990 1/25/2013 IRON PS CMPLX/VIT B12/FA 150-25-1 CAPSULE 0.17231 0.18193 8/9/2013 IRON PS/IRON HEM POLY/FA/B12 22-6-1-25 TABLET 0.00000 2.61148 1/25/2013 IRON, CARB & GLUC/FA/B12/C/DSS 90-1-50 MG TABLET 0.00000 0.78945 5/3/2013 IRON,CARB/DSS/B12IF/FA/MV-MN 150-50-1MG TAB ER 24H 0.00000 0.47055 12/1/2012 IRON,CARBONYL 15 MG TAB CHEW 0.00000 0.42735 12/1/2012 IRON,CARBONYL 15MG/1.25 ORAL SUSP 0.11965 0.12650 1/25/2013 IRON,CARBONYL/FA/MULTIVITS-MIN 50-1.25MG TABLET 0.00000 1.05126 4/19/2013 IRON,CARBONYL/VIT C/VIT B12/FA 100-250-1 TABLET 0.39480 0.21567 3/8/2013 ISONIAZID 100 MG TABLET 0.04090 0.04221 12/13/2013 ISONIAZID 100 MG/ML VIAL 0.00000 63.03150 12/1/2012 ISONIAZID 300 MG TABLET 0.06790 0.06988 12/13/2013 ISONIAZID 50 MG/5 ML SOLUTION 0.00000 0.09983 12/1/2012 ISOPROPYL ALCOHOL/GLYCERIN 95%-5% DROPS 0.08660 0.07020 1/25/2013 ISOSORBIDE DINITRATE 10 MG TABLET 0.75849 0.75850 10/25/2013 ISOSORBIDE DINITRATE 20 MG TABLET 0.65840 0.83433 1/24/2014 ISOSORBIDE DINITRATE 30 MG TABLET 0.77680 0.75358 5/17/2013 ISOSORBIDE DINITRATE 40 MG TABLET ER 0.64714 0.95025 10/25/2013 ISOSORBIDE MONONITRATE 10 MG TABLET 0.25337 0.19730 1/25/2013 ISOSORBIDE MONONITRATE 120 MG TAB ER 24H 0.42893 0.44689 11/29/2013 ISOSORBIDE MONONITRATE 20 MG TABLET 0.10728 0.12251 10/11/2013 ISOSORBIDE MONONITRATE 30 MG TAB ER 24H 0.23713 0.22032 10/4/2013 ISOSORBIDE MONONITRATE 60 MG TAB ER 24H 0.25393 0.24348 9/13/2013 ISOSULFAN BLUE 1 % VIAL 99.96000 102.04250 1/25/2013 ISOTRETINOIN 10 MG CAPSULE 12.11805 12.20900 5/31/2013 ISOTRETINOIN 20 MG CAPSULE 14.43812 14.33891 11/29/2013 ISOTRETINOIN 30 MG CAPSULE 0.00000 11.51617 12/1/2012 ISOTRETINOIN 40 MG CAPSULE 16.54897 16.74549 11/29/2013 ISOXSUPRINE HCL 10 MG TABLET 0.80892 0.67470 1/25/2013 ISRADIPINE 2.5 MG CAPSULE 0.00000 0.95543 12/1/2012 ISRADIPINE 5 MG CAPSULE 0.00000 1.39713 12/1/2012 ITRACONAZOLE 100 MG CAPSULE 6.58834 6.74400 5/17/2013 KETOCONAZOLE 2 % CREAM (G) 0.16350 0.16348 7/26/2013

Page 27 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 KETOCONAZOLE 2 % SHAMPOO 0.14440 0.10040 1/25/2013 KETOCONAZOLE 200 MG TABLET 0.20110 0.19757 3/1/2013 KETOPROFEN 200 MG CAP24H PEL 4.81290 5.10170 2/8/2013 KETOPROFEN 75 MG CAPSULE 0.09402 0.25233 9/27/2013 KETOROLAC TROMETHAMINE 0.4 % DROPS 5.88770 2.38800 12/20/2013 KETOROLAC TROMETHAMINE 0.5 % DROPS 1.29580 1.29534 8/9/2013 KETOROLAC TROMETHAMINE 10 MG TABLET 0.35731 0.55620 9/20/2013 KETOROLAC TROMETHAMINE 15 MG/ML VIAL 0.00000 0.92058 12/1/2012 KETOROLAC TROMETHAMINE 30 MG/ML VIAL 0.00000 1.31943 12/1/2012 KETOROLAC TROMETHAMINE 30MG/ML(1) VIAL 0.64680 0.70560 2/15/2013 KETOROLAC TROMETHAMINE 60 MG/2 ML VIAL 0.50176 0.36960 3/1/2013 KETOTIFEN FUMARATE 0.025 % DROPS 1.19456 1.44982 11/29/2013 L-NORGEST-ETH ESTR/ETHIN ESTRA 100-20(84) TBDSPK 3MO 0.00000 2.06577 12/1/2012 L-NORGEST-ETH ESTR/ETHIN ESTRA 150-30(84) TBDSPK 3MO 2.06577 2.50844 12/20/2013 LABETALOL HCL 100 MG TABLET 0.00000 0.38550 11/1/2012 LABETALOL HCL 20 MG/4 ML SYRINGE 0.00000 0.65310 12/1/2012 LABETALOL HCL 200 MG TABLET 0.44430 0.47750 5/17/2013 LABETALOL HCL 300 MG TABLET 0.00000 0.64820 12/1/2012 LACTIC ACID 10 % CREAM (G) 0.00000 0.08303 12/1/2012 LACTIC ACID 10 % LOTION 0.05446 0.04280 1/25/2013 LACTULOSE 10 G/15 ML SOLUTION 0.04377 0.04574 7/5/2013 LACTULOSE 10 G/15 ML SOLUTION (LAXATIVE) 0.01396 0.01379 8/30/2013 LACTULOSE 10 G/15 ML SOLUTION (MISC) 0.01479 0.01468 1/31/2014 LAMIVUDINE 100 MG TABLET 0.00000 11.27770 1/24/2014 LAMIVUDINE 150 MG TABLET 5.01270 4.60763 9/20/2013 LAMIVUDINE 300 MG TABLET 8.79880 8.50640 11/15/2013 LAMIVUDINE/ZIDOVUDINE 150-300MG TABLET 10.77206 10.76786 1/31/2014 LAMOTRIGINE 100 MG TAB ER 24 9.81784 9.25137 9/20/2013 LAMOTRIGINE 100 MG TABLET 0.06562 0.06559 1/10/2014 LAMOTRIGINE 150 MG TABLET 0.10390 0.10385 2/22/2013 LAMOTRIGINE 200 MG TAB ER 24 9.78420 9.88540 10/11/2013 LAMOTRIGINE 200 MG TABLET 0.11200 0.11202 2/22/2013 LAMOTRIGINE 25 MG TAB ER 24 0.00000 4.58337 3/1/2013 LAMOTRIGINE 25 MG TABLET 0.05561 0.06850 4/12/2013 LAMOTRIGINE 25 MG TB CHW DSP 0.20730 0.29940 5/17/2013 LAMOTRIGINE 250 MG TAB ER 24 37.12239 24.47409 4/26/2013 LAMOTRIGINE 25MG (35) TAB DS PK 0.00000 2.90500 12/1/2012 LAMOTRIGINE 300 MG TAB ER 24 15.70497 13.52610 9/20/2013 LAMOTRIGINE 5 MG TB CHW DSP 0.29964 0.29101 1/24/2014 LAMOTRIGINE 50 MG TAB ER 24 9.16557 9.03040 10/11/2013 LANOLIN/MIN OIL/PETROLAT,WHT OINT. (G) 0.00000 0.91000 12/1/2012 LANSOPRAZOLE 15 MG CAPSULE DR 0.49988 0.50161 8/30/2013 LANSOPRAZOLE 30 MG CAPSULE DR 1.23454 1.19770 3/8/2013 LANSOPRAZOLE/AMOXICILN/CLARITH 30-500-500 COMBO. PKG 0.00000 3.59300 9/27/2013 LATANOPROST 0.005 % DROPS 3.91300 3.52733 8/16/2013 LEFLUNOMIDE 10 MG TABLET 0.50137 0.68509 5/17/2013 LEFLUNOMIDE 20 MG TABLET 0.70792 0.70790 1/25/2013 LETROZOLE 2.5 MG TABLET 0.00000 0.15182 12/1/2012 LEUCOVORIN CALCIUM 10 MG TABLET 5.26466 5.25150 1/25/2013 LEUCOVORIN CALCIUM 10 MG/ML VIAL 0.53387 0.29460 1/25/2013 LEUCOVORIN CALCIUM 15 MG TABLET 0.00000 5.85368 12/1/2012 LEUCOVORIN CALCIUM 200 MG VIAL 18.73200 19.65600 10/11/2013 LEUCOVORIN CALCIUM 25 MG TABLET 7.60425 7.83744 5/17/2013 LEUCOVORIN CALCIUM 5 MG TABLET 0.91164 0.89690 8/16/2013 LEUCOVORIN CALCIUM 50 MG VIAL 6.93000 5.85200 10/11/2013 LEUCOVORIN CALCIUM 500 MG VIAL 0.00000 99.22500 12/1/2012 LEUCOVORIN CALCIUM 500MG/50ML VIAL 0.81228 1.29948 12/14/2012

Page 28 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 LEUPROLIDE ACETATE 1 MG/0.2ML KIT 0.00000 231.00000 2/15/2013 LEVALBUTEROL HCL 0.31MG/3ML VIAL-NEB 1.22344 0.81554 11/29/2013 LEVALBUTEROL HCL 0.63MG/3ML VIAL-NEB 1.45690 1.43806 8/30/2013 LEVALBUTEROL HCL 1.25MG/0.5 VIAL-NEB 2.79420 4.68950 2/1/2013 LEVALBUTEROL HCL 1.25MG/3ML VIAL-NEB 1.39870 1.33575 11/1/2013 LEVETIRACETAM 100 MG/ML SOLUTION 0.06070 0.06076 6/14/2013 LEVETIRACETAM 1000 MG TABLET 0.36538 0.32606 10/4/2013 LEVETIRACETAM 250 MG TABLET 0.09900 0.09903 8/9/2013 LEVETIRACETAM 500 MG TAB ER 24H 0.39021 0.37736 11/1/2013 LEVETIRACETAM 500 MG TABLET 0.15868 0.15635 1/17/2014 LEVETIRACETAM 500 MG/5ML SOLUTION 1.06820 1.06824 5/24/2013 LEVETIRACETAM 500 MG/5ML VIAL 1.65798 1.29524 11/1/2013 LEVETIRACETAM 750 MG TAB ER 24H 0.59674 0.57893 11/1/2013 LEVETIRACETAM 750 MG TABLET 0.23238 0.22077 1/17/2014 LEVETIRACETAM IN NACL (ISO-OS) 1000MG/100 PIGGYBACK 0.00000 0.59877 12/1/2012 LEVETIRACETAM IN NACL (ISO-OS) 1500MG/100 PIGGYBACK 0.00000 0.77967 12/1/2012 LEVETIRACETAM IN NACL (ISO-OS) 500MG/0.1L PIGGYBACK 0.00000 0.36284 12/1/2012 LEVOBUNOLOL HCL 0.25 % DROPS 0.00000 1.24280 12/1/2012 LEVOBUNOLOL HCL 0.5 % DROPS 3.19690 3.38520 4/5/2013 LEVOCARNITINE (WITH SUGAR) 100 MG/ML SOLUTION 0.15655 0.17272 8/30/2013 LEVOCARNITINE 330 MG TABLET 0.60253 0.60260 1/25/2013 LEVOCARNITINE 500 MG TABLET 0.20201 0.21788 8/2/2013 LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 MG/5ML SOLUTION 0.43653 0.43651 1/3/2014 LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG TABLET 0.22244 0.22259 7/19/2013 LEVOFLOXACIN 0.5 % DROPS 0.00000 7.88880 12/1/2012 LEVOFLOXACIN 25 MG/ML VIAL 0.67200 0.71288 3/15/2013 LEVOFLOXACIN 250 MG TABLET 0.14770 0.14767 4/12/2013 LEVOFLOXACIN 250MG/10ML SOLUTION 0.88710 0.88900 8/2/2013 LEVOFLOXACIN 500 MG TABLET 0.29530 0.29534 3/1/2013 LEVOFLOXACIN 750 MG TABLET 0.79934 0.49982 12/13/2013 LEVOFLOXACIN/D5W 250MG/50ML PIGGYBACK 0.11530 0.11656 8/2/2013 LEVOFLOXACIN/D5W 500MG/0.1L PIGGYBACK 0.10794 0.06736 11/15/2013 LEVOFLOXACIN/D5W 750MG/.15L PIGGYBACK 0.05200 0.05398 8/2/2013 LEVOMEFOLATE CALCIUM 15 MG TABLET 2.02080 2.02070 1/25/2013 LEVOMEFOLATE CALCIUM 7.5 MG TABLET 1.98276 2.02070 12/14/2012 LEVONORGESTREL 0.75 MG TABLET 0.00000 12.79600 12/1/2012 LEVONORGESTREL 1.5 MG TABLET 32.20550 27.30000 8/30/2013 LEVONORGESTREL-ETH ESTRADIOL 0.1-0.02 TABLET 0.69393 0.67330 5/17/2013 LEVONORGESTREL-ETH ESTRADIOL 0.15-0.03 TABLET 0.77319 0.77312 1/10/2014 LEVONORGESTREL-ETH ESTRADIOL 0.15-0.03 TBDSPK 3MO 1.11998 1.08403 12/13/2013 LEVONORGESTREL-ETH ESTRADIOL 6-5-10 TABLET 0.68717 0.68718 9/20/2013 LEVORPHANOL TARTRATE 2 MG TABLET 1.23865 1.12600 1/25/2013 LEVOTHYROXINE SODIUM 100 MCG TABLET 0.11840 0.30285 9/27/2013 LEVOTHYROXINE SODIUM 100 MCG VIAL 0.00000 111.63600 12/1/2012 LEVOTHYROXINE SODIUM 112 MCG TABLET 0.16800 0.35042 9/27/2013 LEVOTHYROXINE SODIUM 125 MCG TABLET 0.14810 0.35530 9/27/2013 LEVOTHYROXINE SODIUM 137 MCG TABLET 0.18900 0.36020 9/27/2013 LEVOTHYROXINE SODIUM 150 MCG TABLET 0.14620 0.36558 9/27/2013 LEVOTHYROXINE SODIUM 175MCG TABLET 0.20870 0.43460 9/27/2013 LEVOTHYROXINE SODIUM 200 MCG TABLET 0.21450 0.43551 9/27/2013 LEVOTHYROXINE SODIUM 25 MCG TABLET 0.09590 0.23563 9/27/2013 LEVOTHYROXINE SODIUM 300 MCG TABLET 0.37064 0.58580 9/27/2013 LEVOTHYROXINE SODIUM 50 MCG TABLET 0.09920 0.26733 9/27/2013 LEVOTHYROXINE SODIUM 500 MCG VIAL 0.00000 44.60050 12/1/2012 LEVOTHYROXINE SODIUM 75 MCG TABLET 0.12530 0.29548 9/27/2013 LEVOTHYROXINE SODIUM 88 MCG TABLET 0.20738 0.30072 9/27/2013 LIDOCAINE 5 % CREAM (G) 0.00000 1.01056 12/1/2012

Page 29 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 LIDOCAINE 5 % OINT. (G) 1.38446 1.38450 4/5/2013 LIDOCAINE 5%(700MG) ADH. PATCH 9.17627 6.55223 12/27/2013 LIDOCAINE HCL 2 % JEL (ML) 0.29705 0.30811 1/31/2014 LIDOCAINE HCL 2 % JEL/PF APP 0.62381 0.49084 5/3/2013 LIDOCAINE HCL 20 MG/ML SOLUTION 0.02399 0.02171 12/13/2013 LIDOCAINE HCL 20 MG/ML VIAL 0.00000 0.06084 12/1/2012 LIDOCAINE HCL 4 % SOLUTION 0.00000 1.05248 12/1/2012 LIDOCAINE HCL 40 MG/ML SOLUTION 0.07070 0.07497 3/1/2013 LIDOCAINE HCL/D5W/PF 4 MG/ML IV SOLN 0.01313 0.01280 1/25/2013 LIDOCAINE HCL/D5W/PF 8 MG/ML IV SOLN 0.00000 0.02029 12/1/2012 LIDOCAINE HCL/D7.5W/PF 5 % AMPUL 4.77036 6.05930 1/25/2013 LIDOCAINE HCL/EPINEPHRINE 1%-1:100K VIAL 0.00000 0.06995 12/1/2012 LIDOCAINE HCL/EPINEPHRINE 2 %-1:100K VIAL 0.07848 0.07910 1/25/2013 LIDOCAINE HCL/EPINEPHRINE BIT 2 %-1:100K CARTRIDGE 0.00000 0.14933 12/1/2012 LIDOCAINE HCL/EPINEPHRINE BIT 2%-1:50000 CARTRIDGE 0.00000 0.14933 12/1/2012 LIDOCAINE HCL/EPINEPHRINE/PF 2%-1:200K VIAL 0.35742 0.35740 1/25/2013 LIDOCAINE HCL/PF 10 MG/ML AMPUL 0.35750 0.35751 12/20/2013 LIDOCAINE HCL/PF 100 MG/5ML SYRINGE 0.60251 0.66080 1/25/2013 LIDOCAINE HCL/PF 15 MG/ML AMPUL 0.00000 0.66715 12/1/2012 LIDOCAINE HCL/PF 20 MG/ML AMPUL 0.00000 1.01535 12/27/2013 LIDOCAINE HCL/PF 20 MG/ML VIAL INJ 0.34100 0.48516 12/20/2013 LIDOCAINE HCL/PF 20 MG/ML VIAL IV 0.00000 0.28224 12/1/2012 LIDOCAINE HCL/PF 40 MG/ML AMPUL 0.56784 0.56780 1/25/2013 LIDOCAINE HCL/PF 5 MG/ML VIAL 0.00000 0.11002 12/1/2012 LIDOCAINE HCL/PF 50 MG/5 ML SYRINGE 0.88704 0.88790 1/25/2013 LIDOCAINE/PRILOCAINE 2.5 %-2.5% CREAM (G) 0.41718 0.40512 11/15/2013 LIDOCAINE/PRILOCAINE 2.5 %-2.5% KIT 0.00000 1.40764 12/1/2012 LINDANE 1 % LOTION 1.51940 1.59670 2/8/2013 LINDANE 1 % SHAMPOO 1.51940 1.59670 2/8/2013 LIOTHYRONINE SODIUM 25 MCG TABLET 0.73760 0.58286 8/30/2013 LIOTHYRONINE SODIUM 5 MCG TABLET 0.56180 0.49553 8/30/2013 LIOTHYRONINE SODIUM 50 MCG TABLET 1.11394 1.04708 8/30/2013 LISINOPRIL 10 MG TABLET 0.02112 0.02668 1/17/2014 LISINOPRIL 2.5 MG TABLET 0.01809 0.01793 8/16/2013 LISINOPRIL 20 MG TABLET 0.03282 0.03329 10/4/2013 LISINOPRIL 30 MG TABLET 0.09246 0.09045 1/31/2014 LISINOPRIL 40 MG TABLET 0.06144 0.06821 10/4/2013 LISINOPRIL 5 MG TABLET 0.01709 0.01943 10/4/2013 LISINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.03162 0.03157 7/26/2013 LISINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.04063 0.04135 5/24/2013 LISINOPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.05076 0.05084 1/17/2014 LITHIUM CARBONATE 150 MG CAPSULE 0.06553 0.06132 11/22/2013 LITHIUM CARBONATE 300 MG CAPSULE 0.02884 0.03216 5/17/2013 LITHIUM CARBONATE 300 MG TABLET 0.14917 0.14910 1/25/2013 LITHIUM CARBONATE 300 MG TABLET ER 0.23998 0.23280 1/24/2014 LITHIUM CARBONATE 450 MG TABLET ER 0.26764 0.27832 11/1/2013 LITHIUM CARBONATE 600 MG CAPSULE 0.12956 0.12860 1/25/2013 LITHIUM CITRATE 8 MEQ/5 ML SOLUTION 0.00000 0.03921 12/1/2012 LOPERAMIDE HCL 1MG/7.5ML LIQUID 0.02830 0.02772 2/15/2013 LOPERAMIDE HCL 2 MG CAPSULE 0.15076 0.15512 8/16/2013 LOPERAMIDE HCL 2 MG TABLET 0.08951 0.08953 4/19/2013 LORATADINE 10 MG TAB RAPDIS 0.00000 0.38100 12/1/2012 LORATADINE 10 MG TABLET 0.05132 0.05136 4/19/2013 LORATADINE 5 MG/5 ML SOLUTION 0.03641 0.04500 5/17/2013 LORATADINE/PSEUDOEPHEDRINE 10MG-240MG TAB ER 24H 0.60311 0.58410 1/24/2014 LORAZEPAM 0.5 MG TABLET 0.02688 0.02718 5/24/2013 LORAZEPAM 1 MG TABLET 0.02770 0.02921 5/17/2013

Page 30 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 LORAZEPAM 2 MG TABLET 0.04985 0.04875 7/26/2013 LORAZEPAM 2 MG/ML ORAL CONC 0.60470 0.98130 5/10/2013 LORAZEPAM 2 MG/ML SYRINGE 1.83960 1.76400 2/15/2013 LORAZEPAM 2 MG/ML VIAL 0.72360 0.63000 3/1/2013 LORAZEPAM 4 MG/ML SYRINGE 0.00000 2.46960 12/1/2012 LORAZEPAM 4 MG/ML VIAL 0.00000 1.14324 12/1/2012 LOSARTAN POTASSIUM 100 MG TABLET 0.09759 0.08943 11/22/2013 LOSARTAN POTASSIUM 25 MG TABLET 0.05435 0.05289 10/4/2013 LOSARTAN POTASSIUM 50 MG TABLET 0.06898 0.06700 9/13/2013 LOSARTAN/HYDROCHLOROTHIAZIDE 100-12.5MG TABLET 0.11202 0.11197 4/26/2013 LOSARTAN/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET 0.10180 0.10184 4/5/2013 LOSARTAN/HYDROCHLOROTHIAZIDE 50-12.5 MG TABLET 0.06730 0.07450 1/25/2013 LOVASTATIN 10 MG TABLET 0.09540 0.09447 3/15/2013 LOVASTATIN 20 MG TABLET 0.10291 0.09759 4/26/2013 LOVASTATIN 40 MG TABLET 0.10910 0.32800 10/18/2013 LOXAPINE SUCCINATE 10 MG CAPSULE 0.44707 0.52984 8/16/2013 LOXAPINE SUCCINATE 25 MG CAPSULE 0.65819 0.76755 8/16/2013 LOXAPINE SUCCINATE 5 MG CAPSULE 0.37145 0.37150 12/14/2012 LOXAPINE SUCCINATE 50 MG CAPSULE 0.89791 0.99683 8/16/2013 MAFENIDE ACETATE 50 G PACKET 0.00000 112.55160 4/19/2013 MAG CARB/AL HYDROX/ALGINIC AC 358-95/15 ORAL SUSP 0.00000 0.01253 12/1/2012 MAG HYDROX/AL HYDROX/SIMETH 200-200-20 ORAL SUSP 0.00590 0.00592 12/13/2013 MAG HYDROX/AL HYDROX/SIMETH 200-200-25 TAB CHEW 0.00000 0.03029 12/1/2012 MAG HYDROX/AL HYDROX/SIMETH 400-400-40 ORAL SUSP 0.00000 0.00735 12/1/2012 MAGNESIUM CHLORIDE 64 MG TABLET ER 0.00000 0.08364 12/1/2012 MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP 0.00420 0.00415 3/15/2013 MAGNESIUM OXIDE 400 MG CAPSULE 0.08181 0.08450 1/25/2013 MAGNESIUM OXIDE 400 MG TABLET 0.02910 0.02908 3/8/2013 MAGNESIUM SULFATE 2 G/50 ML PIGGYBACK 0.27600 0.24560 1/25/2013 MAGNESIUM SULFATE 20 G/500ML IV SOLN 0.02031 0.01970 1/25/2013 MAGNESIUM SULFATE 4 G/100 ML PIGGYBACK 0.12464 0.11860 1/25/2013 MAGNESIUM SULFATE 4 G/50 ML PIGGYBACK 0.24644 0.23100 1/25/2013 MAGNESIUM SULFATE 4 MEQ/ML SYRINGE 0.00000 0.63168 12/1/2012 MAGNESIUM SULFATE 40G/1000ML IV SOLN 0.01537 0.01440 1/25/2013 MAGNESIUM SULFATE/D5W 1 G/100 ML PIGGYBACK 0.11997 0.11630 1/25/2013 MALATHION 0.5 % LOTION 2.98650 2.15921 2/15/2013 MANGANESE CHLORIDE 0.1 MG/ML VIAL 0.14448 0.17390 1/25/2013 MANGANESE SULFATE 0.1 MG/ML VIAL 0.00000 0.21874 12/1/2012 MANNITOL 10 % IV SOLN 0.01210 0.01620 1/25/2013 MANNITOL 20 % IV SOLN 0.00000 0.03980 12/1/2012 MANNITOL 5 % IV SOLN 0.00000 0.00866 12/1/2012 MANNITOL/SORBITOL SOLUTION 0.54G-2.7G IRRIG SOLN 0.00000 0.00569 12/1/2012 MAPROTILINE HCL 25 MG TABLET 0.59885 0.59890 1/25/2013 MAPROTILINE HCL 50 MG TABLET 0.88660 0.93980 2/8/2013 MAPROTILINE HCL 75 MG TABLET 1.21653 1.28950 1/25/2013 MECLIZINE HCL 12.5 MG TABLET 0.03465 0.12965 1/10/2014 MECLIZINE HCL 25 MG TABLET 0.31260 0.28090 12/21/2012 MECLOFENAMATE SODIUM 100 MG CAPSULE 3.34761 3.34760 1/25/2013 MECLOFENAMATE SODIUM 50 MG CAPSULE 1.80334 1.91160 1/25/2013 MEDROXYPROGESTERONE ACETATE 10 MG TABLET 0.00000 0.12690 12/1/2012 MEDROXYPROGESTERONE ACETATE 2.5 MG TABLET 0.06137 0.06140 12/14/2012 MEDROXYPROGESTERONE ACETATE 5 MG TABLET 0.08400 0.08240 1/25/2013 MEFENAMIC ACID 250 MG CAPSULE 10.96296 10.93970 1/25/2013 MEFLOQUINE HCL 250 MG TABLET 4.71900 3.74400 4/5/2013 MEGESTROL ACETATE 20 MG TABLET 0.12721 0.15410 8/16/2013 MEGESTROL ACETATE 40 MG TABLET 0.19480 0.19478 1/10/2014 MEGESTROL ACETATE 400MG/10ML (10 ML) ORAL SUSP 0.29157 0.31675 4/26/2013

Page 31 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 MEGESTROL ACETATE 400MG/10ML (40 MG/ML) ORAL SUSP 0.08509 0.08697 12/13/2013 MELATONIN 3 MG TABLET ER 0.00000 0.06370 12/1/2012 MELATONIN/TRYPTOPHAN 3 MG-100MG CAPSULE 0.00000 5.05750 1/31/2014 MELOXICAM 15 MG TABLET 0.03283 0.03190 4/12/2013 MELOXICAM 7.5 MG TABLET 0.02605 0.02541 8/30/2013 MELOXICAM 7.5 MG/5ML ORAL SUSP 1.10061 1.21065 3/15/2013 MENTHOL 10 % GEL (GRAM) 0.00000 0.11397 12/1/2012 MENTHOL 8 MG LOZENGE 0.06965 0.06420 1/25/2013 MEPERIDINE HCL 10 MG/ML CARTRIDGE 0.00000 0.49911 12/1/2012 MEPERIDINE HCL 100 MG TABLET 0.38670 0.32670 2/15/2013 MEPERIDINE HCL 50 MG TABLET 0.00000 0.20435 12/1/2012 MEPERIDINE HCL 50 MG/5 ML SOLUTION 0.00000 0.14191 12/1/2012 MEPERIDINE HCL/PF 100 MG/ML VIAL 0.00000 2.35200 12/1/2012 MEPERIDINE HCL/PF 25 MG/ML VIAL 0.00000 2.12100 12/1/2012 MEPERIDINE HCL/PF 50 MG/ML VIAL 0.00000 0.94080 12/1/2012 MEPIVACAINE HCL/PF 30 MG/ML CARTRIDGE 0.18667 0.17730 1/25/2013 MEPROBAMATE 200 MG TABLET 1.83178 3.66938 12/13/2013 MEPROBAMATE 400 MG TABLET 1.24995 0.98070 1/25/2013 MERCAPTOPURINE 50 MG TABLET 0.00000 1.91920 12/1/2012 MEROPENEM 1 G VIAL 9.85987 10.28808 12/27/2013 MEROPENEM 500 MG VIAL 7.56840 4.50240 5/3/2013 MESALAMINE 4 G/60 ML ENEMA 0.22922 0.24101 12/27/2013 MESALAMINE W/CLEANSING WIPES 4 G/60 ML KIT 0.00000 0.29920 12/1/2012 METAPROTERENOL SULFATE 10 MG TABLET 0.00000 0.69965 12/1/2012 METAPROTERENOL SULFATE 10 MG/5 ML SYRUP 0.04721 0.02460 1/25/2013 METAPROTERENOL SULFATE 20 MG TABLET 0.00000 0.97496 12/1/2012 METAXALONE 800 MG TABLET 3.26060 3.42370 1/25/2013 METFORMIN HCL 1000 MG TAB ER 24 6.34280 7.32690 2/1/2013 METFORMIN HCL 1000 MG TABLET 0.04248 0.04079 12/20/2013 METFORMIN HCL 500 MG TAB ER 24 3.25400 4.02380 2/8/2013 METFORMIN HCL 500 MG TAB ER 24H 0.04516 0.04159 1/3/2014 METFORMIN HCL 500 MG TABLET 0.02720 0.02616 12/20/2013 METFORMIN HCL 750 MG TAB ER 24H 0.09180 0.12958 5/17/2013 METFORMIN HCL 850 MG TABLET 0.04134 0.04051 12/13/2013 METHADONE HCL 10 MG TABLET 0.09433 0.09356 1/31/2014 METHADONE HCL 10 MG/5 ML SOLUTION 0.00000 0.20658 12/1/2012 METHADONE HCL 10 MG/ML ORAL CONC 0.00000 0.62300 12/1/2012 METHADONE HCL 10 MG/ML VIAL 0.00000 6.01720 12/1/2012 METHADONE HCL 40 MG TABLET SOL 0.00000 0.22381 12/1/2012 METHADONE HCL 5 MG TABLET 0.05941 0.06042 4/5/2013 METHADONE HCL 5 MG/5 ML SOLUTION 0.00000 0.12491 12/1/2012 METHAMPHETAMINE HCL 5 MG TABLET 3.02617 3.20775 11/29/2013 METHAZOLAMIDE 25 MG TABLET 1.02360 0.70710 1/25/2013 METHAZOLAMIDE 50 MG TABLET 2.01080 2.25672 4/12/2013 METHEN/M-BLUE/SAL/NA PHOS/HYOS 120-0.12MG TABLET 0.00000 2.09160 9/27/2013 METHENAMINE HIPPURATE 1 G TABLET 1.38360 1.46649 8/16/2013 METHENAMINE MANDELATE 1 G TABLET 1.08069 1.15871 11/29/2013 METHENAMINE MANDELATE 500 MG TABLET 0.00000 0.62041 12/1/2012 METHIMAZOLE 10 MG TABLET 0.25637 0.24092 11/15/2013 METHIMAZOLE 5 MG TABLET 0.15680 0.15678 6/14/2013 METHOCARBAMOL 500 MG TABLET 0.07276 0.06786 10/18/2013 METHOCARBAMOL 750 MG TABLET 0.00000 0.15530 12/1/2012 METHOTREXATE SODIUM 2.5 MG TABLET 2.20323 2.67070 11/15/2013 METHOTREXATE SODIUM 25 MG/ML VIAL 1.63082 1.65075 4/12/2013 METHOTREXATE SODIUM/PF 25 MG/ML VIAL 0.68983 0.60702 4/12/2013 METHSCOPOLAMINE BROMIDE 2.5 MG TABLET 1.54629 1.53056 10/18/2013 METHSCOPOLAMINE BROMIDE 5 MG TABLET 2.40598 2.38030 7/5/2013

Page 32 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 METHYCLOTHIAZIDE 5 MG TABLET 1.14772 1.21660 1/25/2013 METHYL SALICYLATE OIL 0.47545 0.47540 1/25/2013 METHYL-B12/L-MEFOLATE/B6 PHOS 2-3-35 MG TABLET 0.91348 1.01041 12/14/2012 METHYLDOPA 250 MG TABLET 0.09822 0.10117 5/17/2013 METHYLDOPA 500 MG TABLET 0.17650 0.17648 3/1/2013 METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-15MG TABLET 0.63380 0.67180 1/25/2013 METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-25MG TABLET 0.74683 0.79160 1/25/2013 METHYLENE BLUE 1 % AMPUL 2.74680 2.76330 1/25/2013 METHYLERGONOVINE MALEATE .2MG/ML(1) AMPUL 4.35610 4.75860 8/30/2013 METHYLERGONOVINE MALEATE .2MG/ML(1) VIAL 0.00000 6.39450 12/1/2012 METHYLERGONOVINE MALEATE 0.2 MG TABLET 5.39630 12.68875 8/30/2013 METHYLPHENIDATE HCL 10 MG CPMP 30-70 3.98052 4.03956 4/5/2013 METHYLPHENIDATE HCL 10 MG TABLET ER 0.71500 1.20337 7/5/2013 METHYLPHENIDATE HCL 10 MG/5 ML SOLUTION 0.90135 1.21664 11/15/2013 METHYLPHENIDATE HCL 18 MG TAB ER 24 4.35530 4.35526 3/15/2013 METHYLPHENIDATE HCL 20 MG CPMP 30-70 4.03960 4.02091 5/3/2013 METHYLPHENIDATE HCL 20 MG TABLET 1.19790 0.82852 12/20/2013 METHYLPHENIDATE HCL 20 MG TABLET ER 0.00000 1.74180 1/17/2014 METHYLPHENIDATE HCL 27 MG TAB ER 24 4.46446 4.46450 7/19/2013 METHYLPHENIDATE HCL 30 MG CPMP 30-70 3.78352 3.43478 1/24/2014 METHYLPHENIDATE HCL 36 MG TAB ER 24 0.00000 4.60502 12/1/2012 METHYLPHENIDATE HCL 40 MG CPMP 30-70 5.08025 5.14002 5/31/2013 METHYLPHENIDATE HCL 5 MG/5 ML SOLUTION 0.00000 1.34413 12/1/2012 METHYLPHENIDATE HCL 50 MG CPMP 30-70 5.78640 6.70877 2/22/2013 METHYLPHENIDATE HCL 54 MG TAB ER 24 0.00000 5.01081 12/1/2012 METHYLPHENIDATE HCL 60 MG CPMP 30-70 6.73360 6.76633 5/3/2013 METHYLPREDNISOLONE 16 MG TABLET 0.00000 2.17406 12/1/2012 METHYLPREDNISOLONE 32 MG TABLET 0.00000 3.23736 12/1/2012 METHYLPREDNISOLONE 4 MG TAB DS PK 1.24060 1.00070 10/18/2013 METHYLPREDNISOLONE 4 MG TABLET 0.00000 1.24060 12/1/2012 METHYLPREDNISOLONE 8 MG TABLET 0.00000 1.40728 12/1/2012 METHYLPREDNISOLONE ACETATE 40 MG/ML VIAL 3.04720 3.47672 6/7/2013 METHYLPREDNISOLONE ACETATE 80 MG/ML VIAL 6.81700 7.07957 7/19/2013 METHYLPREDNISOLONE SOD SUCC 1000 MG VIAL 0.00000 17.05200 12/1/2012 METHYLPREDNISOLONE SOD SUCC 125 MG VIAL 0.00000 4.08408 12/1/2012 METHYLPREDNISOLONE SOD SUCC 40 MG VIAL 0.00000 3.53132 12/1/2012 METIPRANOLOL 0.3 % DROPS 0.00000 2.91720 12/1/2012 METOCLOPRAMIDE HCL 10 MG TABLET 0.04228 0.04241 11/29/2013 METOCLOPRAMIDE HCL 10 MG/10ML SOLUTION 0.01351 0.04456 8/9/2013 METOCLOPRAMIDE HCL 10 MG/2 ML SYRINGE 0.39900 0.66573 5/24/2013 METOCLOPRAMIDE HCL 5 MG TABLET 0.04250 0.04248 4/26/2013 METOCLOPRAMIDE HCL 5 MG/5 ML SOLUTION 0.01351 0.01217 12/20/2013 METOLAZONE 10 MG TABLET 0.77720 0.84230 5/17/2013 METOLAZONE 2.5 MG TABLET 0.50100 0.48610 5/17/2013 METOLAZONE 5 MG TABLET 0.56910 0.55250 5/17/2013 METOPROLOL SUCCINATE 100 MG TAB ER 24H 0.00000 0.90700 12/1/2012 METOPROLOL SUCCINATE 200 MG TAB ER 24H 1.80192 1.48807 12/13/2013 METOPROLOL SUCCINATE 25 MG TAB ER 24H 0.50491 0.45399 10/11/2013 METOPROLOL SUCCINATE 50 MG TAB ER 24H 0.50491 0.73441 10/4/2013 METOPROLOL TARTRATE 100 MG TABLET 0.03109 0.03212 1/17/2014 METOPROLOL TARTRATE 25 MG TABLET 0.02203 0.02117 10/25/2013 METOPROLOL TARTRATE 5 MG/5 ML AMPUL 0.18818 0.23020 1/25/2013 METOPROLOL TARTRATE 5 MG/5 ML SYRINGE 0.65333 0.70560 1/25/2013 METOPROLOL TARTRATE 50 MG TABLET 0.02034 0.02100 1/17/2014 METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET 1.38030 1.46036 7/26/2013 METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-50MG TABLET 1.44730 1.53410 2/8/2013 METOPROLOL/HYDROCHLOROTHIAZIDE 50 MG-25MG TABLET 0.88790 0.92755 7/26/2013

Page 33 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 METRONIDAZOLE 0.75 % CREAM (G) 0.00000 2.72580 12/1/2012 METRONIDAZOLE 0.75 % GEL (GRAM) 0.00000 2.65770 8/3/2012 METRONIDAZOLE 0.75 % GEL W/APPL 0.00000 0.41004 12/1/2012 METRONIDAZOLE 0.75 % LOTION 0.00000 2.93220 12/1/2012 METRONIDAZOLE 250 MG TABLET 0.00000 0.30300 12/1/2012 METRONIDAZOLE 375 MG CAPSULE 0.00000 3.91048 12/1/2012 METRONIDAZOLE 500 MG TABLET 0.50126 0.50050 1/31/2014 METRONIDAZOLE/SODIUM CHLORIDE 500MG/0.1L PIGGYBACK 0.01431 0.01400 4/5/2013 MEXILETINE HCL 150 MG CAPSULE 0.29170 0.29172 8/9/2013 MEXILETINE HCL 200 MG CAPSULE 0.40240 0.40235 8/9/2013 MEXILETINE HCL 250 MG CAPSULE 0.48190 0.48191 8/9/2013 MICONAZOLE NITRATE 100 MG SUPP.VAG 0.42710 0.44030 12/21/2012 MICONAZOLE NITRATE 2 % CREAM (G) 0.05720 0.05700 4/19/2013 MICONAZOLE NITRATE 2 % CREAM/APPL 0.08640 0.08878 10/18/2013 MICONAZOLE NITRATE 2 % OINT. (G) 0.08474 0.08500 1/25/2013 MICONAZOLE NITRATE 2 % TINCTURE 0.44138 0.39340 1/25/2013 MICONAZOLE NITRATE 200 MG SUPP.VAG 0.00000 12.26633 12/1/2012 MICONAZOLE NITRATE 200 MG-2 % KIT 1.21793 1.09746 11/22/2013 MIDODRINE HCL 10 MG TABLET 0.93009 0.93010 12/14/2012 MIDODRINE HCL 2.5 MG TABLET 0.32320 0.30992 5/17/2013 MIDODRINE HCL 5 MG TABLET 0.38530 0.60470 2/8/2013 MILRINONE LACTATE 1 MG/ML VIAL 0.00000 0.46056 12/1/2012 MILRINONE LACTATE/D5W 20MG/100ML PIGGYBACK 0.13279 0.13280 1/25/2013 MILRINONE LACTATE/D5W 40MG/200ML PIGGYBACK 0.13655 0.12430 1/25/2013 MINERAL OIL LOTION 0.00480 0.01828 6/28/2013 MINERAL OIL/PETROLATUM,WHITE 15 %-83 % OINT. (G) 0.72313 0.81740 1/25/2013 MINERAL OIL/PETROLATUM,WHITE 15%-85% OINT. (G) 4.41666 4.48140 1/25/2013 MINOCYCLINE HCL 100 MG CAPSULE 0.26693 0.28748 5/17/2013 MINOCYCLINE HCL 100 MG TABLET 2.73559 2.56927 1/31/2014 MINOCYCLINE HCL 135 MG TAB ER 24H 0.00000 3.56811 12/1/2012 MINOCYCLINE HCL 45 MG TAB ER 24H 0.00000 3.56811 12/1/2012 MINOCYCLINE HCL 50 MG CAPSULE 0.14123 0.14355 1/3/2014 MINOCYCLINE HCL 50 MG TABLET 0.00000 1.44008 12/1/2012 MINOCYCLINE HCL 75 MG CAPSULE 0.31018 0.35403 1/17/2014 MINOCYCLINE HCL 75 MG TABLET 0.00000 1.69228 12/1/2012 MINOCYCLINE HCL 90 MG TAB ER 24H 0.00000 3.56811 12/1/2012 MINOXIDIL 10 MG TABLET 0.29735 0.29164 10/11/2013 MINOXIDIL 2.5 MG TABLET 0.16710 0.16817 10/11/2013 MIRTAZAPINE 15 MG TAB RAPDIS 0.77764 0.83080 1/17/2014 MIRTAZAPINE 15 MG TABLET 0.09420 0.09156 7/12/2013 MIRTAZAPINE 30 MG TAB RAPDIS 0.79774 0.85582 1/17/2014 MIRTAZAPINE 30 MG TABLET 0.13904 0.13490 7/12/2013 MIRTAZAPINE 45 MG TAB RAPDIS 1.07960 1.11578 1/17/2014 MIRTAZAPINE 45 MG TABLET 0.24830 0.21614 3/15/2013 MIRTAZAPINE 7.5 MG TABLET 0.05985 0.05933 1/3/2014 MISOPROSTOL 100 MCG TABLET 0.56268 0.56252 7/26/2013 MITOMYCIN 40 MG VIAL 235.39125 256.23975 11/1/2013 MODAFINIL 100 MG TABLET 11.07884 11.04840 11/15/2013 MODAFINIL 200 MG TABLET 18.65619 19.24640 3/22/2013 MOEXIPRIL HCL 15 MG TABLET 0.36582 0.37580 2/8/2013 MOEXIPRIL HCL 7.5 MG TABLET 0.37583 0.37580 12/14/2012 MOEXIPRIL/HYDROCHLOROTHIAZIDE 15-12.5MG TABLET 0.51305 0.51310 12/14/2012 MOEXIPRIL/HYDROCHLOROTHIAZIDE 15-25MG TABLET 0.00000 0.37076 12/1/2012 MOEXIPRIL/HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET 0.00000 0.50960 12/1/2012 MOLYBDENUM(AMMONIUM MOLYBDATE) 25 MCG/ML VIAL 0.00000 0.32672 12/1/2012 MOMETASONE FUROATE 0.1 % CREAM (G) 0.23435 0.36894 7/19/2013 MOMETASONE FUROATE 0.1 % OINT. (G) 0.20998 0.26293 7/19/2013

Page 34 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 MOMETASONE FUROATE 0.1 % SOLUTION 0.27470 0.22914 8/2/2013 MONTELUKAST SODIUM 10 MG TABLET 0.00000 0.61330 8/17/2012 MONTELUKAST SODIUM 4 MG TAB CHEW 0.00000 0.61330 8/17/2012 MONTELUKAST SODIUM 5 MG TAB CHEW 0.00000 0.61330 8/17/2012 MORPHINE SULFATE 10 MG CAP ER PEL 3.62712 3.31248 10/4/2013 MORPHINE SULFATE 10 MG SUPP.RECT 4.37500 3.85880 1/25/2013 MORPHINE SULFATE 10 MG/5 ML SOLUTION 0.00000 0.06164 12/1/2012 MORPHINE SULFATE 10 MG/ML CARTRIDGE 3.06600 3.25500 1/25/2013 MORPHINE SULFATE 10 MG/ML VIAL 0.00000 0.74480 12/1/2012 MORPHINE SULFATE 100 MG CAP ER PEL 13.29374 13.29147 8/30/2013 MORPHINE SULFATE 100 MG TABLET ER 0.84907 3.60620 10/11/2013 MORPHINE SULFATE 100 MG/4ML VIAL PORT 4.75650 4.96650 1/25/2013 MORPHINE SULFATE 100 MG/5ML SOLUTION 0.00000 0.29011 12/1/2012 MORPHINE SULFATE 15 MG TABLET 0.08606 0.10517 1/24/2014 MORPHINE SULFATE 15 MG TABLET ER 0.19497 0.62553 10/11/2013 MORPHINE SULFATE 15 MG/ML CARTRIDGE 3.17100 3.25500 1/25/2013 MORPHINE SULFATE 15 MG/ML VIAL 0.52528 0.69440 1/25/2013 MORPHINE SULFATE 2 MG/ML CARTRIDGE 3.06600 3.25500 1/25/2013 MORPHINE SULFATE 20 MG CAP ER PEL 3.65672 3.65617 8/16/2013 MORPHINE SULFATE 20 MG SUPP.RECT 0.00000 5.25000 12/1/2012 MORPHINE SULFATE 20 MG/5 ML SOLUTION 0.09368 0.09460 3/1/2013 MORPHINE SULFATE 200 MG TABLET ER 1.89189 6.25263 10/11/2013 MORPHINE SULFATE 25 MG/ML VIAL 1.15290 1.33770 7/26/2013 MORPHINE SULFATE 250MG/10ML VIAL PORT 1.90680 1.99080 1/25/2013 MORPHINE SULFATE 30 MG CAP ER PEL 0.00000 3.97649 12/1/2012 MORPHINE SULFATE 30 MG SUPP.RECT 0.00000 6.56250 12/1/2012 MORPHINE SULFATE 30 MG TABLET 0.09945 0.12130 2/8/2013 MORPHINE SULFATE 30 MG TABLET ER 0.32428 1.20554 10/25/2013 MORPHINE SULFATE 30 MG/30ML PCA SYRING 0.43749 0.33600 11/8/2013 MORPHINE SULFATE 4 MG/ML CARTRIDGE 3.08700 3.25500 1/25/2013 MORPHINE SULFATE 5 MG SUPP.RECT 0.00000 3.50000 12/1/2012 MORPHINE SULFATE 5 MG/ML VIAL 0.00000 0.83160 12/1/2012 MORPHINE SULFATE 50 MG CAP ER PEL 0.00000 6.64531 12/1/2012 MORPHINE SULFATE 50 MG/ML VIAL 0.39830 0.87665 3/29/2013 MORPHINE SULFATE 60 MG CAP ER PEL 7.95280 7.95284 3/15/2013 MORPHINE SULFATE 60 MG TABLET ER 0.52443 2.31330 10/11/2013 MORPHINE SULFATE 8 MG/ML CARTRIDGE 0.00000 2.98200 12/1/2012 MORPHINE SULFATE 8 MG/ML VIAL 0.00000 0.94080 12/1/2012 MORPHINE SULFATE 80 MG CAP ER PEL 10.60283 11.11482 8/16/2013 MORPHINE SULFATE/PF 0.5 MG/ML AMPUL 0.00000 2.23713 12/1/2012 MORPHINE SULFATE/PF 0.5 MG/ML VIAL 0.36624 0.42080 1/25/2013 MORPHINE SULFATE/PF 1 MG/ML AMPUL 0.00000 3.80940 12/1/2012 MORPHINE SULFATE/PF 1 MG/ML VIAL 0.41244 0.41240 1/25/2013 MORPHINE SULFATE/PF 150MG/30ML PCA VIAL 0.00000 0.61320 12/1/2012 MORPHINE SULFATE/PF 30 MG/30ML PCA VIAL 0.00000 0.50469 12/1/2012 MTH/ME BLUE/SOD PHOS/PHEN/HYOS 81.6-10.8 TABLET 0.00000 0.91000 12/1/2012 MULTIVITAMIN TABLET 0.01090 0.01474 5/10/2013 MULTIVITAMIN W-MINERALS/LUTEIN TABLET 0.04529 0.04780 1/25/2013 MULTIVITAMINS WITH IRON TABLET 0.01580 0.01954 8/16/2013 MULTIVITAMINS WITH MIN NO.7/FA 1 MG CAPSULE 0.06227 0.17550 2/15/2013 MULTIVITAMINS,THER W-MINERALS CAPSULE 0.06622 0.05780 1/25/2013 MULTIVITAMINS,THERAPEUTIC TABLET 0.02439 0.02440 12/14/2012 MULTIVITS W-MIN/FERROUS GLUC 9 MG/15 ML LIQUID 0.01368 0.01674 10/18/2013 MULTIVITS,CA,MINERALS/IRON/FA 9MG-400MCG TABLET 0.00000 0.03497 12/1/2012 MULTIVITS,STRESS FORMULA/ZINC TABLET 0.00000 0.04810 12/1/2012 MULTIVITS-MIN/FA/LYCOPENE/LUT .4-300-250 TABLET 0.04527 0.05523 8/23/2013 MULTIVITS-MIN/FA/LYCOPENE/LUT 500-300MCG TABLET 0.04800 0.05011 7/19/2013

Page 35 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 MULTIVITS-MINERALS/FA/LYCOPENE 0.4MG-600 TABLET 0.00000 0.04620 5/31/2013 MUPIROCIN 2 % OINT. (G) 0.00000 0.47610 12/1/2012 MUPIROCIN CALCIUM 2 % CREAM (G) 3.22800 3.00471 11/22/2013 MV,MIN #10/FA/D3/ALIP ACID/LUT 1-1000-5 TABLET 0.00000 0.53985 6/21/2013 MYCOPHENOLATE MOFETIL 250 MG CAPSULE 0.28338 0.27178 12/13/2013 MYCOPHENOLATE MOFETIL 500 MG TABLET 0.49955 0.46854 9/20/2013 MYCOPHENOLATE SODIUM 180 MG TABLET DR 0.00000 3.19818 1/24/2014 MYCOPHENOLATE SODIUM 360 MG TABLET DR 0.00000 6.39625 1/24/2014 NA PHOS,M-B/NA PHOS,DI-BA 19G-7G/118 ENEMA 0.00622 0.00578 8/30/2013 NABUMETONE 500 MG TABLET 0.25447 0.25366 10/25/2013 NABUMETONE 750 MG TABLET 0.23209 0.22516 1/3/2014 NADOLOL 20 MG TABLET 1.13470 2.11912 12/20/2013 NADOLOL 40 MG TABLET 1.54607 2.78610 8/16/2013 NADOLOL 80 MG TABLET 1.83321 3.78441 12/13/2013 NADOLOL/BENDROFLUMETHIAZIDE 40 MG-5 MG TABLET 0.00000 1.72368 12/1/2012 NADOLOL/BENDROFLUMETHIAZIDE 80 MG-5 MG TABLET 0.00000 2.25914 12/1/2012 NAFCILLIN IN DEXTROSE,ISO-OSM 1 G/50 ML FROZ.PIGGY 0.00000 0.25511 12/1/2012 NAFCILLIN IN DEXTROSE,ISO-OSM 2 G/100 ML FROZ.PIGGY 0.00000 0.17407 12/1/2012 NAFCILLIN SODIUM 1 G VIAL 9.54200 9.96450 4/26/2013 NAFCILLIN SODIUM 1 G VIAL PORT 12.26400 12.56750 1/25/2013 NAFCILLIN SODIUM 10 G VIAL 0.00000 97.14110 12/1/2012 NAFCILLIN SODIUM 2 G VIAL 19.82470 19.41240 10/11/2013 NAFCILLIN SODIUM 2 G VIAL PORT 24.57580 26.14500 3/29/2013 NALBUPHINE HCL 10 MG/ML VIAL 0.00000 1.19280 12/1/2012 NALBUPHINE HCL 20 MG/ML AMPUL 2.89120 3.45670 1/25/2013 NALBUPHINE HCL 20 MG/ML VIAL 1.70016 1.70020 1/25/2013 NALOXONE HCL 0.4 MG/ML SYRINGE 0.00000 3.15000 12/1/2012 NALOXONE HCL 1 MG/ML SYRINGE 0.00000 7.11900 12/1/2012 NALTREXONE HCL 50 MG TABLET 1.16580 1.00054 9/20/2013 NAPHAZOLINE HCL 0.1 % DROPS 0.00000 0.11787 12/1/2012 NAPHAZOLINE HCL/GLYCERIN 0.012-0.2% DROPS 0.15261 0.13640 1/25/2013 NAPROXEN 125 MG/5ML ORAL SUSP 0.13839 0.09332 8/2/2013 NAPROXEN 250 MG TABLET 0.04368 0.04355 5/31/2013 NAPROXEN 375 MG TABLET 0.05534 0.05119 4/26/2013 NAPROXEN 375 MG TABLET DR 0.14870 0.14755 3/1/2013 NAPROXEN 500 MG TABLET 0.06633 0.06321 4/26/2013 NAPROXEN 500 MG TABLET DR 0.16965 0.16393 12/13/2013 NAPROXEN SODIUM 220 MG TABLET 0.06095 0.05975 1/3/2014 NAPROXEN SODIUM 275 MG TABLET 0.08544 0.08189 8/16/2013 NAPROXEN SODIUM 550 MG TABLET 0.11127 0.11254 5/24/2013 NARATRIPTAN HCL 1 MG TABLET 3.37505 5.59223 9/13/2013 NARATRIPTAN HCL 2.5 MG TABLET 3.83120 5.29830 1/25/2013 NATEGLINIDE 120 MG TABLET 0.84591 0.84513 1/3/2014 NATEGLINIDE 60 MG TABLET 0.85197 0.82654 1/3/2014 NEFAZODONE HCL 100 MG TABLET 0.00000 0.57850 12/1/2012 NEFAZODONE HCL 150 MG TABLET 0.60797 0.60800 12/14/2012 NEFAZODONE HCL 200 MG TABLET 0.63678 0.63680 12/14/2012 NEFAZODONE HCL 250 MG TABLET 0.66580 0.66582 8/23/2013 NEFAZODONE HCL 50 MG TABLET 0.00000 0.52117 12/1/2012 NEO/POLYMYX B SULF/DEXAMETH 0.1 % DROPS SUSP 3.76220 3.75440 9/6/2013 NEO/POLYMYX B SULF/DEXAMETH 3.5-10K-.1 OINT. (G) 1.60000 4.73550 2/1/2013 NEOMY SULF/BACITRA/POLYMYXIN B PACKET 0.19333 0.19440 1/25/2013 NEOMY SULF/BACITRA/POLYMYXIN B 3.5MG-400 OINT. (G) 0.00000 8.35200 12/1/2012 NEOMY SULF/BACITRAC ZN/POLY 3.5-400-5K OINT. (G) 0.08536 0.08532 10/18/2013 NEOMY SULF/BACITRAC ZN/POLY/HC 3.5-10K-1 OINT. (G) 0.00000 12.81000 12/1/2012 NEOMY SULF/POLYMYXIN B SULFATE 40-200K/ML AMPUL 7.75416 7.53960 4/12/2013 NEOMY SULF/POLYMYXIN B SULFATE 40-200K/ML VIAL 0.00000 5.02645 12/1/2012

Page 36 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 NEOMYCIN SULFATE 500 MG TABLET 0.89881 0.92990 1/24/2014 NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-1 DROPS SUSP 2.15600 2.15657 2/1/2013 NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-1 SOLUTION 0.00000 1.65100 12/1/2012 NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-10 DROPS SUSP 13.15253 13.05287 3/8/2013 NEOMYCIN/POLYMYXN B/GRAMICIDIN 1.75MG-10K DROPS 1.29350 4.33580 5/24/2013 NEOMYCN/BACI ZN/PMYX BS/PRAMOX 3.5-10K-10 OINT. (G) 0.00000 0.16978 12/1/2012 NEVIRAPINE 200 MG TABLET 0.17702 0.19200 1/25/2013 NEVIRAPINE 50 MG/5 ML ORAL SUSP 0.00000 0.40225 12/1/2012 NIACIN 100 MG TABLET 0.01268 0.01270 12/14/2012 NIACIN 1000 MG TAB ER 24H 0.00000 4.77291 1/3/2014 NIACIN 1000 MG TABLET ER 0.00000 0.05775 12/14/2012 NIACIN 250 MG CAPSULE ER 0.00000 0.04147 12/1/2012 NIACIN 250 MG TABLET ER 0.03660 0.03662 2/8/2013 NIACIN 50 MG TABLET 0.00000 0.01274 12/1/2012 NIACIN 500 MG CAPSULE ER 0.04927 0.04930 12/14/2012 NIACIN 500 MG TAB ER 24H 0.00000 2.69857 1/3/2014 NIACIN 500 MG TABLET 0.01997 0.02000 12/14/2012 NIACIN 500 MG TABLET ER 0.03296 0.03081 10/11/2013 NIACIN 750 MG TABLET ER 0.10383 0.05020 1/25/2013 NIACINAMIDE 500 MG TABLET 0.02415 0.02737 4/5/2013 NICARDIPINE HCL 20 MG CAPSULE 0.32760 0.34500 2/8/2013 NICARDIPINE HCL 30 MG CAPSULE 0.48220 0.35170 1/25/2013 NICOTINE 14MG/24HR PATCH TD24 1.70078 1.65163 1/24/2014 NICOTINE 21 MG/24HR PATCH TD24 1.72059 1.49950 8/23/2013 NICOTINE 7MG/24HR PATCH TD24 1.64073 1.69758 1/24/2014 NICOTINE POLACRILEX 2 MG GUM 0.25977 0.20868 8/30/2013 NICOTINE POLACRILEX 4 MG GUM 0.30653 0.26813 8/30/2013 NIFEDIPINE 10 MG CAPSULE 0.82691 0.78660 11/1/2013 NIFEDIPINE 20 MG CAPSULE 1.61180 1.61182 8/9/2013 NIFEDIPINE 30 MG TAB ER 24 0.41433 0.40522 6/14/2013 NIFEDIPINE 30 MG TABLET ER 0.46632 0.46637 7/19/2013 NIFEDIPINE 60 MG TAB ER 24 0.58800 0.58799 3/1/2013 NIFEDIPINE 60 MG TABLET ER 1.78434 1.00902 1/3/2014 NIFEDIPINE 90 MG TAB ER 24 1.81822 1.02510 8/16/2013 NIFEDIPINE 90 MG TABLET ER 1.85478 1.88509 8/30/2013 NIMODIPINE 30 MG CAPSULE 6.40815 6.55030 12/21/2012 NISOLDIPINE 17 MG TAB ER 24H 0.00000 5.38832 12/1/2012 NISOLDIPINE 20 MG TAB ER 24H 6.46710 6.85510 8/9/2013 NISOLDIPINE 25.5 MG TAB ER 24H 0.00000 5.87636 12/1/2012 NISOLDIPINE 30 MG TAB ER 24H 6.65350 7.05270 2/8/2013 NISOLDIPINE 34 MG TAB ER 24H 0.00000 5.87636 12/1/2012 NISOLDIPINE 40 MG TAB ER 24H 0.00000 6.65350 12/1/2012 NISOLDIPINE 8.5MG TAB ER 24H 0.00000 4.29926 12/1/2012 NITROFURANTOIN 25 MG/5 ML ORAL SUSP 2.00158 1.97672 1/24/2014 NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE 1.68384 1.56470 5/17/2013 NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE 0.95840 0.95835 6/14/2013 NITROFURANTOIN MONOHYD/M-CRYST 100 MG CAPSULE 2.40856 2.42073 12/27/2013 NITROGLYCERIN 0.1MG/HR PATCH TD24 0.66430 0.84067 12/13/2013 NITROGLYCERIN 0.2MG/HR PATCH TD24 0.61550 0.71958 12/13/2013 NITROGLYCERIN 0.4MG/DOSE SPRAY (AEROSOL) 0.00000 27.46701 1/4/2013 NITROGLYCERIN 0.4MG/DOSE SPRAY (NON-AEROSOL) 24.50160 19.55100 7/12/2013 NITROGLYCERIN 0.4MG/HR PATCH TD24 0.67358 0.86654 12/13/2013 NITROGLYCERIN 0.6MG/HR PATCH TD24 1.02281 1.11309 10/11/2013 NITROGLYCERIN 2.5 MG CAPSULE ER 0.22630 0.33267 5/17/2013 NITROGLYCERIN 50 MG/10ML VIAL 0.00000 0.47040 12/1/2012 NITROGLYCERIN 6.5 MG CAPSULE ER 0.13830 0.32960 2/15/2013 NITROGLYCERIN 9 MG CAPSULE ER 0.49568 0.17330 1/25/2013

Page 37 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 NITROGLYCERIN/D5W 200MG/500 INFUS. BTL 0.01446 0.01110 1/25/2013 NITROGLYCERIN/D5W 50MG/500ML INFUS. BTL 0.02648 0.02260 1/25/2013 NIZATIDINE 150 MG CAPSULE 0.27223 0.27805 11/22/2013 NIZATIDINE 150MG/10ML SOLUTION 0.49823 0.49300 6/28/2013 NIZATIDINE 300 MG CAPSULE 0.77260 0.85582 8/30/2013 NORETH A-ET ESTRA/FE FUMARATE 1.5-0.03MG TABLET 0.72336 0.69496 12/13/2013 NORETH A-ET ESTRA/FE FUMARATE 1MG-20MCG TABLET 0.71641 0.71640 10/18/2013 NORETH A-ET ESTRA/FE FUMARATE 5-7-9-7 TABLET 1.42880 1.42884 10/4/2013 NORETH-ETHINYL ESTRADIOL/IRON 0.4-35(21) TAB CHEW 1.82948 1.82950 1/25/2013 NORETHINDRONE 0.35 MG TABLET 0.85114 0.80854 12/13/2013 NORETHINDRONE A-E ESTRADIOL 1.5-0.03MG TABLET 0.96454 0.96456 7/26/2013 NORETHINDRONE A-E ESTRADIOL 1MG-20MCG TABLET 0.00000 0.95522 12/1/2012 NORETHINDRONE ACETATE 5 MG TABLET 1.85400 1.85402 7/12/2013 NORETHINDRONE-ETHINYL ESTRAD 0.4-0.035 TABLET 1.12089 0.91215 8/30/2013 NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET 0.80430 0.80140 1/25/2013 NORETHINDRONE-ETHINYL ESTRAD 1 MG-35MCG TABLET 0.74378 0.74564 1/31/2014 NORETHINDRONE-ETHINYL ESTRAD 7 DAYS X 3 TABLET 0.81672 0.81482 1/10/2014 NORETHINDRONE-ETHINYL ESTRAD 7-9-5 TABLET 0.00000 0.98375 12/1/2012 NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 TABLET 0.51223 0.49332 11/8/2013 NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 28 TABLET 0.51223 0.49939 12/13/2013 NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET 0.75000 0.76300 2/8/2013 NORTRIPTYLINE HCL 10 MG CAPSULE 0.09920 0.09916 3/22/2013 NORTRIPTYLINE HCL 10 MG/5 ML SOLUTION 0.17685 0.20683 12/14/2012 NORTRIPTYLINE HCL 25 MG CAPSULE 0.13600 0.13601 11/15/2013 NORTRIPTYLINE HCL 50 MG CAPSULE 0.16643 0.16216 1/31/2014 NORTRIPTYLINE HCL 75 MG CAPSULE 0.23060 0.23061 11/15/2013 NYSTATIN 100000/G CREAM (G) 0.58062 0.57262 8/16/2013 NYSTATIN 100000/G OINT. (G) 0.00000 0.95120 12/1/2012 NYSTATIN 100000/G POWDER 0.77360 1.01120 2/1/2013 NYSTATIN 100000/ML ORAL SUSP 0.00000 0.09632 1/17/2014 NYSTATIN 10B UNIT POWDER(EA) 0.00000 ########## 12/1/2012 NYSTATIN 150MM UNIT POWDER(EA) MISC (bulk) 408.51650 98.76650 1/25/2013 NYSTATIN 150MM UNIT POWDER(EA) ORAL 0.00000 70.10500 12/1/2012 NYSTATIN 1B UNIT POWDER(EA) 523.22200 404.56500 1/25/2013 NYSTATIN 2B UNIT POWDER(EA) 0.00000 459.38450 12/1/2012 NYSTATIN 500K UNIT TABLET 0.53820 0.51557 1/31/2014 NYSTATIN 500MM UNIT POWDER(EA) MISC (bulk) 0.00000 156.49700 12/1/2012 NYSTATIN 500MM UNIT POWDER(EA) ORAL 2.78014 203.31500 8/30/2013 NYSTATIN 50MM UNIT POWDER(EA) MISC (bulk) 0.00000 47.31300 12/1/2012 NYSTATIN 50MM UNIT POWDER(EA) ORAL 0.00000 3.91430 12/1/2012 NYSTATIN 5B UNIT POWDER(EA) 0.00000 742.07950 12/1/2012 NYSTATIN/TRIAMCIN 100000-0.1 CREAM (G) 0.00000 1.42510 12/13/2013 NYSTATIN/TRIAMCIN 100000-0.1 OINT. (G) 0.00000 2.99433 1/17/2014 OCTREOTIDE ACETATE 100 MCG/ML AMPUL 0.00000 5.70960 12/1/2012 OCTREOTIDE ACETATE 100 MCG/ML SYRINGE 0.00000 10.04850 12/1/2012 OCTREOTIDE ACETATE 100 MCG/ML VIAL 5.54190 5.41401 12/20/2013 OCTREOTIDE ACETATE 1000MCG/ML VIAL 0.00000 30.52860 12/1/2012 OCTREOTIDE ACETATE 200 MCG/ML VIAL 7.30800 8.03760 12/20/2013 OCTREOTIDE ACETATE 50 MCG/ML AMPUL 0.00000 2.84310 12/1/2012 OCTREOTIDE ACETATE 50 MCG/ML SYRINGE 0.00000 5.98920 12/1/2012 OCTREOTIDE ACETATE 50 MCG/ML VIAL 3.08850 6.06060 12/20/2013 OCTREOTIDE ACETATE 500 MCG/ML AMPUL 0.00000 29.90650 12/1/2012 OCTREOTIDE ACETATE 500 MCG/ML SYRINGE 0.00000 45.22560 12/1/2012 OCTREOTIDE ACETATE 500 MCG/ML VIAL 16.18890 19.12365 12/20/2013 OFLOXACIN 0.3 % DROPS OPHTHALMIC 0.37252 0.38726 8/9/2013 OFLOXACIN 0.3 % DROPS OTIC 0.61370 2.58116 7/12/2013 OFLOXACIN 200 MG TABLET 0.00000 3.34859 12/1/2012

Page 38 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 OFLOXACIN 300 MG TABLET 0.00000 3.98503 12/1/2012 OFLOXACIN 400 MG TABLET 4.20252 4.20250 12/14/2012 OLANZAPINE 10 MG TAB RAPDIS 0.00000 8.72300 12/1/2012 OLANZAPINE 10 MG TABLET 0.00000 1.29440 12/1/2012 OLANZAPINE 10 MG VIAL 0.00000 29.05000 12/1/2012 OLANZAPINE 15 MG TAB RAPDIS 0.00000 12.86570 12/1/2012 OLANZAPINE 15 MG TABLET 0.00000 1.94180 12/1/2012 OLANZAPINE 2.5 MG TABLET 0.00000 0.40630 12/1/2012 OLANZAPINE 20 MG TAB RAPDIS 0.00000 17.00830 12/1/2012 OLANZAPINE 20 MG TABLET 0.00000 2.58900 12/1/2012 OLANZAPINE 5 MG TAB RAPDIS 0.00000 5.93670 12/1/2012 OLANZAPINE 5 MG TABLET 0.00000 0.85890 12/1/2012 OLANZAPINE 7.5 MG TABLET 0.00000 0.54020 12/1/2012 OLANZAPINE/FLUOXETINE HCL 12MG-25MG CAPSULE 0.00000 15.27470 12/1/2012 OLANZAPINE/FLUOXETINE HCL 12MG-50MG CAPSULE 0.00000 15.27470 12/1/2012 OLANZAPINE/FLUOXETINE HCL 3 MG-25 MG CAPSULE 7.57062 7.72543 4/5/2013 OLANZAPINE/FLUOXETINE HCL 6MG-25MG CAPSULE 0.00000 10.13740 12/1/2012 OLANZAPINE/FLUOXETINE HCL 6MG-50MG CAPSULE 0.00000 10.13740 12/1/2012 OMEGA-3/DHA/EPA/FISH OIL 1000 MG CAPSULE 0.04020 0.03652 8/9/2013 OMEPRAZOLE 10 MG CAPSULE DR 0.27684 0.26318 9/27/2013 OMEPRAZOLE 20 MG CAPSULE DR 0.10626 0.08670 9/6/2013 OMEPRAZOLE 20 MG TABLET DR 0.00000 0.60836 12/1/2012 OMEPRAZOLE 40 MG CAPSULE DR 0.21400 0.20730 9/20/2013 OMEPRAZOLE/SODIUM BICARBONATE 20MG-1.1G CAPSULE 0.00000 0.48869 12/1/2012 OMEPRAZOLE/SODIUM BICARBONATE 40MG-1.1G CAPSULE 7.97440 8.77497 6/14/2013 ONDANSETRON 4 MG TAB RAPDIS 0.77125 0.55200 12/27/2013 ONDANSETRON 8 MG TAB RAPDIS 1.04610 1.03672 10/11/2013 ONDANSETRON HCL 4 MG TABLET 0.14784 0.14696 8/16/2013 ONDANSETRON HCL 4 MG/5 ML SOLUTION 0.60530 1.94420 2/8/2013 ONDANSETRON HCL 8 MG TABLET 0.15906 0.18894 5/17/2013 ONDANSETRON HCL/PF 4 MG/2 ML AMPUL 0.00000 8.31950 12/1/2012 ONDANSETRON HCL/PF 4 MG/2 ML SYRINGE 1.10670 0.56277 8/30/2013 ONDANSETRON HCL/PF 4 MG/2 ML VIAL 0.32428 0.31460 5/10/2013 OPIUM TINCTURE 10 MG/ML TINCTURE 4.99300 3.65310 8/2/2013 OPIUM/BELLADONNA ALKALOIDS 30-16.2MG SUPP.RECT 16.21380 17.83542 4/5/2013 OPIUM/BELLADONNA ALKALOIDS 60-16.2MG SUPP.RECT 19.71083 21.68192 4/5/2013 ORPHENADRINE CITRATE 100 MG TABLET ER 0.48990 0.39390 12/6/2013 OXACILLIN SODIUM 1 G VIAL 9.75910 10.07977 2/1/2013 OXACILLIN SODIUM 1 G VIAL PORT 0.00000 0.86301 12/1/2012 OXACILLIN SODIUM 10 G VIAL 88.62910 90.95850 2/1/2013 OXACILLIN SODIUM 2 G VIAL 18.87810 18.97980 2/1/2013 OXACILLIN SODIUM 2 G VIAL PORT 0.00000 2.23201 12/1/2012 OXACILLIN SODIUM/DEXTROSE,ISO 1 G/50 ML FROZ.PIGGY 0.25511 0.25790 1/25/2013 OXACILLIN SODIUM/DEXTROSE,ISO 2 G/50 ML FROZ.PIGGY 0.00000 0.21527 12/1/2012 OXANDROLONE 10 MG TABLET 0.00000 9.27840 12/1/2012 OXANDROLONE 2.5 MG TABLET 2.99290 3.00096 6/14/2013 OXAPROZIN 600 MG TABLET 2.34180 2.56480 2/22/2013 OXAZEPAM 10 MG CAPSULE 0.00000 0.73300 12/1/2012 OXAZEPAM 15 MG CAPSULE 0.00000 1.20600 12/1/2012 OXCARBAZEPINE 150 MG TABLET 0.13740 0.13730 9/20/2013 OXCARBAZEPINE 300 MG TABLET 0.28073 0.27459 6/14/2013 OXCARBAZEPINE 300 MG/5ML ORAL SUSP 0.53140 0.57900 12/21/2012 OXCARBAZEPINE 600 MG TABLET 0.53365 0.54703 10/11/2013 OXYBUTYNIN CHLORIDE 10 MG TAB ER 24 1.45930 1.28700 4/12/2013 OXYBUTYNIN CHLORIDE 15 MG TAB ER 24 2.15887 2.15890 12/14/2012 OXYBUTYNIN CHLORIDE 5 MG TAB ER 24 1.45930 1.28700 4/12/2013 OXYBUTYNIN CHLORIDE 5 MG TABLET 0.11958 0.42780 7/19/2013

Page 39 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 OXYBUTYNIN CHLORIDE 5 MG/5 ML SYRUP 0.01960 0.02124 5/17/2013 OXYCODONE HCL 10 MG TABLET 0.24700 0.26460 12/21/2012 OXYCODONE HCL 15 MG TABLET 0.16080 0.28073 12/13/2013 OXYCODONE HCL 20 MG/ML ORAL CONC 5.17720 6.18140 5/31/2013 OXYCODONE HCL 30 MG TABLET 0.32160 0.52193 12/13/2013 OXYCODONE HCL 5 MG CAPSULE 1.02537 1.29200 1/10/2014 OXYCODONE HCL 5 MG TABLET 0.10720 0.31889 12/13/2013 OXYCODONE HCL/ACETAMINOPHEN 10MG-325MG TABLET 1.06873 0.78671 1/17/2014 OXYCODONE HCL/ACETAMINOPHEN 2.5-325MG TABLET 2.87868 1.43437 9/20/2013 OXYCODONE HCL/ACETAMINOPHEN 5MG-325MG TABLET 0.20915 0.25060 12/20/2013 OXYCODONE HCL/ACETAMINOPHEN 7.5-325MG TABLET 0.84876 0.96882 12/13/2013 OXYMORPHONE HCL 10 MG TABLET 3.94550 4.61370 11/1/2013 OXYMORPHONE HCL 5 MG TABLET 2.19465 2.10045 11/1/2013 P-EPHED HCL/CODEINE/GUAIFEN 30-10-100 SYRUP 0.00000 0.04770 12/1/2012 PAMIDRONATE DISODIUM 30 MG VIAL 0.00000 15.22500 12/1/2012 PAMIDRONATE DISODIUM 30MG/10ML VIAL 0.00000 1.51688 12/1/2012 PAMIDRONATE DISODIUM 60 MG/10ML VIAL 0.00000 4.62000 12/1/2012 PAMIDRONATE DISODIUM 90 MG VIAL 0.00000 56.47750 12/1/2012 PAMIDRONATE DISODIUM 90 MG/10ML VIAL 0.00000 4.14700 12/1/2012 PANTOPRAZOLE SODIUM 20 MG TABLET DR 0.11458 0.12179 8/16/2013 PANTOPRAZOLE SODIUM 40 MG TABLET DR 0.10358 0.10079 4/19/2013 PANTOPRAZOLE SODIUM 40 MG VIAL 3.94100 2.53400 7/19/2013 PAREGORIC 2 MG/5 ML LIQUID 0.19635 0.46388 4/26/2013 PARICALCITOL 1 MCG CAPSULE 0.00000 7.76370 10/18/2013 PARICALCITOL 2 MCG CAPSULE 0.00000 15.52623 10/18/2013 PARICALCITOL 4MCG CAPSULE 0.00000 31.05270 10/18/2013 PAROMOMYCIN SULFATE 250 MG CAPSULE 3.13066 2.95152 6/14/2013 PAROXETINE HCL 10 MG TABLET 0.11390 0.11361 10/11/2013 PAROXETINE HCL 12.5 MG TAB ER 24H 2.53237 2.53190 1/25/2013 PAROXETINE HCL 20 MG TABLET 0.11899 0.09581 7/12/2013 PAROXETINE HCL 25 MG TAB ER 24H 2.63724 2.64470 1/25/2013 PAROXETINE HCL 30 MG TABLET 0.16844 0.16840 12/14/2012 PAROXETINE HCL 37.5 MG TAB ER 24H 2.72364 2.72360 1/25/2013 PAROXETINE HCL 40 MG TABLET 0.17155 0.16962 10/11/2013 PEANUT OIL OIL 0.09602 0.09990 1/25/2013 PEG 3350/NA SULF,BICARB,CL/KCL 236-22.74G SOLN RECON 0.00314 0.00313 7/12/2013 PEG 3350/NA SULF,BICARB,CL/KCL 240-22.72G SOLN RECON 0.00210 0.00220 2/8/2013 PEG 400/HYPROMELLOSE/GLYCERIN 1-0.2-0.2% DROPS 0.15805 0.06720 1/25/2013 PEN G POT/DEXTROSE-WATER 1MM/50ML FROZ.PIGGY 0.00000 0.19490 12/1/2012 PEN G POT/DEXTROSE-WATER 2MM/50ML FROZ.PIGGY 0.00000 0.21880 12/1/2012 PEN G POT/DEXTROSE-WATER 3MM/50ML FROZ.PIGGY 0.24007 0.13440 1/25/2013 PENICILLIN G POTASSIUM 20MM UNIT VIAL 95.11250 119.09100 1/31/2014 PENICILLIN G POTASSIUM 5MM UNIT VIAL 29.52250 21.69720 1/25/2013 PENICILLIN G PROCAINE 1.2MM/2 ML SYRINGE 10.86715 11.84540 1/25/2013 PENICILLIN G PROCAINE 600000/ML SYRINGE 0.00000 13.05360 12/1/2012 PENICILLIN G SODIUM 5MM UNIT VIAL 38.58720 40.12055 8/9/2013 PENICILLIN V POTASSIUM 125 MG/5ML SOLN RECON 0.02314 0.02349 4/5/2013 PENICILLIN V POTASSIUM 250 MG TABLET 0.07517 0.07303 7/12/2013 PENICILLIN V POTASSIUM 250 MG/5ML SOLN RECON 0.02537 0.02513 5/31/2013 PENICILLIN V POTASSIUM 500 MG TABLET 0.12301 0.10601 6/28/2013 PENTAZOCINE HCL/NALOXONE HCL 50MG-0.5MG TABLET 1.01468 1.02022 1/31/2014 PENTOXIFYLLINE 400 MG TABLET ER 0.17535 0.16817 11/8/2013 PERINDOPRIL ERBUMINE 2 MG TABLET 0.00000 0.85163 12/1/2012 PERINDOPRIL ERBUMINE 4 MG TABLET 0.00000 0.75205 12/1/2012 PERINDOPRIL ERBUMINE 8 MG TABLET 0.00000 0.85631 12/1/2012 PERMETHRIN 1 % LIQUID 0.00000 0.04372 12/13/2013 PERMETHRIN 5 % CREAM (G) 0.82930 1.40446 6/28/2013

Page 40 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PERPHENAZINE 16 MG TABLET 1.64122 1.67330 7/26/2013 PERPHENAZINE 2 MG TABLET 0.80915 0.80504 11/29/2013 PERPHENAZINE 4 MG TABLET 1.24990 1.11510 10/4/2013 PERPHENAZINE 8 MG TABLET 1.01437 1.38698 5/31/2013 PERPHENAZINE/AMITRIPTYLINE HCL 2 MG-10 MG TABLET 0.42510 0.45060 2/8/2013 PERPHENAZINE/AMITRIPTYLINE HCL 2 MG-25 MG TABLET 0.00000 0.60030 12/1/2012 PERPHENAZINE/AMITRIPTYLINE HCL 4 MG-25 MG TABLET 0.62230 0.66233 7/19/2013 PERPHENAZINE/AMITRIPTYLINE HCL 4MG-10MG TABLET 0.47565 0.47570 1/25/2013 PETROLATUM,WHITE/WATER LOTION 0.01034 0.00860 1/25/2013 PHENAZOPYRIDINE HCL 100 MG TABLET 0.08684 0.08680 12/14/2012 PHENAZOPYRIDINE HCL 200 MG TABLET 0.00000 0.21310 12/1/2012 PHENDIMETRAZINE TARTRATE 35 MG TABLET 0.13900 0.13746 6/14/2013 PHENELZINE SULFATE 15 MG TABLET 0.00000 0.58450 12/1/2012 PHENOBARBITAL 100 MG TABLET 0.22434 0.22053 4/19/2013 PHENOBARBITAL 15 MG TABLET 0.11415 0.11231 4/12/2013 PHENOBARBITAL 16.2 MG TABLET 0.12684 0.15590 1/31/2014 PHENOBARBITAL 20 MG/5 ML ELIXIR 0.12090 0.14799 6/14/2013 PHENOBARBITAL 30 MG TABLET 0.08000 0.12320 3/22/2013 PHENOBARBITAL 32.4 MG TABLET 0.15935 0.19467 1/31/2014 PHENOBARBITAL 64.8 MG TABLET 0.20327 0.24903 1/31/2014 PHENOBARBITAL 97.2MG TABLET 0.29154 0.35623 1/31/2014 PHENOBARBITAL SODIUM 130MG/ML VIAL 24.19200 13.60800 1/25/2013 PHENOBARBITAL SODIUM 65 MG/ML VIAL 18.26916 10.58400 7/26/2013 PHENTERMINE HCL 15 MG CAPSULE 0.76600 0.76603 2/22/2013 PHENTERMINE HCL 30 MG CAPSULE 0.00000 0.20502 12/1/2012 PHENTERMINE HCL 37.5 MG CAPSULE 0.00000 0.31195 12/1/2012 PHENTERMINE HCL 37.5 MG TABLET 0.00000 0.10693 12/1/2012 PHENTOLAMINE MESYLATE 5 MG VIAL 44.58750 59.45000 12/14/2012 PHENTOLAMINE MESYLATE 5 MG/ML(1) VIAL 0.00000 257.37180 12/1/2012 PHENYLEPHRINE HCL 10 % DROPS 0.00000 0.88140 12/1/2012 PHENYLEPHRINE HCL 10 MG TABLET 0.00000 0.03575 12/1/2012 PHENYLEPHRINE HCL 2.5 % DROPS 0.93706 0.93710 6/14/2013 PHENYLEPHRINE HCL 2.5 MG/5ML SOLUTION 0.05222 0.04150 1/25/2013 PHENYLEPHRINE HCL/PROMETH HCL 5-6.25MG/5 SYRUP 0.06227 0.13119 12/27/2013 PHENYLEPHRINE/BROMPHENIRAMINE 10-4MG/5ML LIQUID 0.00000 0.15294 12/1/2012 PHENYLEPHRINE/BROMPHENIRAMINE 10MG-6MG/5 ORAL SUSP 0.00000 0.25513 12/1/2012 PHENYLEPHRINE/CHLOPHEDIANOL/GG 5-12.5-120 LIQUID 0.09590 0.08960 1/25/2013 PHENYLEPHRINE/CHLORPHENIRAMINE 10-4MG/5ML LIQUID 0.02657 0.02660 1/25/2013 PHENYLEPHRINE/CHLORPHENIRAMINE 2MG-1MG/ML DROPS 0.00000 0.45951 12/1/2012 PHENYLEPHRINE/CHLORPHENIRAMINE 3.5-1MG/ML DROPS 0.37657 0.37660 12/14/2012 PHENYLEPHRINE/PYRILAMINE 5-16MG/5ML ORAL SUSP 0.40979 0.40980 1/25/2013 PHENYTOIN 100 MG/4ML ORAL SUSP 0.24360 0.27300 9/6/2013 PHENYTOIN 125 MG/5ML ORAL SUSP 0.10114 0.10191 5/31/2013 PHENYTOIN 50 MG TAB CHEW 0.41347 0.36841 3/29/2013 PHENYTOIN SODIUM 50 MG/ML AMPUL 0.00000 0.57670 1/25/2013 PHENYTOIN SODIUM 50 MG/ML SYRINGE 0.62160 0.68460 1/25/2013 PHENYTOIN SODIUM 50 MG/ML VIAL 0.33999 0.37563 5/10/2013 PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE 0.08831 0.08985 5/24/2013 PHENYTOIN SODIUM EXTENDED 200 MG CAPSULE 0.55987 0.55990 1/25/2013 PHENYTOIN SODIUM EXTENDED 300 MG CAPSULE 0.00000 0.83864 12/1/2012 PHOSP ACID/DEXTROSE/FRUCTOSE SOLUTION 0.02023 0.03038 7/12/2013 PHOSPHORUS #1 250 MG TABLET 0.13195 0.27508 12/20/2013 PHYTONADIONE 10 MG/ML AMPUL 7.92240 7.53480 1/25/2013 PHYTONADIONE 100 MCG TABLET 0.02195 0.02140 1/25/2013 PILOCARPINE HCL 1 % DROPS 1.49990 4.34000 4/26/2013 PILOCARPINE HCL 2 % DROPS 1.68036 4.43940 4/26/2013 PILOCARPINE HCL 4 % DROPS 2.08598 4.65220 4/26/2013

Page 41 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PILOCARPINE HCL 5 MG TABLET 0.23250 0.21420 7/26/2013 PILOCARPINE HCL 7.5 MG TABLET 1.22366 1.32821 7/26/2013 PINDOLOL 10 MG TABLET 0.93352 0.98950 1/25/2013 PINDOLOL 5 MG TABLET 0.68520 0.72630 2/8/2013 PIOGLITAZONE HCL 15 MG TABLET 0.19788 0.19773 12/20/2013 PIOGLITAZONE HCL 30 MG TABLET 0.00000 0.28364 4/19/2013 PIOGLITAZONE HCL 45 MG TABLET 0.30883 0.31415 10/11/2013 PIOGLITAZONE HCL/GLIMEPIRIDE 30 MG-2 MG TABLET 0.00000 21.94569 3/1/2013 PIOGLITAZONE HCL/GLIMEPIRIDE 30 MG-4 MG TABLET 0.00000 21.94569 3/1/2013 PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G VIAL 4.41090 3.74530 11/29/2013 PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G VIAL PORT 0.00000 8.32230 12/1/2012 PIPERACILLIN SODIUM/TAZOBACTAM 3.375 G VIAL 5.91185 11.98000 7/19/2013 PIPERACILLIN SODIUM/TAZOBACTAM 3.375 G VIAL PORT 11.57100 12.66720 1/31/2014 PIPERACILLIN SODIUM/TAZOBACTAM 4.5G VIAL 7.87680 15.01360 7/19/2013 PIPERACILLIN SODIUM/TAZOBACTAM 4.5G VIAL PORT 0.00000 15.73320 12/1/2012 PIPERACILLIN SODIUM/TAZOBACTAM 40.5G VIAL 54.97700 95.66330 11/1/2013 PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% SHAMPOO 0.03610 0.03613 5/3/2013 PIROXICAM 10 MG CAPSULE 0.98560 1.05404 7/26/2013 PIROXICAM 20 MG CAPSULE 1.84730 1.80000 2/8/2013 PN W-CA64/IRON CB&GL/FA/DSS/DH 90-1-300MG COMBO. PKG 0.76697 0.78400 7/5/2013 PNV #8/IRON PS CMP&ASPG/FA/DHA 22-6-1-200 COMBO. PKG 0.49554 0.51920 1/25/2013 PNV #87/IRON BISGLY/FA/DHA 32-1-230MG COMBO. PKG 0.65438 0.59733 1/17/2014 PNV 11-IRON FUM-FOLIC ACID-OM3 28-1-200MG CAPSULE 1.71267 1.55634 3/15/2013 PNV CMB#21/IRON/FOLIC ACID 14 MG-400 TABLET 0.00000 0.06411 12/1/2012 PNV COMBO #19/IRON/FOL AC/DHA 22-6-1-200 CAPSULE 0.00000 2.08973 5/3/2013 PNV COMBO #22/IRON/FA/OM3/DHA 28-6-1-203 COMBO. PKG 0.62148 0.62446 12/6/2013 PNV COMBO#47/IRON/FA #1/DHA 27-1-300MG CAPSULE 1.49746 1.59167 1/31/2014 PNV NO.118/IRON FUMARATE/FA 29 MG-1 MG TAB CHEW 0.27640 0.60102 11/8/2013 PNV NO.15/IRON FUM & PS CMP/FA 85 MG-1 MG CAPSULE 0.00000 1.15359 12/1/2012 PNV NO.22/IRON CBN&GLUC/FA/DSS 27-1-50MG TABLET 0.00000 0.34913 12/1/2012 PNV NO.23-IRON PS COMPLEX-FA 155 MG-1MG CAPSULE 0.00000 0.20689 12/1/2012 PNV NO.25/IRON FUMARATE/FA/DHA 30-975-200 CAPSULE 0.00000 0.55977 4/19/2013 PNV W-CA #40/IRON FUM/FA CMB#1 27 MG-1 MG TABLET 1.49072 1.15123 1/31/2014 PNV W-CA NO.37/IRON/FA/OMEGA-3 27-1-330MG CAPSULE 0.74533 1.00684 8/9/2013 PNV W-O IRON/FA/CALCIUM/B6/B12 1-200-75 TBMP 24HR 0.00000 0.70590 12/1/2012 PNV WITH CA #68/IRON/FA#1/DHA 28-1-300MG CAPSULE 0.00000 1.68677 12/1/2012 PNV WITH CA,NO.71/IRON/FA 27 MG-1 MG TABLET 0.00000 0.06240 12/1/2012 PNV WITH CA,NO.72/IRON,CARB/FA 29 MG-1 MG TABLET 0.06740 0.13210 1/25/2013 PNV WITH CA,NO.72/IRON/FA 27 MG-1 MG TABLET 0.06740 0.06606 6/14/2013 PNV#16/IRON FUM & PS/FA/OM-3 35-1-200MG CAPSULE 0.74013 1.28451 8/30/2013 PNV#20/IRON/FA/DS/FISH/DHA/EPA 27-1-500MG CAPSULE 0.00000 1.34404 5/31/2013 PNV#24/IRON AA CHEL/FA/DHA 30-975-300 COMBO. PKG 0.00000 0.41988 4/19/2013 PNV#26/IRON POLY/FA/DHA 29-1-200MG CAPSULE 0.00000 1.56287 6/7/2013 PNV#79/IRON/FA/LMFOLATE CA/DHA 27-1.13 MG CAPSULE 1.63357 1.81370 1/25/2013 PNV/FA/B6/CALCIUM PHOS/GINGER 1.2-40-100 TABLET 0.00000 0.72360 12/1/2012 PNV115/IRON FUMARATE/FA/DSS 29-1-25 MG TABLET 0.00000 0.59773 1/31/2014 PNV119/IRON FUMARATE/FA/DSS 29-1-25 MG TABLET 0.22000 0.44586 1/31/2014 PNV17/IRON/FA/FISH OIL/DHA/OM 35-5-1.2MG CAPSULE 0.00000 1.61980 12/1/2012 PNV2/IRON B-G SUC-P/FA/OMEGA-3 29-1-250MG COMBO. PKG 0.00000 0.36225 12/1/2012 PNV22/IRON CBN&GLUC/FA/DSS/DHA 27-1-50MG COMBO. PKG 0.00000 0.63047 12/1/2012 PNV34/IRON,CARBONYL/FA/DSS/DHA 30-1-50 MG CAPSULE 0.00000 1.58305 12/1/2012 PNV38/IRON CBN&GLUC/FA/DSS/DHA 35-1-50MG COMBO. PKG 0.78493 0.81655 7/5/2013 PNV51/IRON FUM/FA/OM-3/DHA/EPA 27-800-228 CAPSULE 0.12028 0.11428 5/24/2013 PNV53/IRON B-G HCL-P/FA/OMEGA3 29-1-400MG COMBO. PKG 0.00000 0.43260 12/1/2012 PNV54/IRON B-G HCL-P/FA/OMEGA3 29-1-430MG COMBO. PKG 0.00000 0.43260 12/1/2012 PNV66/IRON FUMARATE/FA/DSS/DHA 26-1.2-55 CAPSULE 0.00000 1.21463 10/25/2013 PNV66/IRON FUMARATE/FA/DSS/DHA 27-1.25-55 CAPSULE 0.00000 1.36056 12/1/2012

Page 42 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PNV69/IRON,CARBONYL/FA/DSS/DHA 28-1-50 MG CAPSULE 0.00000 1.38343 1/31/2014 PNV80/IRON FUMARATE/FA/DSS/DHA 29-1.25-55 CAPSULE 0.00000 1.98769 12/1/2012 PNV81/SOD IRON EDTA& PS/FA/OM3 27-1-430MG CMBPKGDRCP 0.00000 0.86509 12/1/2012 PNV94/SOD IRON EDTA& PS/FA/OM3 26-1-374MG CMBPKGDRCP 0.00000 1.13225 12/1/2012 PNV95/FERROUS FUMARATE/FA 28MG-0.8MG TABLET 0.04200 0.05040 2/15/2013 PODOFILOX 0.5 % SOLUTION 14.15050 16.47695 3/29/2013 POLYETHYLENE GLYCOL 3350 17G POWD PACK 0.10920 1.43752 6/14/2013 POLYETHYLENE GLYCOL 3350 17G/DOSE POWDER 0.00000 0.04100 12/1/2012 POLYMYXIN B SULF/TRIMETHOPRIM 10K/ML-0.1 DROPS 0.00000 0.89840 12/1/2012 POLYVINYL ALCOHOL 1.4 % DROPS 0.00000 0.13400 12/1/2012 POT CHLORIDE/POT BICARB/CIT AC 25 MEQ TABLET EFF 0.00000 0.68997 12/1/2012 POTASSIUM ACETATE 4 MEQ/ML VIAL 0.08400 0.08796 4/5/2013 POTASSIUM BICARBONATE/CIT AC 25 MEQ TABLET EFF 0.22560 0.21200 2/15/2013 POTASSIUM CHLORIDE 10 MEQ CAPSULE ER 0.69475 0.58893 9/6/2013 POTASSIUM CHLORIDE 10 MEQ TAB ER PRT 0.38638 0.37694 1/24/2014 POTASSIUM CHLORIDE 10MEQ/0.1L PIGGYBACK 0.00000 0.02218 12/1/2012 POTASSIUM CHLORIDE 10MEQ/50ML PIGGYBACK 0.04368 0.06570 1/25/2013 POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN 0.00000 0.02806 12/1/2012 POTASSIUM CHLORIDE 2 MEQ/ML VIAL 0.02551 0.02303 4/19/2013 POTASSIUM CHLORIDE 20 MEQ TAB ER PRT 0.39663 0.35162 12/27/2013 POTASSIUM CHLORIDE 20MEQ/0.1L PIGGYBACK 0.02268 0.02180 1/25/2013 POTASSIUM CHLORIDE 20MEQ/15ML LIQUID 0.00000 0.01350 12/1/2012 POTASSIUM CHLORIDE 20MEQ/50ML PIGGYBACK 0.10777 0.10610 1/25/2013 POTASSIUM CHLORIDE 30MEQ/0.1L PIGGYBACK 0.00000 0.04528 12/1/2012 POTASSIUM CHLORIDE 40MEQ/0.1L PIGGYBACK 0.00000 0.04897 12/1/2012 POTASSIUM CHLORIDE 40MEQ/15ML LIQUID 0.03955 0.05677 1/24/2014 POTASSIUM CHLORIDE 8 MEQ CAPSULE ER 0.62810 0.65780 2/1/2013 POTASSIUM CHLORIDE IN 0.9%NACL 20 MEQ/L IV SOLN 0.00295 0.00283 4/19/2013 POTASSIUM CHLORIDE IN 0.9%NACL 40 MEQ/L IV SOLN 0.00601 0.00510 1/25/2013 POTASSIUM CHLORIDE IN D5W 20 MEQ/L IV SOLN 0.00233 0.00310 1/25/2013 POTASSIUM CHLORIDE IN D5W 30 MEQ/L IV SOLN 0.00000 0.00266 12/1/2012 POTASSIUM CHLORIDE IN D5W 40 MEQ/L IV SOLN 0.00000 0.00209 12/1/2012 POTASSIUM CHLORIDE IN LR-D5 20 MEQ/L IV SOLN 0.00739 0.00610 1/25/2013 POTASSIUM CHLORIDE IN LR-D5 40 MEQ/L IV SOLN 0.00000 0.00403 12/1/2012 POTASSIUM CHLORIDE-0.45% NACL 20 MEQ/L IV SOLN 0.00542 0.00410 1/25/2013 POTASSIUM CHLORIDE/D5-0.2%NACL 10 MEQ/L IV SOLN 0.00000 0.00234 12/1/2012 POTASSIUM CHLORIDE/D5-0.2%NACL 20 MEQ/L IV SOLN 0.00000 0.00322 12/1/2012 POTASSIUM CHLORIDE/D5-0.2%NACL 30 MEQ/L IV SOLN 0.00231 0.00200 1/25/2013 POTASSIUM CHLORIDE/D5-0.2%NACL 40 MEQ/L IV SOLN 0.00000 0.00227 12/1/2012 POTASSIUM CHLORIDE/D5-0.3%NACL 20 MEQ/L IV SOLN 0.00000 0.00322 12/1/2012 POTASSIUM CHLORIDE/D5-0.45NACL 10 MEQ/L IV SOLN 0.00230 0.00320 1/25/2013 POTASSIUM CHLORIDE/D5-0.45NACL 20 MEQ/L IV SOLN 0.00150 0.00230 1/25/2013 POTASSIUM CHLORIDE/D5-0.45NACL 30 MEQ/L IV SOLN 0.00000 0.00236 12/1/2012 POTASSIUM CHLORIDE/D5-0.45NACL 40 MEQ/L IV SOLN 0.00000 0.00228 12/1/2012 POTASSIUM CHLORIDE/D5-0.9%NACL 20 MEQ/L IV SOLN 0.00254 0.00320 1/25/2013 POTASSIUM CHLORIDE/D5-0.9%NACL 40 MEQ/L IV SOLN 0.00645 0.00540 1/25/2013 POTASSIUM CITRATE 10 MEQ TABLET ER 0.99260 1.09486 4/12/2013 POTASSIUM CITRATE 15 MEQ TABLET ER 0.00000 1.86389 1/24/2014 POTASSIUM CITRATE 5 MEQ TABLET ER 0.70811 0.78130 4/12/2013 POVIDONE-IODINE 0.3 % SOLUTION 0.00901 0.00990 1/25/2013 POVIDONE-IODINE 10 % MED. SWAB 0.12643 0.15276 7/12/2013 POVIDONE-IODINE 10 % OINT. (G) 0.00000 0.06258 12/1/2012 POVIDONE-IODINE 10 % SOLUTION 0.00643 0.00639 8/30/2013 PRAMIPEXOLE DI-HCL 0.125 MG TABLET 0.08652 0.09800 5/17/2013 PRAMIPEXOLE DI-HCL 0.25 MG TABLET 0.06919 0.09720 11/1/2013 PRAMIPEXOLE DI-HCL 0.5 MG TABLET 0.09001 0.09010 1/31/2014 PRAMIPEXOLE DI-HCL 0.75 MG TABLET 0.17139 0.12212 9/6/2013

Page 43 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PRAMIPEXOLE DI-HCL 1 MG TABLET 0.08464 0.12893 8/16/2013 PRAMIPEXOLE DI-HCL 1.5 MG TABLET 0.09701 0.12893 9/6/2013 PRAMOXINE HCL 1 % TOWELETTE 0.00000 0.35233 12/1/2012 PRAVASTATIN SODIUM 10 MG TABLET 0.47258 0.57456 10/18/2013 PRAVASTATIN SODIUM 20 MG TABLET 0.48030 0.58175 10/11/2013 PRAVASTATIN SODIUM 40 MG TABLET 0.70481 0.75588 10/11/2013 PRAVASTATIN SODIUM 80 MG TABLET 0.70482 0.76587 10/11/2013 PRAZOSIN HCL 1 MG CAPSULE 0.11403 0.13570 5/17/2013 PRAZOSIN HCL 2 MG CAPSULE 0.31306 0.30900 1/31/2014 PRAZOSIN HCL 5 MG CAPSULE 0.33594 0.42850 5/17/2013 PREDNICARBATE 0.1 % CREAM (G) 0.00000 0.86964 12/1/2012 PREDNICARBATE 0.1 % OINT. (G) 1.13044 1.17750 1/25/2013 PREDNISOLONE 15 MG/5 ML SOLUTION 0.03966 0.03992 5/24/2013 PREDNISOLONE ACETATE 1 % DROPS SUSP 7.59326 7.74480 12/20/2013 PREDNISOLONE SOD PHOSPHATE 1 % DROPS 3.22840 4.19720 2/8/2013 PREDNISOLONE SOD PHOSPHATE 15 MG/5 ML SOLUTION 0.06980 0.06969 6/7/2013 PREDNISOLONE SOD PHOSPHATE 25 MG/5 ML SOLUTION 0.00000 1.31101 12/1/2012 PREDNISOLONE SOD PHOSPHATE 5 MG/5 ML SOLUTION 0.00000 0.57224 12/20/2013 PREDNISONE 1 MG TABLET 0.12827 0.15812 9/13/2013 PREDNISONE 10 MG TAB DS PK 0.00000 0.17809 12/1/2012 PREDNISONE 10 MG TABLET 0.03377 0.14630 1/17/2014 PREDNISONE 2.5 MG TABLET 0.03834 0.14040 9/13/2013 PREDNISONE 20 MG TABLET 0.05491 0.17820 10/4/2013 PREDNISONE 5 MG TAB DS PK 0.09286 0.09568 3/29/2013 PREDNISONE 5 MG TABLET 0.02743 0.11870 1/17/2014 PREDNISONE 5 MG/5 ML SOLUTION 0.14241 0.17260 1/31/2014 PREDNISONE 50 MG TABLET 0.28611 0.28608 9/6/2013 PRENAT VIT COMB.10/IRON/FA/DHA 65-1-250MG COMBO. PKG 0.00000 0.80348 6/7/2013 PRENATAL #57/IRON/FA/DSS/DHA 29-1.25-55 CAPSULE 0.00000 1.99010 1/11/2013 PRENATAL CMB#95/IRON/FA/DHA 28-800-200 COMBO. PKG 0.00000 0.10500 4/19/2013 PRENATAL VIT #60/IRON FUM/FA 27 MG-1 MG TABLET 0.00000 0.13125 3/15/2013 PRENATAL VIT #76/IRON,CARB/FA 29 MG-1 MG TABLET 0.00000 0.11903 12/1/2012 PRENATAL VIT #91/FE FUM/FA/DHA 28-975-200 COMBO. PKG 0.00000 0.16328 4/19/2013 PRENATAL VIT 15/IRON CB/FA/DSS 90-1-50 MG TABLET 0.11780 0.11584 3/1/2013 PRENATAL VIT 16/IRON CB/FA/DSS 90-1-50 MG TABLET 0.00000 0.21984 12/1/2012 PRENATAL VIT 18/IRON CB/FA/DSS 90-1-50 MG TABLET 0.08177 0.08180 12/14/2012 PRENATAL VIT NO.73/IRON/FA 28 MG-1 MG TABLET 0.00000 0.18018 12/1/2012 PRENATAL VIT#96/FERROUS FUM/FA 27MG-0.8MG TABLET 0.06840 0.06924 11/22/2013 PRENATAL VIT/IRON FUMARATE/FA 27MG-0.8MG TABLET 0.03120 0.04257 4/12/2013 PRENATAL VIT/IRON FUMARATE/FA 28MG-0.8MG TABLET 0.05604 0.04810 8/16/2013 PRENATAL VIT/IRON FUMARATE/FA 65 MG-1 MG TABLET 0.00000 0.07504 12/1/2012 PRENATAL VIT27&CALCIUM/IRON/FA 60 MG-1 MG TABLET 0.18210 0.20146 5/17/2013 PRENATAL VITAMINS#21, IRON, FA 28-6-1 MG TABLET 1.46985 1.47032 12/6/2013 PRENATAL VITS #33/IRON/FA/DHA 29-1-250MG COMBO. PKG 0.00000 0.78528 6/7/2013 PRENATAL VITS #90/IRON FUM/FA 9 MG-0.5MG TABLET 0.00000 0.08394 12/1/2012 PRENATAL VITS #93/IRON FUM/FA 9MG-267MCG TABLET 0.00000 0.05495 4/19/2013 PRENATAL VITS W-CA,FE,FA(<1MG) TABLET 0.03910 0.04207 4/5/2013 PRIMAQUINE PHOSPHATE 26.3 MG TABLET 0.00000 1.25286 12/1/2012 PRIMIDONE 250 MG TABLET 0.18430 0.18425 6/28/2013 PRIMIDONE 50 MG TABLET 0.08938 0.08940 12/14/2012 PROBENECID 500 MG TABLET 0.51700 0.51720 1/25/2013 PROCAINAMIDE HCL 100 MG/ML VIAL 1.80852 1.98490 1/25/2013 PROCAINAMIDE HCL 500 MG/ML VIAL 7.35000 8.23200 1/25/2013 PROCHLORPERAZINE EDISYLATE 10 MG/2 ML VIAL 1.44060 2.63900 1/17/2014 PROCHLORPERAZINE EDISYLATE 5 MG/ML VIAL 1.95300 1.68000 1/25/2013 PROCHLORPERAZINE MALEATE 10 MG TABLET 0.07032 0.07129 7/12/2013 PROCHLORPERAZINE MALEATE 25 MG SUPP.RECT 9.33313 9.07460 11/1/2013

Page 44 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PROCHLORPERAZINE MALEATE 5 MG TABLET 0.05960 0.05963 7/26/2013 PROGESTERONE 50 MG/ML VIAL 2.08370 2.02150 1/25/2013 PROGESTERONE,MICRONIZED 100 MG CAPSULE 1.48263 1.48011 12/27/2013 PROGESTERONE,MICRONIZED 200 MG CAPSULE 2.81679 2.81641 12/27/2013 PROMETHAZINE HCL 12.5 MG SUPP.RECT 0.00000 3.15330 1/25/2012 PROMETHAZINE HCL 12.5 MG TABLET 0.07735 0.07919 12/13/2013 PROMETHAZINE HCL 25 MG SUPP.RECT 2.80903 8.60160 6/4/2013 PROMETHAZINE HCL 25 MG TABLET 0.00000 0.09320 12/1/2012 PROMETHAZINE HCL 25 MG/ML AMPUL 1.10880 0.99568 11/22/2013 PROMETHAZINE HCL 25 MG/ML SYRINGE 0.00000 1.04160 12/1/2012 PROMETHAZINE HCL 25 MG/ML VIAL 0.72153 0.76113 11/22/2013 PROMETHAZINE HCL 50 MG TABLET 0.12445 0.12177 6/28/2013 PROMETHAZINE HCL 50 MG/ML AMPUL 1.55400 1.79970 3/15/2013 PROMETHAZINE HCL 50 MG/ML VIAL 1.94330 1.91280 5/31/2013 PROMETHAZINE HCL 6.25MG/5ML SYRUP 0.01500 0.01499 8/23/2013 PROMETHAZINE HCL/CODEINE 6.25-10/5 SYRUP 0.01530 0.01528 2/1/2013 PROMETHAZINE/PHENYLEPH/CODEINE 6.25-5-10 SYRUP 0.08488 0.08490 12/14/2012 PROPAFENONE HCL 150 MG TABLET 0.21783 0.21533 7/5/2013 PROPAFENONE HCL 225 MG CAP ER 12H 4.46763 4.78090 2/8/2013 PROPAFENONE HCL 225 MG TABLET 0.34879 0.38643 1/31/2014 PROPAFENONE HCL 300 MG TABLET 1.00958 1.00960 12/14/2012 PROPAFENONE HCL 325 MG CAP ER 12H 5.66020 6.05700 2/1/2013 PROPAFENONE HCL 425 MG CAP ER 12H 5.66020 6.05700 2/8/2013 PROPANTHELINE BROMIDE 15 MG TABLET 0.50037 0.51177 3/15/2013 PROPARACAINE HCL 0.5 % DROPS 0.59222 0.81433 4/5/2013 PROPRANOLOL HCL POWDER 1.69830 17.22364 8/23/2013 PROPRANOLOL HCL 10 MG TABLET 0.02090 0.02085 12/27/2013 PROPRANOLOL HCL 120 MG CAP SA 24H 1.00035 1.16057 12/13/2013 PROPRANOLOL HCL 160 MG CAP SA 24H 1.52197 1.28470 1/17/2014 PROPRANOLOL HCL 20 MG TABLET 0.02210 0.02204 5/24/2013 PROPRANOLOL HCL 20 MG/5 ML SOLUTION 0.13142 0.14456 3/15/2013 PROPRANOLOL HCL 40 MG TABLET 0.00000 0.02640 12/1/2012 PROPRANOLOL HCL 40MG/5ML SOLUTION 0.18736 0.20614 3/15/2013 PROPRANOLOL HCL 60 MG CAP SA 24H 0.80186 0.62990 1/17/2014 PROPRANOLOL HCL 60 MG TABLET 0.54770 0.54766 12/27/2013 PROPRANOLOL HCL 80 MG CAP SA 24H 0.93653 0.78370 1/17/2014 PROPRANOLOL HCL 80 MG TABLET 0.04210 0.04208 12/27/2013 PROPRANOLOL/HYDROCHLOROTHIAZID 40 MG-25MG TABLET 0.71603 0.71600 12/14/2012 PROPRANOLOL/HYDROCHLOROTHIAZID 80 MG-25MG TABLET 0.87941 0.87940 12/14/2012 PROTAMINE SULFATE 10 MG/ML VIAL 0.94451 0.75770 1/25/2013 PROTECT CMB2/CERAMIDE 1,3,6-11 CREAM (G) 1.88196 1.87360 1/25/2013 PROTRIPTYLINE HCL 10 MG TABLET 1.38645 1.45408 1/31/2014 PROTRIPTYLINE HCL 5 MG TABLET 1.07682 0.90758 11/22/2013 PSEUDOEPH/CHLOPHEDIANOL/GG 30-12.5/5 LIQUID 0.08693 0.08600 1/25/2013 PSEUDOEPHED/CHLORPHENIRAMINE 60 MG-4 MG TABLET 0.05308 0.05310 12/14/2012 PSEUDOEPHEDRINE HCL 30 MG TABLET 0.02205 0.03164 12/27/2013 PSEUDOEPHEDRINE HCL 60 MG TABLET 0.04790 0.02105 7/26/2013 PSEUDOEPHEDRINE/BROMPHENIRAMIN 20-4MG/5ML LIQUID 0.19214 0.19210 1/25/2013 PSEUDOEPHEDRINE/TRIPROLIDINE 10-0.938/1 LIQUID 1.25623 1.59900 1/25/2013 PSEUDOEPHEDRINE/TRIPROLIDINE 30-1.25/5 SYRUP 0.00790 0.05830 1/25/2013 PSEUDOEPHEDRINE/TRIPROLIDINE 60MG-2.5MG TABLET 0.00000 0.05247 12/1/2012 PSYLLIUM HUSK (WITH SUGAR) 3.4 G/7 G POWDER 0.01230 0.01170 1/25/2013 PSYLLIUM SEED POWDER 0.01968 0.01780 1/25/2013 PSYLLIUM SEED (WITH DEXTROSE) POWDER 0.01161 0.01140 1/25/2013 PSYLLIUM SEED (WITH SUGAR) PACKET 0.20919 0.22940 1/25/2013 PSYLLIUM SEED (WITH SUGAR) POWDER 0.00990 0.00920 1/25/2013 PSYLLIUM SEED/ASPARTAME POWDER 0.01835 0.01710 1/25/2013

Page 45 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 PYRANTEL PAMOATE 50 MG/ML ORAL SUSP 0.16727 0.16310 1/25/2013 PYRAZINAMIDE 500 MG TABLET 0.69121 0.71150 1/25/2013 PYRIDOSTIGMINE BROMIDE 60 MG TABLET 0.27404 0.28520 1/3/2014 PYRIDOXINE HCL 100 MG TABLET 0.02399 0.02559 8/9/2013 PYRIDOXINE HCL 100 MG/ML VIAL 0.00000 7.86632 12/1/2012 PYRIDOXINE HCL 25 MG TABLET 0.02342 0.02190 1/25/2013 PYRIDOXINE HCL 50 MG TABLET 0.00000 0.01407 12/1/2012 QUETIAPINE FUMARATE 100 MG TABLET 0.00000 0.37260 12/1/2012 QUETIAPINE FUMARATE 200 MG TABLET 0.00000 0.70330 12/1/2012 QUETIAPINE FUMARATE 25 MG TABLET 0.00000 0.21760 12/1/2012 QUETIAPINE FUMARATE 300 MG TABLET 0.00000 0.92200 12/1/2012 QUETIAPINE FUMARATE 400 MG TABLET 0.00000 1.14370 12/1/2012 QUETIAPINE FUMARATE 50 MG TABLET 0.00000 0.35700 12/1/2012 QUINAPRIL HCL 10 MG TABLET 0.17571 0.15690 1/24/2014 QUINAPRIL HCL 20 MG TABLET 0.19240 0.19930 4/19/2013 QUINAPRIL HCL 40 MG TABLET 0.17170 0.19373 1/17/2014 QUINAPRIL HCL 5 MG TABLET 0.18690 0.17976 7/12/2013 QUINAPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.78317 0.72479 12/27/2013 QUINAPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.70590 0.79774 8/16/2013 QUINAPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.68558 0.79075 12/13/2013 QUINIDINE GLUCONATE 324 MG TABLET ER 0.95830 0.84810 1/25/2013 QUINIDINE GLUCONATE 80 MG/ML VIAL 0.00000 3.64770 12/1/2012 QUINIDINE SULFATE 200 MG TABLET 0.14147 0.09930 1/25/2013 QUINIDINE SULFATE 300 MG TABLET 0.27039 0.18360 1/25/2013 QUINIDINE SULFATE 300 MG TABLET ER 0.70850 0.67330 1/25/2013 QUININE SULFATE 324 MG CAPSULE 0.00000 5.12820 12/1/2012 RAMIPRIL 1.25 MG CAPSULE 0.15348 0.17732 8/9/2013 RAMIPRIL 10 MG CAPSULE 0.05840 0.05842 7/19/2013 RAMIPRIL 2.5 MG CAPSULE 0.09530 0.09500 4/19/2013 RAMIPRIL 5 MG CAPSULE 0.06610 0.10440 4/19/2013 RANITIDINE HCL 15 MG/ML SYRUP 0.02023 0.03755 11/15/2013 RANITIDINE HCL 150 MG CAPSULE 0.89981 0.89980 12/14/2012 RANITIDINE HCL 150 MG TABLET 0.02731 0.02862 9/27/2013 RANITIDINE HCL 25 MG/ML VIAL 0.86997 0.97805 12/20/2013 RANITIDINE HCL 300 MG CAPSULE 1.68403 1.71748 11/15/2013 RANITIDINE HCL 300 MG TABLET 0.05183 0.06151 8/30/2013 RANITIDINE HCL 75 MG TABLET 0.09916 0.09782 1/3/2014 REPAGLINIDE 1 MG TABLET 2.56165 2.50403 1/31/2014 REPAGLINIDE 2 MG TABLET 2.56165 2.50403 1/31/2014 RIBAVIRIN 200 MG CAPSULE 0.37791 0.36663 12/27/2013 RIBAVIRIN 200 MG TABLET 0.62030 0.64766 12/27/2013 RIBOFLAVIN 25 MG TABLET 0.01929 0.02310 1/25/2013 RIFAMPIN 150 MG CAPSULE 1.02336 1.02820 5/17/2013 RIFAMPIN 300 MG CAPSULE 0.70390 0.70394 12/13/2013 RILUZOLE 50 MG TABLET 3.18837 3.14860 10/4/2013 RIMANTADINE HCL 100 MG TABLET 2.00122 1.70880 1/25/2013 RINGERS SOLUTION IRRIG SOLN 0.00368 0.00710 1/25/2013 RINGERS SOLUTION IV SOLN 0.00243 0.00250 1/25/2013 RINGERS SOLUTION,LACTATED IRRIG SOLN 0.00000 0.00220 12/1/2012 RINGERS SOLUTION,LACTATED IV SOLN 0.00146 0.00172 5/17/2013 RISPERIDONE 0.25 MG TAB RAPDIS 0.00000 5.90310 12/1/2012 RISPERIDONE 0.25 MG TABLET 0.06231 0.06196 11/8/2013 RISPERIDONE 0.5 MG TAB RAPDIS 1.41703 1.70085 9/20/2013 RISPERIDONE 0.5 MG TABLET 0.07680 0.07638 8/16/2013 RISPERIDONE 1 MG TAB RAPDIS 2.47023 2.54457 1/31/2014 RISPERIDONE 1 MG TABLET 0.09410 0.09403 11/8/2013 RISPERIDONE 1 MG/ML SOLUTION 0.39840 0.55000 5/31/2013

Page 46 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 RISPERIDONE 2 MG TAB RAPDIS 3.00100 3.13350 2/22/2013 RISPERIDONE 2 MG TABLET 0.10160 0.10161 11/8/2013 RISPERIDONE 3 MG TAB RAPDIS 6.29149 6.19397 7/26/2013 RISPERIDONE 3 MG TABLET 0.11296 0.09249 8/16/2013 RISPERIDONE 4 MG TAB RAPDIS 7.34287 7.23401 8/16/2013 RISPERIDONE 4 MG TABLET 0.22066 0.18358 8/16/2013 RIVASTIGMINE TARTRATE 1.5 MG CAPSULE 0.00000 2.05087 12/1/2012 RIVASTIGMINE TARTRATE 3 MG CAPSULE 2.05087 2.84742 11/8/2013 RIVASTIGMINE TARTRATE 4.5 MG CAPSULE 0.00000 2.05087 12/1/2012 RIVASTIGMINE TARTRATE 6 MG CAPSULE 0.00000 2.05087 12/1/2012 RIZATRIPTAN BENZOATE 10 MG TAB RAPDIS 23.26722 23.25010 2/22/2013 RIZATRIPTAN BENZOATE 10 MG TABLET 4.08775 1.71350 8/2/2013 RIZATRIPTAN BENZOATE 5 MG TAB RAPDIS 22.15008 19.20244 1/17/2014 RIZATRIPTAN BENZOATE 5 MG TABLET 5.14855 2.12166 1/31/2014 ROPINIROLE HCL 0.25 MG TABLET 0.16777 0.15370 8/30/2013 ROPINIROLE HCL 0.5 MG TABLET 0.16780 0.15370 8/30/2013 ROPINIROLE HCL 1 MG TABLET 0.16777 0.15370 8/30/2013 ROPINIROLE HCL 12 MG TAB ER 24H 9.57763 7.95362 11/15/2013 ROPINIROLE HCL 2 MG TAB ER 24H 1.91454 1.09254 11/15/2013 ROPINIROLE HCL 2 MG TABLET 0.17031 0.15718 8/30/2013 ROPINIROLE HCL 3 MG TABLET 0.17170 0.15718 8/30/2013 ROPINIROLE HCL 4 MG TAB ER 24H 1.85232 4.28870 11/29/2013 ROPINIROLE HCL 4 MG TABLET 0.17170 0.14976 5/17/2013 ROPINIROLE HCL 5 MG TABLET 0.14976 0.15233 9/27/2013 ROPINIROLE HCL 6 MG TAB ER 24H 5.74373 4.97944 10/11/2013 ROPINIROLE HCL 8 MG TAB ER 24H 5.74373 3.22530 11/15/2013 SALICYLIC ACID 26 % LIQUID 0.00000 6.03610 12/1/2012 SALICYLIC ACID 27.5 % LIQ-FILM 0.00000 7.24360 12/1/2012 SALICYLIC ACID/COAL TAR/SULFUR 2 %-1 %-2% SHAMPOO 0.00000 0.20597 12/1/2012 SALSALATE 500 MG TABLET 0.24620 0.24120 6/21/2013 SALSALATE 750 MG TABLET 0.32820 0.32160 6/21/2013 SCOPOLAMINE HYDROBROMIDE 0.4 MG/ML VIAL 6.67800 3.78000 1/25/2013 SELEGILINE HCL 5 MG CAPSULE 1.42820 1.61280 2/8/2013 SELEGILINE HCL 5 MG TABLET 1.25173 1.25200 12/14/2012 SELENIUM 200 MCG TABLET 0.05611 0.05669 11/1/2013 SELENIUM 40 MCG/ML VIAL 0.00000 0.24063 12/1/2012 SELENIUM SULFIDE 2.5 % SUSPENSION 0.07750 0.07595 5/10/2013 SENNOSIDES 8.6 MG TABLET 0.00978 0.01059 9/20/2013 SENNOSIDES 8.8MG/5ML SYRUP 0.03933 0.04146 11/1/2013 SENNOSIDES/DOCUSATE SODIUM 8.6MG-50MG TABLET 0.01872 0.18687 8/23/2013 SERTRALINE HCL 100 MG TABLET 0.07209 0.07310 3/8/2013 SERTRALINE HCL 25 MG TABLET 0.04548 0.04398 11/22/2013 SERTRALINE HCL 50 MG TABLET 0.05414 0.05250 3/8/2013 SILDENAFIL CITRATE 20 MG TABLET 0.57580 0.57576 6/7/2013 SILVER GEL ER(ML) 0.00000 48.44700 12/1/2012 SILVER NITRATE 0.5 % SOLUTION 0.00000 0.03476 12/1/2012 SILVER SULFADIAZINE 1 % CREAM (G) 0.00000 0.23000 12/1/2012 SIMETHICONE 125 MG CAPSULE 0.09826 0.10676 7/5/2013 SIMETHICONE 125 MG TAB CHEW 0.00000 0.07236 12/1/2012 SIMETHICONE 180 MG CAPSULE 0.13147 0.07816 8/30/2013 SIMETHICONE 40MG/0.6ML DROPS SUSP 0.00000 0.08040 12/1/2012 SIMETHICONE 80 MG TAB CHEW 0.00000 0.02425 12/1/2012 SIMVASTATIN 10 MG TABLET 0.03473 0.03398 11/22/2013 SIMVASTATIN 20 MG TABLET 0.04422 0.04000 4/19/2013 SIMVASTATIN 40 MG TABLET 0.06017 0.06240 4/19/2013 SIMVASTATIN 5 MG TABLET 0.04169 0.03737 1/31/2014 SIMVASTATIN 80 MG TABLET 0.09857 0.10413 8/16/2013

Page 47 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 SIROLIMUS 0.5 MG TABLET 0.00000 5.93649 1/31/2014 SOD/POT/K CIT/SOD CIT/CIT ACID 500-550/5 SOLUTION 0.04724 0.02509 11/29/2013 SODIUM BENZOATE POWDER 0.00000 0.04664 12/1/2012 SODIUM BICARBONATE 0.5MEQ/ML SYRINGE 0.46452 0.44100 1/25/2013 SODIUM BICARBONATE 0.5MEQ/ML VIAL 0.35700 0.42840 3/1/2013 SODIUM BICARBONATE 0.9MEQ/ML SYRINGE 0.00000 0.12734 12/1/2012 SODIUM BICARBONATE 1 MEQ/ML SYRINGE 0.10248 0.09770 1/25/2013 SODIUM BICARBONATE 1 MEQ/ML VIAL 0.08820 0.03770 1/31/2014 SODIUM BICARBONATE 10MEQ/10ML SYRINGE 0.00000 0.74256 12/1/2012 SODIUM BICARBONATE 325 MG TABLET 0.00000 0.02155 12/1/2012 SODIUM BICARBONATE 650 MG TABLET 0.00960 0.00953 3/22/2013 SODIUM CHLORIDE 0.45 % PGGYBK PRT 0.04282 0.03640 1/25/2013 SODIUM CHLORIDE 0.45 % 0.45 % IV SOLN 0.00147 0.00146 4/19/2013 SODIUM CHLORIDE 0.65 % SPRAY 0.02466 0.02590 6/7/2013 SODIUM CHLORIDE 2.5 MEQ/ML VIAL 0.02710 0.02780 4/5/2013 SODIUM CHLORIDE 3 % 3 % IV SOLN 0.00972 0.00878 4/19/2013 SODIUM CHLORIDE 4 MEQ/ML VIAL 0.02077 0.03239 11/22/2013 SODIUM CHLORIDE 5 % 5 % IV SOLN 0.00761 0.00770 1/25/2013 SODIUM CHLORIDE 5 % OINT. (G) 2.49240 2.36194 4/5/2013 SODIUM CHLORIDE FOR INHALATION 0.9 % VIAL-NEB 0.03000 0.02980 3/1/2013 SODIUM CHLORIDE FOR INHALATION 10 % VIAL-NEB 0.05592 0.04183 3/1/2013 SODIUM CHLORIDE FOR INHALATION 3 % VIAL-NEB 0.04285 0.04465 11/1/2013 SODIUM CHLORIDE FOR INHALATION 7 % VIAL-NEB 0.00000 0.07000 12/1/2012 SODIUM CHLORIDE IRRIG SOLUTION 0.9 % IRRIG SOLN 0.00560 0.00580 1/25/2013 SODIUM CHLORIDE/NAHCO3/KCL/PEG 420G SOLN RECON 0.00390 0.00376 8/9/2013 SODIUM FERRIC GLUCONAT/SUCROSE 62.5MG/5ML VIAL 0.00000 5.15216 12/1/2012 SODIUM FLUORIDE 0.25(0.55) TAB CHEW 0.03780 0.03738 3/1/2013 SODIUM FLUORIDE 0.5 MG/ML DROPS 0.20410 0.17316 7/19/2013 SODIUM FLUORIDE 0.5(1.1)MG TAB CHEW 0.03540 0.03740 2/22/2013 SODIUM FLUORIDE 1.1 % CREAM (G) 0.10621 0.08013 8/30/2013 SODIUM FLUORIDE 1.1 % GEL (GRAM) 0.10130 0.06890 2/22/2013 SODIUM FLUORIDE 1MG(2.2MG) TAB CHEW 0.03832 0.03852 4/19/2013 SODIUM HYPOCHLORITE 0.125 % SOLUTION 0.04078 9.54390 1/25/2013 SODIUM HYPOCHLORITE 0.25 % SOLUTION 0.03904 0.04024 12/14/2012 SODIUM HYPOCHLORITE 0.5 % SOLUTION 0.03904 0.04024 12/14/2012 SODIUM LACTATE 5 MEQ/ML VIAL 0.00000 0.39992 12/1/2012 SODIUM MORRHUATE 50 MG/ML VIAL 0.00000 1.96000 12/1/2012 SODIUM POLYSTYRENE SULFONATE POWDER 0.22428 0.22031 11/22/2013 SODIUM POLYSTYRENE SULFONATE 15G/60ML ORAL SUSP 0.09694 0.12694 12/27/2013 SODIUM POLYSTYRENE SULFONATE 30G/120ML ENEMA 0.00000 0.25725 7/26/2013 SODIUM POLYSTYRENE SULFONATE 50G/200ML ENEMA 0.00000 0.15435 7/26/2013 SORBITOL SOLUTION 3 % IRRIG SOLN 0.00000 0.00351 12/1/2012 SORBITOL SOLUTION 3.3% IRRIG SOLN 0.00000 0.00332 12/1/2012 SOTALOL HCL 120 MG TABLET 0.26813 0.36750 11/8/2013 SOTALOL HCL 150MG/10ML VIAL 5.46000 5.68750 1/25/2013 SOTALOL HCL 160 MG TABLET 0.25328 0.35564 5/17/2013 SOTALOL HCL 240 MG TABLET 0.56990 0.35321 3/29/2013 SOTALOL HCL 80 MG TABLET 0.09779 0.09434 11/22/2013 SPINOSAD 0.9 % SUSPENSION 3.07772 1.13995 3/8/2013 SPIRONOLACT/HYDROCHLOROTHIAZID 25 MG-25MG TABLET 0.24310 0.72829 4/26/2013 SPIRONOLACTONE 100 % POWDER 18.81550 4.24580 11/22/2013 SPIRONOLACTONE 100 MG TABLET 0.52147 0.45212 4/26/2013 SPIRONOLACTONE 25 MG TABLET 0.06673 0.06464 4/26/2013 SPIRONOLACTONE 50 MG TABLET 0.25393 0.24616 4/26/2013 SPIRONOLACTONE, MICRONIZED 100 % POWDER 10.61375 9.66880 1/25/2013 STAVUDINE 1 MG/ML SOLN RECON 0.00000 0.27563 12/1/2012 STAVUDINE 15 MG CAPSULE 1.32503 1.32500 12/14/2012

Page 48 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 STAVUDINE 20 MG CAPSULE 1.66710 1.31140 1/25/2013 STAVUDINE 30 MG CAPSULE 1.46810 1.09200 9/27/2013 STAVUDINE 40 MG CAPSULE 1.40760 1.43330 5/17/2013 STREPTOMYCIN SULFATE 1 G VIAL 0.00000 11.16500 12/1/2012 SUCRALFATE 1 G TABLET 0.22280 0.22284 8/16/2013 SUCRALFATE 1 G/10 ML ORAL SUSP 0.41363 0.42069 6/28/2013 SULFACETAMIDE SOD/SULFUR/UREA 10%-4%-10% CLEANSER 0.15690 0.22027 11/22/2013 SULFACETAMIDE SOD/SULFUR/UREA 10%-5%-10% CLEANSER 0.00000 0.49178 12/1/2012 SULFACETAMIDE SODIUM 10 % CLEANSER 0.35504 0.39051 9/27/2013 SULFACETAMIDE SODIUM 10 % CLNSGEL ER 0.00000 0.85753 10/25/2013 SULFACETAMIDE SODIUM 10 % DROPS 1.40450 2.76010 2/1/2013 SULFACETAMIDE SODIUM 10 % OINT. (G) 0.00000 13.17200 12/1/2012 SULFACETAMIDE SODIUM 10 % SUSPENSION 0.00000 0.61247 12/1/2012 SULFACETAMIDE SODIUM/SULFUR 10 %-1 % CLEANSER 0.00000 0.12531 12/1/2012 SULFACETAMIDE SODIUM/SULFUR 10 %-5 % MED. PAD 0.00000 4.47784 8/16/2013 SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) CLEANSER 0.11587 0.14263 10/18/2013 SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) CREAM (G) 4.47804 4.33954 12/27/2013 SULFACETAMIDE SODIUM/SULFUR 8 %-4 % SUSPENSION 0.20795 0.20782 11/8/2013 SULFACETAMIDE SODIUM/SULFUR 9 %-4 % CLEANSER 0.00000 0.22315 12/1/2012 SULFACETAMIDE SODIUM/SULFUR 9 %-4.5 % CLEANSER 0.24900 0.26751 3/15/2013 SULFACETAMIDE/PREDNISOLONE SP 10 %-0.23% DROPS 2.49760 2.56476 2/15/2013 SULFADIAZINE 500 MG TABLET 2.50090 3.00100 2/8/2013 SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ORAL SUSP 0.07070 0.07069 10/25/2013 SULFAMETHOXAZOLE/TRIMETHOPRIM 400MG-80MG TABLET 0.08110 0.07992 5/3/2013 SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML VIAL 0.53850 0.45860 1/25/2013 SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160 MG TABLET 0.05373 0.06180 3/15/2013 SULFASALAZINE 500 MG TABLET 0.17060 0.15600 8/30/2013 SULFASALAZINE 500 MG TABLET DR 0.23852 0.23850 12/14/2012 SULINDAC 150 MG TABLET 0.12532 0.14794 11/15/2013 SULINDAC 200 MG TABLET 0.16308 0.16310 1/25/2013 SUMATRIPTAN 20 MG SPRAY 30.21550 34.47850 5/17/2013 SUMATRIPTAN 5 MG SPRAY 30.21550 34.47850 5/17/2013 SUMATRIPTAN SUCCINATE 100 MG TABLET 0.84326 0.83482 12/13/2013 SUMATRIPTAN SUCCINATE 25 MG TABLET 0.84366 0.83616 1/10/2014 SUMATRIPTAN SUCCINATE 4 MG/0.5ML CARTRIDGE 0.00000 142.35900 12/1/2012 SUMATRIPTAN SUCCINATE 4 MG/0.5ML PEN INJCTR 0.00000 150.29700 12/1/2012 SUMATRIPTAN SUCCINATE 50 MG TABLET 0.83884 0.70574 7/12/2013 SUMATRIPTAN SUCCINATE 6 MG/0.5ML CARTRIDGE 0.00000 129.12200 12/1/2012 SUMATRIPTAN SUCCINATE 6 MG/0.5ML PEN INJCTR 131.41621 136.48620 1/25/2013 SUMATRIPTAN SUCCINATE 6 MG/0.5ML VIAL 63.78575 62.39175 9/13/2013 TACROLIMUS 0.5 MG CAPSULE 1.13742 1.16078 1/31/2014 TACROLIMUS 1 MG CAPSULE 2.02467 2.18148 1/17/2014 TACROLIMUS 5 MG CAPSULE 10.91149 12.32952 8/30/2013 TAMOXIFEN CITRATE 10 MG TABLET 0.15800 0.24955 12/13/2013 TAMOXIFEN CITRATE 20 MG TABLET 0.42166 0.43177 1/24/2014 TAMSULOSIN HCL 0.4 MG CAP ER 24H 0.18144 0.17084 6/14/2013 TEA TREE OIL 100 % OIL 0.23180 0.25509 7/26/2013 TELMISARTAN/AMLODIPINE 40 MG-5 MG TABLET 0.00000 3.81780 1/24/2014 TELMISARTAN/AMLODIPINE 40MG-10MG TABLET 0.00000 3.81780 1/24/2014 TELMISARTAN/AMLODIPINE 80 MG-10MG TABLET 0.00000 3.81780 1/24/2014 TELMISARTAN/AMLODIPINE 80 MG-5 MG TABLET 0.00000 3.81780 1/24/2014 TEMAZEPAM 15 MG CAPSULE 0.06960 0.06955 6/28/2013 TEMAZEPAM 22.5 MG CAPSULE 6.10781 5.90592 11/29/2013 TEMAZEPAM 30 MG CAPSULE 0.08800 0.08362 4/19/2013 TEMAZEPAM 7.5 MG CAPSULE 5.57707 5.18367 10/25/2013 TENIPOSIDE 50 MG/5 ML AMPUL 0.00000 56.11060 8/16/2013

Page 49 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 TERAZOSIN HCL 1 MG CAPSULE 0.05414 0.05410 12/14/2012 TERAZOSIN HCL 10 MG CAPSULE 0.06941 0.06940 12/14/2012 TERAZOSIN HCL 2 MG CAPSULE 0.06100 0.05574 9/27/2013 TERAZOSIN HCL 5 MG CAPSULE 0.06270 0.06266 8/16/2013 TERBINAFINE HCL 1 % CREAM (G) 0.29480 0.32428 5/31/2013 TERBINAFINE HCL 250 MG TABLET 0.16844 0.16823 8/30/2013 TERBUTALINE SULFATE 2.5 MG TABLET 0.28250 0.27990 5/17/2013 TERBUTALINE SULFATE 5 MG TABLET 0.35640 0.40990 5/17/2013 TERCONAZOLE 0.4 % CREAM/APPL 0.67269 0.62205 1/24/2014 TERCONAZOLE 0.8 % CREAM/APPL 0.69615 1.43255 7/5/2013 TERCONAZOLE 80 MG SUPP.VAG 11.41933 22.83867 4/12/2013 TESTOSTERONE CYPIONATE 100 MG/ML VIAL 0.00000 4.13980 12/1/2012 TESTOSTERONE ENANTHATE 200 MG/ML VIAL 11.07040 11.89300 4/19/2013 TETANUS & DIPHTHERIA TOX,ADULT 2-2LF/0.5 VIAL 32.12160 30.27570 1/25/2013 TETANUS,DIPHTHERIA TOXD PED/PF 5-25/0.5ML VIAL 69.10470 75.04140 1/25/2013 TETRACAINE HCL 0.5 % DROPS 0.00000 0.49187 12/1/2012 TETRACAINE HCL/PF 0.5 % DROPS 7.84613 8.12960 1/25/2013 TETRACYCLINE HCL POWDER 0.59426 0.63044 9/27/2013 TETRACYCLINE HCL 250 MG CAPSULE 0.03000 0.04323 11/1/2013 TETRACYCLINE HCL 500 MG CAPSULE 0.05521 0.08260 11/1/2013 THEOPHYLLINE ANHYDROUS 100 MG TAB ER 12H 0.12865 0.12830 1/25/2013 THEOPHYLLINE ANHYDROUS 200 MG TAB ER 12H 0.15430 0.15509 4/26/2013 THEOPHYLLINE ANHYDROUS 300 MG TAB ER 12H 0.19349 0.19326 11/1/2013 THEOPHYLLINE ANHYDROUS 400 MG TABLET ER 0.91040 0.95030 2/1/2013 THEOPHYLLINE ANHYDROUS 450 MG TAB ER 12H 0.00000 0.47789 12/1/2012 THEOPHYLLINE ANHYDROUS 600 MG TABLET ER 1.29650 1.37320 2/1/2013 THEOPHYLLINE ANHYDROUS 80 MG/15ML ELIXIR 0.13875 0.58429 7/5/2013 THEOPHYLLINE ANHYDROUS 80 MG/15ML SOLUTION 0.19140 0.15854 1/31/2014 THEOPHYLLINE/D5W 200MG/0.1L IV SOLN 0.00000 0.03335 12/1/2012 THEOPHYLLINE/D5W 200MG/50ML IV SOLN 0.10836 0.09490 1/25/2013 THEOPHYLLINE/D5W 400MG/.25L IV SOLN 0.00000 0.01852 12/1/2012 THEOPHYLLINE/D5W 400MG/0.5L IV SOLN 0.00000 0.00730 12/1/2012 THEOPHYLLINE/D5W 800MG/.25L IV SOLN 0.02150 0.01890 1/25/2013 THIAMINE HCL 100 MG TABLET 0.01380 0.01375 7/19/2013 THIAMINE HCL 100 MG/ML VIAL 3.29150 4.35316 3/29/2013 THIAMINE HCL 50 MG TABLET 0.00000 0.01586 12/1/2012 THIAMINE MONONITRATE 100 MG TABLET 0.02940 0.02455 7/26/2013 THIORIDAZINE HCL 10 MG TABLET 0.20200 0.20589 3/1/2013 THIORIDAZINE HCL 100 MG TABLET 0.42224 0.43590 8/16/2013 THIORIDAZINE HCL 25 MG TABLET 0.28980 0.24040 2/15/2013 THIORIDAZINE HCL 50 MG TABLET 0.35333 0.37574 12/20/2013 THIOTEPA 15 MG VIAL 89.16988 111.46363 12/14/2012 THIOTHIXENE 2 MG CAPSULE 0.24319 0.25892 7/26/2013 THYROID,PORK 30 MG TABLET 0.00000 0.09114 12/1/2012 THYROID,PORK 60 MG TABLET 0.00000 0.10129 12/1/2012 THYROID,PORK 90 MG TABLET 0.00000 0.15974 12/1/2012 TIAGABINE HCL 2 MG TABLET 4.67694 4.67690 1/25/2013 TIAGABINE HCL 4 MG TABLET 4.67694 4.67690 1/25/2013 TICLOPIDINE HCL 250 MG TABLET 0.65360 0.65364 8/2/2013 TIMOLOL MALEATE 0.25 % DROPS 0.66100 0.65258 3/22/2013 TIMOLOL MALEATE 0.25 % SOL-GEL 0.00000 6.93000 12/1/2012 TIMOLOL MALEATE 0.5 % DROPS 0.00000 0.75330 12/1/2012 TIMOLOL MALEATE 0.5 % SOL-GEL 5.97720 8.19000 2/1/2013 TIMOLOL MALEATE 10 MG TABLET 0.52003 0.55130 1/25/2013 TIMOLOL MALEATE 20 MG TABLET 0.95956 1.01710 1/25/2013 TIMOLOL MALEATE 5 MG TABLET 0.42042 0.44560 1/25/2013 TINIDAZOLE 250 MG TABLET 0.00000 3.68381 12/1/2012

Page 50 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 TINIDAZOLE 500 MG TABLET 7.36765 3.68550 8/30/2013 TIZANIDINE HCL 2 MG CAPSULE 1.72990 1.72987 3/15/2013 TIZANIDINE HCL 2 MG TABLET 0.11631 0.28165 9/20/2013 TIZANIDINE HCL 4 MG CAPSULE 0.00000 2.19301 12/1/2012 TIZANIDINE HCL 4 MG TABLET 0.06000 0.32000 6/21/2013 TIZANIDINE HCL 6 MG CAPSULE 3.40453 3.28900 3/15/2013 TOBRAMYCIN 0.3 % DROPS 1.07200 2.11500 2/15/2013 TOBRAMYCIN SULFATE 1.2 G VIAL 0.00000 74.31250 12/1/2012 TOBRAMYCIN SULFATE 10 MG/ML VIAL 0.00000 1.10250 12/1/2012 TOBRAMYCIN SULFATE 40 MG/ML VIAL 0.00000 0.56843 12/1/2012 TOBRAMYCIN/DEXAMETHASONE 0.3 %-0.1% DROPS SUSP 15.43847 13.95800 4/26/2013 TOBRAMYCIN/SODIUM CHLORIDE 60 MG/50ML PIGGYBACK 0.00000 0.31870 12/1/2012 TOBRAMYCIN/SODIUM CHLORIDE 80MG/100ML PIGGYBACK 0.00000 0.18270 12/1/2012 TOLAZAMIDE 250 MG TABLET 2.20070 2.22090 1/25/2013 TOLAZAMIDE 500 MG TABLET 1.52138 1.52140 1/25/2013 TOLBUTAMIDE 500 MG TABLET 0.73441 0.73440 1/25/2013 TOLMETIN SODIUM 200 MG TABLET 0.45500 0.52500 2/8/2013 TOLMETIN SODIUM 400 MG CAPSULE 0.00000 1.16584 12/1/2012 TOLMETIN SODIUM 600 MG TABLET 2.47646 2.47650 1/25/2013 TOLNAFTATE 1 % AERO POWD 0.00000 0.02769 12/1/2012 TOLNAFTATE 1 % CREAM (G) 0.00000 0.10090 12/1/2012 TOLNAFTATE 1 % POWDER 0.04743 0.04750 1/25/2013 TOLTERODINE TARTRATE 1 MG TABLET 1.07090 1.06340 1/31/2014 TOLTERODINE TARTRATE 2 MG CAP ER 24H 0.00000 4.42997 1/24/2014 TOLTERODINE TARTRATE 2 MG TABLET 1.09920 1.10132 1/31/2014 TOLTERODINE TARTRATE 4 MG CAP ER 24H 0.00000 4.42997 1/24/2014 TOPIRAMATE 100 MG TABLET 0.09235 0.11437 12/6/2013 TOPIRAMATE 15 MG CAP SPRINK 0.46961 0.52930 8/30/2013 TOPIRAMATE 200 MG TABLET 0.11890 0.14700 12/6/2013 TOPIRAMATE 25 MG CAP SPRINK 0.53564 0.64745 8/16/2013 TOPIRAMATE 25 MG TABLET 0.03243 0.08330 11/8/2013 TOPIRAMATE 50 MG TABLET 0.06275 0.10910 12/6/2013 TOPOTECAN HCL 4 MG VIAL 113.93900 68.65706 11/1/2013 TOPOTECAN HCL 4 MG/4 ML VIAL 124.05225 119.60550 5/24/2013 TORSEMIDE 10 MG TABLET 0.14820 0.12600 5/17/2013 TORSEMIDE 100 MG TABLET 0.34680 0.34440 5/17/2013 TORSEMIDE 20 MG TABLET 0.12020 0.12636 5/17/2013 TORSEMIDE 20 MG/2 ML VIAL 0.00000 4.31340 12/1/2012 TORSEMIDE 5 MG TABLET 0.13291 0.11160 5/17/2013 TORSEMIDE 50 MG/5 ML VIAL 0.00000 2.34654 12/1/2012 TRAMADOL HCL 100 MG TAB ER 24H 1.88500 2.54561 1/17/2014 TRAMADOL HCL 100 MG TBMP 24HR 2.96215 1.86080 1/25/2013 TRAMADOL HCL 200 MG TAB ER 24H 4.21009 4.20992 12/13/2013 TRAMADOL HCL 200 MG TBMP 24HR 5.08217 2.95290 1/25/2013 TRAMADOL HCL 300 MG TAB ER 24H 4.10779 7.09800 8/30/2013 TRAMADOL HCL 300 MG TBMP 24HR 0.00000 3.77000 12/1/2012 TRAMADOL HCL 50 MG TABLET 0.02133 0.02131 8/23/2013 TRAMADOL HCL/ACETAMINOPHEN 37.5-325MG TABLET 0.18140 0.18144 3/15/2013 TRANDOLAPRIL 1 MG TABLET 0.25060 0.25064 8/23/2013 TRANDOLAPRIL 2 MG TABLET 0.27370 0.27372 8/23/2013 TRANDOLAPRIL 4 MG TABLET 0.27360 0.25133 8/23/2013 TRANEXAMIC ACID 1000 MG/10 AMPUL 0.00000 3.94380 12/1/2012 TRANEXAMIC ACID 1000 MG/10 VIAL 6.09656 5.59402 8/23/2013 TRANEXAMIC ACID 650 MG TABLET 3.65202 3.65196 12/27/2013 TRANYLCYPROMINE SULFATE 10 MG TABLET 1.80076 2.52312 11/1/2013 TRAVOPROST (BENZALKONIUM) 0.004 % DROPS 0.00000 29.13400 5/3/2013 TRAZODONE HCL 100 MG TABLET 0.04700 0.04706 11/29/2013

Page 51 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 TRAZODONE HCL 150 MG TABLET 0.10560 0.10498 10/11/2013 TRAZODONE HCL 300 MG TABLET 0.00000 3.39183 12/1/2012 TRAZODONE HCL 50 MG TABLET 0.02440 0.02444 11/29/2013 TRETINOIN 0.01 % GEL (GRAM) 1.24605 1.51858 1/10/2014 TRETINOIN 0.025 % CREAM (G) 0.72957 0.75014 1/10/2014 TRETINOIN 0.025 % GEL (GRAM) 1.45074 1.58131 1/10/2014 TRETINOIN 0.05 % CREAM (G) 1.50816 1.51003 12/27/2013 TRETINOIN 0.1 % CREAM (G) 1.73077 1.75361 1/31/2014 TRETINOIN 10 MG CAPSULE 0.00000 20.32926 12/1/2012 TRIAMCINOLONE ACETONIDE 0.025 % CREAM (G) 0.09313 0.09310 12/14/2012 TRIAMCINOLONE ACETONIDE 0.025 % LOTION 0.73030 0.76647 10/25/2013 TRIAMCINOLONE ACETONIDE 0.025 % OINT. (G) 0.09313 0.09310 12/14/2012 TRIAMCINOLONE ACETONIDE 0.1 % CREAM (G) 0.14700 0.21180 2/1/2013 TRIAMCINOLONE ACETONIDE 0.1 % LOTION 0.86497 0.49490 1/31/2014 TRIAMCINOLONE ACETONIDE 0.1 % OINT. (G) 0.04860 0.04864 2/1/2013 TRIAMCINOLONE ACETONIDE 0.1 % PASTE (G) 9.38630 11.22220 12/13/2013 TRIAMCINOLONE ACETONIDE 0.5 % CREAM (G) 0.49690 0.47180 2/22/2013 TRIAMCINOLONE ACETONIDE 0.5 % OINT. (G) 0.47130 0.47133 7/19/2013 TRIAMCINOLONE ACETONIDE 55MCG SPRAY 5.20150 4.80847 7/12/2013 TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25 MG CAPSULE 0.23797 0.21575 10/11/2013 TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25 MG TABLET 0.19700 0.19698 2/15/2013 TRIAMTERENE/HYDROCHLOROTHIAZID 75 MG-50MG TABLET 0.21909 0.18693 10/18/2013 TRIAZOLAM 0.125 MG TABLET 0.23710 0.20980 3/1/2013 TRIAZOLAM 0.25 MG TABLET 0.24442 0.72108 8/30/2013 TRIFLUOPERAZINE HCL 1 MG TABLET 0.25948 0.61215 11/8/2013 TRIFLUOPERAZINE HCL 10 MG TABLET 0.72514 1.67825 9/20/2013 TRIFLUOPERAZINE HCL 2 MG TABLET 0.36440 0.88396 11/8/2013 TRIFLUOPERAZINE HCL 5 MG TABLET 0.48256 1.11338 9/20/2013 TRIFLURIDINE 1 % DROPS 16.31438 16.63947 8/16/2013 TRIHEXYPHENIDYL HCL 2 MG TABLET 0.05410 0.05735 11/22/2013 TRIHEXYPHENIDYL HCL 2 MG/5 ML ELIXIR 0.03900 0.03920 2/8/2013 TRIHEXYPHENIDYL HCL 5 MG TABLET 0.11567 0.12181 1/17/2014 TRIMETHOBENZAMIDE HCL 100 MG/ML VIAL 4.10263 4.38990 1/25/2013 TRIMETHOBENZAMIDE HCL 300 MG CAPSULE 1.49810 1.14618 4/12/2013 TRIMETHOPRIM 100 MG TABLET 0.28926 0.28984 9/27/2013 TROPICAMIDE 0.5 % DROPS 0.44030 0.64860 1/25/2013 TROPICAMIDE 1 % DROPS 0.46107 0.52737 6/28/2013 TROSPIUM CHLORIDE 20 MG TABLET 1.92680 1.92682 6/14/2013 TROSPIUM CHLORIDE 60 MG CAP ER 24H 0.00000 4.71567 12/1/2012 UREA 39 % CREAM (G) 0.00000 1.08841 6/21/2013 UREA 40 % LOTION 0.06888 0.06890 12/14/2012 UREA 40 % NL FM SUSP 11.93033 15.20049 11/29/2013 UREA 45 % GEL/PF APP 0.00000 5.82575 12/1/2012 UREA 45 % LOTION 0.00000 0.17003 12/1/2012 UREA/HYALURONATE SODIUM 40%-0.2% KIT 0.00000 282.72300 12/1/2012 URSODIOL 250 MG TABLET 1.87768 1.24164 1/31/2014 URSODIOL 300 MG CAPSULE 0.32674 0.33353 11/22/2013 URSODIOL 500 MG TABLET 0.00000 3.32738 12/1/2012 VALACYCLOVIR HCL 1000 MG TABLET 1.79804 1.41370 8/30/2013 VALACYCLOVIR HCL 500 MG TABLET 1.02887 0.90628 8/30/2013 VALPROATE SODIUM 100 % POWDER 4.63400 0.74523 10/18/2013 VALPROATE SODIUM 250 MG/5ML SOLUTION 0.01560 0.01420 5/17/2013 VALPROATE SODIUM 250 MG/5ML SOLUTION (U-D) 0.30250 0.15149 1/24/2014 VALPROATE SODIUM 500MG/10ML SOLUTION 0.07088 0.08532 1/24/2014 VALPROIC ACID 250 MG CAPSULE 0.15804 0.16253 9/27/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5MG TABLET 0.89441 0.73040 4/19/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 160-25MG TABLET 0.82920 1.35210 1/17/2014

Page 52 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5MG TABLET 3.79428 3.79442 11/8/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG TABLET 4.30389 0.39991 11/22/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG TABLET 0.65101 0.67110 4/19/2013 VANCOMYCIN HCL 1 G VIAL 4.04820 4.31940 3/1/2013 VANCOMYCIN HCL 1 G VIAL PORT 5.65320 4.40160 2/15/2013 VANCOMYCIN HCL 10 G VIAL 53.87630 35.96050 2/22/2013 VANCOMYCIN HCL 125 MG CAPSULE 21.92457 21.92673 4/19/2013 VANCOMYCIN HCL 250 MG CAPSULE 40.40096 40.40576 11/29/2013 VANCOMYCIN HCL 5 G VIAL 19.20450 19.18350 1/17/2014 VANCOMYCIN HCL 500 MG VIAL 2.48988 2.11680 1/17/2014 VANCOMYCIN HCL 500 MG VIAL PORT 2.94840 2.74260 1/25/2013 VANCOMYCIN HCL 750 MG VIAL 6.84180 6.69900 1/25/2013 VANCOMYCIN HCL 750 MG VIAL PORT 0.00000 10.90110 12/1/2012 VANCOMYCIN HCL/D5W 1G/200ML FROZ.PIGGY 0.08114 0.29790 1/25/2013 VANCOMYCIN HCL/D5W 500MG/0.1L FROZ.PIGGY 0.00000 0.10933 12/1/2012 VANCOMYCIN IN DEXTROSE,ISO-OSM 750MG/.15L FROZ.PIGGY 0.00000 0.17722 12/1/2012 VASOPRESSIN 20 UNIT/ML VIAL 0.00000 1.97529 12/1/2012 VENLAFAXINE HCL 100 MG TABLET 0.36640 0.36636 11/1/2013 VENLAFAXINE HCL 150 MG CAP ER 24H 0.27365 0.27217 11/22/2013 VENLAFAXINE HCL 150 MG TAB ER 24 0.00000 1.46640 12/1/2012 VENLAFAXINE HCL 225 MG TAB ER 24 10.26940 10.83870 1/25/2013 VENLAFAXINE HCL 25 MG TABLET 0.38378 0.37232 11/1/2013 VENLAFAXINE HCL 37.5 MG CAP ER 24H 0.14755 0.14428 10/11/2013 VENLAFAXINE HCL 37.5 MG TAB ER 24 0.00000 2.37658 12/1/2012 VENLAFAXINE HCL 37.5 MG TABLET 0.32250 0.32472 1/24/2014 VENLAFAXINE HCL 50 MG TABLET 0.37141 0.39572 1/24/2014 VENLAFAXINE HCL 75 MG CAP ER 24H 0.19309 0.19296 8/2/2013 VENLAFAXINE HCL 75 MG TAB ER 24 2.38475 2.67169 11/1/2013 VENLAFAXINE HCL 75 MG TABLET 0.32590 0.32589 3/22/2013 VERAPAMIL HCL 100 MG CAP24H PCT 1.23213 1.23210 1/10/2014 VERAPAMIL HCL 120 MG CAP24H PEL 0.41200 0.63239 9/20/2013 VERAPAMIL HCL 120 MG TABLET 0.06167 0.07726 5/17/2013 VERAPAMIL HCL 120 MG TABLET ER 0.29370 0.27215 6/7/2013 VERAPAMIL HCL 180 MG CAP24H PEL 0.44772 0.66547 9/20/2013 VERAPAMIL HCL 180 MG TABLET ER 0.16910 0.16911 8/30/2013 VERAPAMIL HCL 2.5 MG/ML AMPUL 1.56240 1.65480 1/25/2013 VERAPAMIL HCL 2.5 MG/ML SYRINGE 0.00000 4.46460 12/1/2012 VERAPAMIL HCL 2.5 MG/ML VIAL 1.94970 2.14400 1/25/2013 VERAPAMIL HCL 200 MG CAP24H PCT 0.00000 1.58723 12/1/2012 VERAPAMIL HCL 240 MG CAP24H PEL 0.51779 0.76343 9/20/2013 VERAPAMIL HCL 240 MG TABLET ER 0.14490 0.14483 11/8/2013 VERAPAMIL HCL 300 MG CAP24H PCT 1.94224 1.81821 12/27/2013 VERAPAMIL HCL 360 MG CAP24H PEL 0.00000 1.46958 12/1/2012 VERAPAMIL HCL 40 MG TABLET 0.17654 0.17650 12/14/2012 VERAPAMIL HCL 80 MG TABLET 0.05601 0.05600 12/14/2012 VINBLASTINE SULFATE 1 MG/ML VIAL 0.00000 2.22600 12/1/2012 VINBLASTINE SULFATE 10 MG VIAL 0.00000 1.81350 12/1/2012 VIT A,C & E/LUTEIN/MINERALS 1000-60-2 TABLET 0.05410 0.06145 3/29/2013 VIT A/VIT C/VIT E/ZINC/COPPER 14320-226 CAPSULE 0.16160 0.16420 1/25/2013 VIT A/VIT C/VIT E/ZINC/COPPER 7160-113 TABLET 0.07386 0.06620 1/25/2013 VIT B CMPLX 3/FA/VIT C/BIOTIN 1MG-60MG TABLET 0.12805 0.12810 12/14/2012 VIT B COMP/C/FA/IRON/VIT E 500-400-18 TABLET 0.00000 0.05547 12/1/2012 VIT B12/LMEFOLATE CA/VIT B6/B2 1-6-50-5MG TABLET 2.02075 1.43640 1/25/2013 VITAMIN A/VIT C/ZINC/PROPOLIS 15 MG LOZENGE 0.02095 0.02440 1/25/2013 VITAMIN B COMPLEX/LYSINE 790MG/15ML LIQUID 0.03536 0.03270 1/25/2013 VITAMIN E 100 UNIT CAPSULE 0.00000 0.02028 12/1/2012 VITAMIN E 1000 UNIT CAPSULE 0.00000 0.12857 12/1/2012

Page 53 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 VITAMIN E 200 UNIT CAPSULE 0.02873 0.02860 1/25/2013 VITAMIN E 400 UNIT CAPSULE 0.05208 0.04540 1/25/2013 VITAMIN E 50 UNIT/ML DROPS 1.89350 0.94477 1/31/2014 VITAMIN E MIXED 400 UNIT CAPSULE 0.05030 0.05369 7/12/2013 VITAMINS B1,B2,B3,B5,& B6 100-2MG/ML VIAL 0.00000 1.31319 12/1/2012 VITS A & D/WHITE PET/LANOLIN OINT PACK 0.12202 0.03450 1/25/2013 VORICONAZOLE 200 MG TABLET 26.11905 27.54166 1/3/2014 VORICONAZOLE 200 MG VIAL 87.18650 44.58750 7/19/2013 VORICONAZOLE 200 MG/5ML SUSP RECON 0.00000 9.84947 10/18/2013 VORICONAZOLE 50 MG TABLET 7.61796 8.26960 1/24/2014 WARFARIN SODIUM 1 MG TABLET 0.06470 0.06280 4/12/2013 WARFARIN SODIUM 10 MG TABLET 0.06670 0.07125 5/17/2013 WARFARIN SODIUM 2 MG TABLET 0.06476 0.06017 8/30/2013 WARFARIN SODIUM 2.5 MG TABLET 0.06470 0.06280 4/12/2013 WARFARIN SODIUM 3 MG TABLET 0.06030 0.05601 9/20/2013 WARFARIN SODIUM 4 MG TABLET 0.06030 0.05415 9/20/2013 WARFARIN SODIUM 5 MG TABLET 0.06470 0.06280 4/12/2013 WARFARIN SODIUM 6 MG TABLET 0.07125 0.06865 12/20/2013 WARFARIN SODIUM 7.5 MG TABLET 0.06670 0.07142 5/17/2013 WATER LIQUID 0.00000 0.01291 12/1/2012 WATER FOR INJ.,BACTERIOSTATIC VIAL 0.01764 0.02210 1/25/2013 WATER FOR INJECTION,STERILE AMPUL 0.09072 0.08820 1/25/2013 WATER FOR INJECTION,STERILE IV SOLN 0.00214 0.00210 12/14/2012 WATER FOR INJECTION,STERILE VIAL 0.03430 0.04352 11/22/2013 WATER FOR IRRIGATION,STERILE IRRIG SOLN 0.00000 0.00580 12/1/2012 WATER/ME-PARABEN/PROPYLPARABEN VIAL 0.00000 0.10643 12/1/2012 WHEAT GERM OIL OIL 0.00000 0.26600 12/1/2012 WITCH HAZEL 50 % MED. PAD 0.07611 0.07692 6/14/2013 ZAFIRLUKAST 10 MG TABLET 0.00000 1.19188 12/1/2012 ZAFIRLUKAST 20 MG TABLET 1.19188 1.25253 6/14/2013 ZALEPLON 10 MG CAPSULE 0.21695 0.24951 5/17/2013 ZALEPLON 5 MG CAPSULE 0.23040 0.21208 2/22/2013 ZIDOVUDINE 10 MG/ML SYRUP 0.13226 0.12787 5/10/2013 ZIDOVUDINE 100 MG CAPSULE 0.73593 0.82839 11/8/2013 ZIDOVUDINE 300 MG TABLET 0.40279 0.39449 8/16/2013 ZINC CHLORIDE 1 MG/ML VIAL 0.17052 0.17050 1/25/2013 ZINC SULFATE 1 MG/ML VIAL 0.00000 0.21874 12/1/2012 ZINC SULFATE 5 MG/ML VIAL 0.00000 0.65343 12/1/2012 ZIPRASIDONE HCL 20 MG CAPSULE 2.76099 2.69450 5/17/2013 ZIPRASIDONE HCL 40 MG CAPSULE 2.76099 2.69450 5/17/2013 ZIPRASIDONE HCL 60 MG CAPSULE 3.29128 3.08300 5/17/2013 ZIPRASIDONE HCL 80 MG CAPSULE 3.29128 3.08300 5/17/2013 ZOLEDRONIC ACID/MANNITOL&WATER 4 MG/100ML PIGGYBACK 0.00000 10.14930 8/16/2013 ZOLEDRONIC ACID/MANNITOL&WATER 5 MG/100ML PIGGYBACK 0.00000 8.37592 10/25/2013 ZOLMITRIPTAN 2.5 MG TAB RAPDIS 0.00000 35.08983 5/31/2013 ZOLMITRIPTAN 2.5 MG TABLET 0.00000 35.08983 5/31/2013 ZOLMITRIPTAN 5 MG TAB RAPDIS 0.00000 38.79167 5/31/2013 ZOLMITRIPTAN 5 MG TABLET 0.00000 38.79167 5/31/2013 ZOLPIDEM TARTRATE 10 MG TABLET 0.02738 0.02669 8/16/2013 ZOLPIDEM TARTRATE 12.5 MG TAB MPHASE 1.59058 2.76720 1/11/2013 ZOLPIDEM TARTRATE 5 MG TABLET 0.02600 0.02565 4/19/2013 ZOLPIDEM TARTRATE 6.25 MG TAB MPHASE 1.49617 1.39053 8/16/2013 ZONISAMIDE 100 MG CAPSULE 0.22022 0.20180 1/24/2014 ZONISAMIDE 25 MG CAPSULE 0.11658 0.10005 6/21/2013 ZONISAMIDE 50 MG CAPSULE 0.31346 0.12640 11/29/2013

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