West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 0.9 % SODIUM CHLORIDE INJECTION VIAL (ML) 0.9 % 0.05712 08/12/2014 0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 0.9 0.00196 03/06/2015 0.00196 08/21/2015 % 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK WITH THREADED 0.03505 01/30/2015 0.03505 08/21/2015 PORT (ML) 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK WITH VIAL PORT 0.04175 07/18/2014 (NON-THREADED) ABACAVIR SULFATE ORAL TABLET 300 MG 5.57996 04/24/2015 3.25000 11/20/2015 ACAMPROSATE CALCIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.81000 01/27/2017 COATED) 333 MG ACARBOSE ORAL TABLET 100 MG 0.32897 08/21/2015 0.27550 09/30/2016 ACARBOSE ORAL TABLET 25 MG 0.23329 10/10/2014 0.23329 08/21/2015 ACARBOSE ORAL TABLET 50 MG 0.25460 08/21/2015 0.17333 05/20/2016 ACEBUTOLOL HCL ORAL CAPSULE 200 MG 0.21197 02/13/2015 0.21197 08/21/2015 ACEBUTOLOL HCL ORAL CAPSULE 400 MG 0.26000 03/27/2015 0.26000 08/21/2015 ACETAMINOPHEN ORAL CAPSULE 500 MG 0.01093 08/12/2014 ACETAMINOPHEN ORAL DROPS 80MG/0.8ML 0.17160 10/11/2013 0.17160 08/21/2015 ACETAMINOPHEN ORAL ELIXIR 160 MG/5ML 0.01083 09/27/2013 ACETAMINOPHEN ORAL LIQUID (ML) 160 MG/5ML 0.00932 09/27/2013 0.00932 08/21/2015 ACETAMINOPHEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 160 0.02137 08/21/2015 0.02033 02/17/2017 MG/5ML ACETAMINOPHEN ORAL TABLET 325 MG 0.00830 06/20/2014 0.00830 08/21/2015 ACETAMINOPHEN ORAL TABLET 500 MG 0.01040 04/03/2015 0.01040 08/21/2015 ACETAMINOPHEN ORAL TABLET, CHEWABLE 80 MG 0.04651 04/03/2015 0.04651 08/21/2015 ACETAMINOPHEN ORAL TABLET,DISINTEGRATING 80 MG 0.05113 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 120 MG 0.20324 08/22/2014 0.20324 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 325 MG 0.46400 08/22/2014 0.46400 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 650 MG 0.21762 08/22/2014 0.21762 08/21/2015 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.01332 01/30/2015 0.01332 08/21/2015 120-12MG/5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.21394 03/27/2015 0.21394 08/21/2015 120-12MG/5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.10079 03/27/2015 0.10079 08/21/2015 300MG/12.5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.14344 09/19/2014 0.14344 08/21/2015 15MG ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.12060 05/01/2015 0.12060 08/21/2015 30MG ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.22780 08/21/2015 0.19101 05/20/2016 60MG ACETAMINOPHEN/DIPHENHYDRAMINE HCL ORAL TABLET 500MG-25MG 0.04047 04/24/2015 0.04047 08/21/2015 ACETAZOLAMIDE ORAL CAPSULE, EXTENDED RELEASE 500 MG 2.53225 11/20/2015 2.01798 03/25/2016 ACETAZOLAMIDE ORAL TABLET 125 MG 1.52593 01/24/2014 1.52593 08/21/2015 ACETAZOLAMIDE ORAL TABLET 250 MG 2.01817 11/28/2014 ACETIC ACID IRRIGATION SOLUTION, IRRIGATION 0.25 % 0.00350 03/01/2013 ACETIC ACID OTIC SOLUTION, NON-ORAL 2 % 1.81591 06/28/2013 1.81591 08/21/2015 ACETIC ACID/ALUMINUM ACETATE OTIC DROPS 2 % 0.84000 01/25/2013 0.84000 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ACETIC ACID/HYDROCORTISONE OTIC DROPS 2 %-1 % 9.82215 08/21/2015 8.85454 01/13/2017 ACETYLCYSTEINE INTRAVENOUS VIAL (ML) 200 MG/ML 5.26400 03/06/2015 5.26400 08/21/2015 ACETYLCYSTEINE MISCELLANEOUS VIAL (ML) 100 MG/ML 0.45068 08/12/2014 0.45068 08/21/2015 ACETYLCYSTEINE MISCELLANEOUS VIAL (ML) 200 MG/ML 0.39190 02/13/2015 0.39190 08/21/2015 ACETYLCYSTEINE/MECOBALAMIN/LEVOMEFOLATE CALCIUM ORAL 1.89794 02/20/2015 1.89794 08/21/2015 TABLET 600-2-6 MG ACITRETIN ORAL CAPSULE 10 MG 17.18010 11/14/2014 ACITRETIN ORAL CAPSULE 17.5 MG 42.31920 03/21/2014 ACITRETIN ORAL CAPSULE 25 MG 25.13519 09/12/2014 23.09605 09/30/2016 ACYCLOVIR ORAL CAPSULE 200 MG 0.08844 03/27/2015 0.08844 08/21/2015 ACYCLOVIR ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200 MG/5ML 0.65886 09/19/2014 0.65886 08/21/2015 ACYCLOVIR ORAL TABLET 400 MG 0.10104 04/10/2015 0.10104 08/21/2015 ACYCLOVIR ORAL TABLET 800 MG 0.18452 03/27/2015 0.18452 08/21/2015 ACYCLOVIR SODIUM INTRAVENOUS VIAL (EA) 500 MG 31.20600 08/22/2014 31.20600 08/21/2015 ACYCLOVIR SODIUM INTRAVENOUS VIAL (ML) 50 MG/ML 1.40750 07/25/2014 ACYCLOVIR TOPICAL OINTMENT (GRAM) 5 % 18.88402 08/21/2015 17.89067 07/08/2016 ADAPALENE TOPICAL CREAM (GRAM) 0.1 % 3.51289 04/26/2013 ADAPALENE TOPICAL GEL (GRAM) 0.1 % 3.05760 01/25/2013 2.60534 07/08/2016 ADAPALENE TOPICAL GEL (GRAM) 0.3 % 4.68580 11/07/2014 4.68580 08/21/2015 ADAPALENE TOPICAL GEL WITH PUMP (GRAM) 0.3 % 4.61985 04/10/2015 4.61985 08/21/2015 ADEFOVIR DIPIVOXIL ORAL TABLET 10 MG 26.52627 09/27/2013 ALBUMIN HUMAN INTRAVENOUS INTRAVENOUS SOLUTION 25 % 1.51200 05/01/2015 1.51200 08/21/2015 ALBUMIN HUMAN INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.21588 09/19/2014 0.21588 08/21/2015 ALBUTEROL SULFATE INHALATION SOLUTION, NON-ORAL 5 MG/ML 0.72066 10/18/2013 0.72066 08/21/2015 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (EA) 2.5 MG/0.5 0.43876 08/01/2014 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 0.63MG/3ML 0.35633 12/05/2014 0.35633 08/21/2015 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 1.25MG/3ML 0.37645 08/21/2015 0.28465 05/20/2016 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 2.5 MG/3ML 0.05253 04/03/2015 0.05253 08/21/2015 ALBUTEROL SULFATE ORAL SYRUP 2 MG/5 ML 0.01277 05/24/2013 0.01277 08/21/2015 ALBUTEROL SULFATE ORAL TABLET 2 MG 4.56651 08/21/2015 4.05000 12/25/2015 ALBUTEROL SULFATE ORAL TABLET 4 MG 4.11250 08/21/2015 3.62765 12/25/2015 ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 4 MG 1.18451 04/25/2014 ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 8 MG 1.71821 04/05/2013 ALCLOMETASONE DIPROPIONATE TOPICAL CREAM (GRAM) 0.05 % 1.30908 06/21/2013 ALCLOMETASONE DIPROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 0.58692 06/28/2013 ALENDRONATE SODIUM ORAL SOLUTION, ORAL 70 MG/75ML 2.45700 09/27/2013 ALENDRONATE SODIUM ORAL TABLET 10 MG 0.18750 08/12/2014 0.18750 08/21/2015 ALENDRONATE SODIUM ORAL TABLET 35 MG 0.52484 11/07/2014 0.52484 08/21/2015 ALENDRONATE SODIUM ORAL TABLET 40 MG 2.80060 03/27/2015 ALENDRONATE SODIUM ORAL TABLET 5 MG 0.18110 08/12/2014 0.18110 08/21/2015 ALENDRONATE SODIUM ORAL TABLET 70 MG 0.52484 08/21/2015 0.46500 12/02/2016 ALFUZOSIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.13697 04/17/2015 0.13697 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ALLOPURINOL ORAL TABLET 100 MG 0.16332 11/28/2014 0.16332 08/21/2015 ALLOPURINOL ORAL TABLET 300 MG 0.43385 03/25/2016 0.33844 05/20/2016 ALPHA LIPOIC ACID ORAL CAPSULE 200 MG 0.12771 08/08/2014 0.12771 08/21/2015 ALPHA LIPOIC ACID ORAL CAPSULE 50 MG 0.10210 08/12/2014 0.10210 08/21/2015 ALPRAZOLAM ORAL TABLET 0.25 MG 0.01509 05/16/2014 0.01509 08/21/2015 ALPRAZOLAM ORAL TABLET 0.5 MG 0.01780 04/17/2015 0.01780 08/21/2015 ALPRAZOLAM ORAL TABLET 1 MG 0.01970 02/06/2015 0.01970 08/21/2015 ALPRAZOLAM ORAL TABLET 2 MG 0.04007 08/21/2015 0.07213 09/28/2015 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 0.5 MG 0.36136 08/12/2014 0.36136 08/21/2015 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 1 MG 0.44913 08/12/2014 0.44913 08/21/2015 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 0.41600 08/12/2014 0.41600 08/21/2015 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 3 MG 0.79340 08/21/2015 0.55483 11/20/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 0.25 MG 1.36123 03/01/2013 1.36123 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 0.5 MG 1.51669 01/25/2013 1.51669 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 1 MG 2.02358 01/25/2013 2.02358 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 2 MG 3.00202 01/25/2013 3.00202 08/21/2015 ALUMINUM HYDROXIDE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.00813 08/21/2015 320 MG/5ML AMANTADINE HCL ORAL CAPSULE 100 MG 1.15992 04/22/2016 1.10704 08/26/2016 AMANTADINE HCL ORAL SOLUTION, ORAL 50 MG/5 ML 0.01733 04/03/2015 0.01733 08/21/2015 AMANTADINE HCL ORAL TABLET 100 MG 1.59829 04/12/2013 AMCINONIDE TOPICAL CREAM (GRAM) 0.1 % 2.82140 08/12/2014 AMCINONIDE TOPICAL LOTION (ML) 0.1 % 1.90000 08/12/2014 AMCINONIDE TOPICAL OINTMENT (GRAM) 0.1 % 4.53600 08/30/2013 AMIKACIN SULFATE INJECTION VIAL (ML) 1000MG/4ML 3.14373 12/05/2014 3.14373 08/21/2015 AMIKACIN SULFATE INJECTION VIAL (ML) 500 MG/2ML 2.95555 12/05/2014 2.95555 08/21/2015 AMILORIDE HCL ORAL TABLET 5 MG 0.49564 02/13/2015 0.49564 08/21/2015 AMILORIDE HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5 MG-50 MG 0.42250 05/30/2014 0.42250 08/21/2015 AMINO ACIDS ORAL POWDER (GRAM) 0.25540 08/12/2014 AMINOCAPROIC ACID INTRAVENOUS VIAL (ML) 250 MG/ML 0.08148 02/06/2015 0.08148 08/21/2015 AMINOCAPROIC ACID ORAL TABLET 1000 MG 18.30610 08/12/2014 18.30610 08/21/2015 AMINOCAPROIC ACID ORAL TABLET 500 MG 5.37896 10/11/2013 5.37896 08/21/2015 AMINOPHYLLINE INTRAVENOUS VIAL (ML) 250MG/10ML 0.30912 01/30/2015 0.30912 08/21/2015 AMINOPHYLLINE INTRAVENOUS VIAL (ML) 500MG/20ML 0.07270 08/12/2014 AMIODARONE HCL INTRAVENOUS AMPUL (ML) 50 MG/ML 0.33600 01/25/2013 AMIODARONE HCL ORAL TABLET 100 MG 2.55717 03/21/2014 AMIODARONE HCL ORAL TABLET 200 MG 0.16103 08/21/2015 0.12724 09/30/2016 AMIODARONE HCL ORAL TABLET 400 MG 3.19526 08/22/2014 2.81936 12/02/2016 AMITRIPTYLINE HCL ORAL TABLET 10 MG 0.15732 04/03/2015 0.15732 08/21/2015 AMITRIPTYLINE HCL ORAL TABLET 100 MG 1.00016 08/21/2015 0.86682 09/30/2016 AMITRIPTYLINE HCL ORAL TABLET 150 MG 1.40116 08/21/2015 1.71450 10/01/2015 AMITRIPTYLINE HCL ORAL TABLET 25 MG 0.26664 04/03/2015 0.26664 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date AMITRIPTYLINE HCL ORAL TABLET 50 MG 0.51514 08/21/2015 0.41944 09/30/2016 AMITRIPTYLINE HCL ORAL TABLET 75 MG 0.75131 12/19/2014 0.75131 08/21/2015 AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE ORAL TABLET 12.5MG-5MG 1.07296 08/01/2014 AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE ORAL TABLET 25 MG-10MG 1.51380 05/02/2014 AMLODIPINE BESYLATE ORAL TABLET 10 MG 0.02527 04/17/2015 0.02527 08/21/2015 AMLODIPINE BESYLATE ORAL TABLET 2.5 MG 0.05960 03/27/2015 0.05960 08/21/2015 AMLODIPINE BESYLATE ORAL TABLET 5 MG 0.06240 03/27/2015 0.06240 08/21/2015 AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG- 4.92680 08/21/2015 3.63000 09/30/2016 10MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG- 3.93004 04/10/2015 3.93004 08/21/2015 20MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG- 4.24970 04/10/2015 4.24970 08/21/2015 40MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG- 6.55993 06/06/2014 6.55993 08/21/2015 80MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 2.5MG- 5.07347 08/12/2014 5.07347 08/21/2015 10MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 2.5MG- 6.55993 08/21/2015 5.92000 09/30/2016 20MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 2.5MG- 6.55993 08/21/2015 5.92000 09/30/2016 40MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG- 4.55853 04/10/2015 4.55853 08/21/2015 10 MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG- 3.93250 05/01/2015 3.93250 08/21/2015 20 MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG- 4.24970 04/10/2015 4.24970 08/21/2015 40 MG AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG- 6.55993 08/21/2015 5.92000 09/30/2016 80 MG AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 10 MG-20MG 0.41934 05/20/2016 0.22277 09/30/2016 AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 10 MG-40MG 0.53661 09/25/2015 0.39500 08/26/2016 AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 2.5MG-10MG 0.65318 08/21/2015 0.46372 03/25/2016 AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 5 MG-10 MG 0.47840 08/21/2015 0.38990 05/20/2016 AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 5 MG-20 MG 0.49990 08/21/2015 0.47092 07/29/2016 AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 5 MG-40 MG 0.63925 09/25/2015 0.44580 05/20/2016 AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 10 1.45000 01/01/2017 MG-20MG AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 10 1.45000 01/01/2017 MG-40MG AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 5 MG- 1.45000 01/01/2017 20 MG AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 5 MG- 1.45000 01/01/2017 40 MG AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 10MG-160MG 0.47493 08/21/2015 0.47493 04/22/2016 AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 10MG-320MG 0.91941 04/22/2016 0.53089 05/20/2016 AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 5 MG-160MG 0.77918 04/22/2016 0.58411 05/20/2016 AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 5 MG-320MG 0.70511 02/26/2016 0.70511 04/22/2016 AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL 4.40212 08/21/2015 4.40212 01/01/2017 TABLET 10-160-25 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL 2.92338 01/22/2016 2.92338 01/01/2017 TABLET 10-320-25 AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL 4.40212 08/21/2015 4.40212 01/01/2017 TABLET 10MG-160MG AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL 3.88023 08/21/2015 3.88023 01/01/2017 TABLET 5-160-12.5 AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL 3.88023 08/21/2015 3.88023 01/01/2017 TABLET 5-160-25MG AMMONIUM ALUM/SALICYLIC ACID/TALC/BENTONITE TOPICAL POWDER 0.06740 08/12/2014 (GRAM) AMMONIUM ALUM/TALC/BENTONITE TOPICAL POWDER (GRAM) 0.07530 08/12/2014 AMMONIUM CHLORIDE VIAL (ML) 5 MEQ/ML 0.42630 01/25/2013 AMMONIUM LACTATE TOPICAL CREAM (GRAM) 12 % 0.03398 08/12/2014 0.03398 08/21/2015 AMMONIUM LACTATE TOPICAL LOTION (GRAM) 12 % 0.02596 08/21/2015 0.07500 03/25/2016 AMOXAPINE ORAL TABLET 100 MG 1.16865 11/22/2013 AMOXAPINE ORAL TABLET 150 MG 1.28830 01/25/2013 AMOXAPINE ORAL TABLET 25 MG 0.27027 01/25/2013 AMOXAPINE ORAL TABLET 50 MG 0.69923 11/22/2013 AMOXICILLIN ORAL CAPSULE 250 MG 0.04730 04/10/2015 0.04730 08/21/2015 AMOXICILLIN ORAL CAPSULE 500 MG 0.06941 05/01/2015 0.06941 08/21/2015 AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 0.01420 04/24/2015 0.01420 08/21/2015 MG/5ML AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 0.05684 04/03/2015 0.05684 08/21/2015 MG/5ML AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 0.01581 08/21/2015 0.03120 10/01/2015 MG/5ML AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 400 0.02680 04/03/2015 0.02680 08/21/2015 MG/5ML AMOXICILLIN ORAL TABLET 500 MG 0.29145 08/12/2014 0.29145 08/21/2015 AMOXICILLIN ORAL TABLET 875 MG 0.18224 04/03/2015 0.18224 08/21/2015 AMOXICILLIN ORAL TABLET, CHEWABLE 125 MG 0.15067 01/25/2013 AMOXICILLIN ORAL TABLET, CHEWABLE 250 MG 0.26748 10/03/2014 0.26748 08/21/2015 AMOXICILLIN ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 11.26813 12/26/2014 11.26813 08/21/2015 775 MG AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, 0.11239 01/16/2015 0.11239 08/21/2015 RECONSTITUTED, ORAL (ML) 200-28.5/5 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, 0.73220 02/27/2015 0.73220 08/21/2015 RECONSTITUTED, ORAL (ML) 250-62.5/5 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, 0.12021 08/21/2015 0.13600 04/25/2016 RECONSTITUTED, ORAL (ML) 400-57MG/5 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, 0.18521 09/28/2015 0.11742 03/25/2016 RECONSTITUTED, ORAL (ML) 600-42.9/5 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET 250-125 MG 4.14283 02/07/2014 4.14283 08/21/2015 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET 500-125 MG 0.63638 08/21/2015 0.43909 04/22/2016 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET 875-125 MG 0.52059 05/20/2016 0.40985 01/27/2017 AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET, CHEWABLE 200 1.00222 03/01/2013 1.00222 08/21/2015 -28.5MG AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET, CHEWABLE 400 1.51840 08/22/2014 3.77335 04/22/2016 -57MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET, EXTENDED 3.37383 10/31/2014 RELEASE 12 HR 1000-62.5 AMPHOTERICIN B INJECTION VIAL (EA) 50 MG 20.87400 05/30/2014 AMPICILLIN SODIUM INJECTION VIAL (EA) 1 G 2.89120 01/25/2013 AMPICILLIN SODIUM INJECTION VIAL (EA) 10 G 36.92358 12/26/2014 36.92358 08/21/2015 AMPICILLIN SODIUM INJECTION VIAL (EA) 125 MG 3.50250 08/12/2014 AMPICILLIN SODIUM INJECTION VIAL (EA) 2 G 6.57000 11/08/2013 AMPICILLIN SODIUM INJECTION VIAL (EA) 250 MG 1.41638 01/25/2013 AMPICILLIN SODIUM INJECTION VIAL (EA) 500 MG 1.62006 01/25/2013 AMPICILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 12.17907 08/12/2014 G AMPICILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2 23.62640 01/25/2013 G AMPICILLIN SODIUM/SULBACTAM SODIUM INJECTION VIAL (EA) 1.5 G 2.57012 07/18/2014 2.57012 08/21/2015 AMPICILLIN SODIUM/SULBACTAM SODIUM INJECTION VIAL (EA) 15 G 20.70600 08/12/2014 20.70600 08/21/2015 AMPICILLIN SODIUM/SULBACTAM SODIUM INJECTION VIAL (EA) 3 G 6.47640 08/23/2013 6.47640 08/21/2015 AMPICILLIN SODIUM/SULBACTAM SODIUM INTRAVENOUS VIAL WITH 3.24240 01/25/2013 THREADED PORT (EA) 1.5 G AMPICILLIN SODIUM/SULBACTAM SODIUM INTRAVENOUS VIAL WITH 5.22060 01/25/2013 5.22060 08/21/2015 THREADED PORT (EA) 3 G AMPICILLIN TRIHYDRATE ORAL CAPSULE 250 MG 0.09000 08/12/2014 0.09000 08/21/2015 AMPICILLIN TRIHYDRATE ORAL CAPSULE 500 MG 0.14370 01/25/2013 0.14370 08/21/2015 AMPICILLIN TRIHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL 0.03950 02/08/2013 0.03950 08/21/2015 (ML) 125 MG/5ML AMPICILLIN TRIHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL 0.06860 02/08/2013 0.06860 08/21/2015 (ML) 250 MG/5ML ANAGRELIDE HCL ORAL CAPSULE 0.5 MG 0.60112 05/16/2014 ANAGRELIDE HCL ORAL CAPSULE 1 MG 1.29259 05/16/2014 ANASTROZOLE ORAL TABLET 1 MG 0.16214 05/30/2014 0.16214 08/21/2015 ANTIPYRINE/BENZOCAINE DROPS 5.4 %-1.4% 0.43271 02/06/2015 0.43271 08/21/2015 ANTIPYRINE/BENZOCAINE DROPS 5.5 %-1.4% 10.70600 12/26/2014 10.70600 08/21/2015 ANTIVENIN,LATRODECTUS MACTANS INJECTION VIAL (EA) 6000 UNIT 57.33000 12/12/2014 57.33000 08/21/2015 ANTIVENIN,MICRURUS FULVIUS INJECTION VIAL (EA) 1496.32000 01/25/2013 APRACLONIDINE HCL OPHTHALMIC DROPS 0.5 % 12.32550 01/25/2013 12.32550 08/21/2015 ARGATROBAN IN 0.9 % SODIUM CHLORIDE INTRAVENOUS VIAL (ML) 125 11.61817 01/25/2013 MG/125 ARGATROBAN IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS VIAL 3.85000 08/12/2014 (ML) 50 MG/50ML ARGATROBAN INTRAVENOUS VIAL (ML) 100 MG/ML 412.36020 05/01/2015 412.36020 08/21/2015 ARGININE HCL ORAL TABLET 1000 MG 0.14760 08/12/2014 ARGININE ORAL CAPSULE 500 MG 0.08386 08/12/2014 0.08386 08/21/2015 ARIPIPRAZOLE ORAL SOLUTION, ORAL 1 MG/ML 2.96000 01/27/2017 ARIPIPRAZOLE ORAL TABLET 10 MG 3.23116 12/02/2016 2.08747 01/13/2017 ARIPIPRAZOLE ORAL TABLET 15 MG 2.34254 01/13/2017 2.12065 01/27/2017 ARIPIPRAZOLE ORAL TABLET 2 MG 3.26000 09/30/2016 3.10442 12/02/2016 ARIPIPRAZOLE ORAL TABLET 20 MG 2.56993 01/13/2017 1.97615 01/27/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ARIPIPRAZOLE ORAL TABLET 30 MG 3.57857 12/02/2016 2.75295 01/27/2017 ARIPIPRAZOLE ORAL TABLET 5 MG 3.16805 12/02/2016 2.03842 01/13/2017 ASCORBIC ACID ORAL TABLET 1000 MG 0.05352 08/12/2014 0.05352 08/21/2015 ASCORBIC ACID ORAL TABLET 250 MG 0.01807 08/12/2014 0.01807 08/21/2015 ASCORBIC ACID ORAL TABLET 500 MG 0.02550 08/12/2014 0.02550 08/21/2015 ASCORBIC ACID ORAL TABLET, CHEWABLE 250 MG 0.02510 01/25/2013 ASCORBIC ACID ORAL TABLET, CHEWABLE 500 MG 0.04768 08/12/2014 0.04768 08/21/2015 ASCORBIC ACID ORAL TABLET, EXTENDED RELEASE 1000 MG 0.07311 08/12/2014 0.07311 08/21/2015 ASPIRIN ORAL TABLET 325 MG 0.00616 03/27/2015 0.00616 08/21/2015 ASPIRIN ORAL TABLET, CHEWABLE 81 MG 0.02048 05/01/2015 0.02048 08/21/2015 ASPIRIN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 325 MG 0.00872 05/01/2015 0.00872 08/21/2015 ASPIRIN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 81 MG 0.00804 04/03/2015 0.00804 08/21/2015 ASPIRIN/ACETAMINOPHEN/CAFFEINE ORAL TABLET 250-250-65 0.04476 04/24/2015 0.04476 08/21/2015 ASPIRIN/CALCIUM CARBONATE/MAGNESIUM ORAL TABLET 325 MG 0.02015 03/07/2014 0.02015 08/21/2015 ASPIRIN/SODIUM BICARBONATE/CITRIC ACID ORAL TABLET, 0.09644 08/12/2014 0.09644 08/21/2015 EFFERVESCENT 325-1916MG ATENOLOL ORAL TABLET 100 MG 0.03400 04/24/2015 0.03400 08/21/2015 ATENOLOL ORAL TABLET 25 MG 0.02659 04/03/2015 0.02659 08/21/2015 ATENOLOL ORAL TABLET 50 MG 0.01640 04/17/2015 0.01640 08/21/2015 ATENOLOL/CHLORTHALIDONE ORAL TABLET 100MG-25MG 0.62893 09/12/2014 0.62893 08/21/2015 ATENOLOL/CHLORTHALIDONE ORAL TABLET 50 MG-25MG 0.44769 03/27/2015 0.44769 08/21/2015 ATORVASTATIN CALCIUM ORAL TABLET 10 MG 0.11234 02/06/2015 0.11234 08/21/2015 ATORVASTATIN CALCIUM ORAL TABLET 20 MG 0.34882 11/20/2015 0.18069 04/22/2016 ATORVASTATIN CALCIUM ORAL TABLET 40 MG 0.26000 01/22/2016 0.20607 05/20/2016 ATORVASTATIN CALCIUM ORAL TABLET 80 MG 0.37316 10/23/2015 0.23000 01/22/2016 ATOVAQUONE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 750 3.53552 07/08/2016 3.48010 09/30/2016 MG/5ML ATOVAQUONE/PROGUANIL HCL ORAL TABLET 250-100 MG 5.08207 08/21/2015 3.82000 07/29/2016 ATOVAQUONE/PROGUANIL HCL ORAL TABLET 62.5-25 MG 1.85045 06/06/2014 0.92151 01/13/2017 ATROPINE SULFATE INJECTION SYRINGE (ML) 0.05 MG/ML 2.23272 01/25/2013 ATROPINE SULFATE INJECTION SYRINGE (ML) 0.1 MG/ML 0.43014 01/25/2013 0.43014 08/21/2015 ATROPINE SULFATE INJECTION VIAL (ML) 0.4 MG/ML 0.85480 08/12/2014 0.85480 08/21/2015 ATROPINE SULFATE INJECTION VIAL (ML) 1 MG/ML 1.50320 08/12/2014 ATROPINE SULFATE OPHTHALMIC DROPS 1 % 1.76890 08/21/2015 8.17320 08/22/2015 ATROPINE SULFATE OPHTHALMIC OINTMENT (GRAM) 1 % 3.98000 02/08/2013 AZATHIOPRINE ORAL TABLET 50 MG 0.46520 04/28/2016 0.40791 09/30/2016 AZELASTINE HCL NASAL AEROSOL, SPRAY WITH PUMP (ML) 137 MCG 1.02376 08/21/2015 0.72700 12/25/2015 AZELASTINE HCL OPHTHALMIC DROPS 0.05 % 6.87166 12/25/2015 6.28333 07/08/2016 AZITHROMYCIN INTRAVENOUS VIAL (EA) 500 MG 3.77260 08/12/2014 3.77260 08/21/2015 AZITHROMYCIN INTRAVENOUS VIAL WITH THREADED PORT (EA) 500 MG 12.68820 01/25/2013 AZITHROMYCIN ORAL PACKET (EA) 1 G 20.29440 01/17/2014 20.29440 08/21/2015 AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100 0.90850 02/27/2015 0.90850 08/21/2015 MG/5ML West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 0.52490 05/20/2016 0.44141 09/30/2016 MG/5ML AZITHROMYCIN ORAL TABLET 250 MG 0.45485 04/17/2015 0.45485 08/21/2015 AZITHROMYCIN ORAL TABLET 500 MG 3.15413 08/21/2015 1.52237 04/22/2016 AZITHROMYCIN ORAL TABLET 600 MG 1.57567 04/22/2016 2.04520 08/08/2016 AZTREONAM INJECTION VIAL (EA) 1 G 27.67800 08/15/2014 AZTREONAM INJECTION VIAL (EA) 2 G 39.02640 01/30/2015 39.02640 08/21/2015 B COMPLEX WITH VITAMIN C ORAL TABLET 0.02618 08/15/2014 0.02618 08/21/2015 BACITRACIN OPHTHALMIC OINTMENT (GRAM) 500 UNIT/G 13.86800 08/15/2014 13.86800 08/21/2015 BACITRACIN TOPICAL OINTMENT (GRAM) 500 UNIT/G 0.06722 04/19/2013 0.06722 08/21/2015 BACITRACIN ZINC TOPICAL OINTMENT (GRAM) 500 UNIT/G 0.10676 04/17/2015 0.10676 08/21/2015 BACITRACIN/POLYMYXIN B SULFATE OPHTHALMIC OINTMENT (GRAM) 2.81450 12/19/2014 2.81450 08/21/2015 500-10K/G BACITRACIN/POLYMYXIN B SULFATE TOPICAL OINTMENT (GRAM) 500- 0.27376 01/25/2013 0.27376 08/21/2015 10K/G BACLOFEN MISCELLANEOUS POWDER (GRAM) 100 % 2.61831 02/13/2015 2.61831 08/21/2015 BACLOFEN ORAL TABLET 10 MG 0.23194 08/21/2015 0.18244 05/20/2016 BACLOFEN ORAL TABLET 20 MG 0.28843 03/25/2016 0.23334 01/13/2017 BALSALAZIDE DISODIUM ORAL CAPSULE 750 MG 0.56605 03/06/2015 BCG LIVE INTRAVESICAL VIAL (EA) 50 MG 291.39600 01/25/2013 BENAZEPRIL HCL ORAL TABLET 10 MG 0.05197 03/27/2015 0.05197 08/21/2015 BENAZEPRIL HCL ORAL TABLET 20 MG 0.05197 03/27/2015 0.05197 08/21/2015 BENAZEPRIL HCL ORAL TABLET 40 MG 0.08061 03/27/2015 0.08061 08/21/2015 BENAZEPRIL HCL ORAL TABLET 5 MG 0.05199 03/27/2015 0.05199 08/21/2015 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 1.44718 03/27/2015 1.44718 08/21/2015 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20 MG-25MG 1.44718 08/21/2015 0.90520 07/08/2016 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG 1.44718 08/21/2015 0.90520 07/08/2016 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5-6.25MG 0.45890 08/21/2015 BENZOCAINE/MENTHOL MUCOUS MEMBRANE LOZENGE 15MG-3.6MG 0.09806 02/13/2015 0.09806 08/21/2015 BENZONATATE ORAL CAPSULE 100 MG 0.15243 08/21/2015 0.24120 01/24/2016 BENZONATATE ORAL CAPSULE 200 MG 0.26347 08/21/2015 0.14064 09/30/2016 BENZOYL PEROXIDE TOPICAL CLEANSER (GRAM) 10 % 0.04197 05/01/2015 0.04197 08/21/2015 BENZOYL PEROXIDE TOPICAL CLEANSER (GRAM) 5 % 0.04075 08/09/2013 0.04075 08/21/2015 BENZOYL PEROXIDE TOPICAL FOAM (GRAM) 5.3% 2.00832 08/12/2014 BENZOYL PEROXIDE TOPICAL FOAM (GRAM) 9.8 % 1.60318 08/12/2014 BENZOYL PEROXIDE TOPICAL GEL (GRAM) 10 % 0.21574 03/20/2015 0.21574 08/21/2015 BENZOYL PEROXIDE TOPICAL GEL (GRAM) 2.5 % 0.23088 08/16/2013 BENZOYL PEROXIDE TOPICAL GEL (GRAM) 5 % 0.18789 02/27/2015 0.18789 08/21/2015 BENZPHETAMINE HCL ORAL TABLET 50 MG 0.43389 11/07/2014 0.43389 08/21/2015 BENZTROPINE MESYLATE INJECTION AMPUL (ML) 2 MG/2 ML 23.40625 08/12/2014 BENZTROPINE MESYLATE INJECTION VIAL (ML) 2 MG/2 ML 40.39560 01/25/2013 40.39560 08/21/2015 BENZTROPINE MESYLATE ORAL TABLET 0.5 MG 0.13400 08/21/2015 0.09985 09/30/2016 BENZTROPINE MESYLATE ORAL TABLET 1 MG 0.17420 08/21/2015 0.14177 05/20/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date BENZTROPINE MESYLATE ORAL TABLET 2 MG 0.22780 04/03/2015 0.22780 08/21/2015 BETA-CAROTENE(A) W-C AND E/LUTEIN/MINERALS ORAL TABLET 1000- 0.06145 08/12/2014 0.06145 08/21/2015 60-2 BETA-CAROTENE/ASCORBIC ACID/VITE AC/ZINC OXIDE/CUPRIC OXIDE 0.16420 08/12/2014 0.16420 08/21/2015 ORAL CAPSULE 14320-226 BETA-CAROTENE/ASCORBIC ACID/VITE AC/ZINC OXIDE/CUPRIC OXIDE 0.06620 08/12/2014 ORAL TABLET 7160-113 BETAMETHASONE ACETATE/BETAMETHASONE SODIUM PHOSPHATE 5.60000 01/25/2013 5.60000 08/21/2015 INJECTION VIAL (ML) 6 MG/ML BETAMETHASONE DIPROPIONATE TOPICAL CREAM (GRAM) 0.05 % 1.62527 08/21/2015 1.50299 07/08/2016 BETAMETHASONE DIPROPIONATE TOPICAL GEL (GRAM) 0.05 % 1.21450 01/25/2013 BETAMETHASONE DIPROPIONATE TOPICAL LOTION (ML) 0.05 % 0.53761 05/03/2013 0.55988 01/28/2016 BETAMETHASONE DIPROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 1.57591 03/29/2013 1.57591 08/21/2015 BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL TOPICAL 0.34930 12/12/2014 0.34930 08/21/2015 CREAM (GRAM) 0.05 % BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL TOPICAL 1.77637 08/16/2013 LOTION (ML) 0.05 % BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL TOPICAL 2.15884 02/07/2014 OINTMENT (GRAM) 0.05 % BETAMETHASONE VALERATE TOPICAL CREAM (GRAM) 0.1 % 0.73849 08/21/2015 0.56720 07/08/2016 BETAMETHASONE VALERATE TOPICAL FOAM (GRAM) 0.12 % 3.31660 07/25/2014 3.31660 08/21/2015 BETAMETHASONE VALERATE TOPICAL LOTION (ML) 0.1 % 0.79430 03/29/2013 0.79430 08/21/2015 BETAMETHASONE VALERATE TOPICAL OINTMENT (GRAM) 0.1 % 0.07080 02/07/2014 0.07080 08/21/2015 BETAXOLOL HCL OPHTHALMIC DROPS 0.5 % 7.27680 01/25/2013 BETHANECHOL CHLORIDE ORAL TABLET 10 MG 0.47540 11/23/2015 0.43078 05/20/2016 BETHANECHOL CHLORIDE ORAL TABLET 25 MG 0.32806 09/30/2016 0.50274 11/14/2016 BETHANECHOL CHLORIDE ORAL TABLET 5 MG 0.24258 04/10/2015 0.24258 08/21/2015 BETHANECHOL CHLORIDE ORAL TABLET 50 MG 0.96567 12/25/2015 0.28034 12/02/2016 BICALUTAMIDE ORAL TABLET 50 MG 0.29815 11/14/2014 0.29815 08/21/2015 BIOFLAVONOID, LEMON/VITAMIN B COMP AND C ORAL TABLET 200-100 0.14285 05/03/2013 MG BIOTIN ORAL CAPSULE 2500 MCG 0.09390 08/12/2014 BISACODYL ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 5 MG 0.00996 01/16/2015 0.00996 08/21/2015 BISACODYL RECTAL SUPPOSITORY, RECTAL 10 MG 0.09491 08/12/2014 0.09491 08/21/2015 BISMUTH SUBSALICYLATE ORAL SUSPENSION, ORAL (FINAL DOSE 0.00732 03/20/2015 0.00732 08/21/2015 FORM) 262MG/15ML BISMUTH SUBSALICYLATE ORAL SUSPENSION, ORAL (FINAL DOSE 0.01095 04/24/2015 0.01095 08/21/2015 FORM) 525MG/15ML BISMUTH SUBSALICYLATE ORAL TABLET, CHEWABLE 262 MG 0.09120 02/27/2015 0.09120 08/21/2015 BISOPROLOL FUMARATE ORAL TABLET 10 MG 0.64320 08/21/2015 0.23333 05/20/2016 BISOPROLOL FUMARATE ORAL TABLET 5 MG 0.43441 12/25/2015 0.34200 05/20/2016 BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 10- 0.06432 04/17/2015 0.06432 08/21/2015 6.25MG BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 2.5- 0.06435 04/03/2015 0.06435 08/21/2015 6.25MG BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 5- 0.17971 12/25/2015 0.13656 09/30/2016 6.25MG BRIMONIDINE TARTRATE OPHTHALMIC DROPS 0.15 % 16.27762 08/21/2015 16.27762 04/22/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date BRIMONIDINE TARTRATE OPHTHALMIC DROPS 0.2 % 1.04560 06/06/2014 1.04560 08/21/2015 BROMFENAC SODIUM OPHTHALMIC DROPS 0.09% 39.30875 09/26/2014 39.30875 08/21/2015 BROMOCRIPTINE MESYLATE ORAL CAPSULE 5 MG 6.51728 08/21/2015 6.00042 03/25/2016 BROMOCRIPTINE MESYLATE ORAL TABLET 2.5 MG 3.21022 08/21/2015 2.98997 05/20/2016 BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL ORAL LIQUID (ML) 0.15294 01/25/2013 0.15294 08/21/2015 4-10MG/5ML BROMPHENIRAMINE MALEATE/PHENYLEPHRINE 0.11830 09/13/2013 0.11830 08/21/2015 HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 4-10-20/5 BROMPHENIRAMINE MALEATE/PHENYLEPHRINE 0.09960 12/12/2014 0.09960 08/21/2015 HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 4-7.5-15/5 BROMPHENIRAMINE MALEATE/PHENYLEPHRINE 0.01700 02/06/2015 0.01700 08/21/2015 HCL/DEXTROMETHORPHAN ORAL SOLUTION, ORAL 1-2.5-5/5 BROMPHENIRAMINE MALEATE/PSEUDOEPHEDRINE 0.01880 03/27/2015 HCL/DEXTROMETHORPHAN ORAL ELIXIR 1-15-5MG/5 BROMPHENIRAMINE MALEATE/PSEUDOEPHEDRINE 0.17383 02/20/2015 0.17383 08/21/2015 HCL/DEXTROMETHORPHAN ORAL SYRUP 2-30-10/5 BUDESONIDE INHALATION AMPUL FOR NEBULIZATION (ML) 0.25MG/2ML 3.32730 03/27/2015 2.80662 12/02/2016 BUDESONIDE INHALATION AMPUL FOR NEBULIZATION (ML) 0.5 MG/2ML 3.87765 03/27/2015 3.01583 12/02/2016 BUDESONIDE ORAL CAPSULE, DELAYED, AND EXTENDED RELEASE 3 9.43197 07/08/2016 7.50912 09/30/2016 MG BUMETANIDE INJECTION VIAL (ML) 0.25 MG/ML 0.26572 01/25/2013 0.26572 08/21/2015 BUMETANIDE ORAL TABLET 0.5 MG 0.15517 02/20/2015 0.15517 08/21/2015 BUMETANIDE ORAL TABLET 1 MG 0.19470 08/21/2015 0.53210 09/12/2015 BUMETANIDE ORAL TABLET 2 MG 0.26224 08/21/2015 0.99030 05/24/2016 BUPIVACAINE HCL INJECTION VIAL (ML) 2.5 MG/ML 0.04200 04/25/2014 BUPIVACAINE HCL INJECTION VIAL (ML) 5 MG/ML 0.05090 04/25/2014 0.05090 08/21/2015 BUPIVACAINE HCL/EPINEPHRINE BITARTRATE INJECTION CARTRIDGE 0.26130 08/12/2014 (ML) 0.5-1:200K BUPIVACAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 0.25-.0005 0.12253 01/25/2013 BUPIVACAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 0.5-1:200K 0.11900 01/25/2013 BUPIVACAINE HCL/EPINEPHRINE/PF INJECTION VIAL (ML) 0.25-.0005 0.27733 01/25/2013 BUPIVACAINE HCL/EPINEPHRINE/PF INJECTION VIAL (ML) 0.5-1:200K 0.25992 01/25/2013 BUPIVACAINE HCL/PF INJECTION AMPUL (ML) 2.5 MG/ML 0.11790 08/12/2014 BUPIVACAINE HCL/PF INJECTION AMPUL (ML) 5 MG/ML 0.08690 08/12/2014 BUPIVACAINE HCL/PF INJECTION AMPUL (ML) 7.5 MG/ML 0.10478 01/25/2013 0.10478 08/21/2015 BUPIVACAINE HCL/PF INJECTION VIAL (ML) 2.5 MG/ML 0.06089 08/12/2014 BUPIVACAINE HCL/PF INJECTION VIAL (ML) 5 MG/ML 0.06736 08/12/2014 BUPIVACAINE HCL/PF INJECTION VIAL (ML) 7.5 MG/ML 0.13428 08/12/2014 BUPRENORPHINE HCL INJECTION SYRINGE (ML) 0.3 MG/ML 12.18000 01/25/2013 BUPRENORPHINE HCL SUBLINGUAL TABLET, SUBLINGUAL 2 MG 2.04045 04/24/2015 1.67804 07/08/2016 BUPRENORPHINE HCL SUBLINGUAL TABLET, SUBLINGUAL 8 MG 1.99675 04/24/2015 1.76344 01/13/2017 BUPRENORPHINE HCL/NALOXONE HCL SUBLINGUAL TABLET, 4.07797 08/21/2015 2.95157 10/23/2015 SUBLINGUAL 2 MG-0.5MG BUPRENORPHINE HCL/NALOXONE HCL SUBLINGUAL TABLET, 4.39969 02/26/2016 4.01746 01/27/2017 SUBLINGUAL 8 MG-2 MG BUPROPION HCL ORAL TABLET 100 MG 0.38222 07/29/2016 0.21303 09/30/2016 BUPROPION HCL ORAL TABLET 75 MG 0.46503 08/21/2015 0.22965 05/20/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 100 MG 0.24616 04/17/2015 0.24616 08/21/2015 BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 150 MG 0.58090 08/21/2015 0.44367 03/25/2016 BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 150 MG 0.15500 05/20/2016 0.18520 09/21/2016 BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 200 MG 0.32666 01/13/2017 0.23349 01/27/2017 BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 24 HR 150 MG 0.66256 01/22/2016 0.53308 03/25/2016 BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 0.45724 04/22/2016 0.36924 12/02/2016 BUSPIRONE HCL ORAL TABLET 10 MG 0.05791 04/24/2015 0.05791 08/21/2015 BUSPIRONE HCL ORAL TABLET 15 MG 0.10211 04/17/2015 0.10211 08/21/2015 BUSPIRONE HCL ORAL TABLET 30 MG 0.76395 12/05/2014 0.56195 12/25/2015 BUSPIRONE HCL ORAL TABLET 5 MG 0.04020 04/03/2015 0.04020 08/21/2015 BUSPIRONE HCL ORAL TABLET 7.5 MG 0.73323 01/13/2017 0.48665 01/27/2017 BUTALBITAL/ACETAMINOPHEN ORAL TABLET 50MG-325MG 0.86233 03/14/2014 1.09000 08/07/2015 BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL CAPSULE 50-300-40 2.05800 01/30/2015 2.05555 05/21/2015 BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL CAPSULE 50-325-40 1.35905 03/27/2015 BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL TABLET 50-325-40 0.97430 07/11/2015 0.55996 05/20/2016 BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE ORAL 4.30822 03/06/2015 CAPSULE 50-300-30 BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE ORAL 1.04965 08/01/2014 1.04965 08/21/2015 CAPSULE 50-325-30 BUTALBITAL/ASPIRIN/CAFFEINE ORAL CAPSULE 50-325-40 1.06161 08/15/2014 1.06161 08/21/2015 BUTENAFINE HCL TOPICAL CREAM (GRAM) 1 % 0.40179 01/25/2013 0.40179 08/21/2015 BUTORPHANOL TARTRATE INJECTION VIAL (ML) 1 MG/ML 1.94300 01/25/2013 1.94300 08/21/2015 BUTORPHANOL TARTRATE INJECTION VIAL (ML) 2 MG/ML 1.94300 01/25/2013 1.94300 08/21/2015 BUTORPHANOL TARTRATE NASAL AEROSOL, SPRAY (ML) 10 MG/ML 16.32960 02/20/2015 16.32960 08/21/2015 CABERGOLINE ORAL TABLET 0.5 MG 12.40113 12/26/2014 8.57867 07/08/2016 CAFFEINE CITRATE INTRAVENOUS VIAL (ML) 60 MG/3 ML 3.35400 04/03/2015 3.35400 08/21/2015 CAFFEINE CITRATE ORAL SOLUTION, ORAL 60 MG/3 ML 6.70190 04/17/2015 6.70190 08/21/2015 CAFFEINE/SODIUM BENZOATE INJECTION VIAL (ML) 250 MG/ML 2.73000 01/25/2013 CALCIPOTRIENE TOPICAL CREAM (GRAM) 0.005 % 4.93815 02/06/2015 4.93815 08/21/2015 CALCIPOTRIENE TOPICAL OINTMENT (GRAM) 0.005 % 4.22790 08/12/2014 CALCIPOTRIENE TOPICAL SOLUTION, NON-ORAL 0.005 % 3.36520 11/15/2013 3.36520 08/21/2015 CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE TOPICAL OINTMENT 8.85004 04/18/2014 8.85004 01/01/2017 (GRAM) 0.005-.064 CALCITONIN,SALMON,SYNTHETIC NASAL AEROSOL, SPRAY WITH PUMP 10.40270 09/25/2015 9.78378 09/30/2016 (ML) 200/SPRAY CALCITRIOL INTRAVENOUS AMPUL (ML) 1 MCG/ML 4.68130 05/10/2013 CALCITRIOL ORAL CAPSULE 0.25 MCG 0.48079 08/21/2015 0.34379 09/30/2016 CALCITRIOL ORAL CAPSULE 0.5 MCG 0.54000 05/20/2016 0.62350 07/27/2016 CALCITRIOL ORAL SOLUTION, ORAL 1 MCG/ML 7.01272 07/05/2013 5.49667 08/26/2016 CALCITRIOL TOPICAL OINTMENT (GRAM) 3 MCG/G 6.43120 01/09/2015 CALCIUM ACETATE ORAL CAPSULE 667 MG 0.71855 08/21/2015 0.28519 05/20/2016 CALCIUM ACETATE ORAL TABLET 667 MG 0.36813 01/03/2014 CALCIUM ACETATE/ALUMINUM SULFATE TOPICAL POWDER IN PACKET 0.72740 01/25/2013 (EA) 952-1347MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CALCIUM CARBONATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.01799 01/25/2013 500 MG/5ML CALCIUM CARBONATE ORAL TABLET 500(1250) 0.01434 06/21/2013 0.01434 08/21/2015 CALCIUM CARBONATE ORAL TABLET 600 MG 0.02144 07/26/2013 0.02144 08/21/2015 CALCIUM CARBONATE ORAL TABLET, CHEWABLE 200(500)MG 0.01357 02/06/2015 0.01357 08/21/2015 CALCIUM CARBONATE ORAL TABLET, CHEWABLE 300MG(750) 0.02554 02/27/2015 0.02554 08/21/2015 CALCIUM CARBONATE ORAL TABLET, CHEWABLE 400(1000) 0.04240 08/21/2015 CALCIUM CARBONATE ORAL TABLET, CHEWABLE 500(1250) 0.03420 08/12/2014 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL 0.04855 08/12/2014 CAPSULE 600 MG-400 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.01032 01/25/2013 0.01032 08/21/2015 250 MG-125 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.01599 08/12/2014 0.01599 08/21/2015 500 MG-200 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.03507 08/12/2014 0.03507 08/21/2015 500 MG-400 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.01899 01/25/2013 0.01899 08/21/2015 600 MG-200 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.01956 02/27/2015 0.01956 08/21/2015 600 MG-400 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 0.05873 02/13/2015 0.05873 08/21/2015 600 MG-800 CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET, 0.03420 08/21/2015 CHEWABLE 500 MG-100 CALCIUM CARBONATE/ERGOCALCIFEROL (VITAMIN D2) ORAL TABLET 0.02170 08/12/2014 0.02170 08/21/2015 250 MG-125 CALCIUM CARBONATE/MAGNESIUM HYDROXIDE ORAL TABLET, 0.01352 08/21/2015 CHEWABLE 675-135 MG CALCIUM CHLORIDE INTRAVENOUS SYRINGE (ML) 100 MG/ML 0.47124 08/12/2014 0.47124 08/21/2015 CALCIUM CHLORIDE INTRAVENOUS VIAL (ML) 100 MG/ML 0.17500 01/25/2013 CALCIUM CITRATE ORAL TABLET 200(950)MG 0.03070 08/12/2014 0.03070 08/21/2015 CALCIUM CITRATE ORAL TABLET 250 MG 0.05565 01/25/2013 CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 200 0.04005 08/12/2014 MG-250 CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 315 0.05724 08/12/2014 0.05724 08/21/2015 MG-200 CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 315 0.04615 11/21/2014 0.04615 08/21/2015 MG-250 CALCIUM POLYCARBOPHIL ORAL TABLET 625 MG 0.06417 08/12/2014 0.06417 08/21/2015 CANDESARTAN CILEXETIL ORAL TABLET 16 MG 1.70647 08/22/2014 1.70647 08/21/2015 CANDESARTAN CILEXETIL ORAL TABLET 32 MG 2.35304 08/22/2014 2.35304 08/21/2015 CANDESARTAN CILEXETIL ORAL TABLET 4 MG 1.62543 08/12/2014 CANDESARTAN CILEXETIL ORAL TABLET 8 MG 1.61850 08/12/2014 CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE ORAL TABLET 16- 1.87708 11/07/2014 1.87708 08/21/2015 12.5MG CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE ORAL TABLET 32- 2.91948 01/25/2013 2.91948 08/21/2015 12.5MG CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE ORAL TABLET 3.15984 08/12/2014 3.15984 08/21/2015 32MG-25MG CAPECITABINE ORAL TABLET 150 MG 8.21479 04/24/2015 8.21479 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CAPECITABINE ORAL TABLET 500 MG 24.00838 02/26/2016 21.64318 10/28/2016 CAPSAICIN TOPICAL CREAM (GRAM) 0.025 % 0.06709 04/05/2013 0.06709 08/21/2015 CAPSAICIN TOPICAL CREAM (GRAM) 0.075 % 0.09338 08/12/2014 0.09338 08/21/2015 CAPSAICIN/METHYL SALICYLATE/MENTHOL TOPICAL LOTION (GRAM) 2.36327 01/25/2013 0.002%-20% CAPTOPRIL MISCELLANEOUS POWDER (GRAM) 100 % 56.85764 02/22/2013 56.85764 08/21/2015 CAPTOPRIL ORAL TABLET 100 MG 1.12780 05/09/2014 1.12780 08/21/2015 CAPTOPRIL ORAL TABLET 12.5 MG 0.46645 08/15/2014 0.46645 08/21/2015 CAPTOPRIL ORAL TABLET 25 MG 0.99791 11/07/2014 0.99791 08/21/2015 CAPTOPRIL ORAL TABLET 50 MG 1.57900 02/27/2015 1.57900 08/21/2015 CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-15MG 0.33384 12/27/2013 0.33384 08/21/2015 CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-25MG 1.10214 05/30/2014 1.10214 08/21/2015 CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG-15MG 1.89163 05/30/2014 1.89163 08/21/2015 CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG-25MG 1.89163 05/30/2014 1.89163 08/21/2015 CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 1.25113 03/14/2014 1.25113 01/01/2017 12HR 100 MG CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 1.25113 08/21/2015 12HR 200 MG CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 1.25113 05/21/2015 1.25113 01/01/2017 12HR 200 MG CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 1.20587 03/27/2015 1.20587 01/01/2017 12HR 300 MG CARBAMAZEPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 0.11631 07/18/2014 MG/5ML CARBAMAZEPINE ORAL TABLET 200 MG 0.52933 09/30/2016 0.56210 10/31/2016 CARBAMAZEPINE ORAL TABLET, CHEWABLE 100 MG 0.46095 04/28/2016 0.33532 07/08/2016 CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 200 MG 1.45495 01/21/2016 1.45495 01/01/2017 CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 400 MG 2.90780 03/22/2016 2.90780 01/01/2017 CARBAMIDE PEROXIDE OTIC DROPS 6.5 % 0.11614 04/03/2015 0.11614 08/21/2015 CARBIDOPA ORAL TABLET 25 MG 8.17818 02/13/2015 CARBIDOPA/LEVODOPA ORAL TABLET 10MG-100MG 0.14258 08/12/2014 0.14258 08/21/2015 CARBIDOPA/LEVODOPA ORAL TABLET 25MG-100MG 0.13068 11/07/2014 0.13068 08/21/2015 CARBIDOPA/LEVODOPA ORAL TABLET 25MG-250MG 0.18023 08/12/2014 0.18023 08/21/2015 CARBIDOPA/LEVODOPA ORAL TABLET, EXTENDED RELEASE 25MG- 0.31595 08/12/2014 0.31595 08/21/2015 100MG CARBIDOPA/LEVODOPA ORAL TABLET, EXTENDED RELEASE 50MG- 0.47443 09/30/2016 0.40390 01/13/2017 200MG CARBIDOPA/LEVODOPA ORAL TABLET,DISINTEGRATING 10MG-100MG 0.77305 01/25/2013 0.77305 08/21/2015 CARBIDOPA/LEVODOPA ORAL TABLET,DISINTEGRATING 25MG-100MG 0.94146 04/10/2015 0.94146 08/21/2015 CARBIDOPA/LEVODOPA ORAL TABLET,DISINTEGRATING 25MG-250MG 1.10100 01/25/2013 1.10100 08/21/2015 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 12.5-50 MG 2.13334 08/21/2015 2.13334 04/22/2016 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 18.75-75MG 2.62496 08/12/2014 2.62496 04/22/2016 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 25-100-200 1.41900 02/27/2015 1.41900 04/22/2016 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 31.25-125 2.62481 08/12/2014 2.62481 04/22/2016 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 37.5-150MG 1.74240 08/12/2014 1.74240 04/22/2016 CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 50-200-200 1.74240 08/12/2014 1.74240 04/22/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CARBINOXAMINE MALEATE ORAL LIQUID (ML) 4 MG/5 ML 0.09112 03/15/2013 0.09112 08/21/2015 CARBINOXAMINE MALEATE ORAL TABLET 4 MG 0.49602 05/10/2013 0.49602 08/21/2015 CARBOXYMETHYLCELLULOSE SODIUM OPHTHALMIC DROPPERETTE, 0.32162 03/29/2013 GEL 1 % CARBOXYMETHYLCELLULOSE SODIUM OPHTHALMIC DROPPERETTE, 0.20828 08/12/2014 0.20828 08/21/2015 SINGLE-USE DROP DISPENSER 0.5 % CARBOXYMETHYLCELLULOSE SODIUM OPHTHALMIC DROPS 0.5 % 0.33524 08/12/2014 0.33524 08/21/2015 CARISOPRODOL ORAL TABLET 250 MG 2.31410 02/08/2013 CARISOPRODOL ORAL TABLET 350 MG 0.07909 03/20/2015 0.07909 08/21/2015 CARISOPRODOL/ASPIRIN ORAL TABLET 200-325 MG 1.52430 08/12/2014 1.52430 08/21/2015 CARISOPRODOL/ASPIRIN/CODEINE PHOSPHATE ORAL TABLET 200-325- 1.94250 01/25/2013 1.94250 08/21/2015 16 CARTEOLOL HCL OPHTHALMIC DROPS 1 % 1.17210 01/25/2013 CARVEDILOL ORAL TABLET 12.5 MG 0.04968 04/17/2015 0.04968 08/21/2015 CARVEDILOL ORAL TABLET 25 MG 0.03886 04/17/2015 0.03886 08/21/2015 CARVEDILOL ORAL TABLET 3.125 MG 0.03629 03/06/2015 0.03629 08/21/2015 CARVEDILOL ORAL TABLET 6.25 MG 0.04950 05/01/2015 0.04950 08/21/2015 CASTOR OIL ORAL OIL (ML) 0.05545 01/25/2013 CEFACLOR ORAL CAPSULE 250 MG 1.39260 02/01/2013 1.39260 08/21/2015 CEFACLOR ORAL CAPSULE 500 MG 1.61040 08/12/2014 1.61040 08/21/2015 CEFACLOR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 0.68231 01/25/2013 MG/5ML CEFACLOR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 1.36453 01/25/2013 1.36453 08/21/2015 MG/5ML CEFACLOR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 375 2.04680 01/25/2013 MG/5ML CEFACLOR ORAL TABLET, EXTENDED RELEASE 12 HR 500 MG 3.48600 01/25/2013 3.48600 08/21/2015 CEFADROXIL ORAL CAPSULE 500 MG 0.38190 08/21/2015 0.27503 09/30/2016 CEFADROXIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 0.36218 02/06/2015 MG/5ML CEFADROXIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 500 0.50605 02/06/2015 MG/5ML CEFADROXIL ORAL TABLET 1 G 2.32518 01/25/2013 CEFAZOLIN SODIUM INJECTION VIAL (EA) 1 G 5.80360 09/26/2014 5.80360 08/21/2015 CEFAZOLIN SODIUM INJECTION VIAL (EA) 10 G 6.55920 09/26/2014 6.55920 08/21/2015 CEFAZOLIN SODIUM INJECTION VIAL (EA) 500 MG 1.03662 01/25/2013 CEFAZOLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 4.26300 01/25/2013 G CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS 0.20427 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS 17.93574 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV 0.07526 07/18/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML CEFDINIR ORAL CAPSULE 300 MG 0.81778 01/13/2017 0.76371 01/27/2017 CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML 0.46513 03/25/2016 0.36508 07/29/2016 CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML 0.45621 03/25/2016 0.42540 09/30/2016 CEFDITOREN PIVOXIL ORAL TABLET 200 MG 10.31835 11/28/2014 10.31835 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CEFDITOREN PIVOXIL ORAL TABLET 400 MG 10.31835 11/28/2014 10.31835 08/21/2015 CEFEPIME HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.55476 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFEPIME HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 14.59910 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFEPIME HCL IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV 1.09878 11/07/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML CEFEPIME HCL IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV 0.88078 07/25/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2 G/100 ML CEFEPIME HCL INJECTION VIAL (EA) 1 G 4.48630 09/27/2013 4.48630 08/21/2015 CEFEPIME HCL INJECTION VIAL (EA) 2 G 8.31600 08/09/2013 8.31600 08/21/2015 CEFIXIME ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100 MG/5ML 3.56300 05/01/2015 3.56300 08/21/2015 CEFIXIME ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 MG/5ML 7.12610 05/01/2015 7.12610 08/21/2015 CEFOTAXIME SODIUM INJECTION VIAL (EA) 1 G 2.12524 09/06/2013 2.12524 08/21/2015 CEFOTAXIME SODIUM INJECTION VIAL (EA) 10 G 18.35400 01/25/2013 CEFOTAXIME SODIUM INJECTION VIAL (EA) 2 G 4.12516 08/12/2014 4.12516 08/21/2015 CEFOTAXIME SODIUM INJECTION VIAL (EA) 500 MG 1.26000 10/04/2013 1.26000 08/21/2015 CEFOTETAN DISODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS 12.81880 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFOTETAN DISODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS 17.59800 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFOTETAN DISODIUM INJECTION VIAL (EA) 1 G 9.55920 01/25/2013 CEFOTETAN DISODIUM INJECTION VIAL (EA) 2 G 19.91500 01/25/2013 CEFOTETAN DISODIUM INTRAVENOUS VIAL (EA) 10 G 98.60200 01/25/2013 CEFOXITIN SODIUM INTRAVENOUS VIAL (EA) 1 G 4.45484 03/20/2015 4.45484 08/21/2015 CEFOXITIN SODIUM INTRAVENOUS VIAL (EA) 10 G 32.13068 01/25/2013 CEFOXITIN SODIUM INTRAVENOUS VIAL (EA) 2 G 7.94256 03/20/2015 7.94256 08/21/2015 CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS 0.45037 04/19/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS 0.92383 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFPODOXIME PROXETIL ORAL SUSPENSION, RECONSTITUTED, ORAL 1.14772 03/29/2013 (ML) 100 MG/5ML CEFPODOXIME PROXETIL ORAL SUSPENSION, RECONSTITUTED, ORAL 0.52444 08/12/2014 (ML) 50 MG/5 ML CEFPODOXIME PROXETIL ORAL TABLET 100 MG 4.71590 05/03/2013 CEFPODOXIME PROXETIL ORAL TABLET 200 MG 5.83512 02/07/2014 CEFPROZIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 0.29385 08/22/2014 MG/5ML CEFPROZIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 0.65389 08/21/2015 0.55860 01/13/2017 MG/5ML CEFPROZIL ORAL TABLET 250 MG 0.98670 08/22/2014 0.98670 08/21/2015 CEFPROZIL ORAL TABLET 500 MG 1.55100 03/14/2014 1.55100 08/21/2015 CEFTAZIDIME IN DEXTROSE 5% AND WATER INTRAVENOUS 9.03846 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFTAZIDIME IN DEXTROSE 5% AND WATER INTRAVENOUS 13.01154 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFTAZIDIME INJECTION VIAL (EA) 1 G 4.82560 11/08/2013 4.82560 08/21/2015 CEFTAZIDIME INJECTION VIAL (EA) 2 G 10.56045 11/01/2013 10.56045 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CEFTAZIDIME INJECTION VIAL (EA) 6 G 24.35825 08/12/2014 24.35825 08/21/2015 CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS 0.54291 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS 0.94697 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV 0.23839 07/18/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV 0.56464 04/04/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2 G/50 ML CEFTRIAXONE SODIUM INJECTION VIAL (EA) 1 G 2.25000 08/21/2015 2.17232 09/30/2016 CEFTRIAXONE SODIUM INJECTION VIAL (EA) 10 G 16.22880 01/24/2014 16.22880 08/21/2015 CEFTRIAXONE SODIUM INJECTION VIAL (EA) 2 G 3.36383 08/21/2015 3.06517 12/02/2016 CEFTRIAXONE SODIUM INJECTION VIAL (EA) 250 MG 1.06730 08/12/2014 1.06730 08/21/2015 CEFTRIAXONE SODIUM INJECTION VIAL (EA) 500 MG 1.32048 04/24/2015 1.32048 08/21/2015 CEFTRIAXONE SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 3.51120 02/15/2013 1 G CEFTRIAXONE SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 6.39660 01/25/2013 2 G CEFUROXIME AXETIL ORAL TABLET 250 MG 1.26898 04/17/2015 1.26898 08/21/2015 CEFUROXIME AXETIL ORAL TABLET 500 MG 2.40658 02/26/2016 2.04000 08/26/2016 CEFUROXIME SODIUM INJECTION VIAL (EA) 1.5 G 4.35422 08/12/2014 4.35422 08/21/2015 CEFUROXIME SODIUM INJECTION VIAL (EA) 750 MG 2.72428 11/14/2014 2.72428 08/21/2015 CEFUROXIME SODIUM INTRAVENOUS VIAL (EA) 1.5 G 4.35422 08/12/2014 4.35422 08/21/2015 CEFUROXIME SODIUM INTRAVENOUS VIAL (EA) 7.5 G 17.79645 08/12/2014 17.79645 08/21/2015 CELECOXIB ORAL CAPSULE 100 MG 0.92010 10/23/2015 0.71897 05/20/2016 CELECOXIB ORAL CAPSULE 200 MG 0.81221 05/20/2016 0.66218 01/27/2017 CELECOXIB ORAL CAPSULE 400 MG 2.94173 08/21/2015 1.25000 09/30/2016 CELECOXIB ORAL CAPSULE 50 MG 0.58420 04/24/2015 0.58420 08/21/2015 CEPHALEXIN ORAL CAPSULE 250 MG 0.09134 03/27/2015 0.09134 08/21/2015 CEPHALEXIN ORAL CAPSULE 500 MG 0.10023 04/10/2015 0.10023 08/21/2015 CEPHALEXIN ORAL CAPSULE 750 MG 5.38300 06/07/2013 CEPHALEXIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 0.14563 05/16/2014 0.14563 08/21/2015 MG/5ML CEPHALEXIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 0.17031 05/01/2015 0.17031 08/21/2015 MG/5ML CEPHALEXIN ORAL TABLET 250 MG 0.40092 01/25/2013 CEPHALEXIN ORAL TABLET 500 MG 0.80132 01/25/2013 CETIRIZINE HCL ORAL SOLUTION, ORAL 1 MG/ML 0.03306 12/26/2014 0.03306 08/21/2015 CETIRIZINE HCL ORAL TABLET 10 MG 0.10500 08/21/2015 0.06520 01/22/2016 CETIRIZINE HCL ORAL TABLET 5 MG 0.07567 09/26/2014 0.07567 08/21/2015 CETIRIZINE HCL ORAL TABLET, CHEWABLE 10 MG 1.66170 06/06/2014 1.66170 08/21/2015 CETIRIZINE HCL ORAL TABLET, CHEWABLE 5 MG 2.74179 02/13/2015 2.74179 08/21/2015 CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ORAL TABLET, EXTENDED 0.69707 02/27/2015 0.69707 08/21/2015 RELEASE 12 HR 5 MG-120MG CEVIMELINE HCL ORAL CAPSULE 30 MG 1.93172 09/25/2015 1.52283 03/25/2016 CHLORAMPHENICOL SOD SUCCINATE INTRAVENOUS VIAL (EA) 1 G 2.64689 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CHLORDIAZEPOXIDE HCL ORAL CAPSULE 10 MG 0.08863 04/24/2015 0.08863 08/21/2015 CHLORDIAZEPOXIDE HCL ORAL CAPSULE 25 MG 0.08949 08/15/2014 0.08949 08/21/2015 CHLORDIAZEPOXIDE HCL ORAL CAPSULE 5 MG 0.10875 08/15/2014 0.10875 08/21/2015 CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE ORAL CAPSULE 5 MG-2.5MG 0.27604 02/27/2015 0.27604 08/21/2015 CHLORHEXIDINE GLUCONATE MUCOUS MEMBRANE MOUTHWASH 0.12 0.00598 03/13/2015 0.00598 08/21/2015 % CHLOROQUINE PHOSPHATE ORAL TABLET 250 MG 0.86970 03/01/2013 0.86970 08/21/2015 CHLOROQUINE PHOSPHATE ORAL TABLET 500 MG 3.44058 08/12/2014 3.44058 08/21/2015 CHLOROTHIAZIDE ORAL TABLET 250 MG 0.15141 12/13/2013 0.15141 08/21/2015 CHLOROTHIAZIDE SODIUM INTRAVENOUS VIAL (EA) 500 MG 98.11300 04/17/2015 98.11300 08/21/2015 CHLORPHENIRAMINE MALEATE ORAL SYRUP 2 MG/5 ML 0.01798 01/25/2013 0.01798 08/21/2015 CHLORPHENIRAMINE MALEATE ORAL TABLET 4 MG 0.00634 02/06/2015 0.00634 08/21/2015 CHLORPHENIRAMINE MALEATE ORAL TABLET, EXTENDED RELEASE 12 0.34709 08/21/2015 MG CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE HCL ORAL LIQUID (ML) 0.02660 08/12/2014 4-10MG/5ML CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE 0.06860 08/12/2014 0.06860 08/21/2015 HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 2-5-15MG/5 CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE 0.04500 08/12/2014 HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 4-10-15/5 CHLORPHENIRAMINE MALEATE/PSEUDOEPHEDRINE HCL ORAL TABLET 0.05310 08/12/2014 4 MG-60 MG CHLORPHENIRAMINE 0.01868 01/25/2013 0.01868 08/21/2015 MALEATE/PSEUDOEPHEDRINE/DEXTROMETHORPHAN ORAL LIQUID (ML) 1-15-5MG/5 CHLORPROMAZINE HCL INJECTION AMPUL (ML) 25 MG/ML 18.81600 11/08/2013 CHLORPROMAZINE HCL ORAL TABLET 10 MG 2.65000 01/22/2016 CHLORPROMAZINE HCL ORAL TABLET 100 MG 6.95000 01/22/2016 CHLORPROMAZINE HCL ORAL TABLET 200 MG 9.75000 01/22/2016 CHLORPROMAZINE HCL ORAL TABLET 25 MG 3.40000 01/22/2016 CHLORPROMAZINE HCL ORAL TABLET 50 MG 4.95000 01/22/2016 CHLORPROPAMIDE ORAL TABLET 100 MG 0.84154 06/27/2014 0.84154 08/21/2015 CHLORPROPAMIDE ORAL TABLET 250 MG 0.85230 08/12/2014 CHLORTHALIDONE ORAL TABLET 25 MG 0.84483 01/27/2016 0.67326 09/30/2016 CHLORTHALIDONE ORAL TABLET 50 MG 1.04188 03/13/2015 1.04188 08/21/2015 CHLORZOXAZONE ORAL TABLET 500 MG 0.23400 04/10/2015 0.23400 08/21/2015 CHOLECALCIFEROL (VIT D3)/FOLIC ACID ORAL CAPSULE 3775 UNIT 15.16153 05/01/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 10000 UNIT 0.64783 12/26/2014 0.64783 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 400 UNIT 0.03240 05/01/2015 0.03240 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 4000 UNIT 0.06993 02/08/2013 CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 50000 UNIT 0.14700 09/26/2014 CHOLECALCIFEROL (VITAMIN D3) ORAL DROPS 5000/ML 0.07303 08/12/2014 CHOLECALCIFEROL (VITAMIN D3) ORAL LIQUID (ML) 400 UNIT/5 0.02914 01/25/2013 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 1000 UNIT 0.01997 08/12/2014 0.01997 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 2000 UNIT 0.02861 12/05/2014 0.02861 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 3000 UNIT 0.05516 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 400 UNIT 0.01786 04/17/2015 0.01786 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 5000 UNIT 0.05258 05/01/2015 0.05258 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET, CHEWABLE 1000 UNIT 0.06098 08/12/2014 0.06098 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET, CHEWABLE 400 UNIT 0.02509 01/25/2013 0.02509 08/21/2015 CHOLECALCIFEROL (VITAMIN D3) SUBLINGUAL SPRAY, SUSPENSION 0.30847 01/25/2013 (ML) 1000/SPRAY CHOLESTYRAMINE (WITH SUGAR) ORAL POWDER (GRAM) 4 G 0.21272 04/03/2015 0.21272 08/21/2015 CHOLESTYRAMINE (WITH SUGAR) ORAL POWDER IN PACKET (EA) 4 G 1.96666 05/15/2015 1.87503 07/08/2016 CHOLESTYRAMINE/ASPARTAME ORAL POWDER (GRAM) 4 G 0.29520 12/13/2013 CHOLESTYRAMINE/ASPARTAME ORAL POWDER IN PACKET (EA) 4 G 2.02874 03/14/2014 2.02874 08/21/2015 CHOLINE SALICYLATE/MAGNESIUM SALICYLATE ORAL LIQUID (ML) 500 0.12848 01/25/2013 MG/5ML CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR VIAL (EA) 10000 184.04000 07/12/2013 UNIT CICLOPIROX OLAMINE TOPICAL CREAM (GRAM) 0.77 % 0.14964 08/12/2014 CICLOPIROX OLAMINE TOPICAL SUSPENSION, TOPICAL (ML) 0.77 % 0.37748 01/25/2013 CICLOPIROX TOPICAL GEL (GRAM) 0.77 % 1.88253 04/18/2014 1.88253 08/21/2015 CICLOPIROX TOPICAL SHAMPOO 1 % 0.57510 01/25/2013 0.57510 08/21/2015 CICLOPIROX TOPICAL SOLUTION, NON-ORAL 8 % 2.81720 02/27/2015 2.81720 08/21/2015 CICLOPIROX/UREA/CAMPHOR/MENTHOL/EUCALYPTOL TOPICAL 266.99400 01/25/2013 SOLUTION, NON-ORAL 8 % CIDOFOVIR INTRAVENOUS VIAL (ML) 75 MG/ML 118.10400 08/12/2014 CILOSTAZOL ORAL TABLET 100 MG 0.13490 08/12/2014 0.13490 08/21/2015 CILOSTAZOL ORAL TABLET 50 MG 0.13853 02/27/2015 0.13853 08/21/2015 CIMETIDINE HCL ORAL SOLUTION, ORAL 300 MG/5ML 0.06283 05/17/2013 0.06283 08/21/2015 CIMETIDINE ORAL TABLET 200 MG 0.23684 08/12/2014 0.23684 08/21/2015 CIMETIDINE ORAL TABLET 300 MG 0.26286 04/10/2015 0.26286 08/21/2015 CIMETIDINE ORAL TABLET 400 MG 0.31057 08/21/2015 0.44250 08/24/2016 CIMETIDINE ORAL TABLET 800 MG 1.28479 04/10/2015 1.28479 08/21/2015 CIPROFLOXACIN HCL OPHTHALMIC DROPS 0.3 % 0.68876 11/21/2014 0.68876 08/21/2015 CIPROFLOXACIN HCL ORAL TABLET 100 MG 10.65167 09/26/2014 CIPROFLOXACIN HCL ORAL TABLET 250 MG 0.16174 02/06/2015 0.16174 08/21/2015 CIPROFLOXACIN HCL ORAL TABLET 500 MG 0.30924 08/21/2015 0.27578 09/30/2016 CIPROFLOXACIN HCL ORAL TABLET 750 MG 0.34599 02/06/2015 0.34599 08/21/2015 CIPROFLOXACIN HCL OTIC DROPPERETTE, SINGLE-USE DROP 12.61951 08/01/2014 DISPENSER 0.2 % CIPROFLOXACIN LACTATE INTRAVENOUS VIAL (ML) 200MG/20ML 0.08890 01/25/2013 CIPROFLOXACIN LACTATE INTRAVENOUS VIAL (ML) 400MG/40ML 0.06320 08/12/2014 CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.01697 01/25/2013 0.01697 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 200MG/0.1L CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.01204 03/01/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 400MG/0.2L CIPROFLOXACIN ORAL SUSPENSION, MICROCAPSULE RECONSTITUTED 0.85323 08/22/2014 250 MG/5ML CIPROFLOXACIN ORAL SUSPENSION, MICROCAPSULE RECONSTITUTED 0.99890 08/22/2014 500 MG/5ML West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CIPROFLOXACIN/CIPROFLOXACIN HCL ORAL TABLET,EXTENDED 7.79233 01/25/2013 7.79233 08/21/2015 RELEASE MULTIPHASE 24 HR 1000 MG CIPROFLOXACIN/CIPROFLOXACIN HCL ORAL TABLET,EXTENDED 6.85916 01/25/2013 6.85916 08/21/2015 RELEASE MULTIPHASE 24 HR 500 MG CISATRACURIUM BESYLATE INTRAVENOUS VIAL (ML) 10 MG/ML 11.95425 01/16/2015 11.95425 08/21/2015 CISATRACURIUM BESYLATE INTRAVENOUS VIAL (ML) 2 MG/ML 2.36880 08/12/2014 2.36880 08/21/2015 CITALOPRAM HYDROBROMIDE ORAL SOLUTION, ORAL 10 MG/5 ML 0.18230 01/25/2013 CITALOPRAM HYDROBROMIDE ORAL TABLET 10 MG 0.02661 05/01/2015 0.02661 08/21/2015 CITALOPRAM HYDROBROMIDE ORAL TABLET 20 MG 0.03382 03/06/2015 0.03382 08/21/2015 CITALOPRAM HYDROBROMIDE ORAL TABLET 40 MG 0.04139 03/06/2015 0.04139 08/21/2015 CITRATE PHOSPHATE DEXTROS SOLN MISCELLANEOUS SOLUTION, 0.08318 01/25/2013 NON-ORAL 2.63 G/100 CITRIC ACID/SODIUM CITRATE ORAL SOLUTION, ORAL 334-500MG 0.02013 11/14/2014 0.02013 08/21/2015 CLARITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 0.36569 05/17/2013 MG/5ML CLARITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 0.69628 02/07/2014 0.69628 08/21/2015 MG/5ML CLARITHROMYCIN ORAL TABLET 250 MG 2.64794 05/30/2014 2.64794 08/21/2015 CLARITHROMYCIN ORAL TABLET 500 MG 1.02599 09/30/2016 0.87519 01/13/2017 CLARITHROMYCIN ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 3.50443 08/12/2014 3.50443 08/21/2015 CLINDAMYCIN HCL ORAL CAPSULE 150 MG 0.08641 05/01/2015 0.08641 08/21/2015 CLINDAMYCIN HCL ORAL CAPSULE 300 MG 0.25661 03/06/2015 0.25661 08/21/2015 CLINDAMYCIN HCL ORAL CAPSULE 75 MG 0.41720 01/25/2013 CLINDAMYCIN PALMITATE HCL ORAL SOLUTION, RECONSTITUTED, 0.35170 03/25/2016 0.29126 05/20/2016 ORAL 75 MG/5 ML CLINDAMYCIN PHOSPHATE INJECTION VIAL (ML) 150 MG/ML 0.35600 08/12/2014 CLINDAMYCIN PHOSPHATE INTRAVENOUS VIAL WITH THREADED PORT 2.99418 01/25/2013 (ML) 300 MG/2ML CLINDAMYCIN PHOSPHATE INTRAVENOUS VIAL WITH THREADED PORT 1.60881 01/25/2013 (ML) 600 MG/4ML CLINDAMYCIN PHOSPHATE INTRAVENOUS VIAL WITH THREADED PORT 1.51899 01/25/2013 (ML) 900MG/6ML CLINDAMYCIN PHOSPHATE TOPICAL FOAM (GRAM) 1 % 3.71476 04/03/2015 3.71476 08/21/2015 CLINDAMYCIN PHOSPHATE TOPICAL LOTION (ML) 1 % 1.35558 01/30/2015 1.27719 10/28/2016 CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION, NON-ORAL 1 % 0.80190 09/30/2016 0.73057 10/28/2016 CLINDAMYCIN PHOSPHATE TOPICAL SWAB, MEDICATED 1 % 0.38856 08/21/2015 0.26373 05/20/2016 CLINDAMYCIN PHOSPHATE VAGINAL CREAM WITH APPLICATOR 2 % 1.72201 07/04/2014 1.72201 08/21/2015 CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE TOPICAL GEL (GRAM) 1 3.76643 08/12/2014 3.76643 08/21/2015 %-5 % CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE TOPICAL GEL (GRAM) 3.16462 08/12/2014 1.2(1)%-5% CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.11749 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 300MG/50ML CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.16505 11/07/2014 0.16505 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 600MG/50ML CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.21492 10/24/2014 0.21492 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 900MG/50ML CLOBETASOL PROPIONATE TOPICAL CREAM (GRAM) 0.05 % 3.30786 07/08/2016 2.63962 12/02/2016 CLOBETASOL PROPIONATE TOPICAL FOAM (GRAM) 0.05 % 4.69223 02/14/2014 4.69223 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CLOBETASOL PROPIONATE TOPICAL GEL (GRAM) 0.05 % 4.56000 07/08/2016 3.57276 12/02/2016 CLOBETASOL PROPIONATE TOPICAL LOTION (ML) 0.05 % 3.84385 04/03/2015 CLOBETASOL PROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 4.85100 08/21/2015 3.93135 12/02/2016 CLOBETASOL PROPIONATE TOPICAL SHAMPOO 0.05 % 2.36951 12/05/2014 CLOBETASOL PROPIONATE TOPICAL SOLUTION, NON-ORAL 0.05 % 1.21343 07/08/2016 2.39520 10/21/2016 CLOBETASOL PROPIONATE TOPICAL SPRAY, NON-AEROSOL (ML) 0.05 % 4.33264 03/06/2015 CLOBETASOL PROPIONATE/EMOLLIENT BASE TOPICAL CREAM (GRAM) 2.38513 02/27/2015 0.05 % CLOBETASOL PROPIONATE/EMOLLIENT BASE TOPICAL FOAM (GRAM) 3.64100 08/12/2014 3.64100 08/21/2015 0.05 % CLOCORTOLONE PIVALATE TOPICAL CREAM (GRAM) 0.1 % 5.01620 03/07/2014 CLOMIPHENE CITRATE ORAL TABLET 50 MG 1.01394 08/12/2014 1.01394 08/21/2015 CLOMIPRAMINE HCL ORAL CAPSULE 25 MG 7.86937 08/21/2015 7.57615 12/02/2016 CLOMIPRAMINE HCL ORAL CAPSULE 50 MG 8.39154 08/21/2015 7.62005 11/20/2015 CLOMIPRAMINE HCL ORAL CAPSULE 75 MG 7.86940 08/21/2015 7.63578 05/20/2016 CLONAZEPAM ORAL TABLET 0.5 MG 0.01635 12/12/2014 0.01635 08/21/2015 CLONAZEPAM ORAL TABLET 1 MG 0.02613 02/06/2015 0.02613 08/21/2015 CLONAZEPAM ORAL TABLET 2 MG 0.04039 02/13/2015 0.04039 08/21/2015 CLONAZEPAM ORAL TABLET,DISINTEGRATING 0.125 MG 0.72847 09/19/2014 CLONAZEPAM ORAL TABLET,DISINTEGRATING 0.25 MG 0.70041 10/31/2014 CLONAZEPAM ORAL TABLET,DISINTEGRATING 0.5 MG 0.72116 08/22/2014 CLONAZEPAM ORAL TABLET,DISINTEGRATING 1 MG 0.89189 05/02/2014 CLONAZEPAM ORAL TABLET,DISINTEGRATING 2 MG 1.09330 01/25/2013 CLONIDINE HCL ORAL TABLET 0.1 MG 0.02704 02/20/2015 0.02704 08/21/2015 CLONIDINE HCL ORAL TABLET 0.2 MG 0.05338 01/16/2015 0.05338 08/21/2015 CLONIDINE HCL ORAL TABLET 0.3 MG 0.04301 01/16/2015 0.04301 08/21/2015 CLONIDINE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 0.1 MG 3.14977 12/12/2014 3.14977 08/21/2015 CLONIDINE HCL/PF EPIDURAL VIAL (ML) 1000MCG/10 2.29944 08/12/2014 CLONIDINE HCL/PF EPIDURAL VIAL (ML) 5000MCG/10 10.09700 08/12/2014 10.09700 08/21/2015 CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 23.19800 08/21/2015 17.56000 07/08/2016 0.1MG/24HR CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 39.03550 03/27/2015 39.03550 08/21/2015 0.2MG/24HR CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 54.16732 08/21/2015 39.66250 07/08/2016 0.3MG/24HR CLOPIDOGREL BISULFATE ORAL TABLET 300 MG 14.71960 04/17/2015 14.71960 08/21/2015 CLOPIDOGREL BISULFATE ORAL TABLET 75 MG 0.17416 03/25/2016 0.13839 09/30/2016 CLORAZEPATE DIPOTASSIUM ORAL TABLET 15 MG 0.26100 08/21/2015 2.39650 09/19/2016 CLORAZEPATE DIPOTASSIUM ORAL TABLET 3.75 MG 0.19698 08/15/2014 0.19698 08/21/2015 CLORAZEPATE DIPOTASSIUM ORAL TABLET 7.5 MG 0.30128 08/01/2014 0.30128 08/21/2015 CLOTRIMAZOLE MUCOUS MEMBRANE TROCHE 10 MG 0.97392 03/27/2015 CLOTRIMAZOLE TOPICAL CREAM (GRAM) 1 % 0.10907 03/20/2015 0.10907 08/21/2015 CLOTRIMAZOLE TOPICAL SOLUTION, NON-ORAL 1 % 0.32656 01/25/2013 CLOTRIMAZOLE VAGINAL CREAM WITH APPLICATOR 1 % 0.07865 03/01/2013 0.07865 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CLOTRIMAZOLE VAGINAL CREAM WITH APPLICATOR 2 % 0.32760 08/12/2014 0.32760 08/21/2015 CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE TOPICAL CREAM 1.07298 08/21/2015 0.72774 07/08/2016 (GRAM) 1 %-0.05 % CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE TOPICAL LOTION 3.46640 05/31/2013 (ML) 1 %-0.05 % CLOZAPINE ORAL TABLET 100 MG 0.95728 09/25/2015 0.68280 05/20/2016 CLOZAPINE ORAL TABLET 200 MG 2.44224 05/20/2016 2.22336 09/30/2016 CLOZAPINE ORAL TABLET 25 MG 0.49908 09/25/2015 0.43036 05/20/2016 CLOZAPINE ORAL TABLET 50 MG 1.15500 04/04/2014 0.83358 05/20/2016 CLOZAPINE ORAL TABLET,DISINTEGRATING 100 MG 5.72222 02/15/2013 CLOZAPINE ORAL TABLET,DISINTEGRATING 12.5 MG 1.55925 01/25/2013 CLOZAPINE ORAL TABLET,DISINTEGRATING 25 MG 2.09823 01/25/2013 COAL TAR TOPICAL SHAMPOO 1 % 0.03020 08/12/2014 COCAINE HCL TOPICAL SOLUTION, NON-ORAL 4 % 15.19980 01/25/2013 CODEINE PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE ORAL CAPSULE 1.89262 02/21/2014 1.89262 08/21/2015 30-50-325 CODEINE PHOSPHATE/GUAIFENESIN ORAL LIQUID (ML) 10-100MG/5 0.05079 01/30/2015 0.05079 08/21/2015 CODEINE PHOSPHATE/GUAIFENESIN ORAL LIQUID (ML) 6.3-100/5 0.03518 08/12/2014 CODEINE PHOSPHATE/GUAIFENESIN ORAL LIQUID (ML) 7.5-225/5 0.04970 08/12/2014 CODEINE SULFATE ORAL TABLET 15 MG 0.36736 03/01/2013 CODEINE SULFATE ORAL TABLET 30 MG 0.44059 09/19/2014 0.44059 08/21/2015 CODEINE SULFATE ORAL TABLET 60 MG 0.79681 09/19/2014 0.79681 08/21/2015 COLCHICINE ORAL CAPSULE 0.6 MG 4.31599 03/20/2015 COLCHICINE ORAL TABLET 0.6 MG 4.11439 03/20/2015 4.71520 07/29/2015 COLESTIPOL HCL ORAL GRANULES (GRAM) 5 G 0.20871 01/25/2013 COLESTIPOL HCL ORAL PACKET (EA) 5 G 2.75100 01/16/2015 COLESTIPOL HCL ORAL TABLET 1 G 0.86640 02/27/2015 COLISTIN (AS COLISTIMETHATE SODIUM) INJECTION VIAL (EA) 150 MG 12.66880 02/27/2015 CORTISONE ACETATE ORAL TABLET 25 MG 3.04785 02/20/2015 3.04785 08/21/2015 COSYNTROPIN INJECTION VIAL (EA) 0.25 MG 64.39973 04/19/2013 64.39973 08/21/2015 COSYNTROPIN VIAL (ML) 0.25 MG/ML 151.55280 01/25/2013 CROMOLYN SODIUM INHALATION AMPUL FOR NEBULIZATION (ML) 20 1.16380 10/03/2014 MG/2 ML CROMOLYN SODIUM NASAL AEROSOL, SPRAY WITH PUMP (ML) 5.2 MG 0.33554 01/25/2013 0.33554 08/21/2015 CROMOLYN SODIUM OPHTHALMIC DROPS 4 % 0.67817 08/21/2015 0.46600 09/30/2016 CROMOLYN SODIUM ORAL CONCENTRATE, ORAL 20 MG/ML 0.87906 12/19/2014 0.87906 08/21/2015 CUPRIC CHLORIDE INTRAVENOUS VIAL (ML) 0.4 MG/ML 0.15460 08/12/2014 CYANOCOBALAMIN (VITAMIN B-12) ORAL TABLET 100 MCG 0.01365 02/13/2015 0.01365 08/21/2015 CYANOCOBALAMIN (VITAMIN B-12) ORAL TABLET 500 MCG 0.02101 02/13/2015 0.02101 08/21/2015 CYANOCOBALAMIN (VITAMIN B-12) ORAL TABLET, EXTENDED RELEASE 0.03872 08/12/2014 0.03872 08/21/2015 1000 MCG CYANOCOBALAMIN (VITAMIN B-12) SUBLINGUAL TABLET, SUBLINGUAL 0.05332 08/12/2014 0.05332 08/21/2015 1000 MCG CYANOCOBALAMIN (VITAMIN B-12) SUBLINGUAL TABLET, SUBLINGUAL 0.10737 03/08/2013 5000 MCG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date CYANOCOBALAMIN/FOLIC ACID ORAL TABLET 0.5 MG-1MG 0.12600 01/25/2013 CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE ORAL TABLET 2-2.5-25MG 0.43177 03/20/2015 0.43177 08/21/2015 CYANOCOBALAMIN/LEVOMEFOLATE CALCIUM/PYRIDOXINE HCL (B6) 0.89950 07/18/2014 ORAL TABLET 2-1.13-25 CYANOCOBALAMIN/LEVOMEFOLATE CALCIUM/PYRIDOXINE/RIBOFLAVIN 2.02075 02/20/2015 2.02075 08/21/2015 ORAL TABLET 1-6-50-5MG CYCLOBENZAPRINE HCL ORAL TABLET 10 MG 0.02680 02/20/2015 0.02680 08/21/2015 CYCLOBENZAPRINE HCL ORAL TABLET 5 MG 0.04576 04/24/2015 0.04576 08/21/2015 CYCLOBENZAPRINE HCL ORAL TABLET 7.5 MG 3.36504 04/17/2015 3.36504 08/21/2015 CYCLOPENTOLATE HCL OPHTHALMIC DROPS 1 % 1.65266 05/10/2013 1.65266 08/21/2015 CYCLOPENTOLATE HCL OPHTHALMIC DROPS 2 % 3.33840 02/08/2013 CYCLOPHOSPHAMIDE INTRAVENOUS VIAL (EA) 1 G 432.93460 12/12/2014 CYCLOPHOSPHAMIDE INTRAVENOUS VIAL (EA) 2 G 1063.88300 12/12/2014 1063.88300 08/21/2015 CYCLOPHOSPHAMIDE INTRAVENOUS VIAL (EA) 500 MG 266.22500 12/12/2014 266.22500 08/21/2015 CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG 8.29164 09/05/2014 CYCLOSPORINE ORAL CAPSULE 100 MG 5.25882 05/23/2014 CYCLOSPORINE ORAL CAPSULE 25 MG 1.60115 11/07/2014 CYCLOSPORINE, MODIFIED ORAL CAPSULE 100 MG 2.20106 02/27/2015 CYCLOSPORINE, MODIFIED ORAL CAPSULE 25 MG 0.71297 02/26/2016 0.51042 05/20/2016 CYCLOSPORINE, MODIFIED ORAL CAPSULE 50 MG 1.20163 07/25/2014 CYCLOSPORINE, MODIFIED ORAL SOLUTION, ORAL 100 MG/ML 2.51316 05/02/2014 2.51316 08/21/2015 CYPROHEPTADINE HCL ORAL SYRUP 2 MG/5 ML 0.08798 02/27/2015 CYPROHEPTADINE HCL ORAL TABLET 4 MG 0.59169 04/22/2016 0.44179 05/20/2016 CYTARABINE INJECTION VIAL (ML) 20 MG/ML 0.40080 08/12/2014 0.40080 08/21/2015 CYTARABINE/PF INJECTION VIAL (ML) 100 MG/5ML 1.97106 01/25/2013 1.97106 08/21/2015 CYTARABINE/PF INJECTION VIAL (ML) 2 G/20 ML 0.82997 08/12/2014 0.82997 08/21/2015 CYTARABINE/PF INJECTION VIAL (ML) 20 MG/ML 0.76440 01/16/2015 0.76440 08/21/2015 DACARBAZINE INTRAVENOUS VIAL (EA) 100 MG 7.93800 01/25/2013 DANAZOL ORAL CAPSULE 100 MG 3.38527 02/13/2015 DANAZOL ORAL CAPSULE 200 MG 4.80198 03/20/2015 4.80198 08/21/2015 DANAZOL ORAL CAPSULE 50 MG 2.25628 02/13/2015 DANTROLENE SODIUM INTRAVENOUS VIAL (EA) 20 MG 68.04000 01/25/2013 DANTROLENE SODIUM ORAL CAPSULE 100 MG 1.51750 02/08/2013 DANTROLENE SODIUM ORAL CAPSULE 25 MG 0.74851 04/26/2013 0.74851 08/21/2015 DANTROLENE SODIUM ORAL CAPSULE 50 MG 1.21009 03/22/2013 DAPSONE ORAL TABLET 100 MG 0.91000 01/25/2013 1.08520 03/25/2016 DAUNORUBICIN HCL INTRAVENOUS VIAL (ML) 5 MG/ML 18.76077 08/12/2014 18.76077 08/21/2015 DECITABINE INTRAVENOUS VIAL (EA) 50 MG 1375.39150 12/12/2014 1375.39150 08/21/2015 DEFEROXAMINE MESYLATE INJECTION VIAL (EA) 2 G 26.33481 01/25/2013 26.33481 08/21/2015 DEMECLOCYCLINE HCL ORAL TABLET 150 MG 4.14750 05/16/2014 DEMECLOCYCLINE HCL ORAL TABLET 300 MG 7.13944 02/27/2015 7.13944 08/21/2015 DESIPRAMINE HCL ORAL TABLET 10 MG 0.82894 08/12/2014 0.82894 08/21/2015 DESIPRAMINE HCL ORAL TABLET 100 MG 2.97528 08/12/2014 2.97528 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DESIPRAMINE HCL ORAL TABLET 150 MG 4.38839 08/12/2014 DESIPRAMINE HCL ORAL TABLET 25 MG 0.96739 08/12/2014 0.96739 08/21/2015 DESIPRAMINE HCL ORAL TABLET 50 MG 1.83308 08/12/2014 1.83308 08/21/2015 DESIPRAMINE HCL ORAL TABLET 75 MG 2.22992 08/12/2014 DESLORATADINE ORAL TABLET 5 MG 0.93311 08/21/2015 0.57268 11/20/2015 DESLORATADINE ORAL TABLET,DISINTEGRATING 2.5 MG 10.07649 01/24/2014 10.07649 08/21/2015 DESLORATADINE ORAL TABLET,DISINTEGRATING 5 MG 4.07750 01/25/2013 4.07750 08/21/2015 DESMOPRESSIN ACETATE (NON-REFRIGERATED) NASAL AEROSOL, 14.65571 10/28/2016 19.95000 11/02/2016 SPRAY WITH PUMP (ML) 10/SPRAY DESMOPRESSIN ACETATE INJECTION AMPUL (ML) 4 MCG/ML 16.22800 08/30/2013 DESMOPRESSIN ACETATE INJECTION VIAL (ML) 4 MCG/ML 8.62810 05/16/2014 DESMOPRESSIN ACETATE NASAL AEROSOL, SPRAY WITH PUMP (ML) 28.62300 02/06/2015 10/SPRAY DESMOPRESSIN ACETATE NASAL SOLUTION, NON-ORAL 0.1 MG/ML 25.31760 03/08/2013 DESMOPRESSIN ACETATE ORAL TABLET 0.1 MG 1.43956 08/21/2015 0.92971 05/20/2016 DESMOPRESSIN ACETATE ORAL TABLET 0.2 MG 1.03270 04/22/2016 0.72125 01/13/2017 DESOGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.15-0.03 0.62830 01/10/2014 0.42000 10/28/2016 DESOGESTREL-ETHINYL ESTRADIOL ORAL TABLET 7 DAYS X 3 0.81931 10/03/2014 0.81931 08/21/2015 DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL ORAL 0.99160 04/24/2015 0.99160 08/21/2015 TABLET 21-5 DESONIDE TOPICAL CREAM (GRAM) 0.05 % 3.74663 08/21/2015 2.98517 07/08/2016 DESONIDE TOPICAL LOTION (ML) 0.05 % 1.83560 12/05/2014 DESONIDE TOPICAL OINTMENT (GRAM) 0.05 % 2.80467 01/31/2014 DESOXIMETASONE TOPICAL CREAM (GRAM) 0.05 % 3.19548 02/07/2014 DESOXIMETASONE TOPICAL CREAM (GRAM) 0.25 % 1.09076 02/07/2014 1.09076 08/21/2015 DESOXIMETASONE TOPICAL GEL (GRAM) 0.05 % 2.73169 01/25/2013 DESOXIMETASONE TOPICAL OINTMENT (GRAM) 0.05 % 5.41981 02/07/2014 5.41981 08/21/2015 DESOXIMETASONE TOPICAL OINTMENT (GRAM) 0.25 % 4.23663 05/01/2015 4.23663 08/21/2015 DESVENLAFAXINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 4.64370 04/04/2014 HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 4.64370 04/04/2014 HR 50 MG DEXAMETHASONE ORAL ELIXIR 0.5 MG/5ML 0.17085 09/26/2014 DEXAMETHASONE ORAL SOLUTION, ORAL 0.5 MG/5ML 0.03446 08/22/2014 DEXAMETHASONE ORAL TABLET 1.5 MG 0.09841 02/07/2014 0.09841 08/21/2015 DEXAMETHASONE ORAL TABLET 4 MG 0.10036 08/21/2015 DEXAMETHASONE SOD PHOSPHATE INJECTION VIAL (ML) 10 MG/ML 0.80490 08/12/2014 0.80490 08/21/2015 DEXAMETHASONE SOD PHOSPHATE INJECTION VIAL (ML) 4 MG/ML 0.28517 08/12/2014 0.28517 08/21/2015 DEXAMETHASONE SOD PHOSPHATE OPHTHALMIC DROPS 0.1 % 3.31265 11/01/2013 3.31265 08/21/2015 DEXAMETHASONE SODIUM PHOSPHATE/PF INJECTION VIAL (ML) 10 6.35376 01/25/2013 MG/ML DEXCHLORPHENIRAMINE 0.08050 08/12/2014 MALEATE/PSEUDOEPHEDRINE/CHLOPHEDIANOL ORAL LIQUID (ML) 1-30- 12.5 DEXMETHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 6.50059 03/27/2015 5.84742 12/02/2016 BIPHASIC 50-50 10 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DEXMETHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 5.46315 03/27/2015 BIPHASIC 50-50 5 MG DEXMETHYLPHENIDATE HCL ORAL TABLET 10 MG 0.98000 04/22/2016 0.77890 09/30/2016 DEXMETHYLPHENIDATE HCL ORAL TABLET 2.5 MG 0.94880 04/22/2016 0.47427 12/02/2016 DEXMETHYLPHENIDATE HCL ORAL TABLET 5 MG 0.68159 08/21/2015 0.68159 04/22/2016 DEXRAZOXANE HCL INTRAVENOUS VIAL (EA) 250 MG 165.25050 01/16/2015 DEXRAZOXANE HCL INTRAVENOUS VIAL (EA) 500 MG 286.43625 01/16/2015 DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 4.38388 04/22/2016 3.43015 07/08/2016 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 10 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 4.59455 04/22/2016 3.48365 07/08/2016 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 15 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 3.65640 07/08/2016 3.22969 12/02/2016 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 20 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 4.38928 04/22/2016 3.72080 07/08/2016 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 25 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 4.63862 04/22/2016 3.66664 12/02/2016 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 30 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 4.73708 04/22/2016 3.82332 07/08/2016 ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 5 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.65286 12/25/2015 0.58240 12/02/2016 ASPARTATE ORAL TABLET 10 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.86938 09/30/2016 0.62385 12/02/2016 ASPARTATE ORAL TABLET 12.5 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.83226 09/30/2016 0.61490 12/02/2016 ASPARTATE ORAL TABLET 15 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.55528 05/20/2016 0.30148 01/27/2017 ASPARTATE ORAL TABLET 20 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.80324 08/21/2015 0.62958 05/20/2016 ASPARTATE ORAL TABLET 30 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.66200 10/28/2016 0.58240 12/02/2016 ASPARTATE ORAL TABLET 5 MG DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF- 0.97162 08/21/2015 0.69359 12/02/2016 ASPARTATE ORAL TABLET 7.5 MG DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 3.48697 12/02/2016 3.48697 01/01/2017 10 MG DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 4.26695 12/02/2016 4.26695 01/01/2017 15 MG DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 2.62825 05/19/2016 2.62825 01/01/2017 5 MG DEXTROAMPHETAMINE SULFATE ORAL SOLUTION, ORAL 5 MG/5 ML 1.27716 01/24/2014 1.27716 08/21/2015 DEXTROAMPHETAMINE SULFATE ORAL TABLET 10 MG 1.49211 02/26/2016 1.35258 07/29/2016 DEXTROAMPHETAMINE SULFATE ORAL TABLET 5 MG 1.66977 08/21/2015 1.12949 12/02/2016 DEXTROMETHORPHAN HBR/ACETAMINOPHEN/DOXYLAMINE ORAL 0.01469 08/22/2014 0.01469 08/21/2015 LIQUID (ML) 15-325/15 DEXTROMETHORPHAN HBR/PHENYLEPHRINE 0.05168 08/12/2014 0.05168 08/21/2015 HCL/DEXBROMPHENIRAMINE ORAL SYRUP 20-10-2/5 DEXTROMETHORPHAN POLISTIREX ORAL SUSPENSION, EXTENDED 0.08530 03/20/2015 0.08530 08/21/2015 RELEASE 12 HR 30 MG/5 ML DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS DEHP- 0.04179 01/25/2013 FREE BAG, INJECTION (ML) 10 %-0.2 % DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS 0.03704 01/25/2013 INTRAVENOUS SOLUTION 10 %-0.2 % West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DEXTROSE 10 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.01077 01/25/2013 INTRAVENOUS SOLUTION 10%-0.45% DEXTROSE 10 % IN WATER INTRAVENOUS DEHP-FREE BAG, INJECTION 0.00819 01/25/2013 (ML) 10 % DEXTROSE 10 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 10 0.00207 04/05/2013 % DEXTROSE 2.5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.00250 08/12/2014 0.00250 08/21/2015 INTRAVENOUS SOLUTION 2.5%-0.45% DEXTROSE 20 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 20 0.00864 01/25/2013 % DEXTROSE 25 % IN WATER INTRAVENOUS SYRINGE (ML) 25 % 0.38140 08/12/2014 DEXTROSE 30 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 30 0.00877 01/25/2013 0.00877 08/21/2015 % DEXTROSE 40 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 40 0.00870 08/12/2014 % DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS 0.00228 01/25/2013 INTRAVENOUS SOLUTION 5 %-0.2 % DEXTROSE 5 % AND 0.3 % SODIUM CHLORIDE INTRAVENOUS 0.00230 01/25/2013 INTRAVENOUS SOLUTION 5 %-0.3 % DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.00181 08/22/2014 0.00181 08/21/2015 INTRAVENOUS SOLUTION 5 %-0.45 % DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS 0.00274 01/09/2015 0.00274 08/21/2015 INTRAVENOUS SOLUTION 5 %-0.9 % DEXTROSE 5 % IN LACTATED RINGERS INTRAVENOUS INTRAVENOUS 0.00214 01/25/2013 SOLUTION 5 % DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.00275 07/25/2014 0.00275 08/21/2015 DEXTROSE 5 % IN WATER INTRAVENOUS PIGGYBACK WITH THREADED 0.02997 01/30/2015 0.02997 08/21/2015 PORT (ML) DEXTROSE 5 % IN WATER INTRAVENOUS PIGGYBACK WITH VIAL PORT 0.07096 01/25/2013 (NON-THREADED) DEXTROSE 5 % IN WATER INTRAVENOUS VIAL (ML) 5 % 0.53214 01/25/2013 DEXTROSE 50 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 50 0.00630 01/25/2013 0.00630 08/21/2015 % DEXTROSE 50 % IN WATER INTRAVENOUS SYRINGE (ML) 50 % 0.09475 04/05/2013 0.09475 08/21/2015 DEXTROSE 50 % IN WATER INTRAVENOUS VIAL (ML) 50 % 0.02540 08/12/2014 DEXTROSE 70 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 70 0.00532 04/19/2013 0.00532 08/21/2015 % DEXTROSE ORAL SOLUTION, ORAL 5 % 0.01679 01/16/2015 0.01679 08/21/2015 DIAZEPAM INJECTION SYRINGE (ML) 5 MG/ML 3.71280 01/25/2013 DIAZEPAM INJECTION VIAL (ML) 5 MG/ML 1.36920 07/12/2013 DIAZEPAM ORAL CONCENTRATE, ORAL 5 MG/ML 1.83609 01/16/2015 DIAZEPAM ORAL SOLUTION, ORAL 5 MG/5 ML 0.10010 05/09/2014 DIAZEPAM ORAL TABLET 10 MG 0.02396 09/19/2014 0.02396 08/21/2015 DIAZEPAM ORAL TABLET 2 MG 0.02372 04/17/2015 0.02372 08/21/2015 DIAZEPAM ORAL TABLET 5 MG 0.02230 01/23/2015 0.02230 08/21/2015 DIAZEPAM RECTAL KIT 12.5-15-20 234.84300 01/30/2015 DIAZEPAM RECTAL KIT 2.5 MG 197.11300 08/22/2014 DIAZEPAM RECTAL KIT 5-7.5-10MG 233.82800 07/05/2013 DICLOFENAC POTASSIUM ORAL TABLET 50 MG 0.64537 03/20/2015 0.64537 08/21/2015 DICLOFENAC SODIUM OPHTHALMIC DROPS 0.1 % 1.02376 05/02/2014 1.02376 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.99526 03/28/2014 COATED) 25 MG DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.18491 08/21/2015 0.23521 10/02/2015 COATED) 50 MG DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.20100 08/21/2015 0.16490 12/02/2016 COATED) 75 MG DICLOFENAC SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 100 0.51590 08/21/2015 0.38877 09/30/2016 MG DICLOFENAC SODIUM TOPICAL DROPS 1.5 % 1.21660 04/17/2015 1.21660 08/21/2015 DICLOFENAC SODIUM TOPICAL GEL (GRAM) 3 % 9.08250 02/13/2015 8.16004 12/02/2016 DICLOFENAC SODIUM/MISOPROSTOL ORAL TABLET,IMMEDIATE,DELAY 2.34693 12/05/2014 2.34693 08/21/2015 RELEASE,BIPHASE 50 MG-200 DICLOFENAC SODIUM/MISOPROSTOL ORAL TABLET,IMMEDIATE,DELAY 2.34698 12/05/2014 2.34698 08/21/2015 RELEASE,BIPHASE 75 MG-200 DICLOXACILLIN SODIUM ORAL CAPSULE 250 MG 0.33183 09/26/2014 0.33183 08/21/2015 DICLOXACILLIN SODIUM ORAL CAPSULE 500 MG 0.67080 09/26/2014 0.67080 08/21/2015 DICYCLOMINE HCL ORAL CAPSULE 10 MG 0.04277 01/30/2015 0.04277 08/21/2015 DICYCLOMINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.21028 04/03/2015 DICYCLOMINE HCL ORAL TABLET 20 MG 0.05574 04/03/2015 0.05574 08/21/2015 DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 2.70223 01/25/2013 125 MG DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 4.32270 02/08/2013 200 MG DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 5.50853 01/25/2013 250 MG DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 8.60350 02/08/2013 400 MG DIETHYLPROPION HCL ORAL TABLET 25 MG 0.23090 08/12/2014 0.23090 08/21/2015 DIETHYLPROPION HCL ORAL TABLET, EXTENDED RELEASE 75 MG 0.88524 08/22/2014 0.88524 08/21/2015 DIFLORASONE DIACETATE TOPICAL CREAM (GRAM) 0.05 % 3.29067 08/21/2015 DIFLORASONE DIACETATE TOPICAL OINTMENT (GRAM) 0.05 % 2.47670 08/12/2014 2.47670 08/21/2015 DIFLUNISAL ORAL TABLET 500 MG 1.18611 05/17/2013 1.18611 08/21/2015 DIGOXIN INJECTION SYRINGE (ML) 250 MCG/ML 1.58760 01/25/2013 DIGOXIN ORAL SOLUTION, ORAL 50 MCG/ML 0.56138 04/17/2015 DIGOXIN ORAL TABLET 125 MCG 0.80896 07/29/2016 0.60532 09/30/2016 DIGOXIN ORAL TABLET 250 MCG 1.04650 08/21/2015 0.79130 05/20/2016 DIHYDROERGOTAMINE MESYLATE INJECTION AMPUL (ML) 1 MG/ML 104.81800 03/13/2015 DIHYDROERGOTAMINE MESYLATE INJECTION VIAL (ML) 1 MG/ML 37.55430 01/25/2013 DIHYDROERGOTAMINE MESYLATE NASAL AEROSOL, SPRAY WITH 262.70038 12/19/2014 PUMP (ML) 0.5MG/SPRY DILTIAZEM HCL INTRAVENOUS VIAL WITH THREADED PORT (EA) 100 MG 14.71680 01/25/2013 DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 120 MG 0.31101 02/13/2015 0.31101 08/21/2015 DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 180 MG 0.34438 02/13/2015 0.34438 08/21/2015 DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 240 MG 0.52087 04/22/2016 0.47111 09/30/2016 DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 300 MG 0.71100 08/21/2015 0.54900 05/20/2016 DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 360 MG 6.87758 08/21/2015 4.21227 12/02/2016 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 60 MG 1.97040 04/10/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 90 MG 1.05763 05/16/2014 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 120 MG 0.31426 04/10/2015 0.31426 08/21/2015 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 180 MG 0.52372 09/26/2014 0.52372 08/21/2015 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 240 MG 0.60683 04/10/2015 0.60683 08/21/2015 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 300 MG 1.39010 08/21/2015 0.89878 12/02/2016 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 360 MG 0.83909 08/21/2015 0.65333 05/20/2016 DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 420 MG 1.64743 08/21/2015 1.49711 09/30/2016 DILTIAZEM HCL ORAL CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.55010 08/21/2015 0.44907 09/30/2016 120 MG DILTIAZEM HCL ORAL CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.58869 10/24/2014 0.58869 08/21/2015 180 MG DILTIAZEM HCL ORAL CAPSULE, EXTENDED-RELEASE DEGRADABLE 0.64130 08/21/2015 0.50600 01/13/2017 240 MG DILTIAZEM HCL ORAL TABLET 120 MG 0.34606 04/10/2015 DILTIAZEM HCL ORAL TABLET 30 MG 0.09900 04/10/2015 0.09900 08/21/2015 DILTIAZEM HCL ORAL TABLET 60 MG 0.17230 08/21/2015 0.21057 04/28/2016 DILTIAZEM HCL ORAL TABLET 90 MG 0.26263 04/10/2015 0.26263 08/21/2015 DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 180 MG 2.04560 02/27/2015 2.04560 08/21/2015 DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 240 MG 2.33427 11/14/2014 2.33427 08/21/2015 DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 2.97603 12/19/2014 2.97603 08/21/2015 DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 360 MG 3.26737 08/12/2014 DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 420 MG 3.54216 03/21/2014 DILUENT FOR EPOPROSTENOL SODIUM (GLYCINE) INTRAVENOUS VIAL 0.14700 01/25/2013 (ML) DIMENHYDRINATE INJECTION VIAL (ML) 50 MG/ML 4.98960 01/25/2013 DIMENHYDRINATE ORAL TABLET 50 MG 0.01809 01/25/2013 0.01809 08/21/2015 DIMETHICONE TOPICAL CREAM (ML) 5 % 0.03918 04/10/2015 0.03918 08/21/2015 DIMETHICONE TOPICAL SPRAY, NON-AEROSOL (ML) 2 % 0.03000 08/12/2014 DIPHENHYDRAMINE HCL ORAL CAPSULE 25 MG 0.03163 03/06/2015 0.03163 08/21/2015 DIPHENHYDRAMINE HCL ORAL CAPSULE 50 MG 0.17282 08/21/2015 DIPHENHYDRAMINE HCL ORAL CAPSULE 50 MG 0.01743 08/12/2014 0.01743 08/21/2015 DIPHENHYDRAMINE HCL ORAL ELIXIR 12.5MG/5ML 0.00512 01/25/2013 0.00512 08/21/2015 DIPHENHYDRAMINE HCL ORAL LIQUID (ML) 12.5MG/5ML 0.00578 01/16/2015 0.00578 08/21/2015 DIPHENHYDRAMINE HCL ORAL SYRUP 12.5MG/5ML 0.01260 08/12/2014 DIPHENHYDRAMINE HCL ORAL TABLET 25 MG 0.02104 02/06/2015 0.02104 08/21/2015 DIPHENOXYLATE HCL/ATROPINE SULFATE ORAL LIQUID (ML) 2.5-.025/5 0.10803 01/25/2013 DIPHENOXYLATE HCL/ATROPINE SULFATE ORAL TABLET 2.5-.025MG 0.37451 03/27/2015 0.37451 08/21/2015 DIPYRIDAMOLE ORAL TABLET 25 MG 0.05708 02/13/2015 0.05708 08/21/2015 DIPYRIDAMOLE ORAL TABLET 50 MG 0.10810 08/12/2014 0.10810 08/21/2015 DIPYRIDAMOLE ORAL TABLET 75 MG 0.13680 08/12/2014 0.13680 08/21/2015 DISOPYRAMIDE PHOSPHATE ORAL CAPSULE 100 MG 0.34801 05/01/2015 0.34801 08/21/2015 DISOPYRAMIDE PHOSPHATE ORAL CAPSULE 150 MG 0.35458 08/21/2015 DISULFIRAM ORAL TABLET 250 MG 1.08598 07/08/2016 2.09520 09/19/2016 DISULFIRAM ORAL TABLET 500 MG 4.39894 08/21/2015 1.14667 09/30/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DIVALPROEX SODIUM ORAL CAPSULE, SPRINKLE 125 MG 0.68726 08/21/2015 0.58963 12/02/2016 DIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.05896 04/10/2015 0.05896 08/21/2015 COATED) 125 MG DIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.10366 03/20/2015 0.10366 08/21/2015 COATED) 250 MG DIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.20034 04/24/2015 0.20034 08/21/2015 COATED) 500 MG DIVALPROEX SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 250 1.32927 09/25/2015 0.86864 05/20/2016 MG DIVALPROEX SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 500 0.86270 01/13/2017 0.66382 01/27/2017 MG DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.08730 08/12/2014 INTRAVENOUS SOLUTION 1000MG/250 DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.04960 08/12/2014 INTRAVENOUS SOLUTION 250MG/250 DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.02810 08/12/2014 INTRAVENOUS SOLUTION 500 MG/500 DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS 0.05620 08/12/2014 INTRAVENOUS SOLUTION 500MG/250 DOBUTAMINE HCL INTRAVENOUS VIAL (ML) 250MG/20ML 0.15780 08/12/2014 DOBUTAMINE HCL INTRAVENOUS VIAL (ML) 500MG/40ML 0.15830 08/12/2014 DOCETAXEL INTRAVENOUS VIAL (ML) 140 MG/7ML 43.50599 01/23/2015 43.50599 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 160 MG/8ML 675.67500 08/12/2014 DOCETAXEL INTRAVENOUS VIAL (ML) 160MG/16ML 67.85567 08/12/2014 67.85567 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 20 MG/2 ML 60.99275 08/12/2014 60.99275 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 200MG/20ML 42.61540 05/01/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 20MG/ML(1) 53.07450 02/27/2015 53.07450 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 80 MG/4 ML 50.41463 02/27/2015 50.41463 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) 80 MG/8 ML 61.30313 08/12/2014 61.30313 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) FNL 20MG/2 148.61475 01/25/2013 148.61475 08/21/2015 DOCETAXEL INTRAVENOUS VIAL (ML) FNL 80MG/8 297.22950 01/25/2013 297.22950 08/21/2015 DOCUSATE CALCIUM ORAL CAPSULE 240 MG 0.05135 08/12/2014 0.05135 08/21/2015 DOCUSATE SODIUM ORAL CAPSULE 100 MG 0.01474 01/30/2015 0.01474 08/21/2015 DOCUSATE SODIUM ORAL CAPSULE 250 MG 0.04068 03/27/2015 0.04068 08/21/2015 DOCUSATE SODIUM ORAL LIQUID (ML) 50 MG/5 ML 0.00902 08/12/2014 0.00902 08/21/2015 DOCUSATE SODIUM ORAL SYRUP 60 MG/15ML 0.00788 08/12/2014 0.00788 08/21/2015 DOCUSATE SODIUM ORAL TABLET 100 MG 0.02938 02/06/2015 0.02938 08/21/2015 DOCUSATE SODIUM RECTAL ENEMA (ML) 283 MG/5ML 3.28266 08/21/2015 DOCUSATE SODIUM/BENZOCAINE RECTAL ENEMA (ML) 283-20MG/5 2.68029 08/21/2015 DONEPEZIL HCL ORAL TABLET 10 MG 0.15286 08/21/2015 0.12417 09/30/2016 DONEPEZIL HCL ORAL TABLET 23 MG 7.94987 08/21/2015 2.50600 09/30/2016 DONEPEZIL HCL ORAL TABLET 5 MG 0.11410 03/06/2015 0.11410 08/21/2015 DONEPEZIL HCL ORAL TABLET,DISINTEGRATING 10 MG 0.27257 01/30/2015 DONEPEZIL HCL ORAL TABLET,DISINTEGRATING 5 MG 0.37252 10/17/2014 0.37252 08/21/2015 DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC 0.02960 08/12/2014 BAG, INJECTION (ML) 200MG/.25L West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC 0.03690 08/12/2014 BAG, INJECTION (ML) 400MG/.25L DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC 0.04060 08/12/2014 BAG, INJECTION (ML) 400MG/0.5L DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC 0.08010 08/12/2014 BAG, INJECTION (ML) 800MG/.25L DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC 0.05100 08/12/2014 BAG, INJECTION (ML) 800MG/0.5L DOPAMINE HCL INTRAVENOUS VIAL (ML) 400 MG/5ML 0.50263 01/25/2013 DOPAMINE HCL INTRAVENOUS VIAL (ML) 400MG/10ML 0.07980 01/25/2013 DOPAMINE HCL INTRAVENOUS VIAL (ML) 800MG/10ML 0.20101 01/25/2013 DOPAMINE HCL INTRAVENOUS VIAL (ML) 800MG/5ML 0.62837 01/25/2013 DORZOLAMIDE HCL OPHTHALMIC DROPS 2 % 1.20868 08/21/2015 1.09300 09/30/2016 DORZOLAMIDE HCL/TIMOLOL MALEATE OPHTHALMIC DROPS 22.3-6.8/1 1.36144 08/21/2015 1.19780 05/20/2016 DOXAZOSIN MESYLATE ORAL TABLET 1 MG 0.46459 03/25/2016 0.33337 09/30/2016 DOXAZOSIN MESYLATE ORAL TABLET 2 MG 0.29853 07/08/2016 0.50210 07/21/2016 DOXAZOSIN MESYLATE ORAL TABLET 4 MG 0.44362 12/25/2015 0.11311 09/30/2016 DOXAZOSIN MESYLATE ORAL TABLET 8 MG 0.41858 12/25/2015 0.33396 07/08/2016 DOXEPIN HCL ORAL CAPSULE 10 MG 0.37514 04/10/2015 0.37514 08/21/2015 DOXEPIN HCL ORAL CAPSULE 100 MG 1.18739 04/10/2015 1.18739 08/21/2015 DOXEPIN HCL ORAL CAPSULE 150 MG 0.92954 03/20/2015 DOXEPIN HCL ORAL CAPSULE 25 MG 0.49387 04/10/2015 0.49387 08/21/2015 DOXEPIN HCL ORAL CAPSULE 50 MG 0.57615 08/21/2015 0.72779 07/27/2016 DOXEPIN HCL ORAL CAPSULE 75 MG 0.88553 08/21/2015 1.19520 09/18/2016 DOXEPIN HCL ORAL CONCENTRATE, ORAL 10 MG/ML 0.05720 08/12/2014 DOXERCALCIFEROL ORAL CAPSULE 0.5 MCG 11.21120 03/07/2014 11.21120 01/01/2017 DOXERCALCIFEROL ORAL CAPSULE 1 MCG 22.42149 07/25/2014 22.42149 01/01/2017 DOXERCALCIFEROL ORAL CAPSULE 2.5 MCG 25.97343 03/07/2014 25.97343 01/01/2017 DOXORUBICIN HCL INTRAVENOUS VIAL (EA) 10 MG 40.96400 08/08/2014 40.96400 08/21/2015 DOXORUBICIN HCL INTRAVENOUS VIAL (EA) 50 MG 29.40000 03/07/2014 29.40000 08/21/2015 DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS VIAL (ML) 2 80.99070 04/05/2013 MG/ML DOXYCYCLINE HYCLATE INTRAVENOUS VIAL (EA) 100 MG 13.86000 11/14/2014 13.86000 08/21/2015 DOXYCYCLINE HYCLATE ORAL CAPSULE 100 MG 1.09793 02/26/2016 0.85185 09/30/2016 DOXYCYCLINE HYCLATE ORAL CAPSULE 50 MG 1.57724 08/21/2015 0.90000 09/30/2016 DOXYCYCLINE HYCLATE ORAL TABLET 100 MG 1.02500 03/25/2016 0.93374 08/26/2016 DOXYCYCLINE HYCLATE ORAL TABLET 20 MG 0.62690 08/21/2015 0.20961 07/08/2016 DOXYCYCLINE HYCLATE ORAL TABLET, DELAYED RELEASE (ENTERIC 9.20381 11/08/2013 COATED) 100 MG DOXYCYCLINE HYCLATE ORAL TABLET, DELAYED RELEASE (ENTERIC 8.72316 04/24/2015 COATED) 150 MG DOXYCYCLINE HYCLATE ORAL TABLET, DELAYED RELEASE (ENTERIC 7.15693 08/12/2014 COATED) 75 MG DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 100 MG 0.60100 08/21/2015 0.40196 04/22/2016 DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 150 MG 17.25512 01/25/2013 DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 50 MG 0.31736 03/20/2015 0.31736 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 75 MG 11.72204 01/30/2015 11.72204 08/21/2015 DOXYCYCLINE MONOHYDRATE ORAL SUSPENSION, RECONSTITUTED, 0.26565 03/20/2015 ORAL (ML) 25 MG/5 ML DOXYCYCLINE MONOHYDRATE ORAL TABLET 100 MG 0.95020 08/21/2015 0.84880 12/02/2016 DOXYCYCLINE MONOHYDRATE ORAL TABLET 150 MG 4.39361 01/25/2013 4.39361 08/21/2015 DOXYCYCLINE MONOHYDRATE ORAL TABLET 50 MG 0.95174 09/26/2014 0.95174 08/21/2015 DOXYCYCLINE MONOHYDRATE ORAL TABLET 75 MG 0.73370 08/12/2014 0.73370 08/21/2015 DOXYLAMINE SUCCINATE ORAL TABLET 25 MG 0.20563 08/21/2015 DRONABINOL ORAL CAPSULE 10 MG 10.63206 07/29/2016 9.55706 12/02/2016 DRONABINOL ORAL CAPSULE 2.5 MG 3.05283 04/03/2015 2.77364 12/02/2016 DRONABINOL ORAL CAPSULE 5 MG 5.25740 02/26/2016 5.02346 12/02/2016 DROPERIDOL INJECTION AMPUL (ML) 2.5 MG/ML 0.84840 01/25/2013 DROPERIDOL INJECTION VIAL (ML) 2.5 MG/ML 1.48750 01/25/2013 DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.66054 09/30/2016 0.52522 01/13/2017 COATED) 20 MG DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.53787 07/08/2016 0.46713 07/29/2016 COATED) 30 MG DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.51753 07/08/2016 0.28882 01/27/2017 COATED) 60 MG ECONAZOLE NITRATE TOPICAL CREAM (GRAM) 1 % 3.54764 08/21/2015 2.57771 12/02/2016 ELECTROLYTE-48 SOLUTION/DEXTROSE 5 % IN WATER INTRAVENOUS 0.00430 08/12/2014 INTRAVENOUS SOLUTION 5 % ELECTROLYTES/DEXTROSE ORAL SOLUTION, ORAL 0.00517 02/27/2015 0.00517 08/21/2015 EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION (GRAM) 0.44835 01/25/2013 0.44835 08/21/2015 EMOLLIENT COMBINATION NO.32 TOPICAL EMULSION (GRAM) 0.72194 08/29/2014 0.72194 08/21/2015 EMOLLIENT COMBINATION NO.44 TOPICAL FOAM (GRAM) 0.90811 01/25/2013 EMOLLIENT COMBINATION NO.53 TOPICAL CREAM (GRAM) 0.49685 08/12/2014 EMOLLIENT COMBINATION NO.53 TOPICAL FOAM (GRAM) 1.01001 01/25/2013 ENALAPRIL MALEATE MISCELLANEOUS POWDER (GRAM) 100 % 3.35240 08/12/2014 3.35240 08/21/2015 ENALAPRIL MALEATE ORAL TABLET 10 MG 0.27853 02/27/2015 0.27853 08/21/2015 ENALAPRIL MALEATE ORAL TABLET 2.5 MG 0.25621 02/06/2015 0.25621 08/21/2015 ENALAPRIL MALEATE ORAL TABLET 20 MG 0.37467 01/13/2017 0.16731 01/27/2017 ENALAPRIL MALEATE ORAL TABLET 5 MG 0.33007 12/25/2015 0.27850 09/30/2016 ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE ORAL TABLET 10 MG- 0.14036 04/10/2015 0.14036 08/21/2015 25MG ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE ORAL TABLET 5MG- 0.08740 05/31/2013 0.08740 08/21/2015 12.5MG ENALAPRILAT DIHYDRATE INTRAVENOUS VIAL (ML) 1.25 MG/ML 1.78220 09/12/2014 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 100 MG/ML 17.52000 04/22/2016 15.52719 10/28/2016 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 120MG/.8ML 28.37621 11/20/2015 19.56825 02/26/2016 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 150 MG/ML 31.66457 11/20/2015 19.56890 03/25/2016 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 30MG/0.3ML 17.20519 02/26/2016 16.45599 07/29/2016 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 40MG/0.4ML 16.22687 02/26/2016 15.91185 10/28/2016 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 60MG/0.6ML 17.52000 04/22/2016 12.50000 01/27/2017 ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 80MG/0.8ML 17.68000 07/29/2016 15.80000 10/28/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ENOXAPARIN SODIUM SUBCUTANEOUS VIAL (ML) 300MG/3ML 59.20133 03/06/2015 59.20133 08/21/2015 ENTACAPONE ORAL TABLET 200 MG 2.96207 08/21/2015 2.25730 10/23/2015 ENTECAVIR ORAL TABLET 0.5 MG 30.00175 04/24/2015 ENTECAVIR ORAL TABLET 1 MG 30.57985 11/14/2014 ENZYMES,DIGESTIVE ORAL CAPSULE 0.05940 08/12/2014 0.05940 08/21/2015 EPHEDRINE SULFATE INJECTION VIAL (ML) 50 MG/ML 4.10130 01/25/2013 4.10130 08/21/2015 EPINASTINE HCL OPHTHALMIC DROPS 0.05 % 9.27130 08/12/2014 9.27130 08/21/2015 EPINEPHRINE HCL/PF INJECTION AMPUL (ML) 1 MG/ML(1) 682.71000 02/20/2015 EPINEPHRINE INJECTION SYRINGE (ML) 0.1 MG/ML 0.47910 08/12/2014 0.47910 08/21/2015 EPINEPHRINE INJECTION VIAL (ML) 1 MG/ML 0.20160 08/12/2014 0.20160 08/21/2015 EPIRUBICIN HCL INTRAVENOUS VIAL (EA) 200 MG 1992.09500 01/25/2013 EPLERENONE ORAL TABLET 25 MG 2.18578 03/27/2015 2.18578 08/21/2015 EPLERENONE ORAL TABLET 50 MG 2.18578 03/27/2015 2.18578 08/21/2015 EPOPROSTENOL SODIUM (GLYCINE) INTRAVENOUS VIAL (EA) 0.5 MG 12.85200 01/25/2013 EPOPROSTENOL SODIUM (GLYCINE) INTRAVENOUS VIAL (EA) 1.5 MG 24.45100 01/25/2013 EPROSARTAN MESYLATE ORAL TABLET 600 MG 2.39820 01/25/2013 ERGOCALCIFEROL (VITAMIN D2) ORAL CAPSULE 50000 UNIT 0.27818 08/22/2014 0.27818 08/21/2015 ERGOCALCIFEROL (VITAMIN D2) ORAL TABLET 2000 UNIT 0.05446 01/25/2013 ERGOCALCIFEROL (VITAMIN D2) ORAL TABLET 400 UNIT 0.02380 02/08/2013 ERGOLOID MESYLATES ORAL TABLET 1 MG 5.67287 02/06/2015 ERYTHROMYCIN BASE OPHTHALMIC OINTMENT (GRAM) 5 MG/G 3.15228 03/25/2016 2.27186 09/30/2016 ERYTHROMYCIN BASE ORAL CAPSULE,DELAYED RELEASE (ENTERIC 2.41500 05/09/2014 2.41500 08/21/2015 COATED) 250 MG ERYTHROMYCIN BASE ORAL TABLET 250 MG 6.49159 08/21/2015 8.13722 06/30/2016 ERYTHROMYCIN BASE ORAL TABLET 500 MG 9.78572 08/21/2015 12.26652 05/16/2016 ERYTHROMYCIN BASE/BENZOYL PEROXIDE TOPICAL GEL (GRAM) 3 %-5 6.23075 11/21/2015 4.49990 09/30/2016 % ERYTHROMYCIN BASE/ETHYL ALCOHOL TOPICAL GEL (GRAM) 2 % 0.68110 08/21/2015 2.85000 09/23/2016 ERYTHROMYCIN BASE/ETHYL ALCOHOL TOPICAL SOLUTION, NON-ORAL 0.57579 02/07/2014 0.57579 08/21/2015 2 % ERYTHROMYCIN BASE/ETHYL ALCOHOL TOPICAL SWAB, MEDICATED 2 1.10370 02/08/2013 % ESCITALOPRAM OXALATE ORAL SOLUTION, ORAL 5 MG/5 ML 0.46493 04/10/2015 0.36009 02/26/2016 ESCITALOPRAM OXALATE ORAL TABLET 10 MG 0.16950 05/01/2015 0.16950 08/21/2015 ESCITALOPRAM OXALATE ORAL TABLET 20 MG 0.19890 08/21/2015 0.17102 09/30/2016 ESCITALOPRAM OXALATE ORAL TABLET 5 MG 0.15950 08/21/2015 0.10499 09/30/2016 ESOMEPRAZOLE MAGNESIUM ORAL CAPSULE,DELAYED RELEASE 1.57933 01/13/2017 1.52377 01/27/2017 (ENTERIC COATED) 20 MG ESOMEPRAZOLE MAGNESIUM ORAL CAPSULE,DELAYED RELEASE 1.51074 01/13/2017 1.22365 01/27/2017 (ENTERIC COATED) 40 MG ESOMEPRAZOLE SODIUM INTRAVENOUS VIAL (EA) 20 MG 9.22875 04/24/2015 9.22875 08/21/2015 ESOMEPRAZOLE SODIUM INTRAVENOUS VIAL (EA) 40 MG 10.43250 04/24/2015 10.43250 08/21/2015 ESTAZOLAM ORAL TABLET 1 MG 0.26770 08/12/2014 ESTAZOLAM ORAL TABLET 2 MG 0.29330 08/12/2014 0.29330 08/21/2015 ESTRADIOL ORAL TABLET 0.5 MG 0.06790 08/21/2015 0.12156 04/23/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ESTRADIOL ORAL TABLET 1 MG 0.16296 03/27/2015 0.16296 08/21/2015 ESTRADIOL ORAL TABLET 2 MG 0.17998 03/27/2015 0.17998 08/21/2015 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 9.18520 01/25/2016 8.88375 05/20/2016 .025MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 8.10060 02/27/2015 .0375MG/24 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 8.11534 02/27/2015 8.11534 08/21/2015 .075MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 8.10484 08/21/2015 9.12520 02/15/2016 0.05MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 9.52992 01/25/2016 9.29000 12/02/2016 0.1MG/24HR ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 15.92223 09/20/2013 .025MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 15.47000 03/27/2015 13.96711 09/30/2016 .0375MG/24 ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 10.55000 05/02/2014 .075MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 10.57875 04/19/2013 0.05MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 15.47000 04/25/2014 0.06MG/24H ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 15.86974 12/05/2014 14.16352 12/25/2015 0.1MG/24HR ESTRADIOL/NORETHINDRONE ACETATE ORAL TABLET 0.5-0.1 MG 3.30545 08/21/2015 2.39788 12/02/2016 ESTRADIOL/NORETHINDRONE ACETATE ORAL TABLET 1 MG-0.5MG 3.35400 02/13/2015 2.83847 03/25/2016 ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE ORAL TABLET 0.625- 1.58654 08/12/2014 1.58654 08/21/2015 1.25 ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE ORAL TABLET 1.25- 1.74068 08/12/2014 1.74068 08/21/2015 2.5MG ESTROPIPATE ORAL TABLET 0.75 MG 0.36322 04/25/2014 0.36322 08/21/2015 ESTROPIPATE ORAL TABLET 1.5 MG 0.50765 04/25/2014 ESTROPIPATE ORAL TABLET 3 MG 0.70270 08/12/2014 ESZOPICLONE ORAL TABLET 1 MG 0.41903 08/21/2015 0.35600 05/20/2016 ESZOPICLONE ORAL TABLET 2 MG 0.46444 04/24/2015 0.46444 08/21/2015 ESZOPICLONE ORAL TABLET 3 MG 0.52260 05/01/2015 0.52260 08/21/2015 ETHAMBUTOL HCL ORAL TABLET 100 MG 0.44890 03/27/2015 0.44890 08/21/2015 ETHAMBUTOL HCL ORAL TABLET 400 MG 1.17404 03/27/2015 1.17404 08/21/2015 ETHINYL ESTRADIOL/DROSPIRENONE ORAL TABLET 0.02-3(24) 1.63702 04/22/2016 0.79203 09/30/2016 ETHINYL ESTRADIOL/DROSPIRENONE ORAL TABLET 0.03MG-3MG 0.97322 09/30/2016 0.66095 01/27/2017 ETHOSUXIMIDE ORAL CAPSULE 250 MG 1.19162 02/13/2015 ETHOSUXIMIDE ORAL SOLUTION, ORAL 250 MG/5ML 0.32260 02/27/2015 ETHYL ALCOHOL INJECTION AMPUL (ML) 98 % 7.48300 12/12/2014 7.48300 08/21/2015 ETHYL ALCOHOL INJECTION VIAL (ML) 98 % 12.09096 08/12/2014 ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL ORAL TABLET 1 MG- 0.74700 02/08/2013 35MCG ETIDRONATE DISODIUM ORAL TABLET 200 MG 3.02458 01/24/2014 ETIDRONATE DISODIUM ORAL TABLET 400 MG 6.04777 11/22/2013 6.04777 08/21/2015 ETODOLAC ORAL CAPSULE 200 MG 1.00597 04/24/2015 0.89280 01/13/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ETODOLAC ORAL CAPSULE 300 MG 1.13176 02/13/2015 1.13176 08/21/2015 ETODOLAC ORAL TABLET 400 MG 0.84866 03/21/2015 0.73435 09/30/2016 ETODOLAC ORAL TABLET 500 MG 0.83011 08/21/2015 0.65135 05/20/2016 ETODOLAC ORAL TABLET, EXTENDED RELEASE 24 HR 400 MG 2.03084 06/20/2014 2.03084 08/21/2015 ETODOLAC ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 2.15742 08/12/2014 2.15742 08/21/2015 ETODOLAC ORAL TABLET, EXTENDED RELEASE 24 HR 600 MG 2.29187 05/23/2014 2.29187 08/21/2015 ETOPOSIDE ORAL CAPSULE 50 MG 56.82120 02/15/2013 EXEMESTANE ORAL TABLET 25 MG 7.20100 09/22/2016 5.72756 12/02/2016 FAMCICLOVIR ORAL TABLET 125 MG 0.46454 03/27/2015 0.46454 08/21/2015 FAMCICLOVIR ORAL TABLET 250 MG 0.68028 03/27/2015 0.68028 08/21/2015 FAMCICLOVIR ORAL TABLET 500 MG 1.50080 03/13/2015 1.50080 08/21/2015 FAMOTIDINE IN SODIUM CHLORIDE, ISO-OSMOTIC/PF INTRAVENOUS 0.13650 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 20 MG/50ML FAMOTIDINE INTRAVENOUS VIAL (ML) 10 MG/ML 0.26572 01/09/2015 0.26572 08/21/2015 FAMOTIDINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 40MG/5ML 1.71949 09/19/2014 0.85373 09/25/2015 FAMOTIDINE ORAL TABLET 10 MG 0.08920 03/27/2015 0.08920 08/21/2015 FAMOTIDINE ORAL TABLET 20 MG 0.03792 04/03/2015 0.03792 08/21/2015 FAMOTIDINE ORAL TABLET 40 MG 0.08659 04/03/2015 0.08659 08/21/2015 FAMOTIDINE/PF INTRAVENOUS VIAL (ML) 20 MG/2 ML 0.37429 08/12/2014 0.37429 08/21/2015 FELBAMATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 600 MG/5ML 1.87137 04/22/2016 1.58070 12/02/2016 FELBAMATE ORAL TABLET 400 MG 3.64207 04/22/2016 2.67017 07/29/2016 FELBAMATE ORAL TABLET 600 MG 4.17758 04/22/2016 3.84855 12/02/2016 FELODIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.51804 08/21/2015 0.34000 05/20/2016 FELODIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 2.5 MG 0.54257 01/16/2015 0.54257 08/21/2015 FELODIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 5 MG 0.51681 08/21/2015 0.29800 05/20/2016 FENOFIBRATE NANOCRYSTALLIZED ORAL TABLET 145MG 0.76687 04/22/2016 0.76687 01/01/2017 FENOFIBRATE NANOCRYSTALLIZED ORAL TABLET 48 MG 0.60357 12/25/2015 0.60357 01/01/2017 FENOFIBRATE ORAL CAPSULE 150 MG 4.26789 12/02/2016 5.00920 01/23/2017 FENOFIBRATE ORAL CAPSULE 50 MG 1.73180 08/01/2014 FENOFIBRATE ORAL TABLET 160 MG 0.55788 10/28/2016 0.51768 12/02/2016 FENOFIBRATE ORAL TABLET 54 MG 0.50101 08/21/2015 0.45232 05/20/2016 FENOFIBRATE,MICRONIZED ORAL CAPSULE 130 MG 4.84307 04/18/2014 4.84307 08/21/2015 FENOFIBRATE,MICRONIZED ORAL CAPSULE 134 MG 1.37130 04/27/2016 1.09726 09/30/2016 FENOFIBRATE,MICRONIZED ORAL CAPSULE 200 MG 2.13935 12/25/2015 1.82423 12/02/2016 FENOFIBRATE,MICRONIZED ORAL CAPSULE 43 MG 1.64500 04/18/2014 1.64500 08/21/2015 FENOFIBRATE,MICRONIZED ORAL CAPSULE 67 MG 0.73955 08/12/2014 0.73955 08/21/2015 FENOFIBRIC ACID (CHOLINE) ORAL CAPSULE,DELAYED RELEASE 1.98283 12/25/2015 1.81582 04/22/2016 (ENTERIC COATED) 135 MG FENOFIBRIC ACID (CHOLINE) ORAL CAPSULE,DELAYED RELEASE 1.19520 10/02/2015 0.82000 01/13/2017 (ENTERIC COATED) 45 MG FENOFIBRIC ACID ORAL TABLET 105 MG 2.10232 05/30/2014 FENOFIBRIC ACID ORAL TABLET 35 MG 0.70070 08/12/2014 FENOPROFEN CALCIUM ORAL TABLET 600 MG 1.53587 02/07/2014 1.53587 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 1200 MCG 31.46500 01/25/2013 FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 1600 MCG 38.80683 01/25/2013 FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 200 MCG 13.16280 01/25/2013 FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 400 MCG 16.67657 01/25/2013 FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 600 MCG 20.42600 01/25/2013 FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 800 MCG 24.20180 10/25/2013 FENTANYL CITRATE/PF INTRAVENOUS SYRINGE (ML) 100MCG/2ML 0.65520 01/25/2013 0.65520 08/21/2015 FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 100 11.12000 11/28/2016 8.95262 01/27/2017 MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 12 13.43003 12/02/2016 12.38480 01/13/2017 MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 25 4.04536 08/21/2015 2.94497 09/30/2016 MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 42.45400 05/01/2015 37.5MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 6.26500 03/07/2016 5.32478 01/27/2017 50MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 61.68800 05/01/2015 62.5MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 8.61567 09/30/2016 8.01154 01/27/2017 75MCG/HR FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 83.99000 05/01/2015 87.5MCG/HR FERROUS FUMARATE/ASCORBIC ACID/B12-IF/FOLIC ACID ORAL 0.18226 08/30/2013 CAPSULE 110-0.5MG FERROUS GLUCONATE ORAL TABLET 240(27)MG 0.03859 08/12/2014 FERROUS SULFATE ORAL DROPS 15 MG/ML 0.06072 03/06/2015 0.06072 08/21/2015 FERROUS SULFATE ORAL SOLUTION, ORAL 220 (44)/5 0.00626 04/10/2015 0.00626 08/21/2015 FERROUS SULFATE ORAL TABLET 325(65) MG 0.00838 04/10/2015 0.00838 08/21/2015 FEXOFENADINE HCL ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 30 0.05664 02/27/2015 MG/5 ML FEXOFENADINE HCL ORAL TABLET 180 MG 0.36414 04/24/2015 0.36414 08/21/2015 FEXOFENADINE HCL ORAL TABLET 60 MG 0.31707 01/30/2015 0.31707 08/21/2015 FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL ORAL TABLET, 0.66733 08/21/2015 EXTENDED RELEASE 12 HR 60MG-120MG FINASTERIDE ORAL TABLET 1 MG 0.31250 03/25/2016 FINASTERIDE ORAL TABLET 5 MG 0.19234 03/27/2015 0.19234 08/21/2015 FISH OIL/BORAGE OIL/FLAXSEED OIL/OMEGA 3,6,9 COMBINATION NO1 0.06168 08/12/2014 ORAL CAPSULE 400-400 MG FISH OIL/DOCOSAHEXANOIC ACID/EICOSAPENTAENOIC ACID ORAL 0.01579 01/25/2013 CAPSULE 1200-144MG FLAVOXATE HCL ORAL TABLET 100 MG 0.80990 03/27/2015 0.80990 08/21/2015 FLECAINIDE ACETATE ORAL TABLET 100 MG 0.27770 08/12/2014 0.27770 08/21/2015 FLECAINIDE ACETATE ORAL TABLET 150 MG 0.58174 01/09/2015 0.58174 08/21/2015 FLECAINIDE ACETATE ORAL TABLET 50 MG 0.33210 09/17/2016 0.29303 01/13/2017 FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS 0.09824 04/24/2015 0.09824 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 200MG/0.1L FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS 0.05315 04/24/2015 0.05315 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 400MG/0.2L West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS 0.05183 04/24/2015 0.05183 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 200MG/0.1L FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS 0.03369 04/24/2015 0.03369 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 400MG/0.2L FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS IV 0.05285 03/06/2015 0.05285 08/21/2015 SOLUTION, PIGGYBACK, BOTTLE (ML) 200MG/0.1L FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS IV 0.09450 01/25/2013 0.09450 08/21/2015 SOLUTION, PIGGYBACK, BOTTLE (ML) 400MG/0.2L FLUCONAZOLE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 10 0.32278 02/13/2015 0.32278 08/21/2015 MG/ML FLUCONAZOLE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 40 0.73302 02/13/2015 0.73302 08/21/2015 MG/ML FLUCONAZOLE ORAL TABLET 100 MG 1.28881 02/27/2015 1.28881 08/21/2015 FLUCONAZOLE ORAL TABLET 150 MG 2.18426 02/27/2015 2.18426 08/21/2015 FLUCONAZOLE ORAL TABLET 200 MG 2.09000 06/03/2016 1.42653 09/30/2016 FLUCONAZOLE ORAL TABLET 50 MG 0.89200 12/12/2014 0.89200 08/21/2015 FLUCYTOSINE ORAL CAPSULE 250 MG 57.44830 11/21/2014 57.44830 08/21/2015 FLUCYTOSINE ORAL CAPSULE 500 MG 111.16350 11/21/2014 111.16350 08/21/2015 FLUDROCORTISONE ACETATE ORAL TABLET 0.1 MG 0.33798 07/08/2016 0.37080 12/06/2016 FLUNISOLIDE NASAL AEROSOL, SPRAY (ML) 25 MCG 1.92500 03/13/2015 1.92500 08/21/2015 FLUOCINOLONE ACETONIDE OIL OTIC DROPS 0.01 % 7.64750 02/07/2014 7.64750 08/21/2015 FLUOCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.01 % 1.82185 08/12/2014 1.82185 08/21/2015 FLUOCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.025 % 1.39143 08/12/2014 1.39143 08/21/2015 FLUOCINOLONE ACETONIDE TOPICAL OIL (ML) 0.01 % 1.30643 05/02/2014 1.30643 08/21/2015 FLUOCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.025 % 1.18650 08/22/2014 FLUOCINOLONE ACETONIDE TOPICAL SOLUTION, NON-ORAL 0.01 % 2.12450 04/17/2015 2.12450 08/21/2015 FLUOCINOLONE ACETONIDE/SHOWER CAP TOPICAL OIL (ML) 0.01 % 1.31863 08/12/2014 1.31863 08/21/2015 FLUOCINONIDE TOPICAL CREAM (GRAM) 0.05 % 1.33534 08/21/2015 1.03320 07/08/2016 FLUOCINONIDE TOPICAL CREAM (GRAM) 0.1 % 13.23945 02/27/2015 11.07021 12/02/2016 FLUOCINONIDE TOPICAL GEL (GRAM) 0.05 % 0.78283 03/21/2014 0.78283 08/21/2015 FLUOCINONIDE TOPICAL OINTMENT (GRAM) 0.05 % 0.78790 08/30/2013 0.42932 07/08/2016 FLUOCINONIDE TOPICAL SOLUTION, NON-ORAL 0.05 % 1.13388 05/02/2014 FLUOCINONIDE/EMOLLIENT BASE TOPICAL CREAM (GRAM) 0.05 % 0.25684 06/07/2013 0.25684 08/21/2015 FLUOROMETHOLONE OPHTHALMIC SUSPENSION, DROPS(FINAL 10.37820 02/20/2015 DOSAGE FORM)(ML) 0.1 % FLUOROURACIL INTRAVENOUS VIAL (ML) 1 G/20 ML 0.25200 03/27/2015 0.25200 08/21/2015 FLUOROURACIL INTRAVENOUS VIAL (ML) 2.5 G/50ML 0.19859 03/27/2015 FLUOROURACIL INTRAVENOUS VIAL (ML) 5 G/100 ML 0.29560 03/27/2015 FLUOROURACIL INTRAVENOUS VIAL (ML) 500MG/10ML 0.25200 03/27/2015 0.25200 08/21/2015 FLUOROURACIL TOPICAL CREAM (GRAM) 0.5 % 41.44770 12/26/2014 FLUOROURACIL TOPICAL CREAM (GRAM) 5 % 4.05885 08/21/2015 4.05885 04/15/2016 FLUOROURACIL TOPICAL SOLUTION, NON-ORAL 2 % 4.95080 08/12/2014 FLUOROURACIL TOPICAL SOLUTION, NON-ORAL 5 % 7.93170 05/17/2013 FLUOXETINE HCL ORAL CAPSULE 10 MG 0.02814 05/01/2015 0.02814 08/21/2015 FLUOXETINE HCL ORAL CAPSULE 20 MG 0.02988 05/01/2015 0.02988 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date FLUOXETINE HCL ORAL CAPSULE 40 MG 0.17721 08/21/2015 0.12338 01/27/2017 FLUOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC 29.33500 02/21/2014 29.33500 08/21/2015 COATED) 90 MG FLUOXETINE HCL ORAL SOLUTION, ORAL 20 MG/5 ML 0.03461 02/06/2015 0.03461 08/21/2015 FLUOXETINE HCL ORAL TABLET 10 MG 0.05507 03/20/2015 0.05507 08/21/2015 FLUOXETINE HCL ORAL TABLET 20 MG 1.37655 02/27/2015 FLUOXETINE HCL ORAL TABLET 60 MG 2.97158 07/05/2013 FLUPHENAZINE DECANOATE INJECTION VIAL (ML) 25 MG/ML 27.49070 07/18/2014 FLUPHENAZINE HCL INJECTION VIAL (ML) 2.5 MG/ML 10.58000 03/01/2013 FLUPHENAZINE HCL ORAL CONCENTRATE, ORAL 5 MG/ML 0.81136 01/25/2013 FLUPHENAZINE HCL ORAL ELIXIR 2.5 MG/5ML 0.26710 01/25/2013 FLUPHENAZINE HCL ORAL TABLET 1 MG 0.12779 05/17/2013 FLUPHENAZINE HCL ORAL TABLET 10 MG 0.17216 02/27/2015 7.89000 11/22/2016 FLUPHENAZINE HCL ORAL TABLET 2.5 MG 0.18330 08/12/2014 FLUPHENAZINE HCL ORAL TABLET 5 MG 0.16730 01/30/2015 6.44000 09/22/2016 FLURAZEPAM HCL ORAL CAPSULE 15 MG 0.19583 08/22/2014 0.19583 08/21/2015 FLURAZEPAM HCL ORAL CAPSULE 30 MG 0.35100 08/22/2014 0.35100 08/21/2015 FLURBIPROFEN ORAL TABLET 100 MG 0.36823 02/20/2015 0.36823 08/21/2015 FLURBIPROFEN ORAL TABLET 50 MG 0.22113 09/19/2014 0.22113 08/21/2015 FLURBIPROFEN SODIUM OPHTHALMIC DROPS 0.03 % 1.57114 08/30/2013 1.57114 08/21/2015 FLUTAMIDE ORAL CAPSULE 125 MG 0.63643 11/22/2013 0.63643 08/21/2015 FLUTICASONE PROPIONATE NASAL SPRAY, SUSPENSION 50 MCG 0.32375 12/02/2016 0.15892 01/27/2017 FLUTICASONE PROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.55080 02/01/2013 0.55080 08/21/2015 FLUTICASONE PROPIONATE TOPICAL LOTION (ML) 0.05 % 4.54942 08/30/2013 4.54942 08/21/2015 FLUTICASONE PROPIONATE TOPICAL OINTMENT (GRAM) 0.005 % 0.48681 03/01/2013 FLUVASTATIN SODIUM ORAL CAPSULE 20 MG 2.64600 03/27/2015 2.64600 04/22/2016 FLUVASTATIN SODIUM ORAL CAPSULE 40 MG 2.64297 08/23/2013 2.64297 04/22/2016 FLUVOXAMINE MALEATE ORAL CAPSULE, EXT RELEASE 24 HR 100 MG 7.12857 10/10/2014 FLUVOXAMINE MALEATE ORAL CAPSULE, EXT RELEASE 24 HR 150 MG 7.65030 10/10/2014 FLUVOXAMINE MALEATE ORAL TABLET 100 MG 0.21782 03/25/2016 0.26395 04/23/2016 FLUVOXAMINE MALEATE ORAL TABLET 25 MG 0.23769 02/20/2015 0.23769 08/21/2015 FLUVOXAMINE MALEATE ORAL TABLET 50 MG 0.24112 04/03/2015 0.24112 08/21/2015 FOLIC ACID INJECTION VIAL (ML) 5 MG/ML 1.79410 02/15/2013 FOLIC ACID ORAL TABLET 0.4 MG 0.01380 02/06/2015 0.01380 08/21/2015 FOLIC ACID ORAL TABLET 1 MG 0.02320 04/10/2015 0.02320 08/21/2015 FOLIC ACID/ARGININE HCL/CYANOCOBALAMIN/PYRIDOXINE/PEPPER 0.56210 01/25/2013 EXT ORAL TABLET 2-500-500 FOLIC ACID/MULTIVIT WITH MINERALS/LUTEIN ORAL TABLET 0.4MG-250 0.03600 01/25/2013 FOLIC ACID/VITAMIN B COMPLEX AND VITAMIN C ORAL TABLET 0.8 MG 0.09960 08/12/2014 0.09960 08/21/2015 FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 10MG/0.8ML 94.71000 01/09/2015 94.71000 08/21/2015 FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 2.5 MG/0.5 83.02000 01/09/2015 83.02000 08/21/2015 FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 5MG/0.4ML 110.40650 01/09/2015 110.40650 08/21/2015 FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 7.5MG/0.6 129.37800 01/09/2015 129.37800 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date FORMALDEHYDE TOPICAL SOLUTION WITH APPLICATOR (ML) 10 % 0.36953 01/25/2013 FOSCARNET SODIUM INTRAVENOUS INFUSION BOTTLE (ML) 24 MG/ML 0.25326 01/30/2015 0.25326 08/21/2015 FOSINOPRIL SODIUM ORAL TABLET 10 MG 0.15448 06/27/2014 0.15448 08/21/2015 FOSINOPRIL SODIUM ORAL TABLET 20 MG 0.14428 02/20/2015 0.14428 08/21/2015 FOSINOPRIL SODIUM ORAL TABLET 40 MG 0.19096 04/24/2015 0.19096 08/21/2015 FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.74360 08/12/2014 0.74360 08/21/2015 FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 1.06964 08/12/2014 1.06964 08/21/2015 MG FOSPHENYTOIN SODIUM INJECTION VIAL (ML) 100MG PE/2 0.91763 01/30/2015 0.91763 08/21/2015 FOSPHENYTOIN SODIUM INJECTION VIAL (ML) 500 PE/10 0.75985 01/30/2015 0.75985 08/21/2015 FUROSEMIDE INJECTION VIAL (ML) 10 MG/ML 0.40508 12/19/2014 0.40508 08/21/2015 FUROSEMIDE ORAL SOLUTION, ORAL 10 MG/ML 0.11127 05/17/2013 FUROSEMIDE ORAL SOLUTION, ORAL 40MG/5ML 0.14150 01/25/2013 FUROSEMIDE ORAL TABLET 20 MG 0.01363 04/24/2015 0.01363 08/21/2015 FUROSEMIDE ORAL TABLET 40 MG 0.02141 04/24/2015 0.02141 08/21/2015 FUROSEMIDE ORAL TABLET 80 MG 0.03476 01/16/2015 0.03476 08/21/2015 GABAPENTIN MISCELLANEOUS POWDER (GRAM) 100 % 1.14400 08/21/2015 GABAPENTIN ORAL CAPSULE 100 MG 0.03654 04/24/2015 0.03654 08/21/2015 GABAPENTIN ORAL CAPSULE 300 MG 0.06478 04/17/2015 0.06478 08/21/2015 GABAPENTIN ORAL CAPSULE 400 MG 0.08040 03/06/2015 0.08040 08/21/2015 GABAPENTIN ORAL SOLUTION, ORAL 250 MG/5ML 0.29166 01/25/2013 GABAPENTIN ORAL SOLUTION, ORAL 250 MG/5ML 0.13744 08/21/2015 0.09783 09/30/2016 GABAPENTIN ORAL SOLUTION, ORAL 300 MG/6ML 0.29164 01/25/2013 GABAPENTIN ORAL TABLET 600 MG 0.14127 03/25/2016 0.08738 01/27/2017 GABAPENTIN ORAL TABLET 800 MG 0.26533 09/25/2015 0.19608 05/20/2016 GALANTAMINE HBR ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 2.91200 04/17/2015 2.91200 08/21/2015 HR 16 MG GALANTAMINE HBR ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 2.45490 08/12/2014 HR 24 MG GALANTAMINE HBR ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 2.18150 08/12/2014 HR 8 MG GALANTAMINE HBR ORAL SOLUTION, ORAL 4 MG/ML 2.95575 01/25/2013 2.95575 08/21/2015 GALANTAMINE HBR ORAL TABLET 12 MG 1.85768 08/12/2014 1.85768 08/21/2015 GALANTAMINE HBR ORAL TABLET 4 MG 2.15924 08/12/2014 2.15924 08/21/2015 GALANTAMINE HBR ORAL TABLET 8 MG 0.99466 03/25/2016 0.69000 04/22/2016 GANCICLOVIR SODIUM INTRAVENOUS VIAL (EA) 500 MG 62.00208 02/27/2015 GANIRELIX ACETATE SUBCUTANEOUS SYRINGE (ML) 250MCG/0.5 243.87300 01/25/2013 GATIFLOXACIN OPHTHALMIC DROPS 0.5 % 33.08480 04/17/2015 GEMCITABINE HCL INTRAVENOUS VIAL (EA) 1 G 39.64700 01/23/2015 39.64700 08/21/2015 GEMCITABINE HCL INTRAVENOUS VIAL (EA) 2 G 96.93425 08/08/2014 96.93425 08/21/2015 GEMCITABINE HCL INTRAVENOUS VIAL (EA) 200 MG 9.28800 01/23/2015 9.28800 08/21/2015 GEMCITABINE HCL INTRAVENOUS VIAL (ML) 1 G/26.3ML 2.87559 08/12/2014 GEMCITABINE HCL INTRAVENOUS VIAL (ML) 2 G/52.6ML 3.25580 08/12/2014 GEMCITABINE HCL INTRAVENOUS VIAL (ML) 200MG/5.26 3.55320 08/12/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date GEMFIBROZIL ORAL TABLET 600 MG 0.09960 04/03/2015 0.09960 08/21/2015 GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC 0.13213 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 100MG/50ML GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC 0.06630 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 120MG/0.1L GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC 0.15469 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 70 MG/50ML GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC 0.07491 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 90MG/100ML GENTAMICIN SULFATE INJECTION VIAL (ML) 20 MG/2 ML 1.45158 01/25/2013 GENTAMICIN SULFATE INJECTION VIAL (ML) 40 MG/ML 0.51161 08/12/2014 1.35660 01/16/2017 GENTAMICIN SULFATE OPHTHALMIC DROPS 0.3 % 0.90852 11/28/2014 0.90852 08/21/2015 GENTAMICIN SULFATE OPHTHALMIC OINTMENT (GRAM) 0.3 % 3.99600 09/19/2014 3.99600 08/21/2015 GENTAMICIN SULFATE/PF INJECTION VIAL (ML) 20 MG/2 ML 1.09954 08/12/2014 GENTAMICIN SULFATE/PF INTRAVENOUS VIAL WITH THREADED PORT 0.29434 01/25/2013 (ML) 100MG/10ML GENTAMICIN SULFATE/PF INTRAVENOUS VIAL WITH THREADED PORT 0.39255 01/25/2013 (ML) 60 MG/6 ML GLIMEPIRIDE ORAL TABLET 1 MG 0.09384 02/06/2015 0.09384 08/21/2015 GLIMEPIRIDE ORAL TABLET 2 MG 0.18354 05/01/2015 0.18354 08/21/2015 GLIMEPIRIDE ORAL TABLET 4 MG 0.21249 02/26/2016 0.14961 09/30/2016 GLIPIZIDE ORAL TABLET 10 MG 0.05265 05/01/2015 0.05265 08/21/2015 GLIPIZIDE ORAL TABLET 5 MG 0.03000 03/27/2015 0.03000 08/21/2015 GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.40120 08/21/2015 0.32488 09/30/2016 GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 2.5 MG 0.20110 03/21/2014 0.20110 08/21/2015 GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 5 MG 0.18940 01/03/2014 0.18940 08/21/2015 GLIPIZIDE/METFORMIN HCL ORAL TABLET 2.5-250 MG 0.34151 11/08/2013 0.34151 08/21/2015 GLIPIZIDE/METFORMIN HCL ORAL TABLET 2.5-500 MG 0.54389 12/25/2015 0.43480 05/20/2016 GLIPIZIDE/METFORMIN HCL ORAL TABLET 5 MG-500MG 0.66827 08/21/2015 0.34950 05/20/2016 GLUCOSAMINE SULFATE ORAL TABLET 750 MG 0.33095 01/25/2013 GLUCOSAMINE SULFATE/CHONDROITIN 1.20120 01/25/2013 SULFATE/METHYLSULFONYLMETHAN ORAL TABLET 500-200 MG GLYBURIDE ORAL TABLET 1.25 MG 0.14217 07/11/2014 0.14217 08/21/2015 GLYBURIDE ORAL TABLET 2.5 MG 0.13169 01/30/2015 0.13169 08/21/2015 GLYBURIDE ORAL TABLET 5 MG 0.20355 08/21/2015 0.13290 05/20/2016 GLYBURIDE,MICRONIZED ORAL TABLET 1.5 MG 0.02590 08/12/2014 0.02590 08/21/2015 GLYBURIDE,MICRONIZED ORAL TABLET 3 MG 0.02840 08/12/2014 0.02840 08/21/2015 GLYBURIDE,MICRONIZED ORAL TABLET 6 MG 0.09900 05/17/2013 0.09900 08/21/2015 GLYBURIDE/METFORMIN HCL ORAL TABLET 1.25-250MG 0.09353 08/12/2014 0.09353 08/21/2015 GLYBURIDE/METFORMIN HCL ORAL TABLET 2.5-500 MG 0.08911 03/14/2014 0.08911 08/21/2015 GLYBURIDE/METFORMIN HCL ORAL TABLET 5 MG-500MG 0.08868 05/01/2015 0.08868 08/21/2015 GLYCINE ORAL POWDER (GRAM) 0.21190 08/12/2014 GLYCINE UROLOGIC SOLUTION IRRIGATION SOLUTION, IRRIGATION 1.5 0.00291 08/12/2014 % GLYCOPYRROLATE INJECTION VIAL (ML) 0.2 MG/ML 0.22100 08/21/2015 GLYCOPYRROLATE ORAL TABLET 1 MG 0.46960 08/21/2015 0.30938 12/25/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date GLYCOPYRROLATE ORAL TABLET 2 MG 1.53972 08/21/2015 0.61852 09/25/2015 GRANISETRON HCL INTRAVENOUS VIAL (ML) 1 MG/ML 4.71250 01/25/2013 4.71250 08/21/2015 GRANISETRON HCL INTRAVENOUS VIAL (ML) 1 MG/ML(1) 7.21995 01/25/2013 GRANISETRON HCL ORAL TABLET 1 MG 1.52404 02/27/2015 1.52404 08/21/2015 GRANISETRON HCL/PF INTRAVENOUS VIAL (ML) 100 MCG/ML 3.21880 08/12/2014 GRISEOFULVIN ULTRAMICROSIZE ORAL TABLET 125 MG 3.68837 10/17/2014 3.68837 08/21/2015 GRISEOFULVIN ULTRAMICROSIZE ORAL TABLET 250 MG 4.28393 10/17/2014 4.28393 08/21/2015 GRISEOFULVIN, MICROSIZE ORAL SUSPENSION, ORAL (FINAL DOSE 0.12406 01/31/2014 0.12406 08/21/2015 FORM) 125 MG/5ML GRISEOFULVIN, MICROSIZE ORAL TABLET 500 MG 5.95588 12/05/2014 GUAIFENESIN ORAL LIQUID (ML) 100 MG/5ML 0.00603 09/19/2014 0.00603 08/21/2015 GUAIFENESIN ORAL TABLET 200 MG 0.04248 10/31/2014 0.04248 08/21/2015 GUAIFENESIN ORAL TABLET 400 MG 0.05655 08/12/2014 0.05655 08/21/2015 GUAIFENESIN ORAL TABLET, EXTENDED RELEASE 12 HR 600 MG 0.31161 08/21/2015 GUAIFENESIN/DEXTROMETHORPHAN HBR ORAL LIQUID (ML) 100- 0.01776 11/07/2014 0.01776 08/21/2015 10MG/5 GUAIFENESIN/DEXTROMETHORPHAN HBR ORAL SYRUP 100-10MG/5 0.00801 08/12/2014 0.00801 08/21/2015 GUAIFENESIN/DEXTROMETHORPHAN HBR ORAL TABLET 400MG-20MG 0.07778 08/21/2015 GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.15389 10/10/2014 DROPS 5-2.5MG/ML GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.01987 04/24/2015 0.01987 08/21/2015 LIQUID (ML) 100-10-5MG GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.03941 08/12/2014 0.03941 08/21/2015 LIQUID (ML) 100-15-5/5 GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.02590 08/12/2014 LIQUID (ML) 200-10-5/5 GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.07980 08/12/2014 0.07980 08/21/2015 LIQUID (ML) 200-20-10 GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL 0.47192 12/12/2014 0.47192 08/21/2015 TABLET 380-15-10 GUAIFENESIN/PHENYLEPHRINE HCL ORAL TABLET 380MG-10MG 0.43170 08/12/2014 GUANFACINE HCL ORAL TABLET 1 MG 0.07999 08/12/2014 0.07999 08/21/2015 GUANFACINE HCL ORAL TABLET 2 MG 0.11665 03/13/2015 0.11665 08/21/2015 GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1 MG 0.72000 04/22/2016 0.60187 05/20/2016 GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 0.70060 12/25/2015 0.60290 05/20/2016 GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 3 MG 0.86035 09/25/2015 0.80227 01/13/2017 GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 4 MG 0.89634 09/25/2015 0.72000 04/22/2016 GUANIDINE HCL ORAL TABLET 125 MG 0.17724 01/25/2013 HALOBETASOL PROPIONATE TOPICAL CREAM (GRAM) 0.05 % 2.67890 08/15/2014 2.67890 08/21/2015 HALOBETASOL PROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 3.11640 02/06/2015 HALOPERIDOL DECANOATE INTRAMUSCULAR AMPUL (ML) 100 MG/ML 41.45400 08/30/2013 HALOPERIDOL DECANOATE INTRAMUSCULAR AMPUL (ML) 50 MG/ML 21.74667 01/25/2013 HALOPERIDOL DECANOATE INTRAMUSCULAR VIAL (ML) 100 MG/ML 39.94728 08/21/2015 43.24600 10/13/2015 HALOPERIDOL DECANOATE INTRAMUSCULAR VIAL (ML) 50 MG/ML 22.14000 10/10/2014 22.14000 08/21/2015 HALOPERIDOL LACTATE INJECTION AMPUL (ML) 5 MG/ML 5.15760 01/25/2013 HALOPERIDOL LACTATE INJECTION VIAL (ML) 5 MG/ML 1.02376 08/12/2014 1.02376 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date HALOPERIDOL LACTATE ORAL CONCENTRATE, ORAL 2 MG/ML 0.05316 05/17/2013 0.05316 08/21/2015 HALOPERIDOL ORAL TABLET 0.5 MG 0.21117 10/11/2013 HALOPERIDOL ORAL TABLET 1 MG 0.35311 03/20/2015 0.24483 09/30/2016 HALOPERIDOL ORAL TABLET 10 MG 1.07290 04/10/2015 0.83542 03/25/2016 HALOPERIDOL ORAL TABLET 2 MG 0.31789 09/30/2016 0.45210 10/21/2016 HALOPERIDOL ORAL TABLET 20 MG 2.13980 10/11/2013 1.67873 04/22/2016 HALOPERIDOL ORAL TABLET 5 MG 0.80778 02/06/2015 0.55175 05/20/2016 HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.04754 04/10/2015 0.04754 08/21/2015 INTRAVENOUS SOLUTION 12500/250 HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.02356 04/10/2015 0.02356 08/21/2015 INTRAVENOUS SOLUTION 25000/250 HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.01978 04/10/2015 0.01978 08/21/2015 INTRAVENOUS SOLUTION 25000/500 HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM CHLORIDE/PF 0.00720 01/25/2013 0.00720 08/21/2015 INTRAVENOUS INTRAVENOUS SOLUTION 1000/500ML HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM CHLORIDE/PF 0.00440 08/12/2014 0.00440 08/21/2015 INTRAVENOUS INTRAVENOUS SOLUTION 2K/1000ML HEPARIN SODIUM,PORCINE INJECTION CARTRIDGE (ML) 5000/ML(1) 3.65400 01/25/2013 HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 1000/ML 0.20739 11/28/2014 0.20739 08/21/2015 HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 10000/ML 2.31659 05/01/2015 2.31659 08/21/2015 HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 20000/ML 8.04388 04/03/2015 HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 5000/ML 1.15725 01/30/2015 HEPARIN SODIUM,PORCINE INTRAVENOUS SYRINGE (ML) 500/5 ML 0.32928 11/15/2013 HEPARIN SODIUM,PORCINE INTRAVENOUS VIAL (ML) 100/ML 0.03983 04/05/2013 0.03983 08/21/2015 HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.05431 04/24/2015 0.05431 08/21/2015 INTRAVENOUS SOLUTION 12500/250 HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.01097 04/17/2015 0.01097 08/21/2015 INTRAVENOUS SOLUTION 20K/500ML HEPARIN SODIUM,PORCINE/PF INJECTION SYRINGE (ML) 5000/0.5ML 3.99840 05/01/2015 3.99840 08/21/2015 HEPARIN SODIUM,PORCINE/PF INJECTION VIAL (ML) 1000/ML 3.64676 08/12/2014 HEPARIN SODIUM,PORCINE/PF INJECTION VIAL (ML) 5000/0.5ML 9.36923 01/25/2013 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 1 UNIT/ML 0.53235 05/31/2013 0.53235 08/21/2015 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 10 UNIT/ML 0.15678 05/31/2013 0.15678 08/21/2015 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 100/ML (1) 0.14740 05/31/2013 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 1000/10 ML 0.14740 05/31/2013 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 200/2 ML 0.14740 05/31/2013 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 300/3 ML 0.15513 07/25/2014 0.15513 08/21/2015 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 500/5 ML 0.09299 03/07/2014 0.09299 08/21/2015 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS VIAL (ML) 10 UNIT/ML 1.27250 08/12/2014 HEPARIN SODIUM,PORCINE/PF INTRAVENOUS VIAL (ML) 100/ML (1) 1.63384 01/25/2013 HYDRALAZINE HCL INJECTION VIAL (ML) 20 MG/ML 4.60408 07/19/2013 HYDRALAZINE HCL ORAL TABLET 10 MG 0.05309 09/12/2014 0.05309 08/21/2015 HYDRALAZINE HCL ORAL TABLET 100 MG 0.11896 05/20/2016 0.06535 09/30/2016 HYDRALAZINE HCL ORAL TABLET 25 MG 0.08664 02/27/2015 0.08664 08/21/2015 HYDRALAZINE HCL ORAL TABLET 50 MG 0.12510 01/29/2016 0.07186 05/20/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date HYDROCHLOROTHIAZIDE ORAL CAPSULE 12.5 MG 0.05352 05/01/2015 0.05352 08/21/2015 HYDROCHLOROTHIAZIDE ORAL TABLET 12.5 MG 0.14500 03/28/2014 0.14500 08/21/2015 HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG 0.02250 04/24/2015 0.02250 08/21/2015 HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG 0.04931 04/24/2015 0.04931 08/21/2015 HYDROCODONE BITARTRATE MISCELLANEOUS POWDER (GRAM) 100 % 7.56450 08/21/2015 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 0.56630 05/30/2014 2.5-108/5 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 0.47191 01/25/2013 2.5-167/5 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 0.59709 08/01/2014 5-217MG/10 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 0.16755 08/12/2014 7.5-325/15 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 0.10206 07/08/2016 0.05556 07/29/2016 7.5-325/15 HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 10MG- 1.78019 10/17/2014 300MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 10MG- 0.32219 08/21/2015 0.19168 03/25/2016 325MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 2.5-325 0.69069 04/03/2015 MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 5 MG- 1.22789 10/17/2014 1.22789 08/21/2015 300MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 5 MG- 0.18775 03/27/2015 0.18775 08/21/2015 325MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 7.5-300 1.43205 10/17/2014 MG HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 7.5-325 0.21181 05/20/2016 0.19130 07/29/2016 MG HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE ORAL 0.52500 01/25/2013 SYRUP 5-1.5 MG/5 HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE ORAL 0.06580 08/12/2014 SYRUP 5-1.5 MG/5 HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE ORAL 0.71674 01/30/2015 0.71674 08/21/2015 TABLET 5 MG-1.5MG HYDROCODONE POLISTIREX/CHLORPHENIRAMINE POLISTIREX ORAL 0.46416 11/28/2014 0.46416 08/21/2015 SUSPENSION, EXTENDED RELEASE 12 HR 10-8MG/5ML HYDROCODONE/IBUPROFEN ORAL TABLET 10MG-200MG 3.99069 04/10/2015 3.99069 08/21/2015 HYDROCODONE/IBUPROFEN ORAL TABLET 2.5-200MG 2.04491 01/25/2013 2.04491 08/21/2015 HYDROCODONE/IBUPROFEN ORAL TABLET 5MG-200MG 2.49634 11/21/2014 2.49634 08/21/2015 HYDROCODONE/IBUPROFEN ORAL TABLET 7.5-200 MG 0.42585 08/21/2015 0.25323 05/20/2016 HYDROCORTISONE ACETATE MISCELLANEOUS POWDER (GRAM) 3.23180 01/25/2013 3.23180 08/21/2015 HYDROCORTISONE ACETATE RECTAL SUPPOSITORY, RECTAL 25 MG 3.64114 08/12/2014 3.64114 08/21/2015 HYDROCORTISONE ACETATE RECTAL SUPPOSITORY, RECTAL 30 MG 3.95180 08/12/2014 HYDROCORTISONE ACETATE/LIDOCAINE HCL/ALOE VERA RECTAL KIT 251.09000 07/18/2014 2.5-3%(7G) HYDROCORTISONE ACETATE/PRAMOXINE HCL TOPICAL CREAM (GRAM) 1.29675 05/01/2015 1.29675 08/21/2015 2.5 %-1 % HYDROCORTISONE BUTYRATE TOPICAL CREAM (GRAM) 0.1 % 1.02530 02/15/2013 1.02530 08/21/2015 HYDROCORTISONE BUTYRATE TOPICAL OINTMENT (GRAM) 0.1 % 1.88020 05/09/2014 1.88020 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date HYDROCORTISONE BUTYRATE TOPICAL SOLUTION, NON-ORAL 0.1 % 0.21870 07/25/2014 0.21870 08/21/2015 HYDROCORTISONE BUTYRATE/EMOLLIENT BASE TOPICAL CREAM 6.29588 12/27/2013 (GRAM) 0.1 % HYDROCORTISONE MISCELLANEOUS POWDER (GRAM) 2.18774 08/12/2014 2.18774 08/21/2015 HYDROCORTISONE ORAL TABLET 10 MG 0.41100 08/21/2015 0.28362 05/20/2016 HYDROCORTISONE ORAL TABLET 20 MG 0.76090 08/21/2015 0.67427 02/26/2016 HYDROCORTISONE ORAL TABLET 5 MG 0.25311 08/29/2014 0.25311 08/21/2015 HYDROCORTISONE RECTAL ENEMA (ML) 100MG/60ML 0.06885 12/05/2014 0.06885 08/21/2015 HYDROCORTISONE TOPICAL CREAM (GRAM) 0.5 % 0.08224 04/05/2013 0.08224 08/21/2015 HYDROCORTISONE TOPICAL CREAM (GRAM) 1 % 0.05060 01/30/2015 0.05060 08/21/2015 HYDROCORTISONE TOPICAL CREAM (GRAM) 2.5 % 0.09447 02/27/2015 0.09447 08/21/2015 HYDROCORTISONE TOPICAL CREAM WITH PERINEAL APPLICATOR 1 % 0.66820 01/25/2013 HYDROCORTISONE TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 2.03770 11/21/2014 1.56170 09/30/2016 % HYDROCORTISONE TOPICAL LOTION (GRAM) 1 % 0.04414 08/12/2014 HYDROCORTISONE TOPICAL LOTION (ML) 1 % 0.03153 08/12/2014 0.03153 08/21/2015 HYDROCORTISONE TOPICAL LOTION (ML) 2.5 % 0.23863 04/12/2013 HYDROCORTISONE TOPICAL OINTMENT (GRAM) 1 % 0.10490 01/30/2015 0.10490 08/21/2015 HYDROCORTISONE TOPICAL OINTMENT (GRAM) 2.5 % 0.11200 08/12/2014 0.11200 08/21/2015 HYDROCORTISONE VALERATE TOPICAL CREAM (GRAM) 0.2 % 2.31447 08/21/2015 2.24350 01/27/2017 HYDROCORTISONE VALERATE TOPICAL OINTMENT (GRAM) 0.2 % 4.59200 07/25/2014 4.59200 08/21/2015 HYDROCORTISONE/ALOE VERA TOPICAL CREAM (GRAM) 1 % 0.08883 08/21/2015 HYDROCORTISONE/IODOQUINOL TOPICAL CREAM (GRAM) 1 %-1 % 0.43200 08/12/2014 HYDROCORTISONE/MINERAL OIL/PETROLATUM,WHITE TOPICAL 0.12564 01/25/2013 OINTMENT (GRAM) 1 % HYDROMORPHONE HCL INJECTION SYRINGE (ML) 0.5MG/.5ML 8.44200 06/21/2013 HYDROMORPHONE HCL INJECTION SYRINGE (ML) 1 MG/ML 3.90600 01/25/2013 HYDROMORPHONE HCL INJECTION SYRINGE (ML) 2 MG/ML 1.88160 12/26/2014 HYDROMORPHONE HCL INJECTION SYRINGE (ML) 4 MG/ML 3.78000 01/25/2013 HYDROMORPHONE HCL INJECTION VIAL (ML) 2 MG/ML 0.87780 08/12/2014 HYDROMORPHONE HCL ORAL LIQUID (ML) 1 MG/ML 0.27988 01/25/2013 HYDROMORPHONE HCL ORAL TABLET 2 MG 0.09250 03/22/2013 0.09250 08/21/2015 HYDROMORPHONE HCL ORAL TABLET 4 MG 0.11269 05/24/2013 0.11269 08/21/2015 HYDROMORPHONE HCL ORAL TABLET 8 MG 0.42855 08/29/2014 0.28295 09/30/2016 HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 12 14.29670 08/01/2014 14.29670 08/21/2015 MG HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 16 19.06219 08/01/2014 19.06219 08/21/2015 MG HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 32 37.91137 08/01/2014 MG HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 8 9.53110 08/01/2014 9.53110 08/21/2015 MG HYDROMORPHONE HCL RECTAL SUPPOSITORY, RECTAL 3 MG 8.58670 02/01/2013 HYDROMORPHONE HCL/PF INJECTION AMPUL (ML) 1 MG/ML 0.87360 01/25/2013 HYDROMORPHONE HCL/PF INJECTION AMPUL (ML) 2 MG/ML 0.94080 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date HYDROMORPHONE HCL/PF INJECTION AMPUL (ML) 4 MG/ML 1.33560 01/25/2013 HYDROMORPHONE HCL/PF INJECTION VIAL (ML) 10 MG/ML 1.90750 01/30/2015 1.61638 12/02/2016 HYDROQUINONE MICROSPHERES TOPICAL CREAM, EXTENDED 2.49387 01/25/2013 RELEASE (GRAM) 4 % HYDROQUINONE TOPICAL CREAM (GRAM) 4 % 2.30566 12/12/2014 2.30566 08/21/2015 HYDROXOCOBALAMIN INTRAMUSCULAR VIAL (ML) 1000MCG/ML 0.89273 01/25/2013 HYDROXYUREA ORAL CAPSULE 500 MG 0.35730 08/09/2013 HYDROXYZINE HCL INTRAMUSCULAR VIAL (ML) 50 MG/ML 1.75000 01/25/2013 1.75000 08/21/2015 HYDROXYZINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.05916 05/02/2014 0.05916 08/21/2015 HYDROXYZINE HCL ORAL TABLET 10 MG 0.07338 04/10/2015 0.07338 08/21/2015 HYDROXYZINE HCL ORAL TABLET 25 MG 0.08646 05/01/2015 0.08646 08/21/2015 HYDROXYZINE HCL ORAL TABLET 50 MG 0.15841 02/26/2016 0.10547 05/20/2016 HYDROXYZINE PAMOATE ORAL CAPSULE 100 MG 0.52378 08/15/2014 0.52378 08/21/2015 HYDROXYZINE PAMOATE ORAL CAPSULE 25 MG 0.09158 03/20/2015 0.09158 08/21/2015 HYDROXYZINE PAMOATE ORAL CAPSULE 50 MG 0.08680 07/18/2014 0.08680 08/21/2015 HYOSCYAMINE SULFATE ORAL DROPS 0.125MG/ML 1.29622 04/24/2015 1.29622 08/21/2015 HYOSCYAMINE SULFATE ORAL ELIXIR 125MCG/5ML 0.04790 12/26/2014 HYOSCYAMINE SULFATE ORAL TABLET 0.125 MG 0.28847 08/21/2015 0.15268 10/28/2016 HYOSCYAMINE SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 0.60697 07/18/2014 0.60697 08/21/2015 0.375 MG HYOSCYAMINE SULFATE ORAL TABLET,DISINTEGRATING 0.125 MG 0.27872 08/21/2015 0.26540 01/13/2017 HYOSCYAMINE SULFATE SUBLINGUAL TABLET, SUBLINGUAL 0.125 MG 0.44000 08/21/2015 0.19432 12/25/2015 HYPROMELLOSE OPHTHALMIC DROPS 0.3 % 0.35978 08/12/2014 HYPROMELLOSE OPHTHALMIC DROPS 0.4 % 0.17850 01/25/2013 IBANDRONATE SODIUM INTRAVENOUS SYRINGE (ML) 3 MG/3 ML 74.36375 11/14/2014 IBANDRONATE SODIUM ORAL TABLET 150 MG 26.46424 07/29/2016 25.51067 12/02/2016 IBUPROFEN ORAL CAPSULE 200 MG 0.10261 04/10/2015 0.10261 08/21/2015 IBUPROFEN ORAL SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 50 0.22167 01/30/2015 0.22167 08/21/2015 MG/1.25 IBUPROFEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 MG/5ML 0.02262 04/17/2015 0.02262 08/21/2015 IBUPROFEN ORAL TABLET 200 MG 0.01635 01/16/2015 0.01635 08/21/2015 IBUPROFEN ORAL TABLET 400 MG 0.06240 04/03/2015 0.06240 08/21/2015 IBUPROFEN ORAL TABLET 600 MG 0.06700 04/03/2015 0.06700 08/21/2015 IBUPROFEN ORAL TABLET 800 MG 0.07263 04/03/2015 0.07263 08/21/2015 IBUPROFEN ORAL TABLET, CHEWABLE 100 MG 0.12702 08/21/2015 IBUPROFEN/OXYCODONE HCL ORAL TABLET 400MG-5MG 1.03130 08/12/2014 1.03130 08/21/2015 IFOSFAMIDE INTRAVENOUS VIAL (EA) 3 G 88.61300 01/25/2013 IFOSFAMIDE INTRAVENOUS VIAL (ML) 1 G/20 ML 2.09300 02/27/2015 2.09300 08/21/2015 IFOSFAMIDE INTRAVENOUS VIAL (ML) 3 G/60 ML 1.93007 10/17/2014 1.93007 08/21/2015 IFOSFAMIDE/MESNA INTRAVENOUS KIT 3G-1G 281.14725 01/25/2013 IMIPENEM/CILASTATIN SODIUM INTRAVENOUS VIAL (EA) 250 MG 4.41000 08/12/2014 4.41000 08/21/2015 IMIPENEM/CILASTATIN SODIUM INTRAVENOUS VIAL (EA) 500 MG 8.82000 04/18/2014 8.82000 08/21/2015 IMIPRAMINE HCL ORAL TABLET 10 MG 0.13202 04/12/2013 0.13202 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date IMIPRAMINE HCL ORAL TABLET 25 MG 0.14740 04/03/2015 0.14740 08/21/2015 IMIPRAMINE HCL ORAL TABLET 50 MG 0.17905 05/20/2016 0.20400 09/17/2016 IMIPRAMINE PAMOATE ORAL CAPSULE 100 MG 5.97100 03/07/2014 IMIPRAMINE PAMOATE ORAL CAPSULE 125 MG 8.87087 04/10/2015 IMIPRAMINE PAMOATE ORAL CAPSULE 150 MG 11.22875 04/10/2015 IMIPRAMINE PAMOATE ORAL CAPSULE 75 MG 7.95000 12/27/2013 IMIQUIMOD TOPICAL CREAM IN PACKET (EA) 5 % 6.88410 08/21/2015 6.88410 04/22/2016 INDAPAMIDE ORAL TABLET 1.25 MG 0.30448 08/01/2014 INDAPAMIDE ORAL TABLET 2.5 MG 0.30502 04/24/2015 INDOMETHACIN ORAL CAPSULE 25 MG 0.12514 08/21/2015 0.09935 09/30/2016 INDOMETHACIN ORAL CAPSULE 50 MG 0.14030 12/12/2014 0.14030 08/21/2015 INDOMETHACIN ORAL CAPSULE, EXTENDED RELEASE 75 MG 1.29820 12/27/2013 1.29820 08/21/2015 INDOMETHACIN SODIUM INTRAVENOUS VIAL (EA) 1 MG 365.86025 08/12/2014 IPRATROPIUM BROMIDE INHALATION SOLUTION, NON-ORAL 0.2 MG/ML 0.06013 03/13/2015 0.06013 08/21/2015 IPRATROPIUM BROMIDE NASAL AEROSOL, SPRAY (ML) 21 MCG 0.76232 11/20/2015 0.62500 12/25/2015 IPRATROPIUM BROMIDE NASAL AEROSOL, SPRAY (ML) 42 MCG 1.45433 12/25/2015 1.38467 12/02/2016 IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION AMPUL FOR 0.09290 03/13/2015 0.09290 08/21/2015 NEBULIZATION (ML) 0.5-3MG/3 IRBESARTAN ORAL TABLET 150 MG 0.14740 08/21/2015 0.23152 01/27/2016 IRBESARTAN ORAL TABLET 300 MG 0.31320 08/21/2015 0.25774 09/30/2016 IRBESARTAN ORAL TABLET 75 MG 0.14563 08/12/2014 0.14563 08/21/2015 IRBESARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 150-12.5MG 0.38027 06/06/2014 0.38027 08/21/2015 IRBESARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 300-12.5MG 0.56000 01/22/2016 0.46026 07/08/2016 IRON CARBONYL,GLUC/FOLIC ACID/VIT B12/VIT C/DOCUSATE SODIUM 0.78945 10/25/2013 0.78945 08/21/2015 ORAL TABLET 90-1-50 MG IRON POLYSACCHAR COMPLX/IRON HEME POLYPEPTIDE/FOLIC 2.61148 01/25/2013 2.61148 08/21/2015 ACID/B12 ORAL TABLET 22-6-1-25 IRON POLYSACCHARIDE COMPLEX ORAL CAPSULE 150 MG 0.12990 08/16/2013 0.12990 08/21/2015 IRON POLYSACCHARIDE COMPLEX/CYANOCOBALAMIN/FOLIC ACID 0.19524 02/20/2015 0.19524 08/21/2015 ORAL CAPSULE 150-25-1 IRON POLYSACCHARIDE COMPLEX/IRON HEME POLYPEPTIDE ORAL 0.37090 08/12/2014 TABLET 28 MG IRON,CARBONYL ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.12650 08/12/2014 15MG/1.25 IRON,CARBONYL/ASCORBIC ACID/CYANOCOBALAMIN/FOLIC ACID ORAL 0.80738 08/12/2014 TABLET 100-250-1 IRON,CARBONYL/DOCUSATE SODIUM/B12-IF/FOLIC ACID/MULTIVIT-MIN 0.47055 01/25/2013 ORAL TABLET, EXTENDED RELEASE 24 HR 150-50-1MG IRON,CARBONYL/FOLIC ACID/MULTIVIT WITH MINERALS ORAL TABLET 1.05126 04/19/2013 50-1.25MG ISOMETHEPTENE MUCATE/DICHLORALPHENAZONE/ACETAMINOPHEN 4.71877 09/19/2014 4.71877 08/21/2015 ORAL CAPSULE 65-100-325 ISONIAZID INJECTION VIAL (ML) 100 MG/ML 63.03150 01/25/2013 ISONIAZID ORAL SOLUTION, ORAL 50 MG/5 ML 0.09983 01/25/2013 ISONIAZID ORAL TABLET 100 MG 0.04221 12/13/2013 0.04221 08/21/2015 ISONIAZID ORAL TABLET 300 MG 0.06993 11/28/2014 0.06993 08/21/2015 ISOPROPYL ALCOHOL IN GLYCERIN OTIC DROPS 95 %-5 % 0.07020 08/12/2014 0.07020 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ISOSORBIDE DINITRATE ORAL TABLET 10 MG 0.68863 08/21/2015 0.22376 09/30/2016 ISOSORBIDE DINITRATE ORAL TABLET 20 MG 0.61211 05/20/2016 0.54934 09/30/2016 ISOSORBIDE DINITRATE ORAL TABLET 30 MG 0.83200 10/10/2014 0.83200 08/21/2015 ISOSORBIDE DINITRATE ORAL TABLET 5 MG 0.62980 04/03/2015 0.62980 08/21/2015 ISOSORBIDE DINITRATE ORAL TABLET, EXTENDED RELEASE 40 MG 1.24501 12/05/2014 1.24501 08/21/2015 ISOSORBIDE MONONITRATE ORAL TABLET 10 MG 0.19730 01/25/2013 0.19730 08/21/2015 ISOSORBIDE MONONITRATE ORAL TABLET 20 MG 0.12251 10/11/2013 ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.41178 04/24/2015 0.41178 08/21/2015 120 MG ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.24033 08/21/2015 0.15142 07/08/2016 30 MG ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.23805 04/17/2015 0.23805 08/21/2015 60 MG ISOSULFAN BLUE SUBCUTANEOUS VIAL (ML) 1 % 110.57218 04/03/2015 110.57218 08/21/2015 ISOTRETINOIN ORAL CAPSULE 10 MG 11.76397 08/21/2015 6.52054 01/22/2016 ISOTRETINOIN ORAL CAPSULE 20 MG 6.21094 09/25/2015 6.09199 07/29/2016 ISOTRETINOIN ORAL CAPSULE 30 MG 11.51617 08/21/2015 7.81200 08/26/2016 ISOTRETINOIN ORAL CAPSULE 40 MG 7.01007 09/25/2015 6.60559 12/02/2016 ISOXSUPRINE HCL ORAL TABLET 10 MG 0.80892 04/03/2015 0.80892 08/21/2015 ISRADIPINE ORAL CAPSULE 2.5 MG 0.95543 02/13/2015 0.95543 08/21/2015 ISRADIPINE ORAL CAPSULE 5 MG 1.39713 03/27/2015 1.39713 08/21/2015 ITRACONAZOLE ORAL CAPSULE 100 MG 5.49100 02/27/2015 4.46533 08/26/2016 IVERMECTIN ORAL TABLET 3 MG 7.57155 01/16/2015 KETOCONAZOLE ORAL TABLET 200 MG 1.25998 07/25/2014 1.25998 08/21/2015 KETOCONAZOLE TOPICAL CREAM (GRAM) 2 % 0.92300 08/27/2015 1.15210 12/21/2015 KETOCONAZOLE TOPICAL SHAMPOO 2 % 0.10040 01/25/2013 0.10040 08/21/2015 KETOPROFEN ORAL CAPSULE 75 MG 0.40169 03/06/2015 0.40169 08/21/2015 KETOPROFEN ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 5.64648 03/13/2015 5.64648 08/21/2015 200 MG KETOROLAC TROMETHAMINE INJECTION SYRINGE (ML) 30 MG/ML 1.81000 04/25/2014 KETOROLAC TROMETHAMINE INJECTION VIAL (ML) 15 MG/ML 1.01304 02/13/2015 1.01304 08/21/2015 KETOROLAC TROMETHAMINE INJECTION VIAL (ML) 30 MG/ML 1.31943 01/25/2013 KETOROLAC TROMETHAMINE INJECTION VIAL (ML) 30MG/ML(1) 1.08696 02/13/2015 1.08696 08/21/2015 KETOROLAC TROMETHAMINE INTRAMUSCULAR VIAL (ML) 60 MG/2 ML 0.97981 02/13/2015 0.97981 08/21/2015 KETOROLAC TROMETHAMINE OPHTHALMIC DROPS 0.4 % 7.81600 03/27/2015 7.81600 08/21/2015 KETOROLAC TROMETHAMINE OPHTHALMIC DROPS 0.5 % 1.29534 08/12/2014 1.29534 08/21/2015 KETOROLAC TROMETHAMINE ORAL TABLET 10 MG 0.55620 08/21/2015 0.83500 04/23/2016 KETOTIFEN FUMARATE OPHTHALMIC DROPS 0.025 % 0.92080 03/27/2015 0.92080 08/21/2015 LABETALOL HCL INTRAVENOUS SYRINGE (ML) 20 MG/4 ML 0.65310 01/25/2013 0.65310 08/21/2015 LABETALOL HCL ORAL TABLET 100 MG 0.28263 08/21/2015 0.22860 09/30/2016 LABETALOL HCL ORAL TABLET 200 MG 0.35210 11/20/2015 0.25114 05/20/2016 LABETALOL HCL ORAL TABLET 300 MG 0.64820 08/21/2015 0.45636 04/22/2016 LACTIC ACID TOPICAL CREAM (GRAM) 10 % 0.08303 01/25/2013 LACTIC ACID TOPICAL LOTION (ML) 10 % 0.04280 08/12/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LACTULOSE ORAL SOLUTION, ORAL 10 G/15 ML 0.03407 04/03/2015 LACTULOSE ORAL SOLUTION, ORAL 10 G/15 ML 0.01396 04/24/2015 LACTULOSE ORAL SOLUTION, ORAL 10 G/15 ML 0.01301 11/21/2014 0.01301 08/21/2015 LACTULOSE ORAL SOLUTION, ORAL 20 G/30 ML 0.02205 02/07/2014 0.02205 08/21/2015 LAMIVUDINE ORAL SOLUTION, ORAL 10 MG/ML 0.34922 03/13/2015 LAMIVUDINE ORAL TABLET 100 MG 11.27770 08/21/2015 11.27770 01/01/2017 LAMIVUDINE ORAL TABLET 150 MG 3.23094 02/26/2016 2.17041 10/28/2016 LAMIVUDINE ORAL TABLET 300 MG 8.50800 04/03/2015 8.50800 08/21/2015 LAMIVUDINE/ZIDOVUDINE ORAL TABLET 150-300MG 4.58863 02/26/2016 2.69650 10/28/2016 LAMOTRIGINE ORAL TABLET 100 MG 0.06700 03/27/2015 0.06700 08/21/2015 LAMOTRIGINE ORAL TABLET 150 MG 0.10385 03/27/2015 0.10385 08/21/2015 LAMOTRIGINE ORAL TABLET 200 MG 0.08236 04/03/2015 0.08236 08/21/2015 LAMOTRIGINE ORAL TABLET 25 MG 0.05975 03/27/2015 0.05975 08/21/2015 LAMOTRIGINE ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG 0.29940 05/17/2013 0.29940 08/21/2015 LAMOTRIGINE ORAL TABLET, CHEWABLE DISPERSIBLE 5 MG 0.25402 09/26/2014 0.25402 08/21/2015 LAMOTRIGINE ORAL TABLET, DOSE PACK 25MG (35) 2.90500 01/25/2013 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG 7.90210 02/19/2016 5.75366 07/08/2016 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 200 MG 7.71191 09/30/2016 7.34952 10/28/2016 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 25 MG 4.05817 01/23/2015 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 250 MG 24.47409 04/26/2013 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 11.06216 12/25/2015 10.22188 12/02/2016 LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 50 MG 8.09965 11/28/2014 6.19133 05/20/2016 LAMOTRIGINE ORAL TABLET,DISINTEGRATING 100 MG 19.92621 08/21/2015 10.52000 07/08/2016 LAMOTRIGINE ORAL TABLET,DISINTEGRATING 200 MG 23.77830 04/03/2015 23.77830 08/21/2015 LAMOTRIGINE ORAL TABLET,DISINTEGRATING 25 MG 17.44749 04/03/2015 17.44749 08/21/2015 LAMOTRIGINE ORAL TABLET,DISINTEGRATING 50 MG 18.68721 04/03/2015 18.68721 08/21/2015 LANOLIN/MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT 0.91000 01/25/2013 0.91000 08/21/2015 (GRAM) LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.46166 04/10/2015 0.46166 08/21/2015 COATED) 15 MG LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC 0.32390 09/30/2016 0.28562 10/28/2016 COATED) 30 MG LANSOPRAZOLE/AMOXICILLIN TRIHYDRATE/CLARITHROMYCIN ORAL 3.59300 03/20/2015 COMBINATION PACKAGE (EA) 30-500-500 LATANOPROST OPHTHALMIC DROPS 0.005 % 2.87014 09/30/2016 2.68354 01/27/2017 LEFLUNOMIDE ORAL TABLET 10 MG 0.71288 08/21/2015 4.20000 06/17/2016 LEFLUNOMIDE ORAL TABLET 20 MG 4.60693 08/22/2015 4.43400 07/29/2016 LETROZOLE ORAL TABLET 2.5 MG 0.15186 08/21/2015 0.20540 04/28/2016 LEUCOVORIN CALCIUM INJECTION VIAL (EA) 200 MG 16.25400 08/12/2014 16.25400 08/21/2015 LEUCOVORIN CALCIUM INJECTION VIAL (EA) 50 MG 5.85200 08/12/2014 5.85200 08/21/2015 LEUCOVORIN CALCIUM INJECTION VIAL (EA) 500 MG 99.22500 01/25/2013 LEUCOVORIN CALCIUM INJECTION VIAL (ML) 10 MG/ML 0.29460 08/12/2014 0.29460 08/21/2015 LEUCOVORIN CALCIUM ORAL TABLET 10 MG 5.25150 08/12/2014 LEUCOVORIN CALCIUM ORAL TABLET 15 MG 5.85368 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LEUCOVORIN CALCIUM ORAL TABLET 25 MG 7.83744 05/17/2013 LEUCOVORIN CALCIUM ORAL TABLET 5 MG 0.90784 03/20/2015 0.64904 12/02/2016 LEUPROLIDE ACETATE SUBCUTANEOUS KIT 1 MG/0.2ML 129.30375 03/13/2015 129.30375 08/21/2015 LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (EA) 1.25MG/0.5 4.52639 12/26/2014 4.52639 08/21/2015 LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (ML) 0.31MG/3ML 0.78893 01/30/2015 0.78893 08/21/2015 LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (ML) 0.63MG/3ML 0.72006 01/16/2015 0.72006 08/21/2015 LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (ML) 1.25MG/3ML 0.72006 12/12/2014 0.72006 08/21/2015 LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS 0.59877 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 1000MG/100 LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS 0.77967 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 1500MG/100 LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS 0.36284 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 500MG/0.1L LEVETIRACETAM INTRAVENOUS VIAL (ML) 500 MG/5ML 1.29524 08/12/2014 1.29524 08/21/2015 LEVETIRACETAM ORAL SOLUTION, ORAL 100 MG/ML 0.04966 03/27/2015 0.04966 08/21/2015 LEVETIRACETAM ORAL SOLUTION, ORAL 500 MG/5ML 1.06824 08/21/2015 0.05210 09/30/2016 LEVETIRACETAM ORAL TABLET 1000 MG 0.32163 03/25/2016 0.26621 01/27/2017 LEVETIRACETAM ORAL TABLET 250 MG 0.07448 02/20/2015 0.07448 08/21/2015 LEVETIRACETAM ORAL TABLET 500 MG 0.12714 03/27/2015 0.12714 08/21/2015 LEVETIRACETAM ORAL TABLET 750 MG 0.53210 06/23/2016 0.18265 09/30/2016 LEVETIRACETAM ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.36275 02/13/2015 0.36275 08/21/2015 LEVETIRACETAM ORAL TABLET, EXTENDED RELEASE 24 HR 750 MG 0.53184 02/06/2015 0.53184 08/21/2015 LEVOBUNOLOL HCL OPHTHALMIC DROPS 0.5 % 3.38520 04/05/2013 2.15200 09/30/2016 LEVOCARNITINE (WITH SUGAR) ORAL SOLUTION, ORAL 100 MG/ML 0.79500 11/16/2016 0.71721 01/27/2017 LEVOCARNITINE ORAL TABLET 330 MG 0.53495 04/24/2015 LEVOCARNITINE ORAL TABLET 500 MG 0.24450 10/24/2014 0.24450 08/21/2015 LEVOCETIRIZINE DIHYDROCHLORIDE ORAL SOLUTION, ORAL 2.5 0.43651 08/12/2014 0.43651 08/21/2015 MG/5ML LEVOCETIRIZINE DIHYDROCHLORIDE ORAL TABLET 5 MG 0.30448 08/21/2015 0.20891 05/20/2016 LEVOFLOXACIN INTRAVENOUS VIAL (ML) 25 MG/ML 0.55298 08/12/2014 LEVOFLOXACIN OPHTHALMIC DROPS 0.5 % 7.88880 01/25/2013 LEVOFLOXACIN ORAL SOLUTION, ORAL 250MG/10ML 0.88900 08/12/2014 LEVOFLOXACIN ORAL TABLET 250 MG 0.14767 05/02/2014 0.14767 08/21/2015 LEVOFLOXACIN ORAL TABLET 500 MG 0.24656 05/01/2015 0.24656 08/21/2015 LEVOFLOXACIN ORAL TABLET 750 MG 0.44488 12/26/2014 0.44488 08/21/2015 LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS 0.11258 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 250MG/50ML LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS 0.06601 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 500MG/0.1L LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS 0.05357 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 750MG/.15L LEVOMEFOLATE CALCIUM ORAL TABLET 15 MG 2.04831 01/23/2015 2.04831 08/21/2015 LEVOMEFOLATE CALCIUM ORAL TABLET 7.5 MG 2.05620 02/20/2015 2.05620 08/21/2015 LEVONORGESTREL ORAL TABLET 0.75 MG 12.79600 01/25/2013 12.79600 08/21/2015 LEVONORGESTREL ORAL TABLET 1.5 MG 22.60650 02/27/2015 22.60650 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LEVONORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.1-0.02 0.41047 08/26/2016 0.37476 09/30/2016 LEVONORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.15-0.03 0.49544 02/26/2016 0.19619 09/30/2016 LEVONORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 6-5-10 0.68718 08/12/2014 0.18904 07/08/2016 LEVONORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 90-20 MCG 1.48500 04/24/2015 LEVONORGESTREL-ETHINYL ESTRADIOL ORAL TABLET, DOSE PACK, 3 0.91016 08/21/2015 0.66314 12/02/2016 MONTHS 0.15-0.03 LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL 2.06577 01/25/2013 ORAL TABLET, DOSE PACK, 3 MONTHS 100-20(84) LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL 2.06577 03/13/2015 1.69724 12/02/2016 ORAL TABLET, DOSE PACK, 3 MONTHS 150-30(84) LEVORPHANOL TARTRATE ORAL TABLET 2 MG 1.12600 08/12/2014 1.12600 08/21/2015 LEVOTHYROXINE SODIUM INTRAVENOUS VIAL (EA) 100 MCG 77.11900 11/07/2014 77.11900 08/21/2015 LEVOTHYROXINE SODIUM INTRAVENOUS VIAL (EA) 500 MCG 44.60050 01/25/2013 44.60050 08/21/2015 LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG 0.47587 08/21/2015 0.42673 01/27/2017 LEVOTHYROXINE SODIUM ORAL TABLET 112 MCG 0.49014 03/20/2015 0.49014 08/21/2015 LEVOTHYROXINE SODIUM ORAL TABLET 125 MCG 0.52536 08/21/2015 0.46229 09/30/2016 LEVOTHYROXINE SODIUM ORAL TABLET 137 MCG 0.46746 09/19/2014 0.46746 08/21/2015 LEVOTHYROXINE SODIUM ORAL TABLET 150 MCG 0.55223 02/13/2015 0.55223 08/21/2015 LEVOTHYROXINE SODIUM ORAL TABLET 175MCG 0.65123 08/21/2015 0.55979 02/26/2016 LEVOTHYROXINE SODIUM ORAL TABLET 200 MCG 0.54139 02/26/2016 0.49196 01/27/2017 LEVOTHYROXINE SODIUM ORAL TABLET 25 MCG 0.36432 02/06/2015 0.36432 08/21/2015 LEVOTHYROXINE SODIUM ORAL TABLET 300 MCG 0.75992 07/25/2014 0.75992 08/21/2015 LEVOTHYROXINE SODIUM ORAL TABLET 50 MCG 0.34720 07/25/2014 0.34720 08/21/2015 LEVOTHYROXINE SODIUM ORAL TABLET 75 MCG 0.45173 08/21/2015 0.40814 01/27/2017 LEVOTHYROXINE SODIUM ORAL TABLET 88 MCG 0.43870 02/13/2015 0.43870 08/21/2015 LIDOCAINE HCL IN DEXTROSE 5% IN WATER/PF INTRAVENOUS 0.01280 08/12/2014 INTRAVENOUS SOLUTION 4 MG/ML LIDOCAINE HCL IN DEXTROSE 5% IN WATER/PF INTRAVENOUS 0.02029 01/25/2013 INTRAVENOUS SOLUTION 8 MG/ML LIDOCAINE HCL IN DEXTROSE 7.5 % IN WATER/PF INTRATHECAL AMPUL 6.05930 08/12/2014 (ML) 5 % LIDOCAINE HCL INJECTION VIAL (ML) 10 MG/ML 0.05802 02/07/2014 0.05802 08/21/2015 LIDOCAINE HCL INJECTION VIAL (ML) 20 MG/ML 0.06084 01/25/2013 LIDOCAINE HCL MUCOUS MEMBRANE JELLY (ML) 2 % 0.27545 02/14/2014 0.27545 08/21/2015 LIDOCAINE HCL MUCOUS MEMBRANE JELLY WITH PREFILLED 0.34943 12/12/2014 0.34943 08/21/2015 APPLICATOR (ML) 2 % LIDOCAINE HCL MUCOUS MEMBRANE SOLUTION, NON-ORAL 40 MG/ML 0.06266 08/12/2014 0.06266 08/21/2015 LIDOCAINE HCL MUCOUS MEMBRANE SOLUTION, ORAL 2 % 0.02375 05/01/2015 0.02375 08/21/2015 LIDOCAINE HCL TOPICAL SOLUTION, ORAL 4 % 1.05248 01/25/2013 LIDOCAINE HCL/EPINEPHRINE BITARTRATE INJECTION CARTRIDGE (ML) 0.14933 01/25/2013 2 %-1:100K LIDOCAINE HCL/EPINEPHRINE BITARTRATE INJECTION CARTRIDGE (ML) 0.14933 01/25/2013 2%-1:50000 LIDOCAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 1%-1:100K 0.06995 01/25/2013 0.06995 08/21/2015 LIDOCAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 2 %-1:100K 0.07910 08/12/2014 0.07910 08/21/2015 LIDOCAINE HCL/EPINEPHRINE/PF INJECTION VIAL (ML) 2%-1:200K 0.35740 08/12/2014 0.35740 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL CREAM (GRAM) 3 1.78500 03/13/2015 %-0.5 % LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL CREAM WITH 1.37036 02/06/2015 1.37036 08/21/2015 APPLICATOR 3 %-0.5 % LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL CREAM WITH 251.09000 01/25/2013 APPLICATOR 3%-1%(7 G) LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL GEL WITH 251.09000 01/25/2013 APPLICATOR (GRAM) 3-2.5%(7G) LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL KIT 3 %-0.5 % 7.69340 08/21/2015 LIDOCAINE HCL/PF INJECTION AMPUL (ML) 10 MG/ML 0.35751 12/20/2013 0.35751 08/21/2015 LIDOCAINE HCL/PF INJECTION AMPUL (ML) 15 MG/ML 0.66715 01/25/2013 LIDOCAINE HCL/PF INJECTION AMPUL (ML) 20 MG/ML 1.01535 12/27/2013 LIDOCAINE HCL/PF INJECTION AMPUL (ML) 40 MG/ML 0.56780 08/12/2014 LIDOCAINE HCL/PF INJECTION VIAL (ML) 20 MG/ML 0.48516 08/12/2014 LIDOCAINE HCL/PF INJECTION VIAL (ML) 5 MG/ML 0.11002 01/25/2013 LIDOCAINE HCL/PF INTRAVENOUS SYRINGE (ML) 100 MG/5ML 0.66080 01/25/2013 0.66080 08/21/2015 LIDOCAINE HCL/PF INTRAVENOUS SYRINGE (ML) 50 MG/5 ML 0.88790 08/12/2014 LIDOCAINE HCL/PF INTRAVENOUS VIAL (ML) 20 MG/ML 0.28224 01/25/2013 LIDOCAINE MISCELLANEOUS POWDER (GRAM) 0.19471 08/21/2015 LIDOCAINE TOPICAL ADHESIVE PATCH, MEDICATED 5 % 4.85371 12/02/2016 4.85371 01/01/2017 LIDOCAINE TOPICAL CREAM (GRAM) 5 % 1.05645 12/26/2014 1.05645 08/21/2015 LIDOCAINE TOPICAL OINTMENT (GRAM) 5 % 3.94780 04/25/2016 5.33306 07/12/2016 LIDOCAINE/PRILOCAINE TOPICAL CREAM (GRAM) 2.5 %-2.5% 0.97542 09/14/2015 0.69824 07/08/2016 LIDOCAINE/PRILOCAINE TOPICAL KIT 2.5 %-2.5% 1.40764 01/25/2013 1.40764 08/21/2015 LINDANE TOPICAL LOTION (ML) 1 % 1.59670 02/08/2013 1.59670 08/21/2015 LINDANE TOPICAL SHAMPOO 1 % 1.59670 02/08/2013 1.59670 08/21/2015 LINEZOLID INTRAVENOUS INTRAVENOUS SOLUTION 600MG/300 0.50400 03/13/2015 0.50400 08/21/2015 LINEZOLID ORAL TABLET 600 MG 5.95600 03/26/2016 5.95600 03/26/2016 LIOTHYRONINE SODIUM ORAL TABLET 25 MCG 0.57166 11/28/2014 0.69201 05/15/2015 LIOTHYRONINE SODIUM ORAL TABLET 5 MCG 0.46865 12/12/2014 LIOTHYRONINE SODIUM ORAL TABLET 50 MCG 1.01491 04/24/2015 LISINOPRIL ORAL TABLET 10 MG 0.02112 04/17/2015 0.02112 08/21/2015 LISINOPRIL ORAL TABLET 2.5 MG 0.01635 05/01/2015 0.01635 08/21/2015 LISINOPRIL ORAL TABLET 20 MG 0.03477 04/17/2015 0.03477 08/21/2015 LISINOPRIL ORAL TABLET 30 MG 0.07504 02/27/2015 0.07504 08/21/2015 LISINOPRIL ORAL TABLET 40 MG 0.06145 04/10/2015 0.06145 08/21/2015 LISINOPRIL ORAL TABLET 5 MG 0.01809 05/01/2015 0.01809 08/21/2015 LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.02693 03/06/2015 0.02693 08/21/2015 LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 20 MG-25MG 0.05186 04/24/2015 0.05186 08/21/2015 LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG 0.04063 04/24/2015 0.04063 08/21/2015 LITHIUM CARBONATE ORAL CAPSULE 150 MG 0.06052 02/13/2015 0.06052 08/21/2015 LITHIUM CARBONATE ORAL CAPSULE 300 MG 0.03114 04/24/2015 0.03114 08/21/2015 LITHIUM CARBONATE ORAL CAPSULE 600 MG 0.14351 01/16/2015 0.14351 08/21/2015 LITHIUM CARBONATE ORAL TABLET 300 MG 0.14961 04/17/2015 0.14961 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date LITHIUM CARBONATE ORAL TABLET, EXTENDED RELEASE 300 MG 0.22538 11/14/2014 0.22538 08/21/2015 LITHIUM CARBONATE ORAL TABLET, EXTENDED RELEASE 450 MG 0.24003 02/13/2015 0.24003 08/21/2015 LITHIUM CITRATE ORAL SOLUTION, ORAL 8 MEQ/5 ML 0.03921 01/25/2013 LOPERAMIDE HCL ORAL CAPSULE 2 MG 0.21721 08/21/2015 0.34521 09/28/2015 LOPERAMIDE HCL ORAL LIQUID (ML) 1MG/7.5ML 0.03361 08/12/2014 0.03361 08/21/2015 LOPERAMIDE HCL ORAL TABLET 2 MG 0.08953 08/12/2014 0.08953 08/21/2015 LORATADINE ORAL SOLUTION, ORAL 5 MG/5 ML 0.04500 03/27/2015 0.04500 08/21/2015 LORATADINE ORAL TABLET 10 MG 0.05136 04/10/2015 0.05136 08/21/2015 LORATADINE ORAL TABLET,DISINTEGRATING 10 MG 0.38100 02/01/2013 0.38100 08/21/2015 LORATADINE/PSEUDOEPHEDRINE SULFATE ORAL TABLET, EXTENDED 0.58500 08/21/2015 RELEASE 12 HR 5 MG-120MG LORATADINE/PSEUDOEPHEDRINE SULFATE ORAL TABLET, EXTENDED 0.57203 03/27/2015 0.57203 08/21/2015 RELEASE 24 HR 10MG-240MG LORAZEPAM INJECTION SYRINGE (ML) 2 MG/ML 1.76400 02/15/2013 1.76400 08/21/2015 LORAZEPAM INJECTION SYRINGE (ML) 4 MG/ML 2.46960 01/25/2013 LORAZEPAM INJECTION VIAL (ML) 2 MG/ML 0.63000 03/01/2013 LORAZEPAM INJECTION VIAL (ML) 4 MG/ML 1.14324 01/25/2013 LORAZEPAM ORAL CONCENTRATE, ORAL 2 MG/ML 0.84150 12/25/2015 0.46567 01/13/2017 LORAZEPAM ORAL TABLET 0.5 MG 0.03047 05/01/2015 0.03047 08/21/2015 LORAZEPAM ORAL TABLET 1 MG 0.03287 05/01/2015 0.03287 08/21/2015 LORAZEPAM ORAL TABLET 2 MG 0.05247 05/01/2015 0.05247 08/21/2015 LOSARTAN POTASSIUM ORAL TABLET 100 MG 0.12347 05/01/2015 0.12347 08/21/2015 LOSARTAN POTASSIUM ORAL TABLET 25 MG 0.04422 05/01/2015 0.04422 08/21/2015 LOSARTAN POTASSIUM ORAL TABLET 50 MG 0.05994 05/01/2015 0.05994 08/21/2015 LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 100- 0.10720 04/03/2015 0.10720 08/21/2015 12.5MG LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 100MG- 0.09380 04/10/2015 0.09380 08/21/2015 25MG LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 50-12.5 0.07450 04/17/2015 0.07450 08/21/2015 MG LOVASTATIN ORAL TABLET 10 MG 0.03471 08/21/2015 0.07840 01/27/2016 LOVASTATIN ORAL TABLET 20 MG 0.07601 04/03/2015 0.07601 08/21/2015 LOVASTATIN ORAL TABLET 40 MG 0.16865 03/25/2016 0.14289 09/30/2016 LOXAPINE SUCCINATE ORAL CAPSULE 10 MG 0.53024 11/28/2014 0.53024 08/21/2015 LOXAPINE SUCCINATE ORAL CAPSULE 25 MG 0.76809 11/28/2014 0.76809 08/21/2015 LOXAPINE SUCCINATE ORAL CAPSULE 5 MG 0.37172 11/28/2014 0.37172 08/21/2015 LOXAPINE SUCCINATE ORAL CAPSULE 50 MG 0.99763 11/28/2014 0.99763 08/21/2015 MAGNESIUM CARBONATE/ALUMINUM HYDROXIDE/ALGINIC ACID ORAL 0.01253 01/25/2013 SUSPENSION, ORAL (FINAL DOSE FORM) 358-95/15 MAGNESIUM CHLORIDE ORAL TABLET, EXTENDED RELEASE 64 MG 0.08364 01/25/2013 MAGNESIUM HYDROXIDE ORAL SUSPENSION, ORAL (FINAL DOSE 0.00419 08/12/2014 0.00419 08/21/2015 FORM) 400 MG/5ML MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ORAL 0.00592 09/19/2014 0.00592 08/21/2015 SUSPENSION, ORAL (FINAL DOSE FORM) 200-200-20 MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ORAL 0.00967 12/26/2014 0.00967 08/21/2015 SUSPENSION, ORAL (FINAL DOSE FORM) 400-400-40 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ORAL 0.03062 08/12/2014 0.03062 08/21/2015 TABLET, CHEWABLE 200-200-25 MAGNESIUM OXIDE ORAL CAPSULE 400 MG 0.08450 08/12/2014 MAGNESIUM OXIDE ORAL TABLET 400 MG 0.02077 02/06/2015 0.02077 08/21/2015 MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS 0.01970 08/12/2014 INTRAVENOUS SOLUTION 20 G/500ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS 0.01440 08/12/2014 INTRAVENOUS SOLUTION 40G/1000ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS 0.24560 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 2 G/50 ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS 0.13419 07/25/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 4 G/100 ML MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS 0.23100 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 4 G/50 ML MAGNESIUM SULFATE INJECTION SYRINGE (ML) 4 MEQ/ML 0.63168 01/25/2013 MAGNESIUM SULFATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.11630 08/12/2014 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 1 G/100 ML MALATHION TOPICAL LOTION (ML) 0.5 % 2.54547 04/03/2015 2.54547 08/21/2015 MANGANESE CHLORIDE INTRAVENOUS VIAL (ML) 0.1 MG/ML 0.17390 08/12/2014 MANNITOL INTRAVENOUS INTRAVENOUS SOLUTION 10 % 0.01620 08/12/2014 MANNITOL INTRAVENOUS INTRAVENOUS SOLUTION 20 % 0.03980 01/25/2013 MANNITOL INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.00866 01/25/2013 MANNITOL/SORBITOL SOLUTION URETHRAL SOLUTION, IRRIGATION 0.00569 01/25/2013 0.54G-2.7G MAPROTILINE HCL ORAL TABLET 25 MG 0.59890 08/12/2014 MAPROTILINE HCL ORAL TABLET 50 MG 0.93980 02/08/2013 MAPROTILINE HCL ORAL TABLET 75 MG 1.28950 08/12/2014 MECLIZINE HCL ORAL TABLET 12.5 MG 0.03685 02/27/2015 0.03685 08/21/2015 MECLIZINE HCL ORAL TABLET 25 MG 0.28090 08/21/2015 0.19658 05/20/2016 MECLOFENAMATE SODIUM ORAL CAPSULE 100 MG 3.34760 08/12/2014 3.34760 08/21/2015 MECLOFENAMATE SODIUM ORAL CAPSULE 50 MG 1.91160 08/12/2014 MECOBALAMIN/LEVOMEFOLATE CALCIUM/PYRIDOXAL PHOSPHATE 0.88358 03/27/2015 0.88358 08/21/2015 ORAL TABLET 2-3-35 MG MEDROXYPROGESTERONE ACETATE ORAL TABLET 10 MG 0.12690 05/01/2015 0.12690 08/21/2015 MEDROXYPROGESTERONE ACETATE ORAL TABLET 2.5 MG 0.12866 09/26/2014 0.12866 08/21/2015 MEDROXYPROGESTERONE ACETATE ORAL TABLET 5 MG 0.23339 09/26/2014 0.23339 08/21/2015 MEFENAMIC ACID ORAL CAPSULE 250 MG 11.22208 11/07/2014 11.22208 08/21/2015 MEFLOQUINE HCL ORAL TABLET 250 MG 3.74400 04/05/2013 3.74400 08/21/2015 MEGESTROL ACETATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.06918 01/30/2015 400MG/10ML MEGESTROL ACETATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.29429 08/08/2014 0.29429 08/21/2015 400MG/10ML MEGESTROL ACETATE ORAL TABLET 20 MG 0.11377 06/27/2014 MEGESTROL ACETATE ORAL TABLET 40 MG 0.21660 08/21/2015 0.17936 05/20/2016 MELATONIN ORAL TABLET, EXTENDED RELEASE 3 MG 0.06370 01/25/2013 MELATONIN/TRYPTOPHAN ORAL CAPSULE 3 MG-100MG 5.05750 01/31/2014 MELOXICAM ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 7.5 MG/5ML 1.33161 02/21/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date MELOXICAM ORAL TABLET 15 MG 0.03190 05/01/2015 0.03190 08/21/2015 MELOXICAM ORAL TABLET 7.5 MG 0.02466 05/01/2015 0.02466 08/21/2015 MEMANTINE HCL ORAL TABLET 10 MG 0.52000 10/23/2015 0.52000 01/01/2017 MEMANTINE HCL ORAL TABLET 5 MG 0.34267 05/20/2016 0.24910 10/28/2016 MENTHOL MUCOUS MEMBRANE LOZENGE 8 MG 0.06420 08/12/2014 MENTHOL TOPICAL GEL (GRAM) 10 % 0.11397 01/25/2013 MEPERIDINE HCL INJECTION CARTRIDGE (ML) 10 MG/ML 0.49911 01/25/2013 MEPERIDINE HCL ORAL SOLUTION, ORAL 50 MG/5 ML 0.14191 01/25/2013 MEPERIDINE HCL ORAL TABLET 100 MG 0.32670 03/06/2015 MEPERIDINE HCL ORAL TABLET 50 MG 1.31433 10/31/2014 1.31433 08/21/2015 MEPERIDINE HCL/PF INJECTION VIAL (ML) 100 MG/ML 2.35200 01/25/2013 MEPERIDINE HCL/PF INJECTION VIAL (ML) 25 MG/ML 2.12100 01/25/2013 MEPERIDINE HCL/PF INJECTION VIAL (ML) 50 MG/ML 0.94080 01/25/2013 MEPIVACAINE HCL/PF INJECTION CARTRIDGE (ML) 30 MG/ML 0.17730 08/12/2014 MEPROBAMATE ORAL TABLET 200 MG 4.81285 10/17/2014 4.81285 08/21/2015 MEPROBAMATE ORAL TABLET 400 MG 0.98070 01/25/2013 0.98070 08/21/2015 MERCAPTOPURINE ORAL TABLET 50 MG 1.91920 02/01/2013 1.64482 12/02/2016 MEROPENEM INTRAVENOUS VIAL (EA) 1 G 11.34682 08/21/2015 16.85013 01/23/2017 MEROPENEM INTRAVENOUS VIAL (EA) 500 MG 4.50240 12/26/2014 4.50240 08/21/2015 MESALAMINE RECTAL ENEMA (ML) 4 G/60 ML 0.22825 09/19/2014 0.22825 08/21/2015 MESALAMINE WITH CLEANSING WIPES RECTAL ENEMA KIT 4 G/60 ML 119.73500 12/26/2014 METAPROTERENOL SULFATE ORAL SYRUP 10 MG/5 ML 0.02460 08/12/2014 0.02460 08/21/2015 METAPROTERENOL SULFATE ORAL TABLET 10 MG 0.69965 01/25/2013 0.69965 08/21/2015 METAPROTERENOL SULFATE ORAL TABLET 20 MG 0.97496 01/25/2013 0.97496 08/21/2015 METAXALONE ORAL TABLET 800 MG 3.79171 08/21/2015 2.77400 05/20/2016 METFORMIN HCL ORAL TABLET 1000 MG 0.03664 04/24/2015 0.03664 08/21/2015 METFORMIN HCL ORAL TABLET 500 MG 0.01932 04/24/2015 0.01932 08/21/2015 METFORMIN HCL ORAL TABLET 850 MG 0.02986 05/01/2015 0.02986 08/21/2015 METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1000 MG 12.33520 02/19/2016 10.09759 07/08/2016 METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 3.60978 12/26/2014 METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.04020 05/01/2015 0.04020 08/21/2015 METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 750 MG 0.09822 04/03/2015 0.09822 08/21/2015 METHADONE HCL INJECTION VIAL (ML) 10 MG/ML 6.01720 01/25/2013 METHADONE HCL ORAL CONCENTRATE, ORAL 10 MG/ML 0.62300 02/01/2013 METHADONE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.09670 07/18/2014 METHADONE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.12491 01/25/2013 METHADONE HCL ORAL TABLET 10 MG 0.17193 02/26/2016 0.12374 03/25/2016 METHADONE HCL ORAL TABLET 5 MG 0.19503 03/13/2015 0.19503 08/21/2015 METHADONE HCL ORAL TABLET, SOLUBLE 40 MG 0.22381 01/25/2013 0.22381 08/21/2015 METHAMPHETAMINE HCL ORAL TABLET 5 MG 4.11749 05/01/2015 4.11749 08/21/2015 METHAZOLAMIDE ORAL TABLET 25 MG 2.68163 03/13/2015 METHAZOLAMIDE ORAL TABLET 50 MG 2.59840 12/05/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date METHENAMINE HIPPURATE ORAL TABLET 1 G 1.46649 08/21/2015 1.31940 05/20/2016 METHENAMINE MANDELATE ORAL TABLET 500 MG 0.62041 01/25/2013 METHENAMINE/METHYLENE BLUE/SOD 1.80978 03/06/2015 1.80978 08/21/2015 PHOS/P.SALICYLATE/HYOSCYAMINE ORAL CAPSULE 118-10-36 METHENAMINE/METHYLENE BLUE/SOD 4.27272 03/06/2015 4.27272 08/21/2015 PHOS/P.SALICYLATE/HYOSCYAMINE ORAL TABLET 81-0.12MG METHENAMINE/METHYLENE BLUE/SOD 0.91000 09/12/2014 PHOS/P.SALICYLATE/HYOSCYAMINE ORAL TABLET 81.6-10.8 METHENAMINE/SOD PHOSPH,MONOBASIC/METHYLENE 2.26793 03/06/2015 BLUE/HYOSCYAMINE ORAL TABLET 81.6-.12MG METHIMAZOLE ORAL TABLET 10 MG 0.15839 01/16/2015 0.15839 08/21/2015 METHIMAZOLE ORAL TABLET 5 MG 0.08482 02/27/2015 METHOCARBAMOL INJECTION VIAL (ML) 100 MG/ML 4.14861 02/13/2015 METHOCARBAMOL ORAL TABLET 500 MG 0.04462 08/21/2015 0.10250 01/27/2016 METHOCARBAMOL ORAL TABLET 750 MG 0.15530 08/21/2015 0.10952 09/30/2016 METHOTREXATE SODIUM INJECTION VIAL (ML) 25 MG/ML 3.00720 01/30/2015 METHOTREXATE SODIUM ORAL TABLET 2.5 MG 1.23538 05/20/2016 1.06288 09/30/2016 METHOTREXATE SODIUM/PF INJECTION VIAL (ML) 25 MG/ML 0.58357 10/17/2014 0.58357 08/21/2015 METHOXSALEN ORAL CAPSULE, LIQUID-FILLED, RAPID RELEASE 10 MG 66.75860 09/05/2014 METHSCOPOLAMINE BROMIDE ORAL TABLET 2.5 MG 1.53056 08/12/2014 1.53056 08/21/2015 METHSCOPOLAMINE BROMIDE ORAL TABLET 5 MG 2.38030 08/21/2015 2.17750 05/20/2016 METHYCLOTHIAZIDE ORAL TABLET 5 MG 1.21660 01/25/2013 METHYL SALICYLATE MISCELLANEOUS OIL (ML) 0.47540 08/12/2014 METHYLDOPA ORAL TABLET 250 MG 0.18493 02/06/2015 METHYLDOPA ORAL TABLET 500 MG 0.32656 02/06/2015 0.32656 08/21/2015 METHYLDOPA/HYDROCHLOROTHIAZIDE ORAL TABLET 250MG-15MG 0.67180 08/12/2014 METHYLDOPA/HYDROCHLOROTHIAZIDE ORAL TABLET 250MG-25MG 1.51046 12/26/2014 METHYLERGONOVINE MALEATE INJECTION AMPUL (ML) .2MG/ML(1) 4.75860 08/12/2014 METHYLERGONOVINE MALEATE INJECTION VIAL (ML) .2MG/ML(1) 6.39450 01/25/2013 METHYLERGONOVINE MALEATE ORAL TABLET 0.2 MG 18.98513 02/14/2014 18.98513 08/21/2015 METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 4.03956 04/05/2013 BIPHASIC 30-70 10 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 3.38494 11/07/2014 2.94350 07/08/2016 BIPHASIC 30-70 20 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 2.96640 03/27/2015 BIPHASIC 30-70 30 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 4.30300 10/03/2014 BIPHASIC 30-70 40 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 6.43734 03/27/2015 6.43734 08/21/2015 BIPHASIC 30-70 50 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 6.76633 05/03/2013 BIPHASIC 30-70 60 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 4.27722 04/25/2014 BIPHASIC 50-50 20 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 4.36506 04/25/2014 BIPHASIC 50-50 30 MG METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE 4.66236 04/25/2014 4.57571 02/26/2016 BIPHASIC 50-50 40 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date METHYLPHENIDATE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.90135 04/10/2015 METHYLPHENIDATE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.73600 02/27/2015 0.73600 03/02/2016 METHYLPHENIDATE HCL ORAL TABLET 10 MG 0.65546 03/25/2016 0.54698 05/20/2016 METHYLPHENIDATE HCL ORAL TABLET 20 MG 0.70877 01/13/2017 0.61728 01/27/2017 METHYLPHENIDATE HCL ORAL TABLET 5 MG 0.38367 05/20/2016 0.33839 01/27/2017 METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 10 MG 5.25000 04/24/2015 5.25000 08/21/2015 METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 20 MG 4.52552 07/08/2016 3.23954 09/30/2016 METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 18 5.74805 08/21/2015 4.46919 01/27/2017 MG METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 27 6.98215 12/14/2016 6.98215 12/29/2016 MG METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 36 6.07761 11/04/2016 7.20195 01/06/2017 MG METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 54 7.08615 09/30/2016 7.58500 12/08/2016 MG METHYLPREDNISOLONE ACETATE INJECTION VIAL (ML) 40 MG/ML 3.47672 08/12/2014 3.47672 08/21/2015 METHYLPREDNISOLONE ACETATE INJECTION VIAL (ML) 80 MG/ML 7.07957 08/12/2014 7.07957 08/21/2015 METHYLPREDNISOLONE ORAL TABLET 16 MG 2.47842 04/03/2015 METHYLPREDNISOLONE ORAL TABLET 32 MG 3.62572 04/03/2015 METHYLPREDNISOLONE ORAL TABLET 4 MG 1.24060 12/06/2013 0.94632 05/20/2016 METHYLPREDNISOLONE ORAL TABLET 8 MG 1.40728 04/19/2013 1.40728 08/21/2015 METHYLPREDNISOLONE ORAL TABLET, DOSE PACK 4 MG 0.60810 03/25/2016 0.54952 12/02/2016 METHYLPREDNISOLONE SODIUM SUCCINATE INJECTION VIAL (EA) 125 4.08408 01/25/2013 MG METHYLPREDNISOLONE SODIUM SUCCINATE INJECTION VIAL (EA) 40 3.53132 01/25/2013 MG METHYLPREDNISOLONE SODIUM SUCCINATE INTRAVENOUS VIAL (EA) 17.05200 01/25/2013 1000 MG METIPRANOLOL OPHTHALMIC DROPS 0.3 % 2.91720 01/25/2013 METOCLOPRAMIDE HCL INJECTION SYRINGE (ML) 10 MG/2 ML 0.66573 05/24/2013 0.66573 08/21/2015 METOCLOPRAMIDE HCL INJECTION VIAL (ML) 5 MG/ML 0.37728 02/13/2015 0.37728 08/21/2015 METOCLOPRAMIDE HCL ORAL SOLUTION, ORAL 10 MG/10ML 0.04456 08/09/2013 0.04456 08/21/2015 METOCLOPRAMIDE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.01217 12/20/2013 0.01217 08/21/2015 METOCLOPRAMIDE HCL ORAL TABLET 10 MG 0.04069 04/17/2015 0.04069 08/21/2015 METOCLOPRAMIDE HCL ORAL TABLET 5 MG 0.04126 02/20/2015 0.04126 08/21/2015 METOLAZONE ORAL TABLET 10 MG 0.84230 05/17/2013 METOLAZONE ORAL TABLET 2.5 MG 1.11312 04/24/2015 1.02753 05/20/2016 METOLAZONE ORAL TABLET 5 MG 1.35440 04/24/2015 1.35440 08/21/2015 METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.60468 02/26/2016 0.47599 09/30/2016 100 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 1.12520 09/19/2016 1.09263 01/13/2017 200 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.37683 05/20/2016 0.33669 09/30/2016 25 MG METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 0.36119 09/30/2016 0.33710 01/13/2017 50 MG METOPROLOL TARTRATE INTRAVENOUS AMPUL (ML) 5 MG/5 ML 0.23020 08/12/2014 0.23020 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date METOPROLOL TARTRATE INTRAVENOUS SYRINGE (ML) 5 MG/5 ML 0.70560 01/25/2013 METOPROLOL TARTRATE ORAL TABLET 100 MG 0.03114 05/01/2015 0.03114 08/21/2015 METOPROLOL TARTRATE ORAL TABLET 25 MG 0.02399 05/01/2015 0.02399 08/21/2015 METOPROLOL TARTRATE ORAL TABLET 50 MG 0.02097 12/26/2014 0.02097 08/21/2015 METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE ORAL TABLET 1.42966 12/26/2014 1.42966 08/21/2015 100MG-25MG METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE ORAL TABLET 1.53410 02/08/2013 100MG-50MG METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE ORAL TABLET 50 1.05445 04/03/2015 1.05445 08/21/2015 MG-25MG METRONIDAZOLE IN SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS 0.01400 04/05/2013 0.01400 08/21/2015 SOLUTION, PIGGYBACK (ML) 500MG/0.1L METRONIDAZOLE ORAL CAPSULE 375 MG 3.91048 01/31/2014 3.91048 08/21/2015 METRONIDAZOLE ORAL TABLET 250 MG 0.30300 08/15/2014 0.30300 08/21/2015 METRONIDAZOLE ORAL TABLET 500 MG 0.50050 08/21/2015 0.36209 05/20/2016 METRONIDAZOLE TOPICAL CREAM (GRAM) 0.75 % 2.72580 08/21/2015 2.12678 07/08/2016 METRONIDAZOLE TOPICAL GEL (GRAM) 0.75 % 2.52780 05/01/2015 METRONIDAZOLE TOPICAL LOTION (ML) 0.75 % 2.93220 01/17/2014 METRONIDAZOLE VAGINAL GEL WITH APPLICATOR (GRAM) 0.75 % 0.41020 08/21/2015 0.41020 01/01/2017 MEXILETINE HCL ORAL CAPSULE 150 MG 0.55042 01/30/2015 0.55042 08/21/2015 MEXILETINE HCL ORAL CAPSULE 200 MG 0.70746 10/03/2014 MEXILETINE HCL ORAL CAPSULE 250 MG 0.48191 08/09/2013 MICONAZOLE NITRATE TOPICAL CREAM (GRAM) 2 % 0.05700 03/07/2014 0.05700 08/21/2015 MICONAZOLE NITRATE TOPICAL OINTMENT (GRAM) 2 % 0.08500 08/12/2014 MICONAZOLE NITRATE TOPICAL TINCTURE 2 % 0.39340 08/12/2014 MICONAZOLE NITRATE VAGINAL CREAM WITH APPLICATOR 2 % 0.09470 04/24/2015 0.09470 08/21/2015 MICONAZOLE NITRATE VAGINAL KIT 200 MG-2 % 7.83470 01/09/2015 7.83470 08/21/2015 MICONAZOLE NITRATE VAGINAL SUPPOSITORY, VAGINAL 100 MG 0.44030 01/25/2013 0.44030 08/21/2015 MICONAZOLE NITRATE VAGINAL SUPPOSITORY, VAGINAL 200 MG 12.26633 01/25/2013 MIDODRINE HCL ORAL TABLET 10 MG 1.20000 11/20/2015 0.80259 09/30/2016 MIDODRINE HCL ORAL TABLET 2.5 MG 0.36980 02/13/2015 0.36980 08/21/2015 MIDODRINE HCL ORAL TABLET 5 MG 0.60470 08/21/2015 0.42587 05/20/2016 MILRINONE LACTATE INTRAVENOUS VIAL (ML) 1 MG/ML 0.38297 05/01/2015 0.38297 08/21/2015 MILRINONE LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.13280 08/12/2014 0.13280 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 20MG/100ML MILRINONE LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.16676 10/03/2014 0.16676 08/21/2015 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 40MG/200ML MINERAL OIL RECTAL ENEMA (ML) 0.01182 08/21/2015 MINERAL OIL TOPICAL LOTION (ML) 0.01828 08/12/2014 MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT (GRAM) 15 0.81740 08/12/2014 %-83 % MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT (GRAM) 1.90107 01/16/2015 1.90107 08/21/2015 15%-85% MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT (GRAM) 3 4.48140 08/21/2015 %-94 % MINOCYCLINE HCL ORAL CAPSULE 100 MG 0.30445 04/17/2015 0.30445 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date MINOCYCLINE HCL ORAL CAPSULE 50 MG 0.25765 04/17/2015 0.25765 08/21/2015 MINOCYCLINE HCL ORAL CAPSULE 75 MG 0.35403 08/12/2014 MINOCYCLINE HCL ORAL TABLET 100 MG 2.72821 04/11/2014 2.72821 08/21/2015 MINOCYCLINE HCL ORAL TABLET 50 MG 1.44008 01/25/2013 1.44008 08/21/2015 MINOCYCLINE HCL ORAL TABLET 75 MG 1.69228 01/25/2013 1.69228 08/21/2015 MINOCYCLINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 135 MG 3.56811 01/25/2013 3.56811 08/21/2015 MINOCYCLINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 45 MG 3.56811 01/25/2013 3.56811 08/21/2015 MINOCYCLINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 90 MG 3.56811 01/25/2013 3.56811 08/21/2015 MINOXIDIL ORAL TABLET 10 MG 0.29185 08/22/2014 0.29185 08/21/2015 MINOXIDIL ORAL TABLET 2.5 MG 0.15911 09/26/2014 0.11699 05/20/2016 MIRTAZAPINE ORAL TABLET 15 MG 0.21914 05/20/2016 0.17097 09/30/2016 MIRTAZAPINE ORAL TABLET 30 MG 0.23702 03/25/2016 0.16374 12/02/2016 MIRTAZAPINE ORAL TABLET 45 MG 0.41519 09/05/2014 0.41519 08/21/2015 MIRTAZAPINE ORAL TABLET 7.5 MG 1.38983 07/29/2016 2.10000 11/07/2016 MIRTAZAPINE ORAL TABLET,DISINTEGRATING 15 MG 1.64850 08/21/2015 0.92033 04/22/2016 MIRTAZAPINE ORAL TABLET,DISINTEGRATING 30 MG 0.91210 08/21/2015 0.82945 01/13/2017 MIRTAZAPINE ORAL TABLET,DISINTEGRATING 45 MG 1.16848 08/21/2015 0.82001 12/02/2016 MISOPROSTOL ORAL TABLET 100 MCG 0.42254 09/19/2014 0.42254 08/21/2015 MISOPROSTOL ORAL TABLET 200 MCG 0.93932 08/21/2015 0.77996 07/29/2016 MITOMYCIN INTRAVENOUS VIAL (EA) 40 MG 256.23975 08/21/2015 990.94800 11/05/2015 MODAFINIL ORAL TABLET 100 MG 4.38622 11/20/2015 4.38622 03/24/2016 MODAFINIL ORAL TABLET 200 MG 4.81219 07/08/2016 3.02496 12/02/2016 MOEXIPRIL HCL ORAL TABLET 15 MG 0.37580 02/08/2013 0.37580 08/21/2015 MOEXIPRIL HCL ORAL TABLET 7.5 MG 0.37580 08/12/2014 0.37580 08/21/2015 MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 15-12.5MG 0.51310 08/12/2014 MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 15-25MG 0.37076 01/25/2013 0.37076 08/21/2015 MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 7.5-12.5MG 0.50960 01/25/2013 0.50960 08/21/2015 MOLYBDENUM (AMMONIUM MOLYBDATE) VIAL (ML) 25 MCG/ML 0.32672 01/25/2013 MOMETASONE FUROATE TOPICAL CREAM (GRAM) 0.1 % 0.33269 02/27/2015 0.33269 08/21/2015 MOMETASONE FUROATE TOPICAL OINTMENT (GRAM) 0.1 % 0.26293 07/19/2013 0.26293 08/21/2015 MOMETASONE FUROATE TOPICAL SOLUTION, NON-ORAL 0.1 % 0.22914 08/02/2013 0.22914 08/21/2015 MONTELUKAST SODIUM ORAL GRANULES IN PACKET (EA) 4 MG 3.95033 02/26/2016 3.87400 05/20/2016 MONTELUKAST SODIUM ORAL TABLET 10 MG 0.24206 01/22/2016 0.16953 03/25/2016 MONTELUKAST SODIUM ORAL TABLET, CHEWABLE 4 MG 0.44500 11/20/2015 0.25800 04/22/2016 MONTELUKAST SODIUM ORAL TABLET, CHEWABLE 5 MG 0.28606 04/17/2015 0.28606 08/21/2015 MORPHINE SULFATE INJECTION SYRINGE (ML) 10 MG/ML 1.83954 05/23/2014 1.83954 08/21/2015 MORPHINE SULFATE INJECTION SYRINGE (ML) 2 MG/ML 1.83954 04/25/2014 1.83954 08/21/2015 MORPHINE SULFATE INJECTION SYRINGE (ML) 4 MG/ML 1.83954 05/23/2014 1.83954 08/21/2015 MORPHINE SULFATE INJECTION SYRINGE (ML) 5 MG/ML 1.83954 05/23/2014 MORPHINE SULFATE INJECTION SYRINGE (ML) 8 MG/ML 1.83954 05/23/2014 1.83954 08/21/2015 MORPHINE SULFATE INJECTION VIAL (ML) 10 MG/ML 0.74480 01/25/2013 MORPHINE SULFATE INJECTION VIAL (ML) 15 MG/ML 0.69440 01/25/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date MORPHINE SULFATE INJECTION VIAL (ML) 5 MG/ML 0.83160 01/25/2013 MORPHINE SULFATE INJECTION VIAL (ML) 8 MG/ML 0.94080 01/25/2013 MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 10 MG/ML 3.25500 01/25/2013 MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 15 MG/ML 3.25500 01/25/2013 MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 2 MG/ML 3.25500 01/25/2013 MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 4 MG/ML 3.25500 01/25/2013 MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 8 MG/ML 2.98200 01/25/2013 MORPHINE SULFATE INTRAVENOUS PATIENT CONTROLLED ANALGESIA 0.33600 11/08/2013 0.33600 08/21/2015 SYRINGE 30 MG/30ML MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 10 MG/ML 1.80600 12/26/2014 MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 2 MG/ML 1.80600 03/28/2014 MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 4 MG/ML 1.80600 03/28/2014 MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 8 MG/ML 1.80600 12/26/2014 MORPHINE SULFATE INTRAVENOUS VIAL (ML) 25 MG/ML 1.33770 07/26/2013 MORPHINE SULFATE INTRAVENOUS VIAL (ML) 50 MG/ML 1.03719 06/27/2014 MORPHINE SULFATE INTRAVENOUS VIAL WITH THREADED PORT (ML) 4.96650 01/25/2013 100 MG/4ML MORPHINE SULFATE INTRAVENOUS VIAL WITH THREADED PORT (ML) 1.99080 01/25/2013 250MG/10ML MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 10 3.31248 08/29/2014 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 12.63000 08/21/2015 11.91976 12/02/2016 100 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 20 3.66023 08/21/2015 2.94931 12/02/2016 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 30 3.97979 10/03/2014 3.97979 08/21/2015 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 50 6.65266 11/14/2014 6.65266 08/21/2015 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 60 7.95944 08/21/2015 5.37753 01/27/2017 MG MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 80 10.60675 11/28/2014 10.60675 08/21/2015 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 13.81709 02/21/2014 24HR 120 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 4.01072 02/21/2014 24HR 30 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 5.94685 02/21/2014 24HR 45 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 7.78841 02/21/2014 24HR 60 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 9.91130 02/21/2014 24HR 75 MG MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 11.71044 02/21/2014 24HR 90 MG MORPHINE SULFATE ORAL SOLUTION, ORAL 10 MG/5 ML 0.05473 01/16/2015 0.05473 08/21/2015 MORPHINE SULFATE ORAL SOLUTION, ORAL 100 MG/5ML 0.43460 04/25/2014 0.23910 09/30/2016 MORPHINE SULFATE ORAL SOLUTION, ORAL 20 MG/5 ML 0.08307 01/16/2015 0.08307 08/21/2015 MORPHINE SULFATE ORAL TABLET 15 MG 0.11466 04/03/2015 MORPHINE SULFATE ORAL TABLET 30 MG 0.17240 04/11/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 100 MG 3.60620 08/21/2015 2.26000 09/30/2016 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 15 MG 0.21892 07/08/2016 0.38200 09/17/2016 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 200 MG 6.25263 08/21/2015 4.40000 08/26/2016 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 30 MG 0.57580 01/13/2017 0.51477 01/27/2017 MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 60 MG 1.66203 12/25/2015 1.04421 09/30/2016 MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 10 MG 3.85880 08/12/2014 MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 20 MG 5.25000 01/25/2013 MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 30 MG 6.56250 01/25/2013 MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 5 MG 3.50000 01/25/2013 MORPHINE SULFATE/PF INJECTION AMPUL (ML) 0.5 MG/ML 2.23713 01/25/2013 MORPHINE SULFATE/PF INJECTION AMPUL (ML) 1 MG/ML 3.80940 01/25/2013 MORPHINE SULFATE/PF INJECTION VIAL (ML) 0.5 MG/ML 0.42080 08/12/2014 MORPHINE SULFATE/PF INJECTION VIAL (ML) 1 MG/ML 0.41240 08/12/2014 MORPHINE SULFATE/PF INTRAVENOUS PATIENT CONTROLLED 0.61320 01/25/2013 ANALGESIA VIAL 150MG/30ML MORPHINE SULFATE/PF INTRAVENOUS PATIENT CONTROLLED 0.50469 01/25/2013 ANALGESIA VIAL 30 MG/30ML MOXIFLOXACIN HCL ORAL TABLET 400 MG 10.04207 07/08/2016 6.21000 09/30/2016 MULTIVIT WITH MINERALS/FOLIC ACID ORAL TABLET 0.4 MG 0.80780 08/12/2014 0.80780 08/21/2015 MULTIVITAMIN ORAL TABLET 0.01441 02/20/2015 0.01441 08/21/2015 MULTIVITAMIN WITH IRON ORAL TABLET 0.01954 08/12/2014 0.01954 08/21/2015 MULTIVITAMIN WITH MINERALS NO.7/FOLIC ACID ORAL CAPSULE 1 MG 0.17550 02/15/2013 MULTIVITAMIN WITH MINERALS/FERROUS GLUCONATE ORAL LIQUID 0.01674 08/12/2014 0.01674 08/21/2015 (ML) 9 MG/15 ML MULTIVITAMIN WITH MINERALS/FOLIC ACID/LYCOPENE/LUTEIN ORAL 0.04317 03/27/2015 0.04317 08/21/2015 TABLET .4-300-250 MULTIVITAMIN WITH MINERALS/FOLIC ACID/LYCOPENE/LUTEIN ORAL 0.05011 08/12/2014 TABLET 500-300MCG MULTIVITAMIN WITH MINERALS/LUTEIN ORAL TABLET 0.04780 08/12/2014 0.04780 08/21/2015 MULTIVITAMIN,STRESS FORMULA/ZINC ORAL TABLET 0.04810 05/02/2014 0.04810 08/21/2015 MULTIVITAMIN,THERAPEUTIC ORAL TABLET 0.02440 08/12/2014 MULTIVITS WITH CALCIUM AND MINERALS/IRON FUMARATE/FOLIC ACID 0.03495 08/12/2014 ORAL TABLET 9MG-400MCG MUPIROCIN CALCIUM TOPICAL CREAM (GRAM) 2 % 2.58284 02/06/2015 2.58284 08/21/2015 MUPIROCIN TOPICAL OINTMENT (GRAM) 2 % 0.40519 03/25/2016 0.31455 12/02/2016 MYCOPHENOLATE MOFETIL ORAL CAPSULE 250 MG 0.24316 04/17/2015 0.24316 08/21/2015 MYCOPHENOLATE MOFETIL ORAL SUSPENSION, RECONSTITUTED, 12.04600 01/23/2015 ORAL (ML) 200 MG/ML MYCOPHENOLATE MOFETIL ORAL TABLET 500 MG 0.41540 08/21/2015 0.33626 01/13/2017 MYCOPHENOLATE SODIUM ORAL TABLET, DELAYED RELEASE 3.19818 02/13/2015 2.74952 12/02/2016 (ENTERIC COATED) 180 MG MYCOPHENOLATE SODIUM ORAL TABLET, DELAYED RELEASE 6.39625 04/17/2015 5.13027 02/26/2016 (ENTERIC COATED) 360 MG NABUMETONE ORAL TABLET 500 MG 0.26505 08/21/2015 0.21736 05/20/2016 NABUMETONE ORAL TABLET 750 MG 0.24565 05/20/2016 0.21983 09/30/2016 NADOLOL ORAL TABLET 20 MG 2.37573 08/01/2014 1.88126 12/02/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date NADOLOL ORAL TABLET 40 MG 2.17792 02/27/2015 1.95798 05/20/2016 NADOLOL ORAL TABLET 80 MG 3.57963 08/22/2014 3.31195 12/02/2016 NADOLOL/BENDROFLUMETHIAZIDE ORAL TABLET 40 MG-5 MG 1.72368 01/25/2013 NADOLOL/BENDROFLUMETHIAZIDE ORAL TABLET 80 MG-5 MG 2.25914 01/25/2013 NAFCILLIN IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV SOLUTION, 0.25511 01/25/2013 PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML NAFCILLIN IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV SOLUTION, 0.53762 07/25/2014 PIGGYBACK PREMIX FROZEN(ML) 2 G/100 ML NAFCILLIN SODIUM INJECTION VIAL (EA) 1 G 11.78070 01/16/2015 NAFCILLIN SODIUM INJECTION VIAL (EA) 10 G 69.68850 03/06/2015 NAFCILLIN SODIUM INJECTION VIAL (EA) 2 G 11.96470 03/06/2015 11.96470 08/21/2015 NAFCILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 G 12.56750 08/12/2014 NAFCILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2 G 26.14500 03/29/2013 NALBUPHINE HCL INJECTION AMPUL (ML) 20 MG/ML 3.45670 01/25/2013 NALBUPHINE HCL INJECTION VIAL (ML) 10 MG/ML 1.19280 01/25/2013 1.19280 08/21/2015 NALBUPHINE HCL INJECTION VIAL (ML) 20 MG/ML 1.70020 08/12/2014 NALOXONE HCL INJECTION SYRINGE (ML) 0.4 MG/ML 3.15000 01/25/2013 NALOXONE HCL INJECTION SYRINGE (ML) 1 MG/ML 7.11900 11/15/2013 7.11900 08/21/2015 NALTREXONE HCL ORAL TABLET 50 MG 0.86993 04/24/2015 0.86993 08/21/2015 NAPHAZOLINE HCL DROPS 0.1 % 0.11787 01/25/2013 0.11787 08/21/2015 NAPHAZOLINE HCL/GLYCERIN OPHTHALMIC DROPS 0.012-0.25 0.13090 04/03/2015 NAPROXEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 125 MG/5ML 0.11088 04/03/2015 0.11088 08/21/2015 NAPROXEN ORAL TABLET 250 MG 0.04181 08/12/2014 0.04181 08/21/2015 NAPROXEN ORAL TABLET 375 MG 0.05065 11/21/2014 0.05065 08/21/2015 NAPROXEN ORAL TABLET 500 MG 0.06330 05/01/2015 0.06330 08/21/2015 NAPROXEN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 375 0.14664 08/12/2014 0.14664 08/21/2015 MG NAPROXEN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 500 0.17979 04/04/2014 0.17979 08/21/2015 MG NAPROXEN SODIUM ORAL TABLET 220 MG 0.04739 04/03/2015 0.04739 08/21/2015 NAPROXEN SODIUM ORAL TABLET 275 MG 0.10251 10/01/2015 1.31200 11/09/2015 NAPROXEN SODIUM ORAL TABLET 550 MG 2.15560 08/22/2015 1.52104 05/20/2016 NARATRIPTAN HCL ORAL TABLET 1 MG 5.59223 09/13/2013 4.82300 09/30/2016 NARATRIPTAN HCL ORAL TABLET 2.5 MG 3.72922 01/22/2016 2.77969 07/08/2016 NATEGLINIDE ORAL TABLET 120 MG 0.55468 05/20/2016 0.48517 09/30/2016 NATEGLINIDE ORAL TABLET 60 MG 1.00887 05/01/2015 0.67318 04/22/2016 NEFAZODONE HCL ORAL TABLET 100 MG 1.09937 10/03/2014 1.09937 08/21/2015 NEFAZODONE HCL ORAL TABLET 150 MG 1.18018 02/13/2015 1.18018 08/21/2015 NEFAZODONE HCL ORAL TABLET 200 MG 1.18438 10/17/2014 1.18438 08/21/2015 NEFAZODONE HCL ORAL TABLET 250 MG 0.66582 08/23/2013 NEFAZODONE HCL ORAL TABLET 50 MG 0.56680 08/12/2014 NEOMYCIN SULF/BACITRACIN ZINC/POLYMYXIN B SULF/PRAMOXINE 0.16974 08/08/2014 0.16974 08/21/2015 HCL TOPICAL OINTMENT (GRAM) 3.5-10K-10 NEOMYCIN SULFATE ORAL TABLET 500 MG 0.78260 04/04/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date NEOMYCIN SULFATE/BACITRACIN ZINC/POLYMYXIN B TOPICAL 0.08442 02/13/2015 0.08442 08/21/2015 OINTMENT (GRAM) 3.5-400-5K NEOMYCIN SULFATE/BACITRACIN ZINC/POLYMYXIN 12.81263 02/06/2015 12.81263 08/21/2015 B/HYDROCORTISONE OPHTHALMIC OINTMENT (GRAM) 3.5-10K-1 NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B OPHTHALMIC 8.09100 02/06/2015 8.09100 08/21/2015 OINTMENT (GRAM) 3.5MG-400 NEOMYCIN SULFATE/POLYMYXIN B SULFATE IRRIGATION AMPUL (ML) 7.53960 04/12/2013 40-200K/ML NEOMYCIN SULFATE/POLYMYXIN B SULFATE IRRIGATION VIAL (ML) 40- 5.02645 01/25/2013 200K/ML NEOMYCIN SULFATE/POLYMYXIN B SULFATE/GRAMICIDIN D 4.33580 05/24/2013 4.33580 08/21/2015 OPHTHALMIC DROPS 1.75MG-10K NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE 13.05287 03/08/2013 OPHTHALMIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 3.5-10K- 10 NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE OTIC 2.05680 08/21/2015 7.04760 09/22/2015 SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 3.5-10K-1 NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE OPHTHALMIC 4.73550 04/22/2016 4.12000 01/13/2017 OINTMENT (GRAM) 3.5-10K-.1 NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE OPHTHALMIC 3.79776 04/22/2016 3.67556 01/13/2017 SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 0.1 % NEVIRAPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 50 MG/5 ML 0.40225 01/25/2013 NEVIRAPINE ORAL TABLET 200 MG 0.19200 03/29/2013 0.19200 08/21/2015 NEVIRAPINE ORAL TABLET, EXTENDED RELEASE 24 HR 400 MG 15.82373 11/07/2014 15.82373 08/21/2015 NIACIN (INOSITOL NIACINATE) ORAL TABLET 500 MG 0.02737 08/21/2015 NIACIN ORAL CAPSULE, EXTENDED RELEASE 250 MG 0.04147 02/01/2013 NIACIN ORAL CAPSULE, EXTENDED RELEASE 500 MG 0.04930 08/12/2014 NIACIN ORAL TABLET 100 MG 0.01270 08/12/2014 0.01270 08/21/2015 NIACIN ORAL TABLET 50 MG 0.01274 01/25/2013 NIACIN ORAL TABLET 500 MG 0.02000 08/12/2014 0.02000 08/21/2015 NIACIN ORAL TABLET, EXTENDED RELEASE 1000 MG 0.05775 01/25/2013 NIACIN ORAL TABLET, EXTENDED RELEASE 24 HR 1000 MG 5.24533 03/27/2015 5.24533 08/21/2015 NIACIN ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 2.96574 03/27/2015 1.81708 12/02/2016 NIACIN ORAL TABLET, EXTENDED RELEASE 250 MG 0.03662 02/08/2013 NIACIN ORAL TABLET, EXTENDED RELEASE 500 MG 0.03081 08/12/2014 0.03081 08/21/2015 NIACIN ORAL TABLET, EXTENDED RELEASE 750 MG 0.05020 08/12/2014 NIACINAMIDE ORAL TABLET 500 MG 0.02737 04/05/2013 NICARDIPINE HCL ORAL CAPSULE 20 MG 0.34500 02/08/2013 NICARDIPINE HCL ORAL CAPSULE 30 MG 0.35170 08/12/2014 NICOTINE POLACRILEX BUCCAL GUM 2 MG 0.21464 04/03/2015 0.21464 08/21/2015 NICOTINE POLACRILEX BUCCAL GUM 4 MG 0.24376 04/24/2015 0.24376 08/21/2015 NICOTINE POLACRILEX BUCCAL LOZENGE 2 MG 0.36791 08/21/2015 NICOTINE POLACRILEX BUCCAL LOZENGE 4 MG 0.38277 08/21/2015 NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 1.68043 02/27/2015 1.68043 08/21/2015 14MG/24HR NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 21 1.82000 12/25/2015 1.74179 05/20/2016 MG/24HR NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 7MG/24HR 1.66489 12/05/2014 1.66489 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date NIFEDIPINE MISCELLANEOUS POWDER (GRAM) 2.02800 08/21/2015 NIFEDIPINE ORAL CAPSULE 10 MG 0.75080 05/20/2016 0.63522 07/29/2016 NIFEDIPINE ORAL CAPSULE 20 MG 1.61182 08/12/2014 1.61182 08/21/2015 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 30 MG 0.41379 04/03/2015 0.41379 08/21/2015 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 60 MG 0.58531 08/21/2015 0.50647 05/20/2016 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 90 MG 0.81941 08/21/2015 0.69097 12/25/2015 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 30 MG 0.41460 08/21/2015 0.25480 07/08/2016 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 60 MG 0.81161 08/21/2015 0.57384 12/02/2016 NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 90 MG 1.52840 08/21/2015 0.86180 05/20/2016 NIMODIPINE ORAL CAPSULE 30 MG 13.27890 04/03/2015 13.27890 08/21/2015 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 17 MG 4.66057 04/22/2016 3.86000 05/20/2016 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 20 MG 10.97514 03/13/2015 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 25.5 MG 5.87636 01/25/2013 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 30 MG 7.05270 02/08/2013 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 34 MG 5.87636 01/25/2013 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 40 MG 6.65350 01/25/2013 NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 8.5MG 4.29926 01/25/2013 3.94911 12/02/2016 NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE 100 MG 1.56470 08/21/2015 1.20693 12/25/2015 NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE 50 MG 0.58173 03/25/2016 0.51165 05/20/2016 NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS ORAL CAPSULE 1.38339 03/25/2016 1.06437 05/20/2016 100 MG NITROFURANTOIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 25 1.96822 04/03/2015 1.96822 08/21/2015 MG/5 ML NITROGLYCERIN IN 5 % DEXTROSE IN WATER INTRAVENOUS INFUSION 0.01110 08/12/2014 BOTTLE (ML) 200MG/500 NITROGLYCERIN IN 5 % DEXTROSE IN WATER INTRAVENOUS INFUSION 0.02260 08/12/2014 BOTTLE (ML) 50MG/500ML NITROGLYCERIN INTRAVENOUS VIAL (ML) 50 MG/10ML 0.47040 01/25/2013 NITROGLYCERIN ORAL CAPSULE, EXTENDED RELEASE 2.5 MG 0.33267 05/17/2013 0.33267 08/21/2015 NITROGLYCERIN ORAL CAPSULE, EXTENDED RELEASE 6.5 MG 0.32960 02/15/2013 0.32960 08/21/2015 NITROGLYCERIN ORAL CAPSULE, EXTENDED RELEASE 9 MG 0.17330 08/12/2014 0.17330 08/21/2015 NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.69594 05/30/2014 0.69594 08/21/2015 0.1MG/HR NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.58290 03/06/2015 0.2MG/HR NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.53733 05/20/2016 0.43334 09/30/2016 0.4MG/HR NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.97601 01/16/2015 0.97601 08/21/2015 0.6MG/HR NITROGLYCERIN TRANSLINGUAL AEROSOL, SPRAY (GRAM) 27.46701 01/25/2013 400MCG/SPR NITROGLYCERIN TRANSLINGUAL SPRAY, NON-AEROSOL (GRAM) 19.55100 03/27/2015 19.55100 01/01/2017 400MCG/SPR NIZATIDINE ORAL CAPSULE 150 MG 0.26336 04/03/2015 0.26336 08/21/2015 NIZATIDINE ORAL CAPSULE 300 MG 0.56236 09/12/2014 0.56236 08/21/2015 NIZATIDINE ORAL SOLUTION, ORAL 150MG/10ML 0.49300 06/28/2013 0.49300 08/21/2015 NORETHINDRONE ACETATE ORAL TABLET 5 MG 1.53385 02/26/2016 1.19936 12/02/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1.5- 1.03406 04/17/2015 1.03406 08/21/2015 0.03MG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1MG- 0.88520 01/27/2016 0.82525 09/30/2016 20MCG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1MG- 2.15000 08/26/2016 5MCG NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 0.76760 04/17/2015 ORAL TABLET 1.5-30(21) NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 0.58393 03/25/2016 0.47800 10/28/2016 ORAL TABLET 1MG-20(21) NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 2.23842 02/06/2015 2.23842 08/21/2015 ORAL TABLET 1MG-20(24) NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE 1.42880 02/13/2015 1.42880 08/21/2015 ORAL TABLET 5-7-9-7 NORETHINDRONE ORAL TABLET 0.35 MG 0.22095 09/30/2016 0.18524 01/13/2017 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 0.4-0.035 0.85774 12/25/2015 0.63095 12/02/2016 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 0.5-0.035 0.80140 08/12/2014 0.70263 02/26/2016 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 1 MG-35MCG 0.65892 11/07/2014 0.60029 03/25/2016 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 7 DAYS X 3 0.81151 02/27/2015 0.81151 08/21/2015 NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 7-9-5 0.98375 01/25/2013 NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE ORAL 1.86241 09/05/2014 1.86241 08/21/2015 TABLET, CHEWABLE 0.4-35(21) NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 0.25-0.035 0.40148 05/20/2016 0.34566 09/30/2016 NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 7DAYSX3 28 0.33944 01/13/2017 0.28333 01/27/2017 NORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.3-0.03MG 0.76300 04/26/2013 0.52196 05/20/2016 NORTRIPTYLINE HCL ORAL CAPSULE 10 MG 0.13387 04/24/2015 0.13387 08/21/2015 NORTRIPTYLINE HCL ORAL CAPSULE 25 MG 0.21219 08/21/2015 0.14890 05/20/2016 NORTRIPTYLINE HCL ORAL CAPSULE 50 MG 0.26824 08/21/2015 0.21011 12/02/2016 NORTRIPTYLINE HCL ORAL CAPSULE 75 MG 0.35555 04/24/2015 0.35555 08/21/2015 NORTRIPTYLINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.26055 02/27/2015 0.26055 08/21/2015 NYSTATIN MISCELLANEOUS POWDER (EA) 10B UNIT 17265.36000 01/25/2013 NYSTATIN MISCELLANEOUS POWDER (EA) 150MM UNIT 98.76650 01/25/2013 NYSTATIN MISCELLANEOUS POWDER (EA) 1B UNIT 404.56500 01/25/2013 NYSTATIN MISCELLANEOUS POWDER (EA) 2B UNIT 459.38450 01/25/2013 NYSTATIN MISCELLANEOUS POWDER (EA) 500MM UNIT 156.49700 01/25/2013 156.49700 08/21/2015 NYSTATIN MISCELLANEOUS POWDER (EA) 50MM UNIT 47.31300 01/25/2013 47.31300 08/21/2015 NYSTATIN MISCELLANEOUS POWDER (EA) 5B UNIT 742.07950 01/25/2013 NYSTATIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100000/ML 0.08512 04/17/2015 0.08512 08/21/2015 NYSTATIN ORAL TABLET 500K UNIT 0.58504 08/21/2015 0.48774 07/08/2016 NYSTATIN TOPICAL CREAM (GRAM) 100000/G 0.43389 08/21/2015 0.32320 01/13/2017 NYSTATIN TOPICAL OINTMENT (GRAM) 100000/G 0.52038 02/27/2015 0.52038 08/21/2015 NYSTATIN TOPICAL POWDER (GRAM) 100000/G 0.64498 03/25/2016 0.56608 08/26/2016 NYSTATIN/TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 2.73400 08/21/2015 3.78466 01/26/2017 100000-0.1 NYSTATIN/TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 4.40410 09/12/2014 4.40410 08/21/2015 100000-0.1 OCTREOTIDE ACETATE INJECTION AMPUL (ML) 100 MCG/ML 4.02220 03/07/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date OCTREOTIDE ACETATE INJECTION AMPUL (ML) 50 MCG/ML 2.84310 01/25/2013 OCTREOTIDE ACETATE INJECTION AMPUL (ML) 500 MCG/ML 21.50330 12/26/2014 OCTREOTIDE ACETATE INJECTION SYRINGE (ML) 100 MCG/ML 15.96000 03/21/2014 OCTREOTIDE ACETATE INJECTION SYRINGE (ML) 50 MCG/ML 5.98920 01/25/2013 OCTREOTIDE ACETATE INJECTION SYRINGE (ML) 500 MCG/ML 45.22560 01/25/2013 OCTREOTIDE ACETATE INJECTION VIAL (ML) 100 MCG/ML 5.15580 05/01/2015 5.15580 08/21/2015 OCTREOTIDE ACETATE INJECTION VIAL (ML) 1000MCG/ML 34.03343 02/27/2015 34.03343 08/21/2015 OCTREOTIDE ACETATE INJECTION VIAL (ML) 200 MCG/ML 8.03760 08/12/2014 8.03760 08/21/2015 OCTREOTIDE ACETATE INJECTION VIAL (ML) 50 MCG/ML 2.83010 09/05/2014 2.83010 08/21/2015 OCTREOTIDE ACETATE INJECTION VIAL (ML) 500 MCG/ML 20.95800 05/01/2015 20.95800 08/21/2015 OFLOXACIN OPHTHALMIC DROPS 0.3 % 3.15000 08/21/2015 3.11592 01/13/2017 OFLOXACIN OTIC DROPS 0.3 % 2.58116 10/10/2014 14.24520 06/04/2015 OLANZAPINE INTRAMUSCULAR VIAL (EA) 10 MG 29.05000 02/01/2013 OLANZAPINE ORAL TABLET 10 MG 0.23991 01/30/2015 0.23991 08/21/2015 OLANZAPINE ORAL TABLET 15 MG 0.41460 01/13/2017 0.33339 01/27/2017 OLANZAPINE ORAL TABLET 2.5 MG 0.14460 02/27/2015 0.14460 08/21/2015 OLANZAPINE ORAL TABLET 20 MG 0.49871 08/21/2015 0.45122 09/30/2016 OLANZAPINE ORAL TABLET 5 MG 0.17515 02/06/2015 0.17515 08/21/2015 OLANZAPINE ORAL TABLET 7.5 MG 0.39560 11/20/2015 0.26166 05/20/2016 OLANZAPINE ORAL TABLET,DISINTEGRATING 10 MG 1.74995 09/25/2015 1.61650 01/13/2017 OLANZAPINE ORAL TABLET,DISINTEGRATING 15 MG 1.60523 03/25/2016 1.53750 09/30/2016 OLANZAPINE ORAL TABLET,DISINTEGRATING 20 MG 3.18610 04/03/2015 3.18610 08/21/2015 OLANZAPINE ORAL TABLET,DISINTEGRATING 5 MG 2.04290 08/21/2015 1.15200 09/30/2016 OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 12MG-25MG 15.27470 08/15/2014 OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 12MG-50MG 15.27773 08/12/2014 OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 3 MG-25 MG 7.51917 11/14/2014 7.51917 08/21/2015 OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 6MG-25MG 10.13740 08/01/2014 10.13740 08/21/2015 OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 6MG-50MG 10.13740 08/01/2014 OLOPATADINE HCL NASAL AEROSOL, SPRAY WITH PUMP (GRAM) 0.6 % 6.21646 04/10/2015 5.47838 12/02/2016 OMEGA-3 ACID ETHYL ESTERS ORAL CAPSULE 1 G 0.68039 05/20/2016 0.54661 07/29/2016 OMEGA-3 FATTY ACIDS/DOCOSAHEXANOIC ACID/EPA/FISH OIL ORAL 0.05283 08/12/2014 CAPSULE 1000 MG OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.32521 10/01/2015 0.29980 01/13/2017 10 MG OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.08682 05/01/2015 0.08682 08/21/2015 20 MG OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 0.19433 04/17/2015 0.19433 08/21/2015 40 MG OMEPRAZOLE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 20 0.63937 01/16/2015 0.63937 08/21/2015 MG OMEPRAZOLE/SODIUM BICARBONATE ORAL CAPSULE 20MG-1.1G 11.02580 02/27/2015 11.02580 08/21/2015 OMEPRAZOLE/SODIUM BICARBONATE ORAL CAPSULE 40MG-1.1G 9.65090 06/27/2014 9.65090 08/21/2015 ONDANSETRON HCL INTRAVENOUS VIAL (ML) 2 MG/ML 0.07865 01/16/2015 0.07865 08/21/2015 ONDANSETRON HCL ORAL SOLUTION, ORAL 4 MG/5 ML 0.65000 09/25/2015 0.58078 09/30/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ONDANSETRON HCL ORAL TABLET 4 MG 0.32824 02/26/2016 0.27535 05/20/2016 ONDANSETRON HCL ORAL TABLET 8 MG 0.43208 08/21/2015 0.17880 09/30/2016 ONDANSETRON HCL/PF INJECTION AMPUL (ML) 4 MG/2 ML 8.31950 01/25/2013 ONDANSETRON HCL/PF INJECTION SYRINGE (ML) 4 MG/2 ML 0.93551 05/01/2015 0.93551 08/21/2015 ONDANSETRON HCL/PF INJECTION VIAL (ML) 4 MG/2 ML 0.31460 05/01/2015 0.31460 08/21/2015 ONDANSETRON ORAL TABLET,DISINTEGRATING 4 MG 0.55200 08/21/2015 0.52267 09/30/2016 ONDANSETRON ORAL TABLET,DISINTEGRATING 8 MG 0.71011 09/25/2015 0.53271 01/13/2017 OPIUM TINCTURE ORAL TINCTURE 10 MG/ML 3.65310 08/02/2013 OPIUM/BELLADONNA ALKALOIDS RECTAL SUPPOSITORY, RECTAL 30- 19.61500 07/18/2014 16.2MG OPIUM/BELLADONNA ALKALOIDS RECTAL SUPPOSITORY, RECTAL 60- 23.41675 10/24/2014 16.2MG ORPHENADRINE CITRATE ORAL TABLET, EXTENDED RELEASE 100 MG 0.39390 11/14/2014 0.39390 08/21/2015 OXACILLIN SODIUM INJECTION VIAL (EA) 1 G 8.82240 08/22/2014 8.82240 08/21/2015 OXACILLIN SODIUM INJECTION VIAL (EA) 10 G 86.55715 08/22/2014 OXACILLIN SODIUM INJECTION VIAL (EA) 2 G 15.23550 08/22/2014 15.23550 08/21/2015 OXACILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 G 0.86301 01/25/2013 OXACILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2 G 2.23201 01/25/2013 OXACILLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV 0.25790 01/25/2013 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML OXACILLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV 0.23003 09/26/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2 G/50 ML OXANDROLONE ORAL TABLET 10 MG 9.27840 01/25/2013 9.27840 08/21/2015 OXANDROLONE ORAL TABLET 2.5 MG 3.00096 08/12/2014 3.00096 08/21/2015 OXAPROZIN ORAL TABLET 600 MG 2.56480 08/15/2014 2.56480 08/21/2015 OXAZEPAM ORAL CAPSULE 10 MG 0.56183 01/13/2017 0.51416 01/27/2017 OXAZEPAM ORAL CAPSULE 15 MG 1.20600 04/24/2015 0.77475 12/02/2016 OXAZEPAM ORAL CAPSULE 30 MG 1.11314 04/24/2015 OXCARBAZEPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 300 0.60414 04/22/2016 0.45417 05/20/2016 MG/5ML OXCARBAZEPINE ORAL TABLET 150 MG 0.19336 08/21/2015 0.16948 07/29/2016 OXCARBAZEPINE ORAL TABLET 300 MG 0.23774 07/29/2016 0.19218 09/30/2016 OXCARBAZEPINE ORAL TABLET 600 MG 0.38370 12/02/2016 0.37106 01/13/2017 OXYBUTYNIN CHLORIDE ORAL SYRUP 5 MG/5 ML 0.02124 05/17/2013 0.02124 08/21/2015 OXYBUTYNIN CHLORIDE ORAL TABLET 5 MG 0.25053 09/30/2016 0.35506 10/12/2016 OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 10 0.64895 01/13/2017 0.53452 01/27/2017 MG OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 15 0.87348 05/20/2016 0.77676 09/30/2016 MG OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 5 1.15000 09/25/2015 0.75182 05/20/2016 MG OXYCODONE HCL ORAL CAPSULE 5 MG 1.29200 01/10/2014 1.29200 08/21/2015 OXYCODONE HCL ORAL CONCENTRATE, ORAL 20 MG/ML 6.18140 08/21/2015 3.73320 09/30/2016 OXYCODONE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.19950 02/13/2015 OXYCODONE HCL ORAL TABLET 10 MG 0.26460 08/21/2015 0.18595 05/20/2016 OXYCODONE HCL ORAL TABLET 15 MG 0.25062 04/22/2016 0.21030 05/20/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date OXYCODONE HCL ORAL TABLET 20 MG 0.32400 11/29/2016 0.24678 01/27/2017 OXYCODONE HCL ORAL TABLET 30 MG 0.47585 04/22/2016 0.36450 10/28/2016 OXYCODONE HCL ORAL TABLET 5 MG 0.17089 04/22/2016 0.15334 01/13/2017 OXYCODONE HCL ORAL TABLET,ORAL ONLY,EXTENDED RELEASE 12 6.00434 01/30/2015 6.00434 08/21/2015 HR 40 MG OXYCODONE HCL ORAL TABLET,ORAL ONLY,EXTENDED RELEASE 12 11.43132 08/21/2015 HR 80 MG OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 10MG-325MG 0.45844 04/22/2016 0.32235 01/27/2017 OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 2.5-325 MG 1.43437 05/01/2015 OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 5 MG-325MG 0.17102 05/01/2015 0.17102 08/21/2015 OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 7.5-325 MG 0.51830 09/30/2016 0.45632 01/13/2017 OXYCODONE HCL/ASPIRIN ORAL TABLET 4.8355-325 0.40759 11/07/2014 0.40759 08/21/2015 OXYMORPHONE HCL ORAL TABLET 10 MG 2.50839 04/03/2015 OXYMORPHONE HCL ORAL TABLET 5 MG 1.64692 04/03/2015 1.64692 08/21/2015 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 10 MG 2.43642 05/16/2014 2.43642 08/21/2015 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 15 MG 3.54294 04/03/2015 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 20 MG 4.32131 05/16/2014 4.32131 08/21/2015 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 30 MG 6.21979 05/16/2014 6.21979 08/21/2015 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 40 MG 8.11845 05/16/2014 8.11845 08/21/2015 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 5 MG 1.26886 05/16/2014 1.26886 08/21/2015 OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 7.5 MG 1.91827 05/16/2014 PALIPERIDONE ORAL TABLET, EXTENDED RELEASE 24 HR 6 MG 17.55344 01/01/2017 17.55344 01/03/2017 PAMIDRONATE DISODIUM INTRAVENOUS VIAL (EA) 30 MG 10.37300 02/27/2015 10.37300 08/21/2015 PAMIDRONATE DISODIUM INTRAVENOUS VIAL (EA) 90 MG 26.85500 02/27/2015 26.85500 08/21/2015 PAMIDRONATE DISODIUM INTRAVENOUS VIAL (ML) 30MG/10ML 1.47400 08/12/2014 1.47400 08/21/2015 PAMIDRONATE DISODIUM INTRAVENOUS VIAL (ML) 60 MG/10ML 4.62000 01/25/2013 PAMIDRONATE DISODIUM INTRAVENOUS VIAL (ML) 90 MG/10ML 4.54740 08/08/2014 4.54740 08/21/2015 PANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.13712 04/17/2015 0.13712 08/21/2015 COATED) 20 MG PANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.11779 04/03/2015 0.11779 08/21/2015 COATED) 40 MG PAREGORIC ORAL LIQUID (ML) 2 MG/5 ML 0.46388 04/26/2013 PARICALCITOL INJECTION VIAL (ML) 2 MCG/ML 3.52800 03/27/2015 PARICALCITOL INJECTION VIAL (ML) 5 MCG/ML 8.82000 01/30/2015 PARICALCITOL ORAL CAPSULE 1 MCG 7.76370 07/04/2014 5.14673 12/02/2016 PARICALCITOL ORAL CAPSULE 2 MCG 15.52623 07/04/2014 PARICALCITOL ORAL CAPSULE 4MCG 31.05270 07/04/2014 PAROMOMYCIN SULFATE ORAL CAPSULE 250 MG 2.95152 06/14/2013 PAROXETINE HCL ORAL TABLET 10 MG 0.09558 02/27/2015 0.09558 08/21/2015 PAROXETINE HCL ORAL TABLET 20 MG 0.10912 04/17/2015 0.10912 08/21/2015 PAROXETINE HCL ORAL TABLET 30 MG 0.14156 02/27/2015 0.14156 08/21/2015 PAROXETINE HCL ORAL TABLET 40 MG 0.17420 04/24/2015 0.17420 08/21/2015 PAROXETINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 25 MG 4.40100 08/26/2016 3.69955 12/02/2016 PEANUT OIL MISCELLANEOUS OIL (ML) 0.09990 08/12/2014 0.09990 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM 0.00288 12/05/2014 CHLORIDE ORAL SOLUTION, RECONSTITUTED, ORAL 236-22.74G PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM 0.00219 08/22/2014 0.00219 08/21/2015 CHLORIDE ORAL SOLUTION, RECONSTITUTED, ORAL 240-22.72G PENICILLIN G POTASSIUM INJECTION VIAL (EA) 20MM UNIT 24.80100 08/12/2014 PENICILLIN G POTASSIUM INJECTION VIAL (EA) 5MM UNIT 26.68167 04/17/2015 26.68167 08/21/2015 PENICILLIN G POTASSIUM/DEXTROSE-WATER INTRAVENOUS IV 0.19490 01/25/2013 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1MM/50ML PENICILLIN G POTASSIUM/DEXTROSE-WATER INTRAVENOUS IV 0.21880 01/25/2013 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2MM/50ML PENICILLIN G POTASSIUM/DEXTROSE-WATER INTRAVENOUS IV 0.13440 01/25/2013 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 3MM/50ML PENICILLIN G PROCAINE INTRAMUSCULAR SYRINGE (ML) 1.2MM/2 ML 11.84540 01/25/2013 11.84540 08/21/2015 PENICILLIN G PROCAINE INTRAMUSCULAR SYRINGE (ML) 600000/ML 13.05360 01/25/2013 PENICILLIN G SODIUM INJECTION VIAL (EA) 5MM UNIT 40.12055 08/09/2013 PENICILLIN V POTASSIUM ORAL SOLUTION, RECONSTITUTED, ORAL 125 0.02349 04/05/2013 MG/5ML PENICILLIN V POTASSIUM ORAL SOLUTION, RECONSTITUTED, ORAL 250 0.05111 04/03/2015 MG/5ML PENICILLIN V POTASSIUM ORAL TABLET 250 MG 0.17072 12/26/2014 0.17072 08/21/2015 PENICILLIN V POTASSIUM ORAL TABLET 500 MG 0.33989 11/20/2015 0.19361 03/25/2016 PENTAZOCINE HCL/NALOXONE HCL ORAL TABLET 50MG-0.5MG 2.10324 04/03/2015 2.10324 08/21/2015 PENTOXIFYLLINE ORAL TABLET, EXTENDED RELEASE 400 MG 0.16804 03/27/2015 0.16804 08/21/2015 PERINDOPRIL ERBUMINE ORAL TABLET 2 MG 0.85163 01/25/2013 PERINDOPRIL ERBUMINE ORAL TABLET 4 MG 0.61627 08/29/2014 0.61627 08/21/2015 PERINDOPRIL ERBUMINE ORAL TABLET 8 MG 0.70278 08/29/2014 0.70278 08/21/2015 PERMETHRIN TOPICAL CREAM (GRAM) 5 % 1.10300 07/08/2016 0.69133 09/30/2016 PERMETHRIN TOPICAL LIQUID (ML) 1 % 0.04372 12/13/2013 0.04372 08/21/2015 PERPHENAZINE ORAL TABLET 16 MG 1.67330 10/24/2014 PERPHENAZINE ORAL TABLET 2 MG 0.93292 04/03/2015 PERPHENAZINE ORAL TABLET 4 MG 1.11510 08/21/2015 0.82413 12/25/2015 PERPHENAZINE ORAL TABLET 8 MG 1.38698 05/31/2013 PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 2 MG-10 MG 0.85974 03/13/2015 PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 2 MG-25 MG 1.09466 04/03/2015 PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 4 MG-25 MG 1.19224 03/13/2015 PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 4 MG-50 MG 1.96854 03/13/2015 PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 4MG-10MG 0.47570 08/12/2014 PETROLATUM,WHITE TOPICAL OINTMENT IN PACKET (GRAM) 13.09140 08/21/2015 PETROLATUM,WHITE/WATER TOPICAL LOTION (ML) 0.00860 08/12/2014 PHENAZOPYRIDINE HCL ORAL TABLET 100 MG 0.90001 04/17/2015 0.90001 08/21/2015 PHENAZOPYRIDINE HCL ORAL TABLET 200 MG 1.71455 08/21/2015 1.57804 09/30/2016 PHENDIMETRAZINE TARTRATE ORAL TABLET 35 MG 0.13406 08/12/2014 0.13406 08/21/2015 PHENELZINE SULFATE ORAL TABLET 15 MG 0.58450 01/25/2013 0.44016 09/30/2016 PHENOBARBITAL ORAL ELIXIR 20 MG/5 ML 0.12828 01/30/2015 PHENOBARBITAL ORAL TABLET 100 MG 0.22053 04/19/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PHENOBARBITAL ORAL TABLET 15 MG 0.11231 04/12/2013 PHENOBARBITAL ORAL TABLET 16.2 MG 0.16065 08/21/2015 0.37408 09/23/2015 PHENOBARBITAL ORAL TABLET 30 MG 0.12320 08/29/2014 PHENOBARBITAL ORAL TABLET 32.4 MG 0.47250 09/22/2015 0.55000 08/24/2016 PHENOBARBITAL ORAL TABLET 64.8 MG 0.24982 01/30/2015 0.59066 07/02/2015 PHENOBARBITAL ORAL TABLET 97.2MG 0.35669 08/21/2015 0.83321 11/09/2015 PHENOBARBITAL SODIUM INJECTION VIAL (ML) 130MG/ML 13.60800 01/25/2013 PHENOBARBITAL SODIUM INJECTION VIAL (ML) 65 MG/ML 10.58400 07/26/2013 PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE SULF/SCOPOLAMINE 0.11741 08/21/2015 HB ORAL ELIXIR 16.2MG/5ML PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE SULF/SCOPOLAMINE 0.02701 08/21/2015 HB ORAL TABLET 16.2 MG PHENTERMINE HCL ORAL CAPSULE 15 MG 0.76603 03/22/2013 0.76603 08/21/2015 PHENTERMINE HCL ORAL CAPSULE 30 MG 0.19443 11/21/2014 0.19443 08/21/2015 PHENTERMINE HCL ORAL CAPSULE 37.5 MG 0.32924 11/21/2014 0.32924 08/21/2015 PHENTERMINE HCL ORAL TABLET 37.5 MG 0.08429 04/10/2015 0.08429 08/21/2015 PHENYLEPHRINE HCL OPHTHALMIC DROPS 10 % 6.86000 02/27/2015 6.86000 08/21/2015 PHENYLEPHRINE HCL OPHTHALMIC DROPS 2.5 % 6.61924 02/27/2015 6.61924 08/21/2015 PHENYLEPHRINE HCL ORAL SOLUTION, ORAL 2.5 MG/5ML 0.04150 08/12/2014 PHENYLEPHRINE HCL ORAL TABLET 10 MG 0.04135 09/19/2014 0.04135 08/21/2015 PHENYLEPHRINE HCL/PROMETHAZINE HCL ORAL SYRUP 5-6.25MG/5 0.23791 10/31/2014 0.23791 08/21/2015 PHENYTOIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 MG/4ML 0.27300 08/12/2014 PHENYTOIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 125 MG/5ML 0.10707 07/04/2014 PHENYTOIN ORAL TABLET, CHEWABLE 50 MG 0.36841 07/04/2014 PHENYTOIN SODIUM EXTENDED ORAL CAPSULE 100 MG 0.32270 08/21/2015 0.25363 01/27/2017 PHENYTOIN SODIUM EXTENDED ORAL CAPSULE 200 MG 0.55990 08/12/2014 PHENYTOIN SODIUM INTRAVENOUS AMPUL (ML) 50 MG/ML 0.57670 08/12/2014 PHENYTOIN SODIUM INTRAVENOUS SYRINGE (ML) 50 MG/ML 0.68460 01/25/2013 PHENYTOIN SODIUM INTRAVENOUS VIAL (ML) 50 MG/ML 0.37563 08/12/2014 PHOSPHORIC ACID,DILUTED/DEXTROSE/FRUCTOSE ORAL SOLUTION, 0.03038 08/12/2014 ORAL PHYTONADIONE (VIT K1) INJECTION AMPUL (ML) 10 MG/ML 26.38440 08/22/2014 PHYTONADIONE (VIT K1) ORAL TABLET 100 MCG 0.02140 08/12/2014 0.02140 08/21/2015 PILOCARPINE HCL OPHTHALMIC DROPS 1 % 4.34000 04/26/2013 4.34000 08/21/2015 PILOCARPINE HCL OPHTHALMIC DROPS 2 % 4.43940 04/26/2013 4.43940 08/21/2015 PILOCARPINE HCL OPHTHALMIC DROPS 4 % 4.65220 04/26/2013 4.65220 08/21/2015 PILOCARPINE HCL ORAL TABLET 5 MG 1.10200 03/25/2016 0.73810 12/02/2016 PILOCARPINE HCL ORAL TABLET 7.5 MG 1.44288 12/26/2014 1.15570 05/20/2016 PINDOLOL ORAL TABLET 10 MG 1.25867 08/22/2014 PINDOLOL ORAL TABLET 5 MG 0.92386 05/30/2014 PIOGLITAZONE HCL ORAL TABLET 15 MG 0.17348 05/01/2015 0.17348 08/21/2015 PIOGLITAZONE HCL ORAL TABLET 30 MG 0.14055 08/21/2015 0.24521 01/29/2016 PIOGLITAZONE HCL ORAL TABLET 45 MG 0.27521 10/01/2015 0.19834 09/30/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PIOGLITAZONE HCL/GLIMEPIRIDE ORAL TABLET 30 MG-2 MG 21.94569 03/01/2013 PIOGLITAZONE HCL/GLIMEPIRIDE ORAL TABLET 30 MG-4 MG 21.94569 03/01/2013 PIOGLITAZONE HCL/METFORMIN HCL ORAL TABLET 15MG-500MG 2.33786 03/13/2015 2.33786 08/21/2015 PIOGLITAZONE HCL/METFORMIN HCL ORAL TABLET 15MG-850MG 2.80197 03/20/2015 2.80197 08/21/2015 PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 3.74530 08/21/2015 4.62000 10/05/2016 2.25 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 11.98000 05/01/2015 11.98000 08/21/2015 3.375 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 15.01360 07/19/2013 4.5 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 95.66330 11/01/2013 95.66330 08/21/2015 40.5 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL WITH 8.32230 01/25/2013 THREADED PORT (EA) 2.25 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL WITH 12.66720 01/31/2014 THREADED PORT (EA) 3.375 G PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL WITH 15.73320 01/25/2013 THREADED PORT (EA) 4.5 G PIPERONYL BUTOXIDE/PYRETHRINS TOPICAL SHAMPOO 4%-0.33% 0.03613 05/03/2013 0.03613 08/21/2015 PIROXICAM ORAL CAPSULE 10 MG 0.91650 11/14/2014 0.91650 08/21/2015 PIROXICAM ORAL CAPSULE 20 MG 1.80000 08/21/2015 1.51951 07/29/2016 PNV NO17/IRON,CARB/IRON BISGLY/FA/FISH OIL/DHA/OMEGA 3,6 #1 1.61980 01/25/2013 1.61980 08/21/2015 ORAL CAPSULE 35-5-1.2MG PNV2/FERR BIS-GLY CHEL-IRON SUCC-PR/FOLIC ACID/OMEGA-3 ORAL 0.36225 01/25/2013 COMBINATION PACKAGE (EA) 29-1-250MG PODOFILOX TOPICAL SOLUTION, NON-ORAL 0.5 % 16.47695 04/22/2016 12.20500 09/30/2016 POLYDIMETHYLSILOXANES/SILICON DIOXIDE TOPICAL GEL (GRAM) 3.96690 04/03/2015 POLYETHYLENE GLYCOL 3350 ORAL POWDER (GRAM) 17G/DOSE 0.04100 02/20/2015 0.04100 08/21/2015 POLYETHYLENE GLYCOL 3350 ORAL POWDER IN PACKET (EA) 17G 1.43752 03/13/2015 1.43752 08/21/2015 POLYETHYLENE GLYCOL 400/HYPROMELLOSE/GLYCERIN OPHTHALMIC 0.06720 01/25/2013 DROPS 1-0.2-0.2% POLYMYXIN B SULFATE/TRIMETHOPRIM OPHTHALMIC DROPS 10000- 0.70000 04/22/2016 0.63550 09/30/2016 1/ML POLYVINYL ALCOHOL OPHTHALMIC DROPS 1.4 % 0.13400 01/25/2013 0.13400 08/21/2015 POTASSIUM BICARBONATE/CITRIC ACID ORAL TABLET, EFFERVESCENT 0.21200 05/01/2015 25 MEQ POTASSIUM CHLORIDE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS 0.00410 08/12/2014 INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS 0.00283 04/19/2013 INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS 0.00510 01/25/2013 INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER INTRAVENOUS 0.00310 08/12/2014 INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER INTRAVENOUS 0.00266 01/25/2013 INTRAVENOUS SOLUTION 30 MEQ/L POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER INTRAVENOUS 0.00209 01/25/2013 0.00209 08/21/2015 INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE 0.00320 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE 0.00540 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE 0.00234 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 10 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE 0.00322 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE 0.00200 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 30 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE 0.00227 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE 0.00320 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 10 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE 0.00230 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE 0.00236 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 30 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE 0.00228 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE IN DEXTROSE 5% AND 0.3 % SODIUM CHLORIDE 0.00322 01/25/2013 0.00322 08/21/2015 INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN LACTATED RINGERS AND 5 % DEXTROSE 0.00610 08/12/2014 INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L POTASSIUM CHLORIDE IN LACTATED RINGERS AND 5 % DEXTROSE 0.00403 01/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L POTASSIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 2 0.02779 08/22/2014 MEQ/ML POTASSIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION, 0.02218 01/25/2013 PIGGYBACK (ML) 10MEQ/0.1L POTASSIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION, 0.06570 08/12/2014 PIGGYBACK (ML) 10MEQ/50ML POTASSIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION, 0.02180 01/25/2013 PIGGYBACK (ML) 20MEQ/0.1L POTASSIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION, 0.10610 08/12/2014 PIGGYBACK (ML) 20MEQ/50ML POTASSIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION, 0.04528 01/25/2013 0.04528 08/21/2015 PIGGYBACK (ML) 30MEQ/0.1L POTASSIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION, 0.04897 01/25/2013 PIGGYBACK (ML) 40MEQ/0.1L POTASSIUM CHLORIDE INTRAVENOUS VIAL (ML) 2 MEQ/ML 0.02303 04/19/2013 0.02303 08/21/2015 POTASSIUM CHLORIDE ORAL CAPSULE, EXTENDED RELEASE 10 MEQ 0.45647 03/25/2016 0.38264 09/30/2016 POTASSIUM CHLORIDE ORAL CAPSULE, EXTENDED RELEASE 8 MEQ 0.52381 08/21/2015 0.41723 02/26/2016 POTASSIUM CHLORIDE ORAL LIQUID (ML) 20MEQ/15ML 0.47852 11/10/2016 0.42480 01/27/2017 POTASSIUM CHLORIDE ORAL LIQUID (ML) 40MEQ/15ML 0.11572 04/24/2015 0.11572 08/21/2015 POTASSIUM CHLORIDE ORAL TABLET, EXT RELEASE, 0.31315 04/24/2015 0.31315 08/21/2015 PARTICLES/CRYSTALS 10 MEQ POTASSIUM CHLORIDE ORAL TABLET, EXT RELEASE, 0.30139 02/26/2016 0.25985 01/27/2017 PARTICLES/CRYSTALS 20 MEQ POTASSIUM CHLORIDE ORAL TABLET, EXTENDED RELEASE 10 MEQ 0.27152 09/30/2016 0.24958 01/13/2017 POTASSIUM CHLORIDE ORAL TABLET, EXTENDED RELEASE 8 MEQ 0.35868 04/24/2015 0.35868 08/21/2015 POTASSIUM CHLORIDE/POTASSIUM BICARBONATE/CITRIC ACID ORAL 0.68997 01/25/2013 TABLET, EFFERVESCENT 25 MEQ POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 10 MEQ 1.15256 05/20/2016 0.93766 09/30/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 15 MEQ 1.86389 08/29/2014 POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 5 MEQ 1.00360 08/29/2014 0.92685 09/30/2016 POVIDONE-IODINE TOPICAL OINTMENT (GRAM) 10 % 0.06258 01/25/2013 0.06258 08/21/2015 POVIDONE-IODINE TOPICAL SOLUTION, NON-ORAL 10 % 0.00639 04/17/2015 0.00639 08/21/2015 POVIDONE-IODINE TOPICAL SWAB, MEDICATED 10 % 0.15276 08/12/2014 POVIDONE-IODINE VAGINAL SOLUTION, NON-ORAL 0.3 % 0.00990 08/12/2014 PRAMIPEXOLE DI-HCL ORAL TABLET 0.125 MG 0.09800 02/13/2015 0.09800 08/21/2015 PRAMIPEXOLE DI-HCL ORAL TABLET 0.25 MG 0.09720 02/06/2015 0.09720 08/21/2015 PRAMIPEXOLE DI-HCL ORAL TABLET 0.5 MG 0.09648 02/06/2015 0.09648 08/21/2015 PRAMIPEXOLE DI-HCL ORAL TABLET 0.75 MG 0.09654 02/06/2015 0.09654 08/21/2015 PRAMIPEXOLE DI-HCL ORAL TABLET 1 MG 0.12893 08/21/2015 0.09671 09/30/2016 PRAMIPEXOLE DI-HCL ORAL TABLET 1.5 MG 0.09887 02/13/2015 0.09887 08/21/2015 PRAMIPEXOLE DI-HCL ORAL TABLET, EXTENDED RELEASE 24 HR 0.375 11.95470 05/01/2015 MG PRAMIPEXOLE DI-HCL ORAL TABLET, EXTENDED RELEASE 24 HR 0.75 11.29637 04/24/2015 MG PRAMIPEXOLE DI-HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1.5 MG 11.29637 04/24/2015 PRAMOXINE HCL TOPICAL TOWELETTE (EA) 1 % 0.35233 01/25/2013 PRAVASTATIN SODIUM ORAL TABLET 10 MG 0.36528 08/21/2015 0.23717 10/28/2016 PRAVASTATIN SODIUM ORAL TABLET 20 MG 0.34557 03/25/2016 0.26559 09/30/2016 PRAVASTATIN SODIUM ORAL TABLET 40 MG 0.44320 12/25/2015 0.32740 05/20/2016 PRAVASTATIN SODIUM ORAL TABLET 80 MG 0.46382 05/20/2016 0.43178 12/02/2016 PRAZOSIN HCL ORAL CAPSULE 1 MG 0.41250 09/30/2015 0.45210 09/20/2016 PRAZOSIN HCL ORAL CAPSULE 2 MG 0.49802 08/21/2015 0.70500 09/23/2016 PRAZOSIN HCL ORAL CAPSULE 5 MG 0.42850 08/21/2015 0.93200 07/18/2016 PREDNICARBATE TOPICAL CREAM (GRAM) 0.1 % 1.10483 12/26/2014 1.10483 08/21/2015 PREDNICARBATE TOPICAL OINTMENT (GRAM) 0.1 % 1.13044 04/24/2015 1.13044 08/21/2015 PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION, DROPS(FINAL 7.33593 05/20/2016 6.91823 09/30/2016 DOSAGE FORM)(ML) 1 % PREDNISOLONE ORAL SOLUTION, ORAL 15 MG/5 ML 0.03992 08/30/2013 0.03992 08/21/2015 PREDNISOLONE SOD PHOSPHATE OPHTHALMIC DROPS 1 % 4.19720 02/08/2013 4.19720 08/21/2015 PREDNISOLONE SOD PHOSPHATE ORAL SOLUTION, ORAL 15 MG/5 ML 0.08044 12/26/2014 0.08044 08/21/2015 PREDNISOLONE SOD PHOSPHATE ORAL SOLUTION, ORAL 25 MG/5 ML 1.48119 12/05/2014 PREDNISOLONE SOD PHOSPHATE ORAL SOLUTION, ORAL 5 MG/5 ML 0.57224 02/21/2014 0.57224 08/21/2015 PREDNISOLONE SOD PHOSPHATE ORAL TABLET,DISINTEGRATING 10 10.06877 02/13/2015 10.06877 08/21/2015 MG PREDNISOLONE SOD PHOSPHATE ORAL TABLET,DISINTEGRATING 15 16.78133 02/13/2015 MG PREDNISOLONE SOD PHOSPHATE ORAL TABLET,DISINTEGRATING 30 21.57604 02/13/2015 MG PREDNISONE ORAL SOLUTION, ORAL 5 MG/5 ML 0.17260 01/31/2014 0.17260 08/21/2015 PREDNISONE ORAL TABLET 1 MG 0.19015 03/27/2015 0.09709 09/30/2016 PREDNISONE ORAL TABLET 10 MG 0.15143 04/03/2015 0.15143 08/21/2015 PREDNISONE ORAL TABLET 2.5 MG 0.14040 09/13/2013 0.14040 08/21/2015 PREDNISONE ORAL TABLET 20 MG 0.17820 03/27/2015 0.17820 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PREDNISONE ORAL TABLET 5 MG 0.11870 03/27/2015 0.11870 08/21/2015 PREDNISONE ORAL TABLET 50 MG 0.28608 08/12/2014 PREDNISONE ORAL TABLET, DOSE PACK 10 MG 0.78000 02/06/2015 0.78000 08/21/2015 PREDNISONE ORAL TABLET, DOSE PACK 5 MG 0.45000 10/24/2014 0.45000 08/21/2015 PRENATAL VIT CALC,IRON,FOLIC ACID (LESS THAN 1 MG) ORAL TABLET 0.04207 04/05/2013 0.04207 08/21/2015 PRENATAL VIT NO.16/IRON FUM,PS COMPLEX/FOLIC ACID/OMEGA-3 0.74013 04/10/2015 ORAL CAPSULE 35-1-200MG PRENATAL VIT NO.21/IRON POLYSACCH,HEME POLYPEP/FOLIC ACID 1.47032 08/12/2014 ORAL TABLET 28-6-1 MG PRENATAL VIT NO.22/IRON CBN,GLUCON/FOLIC ACID/DOCUSATE/DHA 0.63047 07/05/2013 0.63047 08/21/2015 ORAL COMBINATION PACKAGE (EA) 27-1-50 MG PRENATAL VIT NO.81/SOD.FEREDETATE-IRON PS/FOLIC ACID/OMEGA-3 0.86509 01/25/2013 ORAL COMBINATION PACKAGE, TABLET AND DR CAP 27-1-430MG PRENATAL VIT WITH CA NO.68/IRON FUMARATE/FOLIC ACID #1/DHA 1.28123 10/10/2014 ORAL CAPSULE 28-1-300MG PRENATAL VIT WITH CALCIUM #69/IRON,CARBON/FOLIC ACID/DSS/DHA 1.38343 01/31/2014 ORAL CAPSULE 28-1-50 MG PRENATAL VIT WITH CALCIUM NO. 40/IRON FUMARATE/FA CMB NO.1 1.33925 05/02/2014 ORAL TABLET 27 MG-1 MG PRENATAL VIT WITH CALCIUM NO.37/IRON,ASPG/FOLIC ACID/OMEGA-3 0.98583 12/26/2014 0.98583 08/21/2015 ORAL CAPSULE 27-1-330MG PRENATAL VIT WITH CALCIUM NO.66/IRON FUM/FOLIC ACID/DSS/DHA 1.21550 08/29/2014 1.21550 08/21/2015 ORAL CAPSULE 26-1.2-55 PRENATAL VIT WITH CALCIUM NO.66/IRON FUM/FOLIC ACID/DSS/DHA 0.45240 09/26/2014 0.45240 08/21/2015 ORAL CAPSULE 27-1.25-55 PRENATAL VIT WITH CALCIUM NO.80/IRON FUM/FOLIC ACID/DSS/DHA 1.98769 01/25/2013 1.98769 08/21/2015 ORAL CAPSULE 29-1.25-55 PRENATAL VIT/FOLIC ACID/B6/CALCIUM PHOSPH DI,TRIBASIC/GINGER 0.72360 01/25/2013 0.72360 08/21/2015 ORAL TABLET 1.2-40-100 PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS FUMARATE/FOLIC 0.20146 05/17/2013 ACID ORAL TABLET 60 MG-1 MG PRENATAL VITAMIN COMB NO.79/IRON FUMARAT/FA/LMEFOLATE 1.81370 01/25/2013 1.81370 08/21/2015 CA/DHA ORAL CAPSULE 27-1.13 MG PRENATAL VITAMIN COMBO NO.22/IRON/FOLIC ACID/OMEGA-3/DHA 0.62446 08/12/2014 ORAL COMBINATION PACKAGE (EA) 28-6-1-203 PRENATAL VITAMIN NO.15/IRON FUMARATE,POLYSAC COMP/FOLIC 1.15359 01/25/2013 ACID ORAL CAPSULE 85 MG-1 MG PRENATAL VITAMIN NO.15/IRON,CARBONYL/FOLIC ACID/DOCUSATE 0.11873 08/29/2014 0.11873 08/21/2015 SOD ORAL TABLET 90-1-50 MG PRENATAL VITAMIN NO.16/IRON,CARBONYL/FOLIC ACID/DOCUSATE 0.13967 08/29/2014 0.13967 08/21/2015 SOD ORAL TABLET 90-1-50 MG PRENATAL VITAMIN NO.18/IRON,CARBONYL/FOLIC ACID/DOCUSATE 0.08180 08/12/2014 0.08180 08/21/2015 SOD ORAL TABLET 90-1-50 MG PRENATAL VITAMIN NO.19/IRON POLYSAC,IRON HEME/FOLIC ACID/DHA 2.08973 05/03/2013 2.08973 08/21/2015 ORAL CAPSULE 22-6-1-200 PRENATAL VITAMIN NO.51/IRON FUMARATE/FA/OMEGA-3/DHA/EPA 0.11428 08/12/2014 ORAL CAPSULE 27-800-228 PRENATAL VITAMIN NO.59/IRON CARB,FUM/FOLIC ACID/DOCUSATE/DHA 4.46109 12/12/2014 ORAL CAPSULE 27-1-50 MG PRENATAL VITAMIN NO.86/IRON BIS-GLYCINATE/FOLIC ACID ORAL 0.83875 09/05/2014 0.83875 08/21/2015 TABLET 32 MG-1 MG PRENATAL VITAMIN WITH CA NO.126/FERROUS FUMARATE/FOLIC ACID 0.04810 01/25/2016 ORAL TABLET 28MG-0.8MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PRENATAL VITAMIN WITH CA NO.128/FERROUS FUMARATE/FOLIC ACID 0.04207 01/25/2016 TABLET 28MG-0.8MG PRENATAL VITAMIN WITH CA NO.129/FERROUS FUMARATE/FOLIC ACID 0.04257 01/25/2016 ORAL TABLET 27MG-0.8MG PRENATAL VITAMIN WITH CA NO.130/FERROUS FUMARATE/FOLIC ACID 0.04207 01/25/2016 ORAL TABLET 27MG-0.8MG PRENATAL VITAMIN WITH CA NO.131/FERROUS FUMARATE/FOLIC ACID 0.04810 01/25/2016 TABLET 28MG-0.8MG PRENATAL VITAMINS COMB NO.115/IRON FUMARATE/FOLIC ACID/DSS 0.61940 04/04/2014 0.61940 08/21/2015 ORAL TABLET 29-1-25 MG PRENATAL VITAMINS COMB NO.119/IRON FUMARATE/FOLIC ACID/DSS 0.44586 01/31/2014 0.44586 08/21/2015 ORAL TABLET 29-1-25 MG PRENATAL VITAMINS COMB NO.21/IRON/FOLIC ACID ORAL TABLET 14 0.06411 01/25/2013 MG-400 PRENATAL VITAMINS COMB NO.53/IRON B-G HCL SUC-P/FA/OMEGA-3 0.43260 01/25/2013 ORAL COMBINATION PACKAGE (EA) 29-1-400MG PRENATAL VITAMINS COMB NO.87/IRON BISGLY/FOLIC ACID/DHA ORAL 0.59733 01/17/2014 0.59733 08/21/2015 COMBINATION PACKAGE (EA) 32-1-230MG PRENATAL VITAMINS COMBO NO.23/IRON PS COMPLEX/FOLIC ACID 0.20689 01/25/2013 CAPSULE 155 MG-1MG PRENATAL VITAMINS COMBO NO.25/FERROUS FUMARATE/FOLIC 0.55977 04/19/2013 AC/DHA CAPSULE 30-975-200 PRENATAL VITAMINS COMBO NO.34/IRON,CARB/FOLIC ACID/DSS/DHA 1.58305 01/25/2013 1.58305 08/21/2015 ORAL CAPSULE 30-1-50 MG PRENATAL VITAMINS NO.11/FERROUS FUMARATE/FOLIC ACID/OMEGA-3 2.01177 04/03/2015 ORAL CAPSULE 28-1-200MG PRENATAL VITAMINS NO.24/IRON AMINO ACID CHELATE/FA/DHA 0.41988 04/19/2013 COMBINATION PACKAGE (EA) 30-975-300 PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID 0.04257 04/12/2013 0.04257 08/21/2015 ORAL TABLET 27MG-0.8MG PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID 0.04810 08/12/2014 0.04810 08/21/2015 ORAL TABLET 28MG-0.8MG PRENATAL VITS WITH CALCIUM #47/IRON FUM/FA CMB #1/DHA ORAL 1.43085 04/24/2015 CAPSULE 27-1-300MG PRENATAL VITS WITH CALCIUM #70/FERROUS FUMARATE/FOLIC 3.34740 09/26/2014 AC/DHA ORAL CAPSULE 28-1-250MG PRENATAL VITS WITH CALCIUM #72/FERROUS FUMARATE/FOLIC ACID 0.06606 03/13/2015 0.06606 08/21/2015 ORAL TABLET 27 MG-1 MG PRENATAL VITS WITH CALCIUM #73/FERROUS FUMARATE/FOLIC ACID 0.26832 08/29/2014 0.26832 08/21/2015 ORAL TABLET 28 MG-1 MG PRENATAL VITS WITH CALCIUM #74/FERROUS FUMARATE/FOLIC ACID 0.02170 08/21/2015 ORAL TABLET 27 MG-1 MG PRENATAL VITS WITH CALCIUM #76/IRON,CARBONYL/FOLIC ACID ORAL 0.22547 08/12/2014 0.22547 08/21/2015 TABLET 29 MG-1 MG PRENATAL VITS WITH CALCIUM #90/FERROUS FUMARATE/FOLIC ACID 0.08394 01/25/2013 ORAL TABLET 9 MG-0.5MG PRENATAL VITS WITH CALCIUM #91/FERROUS FUMARATE/FOLIC 0.16328 04/19/2013 AC/DHA ORAL COMBINATION PACKAGE (EA) 28-975-200 PRENATAL VITS WITH CALCIUM #93/FERROUS FUMARATE/FOLIC ACID 0.05495 04/19/2013 ORAL TABLET 9MG-267MCG PRENATAL VITS WITH CALCIUM #95/FERROUS FUMARATE/FOLIC 0.10500 04/19/2013 AC/DHA ORAL COMBINATION PACKAGE (EA) 28-800-200 PRENATAL VITS WITH CALCIUM #95/FERROUS FUMARATE/FOLIC ACID 0.05924 12/19/2014 0.05924 08/21/2015 ORAL TABLET 28MG-0.8MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PRENATAL VITS WITH CALCIUM #96/FERROUS FUMARATE/FOLIC ACID 0.06924 08/12/2014 ORAL TABLET 27MG-0.8MG PRENATAL VITS WITH CALCIUM#118/FERROUS FUMARATE/FOLIC ACID 0.60102 11/08/2013 0.60102 08/21/2015 ORAL TABLET, CHEWABLE 29 MG-1 MG PRENATAL VITS WITHOUT CALC NO5/FERROUS FUMARATE/FOLIC ACID 0.60753 01/23/2015 0.60753 08/21/2015 ORAL CAPSULE 106.5-1MG PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG 1.17327 11/07/2014 1.17327 08/21/2015 PRIMIDONE ORAL TABLET 250 MG 0.16411 04/03/2015 0.16411 08/21/2015 PRIMIDONE ORAL TABLET 50 MG 0.08737 02/06/2015 0.08737 08/21/2015 PROBENECID ORAL TABLET 500 MG 0.51720 04/24/2015 0.51720 08/21/2015 PROBENECID/COLCHICINE ORAL TABLET 500-0.5 MG 0.67760 10/10/2014 PROCAINAMIDE HCL INJECTION VIAL (ML) 100 MG/ML 1.98490 08/12/2014 PROCAINAMIDE HCL INJECTION VIAL (ML) 500 MG/ML 8.23200 01/25/2013 PROCHLORPERAZINE EDISYLATE INJECTION VIAL (ML) 10 MG/2 ML 2.63900 01/17/2014 2.63900 08/21/2015 PROCHLORPERAZINE EDISYLATE INJECTION VIAL (ML) 5 MG/ML 1.68000 01/25/2013 PROCHLORPERAZINE MALEATE ORAL TABLET 10 MG 0.08482 04/24/2015 0.08482 08/21/2015 PROCHLORPERAZINE MALEATE ORAL TABLET 5 MG 0.05615 08/12/2014 0.05615 08/21/2015 PROCHLORPERAZINE RECTAL SUPPOSITORY, RECTAL 25 MG 8.90000 08/08/2014 8.90000 08/21/2015 PROGESTERONE INTRAMUSCULAR VIAL (ML) 50 MG/ML 2.02150 01/25/2013 PROGESTERONE MISCELLANEOUS POWDER (GRAM) 100 % 0.47840 08/21/2015 PROGESTERONE, MICRONIZED MISCELLANEOUS POWDER (GRAM) 100 0.37440 08/21/2015 % PROGESTERONE, MICRONIZED ORAL CAPSULE 100 MG 1.23985 07/08/2016 0.95114 12/02/2016 PROGESTERONE, MICRONIZED ORAL CAPSULE 200 MG 1.73164 09/25/2015 1.49929 01/13/2017 PROMETHAZINE HCL INJECTION AMPUL (ML) 25 MG/ML 1.67584 10/24/2014 PROMETHAZINE HCL INJECTION AMPUL (ML) 50 MG/ML 1.79970 08/12/2014 PROMETHAZINE HCL INJECTION VIAL (ML) 25 MG/ML 0.76113 11/22/2013 0.76113 08/21/2015 PROMETHAZINE HCL INJECTION VIAL (ML) 50 MG/ML 1.91280 08/12/2014 PROMETHAZINE HCL ORAL SYRUP 6.25MG/5ML 0.01454 02/27/2015 0.01454 08/21/2015 PROMETHAZINE HCL ORAL TABLET 12.5 MG 0.07772 02/20/2015 0.09500 05/15/2015 PROMETHAZINE HCL ORAL TABLET 25 MG 0.09320 03/27/2015 0.09320 08/21/2015 PROMETHAZINE HCL ORAL TABLET 50 MG 0.14740 02/20/2015 0.14740 08/21/2015 PROMETHAZINE HCL RECTAL SUPPOSITORY, RECTAL 12.5 MG 9.20302 05/20/2016 8.24914 01/13/2017 PROMETHAZINE HCL RECTAL SUPPOSITORY, RECTAL 25 MG 0.33196 09/30/2016 5.75000 11/15/2016 PROMETHAZINE HCL RECTAL SUPPOSITORY, RECTAL 50 MG 25.03550 10/17/2014 PROMETHAZINE HCL/CODEINE ORAL SYRUP 6.25-10/5 0.01528 01/25/2013 0.01528 08/21/2015 PROMETHAZINE HCL/DEXTROMETHORPHAN HBR ORAL SYRUP 6.25-15/5 0.01567 04/24/2015 0.01567 08/21/2015 PROMETHAZINE/PHENYLEPHRINE HCL/CODEINE ORAL SYRUP 6.25-5-10 0.08490 08/12/2014 0.08490 08/21/2015 PROPAFENONE HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 225 5.52487 08/21/2015 4.98709 12/02/2016 MG PROPAFENONE HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 325 6.99942 10/31/2014 6.10000 07/29/2016 MG PROPAFENONE HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 425 6.99942 10/31/2014 MG PROPAFENONE HCL ORAL TABLET 150 MG 0.21963 04/24/2015 0.21963 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date PROPAFENONE HCL ORAL TABLET 225 MG 0.32160 04/10/2015 0.32160 08/21/2015 PROPAFENONE HCL ORAL TABLET 300 MG 1.19435 08/21/2015 0.95600 07/29/2016 PROPANTHELINE BROMIDE ORAL TABLET 15 MG 0.59475 03/20/2015 0.59475 08/21/2015 PROPARACAINE HCL OPHTHALMIC DROPS 0.5 % 0.81433 04/05/2013 0.81433 08/21/2015 PROPRANOLOL HCL MISCELLANEOUS POWDER (GRAM) 17.22364 08/23/2013 17.22364 08/21/2015 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 120 MG 2.21950 11/28/2014 2.21950 08/21/2015 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 160 MG 2.30811 10/28/2016 1.40230 01/13/2017 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 60 MG 1.44081 08/21/2015 1.39365 01/13/2017 PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 80 MG 1.68574 08/11/2015 1.47742 12/02/2016 PROPRANOLOL HCL ORAL SOLUTION, ORAL 20 MG/5 ML 0.15914 07/18/2014 PROPRANOLOL HCL ORAL SOLUTION, ORAL 40MG/5ML 0.20614 03/15/2013 PROPRANOLOL HCL ORAL TABLET 10 MG 0.26521 10/01/2015 0.19360 09/30/2016 PROPRANOLOL HCL ORAL TABLET 20 MG 0.02790 08/21/2015 0.25421 08/22/2015 PROPRANOLOL HCL ORAL TABLET 40 MG 0.25380 11/11/2015 0.36638 04/29/2016 PROPRANOLOL HCL ORAL TABLET 60 MG 0.71172 12/02/2016 0.60253 01/13/2017 PROPRANOLOL HCL ORAL TABLET 80 MG 0.56200 06/23/2016 0.52009 09/30/2016 PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 40 MG- 0.71600 08/12/2014 25MG PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 80 MG- 0.87940 08/12/2014 25MG PROTAMINE SULFATE INTRAVENOUS VIAL (ML) 10 MG/ML 1.17782 08/12/2014 PROTECTIVES COMBINATION NO.2/CERAMIDES 1,3,6-11 TOPICAL 1.87360 08/12/2014 CREAM (GRAM) PROTRIPTYLINE HCL ORAL TABLET 10 MG 1.94520 04/24/2015 1.94520 08/21/2015 PROTRIPTYLINE HCL ORAL TABLET 5 MG 1.43575 07/29/2016 1.10701 12/02/2016 PSEUDOEPHEDRINE HCL ORAL TABLET 30 MG 0.02680 11/21/2014 0.02680 08/21/2015 PSEUDOEPHEDRINE HCL ORAL TABLET 60 MG 0.02105 08/12/2014 0.02105 08/21/2015 PSEUDOEPHEDRINE HCL/CHLOPHEDIANOL HCL/GUAIFENESIN ORAL 0.08600 08/12/2014 LIQUID (ML) 30-12.5/5 PSEUDOEPHEDRINE HCL/CODEINE PHOSPHATE/GUAIFENESIN ORAL 0.15863 01/30/2015 0.15863 08/21/2015 SYRUP 30-10-100 PSYLLIUM HUSK (WITH SUGAR) ORAL POWDER (GRAM) 3.4 G/7 G 0.01464 12/26/2014 0.01464 08/21/2015 PSYLLIUM SEED (WITH SUGAR) ORAL POWDER (GRAM) 0.00920 08/12/2014 0.00920 08/21/2015 PSYLLIUM SEED ORAL POWDER (GRAM) 0.01780 01/25/2013 0.01780 08/21/2015 PYRANTEL PAMOATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 50 0.16310 01/25/2013 MG/ML PYRAZINAMIDE ORAL TABLET 500 MG 1.88174 07/25/2014 PYRIDOSTIGMINE BROMIDE ORAL TABLET 60 MG 0.28520 08/21/2015 0.57541 08/22/2015 PYRIDOXINE HCL (VITAMIN B6) INJECTION VIAL (ML) 100 MG/ML 7.86632 01/25/2013 PYRIDOXINE HCL (VITAMIN B6) ORAL TABLET 100 MG 0.02559 08/12/2014 0.02559 08/21/2015 PYRIDOXINE HCL (VITAMIN B6) ORAL TABLET 25 MG 0.02190 08/12/2014 PYRIDOXINE HCL (VITAMIN B6) ORAL TABLET 50 MG 0.01407 09/27/2013 0.01407 08/21/2015 QUETIAPINE FUMARATE ORAL TABLET 100 MG 0.20215 10/23/2015 0.11350 09/30/2016 QUETIAPINE FUMARATE ORAL TABLET 200 MG 0.22174 05/20/2016 0.13073 01/27/2017 QUETIAPINE FUMARATE ORAL TABLET 25 MG 0.13000 05/20/2016 0.11691 01/13/2017 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date QUETIAPINE FUMARATE ORAL TABLET 300 MG 0.26038 07/08/2016 0.21321 01/27/2017 QUETIAPINE FUMARATE ORAL TABLET 400 MG 0.27326 01/13/2017 0.09749 01/27/2017 QUETIAPINE FUMARATE ORAL TABLET 50 MG 0.18435 12/25/2015 0.13002 05/20/2016 QUINAPRIL HCL ORAL TABLET 10 MG 0.15690 11/07/2014 0.15690 08/21/2015 QUINAPRIL HCL ORAL TABLET 20 MG 0.19930 11/07/2014 0.19930 08/21/2015 QUINAPRIL HCL ORAL TABLET 40 MG 0.16429 05/01/2015 0.16429 08/21/2015 QUINAPRIL HCL ORAL TABLET 5 MG 0.19133 11/07/2014 0.19133 08/21/2015 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.56012 07/04/2014 0.56012 08/21/2015 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20 MG-25MG 0.49945 07/04/2014 0.49945 08/21/2015 QUINAPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG 0.42731 03/27/2015 0.42731 08/21/2015 QUINIDINE GLUCONATE INJECTION VIAL (ML) 80 MG/ML 3.64770 01/25/2013 QUINIDINE GLUCONATE ORAL TABLET, EXTENDED RELEASE 324 MG 0.84810 08/12/2014 0.84810 08/21/2015 QUINIDINE SULFATE ORAL TABLET 200 MG 0.09930 01/25/2013 QUINIDINE SULFATE ORAL TABLET 300 MG 0.18360 08/12/2014 QUINIDINE SULFATE ORAL TABLET, EXTENDED RELEASE 300 MG 0.67330 08/12/2014 QUININE SULFATE ORAL CAPSULE 324 MG 3.07125 08/12/2014 3.07125 08/21/2015 RABEPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.62800 01/13/2017 0.49334 01/27/2017 COATED) 20 MG RALOXIFENE HCL ORAL TABLET 60 MG 1.70996 08/26/2016 1.67583 09/30/2016 RAMIPRIL ORAL CAPSULE 1.25 MG 0.18180 01/23/2015 0.18180 08/21/2015 RAMIPRIL ORAL CAPSULE 10 MG 0.05856 05/01/2015 0.05856 08/21/2015 RAMIPRIL ORAL CAPSULE 2.5 MG 0.09500 01/23/2015 0.09500 08/21/2015 RAMIPRIL ORAL CAPSULE 5 MG 0.10440 01/23/2015 0.10440 08/21/2015 RANITIDINE HCL INJECTION VIAL (ML) 25 MG/ML 1.01383 02/20/2015 1.01383 08/21/2015 RANITIDINE HCL ORAL CAPSULE 150 MG 0.70406 02/13/2015 RANITIDINE HCL ORAL CAPSULE 300 MG 1.39303 09/19/2014 RANITIDINE HCL ORAL SYRUP 15 MG/ML 0.03755 04/17/2015 0.03755 08/21/2015 RANITIDINE HCL ORAL TABLET 150 MG 0.04560 05/01/2015 0.04560 08/21/2015 RANITIDINE HCL ORAL TABLET 300 MG 0.15109 04/24/2015 0.15109 08/21/2015 RANITIDINE HCL ORAL TABLET 75 MG 0.09782 08/12/2014 0.09782 08/21/2015 REPAGLINIDE ORAL TABLET 0.5 MG 0.58577 04/22/2016 0.35294 10/28/2016 REPAGLINIDE ORAL TABLET 1 MG 0.51831 04/22/2016 0.26500 07/29/2016 REPAGLINIDE ORAL TABLET 2 MG 0.50920 04/22/2016 0.26333 05/20/2016 RIBAVIRIN ORAL CAPSULE 200 MG 0.79060 03/13/2015 0.79060 08/21/2015 RIBAVIRIN ORAL TABLET 200 MG 0.72584 08/21/2015 0.61089 10/23/2015 RIBOFLAVIN ORAL TABLET 25 MG 0.02310 08/12/2014 RIFABUTIN ORAL CAPSULE 150 MG 12.24594 08/12/2014 RIFAMPIN ORAL CAPSULE 150 MG 1.02820 12/13/2013 0.91689 11/20/2015 RIFAMPIN ORAL CAPSULE 300 MG 1.03166 09/25/2015 0.90182 10/23/2015 RILUZOLE ORAL TABLET 50 MG 3.50952 07/29/2016 2.70236 10/28/2016 RIMANTADINE HCL ORAL TABLET 100 MG 1.70880 08/12/2014 1.70880 08/21/2015 RINGERS SOLUTION INTRAVENOUS INTRAVENOUS SOLUTION 0.00250 08/12/2014 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date RINGERS SOLUTION IRRIGATION SOLUTION, IRRIGATION 0.00710 08/12/2014 RINGERS SOLUTION,LACTATED INTRAVENOUS INTRAVENOUS 0.03400 04/11/2014 0.03400 08/21/2015 SOLUTION RINGERS SOLUTION,LACTATED IRRIGATION SOLUTION, IRRIGATION 0.00220 01/25/2013 RISEDRONATE SODIUM ORAL TABLET 150 MG 122.21000 12/25/2015 97.00000 10/28/2016 RISEDRONATE SODIUM ORAL TABLET 30 MG 29.56000 03/25/2016 RISEDRONATE SODIUM ORAL TABLET 35 MG 29.56000 03/25/2016 RISEDRONATE SODIUM ORAL TABLET 5 MG 4.65000 03/25/2016 4.20000 07/08/2016 RISPERIDONE ORAL SOLUTION, ORAL 1 MG/ML 0.30289 04/22/2016 0.25854 09/30/2016 RISPERIDONE ORAL TABLET 0.25 MG 0.09775 10/31/2014 0.09775 08/21/2015 RISPERIDONE ORAL TABLET 0.5 MG 0.11506 04/03/2015 0.11506 08/21/2015 RISPERIDONE ORAL TABLET 1 MG 0.07836 04/03/2015 0.07836 08/21/2015 RISPERIDONE ORAL TABLET 2 MG 0.13139 04/03/2015 0.13139 08/21/2015 RISPERIDONE ORAL TABLET 3 MG 0.09400 04/03/2015 0.09400 08/21/2015 RISPERIDONE ORAL TABLET 4 MG 0.17420 08/21/2015 0.14101 05/20/2016 RISPERIDONE ORAL TABLET,DISINTEGRATING 0.25 MG 5.90310 03/22/2013 RISPERIDONE ORAL TABLET,DISINTEGRATING 0.5 MG 1.23380 09/25/2015 1.03521 02/26/2016 RISPERIDONE ORAL TABLET,DISINTEGRATING 1 MG 1.24455 10/23/2015 0.93124 01/27/2017 RISPERIDONE ORAL TABLET,DISINTEGRATING 2 MG 2.66064 08/21/2015 1.77337 12/25/2015 RISPERIDONE ORAL TABLET,DISINTEGRATING 3 MG 1.34550 02/06/2015 1.34550 08/21/2015 RISPERIDONE ORAL TABLET,DISINTEGRATING 4 MG 6.09630 02/06/2015 RIVASTIGMINE TARTRATE ORAL CAPSULE 1.5 MG 1.94327 04/10/2015 1.94327 08/21/2015 RIVASTIGMINE TARTRATE ORAL CAPSULE 3 MG 1.56508 01/22/2016 1.39750 01/13/2017 RIVASTIGMINE TARTRATE ORAL CAPSULE 4.5 MG 1.72749 04/10/2015 1.72749 08/21/2015 RIVASTIGMINE TARTRATE ORAL CAPSULE 6 MG 1.90705 04/10/2015 1.90705 08/21/2015 RIVASTIGMINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 8.79000 09/30/2016 7.85449 01/13/2017 9.5MG/24HR RIZATRIPTAN BENZOATE ORAL TABLET 10 MG 1.71350 08/21/2015 1.59524 05/20/2016 RIZATRIPTAN BENZOATE ORAL TABLET 5 MG 1.27225 02/20/2015 1.27225 08/21/2015 RIZATRIPTAN BENZOATE ORAL TABLET,DISINTEGRATING 10 MG 2.18381 10/23/2015 1.60000 10/28/2016 RIZATRIPTAN BENZOATE ORAL TABLET,DISINTEGRATING 5 MG 1.49412 05/23/2014 1.49412 08/21/2015 ROPINIROLE HCL ORAL TABLET 0.25 MG 0.10162 02/06/2015 0.10162 08/21/2015 ROPINIROLE HCL ORAL TABLET 0.5 MG 0.15383 12/26/2014 0.15383 08/21/2015 ROPINIROLE HCL ORAL TABLET 1 MG 0.10620 08/21/2015 0.14521 08/22/2015 ROPINIROLE HCL ORAL TABLET 2 MG 0.13261 04/24/2015 0.13261 08/21/2015 ROPINIROLE HCL ORAL TABLET 3 MG 0.13603 02/20/2015 0.13603 08/21/2015 ROPINIROLE HCL ORAL TABLET 4 MG 0.17017 03/21/2014 0.17017 08/21/2015 ROPINIROLE HCL ORAL TABLET 5 MG 0.15233 08/12/2014 0.15233 08/21/2015 ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 12 MG 7.95362 08/12/2014 7.95362 08/21/2015 ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 1.09254 08/12/2014 1.09254 08/21/2015 ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 4 MG 4.28870 08/21/2015 2.84130 09/25/2015 ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 6 MG 4.97944 11/15/2013 4.97944 08/21/2015 ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 8 MG 3.22530 08/12/2014 3.22530 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ROPIVACAINE HCL/PF INJECTION VIAL (ML) 10 MG/ML 0.49701 10/17/2014 0.49701 08/21/2015 ROPIVACAINE HCL/PF INJECTION VIAL (ML) 2 MG/ML 0.23912 12/05/2014 ROPIVACAINE HCL/PF INJECTION VIAL (ML) 5 MG/ML 0.29748 10/17/2014 ROPIVACAINE HCL/PF INJECTION VIAL (ML) 7.5 MG/ML 0.42672 12/05/2014 ROSUVASTATIN CALCIUM ORAL TABLET 10 MG 0.32367 01/01/2017 0.25500 01/27/2017 ROSUVASTATIN CALCIUM ORAL TABLET 20 MG 0.46500 09/30/2016 0.46500 01/01/2017 ROSUVASTATIN CALCIUM ORAL TABLET 40 MG 0.46500 09/30/2016 0.46500 01/01/2017 ROSUVASTATIN CALCIUM ORAL TABLET 5 MG 0.46500 09/30/2016 0.46500 01/01/2017 SACCHAROMYCES BOULARDII ORAL CAPSULE 250 MG 0.55650 10/10/2014 SALICYLIC ACID TOPICAL FILM-FORMING LIQUID WITH APPLICATOR 27.5 7.24360 01/31/2014 % SALICYLIC ACID TOPICAL LIQUID (ML) 26 % 6.03610 01/25/2013 SALICYLIC ACID/COAL TAR/SULFUR TOPICAL SHAMPOO 2 %-1 %-2% 0.20597 01/25/2013 SALSALATE ORAL TABLET 500 MG 0.24147 11/07/2014 0.24147 08/21/2015 SALSALATE ORAL TABLET 750 MG 1.73054 01/16/2015 1.73054 08/21/2015 SCOPOLAMINE HYDROBROMIDE INJECTION VIAL (ML) 0.4 MG/ML 3.78000 01/25/2013 SELEGILINE HCL ORAL CAPSULE 5 MG 1.61219 08/12/2014 1.61219 08/21/2015 SELEGILINE HCL ORAL TABLET 5 MG 1.25290 11/28/2014 1.25290 08/21/2015 SELENIUM INTRAVENOUS VIAL (ML) 40 MCG/ML 0.24063 01/25/2013 SELENIUM ORAL TABLET 200 MCG 0.05669 08/12/2014 0.05669 08/21/2015 SELENIUM SULFIDE TOPICAL SHAMPOO 2.5 % 0.07952 09/19/2014 0.07952 08/21/2015 SENNOSIDES ORAL SYRUP 8.8MG/5ML 0.04146 08/12/2014 0.04146 08/21/2015 SENNOSIDES ORAL TABLET 8.6 MG 0.00978 05/01/2015 0.00978 08/21/2015 SENNOSIDES/DOCUSATE SODIUM ORAL TABLET 8.6MG-50MG 0.01946 11/07/2014 0.01946 08/21/2015 SERTRALINE HCL ORAL CONCENTRATE, ORAL 20 MG/ML 0.88517 12/02/2016 0.85927 01/13/2017 SERTRALINE HCL ORAL TABLET 100 MG 0.07310 09/26/2014 0.07310 08/21/2015 SERTRALINE HCL ORAL TABLET 25 MG 0.04594 04/17/2015 0.04594 08/21/2015 SERTRALINE HCL ORAL TABLET 50 MG 0.05250 09/12/2014 0.05250 08/21/2015 SILDENAFIL CITRATE ORAL TABLET 20 MG 0.45023 10/28/2016 0.26572 01/27/2017 SILVER NITRATE TOPICAL SOLUTION, NON-ORAL 0.5 % 0.03476 01/25/2013 SILVER SULFADIAZINE TOPICAL CREAM (GRAM) 1 % 0.23000 03/27/2015 0.23000 08/21/2015 SILVER TOPICAL GEL, EXTENDED RELEASE (ML) 48.44700 01/25/2013 SIMETHICONE ORAL CAPSULE 125 MG 0.08754 03/13/2015 0.08754 08/21/2015 SIMETHICONE ORAL CAPSULE 180 MG 0.07370 11/28/2014 0.07370 08/21/2015 SIMETHICONE ORAL SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 0.08040 04/03/2015 0.08040 08/21/2015 40MG/0.6ML SIMETHICONE ORAL TABLET, CHEWABLE 125 MG 0.07236 02/06/2015 0.07236 08/21/2015 SIMETHICONE ORAL TABLET, CHEWABLE 80 MG 0.02452 11/21/2014 0.02452 08/21/2015 SIMVASTATIN ORAL TABLET 10 MG 0.03578 02/27/2015 0.03578 08/21/2015 SIMVASTATIN ORAL TABLET 20 MG 0.04000 04/03/2015 0.04000 08/21/2015 SIMVASTATIN ORAL TABLET 40 MG 0.06240 09/26/2014 0.06240 08/21/2015 SIMVASTATIN ORAL TABLET 5 MG 0.05868 04/10/2015 0.05868 08/21/2015 SIMVASTATIN ORAL TABLET 80 MG 0.09991 08/12/2014 0.09991 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date SIROLIMUS ORAL TABLET 0.5 MG 5.93649 01/31/2014 SIROLIMUS ORAL TABLET 1 MG 11.63078 04/03/2015 11.09106 02/26/2016 SIROLIMUS ORAL TABLET 2 MG 22.65484 01/09/2015 SODIUM BENZOATE MISCELLANEOUS POWDER (GRAM) 0.04664 01/25/2013 0.04664 08/21/2015 SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 0.5MEQ/ML 0.44100 01/25/2013 SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 0.9MEQ/ML 0.12734 01/25/2013 SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 1 MEQ/ML 0.09770 08/12/2014 0.09770 08/21/2015 SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 10MEQ/10ML 0.74256 01/25/2013 SODIUM BICARBONATE INTRAVENOUS VIAL (ML) 0.5MEQ/ML 0.42840 03/01/2013 SODIUM BICARBONATE INTRAVENOUS VIAL (ML) 1 MEQ/ML 0.13238 11/07/2014 SODIUM BICARBONATE ORAL TABLET 325 MG 0.02155 01/25/2013 0.02155 08/21/2015 SODIUM BICARBONATE ORAL TABLET 650 MG 0.00953 03/22/2013 0.00953 08/21/2015 SODIUM CHLORIDE 0.45 % INTRAVENOUS INTRAVENOUS SOLUTION 0.45 0.00260 03/07/2014 % SODIUM CHLORIDE 0.45 % INTRAVENOUS PIGGYBACK WITH THREADED 0.04345 01/30/2015 0.04345 08/21/2015 PORT (ML) SODIUM CHLORIDE 3 % INTRAVENOUS INTRAVENOUS SOLUTION 3 % 0.00878 04/19/2013 SODIUM CHLORIDE 5 % INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.00770 08/12/2014 SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 0.05389 03/06/2015 0.05389 08/21/2015 0.9 % SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 0.04183 03/01/2013 10 % SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 0.04633 04/03/2015 3 % SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 0.07000 11/01/2013 7 % SODIUM CHLORIDE INTRAVENOUS VIAL (ML) 2.5 MEQ/ML 0.02780 04/05/2013 0.02780 08/21/2015 SODIUM CHLORIDE INTRAVENOUS VIAL (ML) 4 MEQ/ML 0.03239 11/22/2013 SODIUM CHLORIDE IRRIGATING SOLUTION IRRIGATION SOLUTION, 0.00764 08/12/2014 0.00764 08/21/2015 IRRIGATION 0.9 % SODIUM CHLORIDE MISCELLANEOUS TABLET, SOLUBLE 1000 MG 0.09895 12/26/2014 SODIUM CHLORIDE NASAL AEROSOL, SPRAY (ML) 0.65 % 0.02561 02/13/2015 0.02561 08/21/2015 SODIUM CHLORIDE OPHTHALMIC OINTMENT (GRAM) 5 % 2.49240 08/12/2014 SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM CHLORIDE/PEG 0.00401 06/27/2014 0.00401 08/21/2015 ORAL SOLUTION, RECONSTITUTED, ORAL 420G SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INTRAVENOUS 5.15944 05/01/2015 5.15944 08/21/2015 VIAL (ML) 62.5MG/5ML SODIUM FLUORIDE DENTAL CREAM (GRAM) 1.1 % 0.08013 08/30/2013 0.08013 08/21/2015 SODIUM FLUORIDE DENTAL GEL (GRAM) 1.1 % 0.06890 09/27/2013 0.06890 08/21/2015 SODIUM FLUORIDE ORAL DROPS 0.5 MG/ML 0.17316 07/19/2013 0.17316 08/21/2015 SODIUM FLUORIDE ORAL TABLET, CHEWABLE 0.25(0.55) 0.03738 03/01/2013 0.03738 08/21/2015 SODIUM FLUORIDE ORAL TABLET, CHEWABLE 0.5(1.1)MG 0.03740 02/22/2013 0.03740 08/21/2015 SODIUM FLUORIDE ORAL TABLET, CHEWABLE 1MG(2.2MG) 0.03852 04/19/2013 0.03852 08/21/2015 SODIUM HYPOCHLORITE MISCELLANEOUS SOLUTION, NON-ORAL 0.125 9.54390 08/12/2014 % SODIUM HYPOCHLORITE MISCELLANEOUS SOLUTION, NON-ORAL 0.25 0.04024 01/25/2013 % West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date SODIUM HYPOCHLORITE MISCELLANEOUS SOLUTION, NON-ORAL 0.5 % 0.04024 01/25/2013 SODIUM LACTATE INTRAVENOUS VIAL (ML) 5 MEQ/ML 0.39992 01/25/2013 SODIUM MORRHUATE VIAL (ML) 50 MG/ML 1.96000 01/25/2013 SODIUM PHOSPHATE,DIBASIC/POT PHOS,MONOB/SOD PHOSPHATE 0.35539 02/06/2015 0.26669 02/26/2016 MONO ORAL TABLET 250 MG SODIUM PHOSPHATE,MONOBASIC/SODIUM PHOSPHATE,DIBASIC 0.00578 08/12/2014 0.00578 08/21/2015 RECTAL ENEMA (ML) 19G-7G/118 SODIUM POLYSTYRENE SULFONATE ORAL POWDER (GRAM) 0.19415 09/19/2014 0.19415 08/21/2015 SODIUM POLYSTYRENE SULFONATE ORAL SUSPENSION, ORAL (FINAL 0.11988 10/10/2014 DOSE FORM) 15 G/60 ML SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA (ML) 30 G/120ML 0.25725 07/26/2013 SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA (ML) 50 G/200ML 0.15435 07/26/2013 SODIUM/POTASSIUM/POTASSIUM CITRATE/SODIUM CITRATE/CIT AC 0.02493 01/23/2015 0.02493 08/21/2015 ORAL SOLUTION, ORAL 500-550/5 SORBITOL SOLUTION IRRIGATION SOLUTION, IRRIGATION 3 % 0.00351 01/25/2013 SORBITOL SOLUTION IRRIGATION SOLUTION, IRRIGATION 3.3 % 0.00332 01/25/2013 SOTALOL HCL INTRAVENOUS VIAL (ML) 150MG/10ML 5.68750 01/25/2013 SOTALOL HCL ORAL TABLET 120 MG 0.36750 08/21/2015 0.15713 05/20/2016 SOTALOL HCL ORAL TABLET 160 MG 0.20247 08/12/2014 0.20247 08/21/2015 SOTALOL HCL ORAL TABLET 240 MG 0.35321 03/29/2013 0.35321 08/21/2015 SOTALOL HCL ORAL TABLET 80 MG 0.09447 08/12/2014 0.09447 08/21/2015 SPINOSAD TOPICAL SUSPENSION, TOPICAL (ML) 0.9 % 1.39265 08/12/2014 1.39265 01/01/2017 SPIRONOLACTONE MISCELLANEOUS POWDER (GRAM) 100 % 4.24580 08/12/2014 4.24580 08/21/2015 SPIRONOLACTONE ORAL TABLET 100 MG 0.46520 08/22/2015 0.32347 09/30/2016 SPIRONOLACTONE ORAL TABLET 25 MG 0.06122 04/03/2015 0.06122 08/21/2015 SPIRONOLACTONE ORAL TABLET 50 MG 0.23345 08/21/2015 0.18788 05/20/2016 SPIRONOLACTONE, MICRONIZED MISCELLANEOUS POWDER (GRAM) 9.66880 08/12/2014 100 % SPIRONOLACTONE/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-25MG 1.05372 12/19/2014 1.05372 08/21/2015 STAVUDINE ORAL CAPSULE 15 MG 1.32500 08/12/2014 STAVUDINE ORAL CAPSULE 20 MG 1.31140 08/12/2014 STAVUDINE ORAL CAPSULE 30 MG 1.09200 09/27/2013 STAVUDINE ORAL CAPSULE 40 MG 1.43330 05/17/2013 0.98233 02/26/2016 STAVUDINE ORAL SOLUTION, RECONSTITUTED, ORAL 1 MG/ML 0.27563 01/25/2013 STREPTOMYCIN SULFATE INTRAMUSCULAR VIAL (EA) 1 G 11.16500 01/25/2013 SUCRALFATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 1 G/10 ML 0.32004 08/21/2015 SUCRALFATE ORAL TABLET 1 G 0.19666 08/21/2015 0.14615 01/13/2017 SULFACETAMIDE SODIUM OPHTHALMIC DROPS 10 % 2.74986 03/13/2015 2.74986 08/21/2015 SULFACETAMIDE SODIUM OPHTHALMIC OINTMENT (GRAM) 10 % 13.17200 05/23/2014 13.17200 08/21/2015 SULFACETAMIDE SODIUM TOPICAL CLEANSER (ML) 10 % 0.37761 08/12/2014 0.37761 08/21/2015 SULFACETAMIDE SODIUM TOPICAL CLEANSER, GEL (ML) 10 % 1.02906 02/13/2015 SULFACETAMIDE SODIUM TOPICAL CLEANSER, GEL EXTENDED 0.85753 10/25/2013 RELEASE 10 % SULFACETAMIDE SODIUM TOPICAL SUSPENSION, TOPICAL (ML) 10 % 0.61247 01/25/2013 0.61247 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE 2.56476 02/15/2013 2.56476 08/21/2015 OPHTHALMIC DROPS 10 %-0.23% SULFACETAMIDE SODIUM/SULFUR TOPICAL CLEANSER (GRAM) 10- 0.07523 02/20/2015 0.07523 08/21/2015 5%(W/W) SULFACETAMIDE SODIUM/SULFUR TOPICAL CLEANSER (GRAM) 9 %-4.5 0.26751 08/12/2014 0.26751 08/21/2015 % SULFACETAMIDE SODIUM/SULFUR TOPICAL CLEANSER (ML) 9 %-4 % 0.22315 01/25/2013 SULFACETAMIDE SODIUM/SULFUR TOPICAL CREAM (GRAM) 10-5%(W/W) 4.86785 08/22/2014 4.86785 08/21/2015 SULFACETAMIDE SODIUM/SULFUR TOPICAL PADS, MEDICATED (EA) 10 4.47784 03/20/2015 4.47784 08/21/2015 %-5 % SULFACETAMIDE SODIUM/SULFUR TOPICAL SUSPENSION, TOPICAL 1.58340 05/02/2014 (GRAM) 10-5%(W/W) SULFACETAMIDE SODIUM/SULFUR TOPICAL SUSPENSION, TOPICAL 0.20782 08/12/2014 (ML) 8 %-4 % SULFACETAMIDE SODIUM/SULFUR/AVOBENZONE/OCTINOXATE/OCTYL 0.47020 11/21/2014 SAL TOPICAL COMBINATION PACKAGE, CLEANSER AND CREAM 9 %-4.5 % SULFACETAMIDE SODIUM/SULFUR/UREA TOPICAL CLEANSER (ML) 10%- 0.49178 01/25/2013 5%-10% SULFADIAZINE ORAL TABLET 500 MG 3.21496 12/05/2014 3.21496 08/21/2015 SULFAMETHOXAZOLE/TRIMETHOPRIM INTRAVENOUS VIAL (ML) 80- 0.78029 11/07/2014 16MG/ML SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL SUSPENSION, ORAL (FINAL 0.29336 09/30/2016 DOSE FORM) 200-40MG/5 SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL TABLET 400MG-80MG 0.07906 03/06/2015 0.07906 08/21/2015 SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL TABLET 800-160 MG 0.06180 08/21/2015 0.10200 09/21/2016 SULFASALAZINE ORAL TABLET 500 MG 0.15600 02/27/2015 0.15600 08/21/2015 SULFASALAZINE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 0.27647 02/13/2015 0.22563 09/30/2016 500 MG SULINDAC ORAL TABLET 150 MG 0.15930 01/09/2015 0.15930 08/21/2015 SULINDAC ORAL TABLET 200 MG 0.21936 02/06/2015 0.21936 08/21/2015 SUMATRIPTAN NASAL SPRAY, NON-AEROSOL (EA) 20 MG 48.76719 12/02/2016 48.76719 01/01/2017 SUMATRIPTAN NASAL SPRAY, NON-AEROSOL (EA) 5 MG 49.14262 12/02/2016 49.14262 01/01/2017 SUMATRIPTAN SUCCINATE ORAL TABLET 100 MG 0.83482 08/21/2015 0.67619 01/27/2017 SUMATRIPTAN SUCCINATE ORAL TABLET 25 MG 0.75388 02/20/2015 0.75388 08/21/2015 SUMATRIPTAN SUCCINATE ORAL TABLET 50 MG 0.91710 05/20/2016 0.80508 09/30/2016 SUMATRIPTAN SUCCINATE SUBCUTANEOUS CARTRIDGE (ML) 6 129.12200 01/25/2013 129.12200 08/21/2015 MG/0.5ML SUMATRIPTAN SUCCINATE SUBCUTANEOUS PEN INJECTOR (ML) 6 150.83066 12/02/2016 150.83066 01/01/2017 MG/0.5ML SUMATRIPTAN SUCCINATE SUBCUTANEOUS VIAL (ML) 6 MG/0.5ML 70.64185 12/02/2016 70.64185 01/01/2017 TACROLIMUS ORAL CAPSULE 0.5 MG 0.45605 12/02/2016 0.45605 01/01/2017 TACROLIMUS ORAL CAPSULE 1 MG 0.51874 01/01/2017 0.27141 01/27/2017 TACROLIMUS ORAL CAPSULE 5 MG 3.36887 10/28/2016 3.36887 01/01/2017 TACROLIMUS TOPICAL OINTMENT (GRAM) 0.03 % 6.80639 01/30/2015 TACROLIMUS TOPICAL OINTMENT (GRAM) 0.1 % 6.80639 01/30/2015 TAMOXIFEN CITRATE ORAL TABLET 10 MG 0.24955 12/13/2013 0.24955 08/21/2015 TAMOXIFEN CITRATE ORAL TABLET 20 MG 0.53478 02/27/2015 0.50800 09/30/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date TAMSULOSIN HCL ORAL CAPSULE, EXT RELEASE 24 HR 0.4 MG 0.35083 05/20/2016 0.25180 07/29/2016 TEA TREE OIL TOPICAL OIL (ML) 100 % 0.25509 08/12/2014 TELMISARTAN ORAL TABLET 20 MG 0.70000 10/23/2015 0.70000 01/01/2017 TELMISARTAN ORAL TABLET 40 MG 0.71000 10/23/2015 0.71000 01/01/2017 TELMISARTAN ORAL TABLET 80 MG 0.70000 10/23/2015 0.70000 01/01/2017 TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 40 MG-10MG 3.87707 10/03/2014 3.87707 08/21/2015 TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 40 MG-5 MG 3.87707 10/03/2014 3.87707 08/21/2015 TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 80 MG-10MG 3.87707 10/03/2014 3.87707 08/21/2015 TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 80 MG-5 MG 3.87707 10/03/2014 3.87707 08/21/2015 TELMISARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 40-12.5 MG 3.38310 08/21/2015 3.38310 01/01/2017 TELMISARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 80 MG-25MG 3.38310 08/21/2015 3.38310 01/01/2017 TELMISARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 80-12.5MG 2.86260 08/21/2015 2.86260 01/01/2017 TEMAZEPAM ORAL CAPSULE 15 MG 0.06445 03/27/2015 0.06445 08/21/2015 TEMAZEPAM ORAL CAPSULE 22.5 MG 5.69722 02/27/2015 5.69722 08/21/2015 TEMAZEPAM ORAL CAPSULE 30 MG 0.08040 03/06/2015 0.08040 08/21/2015 TEMAZEPAM ORAL CAPSULE 7.5 MG 3.79310 04/10/2015 3.79310 08/21/2015 TEMOZOLOMIDE ORAL CAPSULE 100 MG 128.55828 07/29/2016 96.94428 10/28/2016 TEMOZOLOMIDE ORAL CAPSULE 140 MG 128.55828 07/29/2016 TEMOZOLOMIDE ORAL CAPSULE 180 MG 139.03357 07/29/2016 TEMOZOLOMIDE ORAL CAPSULE 20 MG 21.53000 07/29/2016 TEMOZOLOMIDE ORAL CAPSULE 250 MG 241.19000 07/29/2016 TEMOZOLOMIDE ORAL CAPSULE 5 MG 8.05000 07/29/2016 TENIPOSIDE INTRAVENOUS AMPUL (ML) 50 MG/5 ML 56.11060 08/16/2013 56.11060 08/21/2015 TERAZOSIN HCL ORAL CAPSULE 1 MG 0.05574 08/29/2014 0.05574 08/21/2015 TERAZOSIN HCL ORAL CAPSULE 10 MG 0.06888 08/29/2014 0.06888 08/21/2015 TERAZOSIN HCL ORAL CAPSULE 2 MG 0.05574 08/12/2014 0.05574 08/21/2015 TERAZOSIN HCL ORAL CAPSULE 5 MG 0.06266 08/12/2014 0.06266 08/21/2015 TERBINAFINE HCL ORAL TABLET 250 MG 0.15504 12/19/2014 0.15504 08/21/2015 TERBINAFINE HCL TOPICAL CREAM (GRAM) 1 % 0.39135 04/10/2015 0.39135 08/21/2015 TERBUTALINE SULFATE ORAL TABLET 2.5 MG 0.27990 12/26/2014 1.26973 10/01/2015 TERCONAZOLE VAGINAL CREAM WITH APPLICATOR 0.4 % 0.58762 02/13/2015 0.58762 08/21/2015 TERCONAZOLE VAGINAL CREAM WITH APPLICATOR 0.8 % 1.43255 07/05/2013 1.43255 08/21/2015 TERCONAZOLE VAGINAL SUPPOSITORY, VAGINAL 80 MG 22.83867 04/12/2013 22.83867 08/21/2015 TESTOSTERONE CYPIONATE INTRAMUSCULAR VIAL (ML) 100 MG/ML 4.13840 08/12/2014 TESTOSTERONE CYPIONATE INTRAMUSCULAR VIAL (ML) 200 MG/ML 7.09730 03/20/2015 TESTOSTERONE ENANTHATE INTRAMUSCULAR VIAL (ML) 200 MG/ML 11.89300 04/19/2013 11.89300 08/21/2015 TESTOSTERONE MISCELLANEOUS POWDER (GRAM) 0.19136 08/21/2015 TESTOSTERONE PROPIONATE MISCELLANEOUS POWDER (GRAM) 1.55480 08/21/2015 TESTOSTERONE TRANSDERMAL GEL (GRAM) 50 MG (1%) 1.92771 08/21/2015 1.92771 04/22/2016 TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 G 1.92710 03/06/2015 1.92710 08/21/2015 (1%) TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG 13.97550 11/14/2014 (2%) West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date TESTOSTERONE TRANSDERMAL GEL IN PACKET (GRAM) 25MG(1%) 4.08296 03/06/2015 TESTOSTERONE TRANSDERMAL GEL IN PACKET (GRAM) 50 MG (1%) 1.98413 01/01/2017 1.98413 01/03/2017 TETANUS AND DIPHTHERIA TOXOIDS, ADULT INTRAMUSCULAR VIAL 30.27570 01/25/2013 30.27570 08/21/2015 (ML) 2-2 LF/0.5 TETANUS,DIPHTHERIA TOXOID PED/PF INTRAMUSCULAR VIAL (ML) 5- 150.18360 11/07/2014 150.18360 08/21/2015 25/0.5ML TETRACAINE HCL OPHTHALMIC DROPS 0.5 % 0.49187 01/25/2013 0.49187 08/21/2015 TETRACAINE HCL/PF OPHTHALMIC DROPS 0.5 % 8.12960 08/12/2014 TETRACYCLINE HCL MISCELLANEOUS POWDER (GRAM) 0.66757 05/01/2015 0.66757 08/21/2015 TETRACYCLINE HCL ORAL CAPSULE 250 MG 4.62950 09/19/2014 4.62950 08/21/2015 TETRACYCLINE HCL ORAL CAPSULE 500 MG 9.52140 03/21/2016 9.23746 12/02/2016 THEOPHYLLINE ANHYDROUS ORAL ELIXIR 80 MG/15ML 0.58429 07/05/2013 0.58429 08/21/2015 THEOPHYLLINE ANHYDROUS ORAL SOLUTION, ORAL 80 MG/15ML 0.15122 08/12/2014 0.15122 08/21/2015 THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 0.31010 01/30/2015 0.31010 08/21/2015 100 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 0.39893 01/30/2015 0.39893 08/21/2015 200 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 0.36582 08/21/2015 2.29512 11/01/2016 300 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 0.66388 07/11/2014 450 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 400 0.95030 02/01/2013 MG THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 600 1.37320 02/01/2013 MG THEOPHYLLINE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.03335 01/25/2013 INTRAVENOUS SOLUTION 200MG/0.1L THEOPHYLLINE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.09490 08/12/2014 INTRAVENOUS SOLUTION 200MG/50ML THEOPHYLLINE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.01852 01/25/2013 INTRAVENOUS SOLUTION 400MG/.25L THEOPHYLLINE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.00730 01/25/2013 INTRAVENOUS SOLUTION 400MG/0.5L THEOPHYLLINE/DEXTROSE 5 % IN WATER INTRAVENOUS 0.01890 08/12/2014 INTRAVENOUS SOLUTION 800MG/.25L THIAMINE HCL INJECTION VIAL (ML) 100 MG/ML 3.68193 08/12/2014 THIAMINE HCL ORAL TABLET 100 MG 0.01375 08/12/2014 0.01375 08/21/2015 THIAMINE HCL ORAL TABLET 50 MG 0.01586 01/25/2013 THIAMINE HCL/RIBOFLAVIN/NIACINAMIDE/DEXPANTHENOL/PYRIDOXINE 1.31319 01/25/2013 INJECTION VIAL (ML) 100-2MG/ML THIAMINE MONONITRATE ORAL TABLET 100 MG 0.02524 04/24/2015 0.02524 08/21/2015 THIORIDAZINE HCL ORAL TABLET 10 MG 0.35490 05/30/2014 THIORIDAZINE HCL ORAL TABLET 100 MG 0.79650 07/21/2016 0.83510 01/20/2017 THIORIDAZINE HCL ORAL TABLET 25 MG 0.24040 02/15/2013 THIORIDAZINE HCL ORAL TABLET 50 MG 0.70250 07/21/2016 0.73332 09/23/2016 THIOTHIXENE ORAL CAPSULE 1 MG 0.44352 12/26/2014 0.44352 08/21/2015 THIOTHIXENE ORAL CAPSULE 10 MG 1.88013 04/10/2015 1.88013 08/21/2015 THIOTHIXENE ORAL CAPSULE 2 MG 0.85163 03/13/2015 0.85163 08/21/2015 THIOTHIXENE ORAL CAPSULE 5 MG 1.29668 04/03/2015 1.29668 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date TIAGABINE HCL ORAL TABLET 2 MG 4.68720 03/27/2015 4.68720 08/21/2015 TIAGABINE HCL ORAL TABLET 4 MG 4.68720 03/27/2015 4.68720 08/21/2015 TICLOPIDINE HCL ORAL TABLET 250 MG 1.31502 11/14/2014 1.31502 08/21/2015 TIMOLOL MALEATE OPHTHALMIC DROPS 0.25 % 0.65258 03/22/2013 0.65258 08/21/2015 TIMOLOL MALEATE OPHTHALMIC DROPS 0.5 % 0.75330 01/25/2013 0.75330 08/21/2015 TIMOLOL MALEATE OPHTHALMIC GEL-FORMING SOLUTION 0.25 % 19.30600 06/27/2014 TIMOLOL MALEATE OPHTHALMIC GEL-FORMING SOLUTION 0.5 % 19.15060 07/18/2014 TIMOLOL MALEATE ORAL TABLET 10 MG 0.99344 06/06/2014 TIMOLOL MALEATE ORAL TABLET 20 MG 1.83281 06/06/2014 TIMOLOL MALEATE ORAL TABLET 5 MG 0.44560 08/12/2014 TINIDAZOLE ORAL TABLET 250 MG 0.87620 08/22/2014 0.87620 01/01/2017 TINIDAZOLE ORAL TABLET 500 MG 1.64820 08/21/2015 1.64820 01/01/2017 TIZANIDINE HCL ORAL CAPSULE 2 MG 1.89802 08/12/2014 TIZANIDINE HCL ORAL CAPSULE 4 MG 2.40580 08/12/2014 1.28280 12/02/2016 TIZANIDINE HCL ORAL CAPSULE 6 MG 3.53463 02/13/2015 2.02220 05/20/2016 TIZANIDINE HCL ORAL TABLET 2 MG 0.16674 02/13/2015 0.16674 08/21/2015 TIZANIDINE HCL ORAL TABLET 4 MG 0.06003 08/21/2015 TOBRAMYCIN OPHTHALMIC DROPS 0.3 % 2.11500 08/21/2015 2.04817 09/30/2016 TOBRAMYCIN SULFATE INJECTION VIAL (EA) 1.2 G 67.77984 08/01/2014 TOBRAMYCIN SULFATE INJECTION VIAL (ML) 10 MG/ML 1.10250 01/25/2013 TOBRAMYCIN SULFATE INJECTION VIAL (ML) 40 MG/ML 0.57335 10/03/2014 0.57335 08/21/2015 TOBRAMYCIN SULFATE/SODIUM CHLORIDE INTRAVENOUS 0.31870 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 60 MG/50ML TOBRAMYCIN SULFATE/SODIUM CHLORIDE INTRAVENOUS 0.18270 01/25/2013 INTRAVENOUS SOLUTION, PIGGYBACK (ML) 80MG/100ML TOBRAMYCIN/DEXAMETHASONE OPHTHALMIC SUSPENSION, DROPS 15.31800 07/08/2016 15.31800 01/01/2017 (FINAL DOSAGE FORM)(ML) 0.3 %-0.1% TOLAZAMIDE ORAL TABLET 250 MG 2.22090 08/12/2014 2.22090 08/21/2015 TOLAZAMIDE ORAL TABLET 500 MG 1.52140 08/12/2014 TOLBUTAMIDE ORAL TABLET 500 MG 0.73440 08/12/2014 TOLMETIN SODIUM ORAL CAPSULE 400 MG 1.16584 01/25/2013 1.16584 08/21/2015 TOLMETIN SODIUM ORAL TABLET 200 MG 0.52500 02/08/2013 TOLMETIN SODIUM ORAL TABLET 600 MG 2.47650 08/12/2014 2.47650 08/21/2015 TOLNAFTATE TOPICAL AEROSOL, POWDER (GRAM) 1 % 0.04750 08/21/2015 TOLNAFTATE TOPICAL CREAM (GRAM) 1 % 0.11078 01/09/2015 0.11078 08/21/2015 TOLNAFTATE TOPICAL POWDER (GRAM) 1 % 0.04750 08/12/2014 0.04750 08/21/2015 TOLTERODINE TARTRATE ORAL CAPSULE, EXT RELEASE 24 HR 2 MG 4.79678 02/26/2016 3.84868 01/13/2017 TOLTERODINE TARTRATE ORAL CAPSULE, EXT RELEASE 24 HR 4 MG 3.66916 07/08/2016 3.53667 08/26/2016 TOLTERODINE TARTRATE ORAL TABLET 1 MG 1.06340 08/12/2014 TOLTERODINE TARTRATE ORAL TABLET 2 MG 1.10132 08/12/2014 1.10132 08/21/2015 TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 12.64551 09/19/2014 100 MG TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 15.54000 09/19/2014 150 MG West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 17.26689 09/19/2014 200 MG TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 25 4.87551 09/19/2014 MG TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 50 6.34830 09/19/2014 MG TOPIRAMATE ORAL CAPSULE, SPRINKLE 15 MG 0.35240 02/27/2015 0.35240 08/21/2015 TOPIRAMATE ORAL CAPSULE, SPRINKLE 25 MG 0.61251 11/20/2015 0.46055 09/30/2016 TOPIRAMATE ORAL TABLET 100 MG 0.09027 04/03/2015 0.09027 08/21/2015 TOPIRAMATE ORAL TABLET 200 MG 0.14700 04/03/2015 0.14700 08/21/2015 TOPIRAMATE ORAL TABLET 25 MG 0.04470 04/03/2015 0.04470 08/21/2015 TOPIRAMATE ORAL TABLET 50 MG 0.05968 04/03/2015 0.05968 08/21/2015 TOPOTECAN HCL INTRAVENOUS VIAL (EA) 4 MG 81.26200 01/23/2015 81.26200 08/21/2015 TOPOTECAN HCL INTRAVENOUS VIAL (ML) 4 MG/4 ML 30.38490 01/09/2015 30.38490 08/21/2015 TORSEMIDE ORAL TABLET 10 MG 0.12600 04/03/2015 TORSEMIDE ORAL TABLET 100 MG 0.34440 04/03/2015 TORSEMIDE ORAL TABLET 20 MG 0.14668 04/03/2015 TORSEMIDE ORAL TABLET 5 MG 0.11160 04/03/2015 TORSEMIDE VIAL (ML) 20 MG/2 ML 4.31340 01/25/2013 TORSEMIDE VIAL (ML) 50 MG/5 ML 2.34654 01/25/2013 TRAMADOL HCL ORAL TABLET 50 MG 0.02642 04/24/2015 0.02642 08/21/2015 TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG 2.54561 08/21/2015 2.33267 05/20/2016 TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 200 MG 4.20992 11/07/2014 4.20992 08/21/2015 TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 7.09800 08/21/2015 4.04500 09/30/2016 TRAMADOL HCL ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 1.86080 08/12/2014 1.86080 08/21/2015 100 MG TRAMADOL HCL ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 5.44880 08/15/2014 5.44880 08/21/2015 200 MG TRAMADOL HCL ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 3.77000 01/25/2013 3.77000 08/21/2015 300 MG TRAMADOL HCL/ACETAMINOPHEN ORAL TABLET 37.5-325MG 0.21668 01/30/2015 0.21668 08/21/2015 TRANDOLAPRIL ORAL TABLET 1 MG 0.25064 08/23/2013 0.25064 08/21/2015 TRANDOLAPRIL ORAL TABLET 2 MG 0.27372 08/23/2013 0.27372 08/21/2015 TRANDOLAPRIL ORAL TABLET 4 MG 0.25133 08/12/2014 0.25133 08/21/2015 TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND 3.70321 05/01/2015 REL BIPHASE 24HR 1-240MG TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND 3.70321 05/01/2015 REL BIPHASE 24HR 2 MG-180MG TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND 3.70321 05/01/2015 REL BIPHASE 24HR 2-240MG TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND 3.70321 05/01/2015 REL BIPHASE 24HR 4-240MG TRANEXAMIC ACID INTRAVENOUS AMPUL (ML) 1000 MG/10 4.94036 04/10/2015 4.94036 08/21/2015 TRANEXAMIC ACID INTRAVENOUS VIAL (ML) 1000 MG/10 4.18675 02/13/2015 4.18675 08/21/2015 TRANEXAMIC ACID ORAL TABLET 650 MG 3.65133 03/13/2015 3.65133 08/21/2015 TRANYLCYPROMINE SULFATE ORAL TABLET 10 MG 2.52312 11/08/2013 2.52312 08/21/2015 TRAVOPROST (BENZALKONIUM) DROPS 0.004 % 29.13400 05/03/2013 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date TRAZODONE HCL ORAL TABLET 100 MG 0.05272 08/21/2015 0.10300 04/20/2016 TRAZODONE HCL ORAL TABLET 150 MG 0.34200 09/23/2015 0.27289 09/30/2016 TRAZODONE HCL ORAL TABLET 300 MG 2.76314 10/03/2014 2.76314 08/21/2015 TRAZODONE HCL ORAL TABLET 50 MG 0.02880 08/21/2015 0.08541 10/02/2015 TRETINOIN ORAL CAPSULE 10 MG 18.81170 12/05/2014 TRETINOIN TOPICAL CREAM (GRAM) 0.025 % 0.75014 03/27/2015 0.75014 08/21/2015 TRETINOIN TOPICAL CREAM (GRAM) 0.05 % 3.91240 03/27/2015 3.91240 08/21/2015 TRETINOIN TOPICAL CREAM (GRAM) 0.1 % 4.55930 03/27/2015 4.55930 08/21/2015 TRETINOIN TOPICAL GEL (GRAM) 0.01 % 1.51858 01/10/2014 1.51858 08/21/2015 TRETINOIN TOPICAL GEL (GRAM) 0.025 % 1.58131 01/10/2014 1.58131 08/21/2015 TRIAMCINOLONE ACETONIDE DENTAL PASTE (GRAM) 0.1 % 9.29840 04/03/2015 9.29840 08/21/2015 TRIAMCINOLONE ACETONIDE INJECTION VIAL (ML) 10 MG/ML 1.52320 08/01/2014 1.52320 08/21/2015 TRIAMCINOLONE ACETONIDE INJECTION VIAL (ML) 40 MG/ML 2.89400 08/01/2014 2.89400 08/21/2015 TRIAMCINOLONE ACETONIDE NASAL AEROSOL, SPRAY (GRAM) 55 MCG 4.71467 03/27/2015 4.71467 08/21/2015 TRIAMCINOLONE ACETONIDE TOPICAL AEROSOL (GRAM) 0.147MG/G 2.72467 05/01/2015 TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.025 % 0.09310 08/12/2014 0.09310 08/21/2015 TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.1 % 0.21180 08/21/2015 0.16380 03/25/2016 TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.5 % 0.47180 02/22/2013 0.47180 08/21/2015 TRIAMCINOLONE ACETONIDE TOPICAL LOTION (ML) 0.025 % 0.76647 08/12/2014 TRIAMCINOLONE ACETONIDE TOPICAL LOTION (ML) 0.1 % 0.49490 01/31/2014 TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.025 % 0.28560 02/07/2014 0.28560 08/21/2015 TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.1 % 0.11910 02/20/2015 0.11910 08/21/2015 TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.5 % 0.47133 08/12/2014 0.47133 08/21/2015 TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL CAPSULE 37.5-25 MG 0.20977 03/06/2015 0.20977 08/21/2015 TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL TABLET 37.5-25 MG 0.19693 03/27/2015 0.19693 08/21/2015 TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL TABLET 75 MG-50MG 0.18148 12/19/2014 0.18148 08/21/2015 TRIAZOLAM ORAL TABLET 0.125 MG 0.20980 03/01/2013 0.20980 08/21/2015 TRIAZOLAM ORAL TABLET 0.25 MG 0.86737 02/13/2015 0.86737 08/21/2015 TRIFLUOPERAZINE HCL ORAL TABLET 1 MG 0.61215 04/24/2015 TRIFLUOPERAZINE HCL ORAL TABLET 10 MG 1.67825 04/24/2015 TRIFLUOPERAZINE HCL ORAL TABLET 2 MG 0.88396 04/24/2015 TRIFLUOPERAZINE HCL ORAL TABLET 5 MG 1.11338 04/24/2015 TRIFLURIDINE OPHTHALMIC DROPS 1 % 16.63947 08/16/2013 16.63947 08/21/2015 TRIHEXYPHENIDYL HCL ORAL ELIXIR 2 MG/5 ML 0.06175 02/13/2015 TRIHEXYPHENIDYL HCL ORAL TABLET 2 MG 0.05735 11/22/2013 TRIHEXYPHENIDYL HCL ORAL TABLET 5 MG 0.12181 01/17/2014 0.12181 08/21/2015 TRIMETHOBENZAMIDE HCL ORAL CAPSULE 300 MG 1.14618 04/12/2013 TRIMETHOPRIM ORAL TABLET 100 MG 0.27023 02/13/2015 TRIPROLIDINE HCL/PSEUDOEPHEDRINE HCL ORAL LIQUID (ML) 0.938- 1.59900 08/12/2014 1.59900 08/21/2015 10/1 TRIPROLIDINE HCL/PSEUDOEPHEDRINE HCL ORAL SYRUP 1.25-30/5 0.05830 08/12/2014 TRIPROLIDINE HCL/PSEUDOEPHEDRINE HCL ORAL TABLET 2.5MG-60MG 0.05247 01/25/2013 0.05247 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date TROPICAMIDE OPHTHALMIC DROPS 0.5 % 0.64860 08/12/2014 TROPICAMIDE OPHTHALMIC DROPS 1 % 0.52737 08/12/2014 TROSPIUM CHLORIDE ORAL CAPSULE, EXT RELEASE 24 HR 60 MG 4.71567 08/21/2015 4.06176 12/02/2016 TROSPIUM CHLORIDE ORAL TABLET 20 MG 1.55230 11/20/2015 1.10267 07/08/2016 UREA TOPICAL CREAM (GRAM) 40 % 0.16364 08/21/2015 UREA TOPICAL FOAM (GRAM) 35 % 0.88531 09/05/2014 UREA TOPICAL GEL WITH PREFILLED APPLICATOR (ML) 45 % 5.82575 01/25/2013 UREA TOPICAL LOTION (GRAM) 45 % 0.17003 01/25/2013 0.17003 08/21/2015 UREA TOPICAL LOTION (ML) 40 % 0.07492 09/26/2014 0.07492 08/21/2015 UREA TOPICAL NAIL FILM SUSPENSION (ML) 40 % 11.93033 02/14/2014 UREA/HYALURONATE SODIUM KIT 40%-0.2% 282.72300 01/25/2013 URSODIOL MISCELLANEOUS POWDER (GRAM) 100 % 1.52880 08/21/2015 URSODIOL ORAL CAPSULE 300 MG 3.30685 05/20/2016 3.00290 01/27/2017 URSODIOL ORAL TABLET 250 MG 1.65842 01/22/2016 0.82953 12/02/2016 URSODIOL ORAL TABLET 500 MG 2.27318 08/21/2015 1.73581 10/28/2016 VALACYCLOVIR HCL ORAL TABLET 1000 MG 0.95006 08/21/2015 0.76655 05/20/2016 VALACYCLOVIR HCL ORAL TABLET 500 MG 0.48375 08/21/2015 0.41200 01/22/2016 VALGANCICLOVIR HCL ORAL TABLET 450 MG 47.80395 04/03/2015 43.34013 07/29/2016 VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) 0.69225 08/12/2014 MISCELLANEOUS POWDER (GRAM) 100 % VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) ORAL 0.01420 05/17/2013 SOLUTION, ORAL 250 MG/5ML VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) ORAL 0.15149 05/01/2015 0.15149 08/21/2015 SOLUTION, ORAL 250 MG/5ML VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) ORAL 0.08532 08/12/2014 SOLUTION, ORAL 500MG/10ML VALPROIC ACID ORAL CAPSULE 250 MG 0.20127 04/24/2015 0.20127 08/21/2015 VALSARTAN ORAL TABLET 160 MG 0.51072 03/06/2015 0.33567 05/20/2016 VALSARTAN ORAL TABLET 320 MG 0.32878 05/20/2016 0.56210 09/22/2016 VALSARTAN ORAL TABLET 40 MG 0.25638 04/03/2015 0.25638 08/21/2015 VALSARTAN ORAL TABLET 80 MG 0.30611 08/21/2015 0.25840 09/30/2016 VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 160-12.5MG 0.30834 03/25/2016 0.27447 05/20/2016 VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 160-25MG 0.39234 09/25/2015 0.38133 01/13/2017 VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 320-12.5MG 0.34840 03/27/2015 0.34840 08/21/2015 VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 320MG-25MG 0.35615 09/30/2016 0.29533 01/27/2017 VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 80-12.5MG 0.24372 03/27/2015 0.24372 08/21/2015 VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 1 G 6.54200 08/21/2015 6.43041 07/08/2016 VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 10 G 35.96050 08/21/2015 41.89000 09/16/2016 VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 5 G 17.77650 08/21/2015 21.82000 07/04/2016 VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 500 MG 2.11680 08/12/2014 2.11680 08/21/2015 VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 750 MG 6.69900 01/25/2013 VANCOMYCIN HCL INTRAVENOUS VIAL WITH THREADED PORT (EA) 750 10.90110 01/25/2013 MG VANCOMYCIN HCL ORAL CAPSULE 125 MG 8.92017 04/22/2016 7.27778 09/30/2016 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date VANCOMYCIN HCL ORAL CAPSULE 250 MG 17.61549 04/17/2015 VANCOMYCIN HCL/DEXTROSE 5 % IN WATER INTRAVENOUS IV 0.29786 07/25/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1G/200ML VANCOMYCIN HCL/DEXTROSE 5 % IN WATER INTRAVENOUS IV 0.18969 11/07/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 500MG/0.1L VANCOMYCIN HCL/DEXTROSE 5 % IN WATER INTRAVENOUS IV 0.17722 07/25/2014 SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 750MG/.15L VASOPRESSIN INJECTION VIAL (ML) 20 UNIT/ML 3.14184 08/12/2014 3.14184 08/21/2015 VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 150 MG 0.20500 08/21/2015 0.16291 01/27/2017 VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 37.5 MG 0.14338 04/24/2015 0.14338 08/21/2015 VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 75 MG 0.25104 12/25/2015 0.20172 07/29/2016 VENLAFAXINE HCL ORAL TABLET 100 MG 0.33688 08/21/2015 0.26704 08/26/2016 VENLAFAXINE HCL ORAL TABLET 25 MG 0.28502 04/17/2015 0.28502 08/21/2015 VENLAFAXINE HCL ORAL TABLET 37.5 MG 0.32482 04/17/2015 0.32482 08/21/2015 VENLAFAXINE HCL ORAL TABLET 50 MG 0.33500 04/17/2015 0.33500 08/21/2015 VENLAFAXINE HCL ORAL TABLET 75 MG 0.32598 08/21/2015 0.27048 08/26/2016 VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 150 MG 3.19458 08/21/2015 2.62298 12/02/2016 VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 225 MG 5.77550 01/09/2015 VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 37.5 MG 3.22698 03/27/2015 VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 75 MG 3.51130 03/27/2015 VERAPAMIL HCL INTRAVENOUS AMPUL (ML) 2.5 MG/ML 1.65480 01/25/2013 VERAPAMIL HCL INTRAVENOUS SYRINGE (ML) 2.5 MG/ML 4.46460 01/25/2013 VERAPAMIL HCL INTRAVENOUS VIAL (ML) 2.5 MG/ML 2.14400 01/25/2013 2.14400 08/21/2015 VERAPAMIL HCL MISCELLANEOUS POWDER (GRAM) 100 % 0.53976 08/21/2015 VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.98378 04/24/2016 1.35700 09/21/2016 120 MG VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.70015 04/10/2015 0.70015 08/21/2015 180 MG VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 0.89550 05/15/2015 0.89550 08/21/2015 240 MG VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 2.54807 04/10/2015 2.54807 08/21/2015 360 MG VERAPAMIL HCL ORAL CAPSULE,24HR EXTENDED RELEASE PELLET CT 1.23210 08/12/2014 1.23210 08/21/2015 100 MG VERAPAMIL HCL ORAL CAPSULE,24HR EXTENDED RELEASE PELLET CT 1.58723 01/25/2013 1.58723 08/21/2015 200 MG VERAPAMIL HCL ORAL CAPSULE,24HR EXTENDED RELEASE PELLET CT 2.09080 02/27/2015 2.09080 08/21/2015 300 MG VERAPAMIL HCL ORAL TABLET 120 MG 0.07726 05/17/2013 0.07726 08/21/2015 VERAPAMIL HCL ORAL TABLET 40 MG 0.18824 05/30/2014 VERAPAMIL HCL ORAL TABLET 80 MG 0.05600 08/12/2014 0.05600 08/21/2015 VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 120 MG 0.22780 02/06/2015 0.22780 08/21/2015 VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 180 MG 0.16830 04/17/2015 0.16830 08/21/2015 VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 240 MG 0.14485 04/17/2015 0.14485 08/21/2015 VINBLASTINE SULFATE INTRAVENOUS VIAL (ML) 1 MG/ML 2.22600 01/25/2013 VIT B COMPLEX/VIT C/FOLIC ACID/FERROUS FUMARATE/VIT E ACET 0.05547 01/25/2013 ORAL TABLET 500-400-18 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date VITAMIN A/ASCORBIC ACID/ZINC/PROPOLIS (BEE GLUE) ORAL LOZENGE 0.02440 08/12/2014 15 MG VITAMIN B COMPLEX AND VITAMIN C NO.20/FOLIC ACID ORAL CAPSULE 0.16037 07/04/2014 0.16037 08/21/2015 1 MG VITAMIN B COMPLEX/LYSINE ORAL LIQUID (ML) 790MG/15ML 0.03270 01/25/2013 VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC ACID/BIOTIN ORAL 0.12810 08/12/2014 0.12810 08/21/2015 TABLET 1MG-60MG VITAMIN E (DL-ALPHA TOCOPHERYL ACETATE) ORAL CAPSULE 400 UNIT 0.04540 08/21/2015 VITAMIN E MIXED ORAL CAPSULE 400 UNIT 0.05369 08/12/2014 0.05369 08/21/2015 VITAMIN E ORAL CAPSULE 100 UNIT 0.02028 01/25/2013 0.02028 08/21/2015 VITAMIN E ORAL CAPSULE 1000 UNIT 0.12857 01/25/2013 0.12857 08/21/2015 VITAMIN E ORAL CAPSULE 200 UNIT 0.02860 08/12/2014 VITAMIN E ORAL CAPSULE 400 UNIT 0.04540 08/12/2014 0.04540 08/21/2015 VITAMIN E ORAL DROPS 50 UNIT/ML 0.94477 01/31/2014 VITAMINS A AND D/WHITE PETROLATUM/LANOLIN TOPICAL OINTMENT 0.03450 08/12/2014 IN PACKET (GRAM) VORICONAZOLE INTRAVENOUS VIAL (EA) 200 MG 44.58750 08/12/2014 VORICONAZOLE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 9.84947 12/27/2013 MG/5ML VORICONAZOLE ORAL TABLET 200 MG 16.52000 12/25/2015 14.55131 09/30/2016 VORICONAZOLE ORAL TABLET 50 MG 7.49080 08/21/2015 5.86000 07/08/2016 WARFARIN SODIUM ORAL TABLET 1 MG 0.20194 04/24/2015 0.20194 08/21/2015 WARFARIN SODIUM ORAL TABLET 10 MG 0.21998 04/24/2015 0.21998 08/21/2015 WARFARIN SODIUM ORAL TABLET 2 MG 0.20194 04/24/2015 0.20194 08/21/2015 WARFARIN SODIUM ORAL TABLET 2.5 MG 0.20194 04/24/2015 0.20194 08/21/2015 WARFARIN SODIUM ORAL TABLET 3 MG 0.20206 04/24/2015 0.20206 08/21/2015 WARFARIN SODIUM ORAL TABLET 4 MG 0.20206 04/24/2015 0.20206 08/21/2015 WARFARIN SODIUM ORAL TABLET 5 MG 0.20194 04/24/2015 0.20194 08/21/2015 WARFARIN SODIUM ORAL TABLET 6 MG 0.23115 04/24/2015 0.23115 08/21/2015 WARFARIN SODIUM ORAL TABLET 7.5 MG 0.17462 04/24/2015 0.17462 08/21/2015 WATER FOR INJ.,BACTERIOSTATIC INJECTION VIAL (ML) 0.02828 03/20/2015 0.02828 08/21/2015 WATER FOR INJECTION,STERILE INJECTION AMPUL (ML) 0.08820 01/25/2013 0.08820 08/21/2015 WATER FOR INJECTION,STERILE INJECTION VIAL (ML) 0.07489 07/18/2014 0.07489 08/21/2015 WATER FOR INJECTION,STERILE INTRAVENOUS INTRAVENOUS 0.00226 05/01/2015 0.00226 08/21/2015 SOLUTION WATER FOR IRRIGATION,STERILE IRRIGATION SOLUTION, IRRIGATION 0.00545 08/12/2014 0.00545 08/21/2015 WATER ORAL LIQUID (ML) 0.01165 01/16/2015 0.01165 08/21/2015 WITCH HAZEL TOPICAL PADS, MEDICATED (EA) 50 % 0.07692 08/12/2014 0.07692 08/21/2015 ZAFIRLUKAST ORAL TABLET 10 MG 1.19188 01/25/2013 1.19188 01/01/2017 ZAFIRLUKAST ORAL TABLET 20 MG 1.25253 08/12/2014 1.25253 01/01/2017 ZALEPLON ORAL CAPSULE 10 MG 0.21311 03/27/2015 0.21311 08/21/2015 ZALEPLON ORAL CAPSULE 5 MG 0.21208 03/01/2013 0.21208 08/21/2015 ZIDOVUDINE ORAL CAPSULE 100 MG 0.82839 11/08/2013 0.82839 08/21/2015 ZIDOVUDINE ORAL SYRUP 10 MG/ML 0.12787 05/10/2013 ZIDOVUDINE ORAL TABLET 300 MG 0.37007 08/12/2014 0.37007 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage
Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ZINC CHLORIDE INTRAVENOUS VIAL (ML) 1 MG/ML 0.17050 08/12/2014 ZINC SULFATE INTRAVENOUS VIAL (ML) 1 MG/ML 0.21874 01/25/2013 ZINC SULFATE INTRAVENOUS VIAL (ML) 5 MG/ML 0.65343 01/25/2013 ZIPRASIDONE HCL ORAL CAPSULE 20 MG 0.92360 02/26/2016 0.61312 03/25/2016 ZIPRASIDONE HCL ORAL CAPSULE 40 MG 0.68889 12/06/2016 0.60276 01/27/2017 ZIPRASIDONE HCL ORAL CAPSULE 60 MG 0.91409 01/30/2015 0.74878 03/25/2016 ZIPRASIDONE HCL ORAL CAPSULE 80 MG 0.63450 12/02/2016 0.58885 01/27/2017 ZOLEDRONIC ACID IN MANNITOL AND WATER FOR INJECTION 10.14930 08/16/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 4 MG/100ML ZOLEDRONIC ACID IN MANNITOL AND WATER FOR INJECTION 8.37592 10/25/2013 INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 5 MG/100ML ZOLMITRIPTAN ORAL TABLET 2.5 MG 35.08983 04/03/2015 35.08983 08/21/2015 ZOLMITRIPTAN ORAL TABLET 5 MG 10.97139 10/23/2015 8.36000 07/08/2016 ZOLMITRIPTAN ORAL TABLET,DISINTEGRATING 2.5 MG 35.08983 05/31/2013 ZOLMITRIPTAN ORAL TABLET,DISINTEGRATING 5 MG 38.79167 05/31/2013 6.52000 07/08/2016 ZOLPIDEM TARTRATE ORAL TABLET 10 MG 0.02680 03/27/2015 0.02680 08/21/2015 ZOLPIDEM TARTRATE ORAL TABLET 5 MG 0.02680 03/13/2015 0.02680 08/21/2015 ZOLPIDEM TARTRATE ORAL TABLET, EXTENDED RELEASE MULTIPHASE 1.37772 08/21/2015 1.05123 12/25/2015 12.5 MG ZOLPIDEM TARTRATE ORAL TABLET, EXTENDED RELEASE MULTIPHASE 1.53819 05/02/2014 1.53819 08/21/2015 6.25 MG ZONISAMIDE ORAL CAPSULE 100 MG 0.26066 08/21/2015 0.20287 03/25/2016 ZONISAMIDE ORAL CAPSULE 25 MG 0.15422 08/15/2014 0.15422 08/21/2015 ZONISAMIDE ORAL CAPSULE 50 MG 0.14366 12/25/2015 0.15682 04/28/2016