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West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.03442 0.03442 2/8/2013 0.9 % SODIUM CHLORIDE PGY VL PRT 0.07096 0.07096 2/8/2013 0.9 % SODIUM CHLORIDE 0.9 % IV SOLN 0.00174 0.00174 2/8/2013 0.9 % SODIUM CHLORIDE 0.9 % VIAL 0.05829 0.05829 2/8/2013 ABACAVIR SULFATE 300 MG TABLET 6.36133 6.36133 2/8/2013 ACARBOSE 100 MG TABLET 0.52381 0.52381 2/8/2013 ACARBOSE 25 MG TABLET 0.47798 0.47798 2/8/2013 ACARBOSE 50 MG TABLET 0.49808 0.49808 2/8/2013 ACEBUTOLOL HCL 200 MG CAPSULE 0.21353 0.21353 2/8/2013 ACEBUTOLOL HCL 400 MG CAPSULE 0.45175 0.45175 2/8/2013 ACETAMINOPHEN 100 MG/ML DROPS 0.15340 0.15340 2/8/2013 ACETAMINOPHEN 120 MG SUPP.RECT 0.16289 0.16289 2/8/2013 ACETAMINOPHEN 160 MG/5ML ELIXIR 0.01085 0.01085 2/8/2013 ACETAMINOPHEN 160 MG/5ML LIQUID 0.00945 0.00945 2/8/2013 ACETAMINOPHEN 160 MG/5ML ORAL SUSP 0.02251 0.02251 2/8/2013 ACETAMINOPHEN 325 MG SUPP.RECT 0.45850 0.45850 2/8/2013 ACETAMINOPHEN 325 MG TABLET 0.00830 0.00830 2/8/2013 ACETAMINOPHEN 500 MG CAPSULE 0.02938 0.02938 2/8/2013 ACETAMINOPHEN 500 MG TABLET 0.00951 0.00951 2/8/2013 ACETAMINOPHEN 650 MG SUPP.RECT 0.21683 0.21683 2/8/2013 ACETAMINOPHEN 80 MG TAB CHEW 0.04854 0.04854 2/8/2013 ACETAMINOPHEN 80 MG TAB RAPDIS 0.05113 0.05113 2/8/2013 ACETAMINOPHEN WITH CODEINE 120-12MG/5 0.15890 0.15890 2/8/2013 ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION 0.01487 0.01487 2/8/2013 ACETAMINOPHEN WITH CODEINE 240-24/10 SOLUTION 0.08525 0.08525 2/8/2013 ACETAMINOPHEN WITH CODEINE 300MG/12.5 SOLUTION 0.07496 0.07496 2/8/2013 ACETAMINOPHEN WITH CODEINE 300MG-15MG TABLET 0.14197 0.14197 2/8/2013 ACETAMINOPHEN WITH CODEINE 300MG-30MG TABLET 0.10693 0.10693 2/8/2013 ACETAMINOPHEN WITH CODEINE 300MG-60MG TABLET 0.22820 0.22820 2/8/2013 ACETAMINOPHEN WITH CODEINE 360-36/15 SOLUTION 0.06622 0.06622 2/8/2013 ACETAMINOPHEN/DIPHENHYDRAMINE 325-12.5MG TABLET 0.15401 0.15401 2/8/2013 ACETAMINOPHEN/DIPHENHYDRAMINE 500MG-25MG TABLET 0.03653 0.03653 2/8/2013 ACETAMINOPHEN/DP-HYDRAMINE 500MG-38MG TABLET 0.11395 0.10563 2/15/2013 ACETAZOLAMIDE 125 MG TABLET 0.38948 0.46732 2/15/2013 ACETAZOLAMIDE 250 MG TABLET 0.53753 0.57212 2/8/2013 ACETAZOLAMIDE 500 MG CAPSULE ER 3.00396 3.00396 2/8/2013 ACETIC ACID 0.25 % IRRIG SOLN 0.00268 0.00268 2/8/2013 ACETIC ACID 2 % SOLUTION 1.70066 1.70066 2/8/2013 ACETIC ACID/ALUMINUM ACETATE 2 % DROPS 0.84000 0.84000 2/8/2013 ACETIC ACID/HYDROCORTISONE 2 %-1 % DROPS 9.82215 9.82215 2/8/2013 ACETYL/METHYL-B12/LMEFOLATE CA 600-2-6 MG TABLET 1.23521 1.23521 2/8/2013 ACETYLCYSTEINE 100 MG/ML VIAL 0.25701 0.25701 2/8/2013 ACETYLCYSTEINE 200 MG/ML VIAL 5.26400 5.26400 2/8/2013 ACYCLOVIR 200 MG CAPSULE 0.10616 0.10616 2/8/2013 ACYCLOVIR 200 MG/5ML ORAL SUSP 0.16860 0.16860 2/8/2013 ACYCLOVIR 800 MG TABLET 0.26854 0.26854 2/8/2013 ACYCLOVIR SODIUM 1000 MG VIAL 7.68600 7.68600 2/8/2013 ACYCLOVIR SODIUM 50 MG/ML VIAL 2.85501 2.85501 2/8/2013 ADAPALENE 0.1 % CREAM (G) 3.66909 3.66909 2/8/2013 ADAPALENE 0.1 % GEL (GRAM) 3.05760 3.05760 2/8/2013 ALBUMIN HUMAN 25 % IV SOLN 0.90300 0.90300 2/8/2013 ALBUMIN HUMAN 25 % VIAL 1.51200 1.51200 2/8/2013 ALBUMIN HUMAN 5 % IV SOLN 0.21000 0.21000 2/8/2013 ALBUTEROL SULFATE 0.63MG/3ML VIAL-NEB 0.37527 0.37527 2/8/2013 ALBUTEROL SULFATE 1.25MG/3ML VIAL-NEB 0.37674 0.37674 2/8/2013 ALBUTEROL SULFATE 2 MG TABLET 0.14473 0.14473 2/8/2013 ALBUTEROL SULFATE 2 MG/5 ML SYRUP 0.01268 0.01268 2/8/2013 Page 1 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price ALBUTEROL SULFATE 2.5 MG/0.5 VIAL-NEB 0.64218 0.64218 2/8/2013 ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB 0.05487 0.05487 2/8/2013 ALBUTEROL SULFATE 4 MG TAB ER 12H 0.98161 0.98161 2/8/2013 ALBUTEROL SULFATE 4 MG TABLET 0.20558 0.20558 2/8/2013 ALBUTEROL SULFATE 5 MG/ML SOLUTION 0.54600 0.54600 2/8/2013 ALBUTEROL SULFATE 8 MG TAB ER 12H 1.84058 1.84058 2/8/2013 ALCLOMETASONE DIPROPIONATE 0.05 % CREAM (G) 0.56414 0.56414 2/8/2013 ALCLOMETASONE DIPROPIONATE 0.05 % OINT. (G) 0.58692 0.58692 2/8/2013 ALENDRONATE SODIUM 10 MG TABLET 0.18747 0.18747 2/8/2013 ALENDRONATE SODIUM 35 MG TABLET 0.69010 0.69010 2/8/2013 ALENDRONATE SODIUM 40 MG TABLET 6.63531 6.63531 2/8/2013 ALENDRONATE SODIUM 5 MG TABLET 0.18113 0.18113 2/8/2013 ALENDRONATE SODIUM 70 MG TABLET 0.69010 0.69010 2/8/2013 ALFUZOSIN HCL 10 MG TAB ER 24H 0.22035 0.22035 2/8/2013 ALLOPURINOL 100 MG TABLET 0.03685 0.03685 2/8/2013 ALLOPURINOL 300 MG TABLET 0.06646 0.06646 2/8/2013 ALPHA LIPOIC ACID 200 MG CAPSULE 0.09998 0.09765 2/15/2013 ALPHA LIPOIC ACID 50 MG CAPSULE 0.10208 0.04900 2/15/2013 ALPRAZOLAM 0.25 MG TAB RAPDIS 1.28921 1.28921 2/8/2013 ALPRAZOLAM 0.25 MG TABLET 0.01541 0.01541 2/8/2013 ALPRAZOLAM 0.5 MG TAB ER 24H 0.33259 0.33259 2/8/2013 ALPRAZOLAM 0.5 MG TAB RAPDIS 1.51669 1.51669 2/8/2013 ALPRAZOLAM 0.5 MG TABLET 0.01809 0.01809 2/8/2013 ALPRAZOLAM 1 MG TAB ER 24H 0.43081 0.43081 2/8/2013 ALPRAZOLAM 1 MG TAB RAPDIS 2.02358 2.02358 2/8/2013 ALPRAZOLAM 1 MG TABLET 0.02010 0.02010 2/8/2013 ALPRAZOLAM 2 MG TAB ER 24H 0.57955 0.57955 2/8/2013 ALPRAZOLAM 2 MG TAB RAPDIS 3.00202 3.00202 2/8/2013 ALPRAZOLAM 2 MG TABLET 0.04087 0.04087 2/8/2013 ALPRAZOLAM 3 MG TAB ER 24H 0.79343 0.79343 2/8/2013 ALUM/SALICYLIC ACID/TALC/BENT POWDER 0.06736 0.06736 2/8/2013 ALUMINUM HYDROXIDE OINT. (G) 0.06484 0.06484 2/8/2013 AMANTADINE HCL 100 MG CAPSULE 1.36390 1.36390 2/8/2013 AMANTADINE HCL 100 MG TABLET 1.24865 1.24865 2/8/2013 AMANTADINE HCL 50 MG/5 ML SYRUP 0.01970 0.01970 2/8/2013 AMCINONIDE 0.1 % CREAM (G) 3.29673 3.29673 2/8/2013 AMCINONIDE 0.1 % LOTION 3.80018 3.80018 2/8/2013 AMCINONIDE 0.1 % OINT. (G) 4.53600 4.53600 2/8/2013 AMIKACIN SULFATE 100 MG/2ML VIAL 2.90325 2.90325 2/8/2013 AMIKACIN SULFATE 1000MG/4ML VIAL 2.74505 2.74505 2/8/2013 AMIKACIN SULFATE 500 MG/2ML VIAL 1.97400 1.97400 2/8/2013 AMILORIDE HCL 5 MG TABLET 0.58045 0.58045 2/8/2013 AMILORIDE/HYDROCHLOROTHIAZIDE 5MG-50MG TABLET 0.24684 0.24684 2/8/2013 AMINO ACIDS POWDER 0.25544 0.25544 2/8/2013 AMINOCAPROIC ACID 1000 MG TABLET 18.30612 18.30612 2/8/2013 AMINOCAPROIC ACID 250 MG/ML SOLUTION 1.11556 1.11556 2/8/2013 AMINOCAPROIC ACID 500 MG TABLET 2.18897 2.18897 2/8/2013 AMINOPHYLLINE 250MG/10ML AMPUL 0.05712 0.05712 2/8/2013 AMINOPHYLLINE 250MG/10ML VIAL 0.13272 0.13272 2/8/2013 AMINOPHYLLINE 500MG/20ML VIAL 0.08736 0.08736 2/8/2013 AMIODARONE HCL 200 MG TABLET 0.16281 0.16281 2/8/2013 AMIODARONE HCL 400 MG TABLET 6.08859 3.70417 2/15/2013 AMIODARONE HCL 50 MG/ML AMPUL 0.27720 0.27720 2/8/2013 AMITRIP HCL/CHLORDIAZEPOXIDE 12.5MG-5MG TABLET 0.77868 0.77868 2/8/2013 AMITRIP HCL/CHLORDIAZEPOXIDE 25 MG-10MG TABLET 1.09860 1.09860 2/8/2013 AMITRIPTYLINE HCL 10 MG TABLET 0.01970 0.01970 2/8/2013 AMITRIPTYLINE HCL 100 MG TABLET 0.05507 0.05507 2/8/2013 Page 2 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price AMITRIPTYLINE HCL 150 MG TABLET 0.09922 0.09922 2/8/2013 AMITRIPTYLINE HCL 25 MG TABLET 0.02265 0.02265 2/8/2013 AMITRIPTYLINE HCL 50 MG TABLET 0.02747 0.02747 2/8/2013 AMITRIPTYLINE HCL 75 MG TABLET 0.04690 0.04690 2/8/2013 AMLODIPINE BESYLATE 10 MG TABLET 0.02533 0.02533 2/8/2013 AMLODIPINE BESYLATE 2.5 MG TABLET 0.01983 0.01983 2/8/2013 AMLODIPINE BESYLATE 5 MG TABLET 0.02131 0.02131 2/8/2013 AMLODIPINE BESYLATE/BENAZEPRIL 10MG-20MG CAPSULE 0.86484 0.86484 2/8/2013 AMLODIPINE BESYLATE/BENAZEPRIL 10MG-40MG CAPSULE 0.97472 0.97472 2/8/2013 AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG CAPSULE 1.69273 1.69273 2/8/2013 AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-10 MG CAPSULE 0.81700 0.81700 2/8/2013 AMLODIPINE BESYLATE/BENAZEPRIL 5MG-20MG CAPSULE 0.82477 0.82477 2/8/2013 AMLODIPINE BESYLATE/BENAZEPRIL 5MG-40MG CAPSULE 0.80695 0.80695 2/8/2013 AMLODIPINE/ATORVASTATIN 10MG-10MG TABLET 3.52613 3.52613 2/8/2013 AMLODIPINE/ATORVASTATIN 10MG-20MG TABLET 4.82418 4.82418 2/8/2013 AMLODIPINE/ATORVASTATIN 10MG-40MG TABLET 4.82425 4.82425 2/8/2013 AMLODIPINE/ATORVASTATIN 10MG-80MG TABLET 4.82425 4.82425 2/8/2013 AMLODIPINE/ATORVASTATIN 2.5MG-10MG TABLET 3.52621 3.52621 2/8/2013 AMLODIPINE/ATORVASTATIN 2.5MG-20MG TABLET 4.82421 4.82421 2/8/2013 AMLODIPINE/ATORVASTATIN 2.5MG-40MG TABLET 4.82421 4.82421 2/8/2013 AMLODIPINE/ATORVASTATIN 5 MG-10 MG TABLET 3.52617 3.52617 2/8/2013 AMLODIPINE/ATORVASTATIN 5MG-20MG TABLET 4.82420 4.82420 2/8/2013 AMLODIPINE/ATORVASTATIN 5MG-40MG TABLET 4.82422 4.82422 2/8/2013 AMLODIPINE/ATORVASTATIN 5MG-80MG TABLET 4.82420 4.82420 2/8/2013 AMMONIUM ALUM/TALC/BENTONITE POWDER 0.07531 0.07531 2/8/2013 AMMONIUM CHLORIDE 5MEQ/ML VIAL 0.42630 0.42630 2/8/2013 AMMONIUM LACTATE 12 % CREAM (G) 0.03672 0.03672 2/8/2013 AMMONIUM LACTATE 12 % LOTION 0.01943 0.01943 2/8/2013 AMOXAPINE 100 MG TABLET 0.72280 0.72280 2/8/2013 AMOXAPINE 150 MG TABLET 1.28830 1.28830 2/8/2013 AMOXAPINE 25 MG TABLET 0.27027 0.27027 2/8/2013 AMOXAPINE 50 MG TABLET 0.40846 0.40846 2/8/2013 AMOXICILLIN 125 MG TAB CHEW 0.15067 0.15067 2/8/2013 AMOXICILLIN 125 MG/5ML SUSP RECON 0.01849 0.01849 2/8/2013 AMOXICILLIN 200 MG/5ML SUSP RECON 0.02876 0.02876 2/8/2013 AMOXICILLIN 250 MG CAPSULE 0.06258 0.06258 2/8/2013 AMOXICILLIN 250 MG/5ML SUSP RECON 0.02318 0.02318 2/8/2013 AMOXICILLIN 400 MG/5ML SUSP RECON 0.03002 0.03002 2/8/2013 AMOXICILLIN 500 MG CAPSULE 0.09018 0.09018 2/8/2013 AMOXICILLIN 500 MG TABLET 0.28243 0.28243 2/8/2013 AMOXICILLIN 875MG TABLET 0.18412 0.18412 2/8/2013 AMOXICILLIN/POTASSIUM CLAV 1000-62.5 TAB ER 12H 2.71530 2.71530 2/8/2013 AMOXICILLIN/POTASSIUM CLAV 200-28.5/5 SUSP RECON 0.10963 0.10963 2/8/2013 AMOXICILLIN/POTASSIUM CLAV 200-28.5MG TAB CHEW 0.96704 0.96704 2/8/2013 AMOXICILLIN/POTASSIUM CLAV 400-57MG TAB CHEW 1.40043 1.40043 2/8/2013 AMOXICILLIN/POTASSIUM CLAV 400-57MG/5 SUSP RECON 0.16063 0.16063 2/8/2013 AMOXICILLIN/POTASSIUM CLAV 500-125 MG TABLET 1.25731 1.25731 2/8/2013 AMOXICILLIN/POTASSIUM CLAV 600-42.9/5 SUSP RECON 0.21300 0.21300 2/8/2013 AMOXICILLIN/POTASSIUM CLAV 875-125 MG TABLET 1.03113 1.03113 2/8/2013 AMPHOTERICIN B 50 MG VIAL 12.76000 12.76000 2/8/2013 AMPICILLIN SODIUM 1 G VIAL 2.89120 2.89120 2/8/2013 AMPICILLIN SODIUM 1 G VIAL PORT 12.52460 12.52460 2/8/2013 AMPICILLIN SODIUM 10 G VIAL 40.47315 40.47315 2/8/2013 AMPICILLIN SODIUM 125 MG VIAL 3.65400 3.65400 2/8/2013 AMPICILLIN SODIUM 2 G VIAL 4.74500 4.74500 2/8/2013 AMPICILLIN SODIUM 2 G VIAL PORT 23.62640 23.62640 2/8/2013 AMPICILLIN SODIUM 250 MG VIAL 1.41638 1.41638 2/8/2013 Page 3 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price AMPICILLIN SODIUM 500 MG VIAL 1.62006 1.62006 2/8/2013 AMPICILLIN SODIUM/SULBACTAM NA 1.5 G VIAL 2.20296 2.20296 2/8/2013 AMPICILLIN SODIUM/SULBACTAM NA 1.5 G VIAL PORT 3.24240 3.24240 2/8/2013 AMPICILLIN SODIUM/SULBACTAM NA 15 G VIAL 21.31500 21.31500 2/8/2013 AMPICILLIN SODIUM/SULBACTAM NA 3 G VIAL 4.18470 4.18470 2/8/2013 AMPICILLIN SODIUM/SULBACTAM NA 3 G VIAL PORT 5.22060 5.22060 2/8/2013 AMPICILLIN TRIHYDRATE 125 MG/5ML SUSP RECON 0.03952 0.03952 2/8/2013 AMPICILLIN TRIHYDRATE 250 MG CAPSULE 0.08999 0.08999 2/8/2013 AMPICILLIN TRIHYDRATE 250 MG/5ML SUSP RECON 0.06858 0.06858 2/8/2013 AMPICILLIN TRIHYDRATE 500 MG CAPSULE 0.14370 0.14370 2/8/2013 ANAGRELIDE HCL 0.5 MG CAPSULE 0.22620 0.22620 2/8/2013 ANAGRELIDE HCL 1 MG CAPSULE 0.43732 0.43732 2/8/2013 ANASTROZOLE 1 MG TABLET 0.15142 0.15142 2/8/2013 ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4 %-1.4% DROPS 0.57706 0.57706 2/8/2013 ANTIVENIN,LATRODECTUS MACTANS COMBO. PKG 28.66500 28.66500 2/8/2013 ANTIVENIN,MICRURUS FULVIUS COMBO. PKG 1,630.98600 1,630.98600 2/8/2013 APRACLONIDINE HCL 0.5 % DROPS 12.32550 12.32550 2/8/2013 ARGATROBAN 100 MG/ML VIAL 1,124.62001 1,124.62001 2/8/2013 ARGATROBAN IN 0.9 % SOD CHLOR 125 MG/125 VIAL 11.61817 11.61817 2/8/2013 ARGININE 500 MG CAPSULE 0.08064 0.08064 2/8/2013 ARGININE HCL 1000 MG TABLET 0.13363 0.13363 2/8/2013 ASCORBIC ACID 1000 MG TABLET 0.05571 0.04930 2/15/2013 ASCORBIC ACID 1000 MG TABLET ER 0.05330 0.05330 2/8/2013 ASCORBIC ACID 250 MG TAB CHEW 0.02510 0.02510 2/8/2013 ASCORBIC ACID 250 MG TABLET 0.01671 0.01671 2/8/2013 ASCORBIC ACID 500 MG TAB CHEW 0.04453 0.04453 2/8/2013 ASCORBIC ACID 500 MG TABLET 0.02278 0.02278 2/8/2013 ASPIRIN 325 MG TABLET 0.00804 0.00804 2/8/2013 ASPIRIN 325 MG TABLET DR 0.00858 0.00858 2/8/2013 ASPIRIN 81 MG TAB CHEW 0.02198 0.02198 2/8/2013 ASPIRIN 81 MG TABLET DR 0.00724 0.00724 2/8/2013 ASPIRIN/ACETAMINOPHEN/CAFFEINE 250-250-65 TABLET 0.04476 0.04476 2/8/2013 ASPIRIN/ CARBONATE/MAG 325 MG TABLET 0.02015 0.02015 2/8/2013 ASPIRIN/SOD BICARB/CITRIC ACID 325-1916MG TABLET EFF 0.08774 0.07967 2/8/2013 ATENOLOL 100 MG TABLET 0.03400 0.03400 2/8/2013 ATENOLOL 25 MG TABLET 0.01327 0.01327 2/8/2013 ATENOLOL 50 MG TABLET 0.01640 0.01640 2/8/2013 ATENOLOL/CHLORTHALIDONE 100MG-25MG TABLET 0.16825 0.16825 2/8/2013 ATENOLOL/CHLORTHALIDONE 50 MG-25MG TABLET 0.10572 0.10572 2/8/2013 ATORVASTATIN CALCIUM 10 MG TABLET 0.55680 0.55680 2/8/2013 ATORVASTATIN CALCIUM 20 MG TABLET 0.79430 0.79430 2/8/2013 ATORVASTATIN CALCIUM 40 MG TABLET 0.79430 0.79430 2/8/2013 ATORVASTATIN CALCIUM 80 MG TABLET 0.95320 0.95320 2/8/2013 ATOVAQUONE/PROGUANIL HCL 250-100 MG TABLET 5.00297 5.00297 2/8/2013 ATOVAQUONE/PROGUANIL HCL 62.5-25MG TABLET 1.85045 1.85045 2/8/2013 ATROPINE SULFATE 0.05MG/ML DISP SYRIN 2.23272 2.23272 2/8/2013 ATROPINE SULFATE 0.1 MG/ML DISP SYRIN 0.43014 0.43014 2/8/2013 ATROPINE SULFATE 0.4 MG/ML VIAL 1.02665 1.02665 2/8/2013 ATROPINE SULFATE 1 % DROPS 1.76890 1.76890 2/8/2013 ATROPINE SULFATE 1 % OINT. (G) 3.98000 3.98000 2/8/2013 ATROPINE SULFATE 1 MG/ML VIAL 1.48447 1.48447 2/8/2013 AZATHIOPRINE 50 MG TABLET 0.15938 0.15938 2/8/2013 AZATHIOPRINE SODIUM 100 MG VIAL 10.56045 10.56045 2/8/2013 AZELASTINE HCL 0.05 % DROPS 11.59817 11.59817 2/8/2013 AZELASTINE HCL 137 MCG SPRAY/PUMP 2.41583 2.41583 2/8/2013 AZITHROMYCIN 1 G PACKET 13.46447 13.46447 2/8/2013 AZITHROMYCIN 100 MG/5ML SUSP RECON 0.79589 0.79589 2/8/2013 Page 4 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price AZITHROMYCIN 200 MG/5ML SUSP RECON 0.71130 0.71130 2/8/2013 AZITHROMYCIN 250 MG TABLET 0.61935 0.61935 2/8/2013 AZITHROMYCIN 500 MG TABLET 1.78220 1.78220 2/8/2013 AZITHROMYCIN 500 MG VIAL 3.97150 3.97150 2/8/2013 AZITHROMYCIN 500 MG VIAL PORT 12.68820 12.68820 2/8/2013 AZITHROMYCIN 600 MG TABLET 3.25871 3.25871 2/8/2013 AZTREONAM 1 G VIAL 27.67800 27.67800 2/8/2013 AZTREONAM 2 G VIAL 56.23800 56.23800 2/8/2013 B COMPLEX WITH VITAMIN C TABLET 0.02613 0.02613 2/8/2013 BACITRACIN 500 UNIT/G OINT. (G) 13.86800 13.86800 2/8/2013 BACITRACIN 500 UNIT/G OINT. (G) 0.06637 0.06637 2/8/2013 BACITRACIN 500 UNIT/G OINT. (G) 0.10720 0.10720 2/8/2013 BACITRACIN/POLYMYXIN B SULFATE 500-10K/G OINT. (G) 3.37025 3.37025 2/8/2013 BACITRACIN/POLYMYXIN B SULFATE 500-10K/G OINT. (G) 0.27376 0.27376 2/8/2013 BACLOFEN 10 MG TABLET 0.04382 0.04382 2/8/2013 BACLOFEN 100 % POWDER 3.64650 3.64650 2/8/2013 BACLOFEN 20 MG TABLET 0.08060 0.08060 2/8/2013 BALSALAZIDE DISODIUM 750 MG CAPSULE 0.24639 0.24639 2/8/2013 BCG LIVE 50 MG VIAL 291.39600 291.39600 2/8/2013 BENAZEPRIL HCL 10 MG TABLET 0.05186 0.05186 2/8/2013 BENAZEPRIL HCL 20 MG TABLET 0.05507 0.05507 2/8/2013 BENAZEPRIL HCL 40 MG TABLET 0.06941 0.06941 2/8/2013 BENAZEPRIL HCL 5 MG TABLET 0.04904 0.04904 2/8/2013 BENAZEPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.43943 0.43943 2/8/2013 BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.44398 0.44398 2/8/2013 BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.44811 0.44811 2/8/2013 BENAZEPRIL/HYDROCHLOROTHIAZIDE 5-6.25MG TABLET 0.45890 0.45890 2/8/2013 BENZOCAINE/MENTHOL 15MG-3.6MG LOZENGE 0.10327 0.11997 2/15/2013 BENZONATATE 100 MG CAPSULE 0.09072 0.09072 2/8/2013 BENZONATATE 200 MG CAPSULE 0.13306 0.13306 2/8/2013 BENZOYL 10 % CLEANSER 0.04186 0.04186 2/8/2013 BENZOYL PEROXIDE 10 % GEL (GRAM) 0.19198 0.19198 2/8/2013 BENZOYL PEROXIDE 4.25 % CLEANSER 0.17892 0.17892 2/8/2013 BENZOYL PEROXIDE 5 % CLEANSER 0.04757 0.04757 2/8/2013 BENZOYL PEROXIDE 5 % GEL (GRAM) 0.18364 0.18364 2/8/2013 BENZOYL PEROXIDE 5.3% FOAM 2.02384 2.02384 2/8/2013 BENZOYL PEROXIDE 9.8 % FOAM 1.61098 1.61098 2/8/2013 BENZPHETAMINE HCL 50 MG TABLET 0.47918 0.47918 2/8/2013 BENZTROPINE MESYLATE 0.5 MG TABLET 0.04770 0.04770 2/8/2013 BENZTROPINE MESYLATE 1 MG TABLET 0.04931 0.04931 2/8/2013 BENZTROPINE MESYLATE 2 MG TABLET 0.06713 0.06713 2/8/2013 BENZTROPINE MESYLATE 2 MG/2 ML AMPUL 23.40625 23.40625 2/8/2013 BENZTROPINE MESYLATE 2 MG/2 ML VIAL 40.39560 40.39560 2/8/2013 BETAMET ACET/BETAMET NA PH 6 MG/ML VIAL 5.60000 5.60000 2/8/2013 BETAMET DIPROP/PROP GLY 0.05 % CREAM (G) 0.25916 0.25916 2/8/2013 BETAMET DIPROP/PROP GLY 0.05 % LOTION 0.70578 0.70578 2/8/2013 BETAMETHASONE DIPROPIONATE 0.05 % CREAM (G) 1.36198 1.36198 2/8/2013 BETAMETHASONE DIPROPIONATE 0.05 % GEL (GRAM) 1.59404 1.59404 2/8/2013 BETAMETHASONE DIPROPIONATE 0.05 % LOTION 0.54060 0.54060 2/8/2013 BETAMETHASONE DIPROPIONATE 0.05 % OINT. (G) 1.59528 1.59528 2/8/2013 BETAMETHASONE VALERATE 0.1 % CREAM (G) 0.59219 0.59219 2/8/2013 BETAMETHASONE VALERATE 0.1 % LOTION 0.79430 0.79430 2/8/2013 BETAMETHASONE VALERATE 0.12 % FOAM 2.71317 2.71317 2/8/2013 BETAXOLOL HCL 0.5 % DROPS 7.27680 7.27680 2/8/2013 BETAXOLOL HCL 10 MG TABLET 0.85566 0.72400 2/8/2013 BETHANECHOL CHLORIDE 10 MG TABLET 0.07812 0.07812 2/8/2013 BETHANECHOL CHLORIDE 25 MG TABLET 0.16134 0.16134 2/8/2013 Page 5 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price BETHANECHOL CHLORIDE 5 MG TABLET 0.05548 0.05548 2/8/2013 BETHANECHOL CHLORIDE 50 MG TABLET 0.32148 0.45410 2/8/2013 50 MG TABLET 0.32321 0.32321 2/8/2013 BIOFLAV,LEMON/VIT BCOMP&C 200-100 MG TABLET 0.14285 0.14285 2/8/2013 BIOTIN 2500MCG CAPSULE 0.09393 0.08104 2/15/2013 BISACODYL 10 MG SUPP.RECT 0.09487 0.09487 2/8/2013 BISACODYL 5 MG TABLET DR 0.00951 0.00951 2/8/2013 BISMUTH SUBSALICYLATE 262 MG TAB CHEW 0.06890 0.06890 2/8/2013 BISMUTH SUBSALICYLATE 262MG/15ML ORAL SUSP 0.00737 0.00737 2/8/2013 BISMUTH SUBSALICYLATE 525MG/15ML ORAL SUSP 0.01099 0.01099 2/8/2013 BISOPROLOL FUMARATE 10 MG TABLET 0.29922 0.29922 2/8/2013 BISOPROLOL FUMARATE 5 MG TABLET 0.29922 0.29922 2/8/2013 BISOPROLOL FUMARATE/HCTZ 10-6.25MG TABLET 0.06057 0.06057 2/8/2013 BISOPROLOL FUMARATE/HCTZ 2.5-6.25MG TABLET 0.05909 0.05909 2/8/2013 BISOPROLOL FUMARATE/HCTZ 5-6.25MG TABLET 0.37000 0.37000 2/8/2013 BRIMONIDINE TARTRATE 0.15 % DROPS 13.44910 13.44910 2/8/2013 BRIMONIDINE TARTRATE 0.2 % DROPS 0.58424 0.58424 2/8/2013 BROMFENAC SODIUM 0.09% DROPS 40.47120 40.47120 2/8/2013 BROMOCRIPTINE MESYLATE 2.5 MG TABLET 1.07776 1.07776 2/8/2013 BROMOCRIPTINE MESYLATE 5 MG CAPSULE 3.23180 3.23180 2/8/2013 BROMPHENIRAMIN/PE/DEXTROMETHOR 1-2.5-5/5 SOLUTION 0.02385 0.02385 2/8/2013 BROMPHENIRAMIN/PE/DEXTROMETHOR 4-10-20/5 LIQUID 0.11830 0.11830 2/8/2013 BROMPHENIRAMIN/PE/DEXTROMETHOR 4-7.5-15/5 LIQUID 0.08546 0.08546 2/8/2013 BUDESONIDE 0.25MG/2ML AMPUL-NEB 3.02400 3.02400 2/8/2013 BUDESONIDE 0.5 MG/2ML AMPUL-NEB 3.55635 3.55635 2/8/2013 BUDESONIDE 3 MG CAPDR & ER 11.98496 11.98496 2/8/2013 BUMETANIDE 0.25 MG/ML VIAL 0.26572 0.26572 2/8/2013 BUMETANIDE 0.5 MG TABLET 0.06994 0.06994 2/8/2013 BUMETANIDE 1 MG TABLET 0.08369 0.08369 2/8/2013 BUMETANIDE 2 MG TABLET 0.09836 0.09836 2/8/2013 BUPIVACAINE HCL 2.5 MG/ML VIAL 0.04200 0.04200 2/8/2013 BUPIVACAINE HCL 5 MG/ML VIAL 0.05090 0.05090 2/8/2013 BUPIVACAINE HCL/EPINEPHRINE 0.25-.0005 VIAL 0.12253 0.12253 2/8/2013 BUPIVACAINE HCL/EPINEPHRINE 0.5-1:200K CARTRIDGE 0.27533 0.27533 2/8/2013 BUPIVACAINE HCL/EPINEPHRINE 0.5-1:200K VIAL 0.11900 0.11900 2/8/2013 BUPIVACAINE HCL/EPINEPHRINE/PF 0.25-.0005 VIAL 0.27733 0.27733 2/8/2013 BUPIVACAINE HCL/EPINEPHRINE/PF 0.5-1:200K VIAL 0.25992 0.25992 2/8/2013 BUPIVACAINE HCL/PF 2.5 MG/ML AMPUL 0.13300 0.13300 2/8/2013 BUPIVACAINE HCL/PF 2.5 MG/ML VIAL 0.06646 0.06646 2/8/2013 BUPIVACAINE HCL/PF 5 MG/ML AMPUL 0.09786 0.09786 2/8/2013 BUPIVACAINE HCL/PF 5 MG/ML VIAL 0.05096 0.05096 2/8/2013 BUPIVACAINE HCL/PF 7.5 MG/ML AMPUL 0.10478 0.10478 2/8/2013 BUPIVACAINE HCL/PF 7.5 MG/ML VIAL 0.14727 0.14727 2/8/2013 BUPRENORPHINE HCL 0.3 MG/ML DISP SYRIN 12.18000 12.18000 2/8/2013 BUPRENORPHINE HCL 2 MG TAB SUBL 1.62015 1.62015 2/8/2013 BUPRENORPHINE HCL 8 MG TAB SUBL 2.79192 2.79192 2/8/2013 BUPROPION HCL 100 MG TABLET 0.42757 0.42757 2/8/2013 BUPROPION HCL 100 MG TABLET ER 0.24656 0.24656 2/8/2013 BUPROPION HCL 150 MG TAB ER 24H 0.80105 0.80105 2/8/2013 BUPROPION HCL 150 MG TABLET ER 0.52272 0.52272 2/8/2013 BUPROPION HCL 150 MG TABLET ER 0.28247 0.28247 2/8/2013 BUPROPION HCL 200 MG TABLET ER 0.50357 0.50357 2/8/2013 BUPROPION HCL 300 MG TAB ER 24H 0.85358 0.85358 2/8/2013 BUPROPION HCL 75 MG TABLET 0.40820 0.40820 2/8/2013 BUSPIRONE HCL 10 MG TABLET 0.06419 0.06419 2/8/2013 BUSPIRONE HCL 15 MG TABLET 0.10291 0.10291 2/8/2013 BUSPIRONE HCL 30 MG TABLET 0.67877 0.67877 2/8/2013 Page 6 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price BUSPIRONE HCL 5 MG TABLET 0.04449 0.04449 2/8/2013 BUSPIRONE HCL 7.5 MG TABLET 1.84460 1.84460 2/8/2013 BUTALB/ACETAMINOPHEN/CAFFEINE 50-325-40 TABLET 0.05990 0.05990 2/8/2013 BUTALB/ACETAMINOPHEN/CAFFEINE 50-500-40 TABLET 0.06352 0.06352 2/8/2013 BUTALBIT/ACETAMIN/CAFF/CODEINE 50-325-30 CAPSULE 0.28609 0.28609 2/8/2013 BUTALBITAL/ACETAMINOPHEN 50MG-325MG TABLET 0.26453 0.26453 2/8/2013 BUTALBITAL/ACETAMINOPHEN 50MG-650MG TABLET 1.35760 1.35760 2/8/2013 BUTALBITAL/ASPIRIN/CAFFEINE 50-325-40 CAPSULE 0.36348 0.36348 2/8/2013 BUTALBITAL/ASPIRIN/CAFFEINE 50-325-40 TABLET 0.10295 0.10295 2/8/2013 BUTENAFINE HCL 1 % CREAM (G) 0.40179 0.40179 2/8/2013 BUTORPHANOL TARTRATE 1 MG/ML VIAL 1.94300 1.94300 2/8/2013 BUTORPHANOL TARTRATE 10 MG/ML SPRAY 4.68429 4.68429 2/8/2013 BUTORPHANOL TARTRATE 2 MG/ML VIAL 1.94300 1.94300 2/8/2013 CABERGOLINE 0.5 MG TABLET 15.29063 15.29063 2/8/2013 CAFFEINE CITRATED 60 MG/3 ML SOLUTION 6.70190 6.70190 2/8/2013 CAFFEINE CITRATED 60 MG/3 ML VIAL 4.29429 4.29429 2/8/2013 CAFFEINE/SODIUM BENZOATE 250 MG/ML VIAL 3.77000 3.77000 2/8/2013 CALCIPOTRIENE 0.005 % CREAM (G) 4.93519 4.93519 2/8/2013 CALCIPOTRIENE 0.005 % OINT. (G) 4.22205 4.22205 2/8/2013 CALCIPOTRIENE 0.005 % SOLUTION 3.92427 3.92427 2/8/2013 CALCITONIN,SALMON,SYNTHETIC 200/DOSE SPRAY/PUMP 13.67625 13.67625 2/8/2013 CALCITRIOL 0.25 MCG CAPSULE 0.52970 0.52970 2/8/2013 CALCITRIOL 0.5 MCG CAPSULE 1.17683 1.17683 2/8/2013 CALCITRIOL 1MCG/ML AMPUL 4.68130 4.68130 2/8/2013 CALCITRIOL 1MCG/ML SOLUTION 7.00445 7.00445 2/8/2013 CALCITRIOL 3MCG/G OINT. (G) 10.42220 10.42220 2/8/2013 CALCIUM ACETATE 667 MG CAPSULE 0.60520 0.60520 2/8/2013 CALCIUM ACETATE 667 MG TABLET 0.08750 0.08750 2/8/2013 CALCIUM ACETATE/ALUMINUM SULF 839-1191MG POWD PACK 0.50621 0.50621 2/8/2013 CALCIUM ACETATE/ALUMINUM SULF 952-1347MG POWD PACK 0.72740 0.67677 2/15/2013 CALCIUM CARBONATE 200(500)MG TAB CHEW 0.01353 0.01353 2/8/2013 CALCIUM CARBONATE 300MG(750) TAB CHEW 0.02330 0.02330 2/8/2013 CALCIUM CARBONATE 500 MG/5ML ORAL SUSP 0.01799 0.01799 2/8/2013 CALCIUM CARBONATE 500(1250) TAB CHEW 0.03423 0.03423 2/8/2013 CALCIUM CARBONATE 500(1250) TABLET 0.01434 0.01434 2/8/2013 CALCIUM CARBONATE 600 MG TABLET 0.02144 0.02144 2/8/2013 CALCIUM CARBONATE/VITAMIN D2 250 MG-125 TABLET 0.02168 0.01841 2/15/2013 CALCIUM CARBONATE/VITAMIN D3 250 MG-125 TABLET 0.01032 0.01032 2/8/2013 CALCIUM CARBONATE/VITAMIN D3 500 MG-200 TABLET 0.01273 0.01273 2/8/2013 CALCIUM CARBONATE/VITAMIN D3 500 MG-400 TABLET 0.02790 0.02790 2/8/2013 CALCIUM CARBONATE/VITAMIN D3 500 MG-600 TAB CHEW 0.17903 0.17903 2/8/2013 CALCIUM CARBONATE/VITAMIN D3 600 MG-200 TABLET 0.01899 0.01899 2/8/2013 CALCIUM CARBONATE/VITAMIN D3 600 MG-400 CAPSULE 0.04583 0.04583 2/8/2013 CALCIUM CARBONATE/VITAMIN D3 600 MG-400 TAB CHEW 0.09663 0.07946 2/15/2013 CALCIUM CARBONATE/VITAMIN D3 600 MG-400 TABLET 0.01956 0.01956 2/8/2013 CALCIUM CHLORIDE 100 MG/ML DISP SYRIN 0.47124 0.47124 2/8/2013 CALCIUM CHLORIDE 100 MG/ML VIAL 0.17500 0.17500 2/8/2013 CALCIUM CITRATE 200(950)MG TABLET 0.03073 0.03073 2/8/2013 CALCIUM CITRATE 250 MG TABLET 0.05565 0.05565 2/8/2013 CALCIUM CITRATE/VITAMIN D3 200 MG-250 TABLET 0.04220 0.03894 2/15/2013 CALCIUM CITRATE/VITAMIN D3 315 MG-200 TABLET 0.04367 0.04367 2/8/2013 CALCIUM CITRATE/VITAMIN D3 315 MG-250 TABLET 0.04703 0.04376 2/15/2013 CALCIUM POLYCARBOPHIL 625 MG TABLET 0.05896 0.05896 2/8/2013 CANDESARTAN/HYDROCHLOROTHIAZID 16-12.5MG TABLET 2.86251 2.86251 2/8/2013 CANDESARTAN/HYDROCHLOROTHIAZID 32-12.5MG TABLET 2.91948 2.91948 2/8/2013 CANDESARTAN/HYDROCHLOROTHIAZID 32MG-25MG TABLET 3.15928 3.15928 2/8/2013 CAPSAICIN 0.025 % CREAM (G) 0.06592 0.06592 2/8/2013 Page 7 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price CAPSAICIN 0.075 % CREAM (G) 0.08472 0.08472 2/8/2013 CAPSAICIN/ME-SALICYLATE/MENTH 0.002%-20% LOTION 2.36327 2.36327 2/8/2013 CAPTOPRIL 100 % POWDER 33.69341 33.69341 2/8/2013 CAPTOPRIL 100 MG TABLET 0.07479 0.07479 2/8/2013 CAPTOPRIL 12.5 MG TABLET 0.01313 0.01313 2/8/2013 CAPTOPRIL 25 MG TABLET 0.01943 0.01943 2/8/2013 CAPTOPRIL 50 MG TABLET 0.02948 0.02948 2/8/2013 CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-25MG TABLET 0.29705 0.29705 2/8/2013 CAPTOPRIL/HYDROCHLOROTHIAZIDE 50 MG-15MG TABLET 0.86296 0.86296 2/8/2013 CARBAMAZEPINE 100 MG CPMP 12HR 1.25787 1.25787 2/8/2013 CARBAMAZEPINE 100 MG TAB CHEW 0.05701 0.05701 2/8/2013 CARBAMAZEPINE 200 MG CPMP 12HR 1.27161 1.25110 2/8/2013 CARBAMAZEPINE 200 MG TAB ER 12H 0.67901 0.67901 2/8/2013 CARBAMAZEPINE 200 MG TABLET 0.04569 0.04569 2/8/2013 CARBAMAZEPINE 300 MG CPMP 12HR 1.27348 1.27348 2/8/2013 CARBAMAZEPINE 400 MG TAB ER 12H 1.55680 1.55680 2/8/2013 CARBAMIDE PEROXIDE 6.5 % DROPS 0.12690 0.12690 2/8/2013 CARBIDOPA/LEVODOPA 10MG-100MG TAB RAPDIS 0.77305 0.77305 2/8/2013 CARBIDOPA/LEVODOPA 10MG-100MG TABLET 0.14686 0.14686 2/8/2013 CARBIDOPA/LEVODOPA 25MG-100MG TAB RAPDIS 0.87334 0.87334 2/8/2013 CARBIDOPA/LEVODOPA 25MG-100MG TABLET 0.13802 0.13802 2/8/2013 CARBIDOPA/LEVODOPA 25MG-100MG TABLET ER 0.31503 0.31503 2/8/2013 CARBIDOPA/LEVODOPA 25MG-250MG TAB RAPDIS 1.11111 1.11111 2/8/2013 CARBIDOPA/LEVODOPA 25MG-250MG TABLET 0.18653 0.18653 2/8/2013 CARBIDOPA/LEVODOPA 50MG-200MG TABLET ER 0.72000 0.72000 2/8/2013 CARBIDOPA/LEVODOPA/ENTACAPONE 12.5-50MG TABLET 2.62406 2.62406 2/8/2013 CARBIDOPA/LEVODOPA/ENTACAPONE 18.75-75MG TABLET 2.62406 2.62406 2/8/2013 CARBIDOPA/LEVODOPA/ENTACAPONE 25-100-200 TABLET 2.62406 2.62406 2/8/2013 CARBIDOPA/LEVODOPA/ENTACAPONE 31.25-125 TABLET 2.62406 2.62406 2/8/2013 CARBIDOPA/LEVODOPA/ENTACAPONE 37.5-150MG TABLET 2.62406 2.62406 2/8/2013 CARBIDOPA/LEVODOPA/ENTACAPONE 50-200-200 TABLET 2.62406 2.62406 2/8/2013 CARBINOXAMINE MALEATE 4 MG TABLET 0.49602 0.49602 2/8/2013 CARBINOXAMINE MALEATE 4 MG/5 ML LIQUID 0.09112 0.09112 2/8/2013 CARBOXYMETHYLCELLULOSE SODIUM 0.5 % DROPERETTE 0.20118 0.20668 2/8/2013 CARBOXYMETHYLCELLULOSE SODIUM 0.5 % DROPS 0.28694 0.28694 2/8/2013 CARISOPRODOL 250 MG TABLET 2.31413 2.31413 2/8/2013 CARISOPRODOL 350 MG TABLET 0.06352 0.06352 2/8/2013 CARISOPRODOL/ASPIRIN 200-325 MG TABLET 1.66115 1.66115 2/8/2013 CARTEOLOL HCL 1 % DROPS 1.17210 1.17210 2/8/2013 CARVEDILOL 12.5 MG TABLET 0.04167 0.04167 2/8/2013 CARVEDILOL 25 MG TABLET 0.04864 0.04864 2/8/2013 CARVEDILOL 3.125 MG TABLET 0.04060 0.04060 2/8/2013 CARVEDILOL 6.25 MG TABLET 0.03886 0.03886 2/8/2013 CASTOR OIL OIL 0.05545 0.05545 2/8/2013 CEFACLOR 125 MG/5ML SUSP RECON 0.68231 0.68231 2/8/2013 CEFACLOR 250 MG CAPSULE 1.39260 1.39260 2/8/2013 CEFACLOR 250 MG/5ML SUSP RECON 1.36453 1.36453 2/8/2013 CEFACLOR 375 MG/5ML SUSP RECON 2.04680 2.04680 2/8/2013 CEFACLOR 500 MG CAPSULE 1.61041 1.61041 2/8/2013 CEFACLOR 500 MG TAB ER 12H 3.48600 3.48600 2/8/2013 CEFADROXIL HYDRATE 1 G TABLET 2.32518 2.32518 2/8/2013 CEFADROXIL HYDRATE 250 MG/5ML SUSP RECON 0.36218 0.36218 2/8/2013 CEFADROXIL HYDRATE 500 MG CAPSULE 0.31383 0.31383 2/8/2013 CEFADROXIL HYDRATE 500 MG/5ML SUSP RECON 0.46346 0.46346 2/8/2013 CEFAZOLIN SODIUM 1 G VIAL 0.90285 0.90285 2/8/2013 CEFAZOLIN SODIUM 1 G VIAL PORT 4.26300 4.26300 2/8/2013 CEFAZOLIN SODIUM 10 G VIAL 7.51332 7.51332 2/8/2013 Page 8 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price CEFAZOLIN SODIUM 500 MG VIAL 1.03662 1.03662 2/8/2013 CEFAZOLIN SODIUM/DEXTROSE,ISO 1 G/50 ML FROZ.PIGGY 0.23169 0.23169 2/8/2013 CEFAZOLIN SODIUM/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.20427 0.20427 2/8/2013 CEFAZOLIN SODIUM/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 17.93574 17.93574 2/8/2013 CEFDINIR 125 MG/5ML SUSP RECON 0.52740 0.52740 2/8/2013 CEFDINIR 250 MG/5ML SUSP RECON 0.98740 0.98740 2/8/2013 CEFDINIR 300 MG CAPSULE 2.05768 2.05768 2/8/2013 CEFDITOREN PIVOXIL 200 MG TABLET 10.31835 10.31835 2/8/2013 CEFEPIME HCL 1 G VIAL 5.31937 5.31937 2/8/2013 CEFEPIME HCL 2 G VIAL 8.69760 8.69760 2/8/2013 CEFEPIME HCL/D5W 1 G/50 ML PIGGYBACK 0.55476 0.55476 2/8/2013 CEFEPIME HCL/D5W 2 G/50 ML PIGGYBACK 14.59908 14.59908 2/8/2013 CEFEPIME HCL/DEXTROSE, ISO-OSM 1 G/50 ML FROZ.PIGGY 1.09878 1.09878 2/8/2013 CEFEPIME HCL/DEXTROSE, ISO-OSM 2 G/100 ML FROZ.PIGGY 0.88078 0.88078 2/8/2013 CEFOTAXIME SODIUM 1 G VIAL 1.38268 1.38268 2/8/2013 CEFOTAXIME SODIUM 10 G VIAL 18.35400 18.35400 2/8/2013 CEFOTAXIME SODIUM 2 G VIAL 4.12516 4.12516 2/8/2013 CEFOTAXIME SODIUM 500 MG VIAL 1.31950 1.31950 2/8/2013 CEFOTETAN DISOD/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 12.30600 12.30600 2/8/2013 CEFOTETAN DISOD/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 17.59800 17.59800 2/8/2013 CEFOTETAN DISODIUM 1 G VIAL 9.55920 9.55920 2/8/2013 CEFOTETAN DISODIUM 10 G VIAL 98.60200 98.60200 2/8/2013 CEFOTETAN DISODIUM 2 G VIAL 19.11840 19.11840 2/8/2013 CEFOXITIN SODIUM 1 G VIAL 4.45380 4.45380 2/8/2013 CEFOXITIN SODIUM 10 G VIAL 32.13068 32.13068 2/8/2013 CEFOXITIN SODIUM 2 G VIAL 8.21424 8.21424 2/8/2013 CEFOXITIN SODIUM/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.50369 0.50369 2/8/2013 CEFOXITIN SODIUM/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.92383 0.92383 2/8/2013 CEFPODOXIME PROXETIL 100 MG TABLET 4.30662 4.30662 2/8/2013 CEFPODOXIME PROXETIL 100 MG/5ML SUSP RECON 1.20638 1.20638 2/8/2013 CEFPODOXIME PROXETIL 50 MG/5 ML SUSP RECON 0.50567 0.50567 2/8/2013 CEFPROZIL 125 MG/5ML SUSP RECON 0.29322 0.29322 2/8/2013 CEFPROZIL 250 MG TABLET 1.82471 1.82471 2/8/2013 CEFPROZIL 250 MG/5ML SUSP RECON 0.54020 0.54020 2/8/2013 CEFPROZIL 500 MG TABLET 3.28617 3.28617 2/8/2013 CEFTAZIDIME PENTAHYDRATE 1 G VIAL 5.07676 5.07676 2/8/2013 CEFTAZIDIME PENTAHYDRATE 2 G VIAL 8.99040 8.99040 2/8/2013 CEFTAZIDIME PENTAHYDRATE 6G VIAL 21.86100 21.86100 2/8/2013 CEFTAZIDIME PENTAHYDRATE/D5W 1 G/50 ML PIGGYBACK 9.03846 9.03846 2/8/2013 CEFTAZIDIME PENTAHYDRATE/D5W 2 G/50 ML PIGGYBACK 13.01154 13.01154 2/8/2013 CEFTRIAXONE NA/DEXTROSE,ISO 1 G/50 ML FROZ.PIGGY 0.33575 0.33575 2/8/2013 CEFTRIAXONE NA/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.54291 0.54291 2/8/2013 CEFTRIAXONE NA/DEXTROSE,ISO 2 G/50 ML FROZ.PIGGY 3.69974 3.69974 2/8/2013 CEFTRIAXONE NA/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.94697 0.94697 2/8/2013 CEFTRIAXONE SODIUM 1 G PGGYBK BTL 33.53700 33.53700 2/8/2013 CEFTRIAXONE SODIUM 1 G VIAL 1.65892 1.65892 2/8/2013 CEFTRIAXONE SODIUM 1 G VIAL PORT 3.51120 3.51120 2/8/2013 CEFTRIAXONE SODIUM 10 G VIAL 17.20950 17.20950 2/8/2013 CEFTRIAXONE SODIUM 2 G PGGYBK BTL 65.91900 65.91900 2/8/2013 CEFTRIAXONE SODIUM 2 G VIAL 3.43070 3.43070 2/8/2013 CEFTRIAXONE SODIUM 2 G VIAL PORT 6.39660 6.39660 2/8/2013 CEFTRIAXONE SODIUM 250 MG VIAL 1.03046 1.03046 2/8/2013 CEFTRIAXONE SODIUM 500 MG VIAL 1.21806 1.21806 2/8/2013 CEFUROXIME AXETIL 250 MG TABLET 0.45717 0.45717 2/8/2013 CEFUROXIME AXETIL 500 MG TABLET 0.73340 0.73340 2/8/2013 CEFUROXIME SODIUM 1.5 G VIAL 4.33524 4.33524 2/8/2013 CEFUROXIME SODIUM 7.5G VIAL 19.28430 19.28430 2/8/2013 Page 9 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price CEFUROXIME SODIUM 750 MG VIAL 2.24102 2.24102 2/8/2013 CEFUROXIME SODIUM/DEXTROSE,ISO 1.5G/50ML PIGGYBACK 0.53477 0.53477 2/8/2013 CEFUROXIME SODIUM/DEXTROSE,ISO 750MG/50ML PIGGYBACK 0.42827 0.42827 2/8/2013 CELLULOSE 80 % POWDER 0.03535 0.03535 2/8/2013 CEPHALEXIN 125 MG/5ML SUSP RECON 0.05280 0.05280 2/8/2013 CEPHALEXIN 250 MG CAPSULE 0.06995 0.06995 2/8/2013 CEPHALEXIN 250 MG TABLET 0.40092 0.40092 2/8/2013 CEPHALEXIN 250 MG/5ML SUSP RECON 0.06845 0.06845 2/8/2013 CEPHALEXIN 500 MG CAPSULE 0.10023 0.10023 2/8/2013 CEPHALEXIN 500 MG TABLET 0.80132 0.80132 2/8/2013 CETIRIZINE HCL 1 MG/ML SOLUTION 0.03471 0.03471 2/8/2013 CETIRIZINE HCL 10 MG TAB CHEW 0.56333 0.56333 2/8/2013 CETIRIZINE HCL 10 MG TABLET 0.06914 0.06914 2/8/2013 CETIRIZINE HCL 5 MG TAB CHEW 0.96200 0.96200 2/8/2013 CETIRIZINE HCL 5 MG TABLET 0.08419 0.08419 2/8/2013 CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H 0.60561 0.60561 2/8/2013 CEVIMELINE HCL 30 MG CAPSULE 2.43968 2.43968 2/8/2013 CHLOPHEDIANOL HCL/GUAIFENESIN 25-200MG/5 LIQUID 0.08649 0.08649 2/8/2013 CHLORAMPHENICOL NA SUCC 1 G VIAL 2.64689 2.64689 2/8/2013 CHLORDIAZEPOXIDE HCL 10 MG CAPSULE 0.07238 0.07238 2/8/2013 CHLORDIAZEPOXIDE HCL 25 MG CAPSULE 0.08947 0.08947 2/8/2013 CHLORDIAZEPOXIDE HCL 5 MG CAPSULE 0.10604 0.10604 2/8/2013 CHLORDIAZEPOXIDE/CLIDINIUM BR 5 MG-2.5MG CAPSULE 0.28408 0.28408 2/8/2013 GLUCONATE 0.12 % 0.00581 0.00581 2/8/2013 CHLOROPROCAINE HCL/PF 20 MG/ML VIAL 0.55650 0.55650 2/8/2013 CHLOROQUINE PHOSPHATE 250 MG TABLET 1.16775 1.16775 2/8/2013 CHLOROQUINE PHOSPHATE 500 MG TABLET 2.61404 2.61404 2/8/2013 CHLOROTHIAZIDE 500 MG TABLET 0.25564 0.25564 2/8/2013 CHLOROTHIAZIDE SODIUM 500 MG VIAL 222.92725 222.92725 2/8/2013 CHLORPHENIRAMINE MALEATE 12 MG TABLET ER 0.40945 0.34709 2/15/2013 CHLORPHENIRAMINE MALEATE 2 MG/5 ML SYRUP 0.01798 0.01798 2/8/2013 CHLORPHENIRAMINE MALEATE 4 MG TABLET 0.00563 0.00563 2/8/2013 CHLORPROMAZINE HCL 25 MG/ML AMPUL 10.56020 10.56020 2/8/2013 CHLORPROPAMIDE 100 MG TABLET 0.34549 0.34549 2/8/2013 CHLORPROPAMIDE 250 MG TABLET 0.85228 0.85228 2/8/2013 CHLORTHALIDONE 25 MG TABLET 0.34700 0.34700 2/8/2013 CHLORTHALIDONE 50 MG TABLET 0.47628 0.47628 2/8/2013 CHLORZOXAZONE 500 MG TABLET 0.08918 0.08918 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT TAB CHEW 0.07209 0.07209 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT TABLET 0.01924 0.01924 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 1000/SPRAY SPRAY SUSP 0.30847 0.30847 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT CAPSULE 0.71680 0.71680 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT TABLET 0.03039 0.03039 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 3000 UNIT TABLET 0.05516 0.05516 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT CAPSULE 0.01806 0.01652 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TAB CHEW 0.02509 0.02509 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TABLET 0.01560 0.01560 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/5 LIQUID 0.02914 0.02914 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 4000 UNIT CAPSULE 0.06993 0.06993 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT TABLET 0.05101 0.05101 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 5000/ML DROPS 0.07973 0.07973 2/8/2013 CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT CAPSULE 0.32251 0.32251 2/8/2013 CHOLESTYRAMINE (WITH SUGAR) 4 G PACKET 0.43000 0.43000 2/8/2013 CHOLESTYRAMINE (WITH SUGAR) 4 G POWDER 0.07879 0.07879 2/8/2013 CHOLESTYRAMINE/ASPARTAME 4 G PACKET 0.43400 0.43400 2/8/2013 CHOLESTYRAMINE/ASPARTAME 4 G POWDER 0.14980 0.14980 2/8/2013 CHOLINE SAL/MAG SALICYLATE 500 MG/5ML LIQUID 0.12848 0.12848 2/8/2013 Page 10 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price CHORIONIC GONADOTROPIN, HUMAN 10000 UNIT VIAL 15.45915 15.45915 2/8/2013 CICLOPIROX 0.77 % GEL (GRAM) 1.36827 1.36827 2/8/2013 CICLOPIROX 1 % 0.57510 0.57510 2/8/2013 CICLOPIROX 8 % SOLUTION 0.63931 0.63931 2/8/2013 CICLOPIROX OLAMINE 0.77 % CREAM (G) 0.13749 0.13749 2/8/2013 CICLOPIROX OLAMINE 0.77 % SUSPENSION 0.37748 0.37748 2/8/2013 CICLOPIROX/URE/CAMPH/MENTH/EUC 8 % SOLUTION 266.99400 266.99400 2/8/2013 CIDOFOVIR 75 MG/ML VIAL 111.88800 111.88800 2/8/2013 CILOSTAZOL 100 MG TABLET 0.13494 0.13494 2/8/2013 CILOSTAZOL 50 MG TABLET 0.15283 0.15283 2/8/2013 200 MG TABLET 0.18934 0.18934 2/8/2013 CIMETIDINE 300 MG TABLET 0.03913 0.03913 2/8/2013 CIMETIDINE 400 MG TABLET 0.05092 0.05092 2/8/2013 CIMETIDINE 800 MG TABLET 0.30277 0.30277 2/8/2013 CIMETIDINE HCL 150 MG/ML VIAL 1.00538 1.00538 2/8/2013 CIMETIDINE HCL 300 MG/5ML SOLUTION 0.03350 0.03350 2/8/2013 CIPROFLOXACIN HCL 0.2 % DROPERETTE 5.25900 5.25900 2/8/2013 CIPROFLOXACIN HCL 0.3 % DROPS 0.66062 0.66062 2/8/2013 CIPROFLOXACIN HCL 100 MG TABLET 2.35900 2.35900 2/8/2013 CIPROFLOXACIN HCL 250 MG TABLET 0.14150 0.14150 2/8/2013 CIPROFLOXACIN HCL 500 MG TABLET 0.16964 0.16964 2/8/2013 CIPROFLOXACIN HCL 750 MG TABLET 0.27859 0.27859 2/8/2013 CIPROFLOXACIN LACTATE 200MG/20ML VIAL 0.09485 0.09485 2/8/2013 CIPROFLOXACIN LACTATE 400MG/40ML VIAL 0.06615 0.06615 2/8/2013 CIPROFLOXACIN LACTATE/D5W 200MG/0.1L PIGGYBACK 0.01697 0.01697 2/8/2013 CIPROFLOXACIN LACTATE/D5W 400MG/0.2L PIGGYBACK 0.01246 0.01246 2/8/2013 CIPROFLOXACIN/CIPROFLOXA HCL 1000 MG TBMP 24HR 7.79233 7.79233 2/8/2013 CIPROFLOXACIN/CIPROFLOXA HCL 500 MG TBMP 24HR 6.85916 6.85916 2/8/2013 CISATRACURIUM BESYLATE 10 MG/ML VIAL 10.93957 10.93957 2/8/2013 CISATRACURIUM BESYLATE 2 MG/ML VIAL 2.16839 2.16839 2/8/2013 CITALOPRAM HYDROBROMIDE 10 MG TABLET 0.02921 0.02921 2/8/2013 CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION 0.18230 0.18230 2/8/2013 CITALOPRAM HYDROBROMIDE 20 MG TABLET 0.03564 0.03564 2/8/2013 CITALOPRAM HYDROBROMIDE 40 MG TABLET 0.04775 0.04775 2/8/2013 CITRATE-PHOS-DEX SOLUTION 2.63G/100 SOLUTION 0.08318 0.08318 2/8/2013 CITRIC ACID/SODIUM CITRATE 334-500MG SOLUTION 0.00966 0.00966 2/8/2013 CLARITHROMYCIN 125 MG/5ML SUSP RECON 0.34465 0.34465 2/8/2013 CLARITHROMYCIN 250 MG TABLET 3.85132 3.85132 2/8/2013 CLARITHROMYCIN 500 MG TAB ER 24H 3.47642 3.47642 2/8/2013 CLARITHROMYCIN 500 MG TABLET 3.84309 3.84309 2/8/2013 CLEMASTINE FUMARATE 1.34 MG TABLET 0.12753 0.12753 2/8/2013 CLEMASTINE FUMARATE 2.68 MG TABLET 0.17190 0.17190 2/8/2013 CLINDAMYCIN HCL 150 MG CAPSULE 0.08790 0.08790 2/8/2013 CLINDAMYCIN HCL 300 MG CAPSULE 0.28636 0.28636 2/8/2013 CLINDAMYCIN HCL 75 MG CAPSULE 0.41720 0.41720 2/8/2013 CLINDAMYCIN PALMITATE HCL 75 MG/5 ML SOLN RECON 0.43421 0.43421 2/8/2013 CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GEL (GRAM) 3.76642 3.76642 2/8/2013 CLINDAMYCIN PHOS/BENZOYL PEROX 1.2(1)%-5% GEL ER (G) 3.16105 3.16105 2/8/2013 CLINDAMYCIN PHOSPHATE 1 % FOAM 1.92528 1.92528 2/8/2013 CLINDAMYCIN PHOSPHATE 1 % LOTION 1.11977 1.11977 2/8/2013 CLINDAMYCIN PHOSPHATE 1 % MED. SWAB 0.40374 0.40374 2/8/2013 CLINDAMYCIN PHOSPHATE 1 % SOLUTION 0.91409 0.91409 2/8/2013 CLINDAMYCIN PHOSPHATE 150 MG/ML VIAL 0.35604 0.35604 2/8/2013 CLINDAMYCIN PHOSPHATE 2 % CREAM/APPL 1.57588 1.57588 2/8/2013 CLINDAMYCIN PHOSPHATE 300 MG/2ML VIAL PORT 2.99418 2.99418 2/8/2013 CLINDAMYCIN PHOSPHATE 600 MG/4ML VIAL PORT 1.60881 1.60881 2/8/2013 CLINDAMYCIN PHOSPHATE 900MG/6ML VIAL PORT 1.51899 1.51899 2/8/2013 Page 11 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price CLINDAMYCIN PHOSPHATE/D5W 300MG/50ML PIGGYBACK 0.00000 0.13773 2/15/2013 CLINDAMYCIN PHOSPHATE/D5W 600MG/50ML PIGGYBACK 0.00000 0.20775 2/15/2013 CLINDAMYCIN PHOSPHATE/D5W 900MG/50ML PIGGYBACK 0.00000 0.25374 2/15/2013 CLOBETASOL PROPIONATE 0.05 % CREAM (G) 0.11926 0.11926 2/8/2013 CLOBETASOL PROPIONATE 0.05 % FOAM 1.88149 1.88149 2/8/2013 CLOBETASOL PROPIONATE 0.05 % GEL (GRAM) 0.36716 0.36716 2/8/2013 CLOBETASOL PROPIONATE 0.05 % LOTION 3.23864 3.23864 2/8/2013 CLOBETASOL PROPIONATE 0.05 % OINT. (G) 0.23120 0.23120 2/8/2013 CLOBETASOL PROPIONATE 0.05 % SHAMPOO 2.38350 2.38350 2/8/2013 CLOBETASOL PROPIONATE 0.05 % SOLUTION 0.31088 0.31088 2/8/2013 CLOBETASOL PROPIONATE/EMOLL 0.05 % CREAM (G) 0.29212 0.29212 2/8/2013 CLOMIPHENE CITRATE 50 MG TABLET 1.01304 1.01304 2/8/2013 CLOMIPRAMINE HCL 25 MG CAPSULE 0.27875 0.27875 2/8/2013 CLOMIPRAMINE HCL 50 MG CAPSULE 0.37654 0.37654 2/8/2013 CLOMIPRAMINE HCL 75 MG CAPSULE 0.49236 0.49236 2/8/2013 CLONAZEPAM 0.125 MG TAB RAPDIS 0.75643 0.75643 2/8/2013 CLONAZEPAM 0.25 MG TAB RAPDIS 0.74617 0.74617 2/8/2013 CLONAZEPAM 0.5 MG TAB RAPDIS 0.78857 0.78857 2/8/2013 CLONAZEPAM 0.5 MG TABLET 0.01648 0.01648 2/8/2013 CLONAZEPAM 1 MG TAB RAPDIS 0.90253 0.90253 2/8/2013 CLONAZEPAM 1 MG TABLET 0.02613 0.02613 2/8/2013 CLONAZEPAM 2 MG TAB RAPDIS 1.09330 1.09330 2/8/2013 CLONAZEPAM 2 MG TABLET 0.04234 0.04234 2/8/2013 CLONIDINE 0.1MG/24HR PATCH TDWK 23.19800 23.19800 2/8/2013 CLONIDINE 0.2MG/24HR PATCH TDWK 36.67625 36.67625 2/8/2013 CLONIDINE 0.3MG/24HR PATCH TDWK 54.19068 54.19068 2/8/2013 CLONIDINE HCL 0.1 MG TABLET 0.03015 0.03015 2/8/2013 CLONIDINE HCL 0.2 MG TABLET 0.04368 0.04368 2/8/2013 CLONIDINE HCL 0.3 MG TABLET 0.05387 0.05387 2/8/2013 CLONIDINE HCL/PF 1000MCG/10 VIAL 2.18075 2.18075 2/8/2013 CLONIDINE HCL/PF 5000MCG/10 VIAL 10.09700 10.09700 2/8/2013 CLOPIDOGREL BISULFATE 300 MG TABLET 15.16652 15.16652 2/8/2013 CLOPIDOGREL BISULFATE 75 MG TABLET 0.35570 0.35570 2/8/2013 CLORAZEPATE DIPOTASSIUM 15 MG TABLET 0.23745 0.23745 2/8/2013 CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET 0.08455 0.08455 2/8/2013 CLORAZEPATE DIPOTASSIUM 7.5 MG TABLET 0.14325 0.14325 2/8/2013 CLOTRIMAZOLE 1 % CREAM (G) 0.07544 0.07544 2/8/2013 CLOTRIMAZOLE 1 % CREAM/APPL 0.07788 0.07788 2/8/2013 CLOTRIMAZOLE 1 % SOLUTION 0.32656 0.32656 2/8/2013 CLOTRIMAZOLE 10 MG TROCHE 0.36152 0.36152 2/8/2013 CLOTRIMAZOLE 2 % CREAM/APPL 0.33423 0.33423 2/8/2013 CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % CREAM (G) 1.32069 1.32069 2/8/2013 CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % LOTION 2.92143 3.16550 2/15/2013 CLOZAPINE 100 MG TAB RAPDIS 5.72241 5.72220 2/15/2013 CLOZAPINE 100 MG TABLET 1.62860 1.62860 2/8/2013 CLOZAPINE 12.5 MG TAB RAPDIS 1.55925 1.55925 2/8/2013 CLOZAPINE 200 MG TABLET 4.37028 4.37028 2/8/2013 CLOZAPINE 25 MG TAB RAPDIS 2.09823 2.09823 2/8/2013 CLOZAPINE 25 MG TABLET 0.90840 0.90840 2/8/2013 CLOZAPINE 50 MG TABLET 1.15500 1.15500 2/8/2013 COAL TAR 1 % SHAMPOO 0.03103 0.03103 2/8/2013 COCAINE HCL 10 % SOLUTION 39.32250 39.32250 2/8/2013 COCAINE HCL 4 % SOLUTION 20.46975 20.46975 2/8/2013 CODEINE SULFATE 15 MG TABLET 0.33397 0.33397 2/8/2013 CODEINE SULFATE 30 MG TABLET 0.35952 0.39550 2/15/2013 CODEINE SULFATE 30 MG/5 ML SOLUTION 0.50492 0.50492 2/8/2013 CODEINE SULFATE 60 MG TABLET 0.65849 0.72436 2/15/2013 Page 12 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price CODEINE/BUTALBITAL/ASA/CAFFEIN 30-50-325 CAPSULE 0.65796 0.65796 2/15/2013 CODEINE/CARISOPRODOL/ASPIRIN 16-200-325 TABLET 1.94250 1.94250 2/8/2013 CODEINE/PROMETHAZINE HCL 10-6.25/5 SYRUP 0.01528 0.01528 2/8/2013 COLCHICINE/PROBENECID 0.5-500MG TABLET 0.67760 0.67760 2/8/2013 COLESTIPOL HCL 1 G TABLET 0.46048 0.46048 2/8/2013 COLESTIPOL HCL 5 G GRANULES 0.20871 0.20871 2/8/2013 COLESTIPOL HCL 5 G PACKET 3.51494 3.51494 2/8/2013 COLISTIN (COLISTIMETHATE NA) 150 MG VIAL 19.47030 19.47030 2/8/2013 CORTISONE ACETATE 25 MG TABLET 0.75600 0.75600 2/8/2013 COSYNTROPIN 0.25 MG VIAL 64.39973 64.39973 2/8/2013 COSYNTROPIN 0.25 MG/ML VIAL 151.55280 151.55280 2/8/2013 CROMOLYN SODIUM 20 MG/2 ML AMPUL-NEB 0.58772 0.58772 2/8/2013 CROMOLYN SODIUM 20 MG/ML SOLUTION 0.87900 0.87900 2/8/2013 CROMOLYN SODIUM 4 % DROPS 0.69948 0.69948 2/8/2013 CROMOLYN SODIUM 5.2 MG SPRAY/PUMP 0.33554 0.33554 2/8/2013 CUPRIC CHLORIDE 0.4 MG/ML VIAL 0.15456 0.15456 2/8/2013 CUPRIC SULFATE 0.4 MG/ML VIAL 0.12958 0.12958 2/8/2013 CYANOCOBALAMIN (VITAMIN B-12) 100 MCG TABLET 0.01242 0.01242 2/8/2013 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TAB SUBL 0.05840 0.05332 2/15/2013 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TABLET ER 0.04583 0.04152 2/15/2013 CYANOCOBALAMIN (VITAMIN B-12) 1000MCG/ML VIAL 0.48575 0.48575 2/8/2013 CYANOCOBALAMIN (VITAMIN B-12) 500 MCG TABLET 0.01867 0.01867 2/8/2013 CYANOCOBALAMIN/FA/PYRIDOXINE 2-2.5-25MG TABLET 0.63884 0.63884 2/8/2013 CYANOCOBALAMIN/FOLIC ACID 0.5 MG-1MG TABLET 0.12600 0.12600 2/8/2013 CYCLOBENZAPRINE HCL 10 MG TABLET 0.03015 0.03015 2/8/2013 CYCLOBENZAPRINE HCL 5 MG TABLET 0.05775 0.05775 2/8/2013 CYCLOPENTOLATE HCL 1 % DROPS 1.18992 1.18992 2/8/2013 CYCLOPENTOLATE HCL 2 % DROPS 3.33840 3.33840 2/8/2013 CYCLOPHOSPHAMIDE 1 G VIAL 371.08400 371.08400 2/8/2013 CYCLOPHOSPHAMIDE 2 G VIAL 742.15400 742.15400 2/8/2013 CYCLOPHOSPHAMIDE 25 MG TABLET 1.41297 1.41297 2/8/2013 CYCLOPHOSPHAMIDE 50 MG TABLET 2.59285 2.59285 2/8/2013 CYCLOPHOSPHAMIDE 500 MG VIAL 185.54200 185.54200 2/8/2013 CYCLOSPORINE 100 MG CAPSULE 5.41333 5.41333 2/8/2013 CYCLOSPORINE 25 MG CAPSULE 1.35543 1.35543 2/8/2013 CYCLOSPORINE 250 MG/5ML VIAL 7.95732 7.95732 2/8/2013 CYCLOSPORINE, MODIFIED 100 MG CAPSULE 3.84737 3.84737 2/8/2013 CYCLOSPORINE, MODIFIED 100 MG/ML SOLUTION 2.88899 2.88899 2/8/2013 CYCLOSPORINE, MODIFIED 25 MG CAPSULE 0.96266 0.96266 2/8/2013 CYCLOSPORINE, MODIFIED 50 MG CAPSULE 1.91683 1.91683 2/8/2013 HCL 2 MG/5 ML SYRUP 0.09529 0.09529 2/8/2013 CYPROHEPTADINE HCL 4 MG TABLET 0.09058 0.09058 2/8/2013 CYTARABINE 20 MG/ML VIAL 0.40077 0.40077 2/8/2013 CYTARABINE/PF 1 G VIAL 40.61400 40.61400 2/8/2013 CYTARABINE/PF 100 MG VIAL 7.10640 7.10640 2/8/2013 CYTARABINE/PF 100 MG/5ML VIAL 1.97106 1.97106 2/8/2013 CYTARABINE/PF 2 G/20 ML VIAL 0.87780 0.87780 2/8/2013 CYTARABINE/PF 20 MG/ML VIAL 0.75096 0.75096 2/8/2013 CYTARABINE/PF 500 MG VIAL 6.30000 6.30000 2/8/2013 DACARBAZINE 100 MG VIAL 7.93800 7.93800 2/8/2013 DACTINOMYCIN 0.5 MG VIAL 1,065.68700 1,065.68700 2/8/2013 100 MG CAPSULE 2.00515 2.00515 2/8/2013 DANAZOL 200 MG CAPSULE 3.79003 3.79003 2/8/2013 DANAZOL 50 MG CAPSULE 1.33637 1.33637 2/8/2013 DANTROLENE SODIUM 100 MG CAPSULE 1.51746 1.51746 2/8/2013 DANTROLENE SODIUM 20 MG VIAL 68.04000 68.04000 2/8/2013 DANTROLENE SODIUM 25 MG CAPSULE 0.74851 0.74851 2/8/2013 Page 13 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price DANTROLENE SODIUM 50 MG CAPSULE 1.21009 1.21009 2/8/2013 DAPSONE 100 MG TABLET 0.91000 0.91000 2/8/2013 DAPSONE 25 MG TABLET 0.74200 0.74200 2/8/2013 DAUNORUBICIN HCL 5 MG/ML VIAL 14.58975 14.58975 2/8/2013 D-CHLORPHENIRA/PSE/CHLOPHEDIAN 1-30-12.5 LIQUID 0.08046 0.08046 2/8/2013 DEFEROXAMINE MESYLATE 2 G VIAL 26.33481 26.33481 2/8/2013 DEFEROXAMINE MESYLATE 500 MG VIAL 8.40600 8.40600 2/8/2013 DEMECLOCYCLINE HCL 150 MG TABLET 2.01027 2.01027 2/8/2013 DEMECLOCYCLINE HCL 300 MG TABLET 3.80900 3.80900 2/8/2013 DESIPRAMINE HCL 10 MG TABLET 0.81684 0.81684 2/8/2013 DESIPRAMINE HCL 100 MG TABLET 3.05543 3.05543 2/8/2013 DESIPRAMINE HCL 150 MG TABLET 4.42708 4.42708 2/8/2013 DESIPRAMINE HCL 25 MG TABLET 0.98479 0.98479 2/8/2013 DESIPRAMINE HCL 75 MG TABLET 2.26422 2.26422 2/8/2013 DESLORATADINE 2.5 MG TAB RAPDIS 11.92731 11.92731 2/8/2013 DESLORATADINE 5 MG TAB RAPDIS 4.07750 4.07750 2/8/2013 DESLORATADINE 5 MG TABLET 1.03622 1.03622 2/8/2013 DESMOPRESSIN ACETATE 0.1 MG TABLET 1.21186 1.21186 2/8/2013 DESMOPRESSIN ACETATE 0.1 MG/ML SOLUTION 25.31760 25.31760 2/8/2013 DESMOPRESSIN ACETATE 0.2 MG TABLET 1.29266 1.29266 2/8/2013 DESMOPRESSIN ACETATE 10/SPRAY SPRAY/PUMP 33.88710 33.88710 2/8/2013 DESMOPRESSIN ACETATE 4MCG/ML AMPUL 7.12530 7.12530 2/8/2013 DESMOPRESSIN ACETATE 4MCG/ML VIAL 13.84457 13.84457 2/8/2013 -ETHINYL 0.15-0.03 TABLET 0.68085 0.68085 2/8/2013 DESOGESTREL-ETHINYL ESTRADIOL 7 DAYS X 3 TABLET 0.83100 0.83100 2/8/2013 DESOG-ET ESTRA/ETHIN ESTRA 21-5 TABLET 1.49950 1.49950 2/8/2013 DESONIDE 0.05 % CREAM (G) 0.57124 0.57124 2/8/2013 DESONIDE 0.05 % LOTION 1.83560 1.83560 2/8/2013 DESONIDE 0.05 % OINT. (G) 0.51711 0.51711 2/8/2013 DESOXIMETASONE 0.05 % GEL (GRAM) 2.73169 2.73169 2/8/2013 DESOXIMETASONE 0.25 % OINT. (G) 3.47632 3.99777 2/15/2013 DEXAMETHASONE 0.5 MG/5ML ELIXIR 0.18810 0.18810 2/8/2013 DEXAMETHASONE 0.5 MG/5ML SOLUTION 0.12675 0.12675 2/8/2013 DEXAMETHASONE SOD PHOSPHATE 0.1 % DROPS 2.96251 2.96251 2/8/2013 DEXAMETHASONE SOD PHOSPHATE 10 MG/ML VIAL 0.66973 0.66973 2/8/2013 DEXAMETHASONE SOD PHOSPHATE 4 MG/ML VIAL 0.19604 0.19604 2/8/2013 DEXAMETHASONE SOD PHOSPHATE/PF 10 MG/ML VIAL 6.35376 6.35376 2/8/2013 DEXMETHYLPHENIDATE HCL 10 MG TABLET 1.92570 1.92570 2/8/2013 DEXMETHYLPHENIDATE HCL 2.5 MG TABLET 0.94878 0.94878 2/8/2013 DEXMETHYLPHENIDATE HCL 5 MG TABLET 1.37844 1.37844 2/8/2013 DEXPANTHENOL 250 MG/ML VIAL 1.36500 1.36500 2/8/2013 DEXTRAN 70/HYPROMELLOSE DROPS 0.43960 0.43960 2/8/2013 DEXTROMETHORPHAN HBR 7.5 MG/5ML SYRUP 0.03067 0.02922 2/15/2013 DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML SUS ER 12H 0.08530 0.08530 2/8/2013 DEXTROSE 10 % AND 0.2 % NACL 10 %-0.2 % DEHP FR BG 0.04179 0.04179 2/8/2013 DEXTROSE 10 % AND 0.2 % NACL 10 %-0.2 % IV SOLN 0.03704 0.03704 2/8/2013 DEXTROSE 10 % AND 0.45 % NACL 10%-0.45% IV SOLN 0.01077 0.01077 2/8/2013 DEXTROSE 10 % IN WATER 10 % DEHP FR BG 0.00819 0.00819 2/8/2013 DEXTROSE 10 % IN WATER 10 % IV SOLN 0.00281 0.00281 2/8/2013 DEXTROSE 2.5 % AND 0.45 % NACL 2.5%-0.45% IV SOLN 0.00257 0.00257 2/8/2013 DEXTROSE 20 % IN WATER 20 % IV SOLN 0.00864 0.00864 2/8/2013 DEXTROSE 25 % IN WATER 25 % DISP SYRIN 0.42672 0.42672 2/8/2013 DEXTROSE 30 % IN WATER 30 % IV SOLN 0.00877 0.00877 2/8/2013 DEXTROSE 40 % IN WATER 40 % IV SOLN 0.01091 0.01091 2/8/2013 DEXTROSE 5 % AND 0.3 % NACL 5 %-0.3 % IV SOLN 0.00213 0.00213 2/8/2013 DEXTROSE 5 % AND 0.9 % NACL 5 %-0.9 % IV SOLN 0.00201 0.00201 2/8/2013 DEXTROSE 5 % IN WATER PGGYBK PRT 0.03324 0.03324 2/8/2013 Page 14 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price DEXTROSE 5 % IN WATER PGY VL PRT 0.07096 0.07096 2/8/2013 DEXTROSE 5 % IN WATER 5 % IV SOLN 0.00174 0.00174 2/8/2013 DEXTROSE 5 % IN WATER 5 % VIAL 0.53214 0.53214 2/8/2013 DEXTROSE 5 % SOLUTION 0.01868 0.01868 2/8/2013 DEXTROSE 5 %-0.2 % NACL 5 %-0.2 % IV SOLN 0.00228 0.00228 2/8/2013 DEXTROSE 5 %-0.45 % NACL 5 %-0.45 % IV SOLN 0.00145 0.00145 2/8/2013 DEXTROSE 5% IN RINGERS 5 % IV SOLN 0.00160 0.00160 2/8/2013 DEXTROSE 5%-LACTATED RINGERS 5 % IV SOLN 0.00214 0.00214 2/8/2013 DEXTROSE 50 % IN WATER 50 % DISP SYRIN 0.12516 0.12516 2/8/2013 DEXTROSE 50 % IN WATER 50 % IV SOLN 0.00630 0.00630 2/8/2013 DEXTROSE 50 % IN WATER 50 % VIAL 0.02822 0.02822 2/8/2013 DEXTROSE 70 % IN WATER 70 % IV SOLN 0.00536 0.00536 2/8/2013 DIAZEPAM 10 MG TABLET 0.02466 0.02466 2/8/2013 DIAZEPAM 12.5-15-20 KIT 156.22100 156.22100 2/8/2013 DIAZEPAM 2 MG TABLET 0.02372 0.02372 2/8/2013 DIAZEPAM 2.5 MG KIT 129.16538 129.16538 2/8/2013 DIAZEPAM 5 MG TABLET 0.02224 0.02224 2/8/2013 DIAZEPAM 5 MG/5 ML SOLUTION 0.16829 0.16829 2/8/2013 DIAZEPAM 5 MG/CUP SOLUTION 0.34174 0.34174 2/8/2013 DIAZEPAM 5 MG/ML DISP SYRIN 3.71280 3.71280 2/8/2013 DIAZEPAM 5 MG/ML ORAL CONC 1.54209 1.54209 2/8/2013 DIAZEPAM 5 MG/ML VIAL 1.36920 1.36920 2/8/2013 DIAZEPAM 5-7.5-10MG KIT 252.35700 252.35700 2/8/2013 DICLOFENAC POTASSIUM 50 MG TABLET 0.20408 0.20408 2/8/2013 DICLOFENAC SODIUM 0.1 % DROPS 1.02376 1.02376 2/8/2013 DICLOFENAC SODIUM 100 MG TAB ER 24H 0.51523 0.51523 2/8/2013 DICLOFENAC SODIUM 25 MG TABLET DR 0.99526 0.99526 2/8/2013 DICLOFENAC SODIUM 50 MG TABLET DR 0.36408 0.36408 2/8/2013 DICLOFENAC SODIUM 75 MG TABLET DR 0.38217 0.38217 2/8/2013 DICLOFENAC SODIUM/MISOPROSTOL 50 MG-200 TAB IR DR 2.34693 2.34693 2/8/2013 DICLOFENAC SODIUM/MISOPROSTOL 75 MG-200 TAB IR DR 2.34697 2.34697 2/8/2013 DICLOXACILLIN SODIUM 250 MG CAPSULE 0.23842 0.23842 2/8/2013 DICLOXACILLIN SODIUM 500 MG CAPSULE 0.47653 0.47653 2/8/2013 DICYCLOMINE HCL 10 MG CAPSULE 0.03497 0.03497 2/8/2013 DICYCLOMINE HCL 10 MG/5 ML SYRUP 0.06924 0.06924 2/8/2013 DICYCLOMINE HCL 20 MG TABLET 0.02774 0.02774 2/8/2013 DIDANOSINE 125 MG CAPSULE DR 2.70223 2.70223 2/8/2013 DIDANOSINE 200 MG CAPSULE DR 4.32273 4.32273 2/8/2013 DIDANOSINE 250 MG CAPSULE DR 5.50853 5.50853 2/8/2013 DIDANOSINE 400 MG CAPSULE DR 8.60347 8.60347 2/8/2013 DIETHYLPROPION HCL 25 MG TABLET 0.23089 0.23089 2/8/2013 DIETHYLPROPION HCL 75 MG TABLET ER 0.80951 0.80951 2/8/2013 DIFLORASONE DIACETATE 0.05 % CREAM (G) 3.29067 3.29067 2/8/2013 DIFLORASONE DIACETATE 0.05 % OINT. (G) 2.91054 2.91054 2/8/2013 DIFLUNISAL 500 MG TABLET 1.19442 1.19442 2/8/2013 DIGOXIN 125 MCG TABLET 0.13792 0.13792 2/8/2013 DIGOXIN 250 MCG TABLET 0.13679 0.13679 2/8/2013 DIGOXIN 250 MCG/ML DISP SYRIN 1.58760 1.58760 2/8/2013 DIGOXIN 50 MCG/ML SOLUTION 0.44648 0.45435 2/15/2013 DIHYDROERGOTAMINE MESYLATE 1 MG/ML AMPUL 53.12404 53.12404 2/8/2013 DIHYDROERGOTAMINE MESYLATE 1 MG/ML VIAL 37.55430 37.55430 2/8/2013 DILTIAZEM HCL 100 MG VIAL PORT 14.71680 14.71680 2/8/2013 DILTIAZEM HCL 120 MG CAP ER 24H 0.48508 0.48508 2/8/2013 DILTIAZEM HCL 120 MG CAP ER DEG 0.55012 0.55012 2/8/2013 DILTIAZEM HCL 120 MG CAPSULE ER 0.54190 0.54190 2/8/2013 DILTIAZEM HCL 120 MG TABLET 0.12169 0.12169 2/8/2013 DILTIAZEM HCL 180 MG CAP ER 24H 0.48066 0.48066 2/8/2013 Page 15 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price DILTIAZEM HCL 180 MG CAP ER DEG 0.62752 0.62752 2/8/2013 DILTIAZEM HCL 180 MG CAPSULE ER 0.65392 0.65392 2/8/2013 DILTIAZEM HCL 180 MG TAB ER 24H 2.08282 2.08282 2/8/2013 DILTIAZEM HCL 240 MG CAP ER 24H 0.66950 0.66950 2/8/2013 DILTIAZEM HCL 240 MG CAP ER DEG 0.69467 0.69467 2/8/2013 DILTIAZEM HCL 240 MG CAPSULE ER 0.92782 0.92782 2/8/2013 DILTIAZEM HCL 240 MG TAB ER 24H 2.33439 2.33439 2/8/2013 DILTIAZEM HCL 30 MG TABLET 0.03323 0.03323 2/8/2013 DILTIAZEM HCL 300 MG CAP ER 24H 0.71100 0.71100 2/8/2013 DILTIAZEM HCL 300 MG CAPSULE ER 1.20198 1.20198 2/8/2013 DILTIAZEM HCL 300 MG TAB ER 24H 3.03687 3.03687 2/8/2013 DILTIAZEM HCL 360 MG CAP ER 24H 7.10505 7.10505 2/8/2013 DILTIAZEM HCL 360 MG CAPSULE ER 1.15562 1.15562 2/8/2013 DILTIAZEM HCL 360 MG TAB ER 24H 3.26729 3.26729 2/8/2013 DILTIAZEM HCL 420MG CAPSULE ER 1.72005 1.72005 2/8/2013 DILTIAZEM HCL 420MG TAB ER 24H 3.54216 3.54216 2/8/2013 DILTIAZEM HCL 60 MG CAP ER 12H 0.86786 0.86786 2/8/2013 DILTIAZEM HCL 60 MG TABLET 0.05883 0.05883 2/8/2013 DILTIAZEM HCL 90 MG TABLET 0.11018 0.11018 2/8/2013 DIMENHYDRINATE 50 MG TABLET 0.01809 0.01809 2/8/2013 DIMENHYDRINATE 50 MG/ML VIAL 4.98960 4.98960 2/8/2013 DIMETHICONE 1 % CREAM(ML) 0.06019 0.05662 2/15/2013 DIMETHICONE 2 % SPRAY 0.02995 0.02995 2/8/2013 DIMETHICONE 5 % CREAM(ML) 0.03805 0.03770 2/15/2013 DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR 0.00512 0.00512 2/8/2013 DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID 0.00590 0.00590 2/8/2013 DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP 0.01258 0.01258 2/8/2013 DIPHENHYDRAMINE HCL 25 MG CAPSULE 0.01635 0.01635 2/8/2013 DIPHENHYDRAMINE HCL 25 MG TABLET 0.02104 0.02104 2/8/2013 DIPHENHYDRAMINE HCL 50 MG CAPSULE 0.01742 0.01742 2/8/2013 DIPHENHYDRAMINE HCL 50 MG/ML VIAL 0.68824 0.68824 2/8/2013 DIPHENOXYLATE HCL/ATROPINE 2.5-.025/5 LIQUID 0.10803 0.10803 2/8/2013 DIPHENOXYLATE HCL/ATROPINE 2.5-.025MG TABLET 0.12154 0.12154 2/8/2013 DIPYRIDAMOLE 25 MG TABLET 0.06874 0.06874 2/8/2013 DIPYRIDAMOLE 50 MG TABLET 0.10814 0.10814 2/8/2013 DIPYRIDAMOLE 75 MG TABLET 0.13681 0.13681 2/8/2013 DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE 0.30511 0.30511 2/8/2013 DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE 0.35458 0.35458 2/8/2013 DISULFIRAM 250 MG TABLET 2.37497 2.37497 2/8/2013 DISULFIRAM 500 MG TABLET 4.53958 4.53958 2/8/2013 DIVALPROEX SODIUM 125 MG CAP SPRINK 0.49955 0.49955 2/8/2013 DIVALPROEX SODIUM 125 MG TABLET DR 0.05186 0.05186 2/8/2013 DIVALPROEX SODIUM 250 MG TAB ER 24H 0.20690 0.20690 2/8/2013 DIVALPROEX SODIUM 250 MG TABLET DR 0.09072 0.09072 2/8/2013 DIVALPROEX SODIUM 500 MG TAB ER 24H 0.38780 0.38780 2/8/2013 DIVALPROEX SODIUM 500 MG TABLET DR 0.15812 0.15812 2/8/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 15-10-2/5 SYRUP 0.04645 0.04645 2/8/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 15-10-4/5 LIQUID 0.04498 0.04498 2/8/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 15-5-2MG/5 LIQUID 0.06863 0.04477 2/15/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 3-2-1MG/ML DROPS 0.55498 0.55498 2/8/2013 DM/PHENYLEPH/CHLORPHENIRAMINE 3-3.5-1/ML DROPS 1.37627 1.37627 2/8/2013 D-METHORPHAN HB/P-EPD HCL/BPM 10-30-2/5 SYRUP 0.13310 0.13310 2/8/2013 D-METHORPHAN HB/P-EPD HCL/BPM 15-30-3/5 LIQUID 0.06225 0.04126 2/15/2013 D-METHORPHAN HB/P-EPD HCL/BPM 20-20-4/5 LIQUID 0.21003 0.21003 2/8/2013 D-METHORPHAN HB/P-EPD HCL/BPM 30-50-3MG LIQUID 0.06913 0.06913 2/8/2013 D-METHORPHAN HB/P-EPD HCL/BPM 5-15-1MG/5 ELIXIR 0.01127 0.01127 2/8/2013 D-METHORPHAN HB/P-EPHED HCL/CP 15-15-2/5 SYRUP 0.04846 0.04846 2/8/2013 Page 16 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price D-METHORPHAN HB/P-EPHED HCL/CP 3-9-0.8/ML DROPS 1.30760 1.30760 2/8/2013 D-METHORPHAN HB/P-EPHED HCL/CP 5-15-1MG/5 LIQUID 0.01868 0.01868 2/8/2013 D-METHORPHAN HB/PROMETH HCL 15-6.25/5 SYRUP 0.01365 0.01365 2/8/2013 D-METHORPHAN/ACETAMIN/DOXYLAMN 15-325/15 LIQUID 0.01873 0.01541 2/15/2013 D-METHORPHAN/PE/DEXBROMPHENIR 20-10-2/5 SYRUP 0.06078 0.05976 2/15/2013 DOBUTAMINE HCL 250MG/20ML VIAL 0.16439 0.16439 2/8/2013 DOBUTAMINE HCL 500MG/40ML VIAL 0.18207 0.18207 2/8/2013 DOBUTAMINE HCL/D5W 1000MG/250 IV SOLN 0.05662 0.05662 2/8/2013 DOBUTAMINE HCL/D5W 250MG/250 IV SOLN 0.03253 0.03253 2/8/2013 DOBUTAMINE HCL/D5W 500 MG/500 IV SOLN 0.02779 0.02779 2/8/2013 DOBUTAMINE HCL/D5W 500MG/250 IV SOLN 0.05475 0.05475 2/8/2013 DOCETAXEL 160 MG/8ML VIAL 255.60500 255.60500 2/8/2013 DOCETAXEL 160MG/16ML VIAL 159.40890 159.40890 2/8/2013 DOCETAXEL 20 MG/2 ML VIAL 150.34425 150.34425 2/8/2013 DOCETAXEL 20MG/ML(1) VIAL 265.52500 265.52500 2/8/2013 DOCETAXEL 80 MG/4 ML VIAL 265.52500 265.52500 2/8/2013 DOCETAXEL 80 MG/8 ML VIAL 150.33770 150.33770 2/8/2013 DOCETAXEL FNL 20MG/2 VIAL 148.61475 148.61475 2/8/2013 DOCETAXEL FNL 80MG/8 VIAL 297.22950 297.22950 2/8/2013 DOCOSAHEXANOIC ACID 200 MG CAPSULE 0.18200 0.18200 2/8/2013 DOCUSATE CALCIUM 240 MG CAPSULE 0.05132 0.05132 2/8/2013 DOCUSATE SODIUM 100 MG CAPSULE 0.01501 0.01501 2/8/2013 DOCUSATE SODIUM 100 MG TABLET 0.03068 0.03068 2/8/2013 DOCUSATE SODIUM 250 MG CAPSULE 0.03978 0.03978 2/8/2013 DOCUSATE SODIUM 283 MG/5ML ENEMA 2.91026 2.91026 2/8/2013 DOCUSATE SODIUM 50 MG/5 ML LIQUID 0.00737 0.00737 2/8/2013 DOCUSATE SODIUM 60 MG/15ML SYRUP 0.00657 0.00657 2/8/2013 DOCUSATE SODIUM/BENZOCAINE 283-20MG/5 ENEMA 2.92776 2.92776 2/8/2013 DONEPEZIL HCL 10 MG TAB RAPDIS 0.27257 0.27257 2/8/2013 DONEPEZIL HCL 10 MG TABLET 0.07517 0.07517 2/8/2013 DONEPEZIL HCL 5 MG TAB RAPDIS 0.27257 0.27257 2/8/2013 DONEPEZIL HCL 5 MG TABLET 0.07517 0.07517 2/8/2013 DOPAMINE HCL 400 MG/5ML VIAL 0.50263 0.50263 2/8/2013 DOPAMINE HCL 400MG/10ML VIAL 0.07980 0.07980 2/8/2013 DOPAMINE HCL 800MG/10ML VIAL 0.20101 0.20101 2/8/2013 DOPAMINE HCL 800MG/5ML VIAL 0.62837 0.62837 2/8/2013 DOPAMINE HCL/D5W 200MG/.25L PLAST. BAG 0.03370 0.03370 2/8/2013 DOPAMINE HCL/D5W 400MG/.25L PLAST. BAG 0.03721 0.03721 2/8/2013 DOPAMINE HCL/D5W 400MG/0.5L PLAST. BAG 0.04064 0.04064 2/8/2013 DOPAMINE HCL/D5W 800MG/.25L PLAST. BAG 0.05361 0.05361 2/8/2013 DOPAMINE HCL/D5W 800MG/0.5L PLAST. BAG 0.05101 0.05101 2/8/2013 DORZOLAMIDE HCL 2 % DROPS 1.45792 1.45792 2/8/2013 DORZOLAMIDE HCL/TIMOLOL MALEAT 2%-0.5% DROPS 2.89120 2.89120 2/8/2013 DOXAZOSIN MESYLATE 1 MG TABLET 0.05630 0.05630 2/8/2013 DOXAZOSIN MESYLATE 2 MG TABLET 0.06101 0.06101 2/8/2013 DOXAZOSIN MESYLATE 4 MG TABLET 0.07315 0.07315 2/8/2013 DOXAZOSIN MESYLATE 8 MG TABLET 0.09062 0.09062 2/8/2013 DOXEPIN HCL 10 MG CAPSULE 0.15106 0.15106 2/8/2013 DOXEPIN HCL 10 MG/ML ORAL CONC 0.05716 0.05716 2/8/2013 DOXEPIN HCL 100 MG CAPSULE 0.47710 0.47710 2/8/2013 DOXEPIN HCL 150 MG CAPSULE 0.50211 0.50211 2/8/2013 DOXEPIN HCL 25 MG CAPSULE 0.19887 0.19887 2/8/2013 DOXEPIN HCL 50 MG CAPSULE 0.26429 0.26429 2/8/2013 DOXORUBICIN HCL 10 MG VIAL 8.96000 8.96000 2/8/2013 DOXORUBICIN HCL 50 MG VIAL 23.25700 23.25700 2/8/2013 DOXORUBICIN HCL PEG-LIPOSOMAL 2 MG/ML VIAL 80.58400 80.58400 2/8/2013 DOXYCYCLINE HYCLATE 100 MG CAPSULE 0.05936 0.05936 2/8/2013 Page 17 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price DOXYCYCLINE HYCLATE 100 MG TABLET DR 19.21626 19.21626 2/8/2013 DOXYCYCLINE HYCLATE 100 MG VIAL 13.37070 13.37070 2/8/2013 DOXYCYCLINE HYCLATE 150 MG TABLET DR 25.72164 25.72164 2/8/2013 DOXYCYCLINE HYCLATE 20 MG TABLET 0.76627 0.76627 2/8/2013 DOXYCYCLINE HYCLATE 50 MG CAPSULE 0.81965 0.07660 2/8/2013 DOXYCYCLINE HYCLATE 75 MG TABLET DR 14.94291 14.94291 2/8/2013 DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE 0.41162 0.41162 2/8/2013 DOXYCYCLINE MONOHYDRATE 100 MG TABLET 0.95020 0.95020 2/8/2013 DOXYCYCLINE MONOHYDRATE 150 MG CAPSULE 17.25512 17.25512 2/8/2013 DOXYCYCLINE MONOHYDRATE 150 MG TABLET 4.39361 4.39361 2/8/2013 DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE 0.21255 0.21255 2/8/2013 DOXYCYCLINE MONOHYDRATE 50 MG TABLET 1.35064 1.35064 2/8/2013 DOXYCYCLINE MONOHYDRATE 75 MG CAPSULE 9.06192 9.06192 2/8/2013 DOXYCYCLINE MONOHYDRATE 75 MG TABLET 0.73366 0.73366 2/8/2013 DRONABINOL 10 MG CAPSULE 12.58532 12.58532 2/8/2013 DRONABINOL 2.5 MG CAPSULE 3.72548 3.72548 2/8/2013 DRONABINOL 5 MG CAPSULE 7.47720 7.47720 2/8/2013 DROPERIDOL 2.5 MG/ML AMPUL 0.84840 0.84840 2/8/2013 DROPERIDOL 2.5 MG/ML VIAL 1.42800 1.42800 2/8/2013 ECONAZOLE NITRATE 1 % CREAM (G) 0.16335 0.16335 2/8/2013 ELECTROLYTE,ORAL SOLUTION 0.00415 0.00415 2/8/2013 ELECTROLYTE-48 SOLUTION/D5W 5 % IV SOLN 0.00456 0.00456 2/8/2013 EMOL53/NAMGFS/HA/NAHYPOCHLORIT 96.53 %-3% KT CRM GEL 138.64900 138.64900 2/8/2013 EMOLLIENT COMBINATION NO.10 EMULSN(G) 0.44835 0.44835 2/8/2013 EMOLLIENT COMBINATION NO.32 EMULSN(G) 0.61081 0.61081 2/8/2013 EMOLLIENT COMBINATION NO.44 FOAM 0.90811 0.90811 2/8/2013 EMOLLIENT COMBINATION NO.53 CREAM (G) 0.51341 0.51341 2/8/2013 EMOLLIENT COMBINATION NO.53 FOAM 1.01001 1.01001 2/8/2013 ENALAPRIL MALEATE 10 MG TABLET 0.02961 0.02961 2/8/2013 ENALAPRIL MALEATE 100 % POWDER 3.35244 3.35244 2/8/2013 ENALAPRIL MALEATE 2.5 MG TABLET 0.02439 0.02439 2/8/2013 ENALAPRIL MALEATE 20 MG TABLET 0.03631 0.03631 2/8/2013 ENALAPRIL MALEATE 5 MG TABLET 0.02479 0.02479 2/8/2013 ENALAPRIL/HYDROCHLOROTHIAZIDE 10MG-25MG TABLET 0.11725 0.11725 2/8/2013 ENALAPRIL/HYDROCHLOROTHIAZIDE 5MG-12.5MG TABLET 0.09988 0.09988 2/8/2013 ENALAPRILAT DIHYDRATE 1.25MG/ML VIAL 1.81436 1.81436 2/8/2013 ENOXAPARIN SODIUM 100 MG/ML DISP SYRIN 26.00835 26.00835 2/8/2013 ENOXAPARIN SODIUM 120MG/.8ML DISP SYRIN 31.20920 31.20920 2/8/2013 ENOXAPARIN SODIUM 150 MG/ML DISP SYRIN 39.01150 39.01150 2/8/2013 ENOXAPARIN SODIUM 300MG/3ML VIAL 41.71412 41.71412 2/8/2013 ENOXAPARIN SODIUM 30MG/0.3ML DISP SYRIN 9.13440 9.13440 2/8/2013 ENOXAPARIN SODIUM 40MG/0.4ML DISP SYRIN 11.16500 11.16500 2/8/2013 ENOXAPARIN SODIUM 60MG/0.6ML DISP SYRIN 15.98520 15.98520 2/8/2013 ENOXAPARIN SODIUM 80MG/0.8ML DISP SYRIN 21.31395 21.31395 2/8/2013 ENTACAPONE 200 MG TABLET 2.76836 2.76836 2/8/2013 ENZYMES,DIGESTIVE CAPSULE 0.05944 0.04556 2/15/2013 ENZYMES,DIGESTIVE TABLET 0.08565 0.06552 2/15/2013 EPHEDRINE SULFATE 50 MG/ML VIAL 4.92170 4.92170 2/8/2013 EPINASTINE HCL 0.05 % DROPS 10.45350 10.45350 2/8/2013 EPINEPHRINE 0.1 MG/ML DISP SYRIN 0.53200 0.53200 2/8/2013 EPINEPHRINE 1 MG/ML VIAL 0.18800 0.18800 2/8/2013 EPIRUBICIN HCL 200 MG VIAL 1,992.09500 1,992.09500 2/8/2013 EPIRUBICIN HCL 50 MG VIAL 76.67100 76.67100 2/8/2013 EPLERENONE 25 MG TABLET 2.33425 2.33425 2/8/2013 EPLERENONE 50 MG TABLET 2.33797 2.33797 2/8/2013 EPOPROSTENOL SODIUM (GLYCINE) 0.5 MG VIAL 10.12200 10.12200 2/8/2013 EPOPROSTENOL SODIUM (GLYCINE) 1.5 MG VIAL 24.45100 24.45100 2/8/2013 Page 18 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price EPROSARTAN MESYLATE 600 MG TABLET 2.39820 2.39820 2/8/2013 ERGOCALCIFEROL (VITAMIN D2) 2000 UNIT TABLET 0.05446 0.05446 2/8/2013 ERGOCALCIFEROL (VITAMIN D2) 400 UNIT TABLET 0.02380 0.02380 2/8/2013 ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT CAPSULE 0.24937 0.24937 2/8/2013 ERGOLOID MESYLATES 1 MG TABLET 3.26417 3.26417 2/8/2013 ERGOTAMINE TARTRATE/CAFFEINE 1MG-100MG TABLET 0.84553 0.84553 2/8/2013 ERY E-SUCC/SULFISOXAZOLE 200-600/5 SUSP RECON 0.19123 0.19123 2/8/2013 ERYTHROMYCIN BASE 250 MG CAPSULE DR 2.65405 2.65405 2/8/2013 ERYTHROMYCIN BASE 250 MG TABLET 2.37790 2.37790 2/8/2013 ERYTHROMYCIN BASE 500 MG TABLET 2.79496 2.79496 2/8/2013 ERYTHROMYCIN BASE 5MG/G OINT. (G) 2.97963 2.97963 2/8/2013 ERYTHROMYCIN BASE/ 2 % MED. SWAB 1.10368 1.10368 2/8/2013 ERYTHROMYCIN/BENZOYL PEROXIDE 3 %-5 % GEL (GRAM) 1.11771 1.11771 2/8/2013 ESCITALOPRAM OXALATE 10 MG TABLET 0.16950 0.16950 2/8/2013 ESCITALOPRAM OXALATE 20 MG TABLET 0.19890 0.19890 2/8/2013 ESCITALOPRAM OXALATE 5 MG TABLET 0.15950 0.15950 2/8/2013 ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION 0.55475 0.55475 2/8/2013 ESTAZOLAM 1 MG TABLET 0.26774 0.26774 2/8/2013 ESTAZOLAM 2 MG TABLET 0.29328 0.29328 2/8/2013 ESTRADIOL .025MG/24H PATCH TDWK 11.57200 11.57200 2/8/2013 ESTRADIOL .0375MG/24 PATCH TDWK 11.57200 11.57200 2/8/2013 ESTRADIOL .075MG/24H PATCH TDWK 11.57200 11.57200 2/8/2013 ESTRADIOL 0.05MG/24H PATCH TDWK 11.57200 11.57200 2/8/2013 ESTRADIOL 0.06MG/24H PATCH TDWK 11.57200 11.57200 2/8/2013 ESTRADIOL 0.1MG/24HR PATCH TDWK 11.57200 11.57200 2/8/2013 ESTRADIOL 0.5 MG TABLET 0.05963 0.05963 2/8/2013 ESTRADIOL 1 MG TABLET 0.05119 0.05119 2/8/2013 ESTRADIOL 2 MG TABLET 0.06218 0.06218 2/8/2013 ESTRADIOL/NORETHINDRONE ACET 0.5-0.1MG TABLET 5.28900 5.28900 2/8/2013 ESTRADIOL/NORETHINDRONE ACET 1 MG-0.5MG TABLET 2.68827 2.68827 2/8/2013 ,ESTER/ME- 0.625-1.25 TABLET 0.54404 0.54404 2/8/2013 ESTROGEN,ESTER/ME-TESTOSTERONE 1.25-2.5MG TABLET 0.54404 0.54404 2/8/2013 0.75 MG TABLET 0.23634 0.23634 2/8/2013 ESTROPIPATE 1.5 MG TABLET 0.33059 0.33059 2/8/2013 ESTROPIPATE 3 MG TABLET 0.70273 0.70273 2/8/2013 ETHAMBUTOL HCL 100 MG TABLET 0.30646 0.30646 2/8/2013 ETHAMBUTOL HCL 400 MG TABLET 0.62310 0.62310 2/8/2013 ETHINYL ESTRADIOL/ 0.02-3(24) TABLET 1.77025 1.77025 2/8/2013 ETHINYL ESTRADIOL/DROSPIRENONE 0.03-3MG TABLET 1.53508 1.53508 2/8/2013 ETHOSUXIMIDE 250 MG CAPSULE 0.85461 0.85461 2/8/2013 ETHOSUXIMIDE 250 MG/5ML SOLUTION 0.06070 0.06070 2/8/2013 ETHYL ALCOHOL 98 % AMPUL 6.26450 6.26450 2/8/2013 ETHYL ALCOHOL 98 % VIAL 12.10062 12.10062 2/8/2013 ETHYNODIOL D-ETHINYL ESTRADIOL 1 MG-35MCG TABLET 0.74698 0.74698 2/8/2013 ETIDRONATE DISODIUM 200 MG TABLET 2.85343 2.85343 2/8/2013 ETIDRONATE DISODIUM 400 MG TABLET 5.70547 5.70547 2/8/2013 ETODOLAC 200 MG CAPSULE 0.92480 0.92480 2/8/2013 ETODOLAC 300 MG CAPSULE 1.13180 1.13180 2/8/2013 ETODOLAC 400 MG TAB ER 24H 0.68427 0.68427 2/8/2013 ETODOLAC 500 MG TAB ER 24H 0.84570 0.84570 2/8/2013 ETODOLAC 500 MG TABLET 0.30105 0.30105 2/8/2013 ETODOLAC 600 MG TAB ER 24H 1.33730 1.33730 2/8/2013 ETOPOSIDE 50 MG CAPSULE 46.79395 46.79395 2/8/2013 25 MG TABLET 6.92822 6.92822 2/8/2013 FA/ARGININE HCL/B12/B6/PEP EX 2-500-500 TABLET 0.56210 0.56210 2/8/2013 FAMCICLOVIR 125 MG TABLET 1.06080 1.06080 2/8/2013 FAMCICLOVIR 250 MG TABLET 1.09504 1.09504 2/8/2013 Page 19 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price FAMCICLOVIR 500 MG TABLET 2.16190 2.16190 2/8/2013 FAMOTIDINE 10 MG TABLET 0.08308 0.08308 2/8/2013 FAMOTIDINE 10 MG/ML VIAL 0.27792 0.27792 2/8/2013 FAMOTIDINE 20 MG TABLET 0.03792 0.03792 2/8/2013 FAMOTIDINE 40 MG TABLET 0.06727 0.06727 2/8/2013 FAMOTIDINE 40MG/5ML ORAL SUSP 1.73584 1.73584 2/8/2013 FAMOTIDINE IN NACL,ISO-OSM/PF 20MG/50ML PIGGYBACK 0.13650 0.13650 2/8/2013 FAMOTIDINE/PF 20 MG/2 ML VIAL 0.37429 0.37429 2/8/2013 FE FUMARATE/VIT C/B12-IF/FA 110-0.5MG CAPSULE 0.19764 0.19764 2/8/2013 FELBAMATE 400 MG TABLET 3.64207 3.64207 2/8/2013 FELBAMATE 600 MG TABLET 4.17758 4.17758 2/8/2013 FELBAMATE 600MG/5ML ORAL SUSP 1.87137 1.87137 2/8/2013 FELODIPINE 10 MG TAB ER 24H 0.79047 0.79047 2/8/2013 FELODIPINE 2.5 MG TAB ER 24H 0.54216 0.54216 2/8/2013 FELODIPINE 5 MG TAB ER 24H 0.54377 0.54377 2/8/2013 FENOFIBRATE 160 MG TABLET 1.53510 1.53510 2/8/2013 FENOFIBRATE 54 MG TABLET 0.55448 0.55448 2/8/2013 FENOFIBRATE NANOCRYSTALLIZED 145MG TABLET 3.96421 3.96421 2/8/2013 FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET 1.31113 1.31113 2/8/2013 FENOFIBRATE,MICRONIZED 200 MG CAPSULE 2.31300 2.31300 2/8/2013 FENOFIBRATE,MICRONIZED 67 MG CAPSULE 0.73955 0.73955 2/8/2013 FENOFIBRIC ACID 105 MG TABLET 3.96959 3.96959 2/8/2013 FENOFIBRIC ACID 35 MG TABLET 1.32159 1.32159 2/8/2013 FENTANYL 100 MCG/HR PATCH TD72 21.12400 21.12400 2/8/2013 FENTANYL 25MCG/HR PATCH TD72 4.22240 4.22240 2/8/2013 FENTANYL 50MCG/HR PATCH TD72 6.54558 9.08500 2/8/2013 FENTANYL 75MCG/HR PATCH TD72 11.08370 11.08370 2/8/2013 FENTANYL CITRATE 1200 MCG LOZENGE HD 31.46500 31.46500 2/8/2013 FENTANYL CITRATE 1600 MCG LOZENGE HD 38.80683 38.80683 2/8/2013 FENTANYL CITRATE 200 MCG LOZENGE HD 13.16280 13.16280 2/8/2013 FENTANYL CITRATE 400 MCG LOZENGE HD 16.67657 16.67657 2/8/2013 FENTANYL CITRATE 600 MCG LOZENGE HD 20.42600 20.42600 2/8/2013 FENTANYL CITRATE 800 MCG LOZENGE HD 24.20180 24.20180 2/8/2013 FENTANYL CITRATE/PF 100MCG/2ML DISP SYRIN 0.65520 0.65520 2/8/2013 FERROUS GLUCONATE 240(27)MG TABLET 0.05159 0.04165 2/15/2013 FERROUS SULFATE 140(45)MG TABLET ER 0.15868 0.15868 2/8/2013 FERROUS SULFATE 15 MG/ML DROPS 0.06137 0.06137 2/8/2013 FERROUS SULFATE 220(44)/5 SOLUTION 0.00697 0.00697 2/8/2013 FERROUS SULFATE 325(65) MG TABLET 0.00831 0.00831 2/8/2013 FERROUS SULFATE/VIT C/FA 105-500-.8 TABLET ER 0.45920 0.45920 2/8/2013 FEXOFENADINE HCL 180 MG TABLET 0.36689 0.36689 2/8/2013 FEXOFENADINE HCL 30 MG TAB RAPDIS 1.63275 1.63275 2/8/2013 FEXOFENADINE HCL 30 MG TABLET 0.71400 0.71400 2/8/2013 FEXOFENADINE HCL 30 MG/5 ML ORAL SUSP 0.16328 0.16328 2/8/2013 FEXOFENADINE HCL 60 MG TABLET 0.55637 0.55637 2/8/2013 FEXOFENADINE/PSEUDOEPHEDRINE 180-240MG TAB ER 24H 0.96973 0.96973 2/8/2013 FEXOFENADINE/PSEUDOEPHEDRINE 60MG-120MG TAB ER 12H 0.66733 0.66733 2/8/2013 FINASTERIDE 5 MG TABLET 0.16522 0.16522 2/8/2013 FISH OIL/BORAGE/FLAX/OM3,6,9#1 400-400 MG CAPSULE 0.06491 0.06168 2/15/2013 FISH OIL/DHA/EPA 1200-144MG CAPSULE 0.01579 0.01579 2/8/2013 FLAVOXATE HCL 100 MG TABLET 0.95488 0.95488 2/8/2013 FLECAINIDE ACETATE 100 MG TABLET 0.27773 0.27773 2/8/2013 FLECAINIDE ACETATE 150 MG TABLET 0.54565 0.54565 2/8/2013 FLECAINIDE ACETATE 50 MG TABLET 0.19059 0.19059 2/8/2013 FLUCONAZOLE 10 MG/ML SUSP RECON 0.26780 0.26780 2/8/2013 FLUCONAZOLE 100 MG TABLET 0.17956 0.17956 2/8/2013 FLUCONAZOLE 150 MG TABLET 0.34612 0.34612 2/8/2013 Page 20 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price FLUCONAZOLE 200 MG TABLET 0.28944 0.28944 2/8/2013 FLUCONAZOLE 40 MG/ML SUSP RECON 0.64574 0.64574 2/8/2013 FLUCONAZOLE 50 MG TABLET 0.10873 0.10873 2/8/2013 FLUCONAZOLE IN DEXTROSE,ISO-OS 200MG/0.1L PIGGYBACK 0.09492 0.09492 2/8/2013 FLUCONAZOLE IN DEXTROSE,ISO-OS 400MG/0.2L PIGGYBACK 0.05296 0.05296 2/8/2013 FLUCONAZOLE IN NACL,ISO-OSM 100MG/50ML PGGYBK BTL 0.25410 0.25410 2/8/2013 FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L PGGYBK BTL 0.12676 0.12676 2/8/2013 FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L PIGGYBACK 0.05186 0.05186 2/8/2013 FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L PGGYBK BTL 0.09450 0.09450 2/8/2013 FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L PIGGYBACK 0.03268 0.03268 2/8/2013 FLUCYTOSINE 250 MG CAPSULE 16.21200 16.21200 2/8/2013 FLUCYTOSINE 500 MG CAPSULE 31.37400 31.37400 2/8/2013 FLUDROCORTISONE ACETATE 0.1 MG TABLET 0.51917 0.51917 2/8/2013 FLUNISOLIDE 25 MCG SPRAY 1.92500 1.92500 2/8/2013 FLUNISOLIDE 29MCG SPRAY 1.53888 1.53888 2/8/2013 FLUOCINOLONE ACETONIDE 0.01 % OIL 0.21619 0.21619 2/8/2013 FLUOCINOLONE ACETONIDE 0.01 % SOLUTION 2.10000 2.10000 2/8/2013 FLUOCINOLONE ACETONIDE 0.025 % CREAM (G) 1.27055 1.27055 2/8/2013 FLUOCINOLONE ACETONIDE 0.025 % OINT. (G) 1.41411 1.41411 2/8/2013 FLUOCINOLONE ACETONIDE OIL 0.01 % DROPS 1.10145 1.10145 2/8/2013 FLUOCINOLONE/SHOWER CAP 0.01 % OIL 0.22282 0.22282 2/8/2013 FLUOCINONIDE 0.05 % CREAM (G) 0.35081 0.35081 2/8/2013 FLUOCINONIDE 0.05 % GEL (GRAM) 0.84670 0.84670 2/8/2013 FLUOCINONIDE 0.05 % OINT. (G) 0.78790 0.78790 2/8/2013 FLUOCINONIDE 0.05 % SOLUTION 1.20370 1.20370 2/8/2013 FLUOCINONIDE/EMOLLIENT 0.05 % CREAM (G) 0.20663 0.20663 2/8/2013 FLUOROMETHOLONE 0.1 % DROPS SUSP 1.21055 1.21055 2/8/2013 FLUOROURACIL 1 G/20 ML VIAL 0.49482 0.49482 2/8/2013 FLUOROURACIL 2 % SOLUTION 5.29235 5.29235 2/8/2013 FLUOROURACIL 2.5 G/50ML VIAL 0.21578 0.21578 2/8/2013 FLUOROURACIL 5 % CREAM (G) 5.21612 5.21612 2/8/2013 FLUOROURACIL 5 % SOLUTION 7.86240 7.86240 2/8/2013 FLUOROURACIL 5 G/100 ML VIAL 0.29560 0.29560 2/8/2013 FLUOROURACIL 500MG/10ML VIAL 0.25082 0.25082 2/8/2013 FLUOXETINE HCL 10 MG CAPSULE 0.03034 0.03034 2/8/2013 FLUOXETINE HCL 10 MG TABLET 0.05199 0.05199 2/8/2013 FLUOXETINE HCL 20 MG CAPSULE 0.02479 0.02479 2/8/2013 FLUOXETINE HCL 20 MG TABLET 0.60474 0.60474 2/8/2013 FLUOXETINE HCL 20 MG/5 ML SOLUTION 0.03444 0.03444 2/8/2013 FLUOXETINE HCL 40 MG CAPSULE 0.21373 0.21373 2/8/2013 FLUOXETINE HCL 60 MG TABLET 5.03439 5.03439 2/8/2013 FLUOXETINE HCL 90 MG CAPSULE DR 25.89300 25.89300 2/8/2013 FLUPHENAZINE DECANOATE 25 MG/ML VIAL 17.59500 17.59500 2/8/2013 FLUPHENAZINE HCL 1 MG TABLET 0.11232 0.11232 2/8/2013 FLUPHENAZINE HCL 10 MG TABLET 0.22160 0.22160 2/8/2013 FLUPHENAZINE HCL 2.5 MG TABLET 0.18331 0.18331 2/8/2013 FLUPHENAZINE HCL 2.5 MG/5ML ELIXIR 0.26710 0.26710 2/8/2013 FLUPHENAZINE HCL 2.5 MG/ML VIAL 8.55120 8.55120 2/8/2013 FLUPHENAZINE HCL 5 MG TABLET 0.22016 0.22016 2/8/2013 FLUPHENAZINE HCL 5 MG/ML ORAL CONC 0.81136 0.81136 2/8/2013 FLURAZEPAM HCL 15 MG CAPSULE 0.06291 0.06291 2/8/2013 FLURAZEPAM HCL 30 MG CAPSULE 0.07263 0.07263 2/8/2013 FLURBIPROFEN 100 MG TABLET 0.13655 0.13655 2/8/2013 FLURBIPROFEN 50 MG TABLET 0.10517 0.10517 2/8/2013 FLURBIPROFEN SODIUM 0.03 % DROPS 1.74850 1.74850 2/8/2013 125 MG CAPSULE 0.71033 0.71033 2/8/2013 FLUTICASONE PROPIONATE 0.005 % OINT. (G) 0.49071 0.49071 2/8/2013 Page 21 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price FLUTICASONE PROPIONATE 0.05 % CREAM (G) 0.55080 0.55080 2/8/2013 FLUTICASONE PROPIONATE 0.05 % LOTION 4.54942 4.54942 2/8/2013 FLUTICASONE PROPIONATE 50 MCG SPRAY SUSP 1.06708 1.06708 2/8/2013 FLUVASTATIN SODIUM 20 MG CAPSULE 2.64297 2.64297 2/8/2013 FLUVASTATIN SODIUM 40 MG CAPSULE 2.63545 2.63545 2/8/2013 FLUVOXAMINE MALEATE 100 MG TABLET 0.32327 0.32327 2/8/2013 FLUVOXAMINE MALEATE 25 MG TABLET 0.28885 0.28885 2/8/2013 FLUVOXAMINE MALEATE 50 MG TABLET 0.31200 0.31200 2/8/2013 FOLIC ACID 0.4 MG TABLET 0.01005 0.01005 2/8/2013 FOLIC ACID 1 MG TABLET 0.02320 0.02320 2/8/2013 FOLIC ACID 5 MG/ML VIAL 1.79410 1.79410 2/15/2013 FOLIC ACID/MULTIVITS-MIN 0.4 MG TABLET 0.80777 0.79412 2/15/2013 FOLIC ACID/MULTIVITS-MIN/LUT 0.4MG-250 TABLET 0.03600 0.03600 2/8/2013 FOLIC ACID/MV,FE,OTHER MIN/LUT 0.4-18-250 TABLET 0.04358 0.04358 2/8/2013 FOLIC ACID/VITAMIN B COMP W-C 0.8 MG TABLET 0.09958 0.09958 2/8/2013 FOLIC ACID/VITAMIN B COMP W-C 1 MG CAPSULE 0.59080 0.59080 2/8/2013 FONDAPARINUX SODIUM 10MG/0.8ML DISP SYRIN 94.71000 94.71000 2/8/2013 FONDAPARINUX SODIUM 2.5 MG/0.5 DISP SYRIN 59.81026 59.81026 2/8/2013 FONDAPARINUX SODIUM 5MG/0.4ML DISP SYRIN 176.97650 176.97650 2/8/2013 FONDAPARINUX SODIUM 7.5MG/0.6 DISP SYRIN 147.48213 147.48213 2/8/2013 FORMALDEHYDE 10 % SOL W/APPL 0.36953 0.36953 2/8/2013 FOSINOPRIL SODIUM 10 MG TABLET 0.19773 0.19773 2/8/2013 FOSINOPRIL SODIUM 20 MG TABLET 0.15509 0.15509 2/8/2013 FOSINOPRIL SODIUM 40 MG TABLET 0.17837 0.17837 2/8/2013 FOSINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 1.00740 1.00740 2/8/2013 FOSINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 1.00740 1.00740 2/8/2013 FOSPHENYTOIN SODIUM 100MG PE/2 VIAL 0.84206 0.84206 2/8/2013 FOSPHENYTOIN SODIUM 500 PE/10 VIAL 0.46214 0.46214 2/8/2013 FUROSEMIDE 10 MG/ML DISP SYRIN 0.71988 0.71988 2/8/2013 FUROSEMIDE 10 MG/ML SOLUTION 0.11127 0.11127 2/8/2013 FUROSEMIDE 10 MG/ML VIAL 0.09072 0.09072 2/8/2013 FUROSEMIDE 20 MG TABLET 0.01032 0.01032 2/8/2013 FUROSEMIDE 40 MG TABLET 0.01152 0.01152 2/8/2013 FUROSEMIDE 40MG/5ML SOLUTION 0.14150 0.14150 2/8/2013 FUROSEMIDE 80 MG TABLET 0.02707 0.02707 2/8/2013 GABAPENTIN 100 MG CAPSULE 0.04221 0.04221 2/8/2013 GABAPENTIN 250 MG/5ML SOLUTION 0.13393 0.13393 2/8/2013 GABAPENTIN 250 MG/CUP SOLUTION 0.29166 0.29166 2/8/2013 GABAPENTIN 300 MG CAPSULE 0.06807 0.06807 2/8/2013 GABAPENTIN 300 MG/6ML SOLUTION 0.29164 0.29164 2/8/2013 GABAPENTIN 400 MG CAPSULE 0.09072 0.09072 2/8/2013 GABAPENTIN 600 MG TABLET 0.27550 0.27550 2/8/2013 GABAPENTIN 800 MG TABLET 0.42880 0.42880 2/8/2013 GALANTAMINE HBR 12 MG TABLET 1.78863 1.78863 2/8/2013 GALANTAMINE HBR 16 MG CAP24H PEL 2.23110 2.23110 2/8/2013 GALANTAMINE HBR 24 MG CAP24H PEL 2.45488 2.45488 2/8/2013 GALANTAMINE HBR 4 MG TABLET 1.78863 1.78863 2/8/2013 GALANTAMINE HBR 4 MG/ML SOLUTION 2.95575 2.95575 2/8/2013 GALANTAMINE HBR 8 MG CAP24H PEL 2.18152 2.18152 2/8/2013 GALANTAMINE HBR 8 MG TABLET 1.78863 1.78863 2/8/2013 GANCICLOVIR SODIUM 500 MG VIAL 9.65936 9.65936 2/8/2013 GANIRELIX ACETATE 250MCG/0.5 DISP SYRIN 243.87300 243.87300 2/8/2013 GEMCITABINE HCL 1 G VIAL 39.63675 39.63675 2/8/2013 GEMCITABINE HCL 1 G/26.3ML VIAL 3.16329 3.16329 2/8/2013 GEMCITABINE HCL 2 G VIAL 92.63950 92.63950 2/8/2013 GEMCITABINE HCL 2 G/52.6ML VIAL 3.58109 3.58109 2/8/2013 GEMCITABINE HCL 200 MG VIAL 9.28800 9.28800 2/8/2013 Page 22 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price GEMCITABINE HCL 200MG/5.26 VIAL 3.79680 3.79680 2/8/2013 GEMFIBROZIL 600 MG TABLET 0.12918 0.12918 2/8/2013 GENTAMICIN IN NACL, ISO-OSM 100MG/50ML PIGGYBACK 0.13213 0.13213 2/8/2013 GENTAMICIN IN NACL, ISO-OSM 120MG/0.1L PIGGYBACK 0.06630 0.06630 2/8/2013 GENTAMICIN IN NACL, ISO-OSM 70 MG/50ML PIGGYBACK 0.15469 0.15469 2/8/2013 GENTAMICIN IN NACL, ISO-OSM 90MG/100ML PIGGYBACK 0.07491 0.07491 2/8/2013 GENTAMICIN SULFATE 0.1 % CREAM (G) 0.61870 0.61870 2/8/2013 GENTAMICIN SULFATE 0.1 % OINT. (G) 0.72750 0.72750 2/8/2013 GENTAMICIN SULFATE 0.3 % DROPS 1.24084 1.24084 2/8/2013 GENTAMICIN SULFATE 0.3 % OINT. (G) 3.02900 3.02900 2/8/2013 GENTAMICIN SULFATE 10 MG/ML VIAL 1.45158 1.45158 2/8/2013 GENTAMICIN SULFATE 40 MG/ML VIAL 0.59493 0.59493 2/8/2013 GENTAMICIN SULFATE/PF 100MG/10ML VIAL PORT 0.29434 0.29434 2/8/2013 GENTAMICIN SULFATE/PF 20 MG/2 ML VIAL 1.25658 1.25658 2/8/2013 GENTAMICIN SULFATE/PF 60 MG/6 ML VIAL PORT 0.39255 0.39255 2/8/2013 GENTAMICIN SULFATE/PF 80 MG/8 ML VIAL PORT 0.34262 0.34262 2/8/2013 GLIMEPIRIDE 1 MG TABLET 0.02908 0.02908 2/8/2013 GLIMEPIRIDE 2 MG TABLET 0.05347 0.05347 2/8/2013 GLIMEPIRIDE 4 MG TABLET 0.06861 0.06861 2/8/2013 GLIPIZIDE 10 MG TAB ER 24 0.40120 0.40120 2/8/2013 GLIPIZIDE 10 MG TABLET 0.04328 0.04328 2/8/2013 GLIPIZIDE 2.5 MG TAB ER 24 0.28467 0.28467 2/8/2013 GLIPIZIDE 5 MG TAB ER 24 0.18940 0.18940 2/8/2013 GLIPIZIDE 5 MG TABLET 0.03000 0.03000 2/8/2013 GLIPIZIDE/METFORMIN HCL 2.5-250 MG TABLET 0.34151 0.34151 2/8/2013 GLIPIZIDE/METFORMIN HCL 2.5-500 MG TABLET 0.39585 0.39585 2/8/2013 GLIPIZIDE/METFORMIN HCL 5 MG-500MG TABLET 0.39585 0.39585 2/8/2013 GLUC/CHON-MSM#1/C/MANG/BOS/BOR 750-625MG TABLET 0.20448 0.20448 2/8/2013 GLUCOSAMINE SULFATE 750 MG TABLET 0.33095 0.33095 2/8/2013 GLUCOSAMINE/MSM/CHONDROITIN A 500-150 MG TABLET 1.20120 1.20120 2/8/2013 GLUTAMINE 500 MG TABLET 0.11404 0.09395 2/15/2013 GLYBURIDE 1.25 MG TABLET 0.12315 0.12315 2/8/2013 GLYBURIDE 2.5 MG TABLET 0.14767 0.14767 2/8/2013 GLYBURIDE 5 MG TABLET 0.22579 0.22579 2/8/2013 GLYBURIDE,MICRONIZED 1.5 MG TABLET 0.02587 0.02587 2/8/2013 GLYBURIDE,MICRONIZED 3 MG TABLET 0.02841 0.02841 2/8/2013 GLYBURIDE,MICRONIZED 6 MG TABLET 0.05507 0.05507 2/8/2013 GLYBURIDE/METFORMIN HCL 1.25-250MG TABLET 0.09935 0.09935 2/8/2013 GLYBURIDE/METFORMIN HCL 2.5-500 MG TABLET 0.10479 0.10479 2/8/2013 GLYBURIDE/METFORMIN HCL 5 MG-500MG TABLET 0.09514 0.09514 2/8/2013 GLYCINE POWDER 0.21194 0.20644 2/15/2013 GLYCINE 1.5 % IRRIG SOLN 0.00300 0.00267 2/8/2013 GLYCINE/SOD/WATER/SOD HYDROX VIAL 0.14700 0.14700 2/8/2013 GLYCOPYRROLATE 1 MG TABLET 0.25246 0.25246 2/8/2013 GLYCOPYRROLATE 2 MG TABLET 0.95797 0.95797 2/8/2013 GRANISETRON HCL 1 MG TABLET 1.58405 1.58405 2/8/2013 GRANISETRON HCL 1 MG/ML VIAL 4.71250 4.71250 2/8/2013 GRANISETRON HCL 1 MG/ML(1) VIAL 7.21995 7.21995 2/8/2013 GRANISETRON HCL/PF 1 MG/ML(1) VIAL 9.00000 9.00000 2/8/2013 GRANISETRON HCL/PF 100 MCG/ML VIAL 2.49240 2.49240 2/8/2013 GRISEOFULVIN ULTRAMICROSIZE 125 MG TABLET 3.68837 3.68837 2/8/2013 GRISEOFULVIN ULTRAMICROSIZE 250 MG TABLET 4.71086 4.71086 2/8/2013 GRISEOFULVIN,MICROSIZE 125 MG/5ML ORAL SUSP 0.14401 0.14579 2/8/2013 GRISEOFULVIN,MICROSIZE 500 MG TABLET 5.40337 5.40337 2/8/2013 GUAIFENESIN 100 MG/5ML LIQUID 0.00523 0.00523 2/8/2013 GUAIFENESIN 200 MG TABLET 0.05109 0.05109 2/8/2013 GUAIFENESIN 400 MG TABLET 0.10184 0.10184 2/8/2013 Page 23 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price GUAIFENESIN 600 MG TABLET ER 0.30668 0.30668 2/8/2013 GUAIFENESIN/CODEINE PHOSPHATE 100-10MG/5 LIQUID 0.00965 0.00965 2/8/2013 GUAIFENESIN/CODEINE PHOSPHATE 100-6.3/5 LIQUID 0.03518 0.03518 2/8/2013 GUAIFENESIN/CODEINE PHOSPHATE 200MG-9MG CAPSULE 0.25375 0.25375 2/8/2013 GUAIFENESIN/CODEINE PHOSPHATE 225-7.5/5 LIQUID 0.04972 0.04710 2/15/2013 GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 LIQUID 0.03162 0.03162 2/8/2013 GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 SYRUP 0.00643 0.00643 2/8/2013 GUAIFENESIN/DEXTROMETHORPHAN 400-20MG/5 LIQUID 0.00000 0.07583 2/15/2013 GUAIFENESIN/DM/PSEUDOEPHEDRINE 400-15-45 TABLET 0.43610 0.43610 2/8/2013 GUAIFENESIN/D-METHORPHAN HB/PE 100-10-5MG LIQUID 0.01943 0.01943 2/8/2013 GUAIFENESIN/D-METHORPHAN HB/PE 100-15-5/5 LIQUID 0.08674 0.04730 2/15/2013 GUAIFENESIN/D-METHORPHAN HB/PE 200-10-5/5 LIQUID 0.02586 0.02586 2/8/2013 GUAIFENESIN/D-METHORPHAN HB/PE 200-20-10 LIQUID 0.07984 0.07984 2/8/2013 GUAIFENESIN/D-METHORPHAN HB/PE 200-20-5/5 ORAL SUSP 0.06487 0.06487 2/8/2013 GUAIFENESIN/D-METHORPHAN HB/PE 380-15-10 TABLET 0.43610 0.43610 2/8/2013 GUAIFENESIN/PHENYLEPHRINE HCL 380MG-10MG TABLET 0.43166 0.43166 2/8/2013 GUAIFENESIN/PSEUDOEPHEDRNE HCL 400MG-45MG TABLET 0.43166 0.43166 2/8/2013 GUANFACINE HCL 1 MG TABLET 0.07986 0.07986 2/8/2013 GUANFACINE HCL 2 MG TABLET 0.11356 0.11356 2/8/2013 GUANIDINE HCL 125 MG TABLET 0.17724 0.17724 2/8/2013 HALOBETASOL PROPIONATE 0.05 % CREAM (G) 0.88015 0.88015 2/8/2013 HALOBETASOL PROPIONATE 0.05 % OINT. (G) 0.89027 0.89027 2/8/2013 HALOPERIDOL 0.5 MG TABLET 0.05941 0.05941 2/8/2013 HALOPERIDOL 1 MG TABLET 0.09243 0.09243 2/8/2013 HALOPERIDOL 10 MG TABLET 0.97721 0.97721 2/8/2013 HALOPERIDOL 2 MG TABLET 0.12613 0.12613 2/8/2013 HALOPERIDOL 20 MG TABLET 1.69892 1.69892 2/8/2013 HALOPERIDOL 5 MG TABLET 0.14968 0.14968 2/8/2013 HALOPERIDOL DECANOATE 100 MG/ML AMPUL 41.45400 41.45400 2/8/2013 HALOPERIDOL DECANOATE 100 MG/ML VIAL 31.00499 31.00499 2/8/2013 HALOPERIDOL DECANOATE 50 MG/ML AMPUL 21.74667 21.74667 2/8/2013 HALOPERIDOL DECANOATE 50 MG/ML VIAL 14.87250 14.87250 2/8/2013 HALOPERIDOL LACTATE 2 MG/ML ORAL CONC 0.04033 0.04033 2/8/2013 HALOPERIDOL LACTATE 5 MG/ML AMPUL 5.15760 5.15760 2/8/2013 HALOPERIDOL LACTATE 5 MG/ML VIAL 1.14838 1.14838 2/8/2013 HC/MINERAL OIL/PETROLAT,WHT 1 % OINT. (G) 0.12564 0.12564 2/8/2013 HEPARIN SOD,PORK IN 0.45% NACL 12500/250 IV SOLN 0.03400 0.03400 2/8/2013 HEPARIN SOD,PORK IN 0.45% NACL 25000/250 IV SOLN 0.02288 0.02288 2/8/2013 HEPARIN SOD,PORK IN 0.45% NACL 25000/500 IV SOLN 0.01749 0.01749 2/8/2013 HEPARIN SODIUM,PORCINE 10 UNIT/ML DISP SYRIN 0.65863 0.65863 2/8/2013 HEPARIN SODIUM,PORCINE 100/ML VIAL 0.03724 0.03724 2/8/2013 HEPARIN SODIUM,PORCINE 1000/ML VIAL 0.21199 0.21199 2/8/2013 HEPARIN SODIUM,PORCINE 10000/ML VIAL 2.33147 2.33147 2/8/2013 HEPARIN SODIUM,PORCINE 20000/ML VIAL 8.60701 8.60701 2/8/2013 HEPARIN SODIUM,PORCINE 5000/ML CARTRIDGE 3.65400 3.65400 2/8/2013 HEPARIN SODIUM,PORCINE 5000/ML VIAL 0.72534 0.72534 2/8/2013 HEPARIN SODIUM,PORCINE/D5W 12500/250 IV SOLN 0.03780 0.03780 2/8/2013 HEPARIN SODIUM,PORCINE/D5W 20K/500ML IV SOLN 0.01172 0.01172 2/8/2013 HEPARIN SODIUM,PORCINE/NS/PF 1000/500ML IV SOLN 0.00573 0.00573 2/8/2013 HEPARIN SODIUM,PORCINE/NS/PF 2K/1000ML IV SOLN 0.00370 0.00370 2/8/2013 HEPARIN SODIUM,PORCINE/PF 10 UNIT/ML VIAL 1.27811 1.27811 2/8/2013 HEPARIN SODIUM,PORCINE/PF 100/ML VIAL 1.63384 1.63384 2/8/2013 HEPARIN SODIUM,PORCINE/PF 1000/ML VIAL 4.02116 4.02116 2/8/2013 HEPARIN SODIUM,PORCINE/PF 25K/10ML VIAL PORT 0.64512 0.64512 2/8/2013 HEPARIN SODIUM,PORCINE/PF 5000/0.5ML DISP SYRIN 7.45725 7.45725 2/8/2013 HEPARIN SODIUM,PORCINE/PF 5000/0.5ML VIAL 9.36923 9.36923 2/8/2013 HYDRALAZINE HCL 10 MG TABLET 0.05708 0.05708 2/8/2013 Page 24 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price HYDRALAZINE HCL 100 MG TABLET 0.18850 0.18850 2/8/2013 HYDRALAZINE HCL 20 MG/ML VIAL 4.60408 4.60408 2/8/2013 HYDRALAZINE HCL 25 MG TABLET 0.05896 0.05896 2/8/2013 HYDRALAZINE HCL 50 MG TABLET 0.06526 0.06526 2/8/2013 HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE 0.04074 0.04074 2/8/2013 HYDROCHLOROTHIAZIDE 12.5 MG TABLET 0.12831 0.12831 2/8/2013 HYDROCHLOROTHIAZIDE 25 MG TABLET 0.01018 0.01018 2/8/2013 HYDROCHLOROTHIAZIDE 50 MG TABLET 0.01889 0.01889 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 10-660MG TABLET 0.20194 0.20194 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 10-750MG TABLET 0.53554 0.53554 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 10MG-325MG TABLET 0.12368 0.12368 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 10MG-500MG TABLET 0.21500 0.21500 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 10MG-650MG TABLET 0.06660 0.06660 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 2.5-167/5 SOLUTION 0.47191 0.47191 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 2.5-500 MG TABLET 0.20209 0.20209 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 5 MG-500MG TABLET 0.04074 0.04074 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 5-334MG/10 SOLUTION 0.26732 0.26732 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 5MG-325MG TABLET 0.12958 0.12958 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-300MG TABLET 1.34459 1.34459 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-325/15 SOLUTION 0.08900 0.08900 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-325/CP SOLUTION 0.15120 0.15120 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-325MG TABLET 0.15544 0.15544 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-500/15 SOLUTION 0.01726 0.01726 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-500/CP SOLUTION 0.18964 0.18964 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-500MG TABLET 0.05105 0.05105 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-650 MG TABLET 0.06486 0.06486 2/8/2013 HYDROCODONE BIT/ACETAMINOPHEN 7.5-750MG TABLET 0.05588 0.05588 2/8/2013 HYDROCODONE BIT/HOMATROP ME-BR 5 MG-1.5MG TABLET 0.42566 0.42566 2/8/2013 HYDROCODONE BIT/HOMATROP ME-BR 5-1.5 MG/5 SYRUP 0.12020 0.12020 2/8/2013 HYDROCODONE BIT/HOMATROP ME-BR 5-1.5/CUP SYRUP 0.52500 0.52500 2/8/2013 HYDROCODONE/CHLORPHEN POLIS 10-8MG/5ML SUS ER 12H 0.46202 0.46202 2/8/2013 HYDROCODONE/IBUPROFEN 10MG-200MG TABLET 2.86300 2.86300 2/8/2013 HYDROCODONE/IBUPROFEN 2.5-200MG TABLET 2.04491 2.04491 2/8/2013 HYDROCODONE/IBUPROFEN 5MG-200MG TABLET 2.17077 2.17077 2/8/2013 HYDROCODONE/IBUPROFEN 7.5-200 MG TABLET 0.23919 0.23919 2/8/2013 HYDROCORT/PRAMOXN/SKN CLNSR#16 2.35 %-1 % KT CRM TWL 115.64000 115.64000 2/8/2013 HYDROCORTISONE POWDER 2.52898 2.52898 2/8/2013 HYDROCORTISONE 0.5 % CREAM (G) 0.09687 0.08089 2/15/2013 HYDROCORTISONE 1 % CREAM (G) 0.66820 0.66820 2/8/2013 HYDROCORTISONE 1 % CREAM (G) 0.04382 0.04382 2/8/2013 HYDROCORTISONE 1 % LOTION 0.03077 0.03077 2/8/2013 HYDROCORTISONE 1 % OINT. (G) 0.10490 0.10490 2/8/2013 HYDROCORTISONE 10 MG TABLET 0.31148 0.31148 2/8/2013 HYDROCORTISONE 100MG/60ML ENEMA 0.08616 0.08616 2/8/2013 HYDROCORTISONE 2.5 % CREAM (G) 0.14257 0.14257 2/8/2013 HYDROCORTISONE 2.5 % CREAM (G) 0.10318 0.10318 2/8/2013 HYDROCORTISONE 2.5 % LOTION 0.23782 0.23782 2/8/2013 HYDROCORTISONE 2.5 % OINT. (G) 0.11197 0.11197 2/8/2013 HYDROCORTISONE 20 MG TABLET 0.60568 0.60568 2/8/2013 HYDROCORTISONE 5 MG TABLET 0.23730 0.23730 2/8/2013 HYDROCORTISONE AC/LIDOCAINE 0.5 %-3 % CREAM/APPL 1.78500 1.78500 2/8/2013 HYDROCORTISONE AC/LIDOCAINE 1%-3%(7G) CREAM/APPL 251.09000 251.09000 2/8/2013 HYDROCORTISONE AC/LIDOCAINE 2.5-3%(7G) GEL W/APPL 251.09000 251.09000 2/8/2013 HYDROCORTISONE ACETATE POWDER 3.23180 3.23180 2/8/2013 HYDROCORTISONE ACETATE 25 MG SUPP.RECT 1.44809 1.44809 2/8/2013 HYDROCORTISONE ACETATE 30 MG SUPP.RECT 4.26358 4.26358 2/8/2013 HYDROCORTISONE ACETATE/UREA 1 %-10 % CREAM (G) 0.88025 0.88025 2/8/2013 Page 25 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price HYDROCORTISONE BUTYRATE 0.1 % CREAM (G) 0.99543 1.02530 2/15/2013 HYDROCORTISONE BUTYRATE 0.1 % OINT. (G) 0.89227 0.89227 2/8/2013 HYDROCORTISONE BUTYRATE 0.1 % SOLUTION 0.17360 0.17360 2/8/2013 HYDROCORTISONE VALERATE 0.2 % CREAM (G) 0.50250 0.50250 2/8/2013 HYDROCORTISONE/IODOQUINOL 1 %-1 % CREAM (G) 0.43203 0.43203 2/8/2013 HYDROCORTISONE/LIDOCAINE/ALOE 2.5-3%(7G) KIT 3.05119 3.05119 2/8/2013 HYDROCORTISONE/PRAMOXINE 2.5 %-1 % CREAM (G) 1.30835 1.30835 2/8/2013 HYDROMORPHONE HCL 1 MG/ML LIQUID 0.27988 0.27988 2/8/2013 HYDROMORPHONE HCL 2 MG TABLET 0.09305 0.09305 2/8/2013 HYDROMORPHONE HCL 2 MG/ML VIAL 0.53935 0.53935 2/8/2013 HYDROMORPHONE HCL 3 MG SUPP.RECT 8.58667 8.58667 2/8/2013 HYDROMORPHONE HCL 4 MG TABLET 0.10950 0.10950 2/8/2013 HYDROMORPHONE HCL 8 MG TABLET 0.39543 0.39543 2/8/2013 HYDROMORPHONE HCL/PF 1 MG/ML AMPUL 0.87360 0.87360 2/8/2013 HYDROMORPHONE HCL/PF 1 MG/ML DISP SYRIN 3.90600 3.90600 2/8/2013 HYDROMORPHONE HCL/PF 10 MG/ML VIAL 1.54846 1.54846 2/8/2013 HYDROMORPHONE HCL/PF 2 MG/ML AMPUL 0.94080 0.94080 2/8/2013 HYDROMORPHONE HCL/PF 2 MG/ML DISP SYRIN 4.17900 4.17900 2/8/2013 HYDROMORPHONE HCL/PF 2 MG/ML VIAL 1.74300 1.74300 2/8/2013 HYDROMORPHONE HCL/PF 4 MG/ML AMPUL 1.33560 1.33560 2/8/2013 HYDROMORPHONE HCL/PF 4 MG/ML DISP SYRIN 3.78000 3.78000 2/8/2013 HYDROQUINONE 2 % CREAM (G) 0.06280 0.06280 2/8/2013 HYDROQUINONE 4 % CREAM (G) 0.35360 0.35360 2/8/2013 HYDROQUINONE MICROSPHERES 4 % CRM ER (G) 2.49387 2.49387 2/8/2013 HYDROXOCOBALAMIN 1000MCG/ML VIAL 0.89273 0.89273 2/8/2013 HYDROXYCHLOROQUINE SULFATE 200 MG TABLET 0.10720 0.10720 2/8/2013 HYDROXYUREA 500 MG CAPSULE 0.35214 0.35214 2/8/2013 HYDROXYZINE HCL 10 MG TABLET 0.07343 0.07343 2/8/2013 HYDROXYZINE HCL 10 MG/5 ML SYRUP 0.05913 0.05913 2/8/2013 HYDROXYZINE HCL 25 MG TABLET 0.08630 0.08630 2/8/2013 HYDROXYZINE HCL 25 MG/ML VIAL 2.62500 2.62500 2/8/2013 HYDROXYZINE HCL 50 MG TABLET 0.11015 0.11015 2/8/2013 HYDROXYZINE HCL 50 MG/ML VIAL 1.75000 1.75000 2/8/2013 HYDROXYZINE PAMOATE 100 MG CAPSULE 0.29887 0.29887 2/8/2013 HYDROXYZINE PAMOATE 25 MG CAPSULE 0.06620 0.06620 2/8/2013 HYDROXYZINE PAMOATE 50 MG CAPSULE 0.08680 0.08680 2/8/2013 HYOSCYAMINE SULFATE 0.125 MG TAB RAPDIS 0.20020 0.20020 2/8/2013 HYOSCYAMINE SULFATE 0.125 MG TAB SUBL 0.44000 0.44000 2/8/2013 HYOSCYAMINE SULFATE 0.125 MG TABLET 0.21869 0.21869 2/8/2013 HYOSCYAMINE SULFATE 0.125MG/ML DROPS 1.09076 1.09076 2/8/2013 HYOSCYAMINE SULFATE 0.375 MG TAB ER 12H 0.42399 0.42399 2/8/2013 HYOSCYAMINE SULFATE 125MCG/5ML ELIXIR 0.04790 0.04790 2/8/2013 HYPROMELLOSE 0.3 % DROPS 0.34519 0.34519 2/8/2013 HYPROMELLOSE 0.4 % DROPS 0.17850 0.17850 2/8/2013 IBANDRONATE SODIUM 150 MG TABLET 97.13589 97.13589 2/8/2013 IBUPROFEN 100 MG TAB CHEW 0.18346 0.12702 2/15/2013 IBUPROFEN 100 MG TABLET 0.18346 0.12702 2/15/2013 IBUPROFEN 100 MG/5ML ORAL SUSP 0.02690 0.02669 2/15/2013 IBUPROFEN 200 MG CAPSULE 0.05530 0.05530 2/8/2013 IBUPROFEN 200 MG TABLET 0.01474 0.01474 2/8/2013 IBUPROFEN 400 MG TABLET 0.02908 0.02908 2/8/2013 IBUPROFEN 50 MG/1.25 DROPS SUSP 0.21625 0.21625 2/8/2013 IBUPROFEN 600 MG TABLET 0.03899 0.03899 2/8/2013 IBUPROFEN 800 MG TABLET 0.05092 0.05092 2/8/2013 IBUPROFEN/OXYCODONE HCL 400MG-5MG TABLET 1.03131 1.03131 2/8/2013 IFOSFAMIDE 1 G/20 ML VIAL 5.07623 5.07623 2/8/2013 IFOSFAMIDE 3 G VIAL 90.33500 90.33500 2/8/2013 Page 26 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price IFOSFAMIDE 3G/60ML VIAL 3.11430 3.11430 2/8/2013 IFOSFAMIDE/MESNA 3G-1G KIT 281.14725 281.14725 2/8/2013 IMIPENEM/CILASTATIN SODIUM 250 MG VIAL 6.52680 6.52680 2/8/2013 IMIPENEM/CILASTATIN SODIUM 500 MG VIAL 9.87840 9.87840 2/8/2013 IMIPRAMINE HCL 10 MG TABLET 0.12569 0.12569 2/8/2013 IMIPRAMINE HCL 25 MG TABLET 0.16254 0.16254 2/8/2013 IMIPRAMINE HCL 50 MG TABLET 0.23249 0.23249 2/8/2013 IMIPRAMINE PAMOATE 100 MG CAPSULE 5.39803 5.39803 2/8/2013 IMIPRAMINE PAMOATE 125 MG CAPSULE 11.40705 11.40705 2/8/2013 IMIPRAMINE PAMOATE 150 MG CAPSULE 10.62040 10.62040 2/8/2013 IMIPRAMINE PAMOATE 75 MG CAPSULE 7.41581 7.41581 2/8/2013 IMIQUIMOD 5 % CREAM PACK 23.85104 23.85104 2/8/2013 INDAPAMIDE 1.25 MG TABLET 0.07660 0.07660 2/8/2013 INDAPAMIDE 2.5 MG TABLET 0.08740 0.08740 2/8/2013 INDOMETHACIN 25 MG CAPSULE 0.13226 0.13226 2/8/2013 INDOMETHACIN 50 MG CAPSULE 0.16656 0.16656 2/8/2013 INDOMETHACIN 75 MG CAPSULE ER 1.64016 1.64016 2/8/2013 INDOMETHACIN SODIUM 1 MG VIAL 409.47900 409.47900 2/8/2013 IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION 0.06124 0.06124 2/8/2013 IPRATROPIUM BROMIDE 21 MCG SPRAY 0.19370 0.19370 2/8/2013 IPRATROPIUM BROMIDE 42MCG SPRAY 0.38870 0.38870 2/8/2013 IPRATROPIUM/ALBUTEROL SULFATE 0.5-3MG/3 AMPUL-NEB 0.10747 0.10747 2/8/2013 IRBESARTAN 150 MG TABLET 0.19430 0.19430 2/8/2013 IRBESARTAN 300 MG TABLET 0.32951 0.32951 2/8/2013 IRBESARTAN 75 MG TABLET 0.15021 0.15021 2/8/2013 IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG TABLET 0.19296 0.19296 2/8/2013 IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG TABLET 0.32118 0.32118 2/8/2013 IRON FUMARATE/VIT C/VIT B12/FA 460-60MG CAPSULE 0.43155 0.43155 2/8/2013 IRON POLYSACCH/IRON HEME POLYP 28 MG TABLET 0.37088 0.37088 2/8/2013 IRON POLYSACCHARIDES COMPLEX 150 MG CAPSULE 0.12990 0.12990 2/8/2013 IRON PS CMPLX/VIT B12/FA 150-25-1 CAPSULE 0.17323 0.17323 2/8/2013 IRON PS/IRON HEM POLY/FA/B12 22-6-1-25 TABLET 2.61148 2.61148 2/8/2013 IRON,CARB/DSS/B12IF/FA/MV-MN 150-50-1MG TAB ER 24H 0.47055 0.47055 2/8/2013 IRON,CARBONYL 15 MG TAB CHEW 0.42735 0.42735 2/8/2013 IRON,CARBONYL 15MG/1.25 ORAL SUSP 0.12653 0.12653 2/8/2013 IRON,CARBONYL/VIT C/VIT B12/FA 100-250-1 TABLET 0.39480 0.39480 2/8/2013 ISOMETHEPTENE/ACETAMINOPH/CAFF 130-500-20 TABLET 6.04926 6.04926 2/8/2013 ISONIAZID 100 MG TABLET 0.04355 0.04355 2/8/2013 ISONIAZID 100 MG/ML VIAL 63.03150 63.03150 2/8/2013 ISONIAZID 300 MG TABLET 0.07343 0.07343 2/8/2013 ISONIAZID 50 MG/5 ML SOLUTION 0.09983 0.09983 2/8/2013 /GLYCERIN 95%-5% DROPS 0.07023 0.07023 2/8/2013 ISOSORBIDE DINITRATE 10 MG TABLET 0.74219 0.77337 2/8/2013 ISOSORBIDE DINITRATE 2.5 MG TAB SUBL 0.04407 0.04407 2/8/2013 ISOSORBIDE DINITRATE 20 MG TABLET 0.83434 0.83434 2/8/2013 ISOSORBIDE DINITRATE 30 MG TABLET 0.13735 0.13735 2/8/2013 ISOSORBIDE DINITRATE 40 MG TABLET ER 0.55289 0.55289 2/8/2013 ISOSORBIDE DINITRATE 5 MG TAB SUBL 0.04407 0.04407 2/8/2013 ISOSORBIDE MONONITRATE 10 MG TABLET 0.19730 0.19730 2/8/2013 ISOSORBIDE MONONITRATE 120 MG TAB ER 24H 0.42484 0.42484 2/8/2013 ISOSORBIDE MONONITRATE 20 MG TABLET 0.10238 0.10238 2/8/2013 ISOSORBIDE MONONITRATE 30 MG TAB ER 24H 0.24937 0.24937 2/8/2013 ISOSORBIDE MONONITRATE 60 MG TAB ER 24H 0.26572 0.26572 2/8/2013 ISOSULFAN BLUE 1 % VIAL 99.96000 99.96000 2/8/2013 ISOTRETINOIN 10 MG CAPSULE 12.13309 12.13309 2/8/2013 ISOTRETINOIN 20 MG CAPSULE 14.05839 14.05839 2/8/2013 ISOTRETINOIN 30 MG CAPSULE 11.51617 11.51617 2/8/2013 Page 27 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price ISOTRETINOIN 40 MG CAPSULE 16.34669 16.34669 2/8/2013 ISOXSUPRINE HCL 10 MG TABLET 0.80892 0.80892 2/8/2013 ISRADIPINE 2.5 MG CAPSULE 0.95543 0.95543 2/8/2013 ISRADIPINE 5 MG CAPSULE 1.39713 1.39713 2/8/2013 ITRACONAZOLE 100 MG CAPSULE 6.36994 6.36994 2/8/2013 2 % CREAM (G) 0.16348 0.16348 2/8/2013 KETOCONAZOLE 2 % FOAM 2.49939 2.49939 2/8/2013 KETOCONAZOLE 2 % SHAMPOO 0.10040 0.10040 2/8/2013 KETOCONAZOLE 200 MG TABLET 0.20105 0.20105 2/8/2013 KETOPROFEN 200 MG CAP24H PEL 5.10167 5.10167 2/8/2013 KETOPROFEN 75 MG CAPSULE 0.09149 0.09149 2/8/2013 KETOROLAC TROMETHAMINE 0.4 % DROPS 2.03678 2.03678 2/8/2013 KETOROLAC TROMETHAMINE 0.5 % DROPS 1.29578 1.29578 2/8/2013 KETOROLAC TROMETHAMINE 10 MG TABLET 0.36956 0.36956 2/8/2013 KETOROLAC TROMETHAMINE 15 MG/ML VIAL 0.92058 0.92058 2/8/2013 KETOROLAC TROMETHAMINE 30 MG/ML VIAL 1.31943 1.31943 2/8/2013 KETOROLAC TROMETHAMINE 30MG/ML(1) VIAL 0.70560 0.70560 2/8/2013 KETOROLAC TROMETHAMINE 60 MG/2 ML VIAL 0.50176 0.50176 2/8/2013 KETOTIFEN FUMARATE 0.025 % DROPS 1.12683 1.12683 2/8/2013 LABETALOL HCL 100 MG TABLET 0.38550 0.38550 2/8/2013 LABETALOL HCL 20 MG/4 ML DISP SYRIN 0.69510 0.69510 2/8/2013 LABETALOL HCL 200 MG TABLET 0.44434 0.44434 2/8/2013 LABETALOL HCL 300 MG TABLET 0.64820 0.64820 2/8/2013 10 % CREAM (G) 0.08303 0.08303 2/8/2013 LACTIC ACID 10 % LOTION 0.04276 0.04276 2/8/2013 LACTULOSE 10 G/15 ML SOLUTION 0.01367 0.01367 2/8/2013 LACTULOSE 10 G/CUP SOLUTION 0.03815 0.03815 2/8/2013 LAMIVUDINE 150 MG TABLET 5.19198 5.19198 2/8/2013 LAMIVUDINE 300 MG TABLET 10.01992 10.01992 2/8/2013 LAMIVUDINE/ZIDOVUDINE 150-300MG TABLET 10.46392 10.46392 2/8/2013 LAMOTRIGINE 100 MG TABLET 0.06847 0.06847 2/8/2013 LAMOTRIGINE 150 MG TABLET 0.10385 0.10385 2/8/2013 LAMOTRIGINE 200 MG TABLET 0.11202 0.11202 2/8/2013 LAMOTRIGINE 25 MG TABLET 0.05561 0.05561 2/8/2013 LAMOTRIGINE 25 MG TB CHW DSP 0.26689 0.26689 2/8/2013 LAMOTRIGINE 25MG (35) TAB DS PK 2.90500 2.90500 2/8/2013 LAMOTRIGINE 5 MG TB CHW DSP 0.26611 0.26611 2/8/2013 LANOLIN/MIN OIL/PETROLAT,WHT OINT. (G) 0.91000 0.91000 2/8/2013 LANSOPRAZOLE 15 MG CAPSULE DR 0.49988 0.49988 2/8/2013 LANSOPRAZOLE 30 MG CAPSULE DR 1.23454 1.23454 2/8/2013 LATANOPROST 0.005 % DROPS 4.29871 4.29871 2/8/2013 LEFLUNOMIDE 10 MG TABLET 0.51228 0.51228 2/8/2013 LEFLUNOMIDE 20 MG TABLET 0.70792 0.70792 2/8/2013 LETROZOLE 2.5 MG TABLET 0.15182 0.15182 2/8/2013 LEUCOVORIN CALCIUM 10 MG TABLET 5.25146 5.25146 2/8/2013 LEUCOVORIN CALCIUM 10 MG/ML VIAL 0.53387 0.53387 2/8/2013 LEUCOVORIN CALCIUM 15 MG TABLET 5.85368 5.85368 2/8/2013 LEUCOVORIN CALCIUM 200 MG VIAL 19.88700 19.88700 2/8/2013 LEUCOVORIN CALCIUM 25 MG TABLET 7.52648 7.52648 2/8/2013 LEUCOVORIN CALCIUM 5 MG TABLET 0.89418 0.89418 2/8/2013 LEUCOVORIN CALCIUM 50 MG VIAL 6.93000 6.93000 2/8/2013 LEUCOVORIN CALCIUM 500 MG VIAL 99.22500 99.22500 2/8/2013 LEUCOVORIN CALCIUM 500MG/50ML VIAL 1.29948 1.29948 2/8/2013 LEUPROLIDE ACETATE 1MG/0.2ML KIT 0.00000 231.00000 2/15/2013 LEVALBUTEROL HCL 0.31MG/3ML VIAL-NEB 1.45257 1.45257 2/8/2013 LEVALBUTEROL HCL 0.63MG/3ML VIAL-NEB 1.45126 1.45126 2/8/2013 LEVALBUTEROL HCL 1.25MG/0.5 VIAL-NEB 4.68953 4.68953 2/8/2013 Page 28 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price LEVALBUTEROL HCL 1.25MG/3ML VIAL-NEB 1.45257 1.45257 2/8/2013 LEVETIRACETAM 100 MG/ML SOLUTION 0.06070 0.06070 2/8/2013 LEVETIRACETAM 1000 MG TABLET 0.39570 0.39570 2/8/2013 LEVETIRACETAM 250 MG TABLET 0.09903 0.09903 2/8/2013 LEVETIRACETAM 500 MG TAB ER 24H 0.39021 0.39021 2/8/2013 LEVETIRACETAM 500 MG TABLET 0.16562 0.16562 2/8/2013 LEVETIRACETAM 500 MG/5ML SOLUTION 1.06824 1.06824 2/8/2013 LEVETIRACETAM 500 MG/5ML VIAL 1.65798 1.65798 2/8/2013 LEVETIRACETAM 750 MG TAB ER 24H 0.81259 0.81259 2/8/2013 LEVETIRACETAM 750 MG TABLET 0.23222 0.23222 2/8/2013 LEVETIRACETAM IN NACL (ISO-OS) 1000MG/100 PIGGYBACK 0.59877 0.59877 2/8/2013 LEVETIRACETAM IN NACL (ISO-OS) 1500MG/100 PIGGYBACK 0.77967 0.77967 2/8/2013 LEVETIRACETAM IN NACL (ISO-OS) 500MG/0.1L PIGGYBACK 0.36284 0.36284 2/8/2013 LEVOBUNOLOL HCL 0.25 % DROPS 1.24280 1.24280 2/8/2013 LEVOBUNOLOL HCL 0.5 % DROPS 3.21782 3.21782 2/8/2013 LEVOCARNITINE (WITH SUGAR) 100 MG/ML SOLUTION 0.15410 0.15410 2/8/2013 LEVOCARNITINE 330 MG TABLET 0.60257 0.60257 2/8/2013 LEVOCARNITINE 500 MG TABLET 0.20201 0.20201 2/8/2013 LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 MG/5ML SOLUTION 0.43653 0.43653 2/8/2013 LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG TABLET 0.22244 0.22244 2/8/2013 LEVOFLOXACIN 0.5 % DROPS 7.88880 7.88880 2/8/2013 LEVOFLOXACIN 25 MG/ML VIAL 0.67200 0.67200 2/8/2013 LEVOFLOXACIN 250 MG TABLET 0.14767 0.14767 2/8/2013 LEVOFLOXACIN 250MG/10ML SOLUTION 0.88712 0.88712 2/8/2013 LEVOFLOXACIN 500 MG TABLET 0.29534 0.29534 2/8/2013 LEVOFLOXACIN 750 MG TABLET 0.69428 0.69428 2/8/2013 LEVOFLOXACIN/D5W 250MG/50ML PIGGYBACK 0.11945 0.11945 2/8/2013 LEVOFLOXACIN/D5W 500MG/0.1L PIGGYBACK 0.08576 0.08576 2/8/2013 LEVOFLOXACIN/D5W 750MG/.15L PIGGYBACK 0.05199 0.05199 2/8/2013 LEVOMEFOLATE CALCIUM 15 MG TABLET 2.02074 2.02074 2/8/2013 LEVOMEFOLATE CALCIUM 7.5 MG TABLET 2.02070 2.02070 2/8/2013 0.75 MG TABLET 12.79600 12.79600 2/8/2013 LEVONORGESTREL 1.5 MG TABLET 25.59200 25.59200 2/8/2013 LEVONORGESTREL-ETH ESTRADIOL 0.1-0.02 TABLET 0.76326 0.76326 2/8/2013 LEVONORGESTREL-ETH ESTRADIOL 0.15-0.03 TABLET 0.77319 0.77319 2/8/2013 LEVONORGESTREL-ETH ESTRADIOL 0.15-0.03 TBDSPK 3MO 1.11998 1.11998 2/8/2013 LEVONORGESTREL-ETH ESTRADIOL 6-5-10 TABLET 0.68717 0.68717 2/8/2013 LEVORPHANOL TARTRATE 2 MG TABLET 1.23865 1.23865 2/8/2013 LEVOTHYROXINE SODIUM 100 MCG TABLET 0.12207 0.12207 2/8/2013 LEVOTHYROXINE SODIUM 100 MCG VIAL 111.63600 111.63600 2/8/2013 LEVOTHYROXINE SODIUM 112 MCG TABLET 0.14445 0.14445 2/8/2013 LEVOTHYROXINE SODIUM 125 MCG TABLET 0.15263 0.15263 2/8/2013 LEVOTHYROXINE SODIUM 137 MCG TABLET 0.15571 0.15571 2/8/2013 LEVOTHYROXINE SODIUM 150 MCG TABLET 0.15075 0.15075 2/8/2013 LEVOTHYROXINE SODIUM 175MCG TABLET 0.18077 0.18077 2/8/2013 LEVOTHYROXINE SODIUM 200 MCG TABLET 0.18733 0.18733 2/8/2013 LEVOTHYROXINE SODIUM 25 MCG TABLET 0.09889 0.09889 2/8/2013 LEVOTHYROXINE SODIUM 300 MCG TABLET 0.31703 0.31703 2/8/2013 LEVOTHYROXINE SODIUM 50 MCG TABLET 0.10224 0.10224 2/8/2013 LEVOTHYROXINE SODIUM 500 MCG VIAL 44.60050 44.60050 2/8/2013 LEVOTHYROXINE SODIUM 75 MCG TABLET 0.12033 0.12033 2/8/2013 LEVOTHYROXINE SODIUM 88 MCG TABLET 0.12931 0.12931 2/8/2013 LIDOCAINE 5 % CREAM (G) 1.01056 1.01056 2/8/2013 LIDOCAINE 5 % OINT. (G) 1.41234 1.38450 2/15/2013 LIDOCAINE HCL 2 % JEL (ML) 0.29705 0.29705 2/8/2013 LIDOCAINE HCL 2 % JEL/PF APP 0.66018 0.66018 2/8/2013 LIDOCAINE HCL 20 MG/ML SOLUTION 0.02363 0.02363 2/8/2013 Page 29 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price LIDOCAINE HCL 20 MG/ML VIAL 0.06084 0.06084 2/8/2013 LIDOCAINE HCL 4 % SOLUTION 1.05248 1.05248 2/8/2013 LIDOCAINE HCL 40 MG/ML SOLUTION 0.07071 0.07071 2/8/2013 LIDOCAINE HCL/D5W/PF 4 MG/ML IV SOLN 0.01313 0.01313 2/8/2013 LIDOCAINE HCL/D5W/PF 8 MG/ML IV SOLN 0.02029 0.02029 2/8/2013 LIDOCAINE HCL/D7.5W/PF 5 % AMPUL 6.05934 6.05934 2/8/2013 LIDOCAINE HCL/EPINEPHRINE 1%-1:100K VIAL 0.06995 0.06995 2/8/2013 LIDOCAINE HCL/EPINEPHRINE 2%-1:100K VIAL 0.08193 0.08193 2/8/2013 LIDOCAINE HCL/EPINEPHRINE BIT 2%-1:100K CARTRIDGE 0.14933 0.14933 2/8/2013 LIDOCAINE HCL/EPINEPHRINE BIT 2%-1:50000 CARTRIDGE 0.14933 0.14933 2/8/2013 LIDOCAINE HCL/EPINEPHRINE/PF 2%-1:200K VIAL 0.31710 0.31710 2/8/2013 LIDOCAINE HCL/PF 10 MG/ML AMPUL 0.35751 0.35751 2/8/2013 LIDOCAINE HCL/PF 100 MG/5ML DISP SYRIN 0.61824 0.61824 2/8/2013 LIDOCAINE HCL/PF 15 MG/ML AMPUL 0.66715 0.66715 2/8/2013 LIDOCAINE HCL/PF 20 MG/ML VIAL 0.34104 0.34104 2/8/2013 LIDOCAINE HCL/PF 20 MG/ML VIAL 0.28224 0.28224 2/8/2013 LIDOCAINE HCL/PF 40 MG/ML AMPUL 0.59304 0.59304 2/8/2013 LIDOCAINE HCL/PF 5 MG/ML VIAL 0.11002 0.11002 2/8/2013 LIDOCAINE HCL/PF 50 MG/5 ML DISP SYRIN 0.91644 0.91644 2/8/2013 LIDOCAINE/PRILOCAINE 2.5%-2.5% CREAM (G) 0.56106 0.56106 2/8/2013 LIDOCAINE/PRILOCAINE 2.5%-2.5% KIT 1.40764 1.40764 2/8/2013 LINDANE 1 % LOTION 1.59670 1.59670 2/8/2013 LINDANE 1 % SHAMPOO 1.59670 1.59670 2/8/2013 LIOTHYRONINE SODIUM 25 MCG TABLET 0.73755 0.73755 2/8/2013 LIOTHYRONINE SODIUM 5 MCG TABLET 0.56181 0.56181 2/8/2013 LIOTHYRONINE SODIUM 50 MCG TABLET 1.13121 1.13121 2/8/2013 LISINOPRIL 10 MG TABLET 0.02117 0.02117 2/8/2013 LISINOPRIL 2.5 MG TABLET 0.01809 0.01809 2/8/2013 LISINOPRIL 20 MG TABLET 0.03283 0.03283 2/8/2013 LISINOPRIL 30 MG TABLET 0.09246 0.09246 2/8/2013 LISINOPRIL 40 MG TABLET 0.06137 0.06137 2/8/2013 LISINOPRIL 5 MG TABLET 0.01715 0.01715 2/8/2013 LISINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.02964 0.02964 2/8/2013 LISINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.04124 0.04124 2/8/2013 LISINOPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.05079 0.05079 2/8/2013 LITHIUM CARBONATE 150 MG CAPSULE 0.05494 0.05494 2/8/2013 LITHIUM CARBONATE 300 MG CAPSULE 0.03082 0.03082 2/8/2013 LITHIUM CARBONATE 300 MG TABLET 0.14911 0.14911 2/8/2013 LITHIUM CARBONATE 300 MG TABLET ER 0.23709 0.23709 2/8/2013 LITHIUM CARBONATE 450 MG TABLET ER 0.26780 0.26780 2/8/2013 LITHIUM CARBONATE 600 MG CAPSULE 0.12860 0.12860 2/8/2013 LITHIUM CITRATE 8MEQ/5ML SOLUTION 0.03921 0.03921 2/8/2013 L-NORGEST-ETH ESTR/ETHIN ESTRA 100-20(84) TBDSPK 3MO 2.06577 2.06577 2/8/2013 L-NORGEST-ETH ESTR/ETHIN ESTRA 150-30(84) TBDSPK 3MO 2.06577 2.06577 2/8/2013 LOPERAMIDE HCL 1MG/7.5ML LIQUID 0.02772 0.02772 2/8/2013 LOPERAMIDE HCL 2 MG CAPSULE 0.15076 0.15076 2/8/2013 LOPERAMIDE HCL 2 MG TABLET 0.08951 0.08951 2/8/2013 LORATADINE 10 MG TAB RAPDIS 0.38100 0.38100 2/8/2013 LORATADINE 10 MG TABLET 0.05132 0.05132 2/8/2013 LORATADINE 5 MG/5 ML SOLUTION 0.03645 0.03645 2/8/2013 LORATADINE/PSEUDOEPHEDRINE 10MG-240MG TAB ER 24H 0.63939 0.63939 2/8/2013 LORAZEPAM 0.5 MG TABLET 0.02680 0.02680 2/8/2013 LORAZEPAM 1 MG TABLET 0.02774 0.02774 2/8/2013 LORAZEPAM 2 MG TABLET 0.04770 0.04770 2/8/2013 LORAZEPAM 2 MG/ML DISP SYRIN 1.76400 1.76400 2/8/2013 LORAZEPAM 2 MG/ML ORAL CONC 0.60470 0.60470 2/8/2013 LORAZEPAM 2 MG/ML VIAL 0.72356 0.72356 2/8/2013 Page 30 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price LORAZEPAM 4 MG/ML DISP SYRIN 2.38560 2.38560 2/8/2013 LORAZEPAM 4 MG/ML VIAL 1.14324 1.14324 2/8/2013 LOSARTAN POTASSIUM 100 MG TABLET 0.10425 0.10425 2/8/2013 LOSARTAN POTASSIUM 25 MG TABLET 0.05440 0.05440 2/8/2013 LOSARTAN POTASSIUM 50 MG TABLET 0.07276 0.07276 2/8/2013 LOSARTAN/HYDROCHLOROTHIAZIDE 100-12.5MG TABLET 0.11202 0.11202 2/8/2013 LOSARTAN/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET 0.10184 0.10184 2/8/2013 LOSARTAN/HYDROCHLOROTHIAZIDE 50-12.5 MG TABLET 0.07450 0.07450 2/8/2013 LOVASTATIN 10 MG TABLET 0.09541 0.09541 2/8/2013 LOVASTATIN 20 MG TABLET 0.10372 0.10372 2/8/2013 LOVASTATIN 40 MG TABLET 0.11122 0.11122 2/8/2013 LOXAPINE SUCCINATE 10 MG CAPSULE 0.50999 0.50999 2/8/2013 LOXAPINE SUCCINATE 25 MG CAPSULE 0.73124 0.73124 2/8/2013 LOXAPINE SUCCINATE 5 MG CAPSULE 0.37145 0.37145 2/8/2013 LOXAPINE SUCCINATE 50 MG CAPSULE 0.97351 0.97351 2/8/2013 MAG CARB/AL HYDROX/ALGINIC AC 358-95/15 ORAL SUSP 0.01253 0.01253 2/8/2013 MAG HYDROX/AL HYDROX/SIMETH 200-200-20 ORAL SUSP 0.00590 0.00590 2/8/2013 MAG HYDROX/AL HYDROX/SIMETH 200-200-25 TAB CHEW 0.03029 0.03029 2/8/2013 MAG HYDROX/AL HYDROX/SIMETH 400-400-40 ORAL SUSP 0.00735 0.00735 2/8/2013 CHLORIDE 64 MG TABLET ER 0.08364 0.08364 2/8/2013 MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP 0.00415 0.00415 2/8/2013 MAGNESIUM OXIDE 400 MG CAPSULE 0.08449 0.08181 2/15/2013 MAGNESIUM OXIDE 400 MG TABLET 0.02908 0.02908 2/8/2013 MAGNESIUM SULFATE 2 G/50 ML PIGGYBACK 0.24562 0.24562 2/8/2013 MAGNESIUM SULFATE 20 G/500ML IV SOLN 0.01974 0.01974 2/8/2013 MAGNESIUM SULFATE 4 G/100 ML PIGGYBACK 0.11855 0.11855 2/8/2013 MAGNESIUM SULFATE 4 G/50 ML PIGGYBACK 0.23104 0.23104 2/8/2013 MAGNESIUM SULFATE 4 MEQ/ML DISP SYRIN 0.63168 0.63168 2/8/2013 MAGNESIUM SULFATE 40G/1000ML IV SOLN 0.01441 0.01441 2/8/2013 MAGNESIUM SULFATE/D5W 1 G/100 ML PIGGYBACK 0.11632 0.11632 2/8/2013 MALATHION 0.5 % LOTION 2.15921 2.15921 2/8/2013 MANGANESE CHLORIDE 0.1 MG/ML VIAL 0.17388 0.17388 2/8/2013 MANGANESE SULFATE 0.1 MG/ML VIAL 0.21874 0.21874 2/8/2013 MANNITOL 10 % IV SOLN 0.01210 0.01210 2/8/2013 MANNITOL 20 % IV SOLN 0.03980 0.03980 2/8/2013 MANNITOL 5 % IV SOLN 0.00866 0.00866 2/8/2013 MANNITOL/SORBITOL SOLUTION 0.54G-2.7G IRRIG SOLN 0.00569 0.00569 2/8/2013 MAPROTILINE HCL 25 MG TABLET 0.63476 0.63476 2/8/2013 MAPROTILINE HCL 50 MG TABLET 0.93975 0.93975 2/8/2013 MAPROTILINE HCL 75 MG TABLET 1.28954 1.28954 2/8/2013 MECLIZINE HCL 12.5 MG TABLET 0.03139 0.03139 2/8/2013 MECLIZINE HCL 25 MG TABLET 0.28090 0.28090 2/8/2013 MECLOFENAMATE SODIUM 100 MG CAPSULE 3.54845 3.54845 2/8/2013 MECLOFENAMATE SODIUM 50 MG CAPSULE 1.91156 1.91156 2/8/2013 MEDROXYPROGESTERONE ACETATE 10 MG TABLET 0.12690 0.12690 2/8/2013 MEDROXYPROGESTERONE ACETATE 2.5 MG TABLET 0.06137 0.06137 2/8/2013 MEDROXYPROGESTERONE ACETATE 5 MG TABLET 0.08241 0.08241 2/8/2013 MEFENAMIC ACID 250 MG CAPSULE 10.93972 10.93972 2/8/2013 MEFLOQUINE HCL 250 MG TABLET 4.71900 4.71900 2/8/2013 20 MG TABLET 0.15410 0.15410 2/8/2013 MEGESTROL ACETATE 40 MG TABLET 0.19484 0.19484 2/8/2013 MEGESTROL ACETATE 400MG/10ML ORAL SUSP 0.30387 0.30387 2/8/2013 MEGESTROL ACETATE 400MG/10ML ORAL SUSP 0.09012 0.09012 2/8/2013 MELATONIN 3 MG TABLET ER 0.06370 0.06370 2/8/2013 MELOXICAM 15 MG TABLET 0.03283 0.03283 2/8/2013 MELOXICAM 7.5 MG TABLET 0.02921 0.02921 2/8/2013 MELOXICAM 7.5 MG/5ML ORAL SUSP 1.10061 1.10061 2/8/2013 Page 31 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price MENTHOL 10 % GEL (GRAM) 0.11397 0.11397 2/8/2013 MENTHOL 3.5 % GEL (GRAM) 0.10042 0.10042 2/8/2013 MENTHOL 8 MG LOZENGE 0.06423 0.06423 2/8/2013 MEPERIDINE HCL 10 MG/ML CARTRIDGE 0.49911 0.49911 2/8/2013 MEPERIDINE HCL 100 MG TABLET 0.50585 0.32670 2/15/2013 MEPERIDINE HCL 50 MG TABLET 0.20435 0.20435 2/8/2013 MEPERIDINE HCL 50 MG/5 ML SOLUTION 0.14191 0.14191 2/8/2013 MEPERIDINE HCL/PF 100 MG/ML VIAL 2.35200 2.35200 2/8/2013 MEPERIDINE HCL/PF 25 MG/ML VIAL 2.12100 2.12100 2/8/2013 MEPERIDINE HCL/PF 50 MG/ML VIAL 0.94080 0.94080 2/8/2013 MEPIVACAINE HCL/PF 30 MG/ML CARTRIDGE 0.18667 0.18667 2/8/2013 MEPROBAMATE 200 MG TABLET 0.90913 0.90913 2/8/2013 MEPROBAMATE 400 MG TABLET 0.98070 0.98070 2/8/2013 MERCAPTOPURINE 50 MG TABLET 1.91920 1.91920 2/8/2013 MEROPENEM 1 G VIAL 10.68252 10.68252 2/8/2013 MEROPENEM 500 MG VIAL 4.50240 4.50240 2/8/2013 MESALAMINE 4G/60ML ENEMA 0.22786 0.22786 2/8/2013 MESALAMINE W/CLEANSING WIPES 4G/60ML KIT 0.29920 0.29920 2/8/2013 METAPROTERENOL SULFATE 10 MG TABLET 0.69965 0.69965 2/8/2013 METAPROTERENOL SULFATE 10 MG/5 ML SYRUP 0.04721 0.04721 2/8/2013 METAPROTERENOL SULFATE 20 MG TABLET 0.97496 0.97496 2/8/2013 METAXALONE 800 MG TABLET 3.42370 3.42370 2/8/2013 METFORMIN HCL 1000 MG TAB ER 24 7.32694 7.32694 2/8/2013 METFORMIN HCL 1000 MG TABLET 0.04502 0.04502 2/8/2013 METFORMIN HCL 500 MG TAB ER 24 4.02384 4.02384 2/8/2013 METFORMIN HCL 500 MG TAB ER 24H 0.04543 0.04543 2/8/2013 METFORMIN HCL 500 MG TABLET 0.02466 0.02466 2/8/2013 METFORMIN HCL 750 MG TAB ER 24H 0.09179 0.09179 2/8/2013 METFORMIN HCL 850 MG TABLET 0.04208 0.04208 2/8/2013 METHADONE HCL 10 MG TABLET 0.09837 0.09837 2/8/2013 METHADONE HCL 10 MG/5 ML SOLUTION 0.20658 0.20658 2/8/2013 METHADONE HCL 10 MG/ML ORAL CONC 0.62300 0.62300 2/8/2013 METHADONE HCL 10 MG/ML VIAL 6.01720 6.01720 2/8/2013 METHADONE HCL 40 MG TABLET SOL 0.22381 0.22381 2/8/2013 METHADONE HCL 5 MG TABLET 0.05983 0.05983 2/8/2013 METHADONE HCL 5 MG/5 ML SOLUTION 0.12491 0.12491 2/8/2013 METHAMPHETAMINE HCL 5 MG TABLET 3.02617 3.02617 2/8/2013 METHAZOLAMIDE 25 MG TABLET 1.02361 1.02361 2/8/2013 METHAZOLAMIDE 50 MG TABLET 2.01082 2.01082 2/8/2013 METHENAMINE HIPPURATE 1 G TABLET 1.46377 1.46377 2/8/2013 METHENAMINE MANDELATE 1 G TABLET 1.15686 1.15686 2/8/2013 METHENAMINE MANDELATE 500 MG TABLET 0.62041 0.62041 2/8/2013 METHIMAZOLE 10 MG TABLET 0.27175 0.27175 2/8/2013 METHIMAZOLE 5 MG TABLET 0.15678 0.15678 2/8/2013 METHOCARBAMOL 500 MG TABLET 0.05387 0.05387 2/8/2013 METHOCARBAMOL 750 MG TABLET 0.15530 0.15530 2/8/2013 METHOTREXATE SODIUM 2.5 MG TABLET 0.34974 0.34974 2/8/2013 METHOTREXATE SODIUM 25 MG/ML VIAL 1.69325 1.69325 2/8/2013 METHOTREXATE SODIUM/PF 25 MG/ML VIAL 0.68246 0.68246 2/8/2013 METHSCOPOLAMINE BROMIDE 2.5 MG TABLET 1.54629 1.54629 2/8/2013 METHSCOPOLAMINE BROMIDE 5 MG TABLET 2.40598 2.40598 2/8/2013 METHYCLOTHIAZIDE 5 MG TABLET 1.21660 1.21660 2/8/2013 METHYL SALICYLATE OIL 0.47535 0.47535 2/8/2013 METHYL-B12/L-MEFOLATE/B6 PHOS 2-3-35 MG TABLET 1.01041 1.01041 2/8/2013 METHYLDOPA 250 MG TABLET 0.09822 0.09822 2/8/2013 METHYLDOPA 500 MG TABLET 0.17648 0.17648 2/8/2013 METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-15MG TABLET 0.67179 0.67179 2/8/2013 Page 32 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-25MG TABLET 0.79163 0.79163 2/8/2013 METHYLENE BLUE 1 % AMPUL 2.74680 2.74680 2/8/2013 METHYLERGONOVINE MALEATE .2MG/ML(1) AMPUL 5.36060 5.36060 2/8/2013 METHYLERGONOVINE MALEATE .2MG/ML(1) VIAL 6.39450 6.39450 2/8/2013 METHYLERGONOVINE MALEATE 0.2 MG TABLET 5.39625 5.39625 2/8/2013 METHYLPHENIDATE HCL 10 MG CPMP 30-70 3.98052 3.98052 2/8/2013 METHYLPHENIDATE HCL 10 MG TABLET 0.10385 0.10385 2/8/2013 METHYLPHENIDATE HCL 10 MG TABLET ER 0.58513 0.58513 2/8/2013 METHYLPHENIDATE HCL 10 MG/5 ML SOLUTION 1.91621 1.91621 2/8/2013 METHYLPHENIDATE HCL 18 MG TAB ER 24 4.35526 4.35530 2/8/2013 METHYLPHENIDATE HCL 20 MG CPMP 30-70 4.03956 4.03956 2/8/2013 METHYLPHENIDATE HCL 20 MG CPMP 50-50 3.45447 3.45447 2/8/2013 METHYLPHENIDATE HCL 20 MG TABLET 0.16871 0.16871 2/8/2013 METHYLPHENIDATE HCL 27 MG TAB ER 24 4.46446 4.46450 2/8/2013 METHYLPHENIDATE HCL 30 MG CPMP 30-70 3.96871 3.96871 2/8/2013 METHYLPHENIDATE HCL 30 MG CPMP 50-50 3.53314 3.53314 2/8/2013 METHYLPHENIDATE HCL 36 MG TAB ER 24 4.60502 4.60502 2/8/2013 METHYLPHENIDATE HCL 40 MG CPMP 30-70 5.13006 5.13006 2/8/2013 METHYLPHENIDATE HCL 40 MG CPMP 50-50 3.62989 3.62989 2/8/2013 METHYLPHENIDATE HCL 5 MG TABLET 0.08723 0.08723 2/8/2013 METHYLPHENIDATE HCL 5 MG/5 ML SOLUTION 1.34413 1.34413 2/8/2013 METHYLPHENIDATE HCL 50 MG CPMP 30-70 5.80034 5.80034 2/8/2013 METHYLPHENIDATE HCL 54 MG TAB ER 24 5.01081 5.01081 2/8/2013 METHYLPHENIDATE HCL 60 MG CPMP 30-70 6.73362 6.73362 2/8/2013 METHYLPREDNISOLONE 16 MG TABLET 2.17406 2.17406 2/8/2013 METHYLPREDNISOLONE 32 MG TABLET 3.23736 3.23736 2/8/2013 METHYLPREDNISOLONE 4 MG TAB DS PK 1.00052 1.00070 2/8/2013 METHYLPREDNISOLONE 4 MG TABLET 1.24060 1.24060 2/8/2013 METHYLPREDNISOLONE 8 MG TABLET 1.40728 1.40728 2/8/2013 METHYLPREDNISOLONE ACETATE 40 MG/ML VIAL 3.04720 3.04720 2/8/2013 METHYLPREDNISOLONE ACETATE 80 MG/ML VIAL 6.81698 6.81698 2/8/2013 METHYLPREDNISOLONE SOD SUCC 1000 MG VIAL 17.05200 17.05200 2/8/2013 METHYLPREDNISOLONE SOD SUCC 125 MG VIAL 4.08408 4.08408 2/8/2013 METHYLPREDNISOLONE SOD SUCC 40 MG VIAL 3.53132 3.53132 2/8/2013 METIPRANOLOL 0.3 % DROPS 2.91720 2.91720 2/8/2013 METOCLOPRAMIDE HCL 10 MG TABLET 0.04336 0.04336 2/8/2013 METOCLOPRAMIDE HCL 10 MG/2 ML DISP SYRIN 0.39900 0.39900 2/8/2013 METOCLOPRAMIDE HCL 5 MG TABLET 0.04248 0.04248 2/8/2013 METOCLOPRAMIDE HCL 5 MG/5 ML SOLUTION 0.01032 0.01032 2/8/2013 METOLAZONE 10 MG TABLET 0.77720 0.77720 2/8/2013 METOLAZONE 2.5 MG TABLET 0.50103 0.50103 2/8/2013 METOLAZONE 5 MG TABLET 0.56911 0.56911 2/8/2013 METOPROLOL SUCCINATE 100 MG TAB ER 24H 0.90700 0.90700 2/8/2013 METOPROLOL SUCCINATE 200 MG TAB ER 24H 1.79444 1.79444 2/8/2013 METOPROLOL SUCCINATE 25 MG TAB ER 24H 0.63890 0.63890 2/8/2013 METOPROLOL SUCCINATE 50 MG TAB ER 24H 0.63918 0.63918 2/8/2013 METOPROLOL TARTRATE 100 MG TABLET 0.03216 0.03216 2/8/2013 METOPROLOL TARTRATE 25 MG TABLET 0.02399 0.02399 2/8/2013 METOPROLOL TARTRATE 5 MG/5 ML AMPUL 0.23018 0.23018 2/8/2013 METOPROLOL TARTRATE 5 MG/5 ML DISP SYRIN 0.70560 0.70560 2/8/2013 METOPROLOL TARTRATE 50 MG TABLET 0.02077 0.02077 2/8/2013 METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET 1.38833 1.38833 2/8/2013 METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-50MG TABLET 1.53412 1.53412 2/8/2013 METOPROLOL/HYDROCHLOROTHIAZIDE 50 MG-25MG TABLET 0.89167 0.89167 2/8/2013 METRONIDAZOLE 0.75 % CREAM (G) 2.72580 2.72580 2/8/2013 METRONIDAZOLE 0.75 % GEL (GRAM) 2.65770 2.65770 2/8/2013 METRONIDAZOLE 0.75 % GEL W/APPL 0.41004 0.41004 2/8/2013 Page 33 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price METRONIDAZOLE 0.75 % LOTION 2.93220 2.93220 2/8/2013 METRONIDAZOLE 250 MG TABLET 0.30300 0.30300 2/8/2013 METRONIDAZOLE 500 MG TABLET 0.50384 0.50384 2/8/2013 METRONIDAZOLE/SODIUM CHLORIDE 500MG/0.1L PIGGYBACK 0.01288 0.01288 2/8/2013 MEXILETINE HCL 150 MG CAPSULE 0.29172 0.29172 2/8/2013 MEXILETINE HCL 200 MG CAPSULE 0.40235 0.40235 2/8/2013 MEXILETINE HCL 250 MG CAPSULE 0.48191 0.48191 2/8/2013 MICONAZOLE NITRATE 100 MG SUPP.VAG 0.44030 0.44030 2/8/2013 MICONAZOLE NITRATE 2 % CREAM (G) 0.05722 0.05722 2/8/2013 MICONAZOLE NITRATE 2 % CREAM/APPL 0.09072 0.09072 2/8/2013 MICONAZOLE NITRATE 2 % OINT. (G) 0.08502 0.08474 2/15/2013 MICONAZOLE NITRATE 2 % TINCTURE 0.41427 0.41427 2/8/2013 MICONAZOLE NITRATE 200 MG SUPP.VAG 12.26633 12.26633 2/8/2013 MICONAZOLE NITRATE 200 MG-2 % COMBO. PKG 1.21793 1.21793 2/8/2013 MIDODRINE HCL 10 MG TABLET 0.93009 0.93009 2/8/2013 MIDODRINE HCL 2.5 MG TABLET 0.32321 0.32321 2/8/2013 MIDODRINE HCL 5 MG TABLET 0.38525 0.60470 2/8/2013 MILRINONE LACTATE 1 MG/ML VIAL 0.46056 0.46056 2/8/2013 MILRINONE LACTATE/D5W 20MG/100ML PIGGYBACK 0.12146 0.12146 2/8/2013 MILRINONE LACTATE/D5W 40MG/200ML PIGGYBACK 0.12425 0.12425 2/8/2013 MINERAL OIL ENEMA 0.01315 0.01182 2/15/2013 MINERAL OIL LOTION 0.00482 0.00482 2/8/2013 MINERAL OIL/PETROLATUM,WHITE 15 %-83 % OINT. (G) 0.75387 0.75387 2/8/2013 MINERAL OIL/PETROLATUM,WHITE 15%-85% OINT. (G) 4.48140 4.48140 2/8/2013 MINOCYCLINE HCL 100 MG CAPSULE 0.26693 0.26693 2/8/2013 MINOCYCLINE HCL 100 MG TABLET 2.49210 2.49210 2/8/2013 MINOCYCLINE HCL 135 MG TAB ER 24H 3.56811 3.56811 2/8/2013 MINOCYCLINE HCL 45 MG TAB ER 24H 3.56811 3.56811 2/8/2013 MINOCYCLINE HCL 50 MG CAPSULE 0.13690 0.13690 2/8/2013 MINOCYCLINE HCL 50 MG TABLET 1.44008 1.44008 2/8/2013 MINOCYCLINE HCL 75 MG CAPSULE 0.31018 0.31018 2/8/2013 MINOCYCLINE HCL 75 MG TABLET 1.69228 1.69228 2/8/2013 MINOCYCLINE HCL 90 MG TAB ER 24H 3.56811 3.56811 2/8/2013 MINOXIDIL 10 MG TABLET 0.27483 0.27483 2/8/2013 MINOXIDIL 2.5 MG TABLET 0.16028 0.16028 2/8/2013 MIRTAZAPINE 15 MG TAB RAPDIS 0.95314 0.95314 2/8/2013 MIRTAZAPINE 15 MG TABLET 0.09420 0.09420 2/8/2013 MIRTAZAPINE 30 MG TAB RAPDIS 1.12868 1.12868 2/8/2013 MIRTAZAPINE 30 MG TABLET 0.13936 0.13936 2/8/2013 MIRTAZAPINE 45 MG TAB RAPDIS 1.10739 1.10739 2/8/2013 MIRTAZAPINE 45 MG TABLET 0.24830 0.24830 2/8/2013 MIRTAZAPINE 7.5 MG TABLET 0.06028 0.06028 2/8/2013 MISOPROSTOL 100 MCG TABLET 0.41165 0.41165 2/8/2013 MITOMYCIN 40 MG VIAL 235.39125 235.39125 2/8/2013 MODAFINIL 100 MG TABLET 12.89673 12.89673 2/8/2013 MODAFINIL 200 MG TABLET 18.65619 18.65619 2/8/2013 MOEXIPRIL HCL 15 MG TABLET 0.37583 0.37583 2/8/2013 MOEXIPRIL HCL 7.5 MG TABLET 0.37583 0.37583 2/8/2013 MOEXIPRIL/HYDROCHLOROTHIAZIDE 15-12.5MG TABLET 0.51305 0.51305 2/8/2013 MOEXIPRIL/HYDROCHLOROTHIAZIDE 15-25MG TABLET 0.37076 0.37076 2/8/2013 MOEXIPRIL/HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET 0.50960 0.50960 2/8/2013 MOLYBDENUM(AMMONIUM MOLYBDATE) 25 MCG/ML VIAL 0.32672 0.32672 2/8/2013 MOMETASONE FUROATE 0.1 % CREAM (G) 0.23021 0.23021 2/8/2013 MOMETASONE FUROATE 0.1 % OINT. (G) 0.22954 0.22954 2/8/2013 MOMETASONE FUROATE 0.1 % SOLUTION 0.21480 0.21480 2/8/2013 MONTELUKAST SODIUM 10 MG TABLET 0.61330 0.61330 2/8/2013 MONTELUKAST SODIUM 4 MG TAB CHEW 0.61330 0.61330 2/8/2013 Page 34 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price MONTELUKAST SODIUM 5 MG TAB CHEW 0.61330 0.61330 2/8/2013 MORPHINE SULFATE 10 MG SUPP.RECT 4.37500 4.37500 2/8/2013 MORPHINE SULFATE 10 MG/5 ML SOLUTION 0.06164 0.06164 2/8/2013 MORPHINE SULFATE 10 MG/ML DISP SYRIN 1.36920 1.36920 2/8/2013 MORPHINE SULFATE 10 MG/ML VIAL 0.74480 0.74480 2/8/2013 MORPHINE SULFATE 100 MG CAP ER PEL 13.29301 13.29301 2/8/2013 MORPHINE SULFATE 100 MG TABLET ER 0.80353 0.80353 2/8/2013 MORPHINE SULFATE 100 MG/4ML VIAL PORT 4.96650 4.96650 2/8/2013 MORPHINE SULFATE 100 MG/5ML SOLUTION 0.29011 0.29011 2/8/2013 MORPHINE SULFATE 15 MG TABLET 0.07826 0.07826 2/8/2013 MORPHINE SULFATE 15 MG TABLET ER 0.19755 0.19755 2/8/2013 MORPHINE SULFATE 15 MG/ML DISP SYRIN 1.36920 1.36920 2/8/2013 MORPHINE SULFATE 15 MG/ML VIAL 0.69440 0.69440 2/8/2013 MORPHINE SULFATE 2 MG/ML DISP SYRIN 1.36920 1.36920 2/8/2013 MORPHINE SULFATE 20 MG CAP ER PEL 3.65672 3.65672 2/8/2013 MORPHINE SULFATE 20 MG SUPP.RECT 5.25000 5.25000 2/8/2013 MORPHINE SULFATE 20 MG/5 ML SOLUTION 0.09368 0.09368 2/8/2013 MORPHINE SULFATE 200 MG TABLET ER 1.31144 1.31144 2/8/2013 MORPHINE SULFATE 250MG/10ML VIAL PORT 1.99080 1.99080 2/8/2013 MORPHINE SULFATE 30 MG CAP ER PEL 3.97649 3.97649 2/8/2013 MORPHINE SULFATE 30 MG SUPP.RECT 6.56250 6.56250 2/8/2013 MORPHINE SULFATE 30 MG TABLET 0.09945 0.12130 2/8/2013 MORPHINE SULFATE 30 MG TABLET ER 0.28570 0.28570 2/8/2013 MORPHINE SULFATE 30 MG/30ML PCA SYRING 0.00000 0.43749 2/15/2013 MORPHINE SULFATE 4 MG/ML DISP SYRIN 1.36920 1.36920 2/8/2013 MORPHINE SULFATE 5 MG SUPP.RECT 3.50000 3.50000 2/8/2013 MORPHINE SULFATE 5 MG/ML VIAL 0.83160 0.83160 2/8/2013 MORPHINE SULFATE 50 MG CAP ER PEL 6.64531 6.64531 2/8/2013 MORPHINE SULFATE 50 MG/ML VIAL 0.39830 0.39830 2/8/2013 MORPHINE SULFATE 60 MG CAP ER PEL 7.95284 7.95284 2/8/2013 MORPHINE SULFATE 60 MG TABLET ER 0.52662 0.52662 2/8/2013 MORPHINE SULFATE 8 MG/ML DISP SYRIN 1.37760 1.37760 2/8/2013 MORPHINE SULFATE 8 MG/ML VIAL 0.94080 0.94080 2/8/2013 MORPHINE SULFATE 80 MG CAP ER PEL 10.60087 10.60087 2/8/2013 MORPHINE SULFATE/PF 0.5 MG/ML AMPUL 2.23713 2.23713 2/8/2013 MORPHINE SULFATE/PF 0.5 MG/ML VIAL 0.42084 0.42084 2/8/2013 MORPHINE SULFATE/PF 1 MG/ML AMPUL 3.80940 3.80940 2/8/2013 MORPHINE SULFATE/PF 1 MG/ML VIAL 0.46452 0.46452 2/8/2013 MORPHINE SULFATE/PF 10 MG/ML CARTRIDGE 3.25500 3.25500 2/8/2013 MORPHINE SULFATE/PF 15 MG/ML CARTRIDGE 3.25500 3.25500 2/8/2013 MORPHINE SULFATE/PF 150MG/30ML PCA VIAL 0.61320 0.61320 2/8/2013 MORPHINE SULFATE/PF 2 MG/ML CARTRIDGE 3.25500 3.25500 2/8/2013 MORPHINE SULFATE/PF 25 MG/ML VIAL 0.48370 0.48370 2/8/2013 MORPHINE SULFATE/PF 30 MG/30ML PCA VIAL 0.50469 0.50469 2/8/2013 MORPHINE SULFATE/PF 4 MG/ML CARTRIDGE 3.25500 3.25500 2/8/2013 MORPHINE SULFATE/PF 8 MG/ML CARTRIDGE 2.98200 2.98200 2/8/2013 MTH/ME BLUE/SOD PHOS/PHEN/HYOS 81.6-10.8 TABLET 0.91000 0.91000 2/8/2013 MULTIVITAMIN TABLET 0.01085 0.01085 2/8/2013 MULTIVITAMIN W-MINERALS/LUTEIN TABLET 0.04776 0.04776 2/8/2013 MULTIVITAMINS WITH IRON TABLET 0.01581 0.01581 2/8/2013 MULTIVITAMINS WITH MIN NO.7/FA 1 MG CAPSULE 0.20735 0.17550 2/8/2013 MULTIVITAMINS,THER W-MINERALS CAPSULE 0.05782 0.05782 2/8/2013 MULTIVITAMINS,THERAPEUTIC TABLET 0.02439 0.02439 2/8/2013 MULTIVITS W-MIN/FERROUS GLUC 9 MG/15 ML LIQUID 0.01348 0.01348 2/8/2013 MULTIVITS,CA,MINERALS/IRON/FA 9MG-400MCG TABLET 0.03497 0.03497 2/8/2013 MULTIVITS,STRESS FORMULA/ZINC TABLET 0.04810 0.04810 2/8/2013 MULTIVITS-MIN/FA/LYCOPENE/LUT 500-300MCG TABLET 0.04797 0.04797 2/8/2013 Page 35 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 2 % OINT. (G) 0.47610 0.47610 2/8/2013 MUPIROCIN CALCIUM 2 % CREAM (G) 0.00000 3.12644 2/15/2013 MU-VITS-MIN TH/LYCOPENE/LUTEIN .4-300-250 TABLET 0.04529 0.04529 2/8/2013 MYCOPHENOLATE MOFETIL 250 MG CAPSULE 0.28971 0.28971 2/8/2013 MYCOPHENOLATE MOFETIL 500 MG TABLET 0.52260 0.52260 2/8/2013 NA NITRITE/NA THIOSUL/AMYL NIT 300-12.5 KIT 321.77600 321.77600 2/8/2013 NA PHOS,M-B/NA PHOS,DI-BA 19G-7G/118 ENEMA 0.00575 0.00575 2/8/2013 NABUMETONE 500 MG TABLET 0.15544 0.15544 2/8/2013 NABUMETONE 750 MG TABLET 0.23115 0.23115 2/8/2013 NADOLOL 20 MG TABLET 0.20663 0.20663 2/8/2013 NADOLOL 80 MG TABLET 0.39249 0.39249 2/8/2013 NADOLOL/BENDROFLUMETHIAZIDE 40 MG-5 MG TABLET 1.72368 1.72368 2/8/2013 NADOLOL/BENDROFLUMETHIAZIDE 80 MG-5 MG TABLET 2.25914 2.25914 2/8/2013 NAFCILLIN IN DEXTROSE,ISO-OSM 1 G/50 ML FROZ.PIGGY 0.25511 0.25511 2/8/2013 NAFCILLIN IN DEXTROSE,ISO-OSM 2 G/100 ML FROZ.PIGGY 0.17407 0.17407 2/8/2013 NAFCILLIN SODIUM 1 G VIAL 10.06800 10.06800 2/8/2013 NAFCILLIN SODIUM 1 G VIAL PORT 12.87090 12.87090 2/8/2013 NAFCILLIN SODIUM 10 G VIAL 97.14110 97.14110 2/8/2013 NAFCILLIN SODIUM 2 G VIAL 19.62890 19.62890 2/8/2013 NAFCILLIN SODIUM 2 G VIAL PORT 25.36100 25.36100 2/8/2013 NALBUPHINE HCL 10 MG/ML VIAL 1.36920 1.36920 2/8/2013 NALBUPHINE HCL 20 MG/ML AMPUL 3.45670 3.45670 2/8/2013 NALBUPHINE HCL 20 MG/ML VIAL 1.87656 1.87656 2/8/2013 NALOXONE HCL 0.4 MG/ML DISP SYRIN 6.17400 6.17400 2/8/2013 NALOXONE HCL 1 MG/ML DISP SYRIN 7.11900 7.11900 2/8/2013 NALTREXONE HCL 50 MG TABLET 1.16580 1.16580 2/8/2013 NAPHAZOLINE HCL 0.1 % DROPS 0.11787 0.11787 2/8/2013 NAPHAZOLINE HCL/GLYCERIN 0.012-0.2% DROPS 0.13642 0.13642 2/8/2013 NAPROXEN 125 MG/5ML ORAL SUSP 0.13839 0.13839 2/8/2013 NAPROXEN 250 MG TABLET 0.04730 0.04730 2/8/2013 NAPROXEN 375 MG TABLET 0.05695 0.05695 2/8/2013 NAPROXEN 375 MG TABLET DR 0.14872 0.14872 2/8/2013 NAPROXEN 500 MG TABLET 0.06633 0.06633 2/8/2013 NAPROXEN 500 MG TABLET DR 0.17420 0.17420 2/8/2013 NAPROXEN SODIUM 220 MG TABLET 0.05775 0.05775 2/8/2013 NAPROXEN SODIUM 275 MG TABLET 0.08828 0.08828 2/8/2013 NAPROXEN SODIUM 550 MG TABLET 0.11604 0.11604 2/8/2013 NARATRIPTAN HCL 1 MG TABLET 4.95489 4.95489 2/8/2013 NARATRIPTAN HCL 2.5 MG TABLET 5.29830 5.29830 2/8/2013 NATEGLINIDE 120 MG TABLET 0.90490 0.90490 2/8/2013 NATEGLINIDE 60 MG TABLET 1.07160 1.07160 2/8/2013 NEFAZODONE HCL 100 MG TABLET 0.57850 0.57850 2/8/2013 NEFAZODONE HCL 150 MG TABLET 0.60797 0.60797 2/8/2013 NEFAZODONE HCL 200 MG TABLET 0.63678 0.63678 2/8/2013 NEFAZODONE HCL 250 MG TABLET 0.66582 0.66582 2/8/2013 NEFAZODONE HCL 50 MG TABLET 0.52117 0.52117 2/8/2013 NEO/POLYMYX B SULF/DEXAMETH 0.1 % DROPS SUSP 3.81290 3.81290 2/8/2013 NEO/POLYMYX B SULF/DEXAMETH 3.5-10K-.1 OINT. (G) 4.73550 4.73550 2/8/2013 NEOMY SULF/BACITRA/POLYMYXIN B PACKET 0.19439 0.17886 2/15/2013 NEOMY SULF/BACITRA/POLYMYXIN B 3.5MG-400 OINT. (G) 8.35200 8.35200 2/8/2013 NEOMY SULF/BACITRAC ZN/POLY 3.5-400-5K OINT. (G) 0.08536 0.08536 2/8/2013 NEOMY SULF/BACITRAC ZN/POLY/HC 3.5-10K-1 OINT. (G) 12.81000 12.81000 2/8/2013 NEOMY SULF/POLYMYXIN B SULFATE 40-200K/ML AMPUL 7.75416 7.75416 2/8/2013 NEOMY SULF/POLYMYXIN B SULFATE 40-200K/ML VIAL 5.02645 5.02645 2/8/2013 SULFATE 500 MG TABLET 0.90098 0.90098 2/8/2013 NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-1 DROPS SUSP 2.15657 2.15657 2/8/2013 NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-1 SOLUTION 1.65100 1.65100 2/8/2013 Page 36 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-10 DROPS SUSP 11.83747 12.73118 2/15/2013 NEOMYCIN/POLYMYXN B/GRAMICIDIN 1.75MG-10K DROPS 1.30888 1.30888 2/8/2013 NEOMYCN/BACI ZN/PMYX BS/PRAMOX 3.5-10K-10 OINT. (G) 0.16978 0.16978 2/8/2013 NEVIRAPINE 200 MG TABLET 0.19200 0.19200 2/8/2013 NEVIRAPINE 50 MG/5 ML ORAL SUSP 0.40225 0.40225 2/8/2013 100 MG TABLET 0.01268 0.01268 2/8/2013 NIACIN 1000 MG TABLET ER 0.05775 0.05775 2/8/2013 NIACIN 250 MG CAPSULE ER 0.04147 0.04147 2/8/2013 NIACIN 250 MG TABLET ER 0.03662 0.03586 2/15/2013 NIACIN 50 MG TABLET 0.01274 0.01274 2/8/2013 NIACIN 500 MG CAPSULE ER 0.04927 0.04927 2/8/2013 NIACIN 500 MG TABLET 0.01997 0.01997 2/8/2013 NIACIN 500 MG TABLET ER 0.03296 0.03296 2/8/2013 NIACIN 750 MG TABLET ER 0.05018 0.05018 2/8/2013 NIACINAMIDE 500 MG TABLET 0.02415 0.02415 2/8/2013 NICARDIPINE HCL 20 MG CAPSULE 0.34501 0.34501 2/8/2013 NICARDIPINE HCL 30 MG CAPSULE 0.48216 0.48216 2/8/2013 NICOTINE 14MG/24HR PATCH TD24 1.82613 1.82613 2/8/2013 NICOTINE 21 MG/24HR PATCH TD24 1.81516 1.81516 2/8/2013 NICOTINE 7MG/24HR PATCH TD24 1.74771 1.74771 2/8/2013 NICOTINE POLACRILEX 2 MG GUM 0.19564 0.19564 2/8/2013 NICOTINE POLACRILEX 2 MG LOZENGE 0.36791 0.36791 2/8/2013 NICOTINE POLACRILEX 4 MG GUM 0.23879 0.23879 2/8/2013 NICOTINE POLACRILEX 4 MG LOZENGE 0.36377 0.36377 2/8/2013 NIFEDIPINE 10 MG CAPSULE 0.72997 0.72997 2/8/2013 NIFEDIPINE 20 MG CAPSULE 1.61182 1.61182 2/8/2013 NIFEDIPINE 30 MG TAB ER 24 0.41433 0.41433 2/8/2013 NIFEDIPINE 30 MG TABLET ER 0.46565 0.46565 2/8/2013 NIFEDIPINE 60 MG TAB ER 24 0.58799 0.58799 2/8/2013 NIFEDIPINE 60 MG TABLET ER 0.97351 0.97351 2/8/2013 NIFEDIPINE 90 MG TAB ER 24 1.33464 1.33464 2/8/2013 NIFEDIPINE 90 MG TABLET ER 1.89111 1.89111 2/8/2013 NIMODIPINE 30 MG CAPSULE 6.55031 6.55031 2/8/2013 NISOLDIPINE 17 MG TAB ER 24H 5.38832 5.38832 2/8/2013 NISOLDIPINE 20 MG TAB ER 24H 6.46709 6.46709 2/8/2013 NISOLDIPINE 25.5 MG TAB ER 24H 5.87636 5.87636 2/8/2013 NISOLDIPINE 30 MG TAB ER 24H 7.05271 7.05271 2/8/2013 NISOLDIPINE 34 MG TAB ER 24H 5.87636 5.87636 2/8/2013 NISOLDIPINE 40 MG TAB ER 24H 7.05271 7.05271 2/8/2013 NISOLDIPINE 8.5MG TAB ER 24H 4.29926 4.29926 2/8/2013 NITROFURANTOIN 25 MG/5 ML ORAL SUSP 1.95313 1.95313 2/8/2013 NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE 1.68384 1.68384 2/8/2013 NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE 0.95837 0.95837 2/8/2013 NITROFURANTOIN MONOHYD/M-CRYST 100 MG CAPSULE 2.45176 2.45176 2/8/2013 NITROGLYCERIN 0.1MG/HR PATCH TD24 0.66433 0.66433 2/8/2013 NITROGLYCERIN 0.2MG/HR PATCH TD24 0.58250 0.58250 2/8/2013 NITROGLYCERIN 0.4MG/DOSE SPRAY 27.46701 27.46701 2/8/2013 NITROGLYCERIN 0.4MG/DOSE SPRAY 16.29250 16.29250 2/8/2013 NITROGLYCERIN 0.4MG/HR PATCH TD24 0.62846 0.62846 2/8/2013 NITROGLYCERIN 0.6MG/HR PATCH TD24 1.01696 1.01696 2/8/2013 NITROGLYCERIN 2.5 MG CAPSULE ER 0.22633 0.22633 2/8/2013 NITROGLYCERIN 50 MG/10ML VIAL 0.47040 0.47040 2/8/2013 NITROGLYCERIN 6.5 MG CAPSULE ER 0.38714 0.32960 2/15/2013 NITROGLYCERIN 9 MG CAPSULE ER 0.49568 0.49568 2/8/2013 NITROGLYCERIN/D5W 200MG/500 INFUS. BTL 0.01446 0.01446 2/8/2013 NITROGLYCERIN/D5W 50MG/500ML INFUS. BTL 0.02264 0.02264 2/8/2013 NIZATIDINE 150 MG CAPSULE 0.28046 0.28046 2/8/2013 Page 37 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price NIZATIDINE 150MG/10ML SOLUTION 0.48899 0.48899 2/8/2013 NIZATIDINE 300 MG CAPSULE 0.85586 0.85586 2/8/2013 NORETH A-ET ESTRA/FE FUMARATE 1.5-0.03MG TABLET 0.72337 0.72337 2/8/2013 NORETH A-ET ESTRA/FE FUMARATE 1MG-20MCG TABLET 0.71641 0.71641 2/8/2013 NORETH A-ET ESTRA/FE FUMARATE 5-7-9-7 TABLET 1.42881 1.42881 2/8/2013 NORETH-ETHINYL ESTRADIOL/IRON 0.4-35(21) TAB CHEW 1.82950 1.82950 2/8/2013 NORETHINDRONE 0.35 MG TABLET 0.85586 0.85586 2/8/2013 NORETHINDRONE ACETATE 5 MG TABLET 1.85402 1.85402 2/8/2013 NORETHINDRONE A-E ESTRADIOL 1.5-0.03MG TABLET 0.96454 0.96454 2/8/2013 NORETHINDRONE A-E ESTRADIOL 1MG-20MCG TABLET 0.95522 0.95522 2/8/2013 NORETHINDRONE-ETHINYL ESTRAD 0.4-0.035 TABLET 1.10349 1.10349 2/8/2013 NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET 0.80427 0.80427 2/8/2013 NORETHINDRONE-ETHINYL ESTRAD 1 MG-35MCG TABLET 0.74107 0.74107 2/8/2013 NORETHINDRONE-ETHINYL ESTRAD 7 DAYS X 3 TABLET 0.81211 0.81211 2/8/2013 NORETHINDRONE-ETHINYL ESTRAD 7-9-5 TABLET 0.98375 0.98375 2/8/2013 -ETHINYL ESTRADIOL 0.25-0.035 TABLET 0.45253 0.45253 2/8/2013 NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 28 TABLET 0.45253 0.45253 2/8/2013 -ETHINYL ESTRADIOL 0.3-0.03MG TABLET 0.76300 0.76300 2/8/2013 NORTRIPTYLINE HCL 10 MG CAPSULE 0.09916 0.09916 2/8/2013 NORTRIPTYLINE HCL 10 MG/5 ML SOLUTION 0.20683 0.20683 2/8/2013 NORTRIPTYLINE HCL 25 MG CAPSULE 0.13601 0.13601 2/8/2013 NORTRIPTYLINE HCL 50 MG CAPSULE 0.16643 0.16643 2/8/2013 NORTRIPTYLINE HCL 75 MG CAPSULE 0.23061 0.23061 2/8/2013 NYSTATIN 100000/G CREAM (G) 0.58920 0.58920 2/8/2013 NYSTATIN 100000/G OINT. (G) 0.95120 0.95120 2/8/2013 NYSTATIN 100000/G POWDER 1.01120 1.01120 2/8/2013 NYSTATIN 10B UNIT POWDER(EA) 17,265.36000 ########## 2/8/2013 NYSTATIN 150MM UNIT POWDER(EA) 70.10500 70.10500 2/8/2013 NYSTATIN 150MM UNIT POWDER(EA) 408.51650 408.51650 2/8/2013 NYSTATIN 1B UNIT POWDER(EA) 523.22200 523.22200 2/8/2013 NYSTATIN 2B UNIT POWDER(EA) 459.38450 459.38450 2/8/2013 NYSTATIN 500K UNIT TABLET 0.46102 0.46102 2/8/2013 NYSTATIN 500MM UNIT POWDER(EA) 156.49700 156.49700 2/8/2013 NYSTATIN 500MM UNIT POWDER(EA) 2.78014 2.78014 2/8/2013 NYSTATIN 50MM UNIT POWDER(EA) 47.31300 47.31300 2/8/2013 NYSTATIN 50MM UNIT POWDER(EA) 3.91430 3.91430 2/8/2013 NYSTATIN 5B UNIT POWDER(EA) 742.07950 742.07950 2/8/2013 OCTREOTIDE ACETATE 100 MCG/ML AMPUL 5.70960 5.70960 2/8/2013 OCTREOTIDE ACETATE 100 MCG/ML DISP SYRIN 10.04850 10.04850 2/8/2013 OCTREOTIDE ACETATE 100 MCG/ML VIAL 4.39920 4.39920 2/8/2013 OCTREOTIDE ACETATE 1000MCG/ML VIAL 30.52860 30.52860 2/8/2013 OCTREOTIDE ACETATE 200 MCG/ML VIAL 7.30800 7.30800 2/8/2013 OCTREOTIDE ACETATE 50 MCG/ML AMPUL 2.84310 2.84310 2/8/2013 OCTREOTIDE ACETATE 50 MCG/ML DISP SYRIN 5.98920 5.98920 2/8/2013 OCTREOTIDE ACETATE 50 MCG/ML VIAL 3.08845 3.08845 2/8/2013 OCTREOTIDE ACETATE 500 MCG/ML AMPUL 29.90650 29.90650 2/8/2013 OCTREOTIDE ACETATE 500 MCG/ML DISP SYRIN 45.22560 45.22560 2/8/2013 OCTREOTIDE ACETATE 500 MCG/ML VIAL 16.18890 16.18890 2/8/2013 OFLOXACIN 0.3 % DROPS 0.61370 0.61370 2/8/2013 OFLOXACIN 0.3 % DROPS 0.37252 0.37252 2/8/2013 OFLOXACIN 200 MG TABLET 3.34859 3.34859 2/8/2013 OFLOXACIN 300 MG TABLET 3.98503 3.98503 2/8/2013 OFLOXACIN 400 MG TABLET 4.20252 4.20252 2/8/2013 OLANZAPINE 10 MG TAB RAPDIS 8.72300 8.72300 2/8/2013 OLANZAPINE 10 MG TABLET 1.29440 1.29440 2/8/2013 OLANZAPINE 10 MG VIAL 29.05000 29.05000 2/8/2013 OLANZAPINE 15 MG TAB RAPDIS 12.86570 12.86570 2/8/2013 Page 38 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price OLANZAPINE 15 MG TABLET 1.94180 1.94180 2/8/2013 OLANZAPINE 2.5 MG TABLET 0.40630 0.40630 2/8/2013 OLANZAPINE 20 MG TAB RAPDIS 17.00830 17.00830 2/8/2013 OLANZAPINE 20 MG TABLET 2.58900 2.58900 2/8/2013 OLANZAPINE 5 MG TAB RAPDIS 5.93670 5.93670 2/8/2013 OLANZAPINE 5 MG TABLET 0.85890 0.85890 2/8/2013 OLANZAPINE 7.5 MG TABLET 0.54020 0.54020 2/8/2013 OLANZAPINE/FLUOXETINE HCL 12MG-25MG CAPSULE 15.27470 15.27470 2/8/2013 OLANZAPINE/FLUOXETINE HCL 12MG-50MG CAPSULE 15.27470 15.27470 2/8/2013 OLANZAPINE/FLUOXETINE HCL 3MG-25MG CAPSULE 7.57062 7.57062 2/8/2013 OLANZAPINE/FLUOXETINE HCL 6MG-25MG CAPSULE 10.13740 10.13740 2/8/2013 OLANZAPINE/FLUOXETINE HCL 6MG-50MG CAPSULE 10.13740 10.13740 2/8/2013 OM-3/DHA/EPA/B12/FA/B6/PHYTOST 500-0.5-1 CAPSULE 0.64330 0.64330 2/8/2013 OMEGA-3/DHA/EPA/FISH OIL 1000 MG CAPSULE 0.04018 0.03652 2/15/2013 OMEGA-3/DHA/EPA/FISH OIL 500-1000MG CAPSULE 0.10952 0.10952 2/8/2013 OMEPRAZOLE 10 MG CAPSULE DR 0.27684 0.27684 2/8/2013 OMEPRAZOLE 20 MG CAPSULE DR 0.11779 0.11779 2/8/2013 OMEPRAZOLE 20 MG TABLET DR 0.60836 0.60836 2/8/2013 OMEPRAZOLE 40 MG CAPSULE DR 0.23986 0.23986 2/8/2013 OMEPRAZOLE/SODIUM BICARBONATE 20MG-1.1G CAPSULE 0.48869 0.48869 2/8/2013 OMEPRAZOLE/SODIUM BICARBONATE 40MG-1.1G CAPSULE 7.97440 7.97440 2/8/2013 ONDANSETRON 4 MG TAB RAPDIS 0.42185 0.42185 2/8/2013 ONDANSETRON 8 MG TAB RAPDIS 0.55074 0.55074 2/8/2013 ONDANSETRON HCL 4 MG TABLET 0.12556 0.12556 2/8/2013 ONDANSETRON HCL 4 MG/5 ML SOLUTION 0.60533 0.60533 2/8/2013 ONDANSETRON HCL 8 MG TABLET 0.15906 0.15906 2/8/2013 ONDANSETRON HCL/PF 4 MG/2 ML AMPUL 8.31950 8.31950 2/8/2013 ONDANSETRON HCL/PF 4 MG/2 ML DISP SYRIN 1.10670 1.10670 2/8/2013 ONDANSETRON HCL/PF 4 MG/2 ML VIAL 0.32428 0.32428 2/8/2013 ONDANSETRON IN 0.9 % NACL/PF 32 MG/50ML PIGGYBACK 1.51196 1.51196 2/8/2013 OPIUM TINCTURE 10 MG/ML TINCTURE 4.99304 4.99304 2/8/2013 OPIUM/BELLADONNA ALKALOIDS 30-16.2MG SUPP.RECT 16.21375 16.21375 2/8/2013 OPIUM/BELLADONNA ALKALOIDS 60-16.2MG SUPP.RECT 19.71083 19.71083 2/8/2013 ORPHENADRINE CITRATE 100 MG TABLET ER 0.57834 0.57834 2/8/2013 ORPHENADRINE/ASPIRIN/CAFFEINE 25-385-30 TABLET 1.26658 1.26658 2/8/2013 ORPHENADRINE/ASPIRIN/CAFFEINE 50-770-60 TABLET 1.83323 1.83323 2/8/2013 OXACILLIN SODIUM 1 G VIAL 10.07977 10.07977 2/8/2013 OXACILLIN SODIUM 1 G VIAL PORT 0.86301 0.86301 2/8/2013 OXACILLIN SODIUM 10 G VIAL 90.95850 90.95850 2/8/2013 OXACILLIN SODIUM 2 G VIAL 18.97980 18.97980 2/8/2013 OXACILLIN SODIUM 2 G VIAL PORT 2.23201 2.23201 2/8/2013 OXACILLIN SODIUM/DEXTROSE,ISO 1 G/50 ML FROZ.PIGGY 0.25790 0.25790 2/8/2013 OXACILLIN SODIUM/DEXTROSE,ISO 2 G/50 ML FROZ.PIGGY 0.21527 0.21527 2/8/2013 10 MG TABLET 9.27840 9.27840 2/8/2013 OXANDROLONE 2.5 MG TABLET 2.93261 2.93261 2/8/2013 OXAPROZIN 600 MG TABLET 2.34180 2.34180 2/8/2013 OXAZEPAM 10 MG CAPSULE 0.73300 0.73300 2/8/2013 OXAZEPAM 15 MG CAPSULE 1.20600 1.20600 2/8/2013 OXCARBAZEPINE 150 MG TABLET 0.13735 0.13735 2/8/2013 OXCARBAZEPINE 300 MG TABLET 0.28113 0.28113 2/8/2013 OXCARBAZEPINE 300 MG/5ML ORAL SUSP 0.57904 0.57904 2/8/2013 OXCARBAZEPINE 600 MG TABLET 0.54913 0.54913 2/8/2013 OXYBUTYNIN CHLORIDE 10 MG TAB ER 24 1.45926 1.45926 2/8/2013 OXYBUTYNIN CHLORIDE 15 MG TAB ER 24 2.15887 2.15887 2/8/2013 OXYBUTYNIN CHLORIDE 5 MG TAB ER 24 1.45926 1.45926 2/8/2013 OXYBUTYNIN CHLORIDE 5 MG TABLET 0.04221 0.04221 2/8/2013 OXYBUTYNIN CHLORIDE 5 MG/5 ML SYRUP 0.01956 0.01956 2/8/2013 Page 39 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price OXYCODONE HCL 10 MG TABLET 0.26460 0.26460 2/8/2013 OXYCODONE HCL 15 MG TABLET 0.16080 0.16080 2/8/2013 OXYCODONE HCL 20 MG/ML ORAL CONC 5.15819 5.15819 2/8/2013 OXYCODONE HCL 30 MG TABLET 0.32160 0.32160 2/8/2013 OXYCODONE HCL 5 MG CAPSULE 1.15262 1.15262 2/8/2013 OXYCODONE HCL 5 MG TABLET 0.10720 0.10720 2/8/2013 OXYCODONE HCL/ACETAMINOPHEN 10MG-325MG TABLET 0.36783 0.36783 2/8/2013 OXYCODONE HCL/ACETAMINOPHEN 10MG-650MG TABLET 0.73184 0.37370 2/15/2013 OXYCODONE HCL/ACETAMINOPHEN 2.5-325MG TABLET 2.87868 2.87868 2/8/2013 OXYCODONE HCL/ACETAMINOPHEN 5MG-325MG TABLET 0.04864 0.04864 2/8/2013 OXYCODONE HCL/ACETAMINOPHEN 7.5-325MG TABLET 0.30820 0.30820 2/8/2013 OXYCODONE HCL/ACETAMINOPHEN 7.5-500MG TABLET 0.45240 0.45240 2/8/2013 OXYMORPHONE HCL 10 MG TAB ER 12H 2.43642 2.43642 2/8/2013 OXYMORPHONE HCL 10 MG TABLET 3.74451 4.11894 2/15/2013 OXYMORPHONE HCL 15 MG TAB ER 12H 3.61963 3.61963 2/8/2013 OXYMORPHONE HCL 20 MG TAB ER 12H 4.32131 4.32131 2/8/2013 OXYMORPHONE HCL 30 MG TAB ER 12H 6.21978 6.21978 2/8/2013 OXYMORPHONE HCL 40 MG TAB ER 12H 8.11846 8.11846 2/8/2013 OXYMORPHONE HCL 5 MG TAB ER 12H 1.26882 1.26882 2/8/2013 OXYMORPHONE HCL 5 MG TABLET 2.06227 2.26849 2/15/2013 OXYMORPHONE HCL 7.5 MG TAB ER 12H 1.91860 1.91860 2/8/2013 PAMIDRONATE DISODIUM 30 MG VIAL 15.22500 15.22500 2/8/2013 PAMIDRONATE DISODIUM 30MG/10ML VIAL 1.51688 1.51688 2/8/2013 PAMIDRONATE DISODIUM 60 MG/10ML VIAL 4.62000 4.62000 2/8/2013 PAMIDRONATE DISODIUM 90 MG VIAL 56.47750 56.47750 2/8/2013 PAMIDRONATE DISODIUM 90 MG/10ML VIAL 4.14700 4.14700 2/8/2013 PANTOPRAZOLE SODIUM 20 MG TABLET DR 0.12223 0.12223 2/8/2013 PANTOPRAZOLE SODIUM 40 MG TABLET DR 0.10358 0.10358 2/8/2013 PANTOPRAZOLE SODIUM 40 MG VIAL 3.94100 3.94100 2/8/2013 PAREGORIC 2 MG/5 ML LIQUID 0.19635 0.19635 2/8/2013 PAROMOMYCIN SULFATE 250 MG CAPSULE 3.13066 3.13066 2/8/2013 PAROXETINE HCL 10 MG TABLET 0.12234 0.12234 2/8/2013 PAROXETINE HCL 12.5 MG TAB ER 24H 2.53190 2.53190 2/8/2013 PAROXETINE HCL 20 MG TABLET 0.11926 0.11926 2/8/2013 PAROXETINE HCL 25 MG TAB ER 24H 2.64469 2.64469 2/8/2013 PAROXETINE HCL 30 MG TABLET 0.16844 0.16844 2/8/2013 PAROXETINE HCL 37.5 MG TAB ER 24H 2.72364 2.72364 2/8/2013 PAROXETINE HCL 40 MG TABLET 0.17862 0.17862 2/8/2013 PEANUT OIL OIL 0.09992 0.09602 2/15/2013 PEG 3350/NA SULF,BICARB,CL/KCL 236-22.74G SOLN RECON 0.00312 0.00312 2/8/2013 PEG 3350/NA SULF,BICARB,CL/KCL 240-22.72G SOLN RECON 0.00219 0.00219 2/8/2013 PEG 400/HYPROMELLOSE/GLYCERIN 1-0.2-0.2% DROPS 0.06440 0.06440 2/8/2013 PEN G POT/DEXTROSE-WATER 1MM/50ML FROZ.PIGGY 0.19490 0.19490 2/8/2013 PEN G POT/DEXTROSE-WATER 2MM/50ML FROZ.PIGGY 0.21880 0.21880 2/8/2013 PEN G POT/DEXTROSE-WATER 3MM/50ML FROZ.PIGGY 0.13440 0.13440 2/8/2013 PENICILLIN G POTASSIUM 20MM UNIT VIAL 119.09100 119.09100 2/8/2013 PENICILLIN G POTASSIUM 5MM UNIT VIAL 29.52250 29.52250 2/8/2013 PENICILLIN G PROCAINE 1.2MM/2 ML DISP SYRIN 11.84540 11.84540 2/8/2013 PENICILLIN G PROCAINE 600000/ML DISP SYRIN 14.22890 14.22890 2/8/2013 PENICILLIN G SODIUM 5MM UNIT VIAL 40.12055 40.12055 2/8/2013 PENICILLIN V POTASSIUM 125 MG/5ML SOLN RECON 0.02410 0.02410 2/8/2013 PENICILLIN V POTASSIUM 250 MG TABLET 0.07517 0.07517 2/8/2013 PENICILLIN V POTASSIUM 250 MG/5ML SOLN RECON 0.02515 0.02515 2/8/2013 PENICILLIN V POTASSIUM 500 MG TABLET 0.12301 0.12301 2/8/2013 PENTAZOCINE HCL/ACETAMINOPHEN 25-650MG TABLET 0.84920 0.84920 2/8/2013 PENTAZOCINE HCL/NALOXONE HCL 50MG-0.5MG TABLET 0.98373 0.98373 2/8/2013 PENTOXIFYLLINE 400 MG TABLET ER 0.18117 0.18117 2/8/2013 Page 40 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price P-EPHED HCL/CODEINE/GUAIFEN 30-10-100 SYRUP 0.04770 0.04770 2/8/2013 P-EPHED HCL/TRIPROLIDINE HCL 10-0.938/1 LIQUID 1.59898 1.59898 2/8/2013 P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP 0.05834 0.00790 2/15/2013 P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET 0.05247 0.05247 2/8/2013 PERINDOPRIL ERBUMINE 2 MG TABLET 0.85163 0.85163 2/8/2013 PERINDOPRIL ERBUMINE 4 MG TABLET 0.75205 0.75205 2/8/2013 PERINDOPRIL ERBUMINE 8 MG TABLET 0.85631 0.85631 2/8/2013 PERMETHRIN 5 % CREAM (G) 0.82930 0.82930 2/8/2013 PERPHENAZINE 16 MG TABLET 1.33484 1.33484 2/8/2013 PERPHENAZINE 2 MG TABLET 0.57563 0.57563 2/8/2013 PERPHENAZINE 4 MG TABLET 0.79040 0.79040 2/8/2013 PERPHENAZINE 8 MG TABLET 0.98912 0.98912 2/8/2013 PERPHENAZINE/AMITRIPTYLINE HCL 2 MG-10 MG TABLET 0.45059 0.45059 2/8/2013 PERPHENAZINE/AMITRIPTYLINE HCL 2 MG-25 MG TABLET 0.60030 0.60030 2/8/2013 PERPHENAZINE/AMITRIPTYLINE HCL 4 MG-25 MG TABLET 0.62482 0.62482 2/8/2013 PERPHENAZINE/AMITRIPTYLINE HCL 4MG-10MG TABLET 0.50421 0.50421 2/8/2013 PETROLATUM,WHITE OINT PACK 13.09140 13.09140 2/8/2013 PETROLATUM,WHITE/WATER LOTION 0.00862 0.00862 2/8/2013 PHENAZOPYRIDINE HCL 100 MG TABLET 0.08684 0.08684 2/8/2013 PHENAZOPYRIDINE HCL 200 MG TABLET 0.21310 0.21310 2/8/2013 PHENDIMETRAZINE TARTRATE 35 MG TABLET 0.13900 0.13900 2/8/2013 PHENELZINE SULFATE 15 MG TABLET 0.58450 0.58450 2/8/2013 PHENOBARBITAL 100 MG TABLET 0.21437 0.21437 2/8/2013 PHENOBARBITAL 15 MG TABLET 0.11561 0.11561 2/8/2013 PHENOBARBITAL 16.2 MG TABLET 0.08268 0.08268 2/8/2013 PHENOBARBITAL 20 MG/5 ML ELIXIR 0.03732 0.03732 2/8/2013 PHENOBARBITAL 30 MG TABLET 0.08000 0.08000 2/8/2013 PHENOBARBITAL 32.4MG TABLET 0.10387 0.10387 2/8/2013 PHENOBARBITAL 64.8MG TABLET 0.13240 0.13240 2/8/2013 PHENOBARBITAL 97.2MG TABLET 0.19010 0.19010 2/8/2013 PHENOBARBITAL SODIUM 130MG/ML VIAL 24.19200 24.19200 2/8/2013 PHENOBARBITAL SODIUM 65 MG/ML VIAL 18.26916 18.26916 2/8/2013 PHENTERMINE HCL 15 MG CAPSULE 0.76603 0.76603 2/8/2013 PHENTERMINE HCL 30 MG CAPSULE 0.20502 0.20502 2/8/2013 PHENTERMINE HCL 37.5 MG CAPSULE 0.31195 0.31195 2/8/2013 PHENTERMINE HCL 37.5 MG TABLET 0.10693 0.10693 2/8/2013 PHENTOLAMINE MESYLATE 5 MG VIAL 59.45000 59.45000 2/8/2013 PHENTOLAMINE MESYLATE 5 MG/ML(1) VIAL 257.37180 257.37180 2/8/2013 PHENYLEPHRINE HCL 10 % DROPS 0.88140 0.88140 2/8/2013 PHENYLEPHRINE HCL 10 MG TABLET 0.03575 0.03575 2/8/2013 PHENYLEPHRINE HCL 2.5 % DROPS 0.93706 0.93706 2/8/2013 PHENYLEPHRINE HCL 2.5 MG/5ML SOLUTION 0.04146 0.04146 2/8/2013 PHENYLEPHRINE HCL/COD/PROMETH 5-10-6.25 SYRUP 0.08488 0.08488 2/8/2013 PHENYLEPHRINE HCL/PROMETH HCL 5-6.25MG/5 SYRUP 0.06227 0.06227 2/8/2013 PHENYLEPHRINE/BROMPHENIRAMINE 10-4MG/5ML LIQUID 0.15294 0.15294 2/8/2013 PHENYLEPHRINE/BROMPHENIRAMINE 10MG-6MG/5 ORAL SUSP 0.25513 0.25513 2/8/2013 PHENYLEPHRINE/CHLOPHEDIANOL/GG 5-12.5-120 LIQUID 0.08957 0.08957 2/8/2013 PHENYLEPHRINE/CHLORPHENIRAMINE 10-4MG/5ML LIQUID 0.02656 0.02656 2/8/2013 PHENYLEPHRINE/CHLORPHENIRAMINE 2MG-1MG/ML DROPS 0.45951 0.45951 2/8/2013 PHENYLEPHRINE/CHLORPHENIRAMINE 3.5-1MG/ML DROPS 0.37657 0.37657 2/8/2013 PHENYLEPHRINE/PYRILAMINE 5-16MG/5ML ORAL SUSP 0.40978 0.40978 2/8/2013 100 MG/4ML ORAL SUSP 0.27300 0.27300 2/8/2013 PHENYTOIN 125 MG/5ML ORAL SUSP 0.09454 0.09454 2/8/2013 PHENYTOIN 50 MG TAB CHEW 0.36840 0.36840 2/8/2013 PHENYTOIN SODIUM 50 MG/ML AMPUL 0.55356 0.55356 2/8/2013 PHENYTOIN SODIUM 50 MG/ML DISP SYRIN 0.68460 0.68460 2/8/2013 PHENYTOIN SODIUM 50 MG/ML VIAL 0.36005 0.36005 2/8/2013 Page 41 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE 0.08831 0.08831 2/8/2013 PHENYTOIN SODIUM EXTENDED 200 MG CAPSULE 0.55987 0.55987 2/8/2013 PHENYTOIN SODIUM EXTENDED 300 MG CAPSULE 0.83864 0.83864 2/8/2013 PHOSP ACID/DEXTROSE/FRUCTOSE SOLUTION 0.02023 0.02023 2/8/2013 PHOSPHORUS #1 250 MG TABLET 0.13195 0.13195 2/8/2013 PHYTONADIONE 10 MG/ML AMPUL 7.53480 7.53480 2/8/2013 PHYTONADIONE 100 MCG TABLET 0.02144 0.02144 2/8/2013 PILOCARPINE HCL 1 % DROPS 1.49986 1.49986 2/8/2013 PILOCARPINE HCL 2 % DROPS 1.68036 1.68036 2/8/2013 PILOCARPINE HCL 4 % DROPS 2.08598 2.08598 2/8/2013 PILOCARPINE HCL 5 MG TABLET 0.23249 0.23249 2/8/2013 PILOCARPINE HCL 7.5 MG TABLET 1.12463 1.12463 2/8/2013 PINDOLOL 10 MG TABLET 0.98952 0.98952 2/8/2013 PINDOLOL 5 MG TABLET 0.72625 0.72625 2/8/2013 PIOGLITAZONE HCL 15 MG TABLET 2.33598 2.33598 2/8/2013 PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G VIAL 4.27310 4.27310 2/8/2013 PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G VIAL PORT 8.32230 8.32230 2/8/2013 PIPERACILLIN SODIUM/TAZOBACTAM 3.375 G VIAL 5.91185 5.91185 2/8/2013 PIPERACILLIN SODIUM/TAZOBACTAM 3.375 G VIAL PORT 11.57100 11.57100 2/8/2013 PIPERACILLIN SODIUM/TAZOBACTAM 4.5G VIAL 7.49400 7.49400 2/8/2013 PIPERACILLIN SODIUM/TAZOBACTAM 4.5G VIAL PORT 15.73320 15.73320 2/8/2013 PIPERACILLIN SODIUM/TAZOBACTAM 40.5G VIAL 77.53100 77.53100 2/8/2013 PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% SHAMPOO 0.03613 0.03613 2/8/2013 PIROXICAM 10 MG CAPSULE 1.05404 1.05404 2/8/2013 PIROXICAM 20 MG CAPSULE 1.96681 1.80000 2/8/2013 PN W-CA64/IRON CB&GL/FA/DSS/DH 90-1-300MG COMBO. PKG 0.76697 0.76697 2/8/2013 PNV #8/IRON PS CMP&ASPG/FA/DHA 22-6-1-200 COMBO. PKG 0.51923 0.51923 2/8/2013 PNV #87/IRON BISGLY/FA/DHA 32-1-230MG COMBO. PKG 0.65450 0.65450 2/8/2013 PNV 11-IRON FUM-FOLIC ACID-OM3 28-1-200MG CAPSULE 1.71267 1.71267 2/8/2013 PNV CMB#21/IRON/FOLIC ACID 14 MG-400 TABLET 0.06411 0.06411 2/8/2013 PNV CMB#95/FERROUS FUMARATE/FA 28MG-0.8MG TABLET 0.05040 0.05040 2/8/2013 PNV COMBO #22/IRON/FA/OM3/DHA 28-6-1-203 COMBO. PKG 0.62148 0.62148 2/8/2013 PNV COMBO#47/IRON/FA #1/DHA 27-1-300MG CAPSULE 1.59289 1.59289 2/8/2013 PNV NO.15/IRON FUM & PS CMP/FA 85 MG-1 MG CAPSULE 1.15359 1.15359 2/8/2013 PNV NO.22/IRON CBN&GLUC/FA/DSS 27-1-50MG TABLET 0.34913 0.34913 2/8/2013 PNV NO.23-IRON PS COMPLEX-FA 155 MG-1MG CAPSULE 0.20689 0.20689 2/8/2013 PNV W-CA #40/IRON FUM/FA CMB#1 27 MG-1 MG TABLET 1.77551 1.77551 2/8/2013 PNV W-CA NO.37/IRON/FA/OMEGA-3 27-1-330MG CAPSULE 0.74533 0.74533 2/8/2013 PNV WITH CA #68/IRON/FA#1/DHA 28-1-300MG CAPSULE 1.68677 1.68677 2/8/2013 PNV WITH CA,NO.71/IRON/FA 27 MG-1 MG TABLET 0.06240 0.06240 2/8/2013 PNV WITH CA,NO.72/IRON,CARB/FA 29 MG-1 MG TABLET 0.13209 0.13209 2/8/2013 PNV WITH CA,NO.72/IRON/FA 27 MG-1 MG TABLET 0.06740 0.06740 2/8/2013 PNV WITH CA,NO.74/IRON/FA 27 MG-1 MG TABLET 0.02207 0.02207 2/8/2013 PNV W-O CA NO5/FE FUMARATE/FA 106.5-1MG CAPSULE 0.24367 0.24367 2/8/2013 PNV W-O IRON/FA/CALCIUM/B6/B12 1-200-75 TBMP 24HR 0.70590 0.70590 2/8/2013 PNV#16/IRON FUM & PS/FA/OM-3 35-1-200MG CAPSULE 1.28451 1.28451 2/8/2013 PNV#75/IRON FUM/FA/OM3/DHA/EPA 28-800-440 COMBO. PKG 0.13988 0.13988 2/8/2013 PNV#79/IRON/FA/LMFOLATE CA/DHA 27-1.13 MG CAPSULE 1.81370 1.63357 2/8/2013 PNV,CA42/IRON/FA/LMEFOL CA/DHA 27-1.13 MG CAPSULE 1.36127 1.36127 2/8/2013 PNV/FA/B6/CALCIUM PHOS/GINGER 1.2-40-100 TABLET 0.72360 0.72360 2/8/2013 PNV17/IRON/FA/FISH OIL/DHA/OM 35-5-1.2MG CAPSULE 1.61980 1.61980 2/8/2013 PNV2/IRON B-G SUC-P/FA/OMEGA-3 29-1-250MG COMBO. PKG 0.36225 0.36225 2/8/2013 PNV22/IRON CBN&GLUC/FA/DSS/DHA 27-1-50MG COMBO. PKG 0.63047 0.63047 2/8/2013 PNV34/IRON,CARBONYL/FA/DSS/DHA 30-1-50 MG CAPSULE 1.58305 1.58305 2/8/2013 PNV38/IRON CBN&GLUC/FA/DSS/DHA 35-1-50MG COMBO. PKG 0.78493 0.78493 2/8/2013 PNV53/IRON B-G HCL-P/FA/OMEGA3 29-1-400MG COMBO. PKG 0.43260 0.43260 2/8/2013 PNV54/IRON B-G HCL-P/FA/OMEGA3 29-1-430MG COMBO. PKG 0.43260 0.43260 2/8/2013 Page 42 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price PNV66/IRON FUMARATE/FA/DSS/DHA 27-1.25-55 CAPSULE 1.36056 1.36056 2/8/2013 PNV80/IRON FUMARATE/FA/DSS/DHA 29-1.25-55 CAPSULE 1.98769 1.98769 2/8/2013 PNV81/SOD IRON EDTA& PS/FA/OM3 27-1-430MG CMBPKGDRCP 0.86509 0.86509 2/8/2013 PNV94/SOD IRON EDTA& PS/FA/OM3 26-1-374MG CMBPKGDRCP 1.13225 1.13225 2/8/2013 PODOFILOX 0.5 % SOLUTION 14.15050 14.15050 2/8/2013 3350 17G POWD PACK 0.10921 0.10921 2/8/2013 POLYETHYLENE GLYCOL 3350 17G/DOSE POWDER 0.04100 0.04100 2/8/2013 POLYMYXIN B SULF/TRIMETHOPRIM 10K/ML-0.1 DROPS 0.89840 0.89840 2/8/2013 POLYVINYL ALCOHOL 1.4 % DROPS 0.13400 0.13400 2/8/2013 POT CHLORIDE/POT BICARB/CIT AC 25 MEQ TABLET EFF 0.68997 0.68997 2/8/2013 POTASSIUM ACETATE 4 MEQ/ML VIAL 0.08400 0.08400 2/8/2013 POTASSIUM BICARBONATE/CIT AC 25 MEQ TABLET EFF 0.24405 0.21200 2/8/2013 POTASSIUM CHLORIDE 10 MEQ CAPSULE ER 0.69475 0.69475 2/8/2013 POTASSIUM CHLORIDE 10 MEQ TAB ER PRT 0.38632 0.38632 2/8/2013 POTASSIUM CHLORIDE 10MEQ/0.1L PIGGYBACK 0.02218 0.02218 2/8/2013 POTASSIUM CHLORIDE 10MEQ/50ML PIGGYBACK 0.04368 0.04368 2/8/2013 POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN 0.02806 0.02806 2/8/2013 POTASSIUM CHLORIDE 2 MEQ/ML VIAL 0.06472 0.06472 2/8/2013 POTASSIUM CHLORIDE 20 MEQ TAB ER PRT 0.39491 0.39491 2/8/2013 POTASSIUM CHLORIDE 20MEQ/0.1L PIGGYBACK 0.02268 0.02268 2/8/2013 POTASSIUM CHLORIDE 20MEQ/15ML LIQUID 0.01350 0.01350 2/8/2013 POTASSIUM CHLORIDE 20MEQ/50ML PIGGYBACK 0.10605 0.10605 2/8/2013 POTASSIUM CHLORIDE 30MEQ/0.1L PIGGYBACK 0.04528 0.04528 2/8/2013 POTASSIUM CHLORIDE 40MEQ/0.1L PIGGYBACK 0.04897 0.04897 2/8/2013 POTASSIUM CHLORIDE 40MEQ/15ML LIQUID 0.02955 0.02955 2/8/2013 POTASSIUM CHLORIDE 8 MEQ CAPSULE ER 0.65780 0.65780 2/8/2013 POTASSIUM CHLORIDE IN 0.9%NACL 20 MEQ/L IV SOLN 0.00295 0.00295 2/8/2013 POTASSIUM CHLORIDE IN 0.9%NACL 40 MEQ/L IV SOLN 0.00510 0.00510 2/8/2013 POTASSIUM CHLORIDE IN D5W 20 MEQ/L IV SOLN 0.00233 0.00233 2/8/2013 POTASSIUM CHLORIDE IN D5W 30 MEQ/L IV SOLN 0.00266 0.00266 2/8/2013 POTASSIUM CHLORIDE IN D5W 40 MEQ/L IV SOLN 0.00209 0.00209 2/8/2013 POTASSIUM CHLORIDE IN LR-D5 20 MEQ/L IV SOLN 0.00607 0.00607 2/8/2013 POTASSIUM CHLORIDE IN LR-D5 40 MEQ/L IV SOLN 0.00403 0.00403 2/8/2013 POTASSIUM CHLORIDE/D5-0.2%NACL 10 MEQ/L IV SOLN 0.00234 0.00234 2/8/2013 POTASSIUM CHLORIDE/D5-0.2%NACL 20 MEQ/L IV SOLN 0.00322 0.00322 2/8/2013 POTASSIUM CHLORIDE/D5-0.2%NACL 30 MEQ/L IV SOLN 0.00231 0.00231 2/8/2013 POTASSIUM CHLORIDE/D5-0.2%NACL 40 MEQ/L IV SOLN 0.00227 0.00227 2/8/2013 POTASSIUM CHLORIDE/D5-0.3%NACL 20 MEQ/L IV SOLN 0.00322 0.00322 2/8/2013 POTASSIUM CHLORIDE/D5-0.45NACL 10 MEQ/L IV SOLN 0.00230 0.00230 2/8/2013 POTASSIUM CHLORIDE/D5-0.45NACL 20 MEQ/L IV SOLN 0.00228 0.00228 2/8/2013 POTASSIUM CHLORIDE/D5-0.45NACL 30 MEQ/L IV SOLN 0.00236 0.00236 2/8/2013 POTASSIUM CHLORIDE/D5-0.45NACL 40 MEQ/L IV SOLN 0.00228 0.00228 2/8/2013 POTASSIUM CHLORIDE/D5-0.9%NACL 20 MEQ/L IV SOLN 0.00254 0.00254 2/8/2013 POTASSIUM CHLORIDE/D5-0.9%NACL 40 MEQ/L IV SOLN 0.00542 0.00542 2/8/2013 POTASSIUM CHLORIDE-0.45% NACL 20 MEQ/L IV SOLN 0.00414 0.00414 2/8/2013 POTASSIUM CITRATE 10 MEQ TABLET ER 0.99255 0.99255 2/8/2013 POTASSIUM CITRATE 5 MEQ TABLET ER 0.70811 0.70811 2/8/2013 POVIDONE- 0.3 % SOLUTION 0.00989 0.00901 2/15/2013 POVIDONE-IODINE 10 % MED. SWAB 0.14539 0.12280 2/15/2013 POVIDONE-IODINE 10 % OINT. (G) 0.06258 0.06258 2/8/2013 POVIDONE-IODINE 10 % SOLUTION 0.00643 0.00643 2/8/2013 PRAMIPEXOLE DI-HCL 0.125 MG TABLET 0.05317 0.05317 2/8/2013 PRAMIPEXOLE DI-HCL 0.25 MG TABLET 0.06919 0.06919 2/8/2013 PRAMIPEXOLE DI-HCL 0.5 MG TABLET 0.09023 0.09023 2/8/2013 PRAMIPEXOLE DI-HCL 0.75 MG TABLET 0.10719 0.10719 2/8/2013 PRAMIPEXOLE DI-HCL 1 MG TABLET 0.09591 0.09591 2/8/2013 PRAMIPEXOLE DI-HCL 1.5 MG TABLET 0.09909 0.09909 2/8/2013 Page 43 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price PRAMOXINE HCL 1 % TOWELETTE 0.35233 0.35233 2/8/2013 PRAVASTATIN SODIUM 10 MG TABLET 0.07517 0.07517 2/8/2013 PRAVASTATIN SODIUM 20 MG TABLET 0.07732 0.07732 2/8/2013 PRAVASTATIN SODIUM 40 MG TABLET 0.10157 0.10157 2/8/2013 PRAVASTATIN SODIUM 80 MG TABLET 0.19350 0.19350 2/8/2013 PRAZOSIN HCL 1 MG CAPSULE 0.09715 0.09715 2/8/2013 PRAZOSIN HCL 2 MG CAPSULE 0.19135 0.19135 2/8/2013 PRAZOSIN HCL 5 MG CAPSULE 0.30498 0.30498 2/8/2013 PREDNICARBATE 0.1 % CREAM (G) 0.86964 0.86964 2/8/2013 PREDNICARBATE 0.1 % OINT. (G) 1.13044 1.13044 2/8/2013 PREDNISOLONE 15 MG/5 ML SOLUTION 0.02251 0.02251 2/8/2013 PREDNISOLONE ACETATE 1 % DROPS SUSP 1.65624 1.65624 2/8/2013 PREDNISOLONE SOD PHOSPHATE 1 % DROPS 4.19720 4.19720 2/8/2013 PREDNISOLONE SOD PHOSPHATE 15 MG/5 ML SOLUTION 0.06975 0.06975 2/8/2013 PREDNISOLONE SOD PHOSPHATE 25 MG/5 ML SOLUTION 1.31101 1.31101 2/8/2013 PREDNISONE 1 MG TABLET 0.06452 0.06452 2/8/2013 PREDNISONE 10 MG TAB DS PK 0.17809 0.17809 2/8/2013 PREDNISONE 10 MG TABLET 0.03055 0.03055 2/8/2013 PREDNISONE 2.5 MG TABLET 0.03471 0.03471 2/8/2013 PREDNISONE 20 MG TABLET 0.05494 0.05494 2/8/2013 PREDNISONE 5 MG TAB DS PK 0.09286 0.09286 2/8/2013 PREDNISONE 5 MG TABLET 0.01742 0.01742 2/8/2013 PREDNISONE 5 MG/5 ML SOLUTION 0.12892 0.14180 2/15/2013 PREDNISONE 50 MG TABLET 0.21721 0.21721 2/8/2013 PRENATAL #57/IRON/FA/DSS/DHA 29-1.25-55 CAPSULE 1.99010 1.99010 2/8/2013 PRENATAL VIT #76/IRON,CARB/FA 29 MG-1 MG TABLET 0.11903 0.11903 2/8/2013 PRENATAL VIT 15/IRON CB/FA/DSS 90-1-50 MG TABLET 0.11779 0.11779 2/8/2013 PRENATAL VIT 16/IRON CB/FA/DSS 90-1-50 MG TABLET 0.21984 0.21984 2/8/2013 PRENATAL VIT 18/IRON CB/FA/DSS 90-1-50 MG TABLET 0.08177 0.08177 2/8/2013 PRENATAL VIT NO.73/IRON/FA 28 MG-1 MG TABLET 0.18018 0.18018 2/8/2013 PRENATAL VIT#86/IRON BISGLY/FA 32 MG-1 MG TABLET 0.83895 0.83895 2/8/2013 PRENATAL VIT#96/FERROUS FUM/FA 27MG-0.8MG TABLET 0.06840 0.06840 2/8/2013 PRENATAL VIT/FE FUM/DOSS/FA 29 MG-1 MG TABLET 0.26712 0.36358 2/15/2013 PRENATAL VIT/FE FUMARATE/FA/SE 27 MG-1 MG TABLET 0.15301 0.15301 2/8/2013 PRENATAL VIT/IRON FUMARATE/FA 27MG-0.8MG TABLET 0.03120 0.03120 2/8/2013 PRENATAL VIT/IRON FUMARATE/FA 28MG-0.8MG TABLET 0.04810 0.04810 2/8/2013 PRENATAL VIT/IRON FUMARATE/FA 29 MG-1 MG TAB CHEW 0.30968 0.42805 2/15/2013 PRENATAL VIT/IRON FUMARATE/FA 65 MG-1 MG TABLET 0.07504 0.07504 2/8/2013 PRENATAL VIT27&CALCIUM/IRON/FA 60 MG-1 MG TABLET 0.18207 0.18207 2/8/2013 PRENATAL VITAMINS#21, IRON, FA 28-6-1 MG TABLET 1.46985 1.46985 2/8/2013 PRENATAL VITS #90/IRON FUM/FA 9 MG-0.5MG TABLET 0.08394 0.08394 2/8/2013 PRENATAL VITS W-CA,FE,FA(<1MG) TABLET 0.03401 0.03465 2/8/2013 PRIMAQUINE PHOSPHATE 26.3 MG TABLET 1.25286 1.25286 2/8/2013 PRIMIDONE 250 MG TABLET 0.18425 0.18425 2/8/2013 PRIMIDONE 50 MG TABLET 0.08938 0.08938 2/8/2013 PROBENECID 500 MG TABLET 0.51720 0.51720 2/8/2013 PROCAINAMIDE HCL 100 MG/ML VIAL 1.98492 1.98492 2/8/2013 PROCAINAMIDE HCL 500 MG/ML VIAL 8.23200 8.23200 2/8/2013 PROCHLORPERAZINE EDISYLATE 10 MG/2 ML VIAL 1.93200 1.93200 2/8/2013 PROCHLORPERAZINE EDISYLATE 5 MG/ML VIAL 1.95300 1.95300 2/8/2013 PROCHLORPERAZINE MALEATE 10 MG TABLET 0.06594 0.06594 2/8/2013 PROCHLORPERAZINE MALEATE 25 MG SUPP.RECT 3.08073 3.08073 2/8/2013 PROCHLORPERAZINE MALEATE 5 MG TABLET 0.05963 0.05963 2/8/2013 PROGESTERONE 50 MG/ML VIAL 2.02150 2.02150 2/8/2013 PROGESTERONE,MICRONIZED 100 MG CAPSULE 1.49219 1.49219 2/8/2013 PROGESTERONE,MICRONIZED 200 MG CAPSULE 2.83472 2.83472 2/8/2013 PROMETHAZINE HCL 12.5 MG SUPP.RECT 3.15330 3.15330 2/8/2013 Page 44 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price PROMETHAZINE HCL 12.5 MG TABLET 0.08013 0.08013 2/8/2013 PROMETHAZINE HCL 25 MG SUPP.RECT 3.41839 3.41839 2/8/2013 PROMETHAZINE HCL 25 MG TABLET 0.09320 0.09320 2/8/2013 PROMETHAZINE HCL 25 MG/ML AMPUL 1.10880 1.10880 2/8/2013 PROMETHAZINE HCL 25 MG/ML DISP SYRIN 1.04160 1.04160 2/8/2013 PROMETHAZINE HCL 25 MG/ML VIAL 0.76918 0.76918 2/8/2013 PROMETHAZINE HCL 50 MG TABLET 0.12958 0.12958 2/8/2013 PROMETHAZINE HCL 50 MG/ML AMPUL 1.55400 1.55400 2/8/2013 PROMETHAZINE HCL 50 MG/ML VIAL 1.91280 1.91280 2/8/2013 PROMETHAZINE HCL 6.25MG/5ML SYRUP 0.01501 0.01501 2/8/2013 PROPAFENONE HCL 150 MG TABLET 0.22539 0.22539 2/8/2013 PROPAFENONE HCL 225 MG CAP ER 12H 4.78088 4.78088 2/8/2013 PROPAFENONE HCL 225 MG TABLET 0.37440 0.37440 2/8/2013 PROPAFENONE HCL 300 MG TABLET 1.00958 1.00958 2/8/2013 PROPAFENONE HCL 325 MG CAP ER 12H 6.05698 6.05698 2/8/2013 PROPAFENONE HCL 425 MG CAP ER 12H 6.05698 6.05698 2/8/2013 PROPANTHELINE BROMIDE 15 MG TABLET 0.46522 0.50037 2/15/2013 PROPARACAINE HCL 0.5 % DROPS 0.41513 0.41513 2/8/2013 PROPRANOLOL HCL POWDER 1.69832 1.69832 2/8/2013 PROPRANOLOL HCL 10 MG TABLET 0.02090 0.02090 2/8/2013 PROPRANOLOL HCL 120 MG CAP SA 24H 0.86631 0.86631 2/8/2013 PROPRANOLOL HCL 160 MG CAP SA 24H 1.17049 1.17049 2/8/2013 PROPRANOLOL HCL 20 MG TABLET 0.02211 0.02211 2/8/2013 PROPRANOLOL HCL 20 MG/5 ML SOLUTION 0.13142 0.13142 2/8/2013 PROPRANOLOL HCL 40 MG TABLET 0.02640 0.02640 2/8/2013 PROPRANOLOL HCL 40MG/5ML SOLUTION 0.18736 0.18736 2/8/2013 PROPRANOLOL HCL 60 MG CAP SA 24H 0.59777 0.59777 2/8/2013 PROPRANOLOL HCL 60 MG TABLET 0.54766 0.54766 2/8/2013 PROPRANOLOL HCL 80 MG CAP SA 24H 0.82359 0.82359 2/8/2013 PROPRANOLOL HCL 80 MG TABLET 0.04208 0.04208 2/8/2013 PROPRANOLOL/HYDROCHLOROTHIAZID 40 MG-25MG TABLET 0.75901 0.75901 2/8/2013 PROPRANOLOL/HYDROCHLOROTHIAZID 80 MG-25MG TABLET 0.93219 0.93219 2/8/2013 PROTAMINE SULFATE 10 MG/ML VIAL 0.94451 0.94451 2/8/2013 PROTECT CMB2/CERAMIDE 1,3,6-11 CREAM (G) 1.87356 1.87356 2/8/2013 PROTRIPTYLINE HCL 10 MG TABLET 1.43134 1.43134 2/8/2013 PROTRIPTYLINE HCL 5 MG TABLET 0.79017 0.79017 2/8/2013 PSEUDOEPH/CHLOPHEDIANOL/GG 30-12.5/5 LIQUID 0.08601 0.08601 2/8/2013 PSEUDOEPHED/CHLORPHENIRAMINE 60 MG-4 MG TABLET 0.05308 0.05308 2/8/2013 PSEUDOEPHED/CHLORPHENIRAMINE 9-0.8MG/ML DROPS 1.18743 1.18743 2/8/2013 PSEUDOEPHEDRINE HCL 30 MG TABLET 0.02205 0.02205 2/8/2013 PSEUDOEPHEDRINE HCL 60 MG TABLET 0.04787 0.02105 2/15/2013 PSEUDOEPHEDRINE/BROMPHENIRAMIN 20-4MG/5ML LIQUID 0.19213 0.19213 2/8/2013 PSEUDOEPHEDRINE/BROMPHENIRAMIN 7.5-1MG/ML DROPS 1.53592 1.53592 2/8/2013 PSYLLIUM HUSK (WITH SUGAR) 3.4 G/7 G POWDER 0.01233 0.01233 2/8/2013 PSYLLIUM SEED PACKET 0.06499 0.06499 2/8/2013 PSYLLIUM SEED POWDER 0.01838 0.01838 2/8/2013 PSYLLIUM SEED (WITH DEXTROSE) POWDER 0.01135 0.01135 2/8/2013 PSYLLIUM SEED (WITH SUGAR) PACKET 0.22937 0.20919 2/15/2013 PSYLLIUM SEED (WITH SUGAR) POWDER 0.00932 0.00932 2/8/2013 PSYLLIUM SEED/ASPARTAME POWDER 0.01835 0.01835 2/8/2013 PYRANTEL PAMOATE 50 MG/ML ORAL SUSP 0.16310 0.16310 2/8/2013 PYRAZINAMIDE 500 MG TABLET 0.77720 0.77720 2/8/2013 PYRIDOSTIGMINE BROMIDE 60 MG TABLET 0.56207 0.56207 2/8/2013 PYRIDOXINE HCL 100 MG TABLET 0.02399 0.02399 2/8/2013 PYRIDOXINE HCL 100 MG/ML VIAL 7.86632 7.86632 2/8/2013 PYRIDOXINE HCL 25 MG TABLET 0.02188 0.02188 2/8/2013 PYRIDOXINE HCL 50 MG TABLET 0.01407 0.01407 2/8/2013 Page 45 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price QUETIAPINE FUMARATE 100 MG TABLET 0.37260 0.37260 2/8/2013 QUETIAPINE FUMARATE 200 MG TABLET 0.70330 0.70330 2/8/2013 QUETIAPINE FUMARATE 25 MG TABLET 0.21760 0.21760 2/8/2013 QUETIAPINE FUMARATE 300 MG TABLET 0.92200 0.92200 2/8/2013 QUETIAPINE FUMARATE 400 MG TABLET 1.14370 1.14370 2/8/2013 QUETIAPINE FUMARATE 50 MG TABLET 0.35700 0.35700 2/8/2013 QUINAPRIL HCL 10 MG TABLET 0.19240 0.19240 2/8/2013 QUINAPRIL HCL 20 MG TABLET 0.19240 0.19240 2/8/2013 QUINAPRIL HCL 40 MG TABLET 0.18590 0.18590 2/8/2013 QUINAPRIL HCL 5 MG TABLET 0.18685 0.18685 2/8/2013 QUINAPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.74317 0.74317 2/8/2013 QUINAPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.70590 0.70590 2/8/2013 QUINAPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.67571 0.67571 2/8/2013 QUINIDINE GLUCONATE 324 MG TABLET ER 0.95830 0.95830 2/8/2013 QUINIDINE GLUCONATE 80 MG/ML VIAL 3.64770 3.64770 2/8/2013 QUINIDINE SULFATE 200 MG TABLET 0.14147 0.14147 2/8/2013 QUINIDINE SULFATE 300 MG TABLET 0.27039 0.27039 2/8/2013 QUINIDINE SULFATE 300 MG TABLET ER 0.70850 0.70850 2/8/2013 QUININE SULFATE 324 MG CAPSULE 5.12820 5.12820 2/8/2013 RAMIPRIL 1.25 MG CAPSULE 0.15738 0.15738 2/8/2013 RAMIPRIL 10 MG CAPSULE 0.05842 0.05842 2/8/2013 RAMIPRIL 2.5 MG CAPSULE 0.09527 0.09527 2/8/2013 RAMIPRIL 5 MG CAPSULE 0.06606 0.06606 2/8/2013 RANITIDINE HCL 15 MG/ML SYRUP 0.02157 0.02157 2/8/2013 RANITIDINE HCL 150 MG CAPSULE 0.89981 0.89981 2/8/2013 RANITIDINE HCL 150 MG TABLET 0.02586 0.02586 2/8/2013 RANITIDINE HCL 25 MG/ML VIAL 0.86997 0.86997 2/8/2013 RANITIDINE HCL 300 MG CAPSULE 1.57430 1.57430 2/8/2013 RANITIDINE HCL 300 MG TABLET 0.05186 0.05186 2/8/2013 RANITIDINE HCL 75 MG TABLET 0.08884 0.08884 2/8/2013 RIBAVIRIN 200 MG CAPSULE 0.37788 0.37788 2/8/2013 RIBAVIRIN 200 MG TABLET 0.62027 0.62027 2/8/2013 RIBOFLAVIN 25 MG TABLET 0.02308 0.01929 2/15/2013 RIFAMPIN 150 MG CAPSULE 1.02336 1.02336 2/8/2013 RIFAMPIN 300 MG CAPSULE 0.70390 0.70390 2/8/2013 RIMANTADINE HCL 100 MG TABLET 2.00122 2.00122 2/8/2013 RINGERS SOLUTION IRRIG SOLN 0.00337 0.00337 2/8/2013 RINGERS SOLUTION IV SOLN 0.00246 0.00246 2/8/2013 RINGERS SOLUTION,LACTATED IRRIG SOLN 0.00220 0.00220 2/8/2013 RINGERS SOLUTION,LACTATED IV SOLN 0.00179 0.00179 2/8/2013 RISPERIDONE 0.25 MG TAB RAPDIS 5.90310 5.90310 2/8/2013 RISPERIDONE 0.25 MG TABLET 0.06807 0.06807 2/8/2013 RISPERIDONE 0.5 MG TAB RAPDIS 1.63350 1.63350 2/8/2013 RISPERIDONE 0.5 MG TABLET 0.07678 0.07678 2/8/2013 RISPERIDONE 1 MG TAB RAPDIS 2.58522 2.58522 2/8/2013 RISPERIDONE 1 MG TABLET 0.09407 0.09407 2/8/2013 RISPERIDONE 1 MG/ML SOLUTION 0.39838 0.39838 2/8/2013 RISPERIDONE 2 MG TAB RAPDIS 3.00101 3.00101 2/8/2013 RISPERIDONE 2 MG TABLET 0.10157 0.10157 2/8/2013 RISPERIDONE 3 MG TAB RAPDIS 7.26000 7.26000 2/8/2013 RISPERIDONE 3 MG TABLET 0.11296 0.11296 2/8/2013 RISPERIDONE 4 MG TAB RAPDIS 9.32984 9.32984 2/8/2013 RISPERIDONE 4 MG TABLET 0.22070 0.22070 2/8/2013 RIVASTIGMINE TARTRATE 1.5 MG CAPSULE 2.05087 2.05087 2/8/2013 RIVASTIGMINE TARTRATE 3 MG CAPSULE 2.05087 2.05087 2/8/2013 RIVASTIGMINE TARTRATE 4.5 MG CAPSULE 2.05087 2.05087 2/8/2013 RIVASTIGMINE TARTRATE 6 MG CAPSULE 2.05087 2.05087 2/8/2013 Page 46 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price RIZATRIPTAN BENZOATE 10 MG TAB RAPDIS 23.26722 23.26722 2/8/2013 RIZATRIPTAN BENZOATE 10 MG TABLET 5.14855 5.14855 2/8/2013 RIZATRIPTAN BENZOATE 5 MG TAB RAPDIS 23.26722 23.26722 2/8/2013 RIZATRIPTAN BENZOATE 5 MG TABLET 5.19459 5.19459 2/8/2013 ROPINIROLE HCL 0.25 MG TABLET 0.16777 0.16777 2/8/2013 ROPINIROLE HCL 0.5 MG TABLET 0.16777 0.16777 2/8/2013 ROPINIROLE HCL 1 MG TABLET 0.16777 0.16777 2/8/2013 ROPINIROLE HCL 12 MG TAB ER 24H 9.57763 9.57763 2/8/2013 ROPINIROLE HCL 2 MG TAB ER 24H 1.91454 1.91454 2/8/2013 ROPINIROLE HCL 2 MG TABLET 0.17165 0.17165 2/8/2013 ROPINIROLE HCL 3 MG TABLET 0.17165 0.17165 2/8/2013 ROPINIROLE HCL 4 MG TAB ER 24H 3.82900 3.82900 2/8/2013 ROPINIROLE HCL 4 MG TABLET 0.17165 0.17165 2/8/2013 ROPINIROLE HCL 5 MG TABLET 0.17165 0.17165 2/8/2013 ROPINIROLE HCL 6 MG TAB ER 24H 5.74373 5.74373 2/8/2013 ROPINIROLE HCL 8 MG TAB ER 24H 5.74373 5.74373 2/8/2013 SALICYLIC ACID 26 % LIQUID 6.03610 6.03610 2/8/2013 SALICYLIC ACID 27.5 % LIQ-FILM 7.24360 7.24360 2/8/2013 SALICYLIC ACID/COAL TAR/SULFUR 2 %-1 %-2% SHAMPOO 0.20597 0.20597 2/8/2013 SALSALATE 500 MG TABLET 0.24616 0.24616 2/8/2013 SALSALATE 750 MG TABLET 0.32817 0.32817 2/8/2013 SCOPOLAMINE HYDROBROMIDE 0.4 MG/ML VIAL 6.67800 6.67800 2/8/2013 SELEGILINE HCL 5 MG CAPSULE 1.61280 1.61280 2/8/2013 SELEGILINE HCL 5 MG TABLET 1.25196 1.25196 2/8/2013 SELENIUM 200 MCG TABLET 0.05761 0.05575 2/15/2013 SELENIUM 40MCG/ML VIAL 0.24063 0.24063 2/8/2013 SELENIUM SULFIDE 2.5 % SUSPENSION 0.07745 0.07745 2/8/2013 SENNOSIDES 8.6 MG TABLET 0.00978 0.00978 2/8/2013 SENNOSIDES 8.8MG/5ML SYRUP 0.04077 0.04077 2/8/2013 SENNOSIDES/DOCUSATE SODIUM 8.6MG-50MG TABLET 0.01849 0.01849 2/8/2013 SERTRALINE HCL 100 MG TABLET 0.07209 0.07209 2/8/2013 SERTRALINE HCL 25 MG TABLET 0.04543 0.04543 2/8/2013 SERTRALINE HCL 50 MG TABLET 0.05414 0.05414 2/8/2013 SILDENAFIL CITRATE 20 MG TABLET 0.57580 0.57580 2/8/2013 GEL ER(ML) 48.44700 48.44700 2/8/2013 0.5 % SOLUTION 0.03476 0.03476 2/8/2013 SILVER SULFADIAZINE 1 % CREAM (G) 0.23000 0.23000 2/8/2013 SIMETHICONE 125 MG CAPSULE 0.09822 0.09822 2/8/2013 SIMETHICONE 125 MG TAB CHEW 0.07236 0.07236 2/8/2013 SIMETHICONE 180 MG CAPSULE 0.07370 0.07370 2/8/2013 SIMETHICONE 40MG/0.6ML DROPS SUSP 0.08040 0.08040 2/8/2013 SIMETHICONE 80 MG TAB CHEW 0.02425 0.02425 2/8/2013 SIMVASTATIN 10 MG TABLET 0.03471 0.03471 2/8/2013 SIMVASTATIN 20 MG TABLET 0.04422 0.04422 2/8/2013 SIMVASTATIN 40 MG TABLET 0.06204 0.06204 2/8/2013 SIMVASTATIN 5 MG TABLET 0.04167 0.04167 2/8/2013 SIMVASTATIN 80 MG TABLET 0.10104 0.10104 2/8/2013 SOD/POT/K CIT/SOD CIT/CIT ACID 500-550/5 SOLUTION 0.02045 0.02045 2/8/2013 SODIUM BENZOATE POWDER 0.04664 0.04664 2/8/2013 SODIUM BICARBONATE 0.5MEQ/ML DISP SYRIN 0.44100 0.44100 2/8/2013 SODIUM BICARBONATE 0.5MEQ/ML VIAL 0.34272 0.34272 2/8/2013 SODIUM BICARBONATE 0.9MEQ/ML DISP SYRIN 0.12734 0.12734 2/8/2013 SODIUM BICARBONATE 1 MEQ/ML DISP SYRIN 0.10248 0.10248 2/8/2013 SODIUM BICARBONATE 1 MEQ/ML VIAL 0.01764 0.01764 2/8/2013 SODIUM BICARBONATE 10MEQ/10ML DISP SYRIN 0.74256 0.74256 2/8/2013 SODIUM BICARBONATE 325 MG TABLET 0.02155 0.02155 2/8/2013 SODIUM BICARBONATE 650 MG TABLET 0.00955 0.00955 2/8/2013 Page 47 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price SODIUM CHLORIDE 0.45 % PGGYBK PRT 0.03635 0.03635 2/8/2013 SODIUM CHLORIDE 0.45 % 0.45 % IV SOLN 0.00151 0.00151 2/8/2013 SODIUM CHLORIDE 0.65 % SPRAY 0.02466 0.02466 2/8/2013 SODIUM CHLORIDE 2.5 MEQ/ML VIAL 0.02985 0.02985 2/8/2013 SODIUM CHLORIDE 3 % 3 % IV SOLN 0.00947 0.00947 2/8/2013 SODIUM CHLORIDE 4 MEQ/ML VIAL 0.02077 0.02077 2/8/2013 SODIUM CHLORIDE 5 % 5 % IV SOLN 0.00769 0.00769 2/8/2013 SODIUM CHLORIDE 5 % OINT. (G) 2.49240 2.49240 2/8/2013 SODIUM CHLORIDE FOR INHALATION 0.9 % VIAL-NEB 0.02995 0.02995 2/8/2013 SODIUM CHLORIDE FOR INHALATION 10 % VIAL-NEB 0.05592 0.05592 2/8/2013 SODIUM CHLORIDE FOR INHALATION 3 % VIAL-NEB 0.04204 0.04204 2/8/2013 SODIUM CHLORIDE FOR INHALATION 7 % VIAL-NEB 0.07000 0.07000 2/8/2013 SODIUM CHLORIDE IRRIG SOLUTION 0.9 % IRRIG SOLN 0.00579 0.00557 2/15/2013 SODIUM CHLORIDE/NAHCO3/KCL/PEG 420G SOLN RECON 0.00375 0.00375 2/8/2013 SODIUM FERRIC GLUCONAT/SUCROSE 62.5MG/5ML VIAL 5.15216 5.15216 2/8/2013 SODIUM FLUORIDE 0.25(0.55) TAB CHEW 0.03780 0.03780 2/8/2013 SODIUM FLUORIDE 0.5 MG/ML DROPS 0.20409 0.20409 2/8/2013 SODIUM FLUORIDE 0.5(1.1)MG TAB CHEW 0.03543 0.03543 2/8/2013 SODIUM FLUORIDE 1.1 % CREAM (G) 0.08013 0.08013 2/8/2013 SODIUM FLUORIDE 1.1 % GEL (GRAM) 0.10130 0.10130 2/8/2013 SODIUM FLUORIDE 1MG(2.2MG) TAB CHEW 0.03882 0.03882 2/8/2013 SODIUM FLUORIDE 1MG(2.2MG) TABLET 0.03570 0.03570 2/8/2013 0.125 % SOLUTION 9.54389 9.54389 2/8/2013 SODIUM HYPOCHLORITE 0.25 % SOLUTION 0.04024 0.04024 2/8/2013 SODIUM HYPOCHLORITE 0.5 % SOLUTION 0.04024 0.04024 2/8/2013 SODIUM LACTATE 5MEQ/ML VIAL 0.39992 0.39992 2/8/2013 SODIUM MORRHUATE 50 MG/ML VIAL 1.96000 1.96000 2/8/2013 SODIUM POLYSTYRENE SULFONATE POWDER 0.23186 0.23186 2/8/2013 SODIUM POLYSTYRENE SULFONATE 15G/60ML ORAL SUSP 0.09470 0.09470 2/8/2013 SODIUM THIOSULFATE 1 G/10 ML VIAL 1.26000 1.26000 2/8/2013 SODIUM THIOSULFATE 12.5G/50ML VIAL 0.30240 0.30240 2/8/2013 SORBITOL SOLUTION 3 % IRRIG SOLN 0.00351 0.00351 2/8/2013 SORBITOL SOLUTION 3.3% IRRIG SOLN 0.00332 0.00332 2/8/2013 SOTALOL HCL 120 MG TABLET 0.17098 0.17098 2/8/2013 SOTALOL HCL 150MG/10ML VIAL 5.46000 5.46000 2/8/2013 SOTALOL HCL 160 MG TABLET 0.25975 0.25975 2/8/2013 SOTALOL HCL 240 MG TABLET 0.56986 0.56986 2/8/2013 SOTALOL HCL 80 MG TABLET 0.10130 0.10130 2/8/2013 SPINOSAD 0.9 % SUSPENSION 3.07772 3.07772 2/8/2013 SPIRONOLACT/HYDROCHLOROTHIAZID 25 MG-25MG TABLET 0.21407 0.21407 2/8/2013 100 % POWDER 4.24580 4.24580 2/8/2013 SPIRONOLACTONE 100 MG TABLET 0.55704 0.55704 2/8/2013 SPIRONOLACTONE 25 MG TABLET 0.09822 0.09822 2/8/2013 SPIRONOLACTONE 50 MG TABLET 0.28502 0.28502 2/8/2013 SPIRONOLACTONE, MICRONIZED 100 % POWDER 10.61375 10.61375 2/8/2013 STAVUDINE 1 MG/ML SOLN RECON 0.27563 0.27563 2/8/2013 STAVUDINE 15 MG CAPSULE 1.32503 1.32503 2/8/2013 STAVUDINE 20 MG CAPSULE 1.31138 1.31138 2/8/2013 STAVUDINE 30 MG CAPSULE 1.46814 1.46814 2/8/2013 STAVUDINE 40 MG CAPSULE 1.40758 1.40758 2/8/2013 STREPTOMYCIN SULFATE 1 G VIAL 11.16500 11.16500 2/8/2013 SUCRALFATE 1 G TABLET 0.22284 0.22284 2/8/2013 SUCRALFATE 1 G/10 ML ORAL SUSP 0.36838 0.41390 2/8/2013 SULFACETAMIDE SOD/SULFUR/UREA 10%-4%-10% CLEANSER 0.15690 0.15690 2/8/2013 SULFACETAMIDE SOD/SULFUR/UREA 10%-5%-10% CLEANSER 0.49178 0.49178 2/8/2013 SULFACETAMIDE SODIUM 10 % CLEANSER 0.34668 0.34668 2/8/2013 SULFACETAMIDE SODIUM 10 % DROPS 2.76012 2.76012 2/8/2013 Page 48 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price SULFACETAMIDE SODIUM 10 % OINT. (G) 13.17200 13.17200 2/8/2013 SULFACETAMIDE SODIUM 10 % SUSPENSION 0.61247 0.61247 2/8/2013 SULFACETAMIDE SODIUM/SULFUR 10%-1% CLEANSER 0.12531 0.12531 2/8/2013 SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) CLEANSER 0.10664 0.10664 2/8/2013 SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) CREAM (G) 4.57333 4.57333 2/8/2013 SULFACETAMIDE SODIUM/SULFUR 8 %-4 % SUSPENSION 0.20795 0.20795 2/8/2013 SULFACETAMIDE SODIUM/SULFUR 9 %-4 % CLEANSER 0.22315 0.22315 2/8/2013 SULFACETAMIDE SODIUM/SULFUR 9 %-4.5 % CLEANSER 0.24901 0.24901 2/8/2013 SULFACETAMIDE/PREDNISOLONE SP 10 %-0.23% DROPS 2.56476 2.56476 2/8/2013 SULFADIAZINE 500 MG TABLET 3.00104 3.00104 2/8/2013 SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ORAL SUSP 0.07069 0.07069 2/8/2013 SULFAMETHOXAZOLE/TRIMETHOPRIM 400MG-80MG TABLET 0.08107 0.08107 2/8/2013 SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160 MG TABLET 0.06180 0.06180 2/8/2013 SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML VIAL 0.53850 0.53850 2/8/2013 SULFASALAZINE 500 MG TABLET 0.09916 0.09916 2/8/2013 SULFASALAZINE 500 MG TABLET DR 0.23852 0.23852 2/8/2013 SULINDAC 150 MG TABLET 0.14043 0.14043 2/8/2013 SULINDAC 200 MG TABLET 0.16308 0.16308 2/8/2013 SUMATRIPTAN 20 MG SPRAY 30.21550 30.21550 2/8/2013 SUMATRIPTAN 5 MG SPRAY 30.21550 30.21550 2/8/2013 SUMATRIPTAN SUCCINATE 100 MG TABLET 0.95475 0.95475 2/8/2013 SUMATRIPTAN SUCCINATE 25 MG TABLET 0.95395 0.95395 2/8/2013 SUMATRIPTAN SUCCINATE 4 MG/0.5ML CARTRIDGE 142.35900 142.35900 2/8/2013 SUMATRIPTAN SUCCINATE 4 MG/0.5ML PEN INJCTR 150.29700 150.29700 2/8/2013 SUMATRIPTAN SUCCINATE 50 MG TABLET 0.84380 0.84380 2/8/2013 SUMATRIPTAN SUCCINATE 6 MG/0.5ML CARTRIDGE 129.12200 129.12200 2/8/2013 SUMATRIPTAN SUCCINATE 6 MG/0.5ML PEN INJCTR 136.48620 136.48620 2/8/2013 SUMATRIPTAN SUCCINATE 6 MG/0.5ML VIAL 26.86187 26.86187 2/8/2013 TACROLIMUS 0.5 MG CAPSULE 1.32070 1.32070 2/8/2013 TACROLIMUS 1 MG CAPSULE 2.53863 2.53863 2/8/2013 TACROLIMUS 5 MG CAPSULE 11.32336 11.32336 2/8/2013 CITRATE 10 MG TABLET 0.15799 0.15799 2/8/2013 TAMOXIFEN CITRATE 20 MG TABLET 0.38860 0.38860 2/8/2013 TAMSULOSIN HCL 0.4 MG CAP ER 24H 0.21266 0.21266 2/8/2013 TEA TREE OIL 100 % OIL 0.23182 0.23182 2/8/2013 TEMAZEPAM 15 MG CAPSULE 0.06955 0.06955 2/8/2013 TEMAZEPAM 22.5 MG CAPSULE 6.10781 6.10781 2/8/2013 TEMAZEPAM 30 MG CAPSULE 0.08804 0.08804 2/8/2013 TEMAZEPAM 7.5 MG CAPSULE 5.38684 5.38684 2/8/2013 TERAZOSIN HCL 1 MG CAPSULE 0.05414 0.05414 2/8/2013 TERAZOSIN HCL 10 MG CAPSULE 0.06941 0.06941 2/8/2013 TERAZOSIN HCL 2 MG CAPSULE 0.06097 0.06097 2/8/2013 TERAZOSIN HCL 5 MG CAPSULE 0.06271 0.06271 2/8/2013 TERBINAFINE HCL 1 % CREAM (G) 0.29480 0.29480 2/8/2013 TERBINAFINE HCL 250 MG TABLET 0.17192 0.17192 2/8/2013 TERBUTALINE SULFATE 2.5 MG TABLET 0.28248 0.28248 2/8/2013 TERBUTALINE SULFATE 5 MG TABLET 0.35640 0.35640 2/8/2013 TERCONAZOLE 0.4 % CREAM/APPL 0.22438 0.22438 2/8/2013 TERCONAZOLE 0.8 % CREAM/APPL 0.46595 0.46595 2/8/2013 TERCONAZOLE 80 MG SUPP.VAG 11.41933 11.41933 2/8/2013 100 MG/ML VIAL 4.13980 4.13980 2/8/2013 TESTOSTERONE CYPIONATE 200 MG/ML VIAL 7.12343 7.12343 2/8/2013 200 MG/ML VIAL 11.07040 11.07040 2/8/2013 TETANUS & DIPHTHERIA TOX,ADULT 2-2LF/0.5 VIAL 30.27570 30.27570 2/8/2013 TETANUS,DIPHTHERIA TOXD PED/PF 5-25/0.5ML VIAL 75.04140 75.04140 2/8/2013 TETRACAINE HCL 0.5 % DROPS 0.49187 0.49187 2/8/2013 TETRACAINE HCL/PF 0.5 % DROPS 8.12963 8.12963 2/8/2013 Page 49 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price TETRACYCLINE POWDER 3.08672 3.08672 2/8/2013 TETRACYCLINE HCL POWDER 0.64823 0.64823 2/8/2013 TETRACYCLINE HCL 250 MG CAPSULE 0.03000 0.03000 2/8/2013 TETRACYCLINE HCL 500 MG CAPSULE 0.05521 0.05521 2/8/2013 THEOPHYLLINE ANHYDROUS 100 MG TAB ER 12H 0.12830 0.12830 2/8/2013 THEOPHYLLINE ANHYDROUS 200 MG TAB ER 12H 0.15428 0.15428 2/8/2013 THEOPHYLLINE ANHYDROUS 300 MG TAB ER 12H 0.19414 0.19414 2/8/2013 THEOPHYLLINE ANHYDROUS 400 MG TABLET ER 0.95032 0.95032 2/8/2013 THEOPHYLLINE ANHYDROUS 450 MG TAB ER 12H 0.47789 0.47789 2/8/2013 THEOPHYLLINE ANHYDROUS 600 MG TABLET ER 1.37319 1.37319 2/8/2013 THEOPHYLLINE ANHYDROUS 80 MG/15ML SOLUTION 0.13875 0.13875 2/8/2013 THEOPHYLLINE/D5W 200MG/0.1L IV SOLN 0.03335 0.03335 2/8/2013 THEOPHYLLINE/D5W 200MG/50ML IV SOLN 0.10836 0.10836 2/8/2013 THEOPHYLLINE/D5W 400MG/.25L IV SOLN 0.01852 0.01852 2/8/2013 THEOPHYLLINE/D5W 400MG/0.5L IV SOLN 0.00730 0.00730 2/8/2013 THEOPHYLLINE/D5W 800MG/.25L IV SOLN 0.02150 0.02150 2/8/2013 THEOPHYLLINE/D5W 800MG/0.5L IV SOLN 0.00508 0.00508 2/8/2013 THIAMINE HCL 100 MG TABLET 0.01380 0.01380 2/8/2013 THIAMINE HCL 100 MG/ML VIAL 3.94044 3.94044 2/8/2013 THIAMINE HCL 50 MG TABLET 0.01586 0.01586 2/8/2013 THIAMINE MONONITRATE 100 MG TABLET 0.02944 0.02643 2/15/2013 THIORIDAZINE HCL 10 MG TABLET 0.20202 0.20202 2/8/2013 THIORIDAZINE HCL 100 MG TABLET 0.41701 0.41701 2/8/2013 THIORIDAZINE HCL 25 MG TABLET 0.29279 0.24040 2/8/2013 THIORIDAZINE HCL 50 MG TABLET 0.31898 0.31898 2/8/2013 THIOTEPA 15 MG VIAL 111.46363 111.46363 2/8/2013 THIOTHIXENE 10 MG CAPSULE 0.42000 0.42000 2/8/2013 THIOTHIXENE 2 MG CAPSULE 0.20027 0.20027 2/8/2013 THIOTHIXENE 5 MG CAPSULE 0.30264 0.30264 2/8/2013 THYROID,PORK 30 MG TABLET 0.09114 0.09114 2/8/2013 THYROID,PORK 60 MG TABLET 0.10129 0.10129 2/8/2013 THYROID,PORK 90 MG TABLET 0.15974 0.15974 2/8/2013 TIAGABINE HCL 2 MG TABLET 4.67694 4.67694 2/8/2013 TIAGABINE HCL 4 MG TABLET 4.67694 4.67694 2/8/2013 TICLOPIDINE HCL 250 MG TABLET 0.65364 0.65364 2/8/2013 TIMOLOL MALEATE 0.25 % DROPS 0.66102 0.66102 2/8/2013 TIMOLOL MALEATE 0.25 % SOL-GEL 6.93000 6.93000 2/8/2013 TIMOLOL MALEATE 0.5 % DROPS 0.75330 0.75330 2/8/2013 TIMOLOL MALEATE 0.5 % SOL-GEL 8.19000 8.19000 2/8/2013 TIMOLOL MALEATE 10 MG TABLET 0.55125 0.55125 2/8/2013 TIMOLOL MALEATE 20 MG TABLET 1.01710 1.01710 2/8/2013 TIMOLOL MALEATE 5 MG TABLET 0.44562 0.44562 2/8/2013 TINIDAZOLE 250 MG TABLET 3.68381 3.68381 2/8/2013 TINIDAZOLE 500 MG TABLET 7.36765 7.36765 2/8/2013 TIZANIDINE HCL 2 MG CAPSULE 1.72987 1.72987 2/8/2013 TIZANIDINE HCL 2 MG TABLET 0.05159 0.05159 2/8/2013 TIZANIDINE HCL 4 MG CAPSULE 2.19301 2.19301 2/8/2013 TIZANIDINE HCL 4 MG TABLET 0.06003 0.06003 2/8/2013 TIZANIDINE HCL 6 MG CAPSULE 3.40453 3.40453 2/8/2013 TOBRAMYCIN 0.3 % DROPS 0.90852 1.07200 2/8/2013 TOBRAMYCIN SULFATE 1.2 G VIAL 74.31250 74.31250 2/8/2013 TOBRAMYCIN SULFATE 10 MG/ML VIAL 1.19910 1.19910 2/8/2013 TOBRAMYCIN SULFATE 40 MG/ML VIAL 0.56843 0.56843 2/8/2013 TOBRAMYCIN/DEXAMETHASONE 0.3 %-0.1% DROPS SUSP 10.29250 10.29250 2/8/2013 TOBRAMYCIN/SODIUM CHLORIDE 60 MG/50ML PIGGYBACK 0.31870 0.31870 2/8/2013 TOBRAMYCIN/SODIUM CHLORIDE 80MG/100ML PIGGYBACK 0.18270 0.18270 2/8/2013 TOLAZAMIDE 250 MG TABLET 2.22088 2.22088 2/8/2013 Page 50 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price TOLAZAMIDE 500 MG TABLET 1.61266 1.61266 2/8/2013 TOLBUTAMIDE 500 MG TABLET 0.77849 0.77849 2/8/2013 TOLMETIN SODIUM 200 MG TABLET 0.52500 0.52500 2/8/2013 TOLMETIN SODIUM 400 MG CAPSULE 1.16584 1.16584 2/8/2013 TOLMETIN SODIUM 600 MG TABLET 2.62507 2.62507 2/8/2013 TOLNAFTATE 1 % AERO POWD 0.02769 0.02769 2/8/2013 TOLNAFTATE 1 % CREAM (G) 0.10090 0.10090 2/8/2013 TOLNAFTATE 1 % POWDER 0.04726 0.04726 2/8/2013 TOLTERODINE TARTRATE 1 MG TABLET 1.07094 1.07094 2/8/2013 TOLTERODINE TARTRATE 2 MG TABLET 1.09970 1.09970 2/8/2013 TOPIRAMATE 100 MG TABLET 0.09527 0.09527 2/8/2013 TOPIRAMATE 15 MG CAP SPRINK 0.50062 0.50062 2/8/2013 TOPIRAMATE 200 MG TABLET 0.11886 0.11886 2/8/2013 TOPIRAMATE 25 MG CAP SPRINK 0.55143 0.55143 2/8/2013 TOPIRAMATE 25 MG TABLET 0.03243 0.03243 2/8/2013 TOPIRAMATE 50 MG TABLET 0.06338 0.06338 2/8/2013 TOPOTECAN HCL 4 MG VIAL 138.71325 138.71325 2/8/2013 TOPOTECAN HCL 4 MG/4 ML VIAL 124.05225 124.05225 2/8/2013 TORSEMIDE 10 MG TABLET 0.12837 0.12837 2/8/2013 TORSEMIDE 100 MG TABLET 0.34679 0.34679 2/8/2013 TORSEMIDE 20 MG TABLET 0.12020 0.12020 2/8/2013 TORSEMIDE 20 MG/2 ML VIAL 4.31340 4.31340 2/8/2013 TORSEMIDE 5 MG TABLET 0.12156 0.12156 2/8/2013 TORSEMIDE 50 MG/5 ML VIAL 2.34654 2.34654 2/8/2013 TRAMADOL HCL 100 MG TAB ER 24H 2.39231 2.39231 2/8/2013 TRAMADOL HCL 100 MG TBMP 24HR 1.86076 1.86076 2/8/2013 TRAMADOL HCL 200 MG TAB ER 24H 4.20964 4.20964 2/8/2013 TRAMADOL HCL 200 MG TBMP 24HR 2.95287 2.95287 2/8/2013 TRAMADOL HCL 300 MG TAB ER 24H 4.64707 4.64707 2/8/2013 TRAMADOL HCL 300 MG TBMP 24HR 3.77000 3.77000 2/8/2013 TRAMADOL HCL 50 MG TABLET 0.02466 0.02466 2/8/2013 TRAMADOL HCL/ACETAMINOPHEN 37.5-325MG TABLET 0.18144 0.18144 2/8/2013 TRANDOLAPRIL 1 MG TABLET 0.25064 0.25064 2/8/2013 TRANDOLAPRIL 2 MG TABLET 0.27372 0.27372 2/8/2013 TRANDOLAPRIL 4 MG TABLET 0.27359 0.27359 2/8/2013 TRANEXAMIC ACID 1000 MG/10 AMPUL 3.94380 3.94380 2/8/2013 TRANEXAMIC ACID 1000 MG/10 VIAL 6.09656 6.09656 2/8/2013 TRANEXAMIC ACID 650 MG TABLET 3.65202 3.65202 2/8/2013 TRANYLCYPROMINE SULFATE 10 MG TABLET 1.80076 1.80076 2/8/2013 TRAZODONE HCL 100 MG TABLET 0.04703 0.04703 2/8/2013 TRAZODONE HCL 150 MG TABLET 0.10564 0.10564 2/8/2013 TRAZODONE HCL 300 MG TABLET 3.39183 3.39183 2/8/2013 TRAZODONE HCL 50 MG TABLET 0.02439 0.02439 2/8/2013 TRETINOIN 0.01 % GEL (GRAM) 0.85432 0.85432 2/8/2013 TRETINOIN 0.025 % CREAM (G) 0.65525 0.65525 2/8/2013 TRETINOIN 0.025 % GEL (GRAM) 0.95536 0.95536 2/8/2013 TRETINOIN 0.05 % CREAM (G) 1.08428 1.08428 2/8/2013 TRETINOIN 0.1 % CREAM (G) 1.08479 1.08479 2/8/2013 TRETINOIN 10 MG CAPSULE 20.32926 20.32926 2/8/2013 TRETINOIN/EMOLLIENT 0.05 % CREAM (G) 2.30347 2.30347 2/8/2013 TRIAMCINOLONE ACETONIDE 0.025 % CREAM (G) 0.09313 0.09313 2/8/2013 TRIAMCINOLONE ACETONIDE 0.025 % LOTION 0.44094 0.44094 2/8/2013 TRIAMCINOLONE ACETONIDE 0.025 % OINT. (G) 0.09313 0.09313 2/8/2013 TRIAMCINOLONE ACETONIDE 0.1 % CREAM (G) 0.21180 0.21180 2/8/2013 TRIAMCINOLONE ACETONIDE 0.1 % LOTION 0.38860 0.38860 2/8/2013 TRIAMCINOLONE ACETONIDE 0.1 % OINT. (G) 0.04864 0.04864 2/8/2013 TRIAMCINOLONE ACETONIDE 0.1 % PASTE (G) 8.19806 8.19806 2/8/2013 Page 51 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price TRIAMCINOLONE ACETONIDE 0.5 % CREAM (G) 0.49694 0.49694 2/8/2013 TRIAMCINOLONE ACETONIDE 0.5 % OINT. (G) 0.47133 0.47133 2/8/2013 TRIAMCINOLONE ACETONIDE 55MCG SPRAY 5.20145 5.20145 2/8/2013 TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25 MG CAPSULE 0.06405 0.06405 2/8/2013 TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25 MG TABLET 0.19698 0.19698 2/8/2013 TRIAMTERENE/HYDROCHLOROTHIAZID 75 MG-50MG TABLET 0.21909 0.21909 2/8/2013 TRIAZOLAM 0.125 MG TABLET 0.23712 0.23712 2/8/2013 TRIAZOLAM 0.25 MG TABLET 0.14740 0.14740 2/8/2013 TRICLOSAN CLEANSER 0.00568 0.00568 2/8/2013 TRIFLUOPERAZINE HCL 1 MG TABLET 0.27066 0.27066 2/8/2013 TRIFLUOPERAZINE HCL 10 MG TABLET 0.61857 0.61857 2/8/2013 TRIFLUOPERAZINE HCL 2 MG TABLET 0.57226 0.36440 2/15/2013 TRIFLUOPERAZINE HCL 5 MG TABLET 0.48442 0.48442 2/8/2013 TRIFLURIDINE 1 % DROPS 16.63947 16.63947 2/8/2013 TRIHEXYPHENIDYL HCL 2 MG TABLET 0.05414 0.05414 2/8/2013 TRIHEXYPHENIDYL HCL 2 MG/5 ML ELIXIR 0.03921 0.03921 2/8/2013 TRIHEXYPHENIDYL HCL 5 MG TABLET 0.11095 0.11095 2/8/2013 TRIMETHOBENZAMIDE HCL 100 MG/ML VIAL 4.38991 4.38991 2/8/2013 TRIMETHOBENZAMIDE HCL 300 MG CAPSULE 1.49810 1.49810 2/8/2013 TRIMETHOPRIM 100 MG TABLET 0.26294 0.26294 2/8/2013 TRIMIPRAMINE MALEATE 100 MG CAPSULE 4.04880 4.04880 2/8/2013 TRIMIPRAMINE MALEATE 25 MG CAPSULE 1.70263 1.70263 2/8/2013 TRIMIPRAMINE MALEATE 50 MG CAPSULE 2.78507 2.78507 2/8/2013 TROPICAMIDE 0.5 % DROPS 0.64856 0.64856 2/8/2013 TROPICAMIDE 1 % DROPS 0.59054 0.59054 2/8/2013 TROSPIUM CHLORIDE 20 MG TABLET 1.92682 1.92682 2/8/2013 TROSPIUM CHLORIDE 60 MG CAP ER 24H 4.71567 4.71567 2/8/2013 UREA 40 % LOTION 0.06888 0.06888 2/8/2013 UREA 40 % NL FM SUSP 11.93033 11.93033 2/8/2013 UREA 45 % GEL/PF APP 5.82575 5.82575 2/8/2013 UREA 45 % LOTION 0.17003 0.17003 2/8/2013 UREA/HYALURONATE SODIUM 40%-0.2% KIT 282.72300 282.72300 2/8/2013 URSODIOL 250 MG TABLET 1.87768 1.87768 2/8/2013 URSODIOL 300 MG CAPSULE 0.31021 0.31021 2/8/2013 URSODIOL 500 MG TABLET 3.32738 3.32738 2/8/2013 VALACYCLOVIR HCL 1000 MG TABLET 1.79877 1.79877 2/8/2013 VALACYCLOVIR HCL 500 MG TABLET 1.11528 1.11528 2/8/2013 SODIUM 100 % POWDER 3.81340 3.81340 2/8/2013 VALPROATE SODIUM 250 MG/5ML SOLUTION 0.01427 0.01427 2/8/2013 VALPROATE SODIUM 250 MG/CUP SOLUTION 0.30251 0.30251 2/8/2013 VALPROATE SODIUM 500MG/10ML SOLUTION 0.07088 0.07088 2/8/2013 VALPROIC ACID 250 MG CAPSULE 0.15804 0.15804 2/8/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5MG TABLET 2.99468 2.99468 2/8/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 160-25MG TABLET 3.39514 3.39514 2/8/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5MG TABLET 3.79425 3.79425 2/8/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG TABLET 4.30414 4.30414 2/8/2013 VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG TABLET 2.74960 2.74960 2/8/2013 VANCOMYCIN HCL 1 G VIAL 4.04820 4.04820 2/8/2013 VANCOMYCIN HCL 1 G VIAL PORT 4.40160 4.40160 2/8/2013 VANCOMYCIN HCL 10 G VIAL 53.87633 53.87633 2/8/2013 VANCOMYCIN HCL 125 MG CAPSULE 21.92457 21.92457 2/8/2013 VANCOMYCIN HCL 250 MG CAPSULE 40.40119 40.40119 2/8/2013 VANCOMYCIN HCL 5 G VIAL 22.28100 22.28100 2/8/2013 VANCOMYCIN HCL 500 MG VIAL 2.11680 2.11680 2/8/2013 VANCOMYCIN HCL 500 MG VIAL PORT 2.65020 2.65020 2/8/2013 VANCOMYCIN HCL 750 MG VIAL 6.69900 6.69900 2/8/2013 VANCOMYCIN HCL 750 MG VIAL PORT 10.90110 10.90110 2/8/2013 Page 52 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price VANCOMYCIN HCL/D5W 1G/200ML FROZ.PIGGY 0.29786 0.29786 2/8/2013 VANCOMYCIN HCL/D5W 500MG/0.1L FROZ.PIGGY 0.10933 0.10933 2/8/2013 VANCOMYCIN IN DEXTROSE,ISO-OSM 750MG/.15L FROZ.PIGGY 0.17722 0.17722 2/8/2013 VASOPRESSIN 20 UNIT/ML VIAL 1.97529 1.97529 2/8/2013 VENLAFAXINE HCL 100 MG TABLET 0.36636 0.36636 2/8/2013 VENLAFAXINE HCL 150 MG CAP ER 24H 0.28086 0.28086 2/8/2013 VENLAFAXINE HCL 150 MG TAB ER 24 1.46640 1.46640 2/8/2013 VENLAFAXINE HCL 225 MG TAB ER 24 10.83873 10.83873 2/8/2013 VENLAFAXINE HCL 25 MG TABLET 0.34038 0.34038 2/8/2013 VENLAFAXINE HCL 37.5 MG CAP ER 24H 0.14767 0.14767 2/8/2013 VENLAFAXINE HCL 37.5 MG TAB ER 24 2.37658 2.37658 2/8/2013 VENLAFAXINE HCL 37.5 MG TABLET 0.32468 0.32468 2/8/2013 VENLAFAXINE HCL 50 MG TABLET 0.36760 0.36760 2/8/2013 VENLAFAXINE HCL 75 MG CAP ER 24H 0.19309 0.19309 2/8/2013 VENLAFAXINE HCL 75 MG TAB ER 24 3.24613 3.24613 2/8/2013 VENLAFAXINE HCL 75 MG TABLET 0.32589 0.32589 2/8/2013 VERAPAMIL HCL 100 MG CAP24H PCT 1.23213 1.23213 2/8/2013 VERAPAMIL HCL 120 MG CAP24H PEL 0.41197 0.41197 2/8/2013 VERAPAMIL HCL 120 MG TABLET 0.06164 0.06164 2/8/2013 VERAPAMIL HCL 120 MG TABLET ER 0.29373 0.29373 2/8/2013 VERAPAMIL HCL 180 MG CAP24H PEL 0.42649 0.42649 2/8/2013 VERAPAMIL HCL 180 MG TABLET ER 0.16911 0.16911 2/8/2013 VERAPAMIL HCL 2.5 MG/ML AMPUL 1.65480 1.65480 2/8/2013 VERAPAMIL HCL 2.5 MG/ML DISP SYRIN 4.85100 4.85100 2/8/2013 VERAPAMIL HCL 2.5 MG/ML VIAL 2.14400 2.14400 2/8/2013 VERAPAMIL HCL 200 MG CAP24H PCT 1.58723 1.58723 2/8/2013 VERAPAMIL HCL 240 MG CAP24H PEL 0.49816 0.49816 2/8/2013 VERAPAMIL HCL 240 MG TABLET ER 0.14485 0.14485 2/8/2013 VERAPAMIL HCL 300 MG CAP24H PCT 2.25219 2.25219 2/8/2013 VERAPAMIL HCL 360 MG CAP24H PEL 1.46958 1.46958 2/8/2013 VERAPAMIL HCL 40 MG TABLET 0.17654 0.17654 2/8/2013 VERAPAMIL HCL 80 MG TABLET 0.05601 0.05601 2/8/2013 VINBLASTINE SULFATE 1 MG/ML VIAL 2.22600 2.22600 2/8/2013 VINBLASTINE SULFATE 10 MG VIAL 1.81350 1.81350 2/8/2013 VIT A,C & E/LUTEIN/MINERALS 1000-60-2 TABLET 0.05413 0.05413 2/8/2013 VIT A/VIT C/VIT E/ZINC/COPPER 14320-226 CAPSULE 0.16297 0.16297 2/8/2013 VIT A/VIT C/VIT E/ZINC/COPPER 7160-113 TABLET 0.06622 0.06622 2/8/2013 VIT B CMPLX 3/FA/VIT C/BIOTIN 1MG-60MG TABLET 0.12805 0.12805 2/8/2013 VIT B COMP/C/FA/IRON/VIT E 500-400-18 TABLET 0.05547 0.05547 2/8/2013 VIT B12/LMEFOLATE CA/VIT B6/B2 1-6-50-5MG TABLET 1.43635 1.43635 2/8/2013 VITAMIN A/VIT C/ZINC/PROPOLIS 15 MG LOZENGE 0.02443 0.02095 2/15/2013 VITAMIN B COMPLEX/LYSINE 790MG/15ML LIQUID 0.03270 0.03270 2/8/2013 VITAMIN E 100 UNIT CAPSULE 0.02028 0.02028 2/8/2013 VITAMIN E 1000 UNIT CAPSULE 0.12857 0.12857 2/8/2013 VITAMIN E 200 UNIT CAPSULE 0.02862 0.02862 2/8/2013 VITAMIN E 400 UNIT CAPSULE 0.04529 0.04529 2/8/2013 VITAMIN E 50 UNIT/ML DROPS 1.83322 1.83322 2/8/2013 VITAMIN E MIXED 400 UNIT CAPSULE 0.05033 0.05033 2/8/2013 VITAMINS B1,B2,B3,B5,& B6 100-2MG/ML VIAL 1.31319 1.31319 2/8/2013 VITS A & D/WHITE PET/LANOLIN OINT PACK 0.03452 0.03452 2/8/2013 VORICONAZOLE 200 MG TABLET 26.29668 26.29668 2/8/2013 VORICONAZOLE 200 MG VIAL 87.18650 87.18650 2/8/2013 VORICONAZOLE 50 MG TABLET 7.61796 7.61796 2/8/2013 WARFARIN SODIUM 1 MG TABLET 0.06472 0.06472 2/8/2013 WARFARIN SODIUM 10 MG TABLET 0.06673 0.06673 2/8/2013 WARFARIN SODIUM 2 MG TABLET 0.06472 0.06472 2/8/2013 WARFARIN SODIUM 2.5 MG TABLET 0.06472 0.06472 2/8/2013 Page 53 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective February 15, 2013 ‑ Version 2013.07 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price WARFARIN SODIUM 3 MG TABLET 0.06472 0.06472 2/8/2013 WARFARIN SODIUM 4 MG TABLET 0.06472 0.06472 2/8/2013 WARFARIN SODIUM 5 MG TABLET 0.06472 0.06472 2/8/2013 WARFARIN SODIUM 6 MG TABLET 0.06512 0.06512 2/8/2013 WARFARIN SODIUM 7.5 MG TABLET 0.06673 0.06673 2/8/2013 WATER LIQUID 0.01291 0.01291 2/8/2013 WATER FOR INJ.,BACTERIOSTATIC VIAL 0.02212 0.02212 2/8/2013 WATER FOR INJECTION,STERILE AMPUL 0.09072 0.09072 2/8/2013 WATER FOR INJECTION,STERILE IV SOLN 0.00214 0.00214 2/8/2013 WATER FOR INJECTION,STERILE VIAL 0.03430 0.03430 2/8/2013 WATER FOR IRRIGATION,STERILE IRRIG SOLN 0.00579 0.00579 2/8/2013 WATER/ME-/PROPYLPARABEN VIAL 0.10643 0.10643 2/8/2013 WHEAT GERM OIL OIL 0.26600 0.26600 2/8/2013 WITCH HAZEL 50 % MED. PAD 0.07611 0.07611 2/8/2013 ZAFIRLUKAST 10 MG TABLET 1.19188 1.19188 2/8/2013 ZAFIRLUKAST 20 MG TABLET 1.25253 1.25253 2/8/2013 ZALEPLON 10 MG CAPSULE 0.26176 0.26176 2/8/2013 ZALEPLON 5 MG CAPSULE 0.23039 0.23039 2/8/2013 ZIDOVUDINE 10 MG/ML SYRUP 0.13226 0.13226 2/8/2013 ZIDOVUDINE 100 MG CAPSULE 1.19166 1.19166 2/8/2013 ZIDOVUDINE 300 MG TABLET 0.39533 0.39533 2/8/2013 ZINC CHLORIDE 1 MG/ML VIAL 0.17640 0.17640 2/8/2013 ZINC SULFATE 1 MG/ML VIAL 0.21874 0.21874 2/8/2013 ZINC SULFATE 5 MG/ML VIAL 0.65343 0.65343 2/8/2013 ZIPRASIDONE HCL 20 MG CAPSULE 2.81732 2.81732 2/8/2013 ZIPRASIDONE HCL 40 MG CAPSULE 2.81732 2.81732 2/8/2013 ZIPRASIDONE HCL 60 MG CAPSULE 3.49354 3.49354 2/8/2013 ZIPRASIDONE HCL 80 MG CAPSULE 3.49960 3.49960 2/8/2013 ZOLPIDEM TARTRATE 10 MG TABLET 0.02734 0.02734 2/8/2013 ZOLPIDEM TARTRATE 12.5 MG TAB MPHASE 2.76720 2.76720 2/8/2013 ZOLPIDEM TARTRATE 5 MG TABLET 0.02600 0.02600 2/8/2013 ZOLPIDEM TARTRATE 6.25 MG TAB MPHASE 1.59071 1.59071 2/8/2013 ZONISAMIDE 100 MG CAPSULE 0.14311 0.14311 2/8/2013 ZONISAMIDE 25 MG CAPSULE 0.11406 0.11406 2/8/2013 ZONISAMIDE 50 MG CAPSULE 0.11658 0.11658 2/8/2013

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