West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 0.9 % SODIUM CHLORIDE INJECTION VIAL (ML) 0.9 % 0.05712 08/12/2014 0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 0.9 % 0.00196 03/06/2015 0.00196 08/21/2015 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK WITH THREADED 0.03505 01/30/2015 0.03505 08/21/2015 PORT (ML) 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK WITH VIAL PORT 0.04175 07/18/2014 (NON-THREADED) ABACAVIR SULFATE ORAL TABLET 300 MG 1.77633 11/24/2017 1.77633 11/25/2017 ABIRATERONE ACETATE ORAL TABLET 250 MG 3.78000 02/21/2020 4.56040 02/24/2020 ACAMPROSATE CALCIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.67426 02/21/2020 0.74145 04/09/2020 COATED) 333 MG ACARBOSE ORAL TABLET 100 MG 0.18990 03/02/2018 0.13000 11/16/2018 ACARBOSE ORAL TABLET 25 MG 0.23329 08/21/2015 0.13994 08/25/2017 ACARBOSE ORAL TABLET 50 MG 0.14640 05/25/2018 0.12500 11/16/2018 ACEBUTOLOL HCL ORAL CAPSULE 200 MG 0.40001 06/04/2019 0.60776 10/07/2019 ACEBUTOLOL HCL ORAL CAPSULE 400 MG 0.26000 03/27/2015 0.26000 08/21/2015 ACETAMINOPHEN ORAL CAPSULE 500 MG 0.01093 08/12/2014 ACETAMINOPHEN ORAL DROPS 80MG/0.8ML 0.17160 10/11/2013 0.17160 08/21/2015 ACETAMINOPHEN ORAL LIQUID (ML) 160 MG/5ML 0.00932 09/27/2013 0.00932 08/21/2015 ACETAMINOPHEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 160 0.02137 08/21/2015 0.02033 02/17/2017 MG/5ML ACETAMINOPHEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 160 0.01083 06/09/2017 0.02033 03/02/2018 MG/5ML ACETAMINOPHEN ORAL TABLET 325 MG 0.00830 06/20/2014 0.00830 08/21/2015 ACETAMINOPHEN ORAL TABLET 500 MG 0.01040 04/03/2015 0.01040 08/21/2015 ACETAMINOPHEN ORAL TABLET,CHEWABLE 80 MG 0.04651 04/03/2015 0.04651 08/21/2015 ACETAMINOPHEN ORAL TABLET,DISINTEGRATING 80 MG 0.05113 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 120 MG 0.20324 08/22/2014 0.20324 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 325 MG 0.46400 08/22/2014 0.46400 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 650 MG 0.21762 08/22/2014 0.21762 08/21/2015 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.01332 01/30/2015 0.01332 08/21/2015 120-12MG/5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.21394 03/27/2015 0.21394 08/21/2015 120-12MG/5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.10079 03/27/2015 0.10079 08/21/2015 300MG/12.5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.14344 09/19/2014 0.14344 08/21/2015 15MG ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.10480 10/20/2017 0.09167 12/22/2017 30MG ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.19101 05/20/2016 0.17150 08/17/2018 60MG ACETAMINOPHEN/DIPHENHYDRAMINE HCL ORAL TABLET 500MG-25MG 0.04047 04/24/2015 0.04047 08/21/2015 ACETAZOLAMIDE ORAL CAPSULE, EXTENDED RELEASE 500 MG 0.94140 09/22/2017 0.70000 11/16/2018 ACETAZOLAMIDE ORAL TABLET 125 MG 1.52593 08/21/2015 1.29790 11/16/2018 ACETAZOLAMIDE ORAL TABLET 250 MG 1.02880 02/22/2019 0.69948 05/17/2019 ACETIC ACID IRRIGATION SOLUTION, IRRIGATION 0.25 % 0.00350 03/01/2013 ACETIC ACID OTIC SOLUTION, NON-ORAL 2 % 1.81591 08/21/2015 1.65333 02/21/2020 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ACETIC ACID/ALUMINUM ACETATE DROPS 2 % 0.84000 01/25/2013 0.84000 08/21/2015 ACETYLCYSTEINE INTRAVENOUS VIAL (ML) 200 MG/ML 5.26400 03/06/2015 5.26400 08/21/2015 ACETYLCYSTEINE MISCELLANEOUS VIAL (ML) 100 MG/ML 0.45068 08/21/2015 0.35144 02/21/2020 ACETYLCYSTEINE MISCELLANEOUS VIAL (ML) 200 MG/ML 0.19900 02/21/2020 0.34100 03/27/2020 ACETYLCYSTEINE/MECOBALAMIN/LEVOMEFOLATE CALCIUM ORAL 1.89794 02/20/2015 1.89794 08/21/2015 TABLET 600-2-6 MG ACITRETIN ORAL CAPSULE 10 MG 6.66667 11/24/2017 9.53166 12/18/2017 ACITRETIN ORAL CAPSULE 17.5 MG 42.31920 03/21/2014 ACITRETIN ORAL CAPSULE 25 MG 12.56000 01/25/2019 9.33333 05/17/2019 ACYCLOVIR ORAL CAPSULE 200 MG 0.08844 08/21/2015 0.05480 09/22/2017 ACYCLOVIR ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200 MG/5ML 0.37206 11/16/2018 0.40698 01/19/2020 ACYCLOVIR ORAL TABLET 400 MG 0.06655 07/14/2017 0.05351 11/16/2018 ACYCLOVIR ORAL TABLET 800 MG 0.13520 12/22/2017 0.11600 08/16/2019 ACYCLOVIR SODIUM INTRAVENOUS VIAL (EA) 500 MG 31.20600 08/22/2014 31.20600 08/21/2015 ACYCLOVIR SODIUM INTRAVENOUS VIAL (ML) 50 MG/ML 1.40750 07/25/2014 ACYCLOVIR TOPICAL OINTMENT (GRAM) 5 % 6.90000 05/26/2018 1.94109 11/15/2019 ADAPALENE TOPICAL CREAM (GRAM) 0.1 % 3.51289 04/26/2013 ADAPALENE TOPICAL GEL (GRAM) 0.1 % 1.82556 06/22/2018 1.58578 11/15/2019 ADAPALENE TOPICAL GEL (GRAM) 0.3 % 4.68580 08/21/2015 3.41117 06/16/2017 ADAPALENE TOPICAL GEL WITH PUMP (GRAM) 0.3 % 4.61985 04/10/2015 4.61985 08/21/2015 ADEFOVIR DIPIVOXIL ORAL TABLET 10 MG 26.52627 09/27/2013 ALBUMIN HUMAN INTRAVENOUS INTRAVENOUS SOLUTION 25 % 1.51200 05/01/2015 1.51200 08/21/2015 ALBUMIN HUMAN INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.21588 09/19/2014 0.21588 08/21/2015 ALBUTEROL SULFATE INHALATION SOLUTION, NON-ORAL 5 MG/ML 1.45230 10/23/2017 2.12250 12/27/2019 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (EA) 2.5 MG/0.5 0.43876 08/01/2014 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 0.63MG/3ML 0.15441 11/16/2018 0.11333 11/15/2019 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 1.25MG/3ML 0.19073 06/21/2019 0.15240 12/20/2019 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 2.5 MG/3ML 0.05253 08/21/2015 0.03400 01/19/2018 ALBUTEROL SULFATE ORAL SYRUP 2 MG/5 ML 0.01277 08/21/2015 0.03571 08/28/2019 ALBUTEROL SULFATE ORAL TABLET 2 MG 4.56651 08/21/2015 4.05000 12/25/2015 ALBUTEROL SULFATE ORAL TABLET 4 MG 4.11250 08/21/2015 3.62765 12/25/2015 ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 4 MG 1.18451 04/25/2014 ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 8 MG 1.71821 04/05/2013 ALCLOMETASONE DIPROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.88300 08/16/2019 0.62717 03/20/2020 ALCLOMETASONE DIPROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 0.58692 06/28/2013 ALENDRONATE SODIUM ORAL SOLUTION, ORAL 70 MG/75ML 2.45700 09/27/2013 ALENDRONATE SODIUM ORAL TABLET 10 MG 0.18750 08/21/2015 0.13200 10/20/2017 ALENDRONATE SODIUM ORAL TABLET 35 MG 0.35333 08/17/2018 0.23750 05/17/2019 ALENDRONATE SODIUM ORAL TABLET 40 MG 2.80060 03/27/2015 ALENDRONATE SODIUM ORAL TABLET 5 MG 0.18110 08/12/2014 0.18110 08/21/2015 ALENDRONATE SODIUM ORAL TABLET 70 MG 0.27875 10/20/2017 0.23250 09/21/2018 ALFUZOSIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.13697 08/21/2015 0.11326 03/16/2018 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ALLOPURINOL ORAL TABLET 100 MG 0.07267 11/16/2018 0.04709 01/25/2019 ALLOPURINOL ORAL TABLET 300 MG 0.11998 10/19/2018 0.09110 07/26/2019 ALMOTRIPTAN MALATE ORAL TABLET 12.5 MG 25.31000 08/25/2017 16.33370 10/19/2018 ALPHA LIPOIC ACID ORAL CAPSULE 200 MG 0.12771 08/08/2014 0.12771 08/21/2015 ALPHA LIPOIC ACID ORAL CAPSULE 50 MG 0.10210 08/12/2014 0.10210 08/21/2015 ALPRAZOLAM ORAL TABLET 0.25 MG 0.01509 05/16/2014 0.01509 08/21/2015 ALPRAZOLAM ORAL TABLET 0.5 MG 0.01780 04/17/2015 0.01780 08/21/2015 ALPRAZOLAM ORAL TABLET 1 MG 0.01970 02/06/2015 0.01970 08/21/2015 ALPRAZOLAM ORAL TABLET 2 MG 0.07213 09/28/2015 0.04891 12/22/2017 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 0.5 MG 0.36136 08/21/2015 0.18083 09/22/2017 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 1 MG 0.44913 08/21/2015 0.21717 09/22/2017 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 0.41600 08/21/2015 0.40200 08/17/2018 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 3 MG 0.55483 11/20/2015 0.35500 09/22/2017 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 0.25 MG 1.36123 03/01/2013 1.36123 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 0.5 MG 1.51669 01/25/2013 1.51669 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 1 MG 2.02358 01/25/2013 2.02358 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 2 MG 3.00202 01/25/2013 3.00202 08/21/2015 ALUMINUM HYDROXIDE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.00813 08/21/2015 320 MG/5ML AMANTADINE HCL ORAL CAPSULE 100 MG 0.43730 12/22/2017 0.24644 08/17/2018 AMANTADINE HCL ORAL SOLUTION, ORAL 50 MG/5 ML 0.01733 04/03/2015 0.01733 08/21/2015 AMANTADINE HCL ORAL TABLET 100 MG 1.07830 09/21/2018 0.13100 08/16/2019 AMBRISENTAN ORAL TABLET 10 MG 38.40000 02/21/2020 AMBRISENTAN ORAL TABLET 5 MG 38.40000 02/21/2020 AMCINONIDE TOPICAL CREAM (GRAM) 0.1 % 2.82140 08/12/2014 AMCINONIDE TOPICAL LOTION (ML) 0.1 % 1.90000 08/12/2014 AMCINONIDE TOPICAL OINTMENT (GRAM) 0.1 % 4.53600 08/30/2013 AMIKACIN SULFATE INJECTION VIAL (ML) 1000MG/4ML 3.14373 12/05/2014 3.14373 08/21/2015 AMIKACIN SULFATE INJECTION VIAL (ML) 500 MG/2ML 2.95555 12/05/2014 2.95555 08/21/2015 AMILORIDE HCL ORAL TABLET 5 MG 0.20030 11/16/2018 0.14880 11/15/2019 AMILORIDE HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5 MG-50 MG 0.42250 05/30/2014 0.42250 08/21/2015 AMINO ACIDS ORAL POWDER (GRAM) 0.25540 08/12/2014 AMINOCAPROIC ACID INTRAVENOUS VIAL (ML) 250 MG/ML 0.08148 02/06/2015 0.08148 08/21/2015 AMINOCAPROIC ACID ORAL TABLET 1000 MG 18.30610 08/12/2014 18.30610 08/21/2015 AMINOCAPROIC ACID ORAL TABLET 500 MG 5.37896 10/11/2013 5.37896 08/21/2015 AMINOPHYLLINE INTRAVENOUS VIAL (ML) 250MG/10ML 0.30912 01/30/2015 0.30912 08/21/2015 AMINOPHYLLINE INTRAVENOUS VIAL (ML) 500MG/20ML 0.07270 08/12/2014 AMIODARONE HCL INTRAVENOUS AMPUL (ML) 50 MG/ML 0.33600 01/25/2013 AMIODARONE HCL ORAL TABLET 100 MG 2.16500 11/24/2017 1.97100 03/20/2020 AMIODARONE HCL ORAL TABLET 200 MG 0.12724 09/30/2016 0.09890 11/16/2018 AMIODARONE HCL ORAL TABLET 400 MG 3.19526 08/22/2014 2.81936 12/02/2016 AMITRIPTYLINE HCL ORAL TABLET 10 MG 0.05742 11/16/2018 0.03550 08/16/2019 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 5/1/2020 Disclaimer: Price listing does not guarantee coverage Generic Name Prev.