West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 0.9 % SODIUM CHLORIDE PGY VL PRT 0.07096 0.07291 2/22/2013 0.9 % SODIUM CHLORIDE 0.9 % IV SOLN 0.00141 0.00165 12/27/2013 0.9 % SODIUM CHLORIDE 0.9 % VIAL 0.04800 0.05830 1/25/2013 ABACAVIR SULFATE 300 MG TABLET 6.27295 6.21453 9/6/2013 ACARBOSE 100 MG TABLET 0.50679 0.40200 7/12/2013 ACARBOSE 25 MG TABLET 0.46270 0.26023 1/3/2014 ACARBOSE 50 MG TABLET 0.35054 0.33353 1/3/2014 ACEBUTOLOL HCL 200 MG CAPSULE 0.21353 0.21350 12/14/2012 ACETAMINOPHEN 100 MG/ML DROPS 0.15340 0.11667 4/12/2013 ACETAMINOPHEN 120 MG SUPP.RECT 0.16289 0.19717 11/22/2013 ACETAMINOPHEN 160 MG/5ML ELIXIR 0.01968 0.01083 9/27/2013 ACETAMINOPHEN 160 MG/5ML LIQUID 0.01297 0.00932 9/27/2013 ACETAMINOPHEN 160 MG/5ML ORAL SUSP 0.02397 0.02412 5/24/2013 ACETAMINOPHEN 325 MG SUPP.RECT 0.00000 0.45850 12/1/2012 ACETAMINOPHEN 325 MG TABLET 0.00616 0.00830 1/25/2013 ACETAMINOPHEN 500 MG CAPSULE 0.02940 0.01093 5/17/2013 ACETAMINOPHEN 500 MG TABLET 0.00951 0.01093 5/17/2013 ACETAMINOPHEN 650 MG SUPP.RECT 0.21683 0.21680 12/14/2012 ACETAMINOPHEN 80 MG TAB CHEW 0.04850 0.04450 3/1/2013 ACETAMINOPHEN 80MG/0.8ML DROPS 0.27720 0.17160 4/19/2013 ACETAMINOPHEN WITH CODEINE 120-12MG/5 (5 ML) SOLUTION 0.00000 0.15890 12/1/2012 ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION 0.01490 0.01485 4/26/2013 ACETAMINOPHEN WITH CODEINE 300MG-15MG TABLET 0.14200 0.13111 1/10/2014 ACETAMINOPHEN WITH CODEINE 300MG-30MG TABLET 0.10638 0.10461 12/27/2013 ACETAMINOPHEN WITH CODEINE 300MG-60MG TABLET 0.22732 0.21863 1/24/2014 ACETAMINOPHEN WITH CODEINE 300MG/12.5 SOLUTION 0.04760 0.07496 3/1/2013 ACETAMINOPHEN/DIPHENHYDRAMINE 325-12.5MG TABLET 0.15370 0.15400 1/25/2013 ACETAMINOPHEN/DIPHENHYDRAMINE 500MG-25MG TABLET 0.03653 0.04181 9/6/2013 ACETAZOLAMIDE 125 MG TABLET 0.58123 1.52593 1/24/2014 ACETAZOLAMIDE 250 MG TABLET 1.55955 2.16264 1/24/2014 ACETAZOLAMIDE 500 MG CAPSULE ER 3.00454 3.00400 1/25/2013 ACETIC ACID 0.25 % IRRIG SOLN 0.00270 0.00350 3/1/2013 ACETIC ACID 2 % SOLUTION 1.75603 1.81591 6/28/2013 ACETIC ACID/ALUMINUM ACETATE 2 % DROPS 0.00000 0.84000 12/1/2012 ACETIC ACID/HYDROCORTISONE 2 %-1 % DROPS 0.00000 9.82215 12/1/2012 ACETYL/METHYL-B12/LMEFOLATE CA 600-2-6 MG TABLET 1.86527 1.23520 1/25/2013 ACETYLCYSTEINE 100 MG/ML VIAL 0.45068 0.35253 8/9/2013 ACETYLCYSTEINE 200 MG/ML VIAL 0.00000 5.26400 12/1/2012 ACITRETIN 10 MG CAPSULE 0.00000 21.82892 8/2/2013 ACITRETIN 17.5 MG CAPSULE 0.00000 26.92153 8/2/2013 ACITRETIN 25 MG CAPSULE 26.90660 23.63130 11/8/2013 ACYCLOVIR 200 MG CAPSULE 0.09460 0.09058 8/16/2013 ACYCLOVIR 200 MG/5ML ORAL SUSP 0.16775 0.16913 5/31/2013 ACYCLOVIR 400 MG TABLET 0.00000 0.11107 1/17/2014 ACYCLOVIR 5 % OINT. (G) 18.13435 18.17113 12/13/2013 ACYCLOVIR 800 MG TABLET 0.25266 0.24713 1/31/2014 ACYCLOVIR SODIUM 1000 MG VIAL 7.68600 9.04800 1/25/2013 ACYCLOVIR SODIUM 50 MG/ML VIAL 0.00000 2.85501 12/1/2012 ADAPALENE 0.1 % CREAM (G) 3.66909 3.51289 4/26/2013 ADAPALENE 0.1 % GEL (GRAM) 0.00000 3.05760 12/1/2012 ADEFOVIR DIPIVOXIL 10 MG TABLET 0.00000 26.52627 9/27/2013 ALBUMIN HUMAN 25 % IV SOLN 0.90300 0.91240 1/25/2013 ALBUMIN HUMAN 25 % VIAL 1.54350 1.51200 7/26/2013 ALBUMIN HUMAN 5 % IV SOLN 0.21150 0.21000 1/17/2014 ALBUTEROL SULFATE 0.63MG/3ML VIAL-NEB 0.00000 0.37527 12/1/2012 ALBUTEROL SULFATE 1.25MG/3ML VIAL-NEB 0.37674 0.37242 11/15/2013 ALBUTEROL SULFATE 2 MG TABLET 0.14470 4.56651 5/3/2013 Page 1 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 ALBUTEROL SULFATE 2 MG/5 ML SYRUP 0.01260 0.01277 5/24/2013 ALBUTEROL SULFATE 2.5 MG/0.5 VIAL-NEB 0.63406 0.64655 11/22/2013 ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB 0.05117 0.05506 1/17/2014 ALBUTEROL SULFATE 4 MG TAB ER 12H 0.98160 1.04048 7/26/2013 ALBUTEROL SULFATE 4 MG TABLET 0.21051 4.56651 5/3/2013 ALBUTEROL SULFATE 5 MG/ML SOLUTION 0.58175 0.72066 10/18/2013 ALBUTEROL SULFATE 8 MG TAB ER 12H 1.84058 1.71821 4/5/2013 ALCLOMETASONE DIPROPIONATE 0.05 % CREAM (G) 0.56410 1.30908 6/21/2013 ALCLOMETASONE DIPROPIONATE 0.05 % OINT. (G) 0.58690 0.58692 6/28/2013 ALENDRONATE SODIUM 10 MG TABLET 0.18747 0.18750 12/14/2012 ALENDRONATE SODIUM 35 MG TABLET 0.64320 0.63650 1/24/2014 ALENDRONATE SODIUM 40 MG TABLET 6.63531 6.63530 12/14/2012 ALENDRONATE SODIUM 5 MG TABLET 0.18150 0.18110 1/25/2013 ALENDRONATE SODIUM 70 MG TABLET 0.71360 0.69010 1/25/2013 ALENDRONATE SODIUM 70 MG/75ML SOLUTION 0.00000 2.45700 9/27/2013 ALFUZOSIN HCL 10 MG TAB ER 24H 0.21554 0.22634 6/21/2013 ALLOPURINOL 100 MG TABLET 0.03688 0.03388 8/23/2013 ALLOPURINOL 300 MG TABLET 0.06151 0.05850 10/11/2013 ALPHA LIPOIC ACID 200 MG CAPSULE 0.10000 0.09998 8/2/2013 ALPHA LIPOIC ACID 50 MG CAPSULE 0.04900 0.10210 1/25/2013 ALPRAZOLAM 0.25 MG TAB RAPDIS 1.28921 1.36123 3/1/2013 ALPRAZOLAM 0.25 MG TABLET 0.01540 0.01509 6/14/2013 ALPRAZOLAM 0.5 MG TAB ER 24H 0.33260 0.57218 6/28/2013 ALPRAZOLAM 0.5 MG TAB RAPDIS 0.00000 1.51669 12/1/2012 ALPRAZOLAM 0.5 MG TABLET 0.01814 0.01777 6/14/2013 ALPRAZOLAM 1 MG TAB ER 24H 0.43080 0.44913 6/28/2013 ALPRAZOLAM 1 MG TAB RAPDIS 0.00000 2.02358 12/1/2012 ALPRAZOLAM 1 MG TABLET 0.02010 0.01970 6/14/2013 ALPRAZOLAM 2 MG TAB ER 24H 0.57960 0.41600 6/28/2013 ALPRAZOLAM 2 MG TAB RAPDIS 0.00000 3.00202 12/1/2012 ALPRAZOLAM 2 MG TABLET 0.04087 0.04007 6/14/2013 ALPRAZOLAM 3 MG TAB ER 24H 0.79700 0.79340 1/25/2013 ALUM/SALICYLIC ACID/TALC/BENT POWDER 0.06733 0.06740 1/25/2013 AMANTADINE HCL 100 MG CAPSULE 0.00000 1.36390 12/1/2012 AMANTADINE HCL 100 MG TABLET 1.45925 1.59829 4/12/2013 AMANTADINE HCL 50 MG/5 ML SYRUP 0.01740 0.01970 1/25/2013 AMCINONIDE 0.1 % CREAM (G) 3.29673 2.82140 1/25/2013 AMCINONIDE 0.1 % LOTION 3.80018 1.90000 1/25/2013 AMCINONIDE 0.1 % OINT. (G) 2.26800 4.53600 8/30/2013 AMIKACIN SULFATE 1000MG/4ML VIAL 2.74505 3.26100 11/15/2013 AMIKACIN SULFATE 500 MG/2ML VIAL 1.62705 2.81400 7/5/2013 AMILORIDE HCL 5 MG TABLET 0.60351 0.54422 12/20/2013 AMILORIDE/HYDROCHLOROTHIAZIDE 5MG-50MG TABLET 0.24680 0.25763 3/1/2013 AMINO ACIDS POWDER 0.53784 0.25540 1/25/2013 AMINOCAPROIC ACID 1000 MG TABLET 16.95015 18.30610 12/21/2012 AMINOCAPROIC ACID 250 MG/ML SOLUTION 1.24998 2.81233 6/14/2013 AMINOCAPROIC ACID 250 MG/ML VIAL 0.00000 0.08148 8/16/2013 AMINOCAPROIC ACID 500 MG TABLET 2.10790 5.37896 10/11/2013 AMINOPHYLLINE 250MG/10ML AMPUL 0.05712 0.05540 1/25/2013 AMINOPHYLLINE 250MG/10ML VIAL 0.10836 0.10840 1/25/2013 AMINOPHYLLINE 500MG/20ML VIAL 0.07266 0.07270 1/25/2013 AMIODARONE HCL 100 MG TABLET 0.00000 5.20077 8/16/2013 AMIODARONE HCL 200 MG TABLET 0.16280 0.15276 8/16/2013 AMIODARONE HCL 400 MG TABLET 3.85907 3.56070 8/30/2013 AMIODARONE HCL 50 MG/ML AMPUL 0.27720 0.33600 1/25/2013 AMITRIP HCL/CHLORDIAZEPOXIDE 12.5MG-5MG TABLET 0.77870 0.82537 1/3/2014 AMITRIP HCL/CHLORDIAZEPOXIDE 25 MG-10MG TABLET 1.09858 1.16452 8/2/2013 Page 2 of 54 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Jan 31, 2014 ‑ Version 2014.05 Disclaimer: Price listing does not guarantee coverage Old SMAC Current Generic_Name Effective_Date Price SMAC Price 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.04001 0.03440 1/25/2013 AMITRIPTYLINE HCL 10 MG TABLET 0.01919 0.01972 4/26/2013 AMITRIPTYLINE HCL 100 MG TABLET 0.05051 0.05278 5/10/2013 AMITRIPTYLINE HCL 150 MG TABLET 0.10760 0.10451 4/19/2013 AMITRIPTYLINE HCL 25 MG TABLET 0.02023 0.01946 12/13/2013 AMITRIPTYLINE HCL 50 MG TABLET 0.02396 0.02578 4/26/2013 AMITRIPTYLINE HCL 75 MG TABLET 0.04341 0.04596 3/29/2013 AMLODIPINE BESYLATE 10 MG TABLET 0.02533 0.02526 5/31/2013 AMLODIPINE BESYLATE 2.5 MG TABLET 0.01983 0.05960 11/8/2013 AMLODIPINE BESYLATE 5 MG TABLET 0.02125 0.06240 11/8/2013 AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-20MG CAPSULE 0.84835 0.48320 1/17/2014 AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-40MG CAPSULE 0.98222 0.97472 1/3/2014 AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG CAPSULE 1.14784 0.80360 12/27/2013 AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-10 MG CAPSULE 0.81700 0.47840 1/17/2014 AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-20 MG CAPSULE 0.82477 0.49990 1/24/2014 AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-40 MG CAPSULE 0.00000 0.80695 12/1/2012 AMLODIPINE/ATORVASTATIN 10 MG-10MG TABLET 3.52613 4.42173 12/6/2013 AMLODIPINE/ATORVASTATIN 10 MG-20MG TABLET 6.09134 6.55993 1/31/2014 AMLODIPINE/ATORVASTATIN 10 MG-40MG TABLET 6.09134 6.55993 1/31/2014 AMLODIPINE/ATORVASTATIN 10 MG-80MG TABLET 6.09134 6.55993 1/31/2014 AMLODIPINE/ATORVASTATIN 2.5MG-10MG TABLET 3.52621 3.52616 2/22/2013 AMLODIPINE/ATORVASTATIN 2.5MG-20MG TABLET 4.82421 4.82420 2/22/2013 AMLODIPINE/ATORVASTATIN 2.5MG-40MG TABLET 4.82417 4.82420 1/25/2013 AMLODIPINE/ATORVASTATIN 5 MG-10 MG TABLET 0.00000 3.52617 12/1/2012 AMLODIPINE/ATORVASTATIN 5 MG-20 MG TABLET 5.75881 6.09134 12/6/2013 AMLODIPINE/ATORVASTATIN 5 MG-40 MG TABLET 6.09134 6.55993 1/31/2014 AMLODIPINE/ATORVASTATIN 5 MG-80 MG TABLET 6.09134 6.55993 1/31/2014 AMMONIUM ALUM/TALC/BENTONITE POWDER 0.07538 0.07530 1/25/2013 AMMONIUM CHLORIDE 5 MEQ/ML VIAL 0.28522 0.42630 1/25/2013 AMMONIUM LACTATE 12 % CREAM (G) 0.03670 0.04307 10/25/2013 AMMONIUM LACTATE 12 % LOTION 0.01942 0.02596 11/8/2013 AMOXAPINE 100 MG TABLET 0.72280 1.16865 11/22/2013 AMOXAPINE 150 MG TABLET 0.00000 1.28830 12/1/2012 AMOXAPINE 25 MG TABLET 0.00000 0.27027 12/1/2012 AMOXAPINE 50 MG TABLET