West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date 0.9 % SODIUM CHLORIDE INJECTION VIAL (ML) 0.9 % 0.05712 08/12/2014 0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 0.9 0.00196 03/06/2015 0.00196 08/21/2015 % 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK WITH THREADED 0.03505 01/30/2015 0.03505 08/21/2015 PORT (ML) 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK WITH VIAL PORT 0.04175 07/18/2014 (NON-THREADED) ABACAVIR SULFATE ORAL TABLET 300 MG 5.57996 04/24/2015 3.25000 11/20/2015 ACAMPROSATE CALCIUM ORAL TABLET, DELAYED RELEASE (ENTERIC 0.81000 01/27/2017 COATED) 333 MG ACARBOSE ORAL TABLET 100 MG 0.32897 08/21/2015 0.27550 09/30/2016 ACARBOSE ORAL TABLET 25 MG 0.23329 10/10/2014 0.23329 08/21/2015 ACARBOSE ORAL TABLET 50 MG 0.25460 08/21/2015 0.17333 05/20/2016 ACEBUTOLOL HCL ORAL CAPSULE 200 MG 0.21197 02/13/2015 0.21197 08/21/2015 ACEBUTOLOL HCL ORAL CAPSULE 400 MG 0.26000 03/27/2015 0.26000 08/21/2015 ACETAMINOPHEN ORAL CAPSULE 500 MG 0.01093 08/12/2014 ACETAMINOPHEN ORAL DROPS 80MG/0.8ML 0.17160 10/11/2013 0.17160 08/21/2015 ACETAMINOPHEN ORAL ELIXIR 160 MG/5ML 0.01083 09/27/2013 ACETAMINOPHEN ORAL LIQUID (ML) 160 MG/5ML 0.00932 09/27/2013 0.00932 08/21/2015 ACETAMINOPHEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 160 0.02137 08/21/2015 0.02033 02/17/2017 MG/5ML ACETAMINOPHEN ORAL TABLET 325 MG 0.00830 06/20/2014 0.00830 08/21/2015 ACETAMINOPHEN ORAL TABLET 500 MG 0.01040 04/03/2015 0.01040 08/21/2015 ACETAMINOPHEN ORAL TABLET, CHEWABLE 80 MG 0.04651 04/03/2015 0.04651 08/21/2015 ACETAMINOPHEN ORAL TABLET,DISINTEGRATING 80 MG 0.05113 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 120 MG 0.20324 08/22/2014 0.20324 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 325 MG 0.46400 08/22/2014 0.46400 08/21/2015 ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 650 MG 0.21762 08/22/2014 0.21762 08/21/2015 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.01332 01/30/2015 0.01332 08/21/2015 120-12MG/5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.21394 03/27/2015 0.21394 08/21/2015 120-12MG/5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 0.10079 03/27/2015 0.10079 08/21/2015 300MG/12.5 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.14344 09/19/2014 0.14344 08/21/2015 15MG ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.12060 05/01/2015 0.12060 08/21/2015 30MG ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG- 0.22780 08/21/2015 0.19101 05/20/2016 60MG ACETAMINOPHEN/DIPHENHYDRAMINE HCL ORAL TABLET 500MG-25MG 0.04047 04/24/2015 0.04047 08/21/2015 ACETAZOLAMIDE ORAL CAPSULE, EXTENDED RELEASE 500 MG 2.53225 11/20/2015 2.01798 03/25/2016 ACETAZOLAMIDE ORAL TABLET 125 MG 1.52593 01/24/2014 1.52593 08/21/2015 ACETAZOLAMIDE ORAL TABLET 250 MG 2.01817 11/28/2014 ACETIC ACID IRRIGATION SOLUTION, IRRIGATION 0.25 % 0.00350 03/01/2013 ACETIC ACID OTIC SOLUTION, NON-ORAL 2 % 1.81591 06/28/2013 1.81591 08/21/2015 ACETIC ACID/ALUMINUM ACETATE OTIC DROPS 2 % 0.84000 01/25/2013 0.84000 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ACETIC ACID/HYDROCORTISONE OTIC DROPS 2 %-1 % 9.82215 08/21/2015 8.85454 01/13/2017 ACETYLCYSTEINE INTRAVENOUS VIAL (ML) 200 MG/ML 5.26400 03/06/2015 5.26400 08/21/2015 ACETYLCYSTEINE MISCELLANEOUS VIAL (ML) 100 MG/ML 0.45068 08/12/2014 0.45068 08/21/2015 ACETYLCYSTEINE MISCELLANEOUS VIAL (ML) 200 MG/ML 0.39190 02/13/2015 0.39190 08/21/2015 ACETYLCYSTEINE/MECOBALAMIN/LEVOMEFOLATE CALCIUM ORAL 1.89794 02/20/2015 1.89794 08/21/2015 TABLET 600-2-6 MG ACITRETIN ORAL CAPSULE 10 MG 17.18010 11/14/2014 ACITRETIN ORAL CAPSULE 17.5 MG 42.31920 03/21/2014 ACITRETIN ORAL CAPSULE 25 MG 25.13519 09/12/2014 23.09605 09/30/2016 ACYCLOVIR ORAL CAPSULE 200 MG 0.08844 03/27/2015 0.08844 08/21/2015 ACYCLOVIR ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200 MG/5ML 0.65886 09/19/2014 0.65886 08/21/2015 ACYCLOVIR ORAL TABLET 400 MG 0.10104 04/10/2015 0.10104 08/21/2015 ACYCLOVIR ORAL TABLET 800 MG 0.18452 03/27/2015 0.18452 08/21/2015 ACYCLOVIR SODIUM INTRAVENOUS VIAL (EA) 500 MG 31.20600 08/22/2014 31.20600 08/21/2015 ACYCLOVIR SODIUM INTRAVENOUS VIAL (ML) 50 MG/ML 1.40750 07/25/2014 ACYCLOVIR TOPICAL OINTMENT (GRAM) 5 % 18.88402 08/21/2015 17.89067 07/08/2016 ADAPALENE TOPICAL CREAM (GRAM) 0.1 % 3.51289 04/26/2013 ADAPALENE TOPICAL GEL (GRAM) 0.1 % 3.05760 01/25/2013 2.60534 07/08/2016 ADAPALENE TOPICAL GEL (GRAM) 0.3 % 4.68580 11/07/2014 4.68580 08/21/2015 ADAPALENE TOPICAL GEL WITH PUMP (GRAM) 0.3 % 4.61985 04/10/2015 4.61985 08/21/2015 ADEFOVIR DIPIVOXIL ORAL TABLET 10 MG 26.52627 09/27/2013 ALBUMIN HUMAN INTRAVENOUS INTRAVENOUS SOLUTION 25 % 1.51200 05/01/2015 1.51200 08/21/2015 ALBUMIN HUMAN INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.21588 09/19/2014 0.21588 08/21/2015 ALBUTEROL SULFATE INHALATION SOLUTION, NON-ORAL 5 MG/ML 0.72066 10/18/2013 0.72066 08/21/2015 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (EA) 2.5 MG/0.5 0.43876 08/01/2014 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 0.63MG/3ML 0.35633 12/05/2014 0.35633 08/21/2015 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 1.25MG/3ML 0.37645 08/21/2015 0.28465 05/20/2016 ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 2.5 MG/3ML 0.05253 04/03/2015 0.05253 08/21/2015 ALBUTEROL SULFATE ORAL SYRUP 2 MG/5 ML 0.01277 05/24/2013 0.01277 08/21/2015 ALBUTEROL SULFATE ORAL TABLET 2 MG 4.56651 08/21/2015 4.05000 12/25/2015 ALBUTEROL SULFATE ORAL TABLET 4 MG 4.11250 08/21/2015 3.62765 12/25/2015 ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 4 MG 1.18451 04/25/2014 ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 8 MG 1.71821 04/05/2013 ALCLOMETASONE DIPROPIONATE TOPICAL CREAM (GRAM) 0.05 % 1.30908 06/21/2013 ALCLOMETASONE DIPROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 0.58692 06/28/2013 ALENDRONATE SODIUM ORAL SOLUTION, ORAL 70 MG/75ML 2.45700 09/27/2013 ALENDRONATE SODIUM ORAL TABLET 10 MG 0.18750 08/12/2014 0.18750 08/21/2015 ALENDRONATE SODIUM ORAL TABLET 35 MG 0.52484 11/07/2014 0.52484 08/21/2015 ALENDRONATE SODIUM ORAL TABLET 40 MG 2.80060 03/27/2015 ALENDRONATE SODIUM ORAL TABLET 5 MG 0.18110 08/12/2014 0.18110 08/21/2015 ALENDRONATE SODIUM ORAL TABLET 70 MG 0.52484 08/21/2015 0.46500 12/02/2016 ALFUZOSIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.13697 04/17/2015 0.13697 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage Generic Name Prev. SMAC Price Prev. Effective Current SMAC Current Effective Date Price Date ALLOPURINOL ORAL TABLET 100 MG 0.16332 11/28/2014 0.16332 08/21/2015 ALLOPURINOL ORAL TABLET 300 MG 0.43385 03/25/2016 0.33844 05/20/2016 ALPHA LIPOIC ACID ORAL CAPSULE 200 MG 0.12771 08/08/2014 0.12771 08/21/2015 ALPHA LIPOIC ACID ORAL CAPSULE 50 MG 0.10210 08/12/2014 0.10210 08/21/2015 ALPRAZOLAM ORAL TABLET 0.25 MG 0.01509 05/16/2014 0.01509 08/21/2015 ALPRAZOLAM ORAL TABLET 0.5 MG 0.01780 04/17/2015 0.01780 08/21/2015 ALPRAZOLAM ORAL TABLET 1 MG 0.01970 02/06/2015 0.01970 08/21/2015 ALPRAZOLAM ORAL TABLET 2 MG 0.04007 08/21/2015 0.07213 09/28/2015 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 0.5 MG 0.36136 08/12/2014 0.36136 08/21/2015 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 1 MG 0.44913 08/12/2014 0.44913 08/21/2015 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 0.41600 08/12/2014 0.41600 08/21/2015 ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 3 MG 0.79340 08/21/2015 0.55483 11/20/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 0.25 MG 1.36123 03/01/2013 1.36123 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 0.5 MG 1.51669 01/25/2013 1.51669 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 1 MG 2.02358 01/25/2013 2.02358 08/21/2015 ALPRAZOLAM ORAL TABLET,DISINTEGRATING 2 MG 3.00202 01/25/2013 3.00202 08/21/2015 ALUMINUM HYDROXIDE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 0.00813 08/21/2015 320 MG/5ML AMANTADINE HCL ORAL CAPSULE 100 MG 1.15992 04/22/2016 1.10704 08/26/2016 AMANTADINE HCL ORAL SOLUTION, ORAL 50 MG/5 ML 0.01733 04/03/2015 0.01733 08/21/2015 AMANTADINE HCL ORAL TABLET 100 MG 1.59829 04/12/2013 AMCINONIDE TOPICAL CREAM (GRAM) 0.1 % 2.82140 08/12/2014 AMCINONIDE TOPICAL LOTION (ML) 0.1 % 1.90000 08/12/2014 AMCINONIDE TOPICAL OINTMENT (GRAM) 0.1 % 4.53600 08/30/2013 AMIKACIN SULFATE INJECTION VIAL (ML) 1000MG/4ML 3.14373 12/05/2014 3.14373 08/21/2015 AMIKACIN SULFATE INJECTION VIAL (ML) 500 MG/2ML 2.95555 12/05/2014 2.95555 08/21/2015 AMILORIDE HCL ORAL TABLET 5 MG 0.49564 02/13/2015 0.49564 08/21/2015 AMILORIDE HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5 MG-50 MG 0.42250 05/30/2014 0.42250 08/21/2015 AMINO ACIDS ORAL POWDER (GRAM) 0.25540 08/12/2014 AMINOCAPROIC ACID INTRAVENOUS VIAL (ML) 250 MG/ML 0.08148 02/06/2015 0.08148 08/21/2015 AMINOCAPROIC ACID ORAL TABLET 1000 MG 18.30610 08/12/2014 18.30610 08/21/2015 AMINOCAPROIC ACID ORAL TABLET 500 MG 5.37896 10/11/2013 5.37896 08/21/2015 AMINOPHYLLINE INTRAVENOUS VIAL (ML) 250MG/10ML 0.30912 01/30/2015 0.30912 08/21/2015 AMINOPHYLLINE INTRAVENOUS VIAL (ML) 500MG/20ML 0.07270 08/12/2014 AMIODARONE HCL INTRAVENOUS AMPUL (ML) 50 MG/ML 0.33600 01/25/2013 AMIODARONE HCL ORAL TABLET 100 MG 2.55717 03/21/2014 AMIODARONE HCL ORAL TABLET 200 MG 0.16103 08/21/2015 0.12724 09/30/2016 AMIODARONE HCL ORAL TABLET 400 MG 3.19526 08/22/2014 2.81936 12/02/2016 AMITRIPTYLINE HCL ORAL TABLET 10 MG 0.15732 04/03/2015 0.15732 08/21/2015 AMITRIPTYLINE HCL ORAL TABLET 100 MG 1.00016 08/21/2015 0.86682 09/30/2016 AMITRIPTYLINE HCL ORAL TABLET 150 MG 1.40116 08/21/2015 1.71450 10/01/2015 AMITRIPTYLINE HCL ORAL TABLET 25 MG 0.26664 04/03/2015 0.26664 08/21/2015 West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective 2/24/2017 Disclaimer: Price listing does not guarantee coverage Generic Name Prev.