westva mastersmac Oct 11 2013 - dhhr.wv.gov Pharmacy/Documents... · acetylcysteine 200 mg/ml vial...

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Generic_Name Old SMAC Price Current SMAC Price Effective_Date 0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013 0.9 % SODIUM CHLORIDE PGY VL PRT 0.00000 0.07291 2/22/2013 0.9 % SODIUM CHLORIDE 0.9 % IV SOLN 0.00000 0.00165 6/28/2013 0.9 % SODIUM CHLORIDE 0.9 % VIAL 0.00000 0.05830 1/25/2013 ABACAVIR SULFATE 300 MG TABLET 0.00000 6.21453 9/6/2013 ACARBOSE 100 MG TABLET 0.00000 0.40200 7/12/2013 ACARBOSE 25 MG TABLET 0.00000 0.46270 6/14/2013 ACARBOSE 50 MG TABLET 0.49093 0.35054 6/14/2013 ACEBUTOLOL HCL 200 MG CAPSULE 0.00000 0.21350 1/25/2013 ACETAMINOPHEN 100 MG/ML DROPS 0.00000 0.11667 4/12/2013 ACETAMINOPHEN 120 MG SUPP.RECT 0.16290 0.16289 3/1/2013 ACETAMINOPHEN 160 MG/5ML ELIXIR 0.00000 0.01083 9/27/2013 ACETAMINOPHEN 160 MG/5ML LIQUID 0.00000 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 0.00000 0.00830 1/25/2013 ACETAMINOPHEN 500 MG CAPSULE 0.02940 0.01093 5/17/2013 ACETAMINOPHEN 500 MG TABLET 0.00000 0.01093 5/17/2013 ACETAMINOPHEN 650 MG SUPP.RECT 0.00000 0.21680 1/25/2013 ACETAMINOPHEN 80 MG TAB CHEW 0.00000 0.04450 3/1/2013 ACETAMINOPHEN 80 MG TAB RAPDIS 0.00000 0.05113 12/14/2012 ACETAMINOPHEN 80MG/0.8ML DROPS 0.11667 0.17160 4/19/2013 ACETAMINOPHEN WITH CODEINE 120-12MG/5 (5 ML) SOLUTION 0.00000 0.15890 12/14/2012 ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION 0.01490 0.01485 4/26/2013 ACETAMINOPHEN WITH CODEINE 300MG-15MG TABLET 0.00000 0.14200 2/8/2013 ACETAMINOPHEN WITH CODEINE 300MG-30MG TABLET 0.00000 0.10847 10/11/2013 ACETAMINOPHEN WITH CODEINE 300MG-60MG TABLET 0.22820 0.22823 7/5/2013 ACETAMINOPHEN WITH CODEINE 300MG/12.5 SOLUTION 0.00000 0.07496 3/1/2013 ACETAMINOPHEN/DIPHENHYDRAMINE 325-12.5MG TABLET 0.00000 0.15400 1/25/2013 ACETAMINOPHEN/DIPHENHYDRAMINE 500MG-25MG TABLET 0.03653 0.04181 9/6/2013 ACETAZOLAMIDE 125 MG TABLET 0.00000 0.46732 2/15/2013 ACETAZOLAMIDE 250 MG TABLET 0.00000 0.58533 8/9/2013 ACETAZOLAMIDE 500 MG CAPSULE ER 0.00000 3.00400 1/25/2013 ACETIC ACID 0.25 % IRRIG SOLN 0.00000 0.00350 3/1/2013 ACETIC ACID 2 % SOLUTION 0.00000 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 12/14/2012 ACETYL/METHYL-B12/LMEFOLATE CA 600-2-6 MG TABLET 0.00000 1.23520 1/25/2013 ACETYLCYSTEINE 100 MG/ML VIAL 0.00000 0.35253 8/9/2013 ACETYLCYSTEINE 200 MG/ML VIAL 0.00000 5.26400 12/14/2012 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 0.00000 26.90660 8/2/2013 ACYCLOVIR 200 MG CAPSULE 0.00000 0.09058 8/16/2013 ACYCLOVIR 200 MG/5ML ORAL SUSP 0.00000 0.16913 5/31/2013 ACYCLOVIR 5 % OINT. (G) 0.00000 18.24232 8/9/2013 ACYCLOVIR 800 MG TABLET 0.24452 0.24574 8/16/2013 ACYCLOVIR SODIUM 1000 MG VIAL 0.00000 9.04800 1/25/2013 ACYCLOVIR SODIUM 50 MG/ML VIAL 0.00000 2.85501 12/14/2012 ADAPALENE 0.1 % CREAM (G) 0.00000 3.51289 4/26/2013 ADAPALENE 0.1 % GEL (GRAM) 0.00000 3.05760 12/14/2012 ADEFOVIR DIPIVOXIL 10 MG TABLET 0.00000 26.52627 9/27/2013 ALBUMIN HUMAN 25 % IV SOLN 0.00000 0.91240 1/25/2013 ALBUMIN HUMAN 25 % VIAL 1.54350 1.51200 7/26/2013 ALBUMIN HUMAN 5 % IV SOLN 0.00000 0.21150 1/25/2013 Disclaimer: Price listing does not guarantee coverage West Virginia Medicaid State Maximum Allowable Cost (SMAC) List Effective Oct 11, 2013 Version 2013.42 Page 1 of 57

Transcript of westva mastersmac Oct 11 2013 - dhhr.wv.gov Pharmacy/Documents... · acetylcysteine 200 mg/ml vial...

Page 1: westva mastersmac Oct 11 2013 - dhhr.wv.gov Pharmacy/Documents... · acetylcysteine 200 mg/ml vial 0.00000 5.26400 12/14/2012 acitretin 10 mg capsule 0.00000 21.82892 8/2/2013 acitretin

Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/20130.9 % SODIUM CHLORIDE PGY VL PRT 0.00000 0.07291 2/22/20130.9 % SODIUM CHLORIDE 0.9 % IV SOLN 0.00000 0.00165 6/28/20130.9 % SODIUM CHLORIDE 0.9 % VIAL 0.00000 0.05830 1/25/2013ABACAVIR SULFATE 300 MG TABLET 0.00000 6.21453 9/6/2013ACARBOSE 100 MG TABLET 0.00000 0.40200 7/12/2013ACARBOSE 25 MG TABLET 0.00000 0.46270 6/14/2013ACARBOSE 50 MG TABLET 0.49093 0.35054 6/14/2013ACEBUTOLOL HCL 200 MG CAPSULE 0.00000 0.21350 1/25/2013ACETAMINOPHEN 100 MG/ML DROPS 0.00000 0.11667 4/12/2013ACETAMINOPHEN 120 MG SUPP.RECT 0.16290 0.16289 3/1/2013ACETAMINOPHEN 160 MG/5ML ELIXIR 0.00000 0.01083 9/27/2013ACETAMINOPHEN 160 MG/5ML LIQUID 0.00000 0.00932 9/27/2013ACETAMINOPHEN 160 MG/5ML ORAL SUSP 0.02397 0.02412 5/24/2013ACETAMINOPHEN 325 MG SUPP.RECT 0.00000 0.45850 12/1/2012ACETAMINOPHEN 325 MG TABLET 0.00000 0.00830 1/25/2013ACETAMINOPHEN 500 MG CAPSULE 0.02940 0.01093 5/17/2013ACETAMINOPHEN 500 MG TABLET 0.00000 0.01093 5/17/2013ACETAMINOPHEN 650 MG SUPP.RECT 0.00000 0.21680 1/25/2013ACETAMINOPHEN 80 MG TAB CHEW 0.00000 0.04450 3/1/2013ACETAMINOPHEN 80 MG TAB RAPDIS 0.00000 0.05113 12/14/2012ACETAMINOPHEN 80MG/0.8ML DROPS 0.11667 0.17160 4/19/2013ACETAMINOPHEN WITH CODEINE 120-12MG/5 (5 ML) SOLUTION 0.00000 0.15890 12/14/2012ACETAMINOPHEN WITH CODEINE 120-12MG/5 SOLUTION 0.01490 0.01485 4/26/2013ACETAMINOPHEN WITH CODEINE 300MG-15MG TABLET 0.00000 0.14200 2/8/2013ACETAMINOPHEN WITH CODEINE 300MG-30MG TABLET 0.00000 0.10847 10/11/2013ACETAMINOPHEN WITH CODEINE 300MG-60MG TABLET 0.22820 0.22823 7/5/2013ACETAMINOPHEN WITH CODEINE 300MG/12.5 SOLUTION 0.00000 0.07496 3/1/2013ACETAMINOPHEN/DIPHENHYDRAMINE 325-12.5MG TABLET 0.00000 0.15400 1/25/2013ACETAMINOPHEN/DIPHENHYDRAMINE 500MG-25MG TABLET 0.03653 0.04181 9/6/2013ACETAZOLAMIDE 125 MG TABLET 0.00000 0.46732 2/15/2013ACETAZOLAMIDE 250 MG TABLET 0.00000 0.58533 8/9/2013ACETAZOLAMIDE 500 MG CAPSULE ER 0.00000 3.00400 1/25/2013ACETIC ACID 0.25 % IRRIG SOLN 0.00000 0.00350 3/1/2013ACETIC ACID 2 % SOLUTION 0.00000 1.81591 6/28/2013ACETIC ACID/ALUMINUM ACETATE 2 % DROPS 0.00000 0.84000 12/1/2012ACETIC ACID/HYDROCORTISONE 2 %-1 % DROPS 0.00000 9.82215 12/14/2012ACETYL/METHYL-B12/LMEFOLATE CA 600-2-6 MG TABLET 0.00000 1.23520 1/25/2013ACETYLCYSTEINE 100 MG/ML VIAL 0.00000 0.35253 8/9/2013ACETYLCYSTEINE 200 MG/ML VIAL 0.00000 5.26400 12/14/2012ACITRETIN 10 MG CAPSULE 0.00000 21.82892 8/2/2013ACITRETIN 17.5 MG CAPSULE 0.00000 26.92153 8/2/2013ACITRETIN 25 MG CAPSULE 0.00000 26.90660 8/2/2013ACYCLOVIR 200 MG CAPSULE 0.00000 0.09058 8/16/2013ACYCLOVIR 200 MG/5ML ORAL SUSP 0.00000 0.16913 5/31/2013ACYCLOVIR 5 % OINT. (G) 0.00000 18.24232 8/9/2013ACYCLOVIR 800 MG TABLET 0.24452 0.24574 8/16/2013ACYCLOVIR SODIUM 1000 MG VIAL 0.00000 9.04800 1/25/2013ACYCLOVIR SODIUM 50 MG/ML VIAL 0.00000 2.85501 12/14/2012ADAPALENE 0.1 % CREAM (G) 0.00000 3.51289 4/26/2013ADAPALENE 0.1 % GEL (GRAM) 0.00000 3.05760 12/14/2012ADEFOVIR DIPIVOXIL 10 MG TABLET 0.00000 26.52627 9/27/2013ALBUMIN HUMAN 25 % IV SOLN 0.00000 0.91240 1/25/2013ALBUMIN HUMAN 25 % VIAL 1.54350 1.51200 7/26/2013ALBUMIN HUMAN 5 % IV SOLN 0.00000 0.21150 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

Page 1 of 57

Page 2: westva mastersmac Oct 11 2013 - dhhr.wv.gov Pharmacy/Documents... · acetylcysteine 200 mg/ml vial 0.00000 5.26400 12/14/2012 acitretin 10 mg capsule 0.00000 21.82892 8/2/2013 acitretin

Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

ALBUTEROL SULFATE 0.63MG/3ML VIAL-NEB 0.00000 0.37527 12/14/2012ALBUTEROL SULFATE 1.25MG/3ML VIAL-NEB 0.00000 0.37674 12/14/2012ALBUTEROL SULFATE 2 MG TABLET 0.00000 4.56651 5/3/2013ALBUTEROL SULFATE 2 MG/5 ML SYRUP 0.00000 0.01277 5/24/2013ALBUTEROL SULFATE 2.5 MG/0.5 VIAL-NEB 0.00000 0.63406 8/9/2013ALBUTEROL SULFATE 2.5 MG/3ML VIAL-NEB 0.00000 0.05321 8/30/2013ALBUTEROL SULFATE 4 MG TAB ER 12H 0.00000 1.04048 7/26/2013ALBUTEROL SULFATE 4 MG TABLET 0.00000 4.56651 5/3/2013ALBUTEROL SULFATE 5 MG/ML SOLUTION 0.00000 0.58175 10/4/2013ALBUTEROL SULFATE 8 MG TAB ER 12H 0.00000 1.71821 4/5/2013ALCLOMETASONE DIPROPIONATE 0.05 % CREAM (G) 0.00000 1.30908 6/21/2013ALCLOMETASONE DIPROPIONATE 0.05 % OINT. (G) 0.58690 0.58692 6/28/2013ALENDRONATE SODIUM 10 MG TABLET 0.00000 0.18750 1/25/2013ALENDRONATE SODIUM 35 MG TABLET 0.00000 0.64320 6/7/2013ALENDRONATE SODIUM 40 MG TABLET 0.00000 6.63530 1/25/2013ALENDRONATE SODIUM 5 MG TABLET 0.00000 0.18110 1/25/2013ALENDRONATE SODIUM 70 MG TABLET 0.00000 0.69010 1/25/2013ALENDRONATE SODIUM 70 MG/75ML SOLUTION 0.00000 2.45700 9/27/2013ALFUZOSIN HCL 10 MG TAB ER 24H 0.21554 0.22634 6/21/2013ALLOPURINOL 100 MG TABLET 0.00000 0.03388 8/23/2013ALLOPURINOL 300 MG TABLET 0.00000 0.05850 10/11/2013ALPHA LIPOIC ACID 200 MG CAPSULE 0.10000 0.09998 8/2/2013ALPHA LIPOIC ACID 50 MG CAPSULE 0.00000 0.10210 1/25/2013ALPRAZOLAM 0.25 MG TAB RAPDIS 0.00000 1.36123 3/1/2013ALPRAZOLAM 0.25 MG TABLET 0.00000 0.01509 6/14/2013ALPRAZOLAM 0.5 MG TAB ER 24H 0.33260 0.57218 6/28/2013ALPRAZOLAM 0.5 MG TAB RAPDIS 0.00000 1.51669 12/14/2012ALPRAZOLAM 0.5 MG TABLET 0.00000 0.01777 6/14/2013ALPRAZOLAM 1 MG TAB ER 24H 0.43080 0.44913 6/28/2013ALPRAZOLAM 1 MG TAB RAPDIS 0.00000 2.02358 12/14/2012ALPRAZOLAM 1 MG TABLET 0.00000 0.01970 6/14/2013ALPRAZOLAM 2 MG TAB ER 24H 0.57960 0.41600 6/28/2013ALPRAZOLAM 2 MG TAB RAPDIS 0.00000 3.00202 12/14/2012ALPRAZOLAM 2 MG TABLET 0.00000 0.04007 6/14/2013ALPRAZOLAM 3 MG TAB ER 24H 0.00000 0.79340 1/25/2013ALUM/SALICYLIC ACID/TALC/BENT POWDER 0.00000 0.06740 1/25/2013AMANTADINE HCL 100 MG CAPSULE 0.00000 1.36390 12/1/2012AMANTADINE HCL 100 MG TABLET 0.00000 1.59829 4/12/2013AMANTADINE HCL 50 MG/5 ML SYRUP 0.00000 0.01970 1/25/2013AMCINONIDE 0.1 % CREAM (G) 0.00000 2.82140 1/25/2013AMCINONIDE 0.1 % LOTION 0.00000 1.90000 1/25/2013AMCINONIDE 0.1 % OINT. (G) 0.00000 4.53600 8/30/2013AMIKACIN SULFATE 1000MG/4ML VIAL 0.00000 2.74505 12/14/2012AMIKACIN SULFATE 500 MG/2ML VIAL 0.00000 2.81400 7/5/2013AMILORIDE HCL 5 MG TABLET 0.00000 0.58088 8/9/2013AMILORIDE/HYDROCHLOROTHIAZIDE 5MG-50MG TABLET 0.00000 0.25763 3/1/2013AMINO ACIDS POWDER 0.00000 0.25540 1/25/2013AMINOCAPROIC ACID 1000 MG TABLET 0.00000 18.30610 1/25/2013AMINOCAPROIC ACID 250 MG/ML SOLUTION 0.00000 2.81233 6/14/2013AMINOCAPROIC ACID 250 MG/ML VIAL 0.00000 0.08148 8/16/2013AMINOCAPROIC ACID 500 MG TABLET 0.00000 5.37896 10/11/2013AMINOPHYLLINE 250MG/10ML AMPUL 0.00000 0.05540 1/25/2013AMINOPHYLLINE 250MG/10ML VIAL 0.00000 0.10840 1/25/2013AMINOPHYLLINE 500MG/20ML VIAL 0.00000 0.07270 1/25/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

AMIODARONE HCL 100 MG TABLET 0.00000 5.20077 8/16/2013AMIODARONE HCL 200 MG TABLET 0.00000 0.15276 8/16/2013AMIODARONE HCL 400 MG TABLET 0.00000 3.56070 8/30/2013AMIODARONE HCL 50 MG/ML AMPUL 0.00000 0.33600 1/25/2013AMITRIP HCL/CHLORDIAZEPOXIDE 12.5MG-5MG TABLET 0.00000 0.77870 1/25/2013AMITRIP HCL/CHLORDIAZEPOXIDE 25 MG-10MG TABLET 0.00000 1.16452 8/2/2013AMITRIPTYLINE HCL 10 MG TABLET 0.00000 0.01972 4/26/2013AMITRIPTYLINE HCL 100 MG TABLET 0.00000 0.05278 5/10/2013AMITRIPTYLINE HCL 150 MG TABLET 0.00000 0.10451 4/19/2013AMITRIPTYLINE HCL 25 MG TABLET 0.00000 0.02182 8/23/2013AMITRIPTYLINE HCL 50 MG TABLET 0.00000 0.02578 4/26/2013AMITRIPTYLINE HCL 75 MG TABLET 0.00000 0.04596 3/29/2013AMLODIPINE BESYLATE 10 MG TABLET 0.02533 0.02526 5/31/2013AMLODIPINE BESYLATE 2.5 MG TABLET 0.01943 0.01983 7/5/2013AMLODIPINE BESYLATE 5 MG TABLET 0.02131 0.02125 4/19/2013AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-20MG CAPSULE 0.00000 0.84835 5/10/2013AMLODIPINE BESYLATE/BENAZEPRIL 10 MG-40MG CAPSULE 0.00000 0.98222 7/5/2013AMLODIPINE BESYLATE/BENAZEPRIL 2.5MG-10MG CAPSULE 0.00000 1.14784 5/10/2013AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-10 MG CAPSULE 0.00000 0.81700 12/14/2012AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-20 MG CAPSULE 0.00000 0.82480 1/25/2013AMLODIPINE BESYLATE/BENAZEPRIL 5 MG-40 MG CAPSULE 0.00000 0.80695 12/14/2012AMLODIPINE/ATORVASTATIN 10 MG-10MG TABLET 0.00000 3.52613 12/14/2012AMLODIPINE/ATORVASTATIN 10 MG-20MG TABLET 0.00000 5.07214 10/11/2013AMLODIPINE/ATORVASTATIN 10 MG-40MG TABLET 0.00000 6.09134 9/27/2013AMLODIPINE/ATORVASTATIN 10 MG-80MG TABLET 0.00000 5.51847 10/11/2013AMLODIPINE/ATORVASTATIN 2.5MG-10MG TABLET 3.52621 3.52616 2/22/2013AMLODIPINE/ATORVASTATIN 2.5MG-20MG TABLET 4.82421 4.82420 2/22/2013AMLODIPINE/ATORVASTATIN 2.5MG-40MG TABLET 0.00000 4.82420 1/25/2013AMLODIPINE/ATORVASTATIN 5 MG-10 MG TABLET 0.00000 3.52617 12/14/2012AMLODIPINE/ATORVASTATIN 5 MG-20 MG TABLET 0.00000 5.69205 10/11/2013AMLODIPINE/ATORVASTATIN 5 MG-40 MG TABLET 0.00000 5.25811 10/11/2013AMLODIPINE/ATORVASTATIN 5MG-80MG TABLET 0.00000 4.82420 12/21/2012AMMONIUM ALUM/TALC/BENTONITE POWDER 0.00000 0.07530 1/25/2013AMMONIUM CHLORIDE 5 MEQ/ML VIAL 0.00000 0.42630 1/25/2013AMMONIUM LACTATE 12 % CREAM (G) 0.00000 0.03670 1/25/2013AMMONIUM LACTATE 12 % LOTION 0.01940 0.01942 4/26/2013AMOXAPINE 100 MG TABLET 0.00000 0.72280 12/14/2012AMOXAPINE 150 MG TABLET 0.00000 1.28830 12/14/2012AMOXAPINE 25 MG TABLET 0.00000 0.27027 12/14/2012AMOXAPINE 50 MG TABLET 0.00000 0.40850 1/25/2013AMOXICILLIN 125 MG TAB CHEW 0.00000 0.15067 12/14/2012AMOXICILLIN 125 MG/5ML SUSP RECON 0.00000 0.01662 8/16/2013AMOXICILLIN 200 MG/5ML SUSP RECON 0.00000 0.02734 8/16/2013AMOXICILLIN 250 MG CAPSULE 0.00000 0.05499 7/12/2013AMOXICILLIN 250 MG/5ML SUSP RECON 0.00000 0.02171 8/16/2013AMOXICILLIN 400 MG/5ML SUSP RECON 0.00000 0.02693 8/16/2013AMOXICILLIN 500 MG CAPSULE 0.00000 0.08911 6/28/2013AMOXICILLIN 500 MG TABLET 0.00000 0.28243 12/14/2012AMOXICILLIN 875MG TABLET 0.00000 0.13400 7/12/2013AMOXICILLIN/POTASSIUM CLAV 1000-62.5 TAB ER 12H 0.00000 2.71530 2/8/2013AMOXICILLIN/POTASSIUM CLAV 200-28.5/5 SUSP RECON 0.00000 0.10748 4/26/2013AMOXICILLIN/POTASSIUM CLAV 200-28.5MG TAB CHEW 0.00000 1.00222 3/1/2013AMOXICILLIN/POTASSIUM CLAV 400-57MG TAB CHEW 0.00000 1.40040 1/25/2013AMOXICILLIN/POTASSIUM CLAV 400-57MG/5 SUSP RECON 0.00000 0.15075 8/30/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

AMOXICILLIN/POTASSIUM CLAV 500-125 MG TABLET 0.00000 0.97150 10/11/2013AMOXICILLIN/POTASSIUM CLAV 600-42.9/5 SUSP RECON 0.00000 0.21300 12/1/2012AMOXICILLIN/POTASSIUM CLAV 875-125 MG TABLET 0.00000 0.90030 5/10/2013AMPHOTERICIN B 50 MG VIAL 0.00000 15.22500 8/2/2013AMPICILLIN SODIUM 1 G VIAL 0.00000 2.89120 12/14/2012AMPICILLIN SODIUM 1 G VIAL PORT 12.52460 12.17907 8/9/2013AMPICILLIN SODIUM 10 G VIAL 0.00000 40.47315 12/14/2012AMPICILLIN SODIUM 125 MG VIAL 0.00000 3.50250 1/25/2013AMPICILLIN SODIUM 2 G VIAL 0.00000 4.95820 10/11/2013AMPICILLIN SODIUM 2 G VIAL PORT 0.00000 23.62640 12/14/2012AMPICILLIN SODIUM 250 MG VIAL 0.00000 1.41638 12/14/2012AMPICILLIN SODIUM 500 MG VIAL 0.00000 1.62006 12/14/2012AMPICILLIN SODIUM/SULBACTAM NA 1.5 G VIAL 0.00000 3.10147 8/9/2013AMPICILLIN SODIUM/SULBACTAM NA 1.5 G VIAL PORT 0.00000 3.24240 1/11/2013AMPICILLIN SODIUM/SULBACTAM NA 15 G VIAL 21.31500 20.70600 4/5/2013AMPICILLIN SODIUM/SULBACTAM NA 3 G VIAL 0.00000 6.47640 8/9/2013AMPICILLIN SODIUM/SULBACTAM NA 3 G VIAL PORT 0.00000 5.22060 1/11/2013AMPICILLIN TRIHYDRATE 125 MG/5ML SUSP RECON 0.00000 0.03950 2/8/2013AMPICILLIN TRIHYDRATE 250 MG CAPSULE 0.00000 0.09000 1/25/2013AMPICILLIN TRIHYDRATE 250 MG/5ML SUSP RECON 0.00000 0.06860 2/8/2013AMPICILLIN TRIHYDRATE 500 MG CAPSULE 0.00000 0.14370 1/25/2013ANAGRELIDE HCL 0.5 MG CAPSULE 0.00000 0.22620 12/1/2012ANAGRELIDE HCL 1 MG CAPSULE 0.00000 0.43730 1/25/2013ANASTROZOLE 1 MG TABLET 0.00000 0.15140 1/25/2013ANTIPYRINE/BENZOCAINE 5.5 %-1.4% DROPS 0.00000 10.43970 5/24/2013ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4 %-1.4% DROPS 0.00000 0.56723 6/14/2013ANTIVENIN,LATRODECTUS MACTANS COMBO. PKG 0.00000 28.66500 12/14/2012ANTIVENIN,MICRURUS FULVIUS COMBO. PKG 0.00000 1,496.32000 1/25/2013APRACLONIDINE HCL 0.5 % DROPS 0.00000 12.32550 12/14/2012ARGATROBAN 100 MG/ML VIAL 0.00000 1,124.62000 1/25/2013ARGATROBAN IN 0.9 % SOD CHLOR 125 MG/125 VIAL 0.00000 11.61817 12/14/2012ARGATROBAN IN NACL,ISO-OSMOTIC 50 MG/50ML VIAL 6.73915 3.85000 10/4/2013ARGININE 500 MG CAPSULE 0.08060 0.08386 3/8/2013ARGININE HCL 1000 MG TABLET 0.13360 0.14760 4/26/2013ASCORBIC ACID 1000 MG TABLET 0.04930 0.04855 5/24/2013ASCORBIC ACID 1000 MG TABLET ER 0.07153 0.07311 4/5/2013ASCORBIC ACID 250 MG TAB CHEW 0.00000 0.02510 1/25/2013ASCORBIC ACID 250 MG TABLET 0.01670 0.01807 6/21/2013ASCORBIC ACID 500 MG TAB CHEW 0.00000 0.04453 12/14/2012ASCORBIC ACID 500 MG TABLET 0.02280 0.02550 5/17/2013ASPIRIN 325 MG TABLET 0.00800 0.00804 3/22/2013ASPIRIN 325 MG TABLET DR 0.00000 0.01214 5/17/2013ASPIRIN 81 MG TAB CHEW 0.02200 0.02198 3/29/2013ASPIRIN 81 MG TABLET DR 0.00000 0.00949 5/17/2013ASPIRIN/ACETAMINOPHEN/CAFFEINE 250-250-65 TABLET 0.04476 0.07609 8/9/2013ASPIRIN/SOD BICARB/CITRIC ACID 325-1916MG TABLET EFF 0.07967 0.09644 3/8/2013ATENOLOL 100 MG TABLET 0.00000 0.03400 12/1/2012ATENOLOL 25 MG TABLET 0.01327 0.01321 4/19/2013ATENOLOL 50 MG TABLET 0.00000 0.01640 1/25/2013ATENOLOL/CHLORTHALIDONE 100MG-25MG TABLET 0.00000 0.16099 5/31/2013ATENOLOL/CHLORTHALIDONE 50 MG-25MG TABLET 0.00000 0.10097 7/12/2013ATORVASTATIN CALCIUM 10 MG TABLET 0.00000 0.55680 12/1/2012ATORVASTATIN CALCIUM 20 MG TABLET 0.00000 0.79430 12/1/2012ATORVASTATIN CALCIUM 40 MG TABLET 0.00000 0.79430 12/1/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

ATORVASTATIN CALCIUM 80 MG TABLET 0.00000 0.95320 12/1/2012ATOVAQUONE/PROGUANIL HCL 250-100 MG TABLET 5.00297 5.06839 6/7/2013ATOVAQUONE/PROGUANIL HCL 62.5-25 MG TABLET 0.00000 1.85045 12/14/2012ATROPINE SULFATE 0.05MG/ML DISP SYRIN 0.00000 2.23272 12/14/2012ATROPINE SULFATE 0.1 MG/ML DISP SYRIN 0.00000 0.43014 12/14/2012ATROPINE SULFATE 0.4 MG/ML VIAL 0.00000 0.85480 1/25/2013ATROPINE SULFATE 1 % DROPS 0.00000 1.76890 2/1/2013ATROPINE SULFATE 1 % OINT. (G) 0.00000 3.98000 2/8/2013ATROPINE SULFATE 1 MG/ML VIAL 0.00000 1.50320 1/25/2013AZATHIOPRINE 50 MG TABLET 0.00000 0.32500 9/27/2013AZATHIOPRINE SODIUM 100 MG VIAL 0.00000 10.56045 12/14/2012AZELASTINE HCL 0.05 % DROPS 0.00000 7.75667 8/9/2013AZELASTINE HCL 137 MCG SPRAY/PUMP 0.00000 2.02162 9/20/2013AZITHROMYCIN 1 G PACKET 0.00000 13.46447 12/14/2012AZITHROMYCIN 100 MG/5ML SUSP RECON 0.00000 0.83153 6/7/2013AZITHROMYCIN 200 MG/5ML SUSP RECON 0.00000 0.71130 1/25/2012AZITHROMYCIN 250 MG TABLET 0.00000 0.61198 4/12/2013AZITHROMYCIN 500 MG TABLET 0.00000 3.15413 8/30/2013AZITHROMYCIN 500 MG VIAL 3.97150 4.90100 9/20/2013AZITHROMYCIN 500 MG VIAL PORT 0.00000 12.68820 12/14/2012AZITHROMYCIN 600 MG TABLET 0.00000 3.26560 5/17/2013AZTREONAM 1 G VIAL 0.00000 27.67800 12/14/2012AZTREONAM 2 G VIAL 0.00000 56.23800 12/14/2012B COMPLEX WITH VITAMIN C TABLET 0.00000 0.02613 12/14/2012B12/LEVOMEFOLATE CALCIUM/B-6 2-1.13-25 TABLET 0.00000 0.89950 9/27/2013BACITRACIN 500 UNIT/G OINT. (G) OPHTHALMIC 0.00000 13.86800 12/14/2012BACITRACIN 500 UNIT/G OINT. (G) TOPICAL 0.00000 0.06722 4/19/2013BACITRACIN ZINC 500 UNIT/G OINT. (G) 0.00000 0.10720 12/1/2012BACITRACIN/POLYMYXIN B SULFATE 500-10K/G OINT. (G) OPHT 0.00000 5.41640 9/27/2013BACITRACIN/POLYMYXIN B SULFATE 500-10K/G OINT. (G) TOPIC 0.00000 0.27376 12/14/2012BACLOFEN 10 MG TABLET 0.00000 0.04241 8/30/2013BACLOFEN 100 % POWDER 0.00000 2.85072 4/19/2013BACLOFEN 20 MG TABLET 0.00000 0.07625 8/16/2013BALSALAZIDE DISODIUM 750 MG CAPSULE 0.00000 0.23182 6/21/2013BCG LIVE 50 MG VIAL 0.00000 291.39600 12/14/2012BENAZEPRIL HCL 10 MG TABLET 0.05186 0.05028 8/16/2013BENAZEPRIL HCL 20 MG TABLET 0.05510 0.05507 4/19/2013BENAZEPRIL HCL 40 MG TABLET 0.06940 0.06941 8/30/2013BENAZEPRIL HCL 5 MG TABLET 0.00000 0.04900 1/25/2013BENAZEPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.00000 1.44718 9/20/2013BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.00000 1.44718 9/27/2013BENAZEPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.00000 1.44718 9/27/2013BENZOCAINE/MENTHOL 15MG-3.6MG LOZENGE 0.09813 0.10645 4/19/2013BENZONATATE 100 MG CAPSULE 0.00000 0.09072 12/14/2012BENZONATATE 200 MG CAPSULE 0.00000 0.13306 12/14/2012BENZOYL PEROXIDE 10 % CLEANSER 0.00000 0.04239 4/5/2013BENZOYL PEROXIDE 10 % GEL (GRAM) 0.00000 0.19200 1/25/2013BENZOYL PEROXIDE 2.5 % GEL (GRAM) 0.00000 0.23088 8/16/2013BENZOYL PEROXIDE 5 % CLEANSER 0.00000 0.04075 8/9/2013BENZOYL PEROXIDE 5 % GEL (GRAM) 0.00000 0.18360 1/25/2013BENZOYL PEROXIDE 5.3% FOAM 0.00000 2.02384 12/14/2012BENZOYL PEROXIDE 9.8 % FOAM 0.00000 1.61098 12/14/2012BENZPHETAMINE HCL 50 MG TABLET 0.00000 0.47918 12/14/2012BENZTROPINE MESYLATE 0.5 MG TABLET 0.00000 0.16160 9/27/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

BENZTROPINE MESYLATE 1 MG TABLET 0.00000 0.16026 8/23/2013BENZTROPINE MESYLATE 2 MG TABLET 0.00000 0.18065 8/23/2013BENZTROPINE MESYLATE 2 MG/2 ML AMPUL 0.00000 20.56250 8/30/2013BENZTROPINE MESYLATE 2 MG/2 ML VIAL 0.00000 40.39560 12/14/2012BETAMET ACET/BETAMET NA PH 6 MG/ML VIAL 0.00000 5.60000 12/14/2012BETAMETHASONE DIPROPIONATE 0.05 % CREAM (G) 0.00000 1.47641 10/11/2013BETAMETHASONE DIPROPIONATE 0.05 % GEL (GRAM) 0.00000 1.21450 1/25/2013BETAMETHASONE DIPROPIONATE 0.05 % LOTION 0.00000 0.53761 5/3/2013BETAMETHASONE DIPROPIONATE 0.05 % OINT. (G) 0.00000 1.57591 3/29/2013BETAMETHASONE VALERATE 0.1 % CREAM (G) 0.00000 0.78903 10/11/2013BETAMETHASONE VALERATE 0.1 % LOTION 0.00000 0.79430 3/29/2013BETAMETHASONE VALERATE 0.12 % FOAM 0.00000 2.71317 1/25/2013BETAMETHASONE/PROPYLENE GLYC 0.05 % CREAM (G) 0.00000 0.31088 9/13/2013BETAMETHASONE/PROPYLENE GLYC 0.05 % LOTION 0.00000 1.77637 8/16/2013BETAXOLOL HCL 0.5 % DROPS 0.00000 7.27680 12/14/2012BETAXOLOL HCL 10 MG TABLET 0.00000 0.72400 2/15/2013BETHANECHOL CHLORIDE 10 MG TABLET 0.00000 0.06419 8/16/2013BETHANECHOL CHLORIDE 25 MG TABLET 0.00000 0.15650 4/12/2013BETHANECHOL CHLORIDE 5 MG TABLET 0.00000 0.05963 4/12/2013BETHANECHOL CHLORIDE 50 MG TABLET 0.00000 0.45410 2/8/2013BICALUTAMIDE 50 MG TABLET 0.00000 0.30016 6/14/2013BIOFLAV,LEMON/VIT BCOMP&C 200-100 MG TABLET 0.00000 0.14285 12/14/2012BIOTIN 2500 MCG CAPSULE 0.00000 0.09390 1/25/2013BISACODYL 10 MG SUPP.RECT 0.09487 0.09491 7/5/2013BISACODYL 5 MG TABLET DR 0.00947 0.00996 6/21/2013BISMUTH SUBSALICYLATE 262 MG TAB CHEW 0.00000 0.04558 5/3/2013BISMUTH SUBSALICYLATE 262MG/15ML ORAL SUSP 0.00737 0.00882 6/21/2013BISMUTH SUBSALICYLATE 525MG/15ML ORAL SUSP 0.01099 0.01100 6/14/2013BISOPROLOL FUMARATE 10 MG TABLET 0.00000 0.64320 6/14/2013BISOPROLOL FUMARATE 5 MG TABLET 0.00000 0.29172 4/12/2013BISOPROLOL FUMARATE/HCTZ 10-6.25MG TABLET 0.00000 0.06060 1/25/2013BISOPROLOL FUMARATE/HCTZ 2.5-6.25MG TABLET 0.00000 0.05829 4/19/2013BISOPROLOL FUMARATE/HCTZ 5-6.25MG TABLET 0.00000 0.37000 12/1/2012BRIMONIDINE TARTRATE 0.15 % DROPS 0.00000 13.44910 1/25/2013BRIMONIDINE TARTRATE 0.2 % DROPS 0.00000 0.58420 1/25/2013BROMFENAC SODIUM 0.09% DROPS 0.00000 40.47120 2/8/2013BROMOCRIPTINE MESYLATE 2.5 MG TABLET 0.00000 1.07776 12/14/2012BROMOCRIPTINE MESYLATE 5 MG CAPSULE 0.00000 6.51728 7/12/2013BROMPHENIRAM/PHENYLEPHRINE/DM 1-2.5-5/5 SOLUTION 0.00000 0.02385 12/14/2012BROMPHENIRAM/PHENYLEPHRINE/DM 4-10-20/5 LIQUID 0.00000 0.11830 12/14/2012BROMPHENIRAM/PHENYLEPHRINE/DM 4-7.5-15/5 LIQUID 0.08550 0.09255 4/26/2013BUDESONIDE 0.25MG/2ML AMPUL-NEB 0.00000 3.29490 2/22/2013BUDESONIDE 0.5 MG/2ML AMPUL-NEB 0.00000 3.87765 2/22/2013BUDESONIDE 3 MG CAPDR & ER 0.00000 11.98500 1/25/2013BUMETANIDE 0.25 MG/ML VIAL 0.00000 0.26572 12/14/2012BUMETANIDE 0.5 MG TABLET 0.00000 0.10865 5/17/2013BUMETANIDE 1 MG TABLET 0.12197 0.12248 8/16/2013BUMETANIDE 2 MG TABLET 0.00000 0.15169 6/7/2013BUPIVACAINE HCL 2.5 MG/ML VIAL 0.00000 0.04200 1/25/2013BUPIVACAINE HCL 5 MG/ML VIAL 0.00000 0.05090 12/14/2012BUPIVACAINE HCL/EPINEPHRINE 0.25-.0005 VIAL 0.00000 0.12253 12/14/2012BUPIVACAINE HCL/EPINEPHRINE 0.5-1:200K VIAL 0.00000 0.11900 12/14/2012BUPIVACAINE HCL/EPINEPHRINE BI 0.5-1:200K CARTRIDGE 0.00000 0.26130 1/25/2013BUPIVACAINE HCL/EPINEPHRINE/PF 0.25-.0005 VIAL 0.00000 0.27733 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

BUPIVACAINE HCL/EPINEPHRINE/PF 0.5-1:200K VIAL 0.00000 0.25992 12/14/2012BUPIVACAINE HCL/PF 2.5 MG/ML AMPUL 0.00000 0.11790 1/25/2013BUPIVACAINE HCL/PF 2.5 MG/ML VIAL 0.00000 0.06646 12/14/2012BUPIVACAINE HCL/PF 5 MG/ML AMPUL 0.00000 0.08690 1/25/2013BUPIVACAINE HCL/PF 5 MG/ML VIAL 0.00000 0.05100 1/25/2013BUPIVACAINE HCL/PF 7.5 MG/ML AMPUL 0.00000 0.10478 12/14/2012BUPIVACAINE HCL/PF 7.5 MG/ML VIAL 0.00000 0.14727 12/14/2012BUPRENORPHINE HCL 0.3 MG/ML DISP SYRIN 0.00000 12.18000 1/25/2013BUPRENORPHINE HCL 2 MG TAB SUBL 0.00000 1.59160 10/11/2013BUPRENORPHINE HCL 8 MG TAB SUBL 0.00000 2.51416 10/11/2013BUPRENORPHINE HCL/NALOXONE HCL 2 MG-0.5MG TAB SUBL 0.00000 4.07645 3/22/2013BUPRENORPHINE HCL/NALOXONE HCL 8 MG-2 MG TAB SUBL 7.30071 7.30150 8/16/2013BUPROPION HCL 100 MG TABLET 0.00000 0.34760 2/22/2013BUPROPION HCL 100 MG TABLET ER 0.00000 0.24660 1/25/2013BUPROPION HCL 150 MG TAB ER 24H 0.00000 0.64762 2/22/2013BUPROPION HCL 150 MG TABLET ER (ANTIDEPRESSANTS) 0.00000 0.28186 5/3/2013BUPROPION HCL 150 MG TABLET ER (SMOKING DETERRENT) 0.00000 0.58090 3/1/2013BUPROPION HCL 200 MG TABLET ER 0.00000 0.48799 6/14/2013BUPROPION HCL 300 MG TAB ER 24H 0.00000 0.72940 8/16/2013BUPROPION HCL 75 MG TABLET 0.00000 0.40820 12/1/2012BUSPIRONE HCL 10 MG TABLET 0.00000 0.07584 9/13/2013BUSPIRONE HCL 15 MG TABLET 0.00000 0.10768 6/14/2013BUSPIRONE HCL 30 MG TABLET 0.00000 0.76395 7/12/2013BUSPIRONE HCL 5 MG TABLET 0.00000 0.04585 5/17/2013BUSPIRONE HCL 7.5 MG TABLET 0.00000 1.10621 8/16/2013BUTALB/ACETAMINOPHEN/CAFFEINE 50-325-40 TABLET 0.00000 0.05990 12/14/2012BUTALB/ACETAMINOPHEN/CAFFEINE 50-500-40 TABLET 0.00000 0.19390 8/30/2013BUTALBIT/ACETAMIN/CAFF/CODEINE 50-325-30 CAPSULE 0.00000 0.28610 1/25/2013BUTALBITAL/ACETAMINOPHEN 50MG-325MG TABLET 0.00000 0.26453 12/14/2012BUTALBITAL/ASPIRIN/CAFFEINE 50-325-40 CAPSULE 0.00000 0.39703 10/11/2013BUTALBITAL/ASPIRIN/CAFFEINE 50-325-40 TABLET 0.00000 0.10335 4/19/2013BUTENAFINE HCL 1 % CREAM (G) 0.00000 0.40179 12/14/2012BUTORPHANOL TARTRATE 1 MG/ML VIAL 0.00000 1.94300 12/14/2012BUTORPHANOL TARTRATE 10 MG/ML SPRAY 0.00000 4.68430 1/25/2013BUTORPHANOL TARTRATE 2 MG/ML VIAL 0.00000 1.94300 12/14/2012CABERGOLINE 0.5 MG TABLET 0.00000 15.29063 8/30/2013CAFFEINE CITRATED 60 MG/3 ML SOLUTION 0.00000 6.70190 1/25/2013CAFFEINE CITRATED 60 MG/3 ML VIAL 0.00000 4.29429 12/14/2012CAFFEINE/SODIUM BENZOATE 250 MG/ML VIAL 0.00000 2.73000 1/25/2013CALCIPOTRIENE 0.005 % CREAM (G) 0.00000 5.04887 5/31/2013CALCIPOTRIENE 0.005 % OINT. (G) 4.22205 4.22790 8/30/2013CALCIPOTRIENE 0.005 % SOLUTION 0.00000 2.86567 10/11/2013CALCITONIN,SALMON,SYNTHETIC 200/DOSE SPRAY/PUMP 0.00000 12.21825 9/13/2013CALCITRIOL 0.25 MCG CAPSULE 0.52970 0.52974 6/7/2013CALCITRIOL 0.5 MCG CAPSULE 1.17680 1.17683 6/7/2013CALCITRIOL 1MCG/ML AMPUL 0.00000 4.68130 12/14/2012CALCITRIOL 1MCG/ML SOLUTION 0.00000 7.01272 7/5/2013CALCITRIOL 3MCG/G OINT. (G) 0.00000 10.42220 12/14/2012CALCIUM ACETATE 667 MG CAPSULE 0.00000 0.60520 12/1/2012CALCIUM ACETATE 667 MG TABLET 0.00000 0.36813 8/2/2013CALCIUM ACETATE/ALUMINUM SULF 839-1191MG POWD PACK 0.00000 0.50621 12/14/2012CALCIUM ACETATE/ALUMINUM SULF 952-1347MG POWD PACK 0.00000 0.72740 1/25/2013CALCIUM CARBONATE 200(500)MG TAB CHEW 0.01317 0.01394 7/5/2013CALCIUM CARBONATE 300MG(750) TAB CHEW 0.02330 0.02844 8/23/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

CALCIUM CARBONATE 500 MG/5ML ORAL SUSP 0.00000 0.01799 12/14/2012CALCIUM CARBONATE 500(1250) TAB CHEW 0.00000 0.03420 1/25/2013CALCIUM CARBONATE 500(1250) TABLET 0.01430 0.01434 5/24/2013CALCIUM CARBONATE 600 MG TABLET 0.00000 0.02144 12/14/2012CALCIUM CARBONATE/VITAMIN D2 250 MG-125 TABLET 0.00000 0.02170 1/25/2013CALCIUM CARBONATE/VITAMIN D3 250 MG-125 TABLET 0.00000 0.01032 12/14/2012CALCIUM CARBONATE/VITAMIN D3 500 MG-200 TABLET 0.01273 0.01599 6/28/2013CALCIUM CARBONATE/VITAMIN D3 500 MG-400 TABLET 0.03049 0.03179 8/16/2013CALCIUM CARBONATE/VITAMIN D3 600 MG-200 TABLET 0.00000 0.01899 12/14/2012CALCIUM CARBONATE/VITAMIN D3 600 MG-400 CAPSULE 0.04580 0.04855 7/5/2013CALCIUM CARBONATE/VITAMIN D3 600 MG-400 TAB CHEW 0.00000 0.09660 1/25/2013CALCIUM CARBONATE/VITAMIN D3 600 MG-400 TABLET 0.01956 0.01914 9/20/2013CALCIUM CARBONATE/VITAMIN D3 600 MG-800 TABLET 0.06880 0.06272 9/20/2013CALCIUM CHLORIDE 100 MG/ML DISP SYRIN 0.50020 0.47124 2/1/2013CALCIUM CHLORIDE 100 MG/ML VIAL 0.00000 0.17500 12/14/2012CALCIUM CITRATE 200(950)MG TABLET 0.00000 0.03070 1/25/2013CALCIUM CITRATE 250 MG TABLET 0.00000 0.05565 12/14/2012CALCIUM CITRATE/VITAMIN D3 200 MG-250 TABLET 0.00000 0.04220 1/25/2013CALCIUM CITRATE/VITAMIN D3 315 MG-200 TABLET 0.04370 0.05724 5/3/2013CALCIUM CITRATE/VITAMIN D3 315 MG-250 TABLET 0.04535 0.04584 4/5/2013CALCIUM POLYCARBOPHIL 625 MG TABLET 0.05896 0.07532 8/16/2013CANDESARTAN CILEXETIL 16 MG TABLET 0.00000 2.28281 6/7/2013CANDESARTAN CILEXETIL 32 MG TABLET 0.00000 3.09074 6/7/2013CANDESARTAN CILEXETIL 4 MG TABLET 0.00000 2.26738 6/7/2013CANDESARTAN CILEXETIL 8 MG TABLET 0.00000 2.26738 6/7/2013CANDESARTAN/HYDROCHLOROTHIAZID 16-12.5MG TABLET 0.00000 2.86251 12/14/2012CANDESARTAN/HYDROCHLOROTHIAZID 32-12.5MG TABLET 0.00000 2.91948 12/14/2012CANDESARTAN/HYDROCHLOROTHIAZID 32MG-25MG TABLET 3.15928 3.15984 6/14/2013CAPSAICIN 0.025 % CREAM (G) 0.00000 0.06709 4/5/2013CAPSAICIN 0.075 % CREAM (G) 0.00000 0.08472 12/14/2012CAPSAICIN/ME-SALICYLATE/MENTH 0.002%-20% LOTION 0.00000 2.36327 12/14/2012CAPTOPRIL 100 % POWDER 0.00000 56.85764 2/22/2013CAPTOPRIL 100 MG TABLET 0.00000 1.06383 10/4/2013CAPTOPRIL 12.5 MG TABLET 0.00000 0.01310 1/25/2013CAPTOPRIL 25 MG TABLET 0.01943 0.01940 1/25/2013CAPTOPRIL 50 MG TABLET 0.02950 0.02948 2/15/2013CAPTOPRIL/HYDROCHLOROTHIAZIDE 25 MG-25MG TABLET 0.00000 0.31499 7/12/2013CAPTOPRIL/HYDROCHLOROTHIAZIDE 50 MG-15MG TABLET 0.00000 0.86300 1/25/2013CARBAMAZEPINE 100 MG CPMP 12HR 0.00000 1.26436 8/16/2013CARBAMAZEPINE 100 MG TAB CHEW 0.05700 0.05701 5/24/2013CARBAMAZEPINE 200 MG CPMP 12HR 0.00000 1.25110 2/8/2013CARBAMAZEPINE 200 MG TAB ER 12H 0.00000 0.97960 6/14/2013CARBAMAZEPINE 200 MG TABLET 0.00000 0.04386 9/13/2013CARBAMAZEPINE 300 MG CPMP 12HR 0.00000 1.25113 5/3/2013CARBAMAZEPINE 400 MG TAB ER 12H 0.00000 1.95783 7/12/2013CARBAMIDE PEROXIDE 6.5 % DROPS 0.12690 0.12686 5/24/2013CARBIDOPA/LEVODOPA 10MG-100MG TAB RAPDIS 0.00000 0.77305 12/14/2012CARBIDOPA/LEVODOPA 10MG-100MG TABLET 0.00000 0.14690 1/25/2013CARBIDOPA/LEVODOPA 25MG-100MG TAB RAPDIS 0.00000 0.86710 1/25/2013CARBIDOPA/LEVODOPA 25MG-100MG TABLET 0.13178 0.13139 6/14/2013CARBIDOPA/LEVODOPA 25MG-100MG TABLET ER 0.39059 0.38104 10/4/2013CARBIDOPA/LEVODOPA 25MG-250MG TAB RAPDIS 0.00000 1.10100 1/25/2013CARBIDOPA/LEVODOPA 25MG-250MG TABLET 0.00000 0.17529 6/7/2013CARBIDOPA/LEVODOPA 50MG-200MG TABLET ER 0.00000 0.72000 11/1/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

CARBIDOPA/LEVODOPA/ENTACAPONE 12.5-50 MG TABLET 0.00000 2.62406 12/14/2012CARBIDOPA/LEVODOPA/ENTACAPONE 18.75-75MG TABLET 0.00000 2.62406 12/14/2012CARBIDOPA/LEVODOPA/ENTACAPONE 25-100-200 TABLET 0.00000 2.62406 12/14/2012CARBIDOPA/LEVODOPA/ENTACAPONE 31.25-125 TABLET 0.00000 2.62406 12/14/2012CARBIDOPA/LEVODOPA/ENTACAPONE 37.5-150MG TABLET 0.00000 2.62406 12/14/2012CARBIDOPA/LEVODOPA/ENTACAPONE 50-200-200 TABLET 0.00000 2.62406 12/14/2012CARBINOXAMINE MALEATE 4 MG TABLET 0.00000 0.49602 12/14/2012CARBINOXAMINE MALEATE 4 MG/5 ML LIQUID 0.00000 0.09112 12/14/2012CARBOXYMETHYLCELLULOSE SODIUM 0.5 % DROPERETTE 0.22027 0.20329 6/21/2013CARBOXYMETHYLCELLULOSE SODIUM 0.5 % DROPS 0.32289 0.32765 5/17/2013CARBOXYMETHYLCELLULOSE SODIUM 1 % DROPER GEL 0.00000 0.32162 3/29/2013CARISOPRODOL 250 MG TABLET 0.00000 2.31410 2/8/2013CARISOPRODOL 350 MG TABLET 0.06350 0.06352 2/1/2013CARISOPRODOL/ASPIRIN 200-325 MG TABLET 0.00000 1.52430 1/25/2013CARTEOLOL HCL 1 % DROPS 0.00000 1.17210 12/1/2012CARVEDILOL 12.5 MG TABLET 0.00000 0.03819 8/16/2013CARVEDILOL 25 MG TABLET 0.00000 0.04824 6/14/2013CARVEDILOL 3.125 MG TABLET 0.00000 0.03819 8/16/2013CARVEDILOL 6.25 MG TABLET 0.00000 0.03739 8/16/2013CASTOR OIL OIL 0.00000 0.05545 12/14/2012CEFACLOR 125 MG/5ML SUSP RECON 0.00000 0.68231 12/14/2012CEFACLOR 250 MG CAPSULE 0.00000 1.39260 12/1/2012CEFACLOR 250 MG/5ML SUSP RECON 0.00000 1.36453 12/14/2012CEFACLOR 375 MG/5ML SUSP RECON 0.00000 2.04680 12/14/2012CEFACLOR 500 MG CAPSULE 0.00000 1.61040 1/25/2013CEFACLOR 500 MG TAB ER 12H 0.00000 3.48600 12/14/2012CEFADROXIL HYDRATE 1 G TABLET 0.00000 2.32518 12/14/2012CEFADROXIL HYDRATE 250 MG/5ML SUSP RECON 0.00000 0.36218 12/14/2012CEFADROXIL HYDRATE 500 MG CAPSULE 0.33686 0.33735 5/31/2013CEFADROXIL HYDRATE 500 MG/5ML SUSP RECON 0.49266 0.50605 8/30/2013CEFAZOLIN SODIUM 1 G VIAL 0.00000 0.90290 1/25/2013CEFAZOLIN SODIUM 1 G VIAL PORT 0.00000 4.26300 12/14/2012CEFAZOLIN SODIUM 10 G VIAL 0.00000 6.63040 10/11/2013CEFAZOLIN SODIUM 500 MG VIAL 0.00000 1.03662 12/14/2012CEFAZOLIN SODIUM/DEXTROSE,ISO 1 G/50 ML FROZ.PIGGY 0.00000 0.23170 1/25/2013CEFAZOLIN SODIUM/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.00000 0.20427 12/14/2012CEFAZOLIN SODIUM/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 17.93574 12/14/2012CEFDINIR 125 MG/5ML SUSP RECON 0.00000 0.52740 12/14/2012CEFDINIR 250 MG/5ML SUSP RECON 0.00000 0.98740 12/14/2012CEFDINIR 300 MG CAPSULE 0.00000 1.60220 7/12/2013CEFEPIME HCL 1 G VIAL 0.00000 4.48630 9/27/2013CEFEPIME HCL 2 G VIAL 0.00000 8.31600 8/9/2013CEFEPIME HCL/D5W 1 G/50 ML PIGGYBACK 0.00000 0.55476 12/14/2012CEFEPIME HCL/D5W 2 G/50 ML PIGGYBACK 0.00000 14.59910 1/25/2013CEFEPIME HCL/DEXTROSE, ISO-OSM 1 G/50 ML FROZ.PIGGY 0.00000 1.09878 12/14/2012CEFEPIME HCL/DEXTROSE, ISO-OSM 2 G/100 ML FROZ.PIGGY 0.00000 0.88078 12/14/2012CEFOTAXIME SODIUM 1 G VIAL 1.38268 2.12524 9/6/2013CEFOTAXIME SODIUM 10 G VIAL 0.00000 18.35400 12/14/2012CEFOTAXIME SODIUM 2 G VIAL 4.12516 4.80340 10/4/2013CEFOTAXIME SODIUM 500 MG VIAL 1.31950 1.26000 10/4/2013CEFOTETAN DISOD/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.00000 12.81880 1/25/2013CEFOTETAN DISOD/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 17.59800 12/14/2012CEFOTETAN DISODIUM 1 G VIAL 0.00000 9.55920 12/14/2012CEFOTETAN DISODIUM 10 G VIAL 0.00000 98.60200 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

CEFOTETAN DISODIUM 2 G VIAL 0.00000 19.91500 1/25/2013CEFOXITIN SODIUM 1 G VIAL 0.00000 4.45380 12/14/2012CEFOXITIN SODIUM 10 G VIAL 0.00000 32.13068 12/14/2012CEFOXITIN SODIUM 2 G VIAL 0.00000 8.21424 12/14/2012CEFOXITIN SODIUM/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.00000 0.45037 4/19/2013CEFOXITIN SODIUM/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 0.92383 12/14/2012CEFPODOXIME PROXETIL 100 MG TABLET 0.00000 4.71590 5/3/2013CEFPODOXIME PROXETIL 100 MG/5ML SUSP RECON 0.00000 1.14772 3/29/2013CEFPODOXIME PROXETIL 50 MG/5 ML SUSP RECON 0.48050 0.52444 3/15/2013CEFPROZIL 125 MG/5ML SUSP RECON 0.29320 0.29322 3/29/2013CEFPROZIL 250 MG TABLET 0.00000 0.98696 6/28/2013CEFPROZIL 250 MG/5ML SUSP RECON 0.00000 0.54020 12/1/2012CEFPROZIL 500 MG TABLET 0.00000 5.09799 6/28/2013CEFTAZIDIME PENTAHYDRATE 1 G VIAL 0.00000 5.26390 8/30/2013CEFTAZIDIME PENTAHYDRATE 2 G VIAL 0.00000 7.32917 8/30/2013CEFTAZIDIME PENTAHYDRATE 6G VIAL 21.52150 24.35825 8/9/2013CEFTAZIDIME PENTAHYDRATE/D5W 1 G/50 ML PIGGYBACK 0.00000 9.03846 12/14/2012CEFTAZIDIME PENTAHYDRATE/D5W 2 G/50 ML PIGGYBACK 0.00000 13.01154 12/14/2012CEFTRIAXONE NA/DEXTROSE,ISO 1 G/50 ML PIGGYBACK 0.00000 0.54291 12/14/2012CEFTRIAXONE NA/DEXTROSE,ISO 2 G/50 ML FROZ.PIGGY 0.00000 3.11476 7/26/2013CEFTRIAXONE NA/DEXTROSE,ISO 2 G/50 ML PIGGYBACK 0.00000 0.94697 12/14/2012CEFTRIAXONE SODIUM 1 G VIAL 0.00000 2.25000 6/14/2013CEFTRIAXONE SODIUM 1 G VIAL PORT 0.00000 3.51120 2/15/2013CEFTRIAXONE SODIUM 10 G VIAL 0.00000 19.03650 5/31/2013CEFTRIAXONE SODIUM 2 G VIAL 0.00000 3.43070 12/1/2012CEFTRIAXONE SODIUM 2 G VIAL PORT 0.00000 6.39660 1/25/2013CEFTRIAXONE SODIUM 250 MG VIAL 0.00000 1.03050 1/25/2013CEFTRIAXONE SODIUM 500 MG VIAL 1.21810 1.21806 5/10/2013CEFUROXIME AXETIL 250 MG TABLET 0.45566 0.45830 8/30/2013CEFUROXIME AXETIL 500 MG TABLET 0.00000 0.73340 12/1/2012CEFUROXIME SODIUM 1.5 G VIAL 4.33520 4.35422 9/6/2013CEFUROXIME SODIUM 7.5G VIAL 19.28430 17.79645 4/19/2013CEFUROXIME SODIUM 750 MG VIAL 0.00000 2.24102 12/14/2012CEFUROXIME SODIUM/DEXTROSE,ISO 1.5G/50ML PIGGYBACK 0.00000 0.53477 12/14/2012CEFUROXIME SODIUM/DEXTROSE,ISO 750MG/50ML PIGGYBACK 0.00000 0.42827 12/14/2012CELLULOSE 80 % POWDER 0.00000 0.03535 12/14/2012CEPHALEXIN 125 MG/5ML SUSP RECON 0.00000 0.05280 12/1/2012CEPHALEXIN 250 MG CAPSULE 0.00000 0.07772 5/17/2013CEPHALEXIN 250 MG TABLET 0.00000 0.40092 12/14/2012CEPHALEXIN 250 MG/5ML SUSP RECON 0.00000 0.06727 8/16/2013CEPHALEXIN 500 MG CAPSULE 0.00000 0.10023 5/17/2013CEPHALEXIN 500 MG TABLET 0.00000 0.80132 12/14/2012CEPHALEXIN 750 MG CAPSULE 0.00000 5.38300 6/7/2013CETIRIZINE HCL 1 MG/ML SOLUTION 0.00000 0.02747 9/6/2013CETIRIZINE HCL 10 MG TAB CHEW 0.00000 1.93954 8/2/2013CETIRIZINE HCL 10 MG TABLET 0.00000 0.06918 8/30/2013CETIRIZINE HCL 5 MG TAB CHEW 0.00000 1.95217 8/9/2013CETIRIZINE HCL 5 MG TABLET 0.00000 0.08360 3/1/2013CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H 0.00000 0.67289 10/11/2013CEVIMELINE HCL 30 MG CAPSULE 0.00000 2.33208 8/16/2013CHLOPHEDIANOL HCL/GUAIFENESIN 25-200MG/5 LIQUID 0.00000 0.08650 1/25/2013CHLORAMPHENICOL SOD SUCC 1 G VIAL 0.00000 2.64689 12/14/2012CHLORDIAZEPOXIDE HCL 10 MG CAPSULE 0.00000 0.07240 1/25/2013CHLORDIAZEPOXIDE HCL 25 MG CAPSULE 0.00000 0.08950 1/25/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

CHLORDIAZEPOXIDE HCL 5 MG CAPSULE 0.00000 0.10600 1/25/2013CHLORDIAZEPOXIDE/CLIDINIUM BR 5 MG-2.5MG CAPSULE 0.00000 0.28408 12/14/2012CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH 0.00580 0.00581 3/22/2013CHLOROPROCAINE HCL/PF 20 MG/ML VIAL 0.00000 0.49140 1/25/2013CHLOROQUINE PHOSPHATE 250 MG TABLET 0.00000 0.86970 3/1/2013CHLOROQUINE PHOSPHATE 500 MG TABLET 2.61400 3.44058 6/28/2013CHLOROTHIAZIDE SODIUM 500 MG VIAL 0.00000 222.92725 12/14/2012CHLORPHENIRAMINE MALEATE 12 MG TABLET ER 0.00000 0.34710 1/25/2013CHLORPHENIRAMINE MALEATE 2 MG/5 ML SYRUP 0.00000 0.01798 12/14/2012CHLORPHENIRAMINE MALEATE 4 MG TABLET 0.00557 0.00571 6/28/2013CHLORPROMAZINE HCL 25 MG/ML AMPUL 0.00000 8.27700 1/25/2013CHLORPROPAMIDE 100 MG TABLET 0.00000 0.34550 1/25/2013CHLORPROPAMIDE 250 MG TABLET 0.00000 0.85230 1/25/2013CHLORTHALIDONE 25 MG TABLET 0.00000 0.34700 12/1/2012CHLORTHALIDONE 50 MG TABLET 0.00000 0.47630 1/25/2013CHLORZOXAZONE 500 MG TABLET 0.00000 0.24258 5/10/2013CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT TAB CHEW 0.07209 0.07210 1/25/2013CHOLECALCIFEROL (VITAMIN D3) 1000 UNIT TABLET 0.01994 0.01997 8/9/2013CHOLECALCIFEROL (VITAMIN D3) 1000/SPRAY SPRAY SUSP 0.00000 0.30847 12/14/2012CHOLECALCIFEROL (VITAMIN D3) 10000 UNIT CAPSULE 0.00000 0.76007 6/7/2013CHOLECALCIFEROL (VITAMIN D3) 2000 UNIT TABLET 0.02993 0.02924 7/5/2013CHOLECALCIFEROL (VITAMIN D3) 3000 UNIT TABLET 0.00000 0.05516 12/14/2012CHOLECALCIFEROL (VITAMIN D3) 400 UNIT CAPSULE 0.01948 0.02548 7/26/2013CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TAB CHEW 0.00000 0.02509 12/14/2012CHOLECALCIFEROL (VITAMIN D3) 400 UNIT TABLET 0.01635 0.01698 6/21/2013CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/5 LIQUID 0.00000 0.02914 12/14/2012CHOLECALCIFEROL (VITAMIN D3) 4000 UNIT CAPSULE 0.00000 0.06993 12/14/2012CHOLECALCIFEROL (VITAMIN D3) 5000 UNIT TABLET 0.05126 0.05313 7/12/2013CHOLECALCIFEROL (VITAMIN D3) 5000/ML DROPS 0.00000 0.07973 12/14/2012CHOLECALCIFEROL (VITAMIN D3) 50000 UNIT CAPSULE 0.00000 0.27670 5/31/2013CHOLESTYRAMINE (WITH SUGAR) 4 G POWD PACK 0.00000 0.86151 7/5/2013CHOLESTYRAMINE (WITH SUGAR) 4 G POWDER 0.00000 0.21031 10/4/2013CHOLESTYRAMINE/ASPARTAME 4 G POWD PACK 0.00000 1.09344 8/30/2013CHOLESTYRAMINE/ASPARTAME 4 G POWDER 0.00000 0.14980 1/25/2013CHOLINE SAL/MAG SALICYLATE 500 MG/5ML LIQUID 0.00000 0.12848 12/14/2012CHORIONIC GONADOTROPIN, HUMAN 10000 UNIT VIAL 0.00000 184.04000 7/12/2013CICLOPIROX 0.77 % GEL (GRAM) 0.00000 1.36830 1/25/2013CICLOPIROX 1 % SHAMPOO 0.00000 0.57510 12/21/2012CICLOPIROX 8 % SOLUTION 0.00000 5.30497 7/12/2013CICLOPIROX OLAMINE 0.77 % CREAM (G) 0.14968 0.14517 5/24/2013CICLOPIROX OLAMINE 0.77 % SUSPENSION 0.00000 0.37748 12/14/2012CICLOPIROX/URE/CAMPH/MENTH/EUC 8 % SOLUTION 0.00000 266.99400 12/14/2012CIDOFOVIR 75 MG/ML VIAL 87.02400 118.10400 3/15/2013CILOSTAZOL 100 MG TABLET 0.00000 0.13490 1/25/2013CILOSTAZOL 50 MG TABLET 0.00000 0.14589 9/20/2013CIMETIDINE 200 MG TABLET 0.18930 0.23684 3/29/2013CIMETIDINE 300 MG TABLET 0.00000 0.15126 8/16/2013CIMETIDINE 400 MG TABLET 0.00000 0.24350 8/16/2013CIMETIDINE 800 MG TABLET 0.00000 0.53313 5/10/2013CIMETIDINE HCL 300 MG/5ML SOLUTION 0.00000 0.06283 5/17/2013CIPROFLOXACIN HCL 0.2 % DROPERETTE 0.00000 5.25900 12/14/2012CIPROFLOXACIN HCL 0.3 % DROPS 0.00000 0.73968 5/17/2013CIPROFLOXACIN HCL 100 MG TABLET 0.00000 2.35900 12/14/2012CIPROFLOXACIN HCL 250 MG TABLET 0.00000 0.14941 5/17/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

CIPROFLOXACIN HCL 500 MG TABLET 0.00000 0.16804 6/7/2013CIPROFLOXACIN HCL 750 MG TABLET 0.27860 0.27859 3/1/2013CIPROFLOXACIN LACTATE 200MG/20ML VIAL 0.00000 0.08890 1/25/2013CIPROFLOXACIN LACTATE 400MG/40ML VIAL 0.00000 0.06320 1/25/2013CIPROFLOXACIN LACTATE/D5W 200MG/0.1L PIGGYBACK 0.00000 0.01697 12/14/2012CIPROFLOXACIN LACTATE/D5W 400MG/0.2L PIGGYBACK 0.00000 0.01204 3/1/2013CIPROFLOXACIN/CIPROFLOXA HCL 1000 MG TBMP 24HR 0.00000 7.79233 12/14/2012CIPROFLOXACIN/CIPROFLOXA HCL 500 MG TBMP 24HR 0.00000 6.85916 12/14/2012CISATRACURIUM BESYLATE 10 MG/ML VIAL 0.00000 10.93957 12/14/2012CISATRACURIUM BESYLATE 2 MG/ML VIAL 2.13996 2.16839 8/2/2013CITALOPRAM HYDROBROMIDE 10 MG TABLET 0.02920 0.02921 5/3/2013CITALOPRAM HYDROBROMIDE 10 MG/5 ML SOLUTION 0.00000 0.18230 1/25/2012CITALOPRAM HYDROBROMIDE 20 MG TABLET 0.00000 0.03685 5/17/2013CITALOPRAM HYDROBROMIDE 40 MG TABLET 0.00000 0.04887 5/17/2013CITRATE-PHOS-DEX SOLUTION 2.63 G/100 SOLUTION 0.00000 0.08318 12/14/2012CITRIC ACID/SODIUM CITRATE 334-500MG SOLUTION 0.00000 0.00980 8/30/2013CLARITHROMYCIN 125 MG/5ML SUSP RECON 0.00000 0.36569 5/17/2013CLARITHROMYCIN 250 MG TABLET 0.00000 3.45199 10/11/2013CLARITHROMYCIN 500 MG TAB ER 24H 0.00000 3.47640 1/25/2013CLARITHROMYCIN 500 MG TABLET 0.00000 2.89310 5/17/2013CLEMASTINE FUMARATE 0.67MG/5ML SYRUP 0.00000 0.12454 3/22/2013CLEMASTINE FUMARATE 1.34 MG TABLET 0.00000 0.12750 1/25/2013CLINDAMYCIN HCL 150 MG CAPSULE 0.08790 0.08796 5/31/2013CLINDAMYCIN HCL 300 MG CAPSULE 0.28640 0.28636 3/22/2013CLINDAMYCIN HCL 75 MG CAPSULE 0.00000 0.41720 12/14/2012CLINDAMYCIN PALMITATE HCL 75 MG/5 ML SOLN RECON 0.00000 0.43421 12/14/2012CLINDAMYCIN PHOS/BENZOYL PEROX 1 %-5 % GEL (GRAM) 3.76642 3.76643 6/21/2013CLINDAMYCIN PHOS/BENZOYL PEROX 1.2(1)%-5% GEL ER (G) 0.00000 3.16110 1/25/2013CLINDAMYCIN PHOSPHATE 1 % FOAM 0.00000 2.52647 6/7/2013CLINDAMYCIN PHOSPHATE 1 % LOTION 0.00000 1.11977 3/15/2013CLINDAMYCIN PHOSPHATE 1 % MED. SWAB 0.40374 0.40378 6/28/2013CLINDAMYCIN PHOSPHATE 1 % SOLUTION 0.91410 0.91409 9/20/2013CLINDAMYCIN PHOSPHATE 150 MG/ML VIAL 0.00000 0.35600 1/25/2013CLINDAMYCIN PHOSPHATE 2 % CREAM/APPL 0.00000 1.57588 8/23/2013CLINDAMYCIN PHOSPHATE 300 MG/2ML VIAL PORT 0.00000 2.99418 12/14/2012CLINDAMYCIN PHOSPHATE 600 MG/4ML VIAL PORT 0.00000 1.60881 12/14/2012CLINDAMYCIN PHOSPHATE 900MG/6ML VIAL PORT 0.00000 1.51899 12/14/2012CLINDAMYCIN PHOSPHATE/D5W 300MG/50ML PIGGYBACK 0.13773 0.10737 6/7/2013CLINDAMYCIN PHOSPHATE/D5W 600MG/50ML PIGGYBACK 0.20775 0.16162 6/7/2013CLINDAMYCIN PHOSPHATE/D5W 900MG/50ML PIGGYBACK 0.25374 0.19421 6/7/2013CLOBETASOL PROPIONATE 0.05 % CREAM (G) 0.00000 0.32189 8/16/2013CLOBETASOL PROPIONATE 0.05 % FOAM 0.00000 1.88150 1/25/2013CLOBETASOL PROPIONATE 0.05 % GEL (GRAM) 0.00000 0.36720 1/25/2013CLOBETASOL PROPIONATE 0.05 % LOTION 0.00000 3.23864 12/14/2012CLOBETASOL PROPIONATE 0.05 % OINT. (G) 0.00000 0.23120 12/21/2012CLOBETASOL PROPIONATE 0.05 % SHAMPOO 0.00000 2.38350 1/25/2013CLOBETASOL PROPIONATE 0.05 % SOLUTION 0.00000 0.30766 5/17/2013CLOBETASOL PROPIONATE/EMOLL 0.05 % CREAM (G) 0.00000 0.36716 5/17/2013CLOBETASOL PROPIONATE/EMOLL 0.05 % FOAM 0.00000 3.08826 8/2/2013CLOMIPHENE CITRATE 50 MG TABLET 0.00000 1.01304 12/14/2012CLOMIPRAMINE HCL 25 MG CAPSULE 0.00000 7.75151 8/16/2013CLOMIPRAMINE HCL 50 MG CAPSULE 0.00000 7.86937 8/2/2013CLOMIPRAMINE HCL 75 MG CAPSULE 0.00000 7.86939 6/28/2013CLONAZEPAM 0.125 MG TAB RAPDIS 0.00000 0.74711 5/31/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

CLONAZEPAM 0.25 MG TAB RAPDIS 0.00000 0.74233 6/28/2013CLONAZEPAM 0.5 MG TAB RAPDIS 0.00000 0.78857 12/14/2012CLONAZEPAM 0.5 MG TABLET 0.01650 0.01648 3/22/2013CLONAZEPAM 1 MG TAB RAPDIS 0.00000 0.79763 5/31/2013CLONAZEPAM 1 MG TABLET 0.02610 0.02613 2/8/2013CLONAZEPAM 2 MG TAB RAPDIS 0.00000 1.09330 12/14/2012CLONAZEPAM 2 MG TABLET 0.00000 0.04230 1/25/2013CLONIDINE 0.1MG/24HR PATCH TDWK 0.00000 23.20687 9/27/2013CLONIDINE 0.2MG/24HR PATCH TDWK 38.16103 39.07439 7/26/2013CLONIDINE 0.3MG/24HR PATCH TDWK 0.00000 46.30275 9/6/2013CLONIDINE HCL 0.1 MG TABLET 0.03020 0.03015 2/8/2013CLONIDINE HCL 0.2 MG TABLET 0.00000 0.04261 9/13/2013CLONIDINE HCL 0.3 MG TABLET 0.05390 0.05387 3/22/2013CLONIDINE HCL/PF 1000MCG/10 VIAL 0.00000 2.18075 12/14/2012CLONIDINE HCL/PF 5000MCG/10 VIAL 0.00000 8.35920 1/25/2013CLOPIDOGREL BISULFATE 300 MG TABLET 0.00000 15.16650 1/25/2013CLOPIDOGREL BISULFATE 75 MG TABLET 0.00000 0.35570 12/1/2012CLORAZEPATE DIPOTASSIUM 15 MG TABLET 0.00000 0.26100 3/22/2013CLORAZEPATE DIPOTASSIUM 3.75 MG TABLET 0.00000 0.19092 7/5/2013CLORAZEPATE DIPOTASSIUM 7.5 MG TABLET 0.00000 0.15830 5/10/2013CLOTRIMAZOLE 1 % CREAM (G) 0.07540 0.07548 7/26/2013CLOTRIMAZOLE 1 % CREAM/APPL 0.00000 0.07865 3/1/2013CLOTRIMAZOLE 1 % SOLUTION 0.00000 0.32656 12/14/2012CLOTRIMAZOLE 10 MG TROCHE 0.00000 0.36150 1/25/2013CLOTRIMAZOLE 2 % CREAM/APPL 0.33420 0.32760 6/28/2013CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % CREAM (G) 0.00000 1.27401 10/11/2013CLOTRIMAZOLE/BETAMETHASONE DIP 1 %-0.05 % LOTION 0.00000 3.46640 5/31/2013CLOZAPINE 100 MG TAB RAPDIS 0.00000 5.72222 2/15/2013CLOZAPINE 100 MG TABLET 0.00000 1.62860 9/27/2012CLOZAPINE 12.5 MG TAB RAPDIS 0.00000 1.55925 12/14/2012CLOZAPINE 200 MG TABLET 0.00000 4.37030 1/25/2013CLOZAPINE 25 MG TAB RAPDIS 0.00000 2.09823 12/14/2012CLOZAPINE 25 MG TABLET 0.90840 0.90848 7/26/2013CLOZAPINE 50 MG TABLET 0.00000 1.15500 12/1/2012COAL TAR 1 % SHAMPOO 0.00000 0.03020 1/25/2013COCAINE HCL 4 % SOLUTION 0.00000 15.19980 1/25/2013CODEINE SULFATE 15 MG TABLET 0.00000 0.36736 3/1/2013CODEINE SULFATE 30 MG TABLET 0.00000 0.40417 4/5/2013CODEINE SULFATE 30 MG/5 ML SOLUTION 0.00000 0.17982 3/8/2013CODEINE SULFATE 60 MG TABLET 0.00000 0.72436 2/15/2013CODEINE/BUTALBITAL/ASA/CAFFEIN 30-50-325 CAPSULE 0.00000 0.59335 4/26/2013CODEINE/CARISOPRODOL/ASPIRIN 16-200-325 TABLET 0.00000 1.94250 12/14/2012COLCHICINE/PROBENECID 0.5-500MG TABLET 0.00000 0.67760 12/14/2012COLESTIPOL HCL 1 G TABLET 0.00000 0.46050 1/25/2013COLESTIPOL HCL 5 G GRANULES 0.00000 0.20871 12/14/2012COLESTIPOL HCL 5 G PACKET 0.00000 3.51494 12/14/2012COLISTIN (COLISTIMETHATE NA) 150 MG VIAL 0.00000 19.47030 12/14/2012CORTISONE ACETATE 25 MG TABLET 0.00000 0.75600 12/14/2012COSYNTROPIN 0.25 MG VIAL 0.00000 64.39973 12/14/2012COSYNTROPIN 0.25 MG/ML VIAL 0.00000 151.55280 12/14/2012CROMOLYN SODIUM 20 MG/2 ML AMPUL-NEB 0.00000 0.64353 5/17/2013CROMOLYN SODIUM 20 MG/ML SOLUTION 0.00000 0.87900 1/25/2013CROMOLYN SODIUM 4 % DROPS 0.00000 0.69950 1/25/2013CROMOLYN SODIUM 5.2 MG SPRAY/PUMP 0.00000 0.33554 12/14/2012

Page 13 of 57

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

CUPRIC CHLORIDE 0.4 MG/ML VIAL 0.00000 0.15460 1/25/2013CUPRIC SULFATE 0.4 MG/ML VIAL 0.00000 0.12958 12/14/2012CYANOCOBALAMIN (VITAMIN B-12) 100 MCG TABLET 0.00000 0.01242 12/14/2012CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TAB SUBL 0.05840 0.05332 7/12/2013CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG TABLET ER 0.04583 0.04152 3/15/2013CYANOCOBALAMIN (VITAMIN B-12) 500 MCG TABLET 0.00000 0.01867 12/14/2012CYANOCOBALAMIN (VITAMIN B-12) 5000 MCG TAB SUBL 0.00000 0.10737 3/8/2013CYANOCOBALAMIN/FA/PYRIDOXINE 2-2.5-25MG TABLET 0.00000 0.63880 1/25/2013CYANOCOBALAMIN/FOLIC ACID 0.5 MG-1MG TABLET 0.00000 0.12600 12/14/2012CYCLOBENZAPRINE HCL 10 MG TABLET 0.00000 0.02850 5/17/2013CYCLOBENZAPRINE HCL 5 MG TABLET 0.00000 0.05454 8/16/2013CYCLOBENZAPRINE HCL 7.5 MG TABLET 0.00000 3.36504 5/3/2013CYCLOPENTOLATE HCL 1 % DROPS 0.00000 1.65266 5/10/2013CYCLOPENTOLATE HCL 2 % DROPS 0.00000 3.33840 2/8/2013CYCLOPHOSPHAMIDE 1 G VIAL 0.00000 432.93460 6/28/2013CYCLOPHOSPHAMIDE 2 G VIAL 0.00000 578.96300 1/25/2013CYCLOPHOSPHAMIDE 25 MG TABLET 0.00000 1.55428 3/15/2013CYCLOPHOSPHAMIDE 50 MG TABLET 0.00000 2.85220 3/15/2013CYCLOPHOSPHAMIDE 500 MG VIAL 0.00000 237.49600 8/2/2013CYCLOSPORINE 100 MG CAPSULE 0.00000 6.45710 8/2/2013CYCLOSPORINE 25 MG CAPSULE 0.00000 1.62657 8/2/2013CYCLOSPORINE 250 MG/5ML VIAL 0.00000 7.95732 12/14/2012CYCLOSPORINE, MODIFIED 100 MG CAPSULE 0.00000 3.84740 1/25/2013CYCLOSPORINE, MODIFIED 100 MG/ML SOLUTION 0.00000 2.88899 6/28/2013CYCLOSPORINE, MODIFIED 25 MG CAPSULE 0.00000 0.96270 1/25/2013CYCLOSPORINE, MODIFIED 50 MG CAPSULE 0.00000 1.91683 12/14/2012CYPROHEPTADINE HCL 2 MG/5 ML SYRUP 0.00000 0.09530 2/1/2013CYPROHEPTADINE HCL 4 MG TABLET 0.00000 0.11890 5/17/2013CYTARABINE 20 MG/ML VIAL 0.00000 0.40080 1/25/2013CYTARABINE/PF 1 G VIAL 0.00000 40.61400 12/14/2012CYTARABINE/PF 100 MG VIAL 0.00000 7.10640 12/14/2012CYTARABINE/PF 100 MG/5ML VIAL 0.00000 1.97106 12/14/2012CYTARABINE/PF 2 G/20 ML VIAL 0.00000 0.87780 12/14/2012CYTARABINE/PF 20 MG/ML VIAL 0.00000 0.75096 12/14/2012D-CHLORPHENIRA/PSE/CHLOPHEDIAN 1-30-12.5 LIQUID 0.00000 0.08050 1/25/2013D-METHORPHAN HB/P-EPD HCL/BPM 10-30-2/5 SYRUP 0.13310 0.13311 3/1/2013D-METHORPHAN HB/P-EPD HCL/BPM 20-20-4/5 LIQUID 0.00000 0.21000 1/25/2013D-METHORPHAN HB/P-EPD HCL/BPM 30-50-3MG LIQUID 0.00000 0.06910 1/25/2013D-METHORPHAN HB/P-EPD HCL/BPM 5-15-1MG/5 ELIXIR 0.00000 0.01127 8/30/2013D-METHORPHAN HB/P-EPHED HCL/CP 15-15-2/5 SYRUP 0.00000 0.04846 12/14/2012D-METHORPHAN HB/P-EPHED HCL/CP 5-15-1MG/5 LIQUID 0.00000 0.01868 12/14/2012D-METHORPHAN HB/PROMETH HCL 15-6.25/5 SYRUP 0.00000 0.01287 4/12/2013D-METHORPHAN/ACETAMIN/DOXYLAMN 15-325/15 LIQUID 0.01474 0.01469 4/19/2013D-METHORPHAN/PE/DEXBROMPHENIR 20-10-2/5 SYRUP 0.06080 0.05168 2/22/2013DACARBAZINE 100 MG VIAL 0.00000 7.93800 12/14/2012DACTINOMYCIN 0.5 MG VIAL 0.00000 1,065.68700 12/14/2012DANAZOL 100 MG CAPSULE 0.00000 2.00515 12/14/2012DANAZOL 200 MG CAPSULE 0.00000 3.34131 4/26/2013DANAZOL 50 MG CAPSULE 0.00000 1.26890 1/25/2013DANTROLENE SODIUM 100 MG CAPSULE 0.00000 1.51750 2/8/2013DANTROLENE SODIUM 20 MG VIAL 0.00000 68.04000 12/14/2012DANTROLENE SODIUM 25 MG CAPSULE 0.00000 0.74851 12/14/2012DANTROLENE SODIUM 50 MG CAPSULE 0.00000 1.21009 12/14/2012DAPSONE 100 MG TABLET 0.00000 0.91000 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

DAPSONE 25 MG TABLET 0.00000 0.74200 12/14/2012DAUNORUBICIN HCL 5 MG/ML VIAL 0.00000 14.58975 12/14/2012DECITABINE 50 MG VIAL 0.00000 1,365.37800 8/2/2013DEFEROXAMINE MESYLATE 2 G VIAL 0.00000 26.33481 12/14/2012DEFEROXAMINE MESYLATE 500 MG VIAL 0.00000 8.40600 12/14/2012DEMECLOCYCLINE HCL 300 MG TABLET 0.00000 10.99400 7/12/2013DESIPRAMINE HCL 10 MG TABLET 0.00000 0.81200 3/1/2013DESIPRAMINE HCL 100 MG TABLET 0.00000 3.05540 1/25/2013DESIPRAMINE HCL 150 MG TABLET 0.00000 4.40910 4/12/2013DESIPRAMINE HCL 25 MG TABLET 0.00000 0.98480 2/8/2013DESIPRAMINE HCL 75 MG TABLET 0.00000 2.17445 5/31/2013DESLORATADINE 2.5 MG TAB RAPDIS 0.00000 11.92731 6/28/2013DESLORATADINE 5 MG TAB RAPDIS 0.00000 4.07750 1/25/2013DESLORATADINE 5 MG TABLET 0.00000 1.03622 12/14/2012DESMOPRESSIN ACETATE 0.1 MG TABLET 0.00000 1.18821 9/13/2013DESMOPRESSIN ACETATE 0.1 MG/ML SOLUTION 0.00000 25.31760 3/8/2013DESMOPRESSIN ACETATE 0.2 MG TABLET 0.00000 1.27244 8/16/2013DESMOPRESSIN ACETATE 10/SPRAY SPRAY/PUMP 0.00000 27.59120 8/2/2013DESMOPRESSIN ACETATE 4MCG/ML AMPUL 0.00000 16.22800 8/30/2013DESMOPRESSIN ACETATE 4MCG/ML VIAL 0.00000 8.62810 4/12/2013DESOG-ET ESTRA/ETHIN ESTRA 21-5 TABLET 0.00000 1.49950 5/17/2013DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.03 TABLET 0.00000 0.62830 5/17/2013DESOGESTREL-ETHINYL ESTRADIOL 7 DAYS X 3 TABLET 0.00000 0.83100 12/14/2012DESONIDE 0.05 % CREAM (G) 0.00000 4.07913 9/27/2013DESONIDE 0.05 % LOTION 0.00000 1.83560 12/1/2012DESONIDE 0.05 % OINT. (G) 0.00000 2.80467 7/26/2013DESOXIMETASONE 0.05 % GEL (GRAM) 0.00000 2.73169 12/14/2012DESOXIMETASONE 0.25 % OINT. (G) 0.00000 4.15372 5/3/2013DEXAMETHASONE 0.5 MG/5ML ELIXIR 0.00000 0.18810 6/28/2013DEXAMETHASONE 0.5 MG/5ML SOLUTION 0.00000 0.11180 8/9/2013DEXAMETHASONE SOD PHOSPHATE 0.1 % DROPS 0.00000 2.96250 2/8/2013DEXAMETHASONE SOD PHOSPHATE 10 MG/ML VIAL 0.66970 0.33586 9/6/2013DEXAMETHASONE SOD PHOSPHATE 4 MG/ML VIAL 0.00000 0.23878 4/5/2013DEXAMETHASONE SOD PHOSPHATE/PF 10 MG/ML VIAL 0.00000 6.35376 12/14/2012DEXMETHYLPHENIDATE HCL 10 MG TABLET 0.00000 0.98000 10/4/2013DEXMETHYLPHENIDATE HCL 2.5 MG TABLET 0.00000 0.94880 1/25/2013DEXMETHYLPHENIDATE HCL 5 MG TABLET 0.00000 1.37844 12/14/2012DEXPANTHENOL 250 MG/ML VIAL 0.00000 1.42180 1/25/2013DEXTRAN 70/HYPROMELLOSE DROPS 0.00000 0.43960 1/25/2013DEXTROAMPHETAMINE SULFATE 10 MG TABLET 0.00000 1.74148 3/8/2013DEXTROAMPHETAMINE SULFATE 5 MG/5 ML SOLUTION 0.00000 0.89328 7/26/2013DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML SUS ER 12H 0.00000 0.08530 1/25/2013DEXTROSE 10 % AND 0.2 % NACL 10 %-0.2 % DEHP FR BG 0.00000 0.04179 12/14/2012DEXTROSE 10 % AND 0.2 % NACL 10 %-0.2 % IV SOLN 0.00000 0.03704 12/14/2012DEXTROSE 10 % AND 0.45 % NACL 10%-0.45% IV SOLN 0.00000 0.01077 12/14/2012DEXTROSE 10 % IN WATER 10 % DEHP FR BG 0.00000 0.00819 12/14/2012DEXTROSE 10 % IN WATER 10 % IV SOLN 0.00000 0.00207 4/5/2013DEXTROSE 2.5 % AND 0.45 % NACL 2.5%-0.45% IV SOLN 0.00000 0.00250 1/25/2013DEXTROSE 20 % IN WATER 20 % IV SOLN 0.00000 0.00864 12/14/2012DEXTROSE 25 % IN WATER 25 % DISP SYRIN 0.00000 0.38140 1/25/2013DEXTROSE 30 % IN WATER 30 % IV SOLN 0.00000 0.00877 12/14/2012DEXTROSE 40 % IN WATER 40 % IV SOLN 0.00000 0.00870 1/25/2013DEXTROSE 5 % AND 0.3 % NACL 5 %-0.3 % IV SOLN 0.00000 0.00230 1/25/2013DEXTROSE 5 % AND 0.9 % NACL 5 %-0.9 % IV SOLN 0.00000 0.00201 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

DEXTROSE 5 % IN WATER PGGYBK PRT 0.00000 0.03320 1/25/2013DEXTROSE 5 % IN WATER PGY VL PRT 0.00000 0.07096 12/14/2012DEXTROSE 5 % IN WATER 5 % IV SOLN 0.00000 0.00158 4/19/2013DEXTROSE 5 % IN WATER 5 % VIAL 0.00000 0.53214 12/14/2012DEXTROSE 5 % SOLUTION 0.00000 0.01680 1/25/2013DEXTROSE 5 %-0.2 % NACL 5 %-0.2 % IV SOLN 0.00000 0.00228 12/14/2012DEXTROSE 5 %-0.45 % NACL 5 %-0.45 % IV SOLN 0.00000 0.00144 3/15/2013DEXTROSE 5% IN RINGERS 5 % IV SOLN 0.00000 0.00170 1/25/2013DEXTROSE 5%-LACTATED RINGERS 5 % IV SOLN 0.00000 0.00214 12/14/2012DEXTROSE 50 % IN WATER 50 % DISP SYRIN 0.00000 0.09475 4/5/2013DEXTROSE 50 % IN WATER 50 % IV SOLN 0.00000 0.00630 12/14/2012DEXTROSE 50 % IN WATER 50 % VIAL 0.00000 0.02540 1/25/2013DEXTROSE 70 % IN WATER 70 % IV SOLN 0.00000 0.00532 4/19/2013DIAZEPAM 10 MG TABLET 0.00000 0.02395 10/11/2013DIAZEPAM 12.5-15-20 KIT 0.00000 123.06000 8/30/2013DIAZEPAM 2 MG TABLET 0.02431 0.02396 7/19/2013DIAZEPAM 2.5 MG KIT 0.00000 103.82225 8/9/2013DIAZEPAM 5 MG TABLET 0.02230 0.02222 6/14/2013DIAZEPAM 5 MG/5 ML SOLUTION 0.00000 0.18514 3/15/2013DIAZEPAM 5 MG/ML DISP SYRIN 0.00000 3.71280 1/25/2013DIAZEPAM 5 MG/ML ORAL CONC 0.00000 1.69680 3/15/2013DIAZEPAM 5 MG/ML VIAL 0.00000 1.36920 7/12/2013DIAZEPAM 5-7.5-10MG KIT 0.00000 233.82800 7/5/2013DICLOFENAC POTASSIUM 50 MG TABLET 0.00000 0.43017 9/20/2013DICLOFENAC SODIUM 0.1 % DROPS 0.00000 1.02380 1/25/2013DICLOFENAC SODIUM 100 MG TAB ER 24H 0.51520 0.51523 3/15/2013DICLOFENAC SODIUM 25 MG TABLET DR 0.00000 0.99530 1/25/2013DICLOFENAC SODIUM 50 MG TABLET DR 0.00000 0.35590 5/24/2013DICLOFENAC SODIUM 75 MG TABLET DR 0.00000 0.27766 8/30/2013DICLOFENAC SODIUM/MISOPROSTOL 50 MG-200 TAB IR DR 0.00000 2.34693 12/14/2012DICLOFENAC SODIUM/MISOPROSTOL 75 MG-200 TAB IR DR 0.00000 2.34697 12/14/2012DICLOXACILLIN SODIUM 250 MG CAPSULE 0.00000 0.24669 3/1/2013DICLOXACILLIN SODIUM 500 MG CAPSULE 0.00000 0.47953 3/1/2013DICYCLOMINE HCL 10 MG CAPSULE 0.00000 0.04234 5/17/2013DICYCLOMINE HCL 10 MG/5 ML SOLUTION 0.00000 0.33172 7/26/2013DICYCLOMINE HCL 20 MG TABLET 0.00000 0.09093 10/4/2013DIDANOSINE 125 MG CAPSULE DR 0.00000 2.70223 12/14/2012DIDANOSINE 200 MG CAPSULE DR 0.00000 4.32270 2/8/2013DIDANOSINE 250 MG CAPSULE DR 0.00000 5.50853 12/14/2012DIDANOSINE 400 MG CAPSULE DR 0.00000 8.60350 2/8/2013DIETHYLPROPION HCL 25 MG TABLET 0.00000 0.23090 1/25/2013DIETHYLPROPION HCL 75 MG TABLET ER 0.00000 0.80950 1/25/2013DIFLORASONE DIACETATE 0.05 % OINT. (G) 0.00000 2.47670 1/25/2013DIFLUNISAL 500 MG TABLET 0.00000 1.18611 5/17/2013DIGOXIN 125 MCG TABLET 0.00000 0.12286 5/17/2013DIGOXIN 250 MCG TABLET 0.00000 0.13407 7/19/2013DIGOXIN 250 MCG/ML DISP SYRIN 0.00000 1.58760 12/14/2012DIGOXIN 50 MCG/ML SOLUTION 0.00000 0.49117 3/15/2013DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP 0.00000 136.62600 10/4/2013DIHYDROERGOTAMINE MESYLATE 1 MG/ML AMPUL 0.00000 54.10623 2/22/2013DIHYDROERGOTAMINE MESYLATE 1 MG/ML VIAL 0.00000 37.55430 12/14/2012DILTIAZEM HCL 100 MG VIAL PORT 0.00000 14.71680 1/25/2013DILTIAZEM HCL 120 MG CAP ER 24H 0.00000 0.41789 7/26/2013DILTIAZEM HCL 120 MG CAP ER DEG 0.00000 0.55010 1/25/2013

Page 16 of 57

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

DILTIAZEM HCL 120 MG CAPSULE ER 0.00000 0.53252 8/9/2013DILTIAZEM HCL 120 MG TABLET 0.00000 0.13822 8/23/2013DILTIAZEM HCL 180 MG CAP ER 24H 0.48052 0.48047 5/24/2013DILTIAZEM HCL 180 MG CAP ER DEG 0.00000 0.62750 1/25/2013DILTIAZEM HCL 180 MG CAPSULE ER 0.00000 0.64757 8/9/2013DILTIAZEM HCL 180 MG TAB ER 24H 0.00000 2.08282 12/14/2012DILTIAZEM HCL 240 MG CAP ER 24H 0.00000 0.66950 12/21/2012DILTIAZEM HCL 240 MG CAP ER DEG 0.00000 0.67140 9/20/2013DILTIAZEM HCL 240 MG CAPSULE ER 0.00000 0.88771 10/11/2013DILTIAZEM HCL 240 MG TAB ER 24H 0.00000 2.33440 1/25/2013DILTIAZEM HCL 30 MG TABLET 0.00000 0.06084 9/20/2013DILTIAZEM HCL 300 MG CAP ER 24H 0.00000 0.71100 12/21/2012DILTIAZEM HCL 300 MG CAPSULE ER 0.00000 1.39010 2/22/2013DILTIAZEM HCL 300 MG TAB ER 24H 0.00000 3.03690 1/25/2013DILTIAZEM HCL 360 MG CAP ER 24H 0.00000 6.87758 10/4/2013DILTIAZEM HCL 360 MG CAPSULE ER 0.00000 1.27911 8/30/2013DILTIAZEM HCL 360 MG TAB ER 24H 0.00000 3.26730 1/25/2013DILTIAZEM HCL 420MG CAPSULE ER 0.00000 1.72005 12/14/2012DILTIAZEM HCL 420MG TAB ER 24H 0.00000 3.54216 12/14/2012DILTIAZEM HCL 60 MG CAP ER 12H 0.00000 0.91994 7/26/2013DILTIAZEM HCL 60 MG TABLET 0.00000 0.10434 9/20/2013DILTIAZEM HCL 90 MG TABLET 0.00000 0.11968 8/23/2013DIMENHYDRINATE 50 MG TABLET 0.00000 0.01809 12/14/2012DIMENHYDRINATE 50 MG/ML VIAL 0.00000 4.98960 12/14/2012DIMETHICONE 1 % CREAM(ML) 0.00000 0.06020 1/25/2013DIMETHICONE 2 % SPRAY 0.00000 0.03000 1/25/2013DIMETHICONE 5 % CREAM(ML) 0.00000 0.03810 1/25/2013DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR 0.00000 0.00512 1/11/2013DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID 0.00000 0.00592 8/30/2013DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP 0.00000 0.01260 1/25/2013DIPHENHYDRAMINE HCL 25 MG CAPSULE 0.01635 0.01633 4/26/2013DIPHENHYDRAMINE HCL 25 MG TABLET 0.02104 0.05025 7/19/2013DIPHENHYDRAMINE HCL 50 MG CAPSULE 0.01740 0.01742 3/1/2013DIPHENOXYLATE HCL/ATROPINE 2.5-.025/5 LIQUID 0.00000 0.10803 12/14/2012DIPHENOXYLATE HCL/ATROPINE 2.5-.025MG TABLET 0.00000 0.12598 5/10/2013DIPYRIDAMOLE 25 MG TABLET 0.00000 0.06870 1/25/2013DIPYRIDAMOLE 50 MG TABLET 0.00000 0.10810 1/25/2013DIPYRIDAMOLE 75 MG TABLET 0.00000 0.13680 1/25/2013DISOPYRAMIDE PHOSPHATE 100 MG CAPSULE 0.00000 0.30510 1/25/2013DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE 0.00000 0.35460 1/25/2013DISULFIRAM 250 MG TABLET 0.00000 2.44805 9/6/2013DISULFIRAM 500 MG TABLET 0.00000 4.53960 1/25/2013DIVALPROEX SODIUM 125 MG CAP SPRINK 0.00000 0.49955 6/28/2013DIVALPROEX SODIUM 125 MG TABLET DR 0.00000 0.05190 1/25/2013DIVALPROEX SODIUM 250 MG TABLET DR 0.00000 0.09070 1/25/2013DIVALPROEX SODIUM 500 MG TABLET DR 0.15810 0.15812 3/22/2013DM/PHENYLEPH/CHLORPHENIRAMINE 15-10-2/5 SYRUP 0.00000 0.04650 1/25/2013DM/PHENYLEPH/CHLORPHENIRAMINE 15-10-4/5 LIQUID 0.00000 0.04500 1/25/2013DM/PHENYLEPH/CHLORPHENIRAMINE 15-5-2MG/5 LIQUID 0.00000 0.06860 1/25/2013DM/PHENYLEPH/CHLORPHENIRAMINE 3-2-1MG/ML DROPS 0.00000 0.55500 1/25/2013DM/PHENYLEPH/CHLORPHENIRAMINE 3-3.5-1/ML DROPS 0.00000 1.37627 12/14/2012DOBUTAMINE HCL 250MG/20ML VIAL 0.00000 0.15780 1/25/2013DOBUTAMINE HCL 500MG/40ML VIAL 0.00000 0.15830 1/25/2013DOBUTAMINE HCL/D5W 1000MG/250 IV SOLN 0.00000 0.08730 1/25/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

DOBUTAMINE HCL/D5W 250MG/250 IV SOLN 0.00000 0.04960 1/25/2013DOBUTAMINE HCL/D5W 500 MG/500 IV SOLN 0.00000 0.02810 1/25/2013DOBUTAMINE HCL/D5W 500MG/250 IV SOLN 0.00000 0.05620 1/25/2013DOCETAXEL 140 MG/7ML VIAL 0.00000 156.00000 8/2/2013DOCETAXEL 160 MG/8ML VIAL 255.60500 675.67500 6/28/2013DOCETAXEL 160MG/16ML VIAL 0.00000 159.40890 12/14/2012DOCETAXEL 20 MG/2 ML VIAL 0.00000 150.34425 12/14/2012DOCETAXEL 20MG/ML(1) VIAL 274.18067 247.63550 7/26/2013DOCETAXEL 80 MG/4 ML VIAL 274.17833 247.63375 7/26/2013DOCETAXEL 80 MG/8 ML VIAL 0.00000 150.33770 12/14/2012DOCETAXEL FNL 20MG/2 VIAL 0.00000 148.61475 12/14/2012DOCETAXEL FNL 80MG/8 VIAL 0.00000 297.22950 12/14/2012DOCOSAHEXANOIC ACID 200 MG CAPSULE 0.18670 0.19600 3/15/2013DOCUSATE CALCIUM 240 MG CAPSULE 0.05132 0.05135 5/24/2013DOCUSATE SODIUM 100 MG CAPSULE 0.01506 0.01743 5/17/2013DOCUSATE SODIUM 100 MG TABLET 0.00000 0.03068 12/14/2012DOCUSATE SODIUM 250 MG CAPSULE 0.03978 0.04368 6/21/2013DOCUSATE SODIUM 283 MG/5ML ENEMA 0.00000 2.91026 12/14/2012DOCUSATE SODIUM 50 MG/5 ML LIQUID 0.00737 0.02005 8/23/2013DOCUSATE SODIUM 60 MG/15ML SYRUP 0.00000 0.00657 12/14/2012DOCUSATE SODIUM/BENZOCAINE 283-20MG/5 ENEMA 0.00000 2.92776 12/14/2012DONEPEZIL HCL 10 MG TAB RAPDIS 0.27260 0.27257 3/15/2013DONEPEZIL HCL 10 MG TABLET 0.00000 0.15286 10/4/2013DONEPEZIL HCL 23 MG TABLET 0.00000 7.94987 8/16/2013DONEPEZIL HCL 5 MG TAB RAPDIS 0.27260 0.27257 3/15/2013DONEPEZIL HCL 5 MG TABLET 0.00000 0.11410 10/4/2013DOPAMINE HCL 400 MG/5ML VIAL 0.00000 0.50263 12/14/2012DOPAMINE HCL 400MG/10ML VIAL 0.00000 0.07980 1/25/2013DOPAMINE HCL 800MG/10ML VIAL 0.00000 0.20101 12/14/2012DOPAMINE HCL 800MG/5ML VIAL 0.00000 0.62837 12/14/2012DOPAMINE HCL/D5W 200MG/.25L PLAST. BAG 0.00000 0.02960 1/25/2013DOPAMINE HCL/D5W 400MG/.25L PLAST. BAG 0.00000 0.03690 1/25/2013DOPAMINE HCL/D5W 400MG/0.5L PLAST. BAG 0.00000 0.04060 1/25/2013DOPAMINE HCL/D5W 800MG/.25L PLAST. BAG 0.00000 0.08010 1/25/2013DOPAMINE HCL/D5W 800MG/0.5L PLAST. BAG 0.00000 0.05100 1/25/2013DORZOLAMIDE HCL 2 % DROPS 0.00000 1.36928 8/16/2013DORZOLAMIDE HCL/TIMOLOL MALEAT 2%-0.5% DROPS 0.00000 1.83714 8/16/2013DOXAZOSIN MESYLATE 1 MG TABLET 0.00000 0.64990 9/27/2013DOXAZOSIN MESYLATE 2 MG TABLET 0.00000 0.69868 9/27/2013DOXAZOSIN MESYLATE 4 MG TABLET 0.00000 0.73338 9/27/2013DOXAZOSIN MESYLATE 8 MG TABLET 0.00000 0.77023 9/27/2013DOXEPIN HCL 10 MG CAPSULE 0.00000 0.16753 8/16/2013DOXEPIN HCL 10 MG/ML ORAL CONC 0.00000 0.05720 1/25/2013DOXEPIN HCL 100 MG CAPSULE 0.00000 0.53599 8/16/2013DOXEPIN HCL 150 MG CAPSULE 0.00000 0.50211 12/14/2012DOXEPIN HCL 25 MG CAPSULE 0.00000 0.22344 8/16/2013DOXEPIN HCL 50 MG CAPSULE 0.00000 0.29702 8/16/2013DOXORUBICIN HCL 10 MG VIAL 0.00000 9.08830 1/25/2013DOXORUBICIN HCL 50 MG VIAL 0.00000 23.25700 12/14/2012DOXORUBICIN HCL PEG-LIPOSOMAL 2 MG/ML VIAL 80.58400 80.99070 4/5/2013DOXYCYCLINE HYCLATE 100 MG TABLET 0.00000 2.29740 8/9/2013DOXYCYCLINE HYCLATE 100 MG TABLET DR 0.00000 9.20381 4/19/2013DOXYCYCLINE HYCLATE 100 MG VIAL 0.00000 13.37070 1/25/2013DOXYCYCLINE HYCLATE 150 MG TABLET DR 0.00000 12.31958 6/21/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

DOXYCYCLINE HYCLATE 20 MG TABLET 0.00000 0.49892 4/19/2013DOXYCYCLINE HYCLATE 50 MG CAPSULE 0.00000 1.57724 6/28/2013DOXYCYCLINE HYCLATE 75 MG TABLET DR 14.94291 7.15692 6/21/2013DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE 0.00000 0.41162 12/14/2012DOXYCYCLINE MONOHYDRATE 100 MG TABLET 0.00000 0.95020 1/25/2013DOXYCYCLINE MONOHYDRATE 150 MG CAPSULE 0.00000 17.25512 12/14/2012DOXYCYCLINE MONOHYDRATE 150 MG TABLET 0.00000 4.39361 12/14/2012DOXYCYCLINE MONOHYDRATE 25 MG/5 ML SUSP RECON 0.00000 0.26565 6/21/2013DOXYCYCLINE MONOHYDRATE 50 MG CAPSULE 0.00000 0.19253 3/1/2013DOXYCYCLINE MONOHYDRATE 50 MG TABLET 0.00000 1.35060 1/25/2013DOXYCYCLINE MONOHYDRATE 75 MG CAPSULE 0.00000 9.06192 12/14/2012DOXYCYCLINE MONOHYDRATE 75 MG TABLET 0.00000 0.73370 1/25/2013DRONABINOL 10 MG CAPSULE 0.00000 12.58532 12/14/2012DRONABINOL 2.5 MG CAPSULE 0.00000 3.47994 10/11/2013DRONABINOL 5 MG CAPSULE 0.00000 7.27637 10/11/2013DROPERIDOL 2.5 MG/ML AMPUL 0.00000 0.84840 1/25/2013DROPERIDOL 2.5 MG/ML VIAL 0.00000 1.48750 1/25/2013ECONAZOLE NITRATE 1 % CREAM (G) 0.00000 0.22015 8/23/2013ELECTROLYTE,ORAL SOLUTION 0.00409 0.00414 7/26/2013ELECTROLYTE-48 SOLUTION/D5W 5 % IV SOLN 0.00000 0.00430 1/25/2013EMOLLIENT COMBINATION NO.10 EMULSN(G) 0.00000 0.44835 12/14/2012EMOLLIENT COMBINATION NO.32 EMULSN(G) 0.00000 0.61081 12/14/2012EMOLLIENT COMBINATION NO.44 FOAM 0.00000 0.90811 12/14/2012EMOLLIENT COMBINATION NO.53 CREAM (G) 0.00000 0.51341 12/14/2012EMOLLIENT COMBINATION NO.53 FOAM 0.00000 1.01001 12/14/2012ENALAPRIL MALEATE 10 MG TABLET 0.00000 0.14807 8/16/2013ENALAPRIL MALEATE 100 % POWDER 0.00000 3.35240 1/25/2013ENALAPRIL MALEATE 2.5 MG TABLET 0.00000 0.11109 8/16/2013ENALAPRIL MALEATE 20 MG TABLET 0.00000 0.21065 8/16/2013ENALAPRIL MALEATE 5 MG TABLET 0.00000 0.14097 8/16/2013ENALAPRIL/HYDROCHLOROTHIAZIDE 10MG-25MG TABLET 0.00000 0.11725 5/17/2013ENALAPRIL/HYDROCHLOROTHIAZIDE 5MG-12.5MG TABLET 0.00000 0.08740 5/31/2013ENALAPRILAT DIHYDRATE 1.25MG/ML VIAL 0.00000 1.71820 1/25/2013ENOXAPARIN SODIUM 100 MG/ML DISP SYRIN 0.00000 61.85070 7/19/2013ENOXAPARIN SODIUM 120MG/.8ML DISP SYRIN 0.00000 67.48480 7/19/2013ENOXAPARIN SODIUM 150 MG/ML DISP SYRIN 0.00000 67.48810 7/19/2013ENOXAPARIN SODIUM 300MG/3ML VIAL 0.00000 69.34808 9/27/2013ENOXAPARIN SODIUM 30MG/0.3ML DISP SYRIN 0.00000 41.91890 9/20/2013ENOXAPARIN SODIUM 40MG/0.4ML DISP SYRIN 0.00000 42.00000 7/19/2013ENOXAPARIN SODIUM 60MG/0.6ML DISP SYRIN 0.00000 46.65600 9/20/2013ENOXAPARIN SODIUM 80MG/0.8ML DISP SYRIN 0.00000 45.50740 7/19/2013ENTACAPONE 200 MG TABLET 0.00000 2.76836 12/14/2012ENZYMES,DIGESTIVE CAPSULE 0.00000 0.05940 1/25/2013EPHEDRINE SULFATE 50 MG/ML VIAL 0.00000 4.10130 1/25/2013EPINASTINE HCL 0.05 % DROPS 0.00000 10.45350 12/14/2012EPINEPHRINE 0.1 MG/ML DISP SYRIN 0.00000 0.47910 1/25/2013EPINEPHRINE 1 MG/ML VIAL 0.00000 0.18800 12/14/2012EPIRUBICIN HCL 200 MG VIAL 0.00000 1,992.09500 12/14/2012EPIRUBICIN HCL 50 MG VIAL 0.00000 76.67100 12/14/2012EPLERENONE 25 MG TABLET 0.00000 2.30663 9/13/2013EPLERENONE 50 MG TABLET 0.00000 2.33800 1/25/2013EPOPROSTENOL SODIUM (GLYCINE) 0.5 MG VIAL 0.00000 12.85200 1/25/2013EPOPROSTENOL SODIUM (GLYCINE) 1.5 MG VIAL 0.00000 24.45100 12/14/2012EPROSARTAN MESYLATE 600 MG TABLET 0.00000 2.39820 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

ERGOCALCIFEROL (VITAMIN D2) 2000 UNIT TABLET 0.00000 0.05446 12/14/2012ERGOCALCIFEROL (VITAMIN D2) 400 UNIT TABLET 0.00000 0.02380 2/8/2013ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT CAPSULE 0.00000 0.25393 5/24/2013ERGOLOID MESYLATES 1 MG TABLET 0.00000 5.67287 4/26/2013ERY E-SUCC/SULFISOXAZOLE 200-600/5 SUSP RECON 0.00000 0.19120 2/8/2013ERYTHROMYCIN BASE 250 MG CAPSULE DR 0.00000 2.65405 7/5/2013ERYTHROMYCIN BASE 250 MG TABLET 0.00000 2.37790 1/25/2013ERYTHROMYCIN BASE 500 MG TABLET 0.00000 2.79496 2/15/2013ERYTHROMYCIN BASE 5MG/G OINT. (G) 2.91200 2.90875 6/21/2013ERYTHROMYCIN BASE/ETHANOL 2 % MED. SWAB 0.00000 1.10370 2/8/2013ERYTHROMYCIN/BENZOYL PEROXIDE 3 %-5 % GEL (GRAM) 0.00000 1.08735 10/11/2013ESCITALOPRAM OXALATE 10 MG TABLET 0.00000 0.16950 2/1/2013ESCITALOPRAM OXALATE 20 MG TABLET 0.00000 0.19890 2/8/2013ESCITALOPRAM OXALATE 5 MG TABLET 0.00000 0.15950 2/8/2013ESCITALOPRAM OXALATE 5 MG/5 ML SOLUTION 0.00000 0.55475 12/14/2012ESTAZOLAM 1 MG TABLET 0.26774 0.26770 1/25/2013ESTAZOLAM 2 MG TABLET 0.29328 0.29330 1/25/2013ESTRADIOL .025MG/24H PATCH TDWK 0.00000 15.92223 9/20/2013ESTRADIOL .0375MG/24 PATCH TDWK 0.00000 10.74000 8/23/2013ESTRADIOL .075MG/24H PATCH TDWK 0.00000 10.55000 8/23/2013ESTRADIOL 0.05MG/24H PATCH TDWK 0.00000 10.57875 4/19/2013ESTRADIOL 0.06MG/24H PATCH TDWK 0.00000 11.48275 8/2/2013ESTRADIOL 0.1MG/24HR PATCH TDWK 0.00000 15.83261 9/20/2013ESTRADIOL 0.5 MG TABLET 0.00000 0.06790 5/17/2013ESTRADIOL 1 MG TABLET 0.00000 0.08683 2/22/2013ESTRADIOL 2 MG TABLET 0.00000 0.12047 5/17/2013ESTRADIOL/NORETHINDRONE ACET 0.5-0.1MG TABLET 0.00000 5.28900 12/14/2012ESTRADIOL/NORETHINDRONE ACET 1 MG-0.5MG TABLET 0.00000 2.68822 9/27/2013ESTROGEN,ESTER/ME-TESTOSTERONE 0.625-1.25 TABLET 0.00000 0.54404 12/14/2012ESTROGEN,ESTER/ME-TESTOSTERONE 1.25-2.5MG TABLET 0.00000 0.54404 12/14/2012ESTROPIPATE 0.75 MG TABLET 0.00000 0.23630 1/25/2013ESTROPIPATE 1.5 MG TABLET 0.00000 0.33060 1/25/2013ESTROPIPATE 3 MG TABLET 0.00000 0.70270 1/25/2013ETHAMBUTOL HCL 100 MG TABLET 0.30650 0.38773 8/2/2013ETHAMBUTOL HCL 400 MG TABLET 0.00000 1.17404 8/2/2013ETHINYL ESTRADIOL/DROSPIRENONE 0.02-3(24) TABLET 0.00000 1.77025 12/14/2012ETHINYL ESTRADIOL/DROSPIRENONE 0.03-3MG TABLET 0.00000 2.83232 5/10/2013ETHOSUXIMIDE 250 MG CAPSULE 0.00000 0.75335 8/9/2013ETHOSUXIMIDE 250 MG/5ML SOLUTION 0.00000 0.18022 10/11/2013ETHYL ALCOHOL 98 % AMPUL 0.00000 6.94000 3/1/2013ETHYL ALCOHOL 98 % VIAL 12.10060 12.09096 3/29/2013ETHYNODIOL D-ETHINYL ESTRADIOL 1 MG-35MCG TABLET 0.00000 0.74700 2/8/2013ETIDRONATE DISODIUM 200 MG TABLET 0.00000 2.85340 1/25/2013ETIDRONATE DISODIUM 400 MG TABLET 0.00000 5.70550 2/8/2013ETODOLAC 200 MG CAPSULE 0.00000 0.92480 1/25/2013ETODOLAC 300 MG CAPSULE 0.00000 1.13176 6/14/2013ETODOLAC 400 MG TAB ER 24H 0.00000 2.03084 9/20/2013ETODOLAC 500 MG TAB ER 24H 0.00000 2.15747 9/20/2013ETODOLAC 500 MG TABLET 0.00000 0.23740 5/17/2013ETODOLAC 600 MG TAB ER 24H 0.00000 2.29187 9/20/2013ETOPOSIDE 50 MG CAPSULE 0.00000 56.82120 2/15/2013EXEMESTANE 25 MG TABLET 0.00000 5.12530 8/2/2013FA/ARGININE HCL/B12/B6/PEP EX 2-500-500 TABLET 0.00000 0.56210 12/14/2012FAMCICLOVIR 125 MG TABLET 0.00000 1.08160 3/22/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

FAMCICLOVIR 250 MG TABLET 1.21270 1.08272 7/26/2013FAMCICLOVIR 500 MG TABLET 2.43522 2.04591 7/26/2013FAMOTIDINE 10 MG TABLET 0.08310 0.08308 4/12/2013FAMOTIDINE 10 MG/ML VIAL 0.00000 0.27792 12/14/2012FAMOTIDINE 20 MG TABLET 0.03792 0.03788 4/26/2013FAMOTIDINE 40 MG TABLET 0.00000 0.06941 6/7/2013FAMOTIDINE 40MG/5ML ORAL SUSP 0.00000 1.73584 12/14/2012FAMOTIDINE IN NACL,ISO-OSM/PF 20MG/50ML PIGGYBACK 0.00000 0.13650 12/14/2012FAMOTIDINE/PF 20 MG/2 ML VIAL 0.00000 0.37780 1/25/2013FE FUMARATE/VIT C/B12-IF/FA 110-0.5MG CAPSULE 0.00000 0.18226 8/30/2013FELBAMATE 400 MG TABLET 0.00000 3.64207 12/14/2012FELBAMATE 600 MG TABLET 0.00000 4.17758 12/14/2012FELBAMATE 600MG/5ML ORAL SUSP 0.00000 1.87137 12/14/2012FELODIPINE 10 MG TAB ER 24H 0.00000 0.76431 8/16/2013FELODIPINE 2.5 MG TAB ER 24H 0.00000 0.65459 5/17/2013FELODIPINE 5 MG TAB ER 24H 0.54380 0.54377 3/29/2013FENOFIBRATE 160 MG TABLET 0.00000 1.36605 9/13/2013FENOFIBRATE 54 MG TABLET 0.00000 0.55448 12/14/2012FENOFIBRATE NANOCRYSTALLIZED 145MG TABLET 0.00000 3.82670 2/22/2013FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET 0.00000 1.33480 8/16/2013FENOFIBRATE,MICRONIZED 130 MG CAPSULE 0.00000 4.84307 3/15/2013FENOFIBRATE,MICRONIZED 200 MG CAPSULE 0.00000 2.31300 12/1/2012FENOFIBRATE,MICRONIZED 43 MG CAPSULE 0.00000 1.64500 3/15/2013FENOFIBRATE,MICRONIZED 67 MG CAPSULE 0.73960 0.73955 3/1/2013FENOFIBRIC ACID (CHOLINE) 135 MG CAPSULE DR 0.00000 3.11212 8/16/2013FENOFIBRIC ACID (CHOLINE) 45 MG CAPSULE DR 0.00000 1.10787 8/16/2013FENOFIBRIC ACID 105 MG TABLET 0.00000 3.96959 12/14/2012FENOFIBRIC ACID 35 MG TABLET 0.00000 1.32159 12/14/2012FENTANYL 25MCG/HR PATCH TD72 0.00000 3.64000 9/20/2013FENTANYL 50MCG/HR PATCH TD72 0.00000 9.08500 2/8/2013FENTANYL 75MCG/HR PATCH TD72 0.00000 13.25120 2/22/2013FENTANYL CITRATE 1200 MCG LOZENGE HD 0.00000 31.46500 12/14/2012FENTANYL CITRATE 1600 MCG LOZENGE HD 0.00000 38.80683 12/14/2012FENTANYL CITRATE 200 MCG LOZENGE HD 0.00000 13.16280 12/14/2012FENTANYL CITRATE 400 MCG LOZENGE HD 0.00000 16.67657 12/14/2012FENTANYL CITRATE 600 MCG LOZENGE HD 0.00000 20.42600 12/14/2012FENTANYL CITRATE 800 MCG LOZENGE HD 0.00000 24.20180 12/14/2012FENTANYL CITRATE/PF 100MCG/2ML DISP SYRIN 0.00000 0.65520 1/25/2013FERROUS GLUCONATE 240(27)MG TABLET 0.00000 0.05160 1/25/2013FERROUS GLUCONATE 256(28)MG TABLET 0.00000 0.04946 4/19/2013FERROUS SULFATE 15 MG/ML DROPS 0.00000 0.06191 9/27/2013FERROUS SULFATE 220(44)/5 SOLUTION 0.00000 0.00697 12/14/2012FERROUS SULFATE 325(65) MG TABLET 0.00830 0.00831 2/1/2013FERROUS SULFATE/VIT C/FA 105-500-.8 TABLET ER 0.00000 0.45920 12/14/2012FEXOFENADINE HCL 180 MG TABLET 0.37342 0.36687 9/20/2013FEXOFENADINE HCL 30 MG TABLET 0.00000 0.71400 12/1/2012FEXOFENADINE HCL 30 MG/5 ML ORAL SUSP 0.00000 0.16328 12/14/2012FEXOFENADINE HCL 60 MG TABLET 0.55640 0.55637 3/22/2013FEXOFENADINE/PSEUDOEPHEDRINE 180-240MG TAB ER 24H 0.00000 0.96973 12/14/2012FEXOFENADINE/PSEUDOEPHEDRINE 60MG-120MG TAB ER 12H 0.00000 0.66733 12/14/2012FINASTERIDE 5 MG TABLET 0.17866 0.17822 10/11/2013FISH OIL/BORAGE/FLAX/OM3,6,9#1 400-400 MG CAPSULE 0.06490 0.06168 3/8/2013FISH OIL/DHA/EPA 1200-144MG CAPSULE 0.00000 0.01579 12/14/2012FLAVOXATE HCL 100 MG TABLET 0.00000 0.84201 5/17/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

FLECAINIDE ACETATE 100 MG TABLET 0.00000 0.27770 1/25/2013FLECAINIDE ACETATE 150 MG TABLET 0.00000 0.54570 1/25/2013FLECAINIDE ACETATE 50 MG TABLET 0.00000 0.19187 3/1/2013FLUCONAZOLE 10 MG/ML SUSP RECON 0.00000 0.26688 5/3/2013FLUCONAZOLE 100 MG TABLET 1.38741 1.39986 9/20/2013FLUCONAZOLE 150 MG TABLET 0.00000 2.46133 8/30/2013FLUCONAZOLE 200 MG TABLET 0.51412 1.30286 9/20/2013FLUCONAZOLE 40 MG/ML SUSP RECON 0.00000 0.64570 1/25/2013FLUCONAZOLE 50 MG TABLET 0.10870 0.71847 9/20/2013FLUCONAZOLE IN DEXTROSE,ISO-OS 200MG/0.1L PIGGYBACK 0.09490 0.09492 4/12/2013FLUCONAZOLE IN DEXTROSE,ISO-OS 400MG/0.2L PIGGYBACK 0.05300 0.05296 4/12/2013FLUCONAZOLE IN NACL,ISO-OSM 100MG/50ML PGGYBK BTL 0.00000 0.25410 12/14/2012FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L PGGYBK BTL 0.00000 0.12676 12/14/2012FLUCONAZOLE IN NACL,ISO-OSM 200MG/0.1L PIGGYBACK 0.05186 0.05182 4/26/2013FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L PGGYBK BTL 0.00000 0.09450 12/14/2012FLUCONAZOLE IN NACL,ISO-OSM 400MG/0.2L PIGGYBACK 0.03268 0.03369 4/26/2013FLUCYTOSINE 250 MG CAPSULE 0.00000 16.21200 12/14/2012FLUCYTOSINE 500 MG CAPSULE 0.00000 31.37400 12/14/2012FLUDROCORTISONE ACETATE 0.1 MG TABLET 0.00000 0.50277 4/12/2013FLUNISOLIDE 25 MCG SPRAY 0.00000 1.92500 12/14/2012FLUOCINOLONE ACETONIDE 0.01 % OIL 0.21619 0.27073 8/30/2013FLUOCINOLONE ACETONIDE 0.01 % SOLUTION 0.00000 2.10000 12/14/2012FLUOCINOLONE ACETONIDE 0.025 % CREAM (G) 0.00000 1.18223 3/29/2013FLUOCINOLONE ACETONIDE 0.025 % OINT. (G) 0.00000 1.58340 3/29/2013FLUOCINOLONE ACETONIDE OIL 0.01 % DROPS 0.00000 7.64750 10/11/2013FLUOCINOLONE/SHOWER CAP 0.01 % OIL 0.00000 1.31845 10/11/2013FLUOCINONIDE 0.05 % CREAM (G) 0.00000 0.40558 5/17/2013FLUOCINONIDE 0.05 % GEL (GRAM) 0.00000 0.84670 1/25/2013FLUOCINONIDE 0.05 % OINT. (G) 0.00000 0.78790 12/1/2012FLUOCINONIDE 0.05 % SOLUTION 0.00000 1.20370 12/1/2012FLUOCINONIDE/EMOLLIENT 0.05 % CREAM (G) 0.00000 0.25684 6/7/2013FLUOROMETHOLONE 0.1 % DROPS SUSP 0.00000 1.29450 5/31/2013FLUOROURACIL 1 G/20 ML VIAL 0.00000 0.49482 12/14/2012FLUOROURACIL 2 % SOLUTION 0.00000 4.95080 1/25/2013FLUOROURACIL 2.5 G/50ML VIAL 0.00000 0.21630 1/25/2013FLUOROURACIL 5 % CREAM (G) 0.00000 5.37332 8/30/2013FLUOROURACIL 5 % SOLUTION 0.00000 7.93170 5/17/2013FLUOROURACIL 5 G/100 ML VIAL 0.00000 0.29560 2/1/2013FLUOROURACIL 500MG/10ML VIAL 0.00000 0.24490 3/29/2013FLUOXETINE HCL 10 MG CAPSULE 0.03030 0.03034 3/15/2013FLUOXETINE HCL 10 MG TABLET 0.00000 0.05200 1/25/2013FLUOXETINE HCL 20 MG CAPSULE 0.00000 0.02474 5/3/2013FLUOXETINE HCL 20 MG TABLET 0.00000 0.60474 12/14/2012FLUOXETINE HCL 20 MG/5 ML SOLUTION 0.00000 0.03527 7/5/2013FLUOXETINE HCL 40 MG CAPSULE 0.21370 0.21373 3/22/2013FLUOXETINE HCL 60 MG TABLET 0.00000 2.97158 7/5/2013FLUOXETINE HCL 90 MG CAPSULE DR 0.00000 25.89300 12/14/2012FLUPHENAZINE DECANOATE 25 MG/ML VIAL 0.00000 22.97610 4/12/2013FLUPHENAZINE HCL 1 MG TABLET 0.00000 0.12779 5/17/2013FLUPHENAZINE HCL 10 MG TABLET 0.00000 0.22160 1/25/2013FLUPHENAZINE HCL 2.5 MG TABLET 0.00000 0.18330 1/25/2013FLUPHENAZINE HCL 2.5 MG/5ML ELIXIR 0.00000 0.26710 12/14/2012FLUPHENAZINE HCL 2.5 MG/ML VIAL 0.00000 10.58000 3/1/2013FLUPHENAZINE HCL 5 MG TABLET 0.00000 0.22020 1/25/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

FLUPHENAZINE HCL 5 MG/ML ORAL CONC 0.00000 0.81136 12/14/2012FLURAZEPAM HCL 15 MG CAPSULE 0.00000 0.06290 1/25/2013FLURAZEPAM HCL 30 MG CAPSULE 0.00000 0.07260 1/25/2013FLURBIPROFEN 100 MG TABLET 0.00000 0.25139 9/27/2013FLURBIPROFEN 50 MG TABLET 0.00000 0.22100 4/19/2013FLURBIPROFEN SODIUM 0.03 % DROPS 0.00000 1.57114 8/30/2013FLUTAMIDE 125 MG CAPSULE 0.00000 0.71030 1/25/2013FLUTICASONE PROPIONATE 0.005 % OINT. (G) 0.00000 0.48681 3/1/2013FLUTICASONE PROPIONATE 0.05 % CREAM (G) 0.00000 0.55080 12/1/2012FLUTICASONE PROPIONATE 0.05 % LOTION 0.00000 4.54942 12/14/2012FLUTICASONE PROPIONATE 50 MCG SPRAY SUSP 0.00000 0.76967 6/21/2013FLUVASTATIN SODIUM 20 MG CAPSULE 0.00000 3.18873 8/23/2013FLUVASTATIN SODIUM 40 MG CAPSULE 0.00000 2.64297 8/23/2013FLUVOXAMINE MALEATE 100 MG CAP ER 24H 0.00000 7.12857 5/31/2013FLUVOXAMINE MALEATE 100 MG TABLET 0.00000 0.28604 10/11/2013FLUVOXAMINE MALEATE 150 MG CAP ER 24H 0.00000 7.65030 5/3/2013FLUVOXAMINE MALEATE 25 MG TABLET 0.00000 0.29467 9/20/2013FLUVOXAMINE MALEATE 50 MG TABLET 0.00000 0.31115 9/20/2013FOLIC ACID 0.4 MG TABLET 0.00000 0.01005 12/14/2012FOLIC ACID 1 MG TABLET 0.00000 0.02320 12/1/2012FOLIC ACID 5 MG/ML VIAL 0.00000 1.79410 2/15/2013FOLIC ACID/MULTIVITS-MIN 0.4 MG TABLET 0.00000 0.80780 1/25/2013FOLIC ACID/MULTIVITS-MIN/LUT 0.4MG-250 TABLET 0.00000 0.03600 1/25/2013FOLIC ACID/VITAMIN B COMP W-C 0.8 MG TABLET 0.00000 0.09960 1/25/2013FOLIC ACID/VITAMIN B COMP W-C 1 MG CAPSULE 0.00000 0.11915 10/11/2013FONDAPARINUX SODIUM 10MG/0.8ML DISP SYRIN 0.00000 94.71000 1/25/2012FONDAPARINUX SODIUM 2.5 MG/0.5 DISP SYRIN 0.00000 83.02000 9/13/2013FONDAPARINUX SODIUM 5MG/0.4ML DISP SYRIN 0.00000 176.97650 12/14/2012FONDAPARINUX SODIUM 7.5MG/0.6 DISP SYRIN 0.00000 147.48213 8/30/2013FORMALDEHYDE 10 % SOL W/APPL 0.00000 0.36953 12/14/2012FOSINOPRIL SODIUM 10 MG TABLET 0.16728 0.17904 9/20/2013FOSINOPRIL SODIUM 20 MG TABLET 0.13924 0.18515 6/7/2013FOSINOPRIL SODIUM 40 MG TABLET 0.17840 0.18330 9/20/2013FOSINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.00000 0.97530 1/25/2013FOSINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.00000 0.97530 1/25/2013FOSPHENYTOIN SODIUM 100MG PE/2 VIAL 0.84210 0.95795 8/16/2013FOSPHENYTOIN SODIUM 500 PE/10 VIAL 0.46214 0.62205 8/16/2013FUROSEMIDE 10 MG/ML SOLUTION 0.00000 0.11127 5/17/2013FUROSEMIDE 10 MG/ML VIAL 0.00000 0.19752 7/5/2013FUROSEMIDE 20 MG TABLET 0.00000 0.01053 5/17/2013FUROSEMIDE 40 MG TABLET 0.00000 0.01167 5/17/2013FUROSEMIDE 40MG/5ML SOLUTION 0.00000 0.14150 12/14/2012FUROSEMIDE 80 MG TABLET 0.02707 0.02701 4/26/2013GABAPENTIN 100 MG CAPSULE 0.00000 0.04221 9/20/2013GABAPENTIN 250 MG/5ML SOLUTION 0.00000 0.12820 8/16/2013GABAPENTIN 250 MG/CUP SOLUTION 0.00000 0.29166 12/14/2012GABAPENTIN 300 MG CAPSULE 0.06955 0.06928 8/9/2013GABAPENTIN 300 MG/6ML SOLUTION 0.00000 0.29164 12/14/2012GABAPENTIN 400 MG CAPSULE 0.00000 0.09715 9/13/2013GABAPENTIN 600 MG TABLET 0.00000 0.27550 1/25/2013GABAPENTIN 800 MG TABLET 0.00000 0.42880 12/1/2012GALANTAMINE HBR 12 MG TABLET 1.78863 1.85858 5/24/2013GALANTAMINE HBR 16 MG CAP24H PEL 0.00000 2.15874 3/22/2013GALANTAMINE HBR 24 MG CAP24H PEL 0.00000 2.45490 1/25/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

GALANTAMINE HBR 4 MG TABLET 0.00000 1.78863 12/14/2012GALANTAMINE HBR 4 MG/ML SOLUTION 0.00000 2.95575 12/14/2012GALANTAMINE HBR 8 MG CAP24H PEL 0.00000 2.18150 1/25/2013GALANTAMINE HBR 8 MG TABLET 0.00000 1.87242 5/17/2013GANCICLOVIR SODIUM 500 MG VIAL 0.00000 9.65940 1/25/2013GANIRELIX ACETATE 250MCG/0.5 DISP SYRIN 0.00000 243.87300 1/25/2013GEMCITABINE HCL 1 G VIAL 0.00000 39.63675 12/14/2012GEMCITABINE HCL 1 G/26.3ML VIAL 0.00000 3.16329 12/14/2012GEMCITABINE HCL 2 G VIAL 0.00000 92.63950 12/14/2012GEMCITABINE HCL 2 G/52.6ML VIAL 0.00000 3.58109 12/14/2012GEMCITABINE HCL 200 MG VIAL 0.00000 9.28800 12/14/2012GEMCITABINE HCL 200MG/5.26 VIAL 0.00000 3.79680 12/14/2012GEMFIBROZIL 600 MG TABLET 0.00000 0.14583 10/4/2013GENTAMICIN IN NACL, ISO-OSM 100MG/50ML PIGGYBACK 0.00000 0.13213 12/14/2012GENTAMICIN IN NACL, ISO-OSM 120MG/0.1L PIGGYBACK 0.00000 0.06630 12/14/2012GENTAMICIN IN NACL, ISO-OSM 70 MG/50ML PIGGYBACK 0.00000 0.15469 12/14/2012GENTAMICIN IN NACL, ISO-OSM 90MG/100ML PIGGYBACK 0.00000 0.07491 12/14/2012GENTAMICIN SULFATE 0.1 % CREAM (G) 0.00000 0.64186 8/9/2013GENTAMICIN SULFATE 0.1 % OINT. (G) 0.00000 0.72750 12/21/2012GENTAMICIN SULFATE 0.3 % DROPS 0.00000 0.90852 6/14/2013GENTAMICIN SULFATE 0.3 % OINT. (G) 0.00000 3.93562 8/9/2013GENTAMICIN SULFATE 20 MG/2 ML VIAL 0.00000 1.45158 12/14/2012GENTAMICIN SULFATE 40 MG/ML VIAL 0.00000 0.57680 8/9/2013GENTAMICIN SULFATE/PF 100MG/10ML VIAL PORT 0.00000 0.29434 12/14/2012GENTAMICIN SULFATE/PF 20 MG/2 ML VIAL 0.00000 1.25658 12/14/2012GENTAMICIN SULFATE/PF 60 MG/6 ML VIAL PORT 0.00000 0.39255 12/14/2012GENTAMICIN SULFATE/PF 80 MG/8 ML VIAL PORT 0.00000 0.34262 12/14/2012GLIMEPIRIDE 1 MG TABLET 0.02910 0.02908 3/29/2013GLIMEPIRIDE 2 MG TABLET 0.05350 0.05347 2/22/2013GLIMEPIRIDE 4 MG TABLET 0.06860 0.06861 2/22/2013GLIPIZIDE 10 MG TAB ER 24 0.00000 0.40120 12/1/2012GLIPIZIDE 10 MG TABLET 0.00000 0.03948 10/11/2013GLIPIZIDE 2.5 MG TAB ER 24 0.00000 0.21363 9/20/2013GLIPIZIDE 5 MG TAB ER 24 0.00000 0.18940 12/1/2012GLIPIZIDE 5 MG TABLET 0.00000 0.03000 1/25/2013GLIPIZIDE/METFORMIN HCL 2.5-250 MG TABLET 0.00000 0.34151 12/14/2012GLIPIZIDE/METFORMIN HCL 2.5-500 MG TABLET 0.00000 0.39585 12/14/2012GLIPIZIDE/METFORMIN HCL 5 MG-500MG TABLET 0.39585 0.39607 8/2/2013GLUC/CHON-MSM#1/C/MANG/BOS/BOR 750-625MG TABLET 0.20448 0.20452 5/24/2013GLUCOSAMINE SULF/CHONDROITIN A 250-200 MG CAPSULE 0.00000 0.10590 1/25/2013GLUCOSAMINE SULFATE 750 MG TABLET 0.00000 0.33095 12/14/2012GLUCOSAMINE/CHONDROITIN A/MSM 500-200 MG TABLET 0.00000 1.20120 12/14/2012GLYBURIDE 1.25 MG TABLET 0.00000 0.11200 3/15/2013GLYBURIDE 2.5 MG TABLET 0.00000 0.14767 5/17/2013GLYBURIDE 5 MG TABLET 0.00000 0.20127 7/19/2013GLYBURIDE,MICRONIZED 1.5 MG TABLET 0.00000 0.02590 1/25/2013GLYBURIDE,MICRONIZED 3 MG TABLET 0.00000 0.02840 1/25/2013GLYBURIDE,MICRONIZED 6 MG TABLET 0.00000 0.09900 5/17/2013GLYBURIDE/METFORMIN HCL 1.25-250MG TABLET 0.10184 0.10934 8/23/2013GLYBURIDE/METFORMIN HCL 2.5-500 MG TABLET 0.00000 0.08911 7/26/2013GLYBURIDE/METFORMIN HCL 5 MG-500MG TABLET 0.00000 0.08785 4/26/2013GLYCINE POWDER 0.00000 0.21190 1/25/2013GLYCINE 1.5 % IRRIG SOLN 0.00000 0.00300 12/14/2012GLYCINE/SOD/WATER/SOD HYDROX VIAL 0.00000 0.14700 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

GLYCOPYRROLATE 1 MG TABLET 0.00000 0.38840 4/12/2013GLYCOPYRROLATE 2 MG TABLET 0.00000 0.68691 5/27/2013GRANISETRON HCL 1 MG/ML VIAL 0.00000 4.71250 12/14/2012GRANISETRON HCL 1 MG/ML(1) VIAL 0.00000 7.21995 12/14/2012GRANISETRON HCL/PF 1 MG/ML(1) VIAL 0.00000 6.14680 8/30/2013GRANISETRON HCL/PF 100 MCG/ML VIAL 2.49240 3.21880 8/30/2013GRISEOFULVIN ULTRAMICROSIZE 125 MG TABLET 3.68837 3.68840 1/25/2013GRISEOFULVIN ULTRAMICROSIZE 250 MG TABLET 4.71086 4.71090 1/25/2013GRISEOFULVIN,MICROSIZE 125 MG/5ML ORAL SUSP 0.00000 0.16187 3/1/2013GRISEOFULVIN,MICROSIZE 500 MG TABLET 0.00000 5.40337 12/14/2012GUAIFENESIN 100 MG/5ML LIQUID 0.00628 0.00603 8/30/2013GUAIFENESIN 200 MG TABLET 0.00000 0.05110 1/25/2013GUAIFENESIN 400 MG TABLET 0.10180 0.05655 6/7/2013GUAIFENESIN 600 MG TABLET ER 0.36368 0.31792 4/19/2013GUAIFENESIN/CODEINE PHOSPHATE 100-10MG/5 LIQUID 0.01567 0.02044 10/11/2013GUAIFENESIN/CODEINE PHOSPHATE 100-6.3/5 LIQUID 0.00000 0.06360 1/25/2013GUAIFENESIN/CODEINE PHOSPHATE 225-7.5/5 LIQUID 0.00000 0.04970 1/25/2013GUAIFENESIN/D-METHORPHAN HB/PE 100-10-5MG LIQUID 0.00000 0.01943 12/14/2012GUAIFENESIN/D-METHORPHAN HB/PE 100-15-5/5 LIQUID 0.08670 0.03941 10/11/2013GUAIFENESIN/D-METHORPHAN HB/PE 200-10-5/5 LIQUID 0.02586 0.02590 4/19/2013GUAIFENESIN/D-METHORPHAN HB/PE 200-20-10 LIQUID 0.00000 0.07980 1/25/2013GUAIFENESIN/D-METHORPHAN HB/PE 380-15-10 TABLET 0.00000 0.43610 1/25/2013GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 LIQUID 0.03162 0.03762 8/23/2013GUAIFENESIN/DEXTROMETHORPHAN 100-10MG/5 SYRUP 0.01352 0.00801 9/13/2013GUAIFENESIN/DEXTROMETHORPHAN 400-20MG/5 LIQUID 0.07583 0.06510 2/22/2013GUAIFENESIN/PHENYLEPHRINE HCL 380MG-10MG TABLET 0.00000 0.43170 1/25/2013GUANFACINE HCL 1 MG TABLET 0.00000 0.07973 5/3/2013GUANFACINE HCL 2 MG TABLET 0.00000 0.11553 3/1/2013GUANIDINE HCL 125 MG TABLET 0.00000 0.17724 12/14/2012HALOBETASOL PROPIONATE 0.05 % CREAM (G) 0.00000 2.67890 6/21/2013HALOBETASOL PROPIONATE 0.05 % OINT. (G) 0.00000 2.74455 8/9/2013HALOPERIDOL 0.5 MG TABLET 0.00000 0.21117 10/11/2013HALOPERIDOL 1 MG TABLET 0.00000 0.35311 10/11/2013HALOPERIDOL 10 MG TABLET 0.00000 1.07290 10/11/2013HALOPERIDOL 2 MG TABLET 0.00000 0.05077 10/11/2013HALOPERIDOL 20 MG TABLET 0.00000 2.13980 10/11/2013HALOPERIDOL 5 MG TABLET 0.00000 0.67517 10/11/2013HALOPERIDOL DECANOATE 100 MG/ML AMPUL 0.00000 41.45400 8/30/2013HALOPERIDOL DECANOATE 100 MG/ML VIAL 0.00000 33.27379 8/2/2013HALOPERIDOL DECANOATE 50 MG/ML AMPUL 0.00000 21.74667 12/14/2012HALOPERIDOL DECANOATE 50 MG/ML VIAL 0.00000 22.14000 8/23/2013HALOPERIDOL LACTATE 2 MG/ML ORAL CONC 0.00000 0.05316 5/17/2013HALOPERIDOL LACTATE 5 MG/ML AMPUL 0.00000 5.15760 12/14/2012HALOPERIDOL LACTATE 5 MG/ML VIAL 0.00000 1.14840 1/25/2013HC/MINERAL OIL/PETROLAT,WHT 1 % OINT. (G) 0.00000 0.12564 12/14/2012HEPARIN SOD,PORK IN 0.45% NACL 12500/250 IV SOLN 0.00000 0.03400 1/25/2013HEPARIN SOD,PORK IN 0.45% NACL 25000/250 IV SOLN 0.00000 0.02288 12/14/2012HEPARIN SOD,PORK IN 0.45% NACL 25000/500 IV SOLN 0.00000 0.01749 12/14/2012HEPARIN SODIUM,PORCINE 10 UNIT/ML DISP SYRIN 0.00000 0.65250 1/25/2013HEPARIN SODIUM,PORCINE 100/ML VIAL 0.00000 0.03983 4/5/2013HEPARIN SODIUM,PORCINE 1000/ML VIAL 0.21199 0.20726 9/13/2013HEPARIN SODIUM,PORCINE 10000/ML VIAL 2.33150 2.33147 6/21/2013HEPARIN SODIUM,PORCINE 20000/ML VIAL 0.00000 8.04232 5/31/2013HEPARIN SODIUM,PORCINE 5000/ML VIAL 0.72530 0.72537 6/21/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

HEPARIN SODIUM,PORCINE 5000/ML(1) CARTRIDGE 0.00000 3.65400 12/14/2012HEPARIN SODIUM,PORCINE/D5W 12500/250 IV SOLN 0.00000 0.03780 1/25/2013HEPARIN SODIUM,PORCINE/D5W 20K/500ML IV SOLN 0.00000 0.00870 1/25/2013HEPARIN SODIUM,PORCINE/NS/PF 1000/500ML IV SOLN 0.00000 0.00720 1/25/2013HEPARIN SODIUM,PORCINE/NS/PF 2K/1000ML IV SOLN 0.00000 0.00440 1/25/2013HEPARIN SODIUM,PORCINE/PF 1 UNIT/ML DISP SYRIN 0.00000 0.53235 5/31/2013HEPARIN SODIUM,PORCINE/PF 10 UNIT/ML DISP SYRIN 0.00000 0.15678 5/31/2013HEPARIN SODIUM,PORCINE/PF 10 UNIT/ML VIAL 0.00000 1.27250 1/25/2013HEPARIN SODIUM,PORCINE/PF 100/ML (1) VIAL 0.00000 1.63384 12/14/2012HEPARIN SODIUM,PORCINE/PF 100/ML DISP SYRIN 0.00000 0.14740 5/31/2013HEPARIN SODIUM,PORCINE/PF 1000/ML VIAL 4.02116 3.64416 6/21/2013HEPARIN SODIUM,PORCINE/PF 5000/0.5ML DISP SYRIN 0.00000 7.45725 12/14/2012HEPARIN SODIUM,PORCINE/PF 5000/0.5ML VIAL 0.00000 9.36923 12/14/2012HYDRALAZINE HCL 10 MG TABLET 0.00000 0.05641 3/22/2013HYDRALAZINE HCL 100 MG TABLET 0.00000 0.18850 1/25/2013HYDRALAZINE HCL 20 MG/ML VIAL 0.00000 4.60408 12/14/2012HYDRALAZINE HCL 25 MG TABLET 0.05900 0.05896 3/8/2013HYDRALAZINE HCL 50 MG TABLET 0.06530 0.06526 3/8/2013HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE 0.03870 0.03846 9/20/2013HYDROCHLOROTHIAZIDE 12.5 MG TABLET 0.00000 0.22571 10/11/2013HYDROCHLOROTHIAZIDE 25 MG TABLET 0.00000 0.02250 10/4/2013HYDROCHLOROTHIAZIDE 50 MG TABLET 0.00000 0.04003 10/4/2013HYDROCODONE BIT/ACETAMINOPHEN 10-660MG TABLET 0.00000 0.20194 8/2/2013HYDROCODONE BIT/ACETAMINOPHEN 10-750MG TABLET 0.00000 0.53378 7/26/2013HYDROCODONE BIT/ACETAMINOPHEN 10MG-325MG TABLET 0.12020 0.12006 8/16/2013HYDROCODONE BIT/ACETAMINOPHEN 10MG-500MG TABLET 0.00000 0.21500 12/1/2012HYDROCODONE BIT/ACETAMINOPHEN 10MG-650MG TABLET 0.00000 0.07008 6/21/2013HYDROCODONE BIT/ACETAMINOPHEN 2.5-108/5 SOLUTION 0.00000 0.56630 9/27/2013HYDROCODONE BIT/ACETAMINOPHEN 2.5-167/5 SOLUTION 0.00000 0.47191 12/14/2012HYDROCODONE BIT/ACETAMINOPHEN 2.5-500 MG TABLET 0.00000 0.20118 9/13/2013HYDROCODONE BIT/ACETAMINOPHEN 5 MG-500MG TABLET 0.00000 0.03618 6/7/2013HYDROCODONE BIT/ACETAMINOPHEN 5-217MG/10 SOLUTION 0.00000 0.32085 9/27/2013HYDROCODONE BIT/ACETAMINOPHEN 5-334MG/10 SOLUTION 0.00000 0.26732 12/14/2012HYDROCODONE BIT/ACETAMINOPHEN 5MG-325MG TABLET 0.00000 0.12792 8/2/2013HYDROCODONE BIT/ACETAMINOPHEN 7.5-300MG TABLET 0.00000 1.28474 6/14/2013HYDROCODONE BIT/ACETAMINOPHEN 7.5-325/15 SOLUTION 0.08900 0.08700 9/13/2013HYDROCODONE BIT/ACETAMINOPHEN 7.5-325/CP SOLUTION 0.15120 0.17666 9/13/2013HYDROCODONE BIT/ACETAMINOPHEN 7.5-325MG TABLET 0.00000 0.17760 8/30/2013HYDROCODONE BIT/ACETAMINOPHEN 7.5-500/15 SOLUTION 0.00000 0.02296 10/11/2013HYDROCODONE BIT/ACETAMINOPHEN 7.5-500/CP SOLUTION 0.18960 0.18964 6/7/2013HYDROCODONE BIT/ACETAMINOPHEN 7.5-500MG TABLET 0.00000 0.05265 6/7/2013HYDROCODONE BIT/ACETAMINOPHEN 7.5-650 MG TABLET 0.00000 0.03832 8/2/2013HYDROCODONE BIT/ACETAMINOPHEN 7.5-750MG TABLET 0.00000 0.05357 6/7/2013HYDROCODONE BIT/HOMATROP ME-BR 5 MG-1.5MG TABLET 0.00000 0.42566 12/14/2012HYDROCODONE BIT/HOMATROP ME-BR 5-1.5 MG/5 SYRUP 0.00000 0.06580 1/25/2013HYDROCODONE BIT/HOMATROP ME-BR 5-1.5/CUP SYRUP 0.00000 0.52500 12/14/2012HYDROCODONE/CHLORPHEN POLIS 10-8MG/5ML SUS ER 12H 0.00000 0.46202 12/14/2012HYDROCODONE/IBUPROFEN 10MG-200MG TABLET 0.00000 2.86300 12/14/2012HYDROCODONE/IBUPROFEN 2.5-200MG TABLET 0.00000 2.04491 12/14/2012HYDROCODONE/IBUPROFEN 5MG-200MG TABLET 0.00000 2.17077 8/2/2013HYDROCODONE/IBUPROFEN 7.5-200 MG TABLET 0.00000 0.23195 7/26/2013HYDROCORTISONE POWDER 2.52898 2.18774 5/3/2013HYDROCORTISONE 0.5 % CREAM (G) 0.00000 0.08224 4/5/2013HYDROCORTISONE 1 % CREAM (G) RECTAL 0.00000 0.66820 12/1/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

HYDROCORTISONE 1 % CREAM (G) TOPICAL 0.04382 0.04378 4/26/2013HYDROCORTISONE 1 % LOTION (G) 0.03143 0.04428 8/23/2013HYDROCORTISONE 1 % LOTION (ML) 0.03143 0.03153 5/3/2013HYDROCORTISONE 1 % OINT. (G) 0.00000 0.10490 1/25/2013HYDROCORTISONE 10 MG TABLET 0.00000 0.41100 6/14/2013HYDROCORTISONE 100MG/60ML ENEMA 0.00000 0.06868 6/28/2013HYDROCORTISONE 2.5 % CREAM (G) RECTAL 0.00000 0.38173 8/9/2013HYDROCORTISONE 2.5 % CREAM (G) TOPICAL 0.10320 0.10318 8/9/2013HYDROCORTISONE 2.5 % LOTION 0.00000 0.23863 4/12/2013HYDROCORTISONE 2.5 % OINT. (G) 0.00000 0.11200 1/25/2013HYDROCORTISONE 20 MG TABLET 0.00000 0.70980 4/12/2013HYDROCORTISONE 5 MG TABLET 0.00000 0.23730 12/14/2012HYDROCORTISONE AC/LIDOCAINE 0.5 %-3 % CREAM/APPL 0.00000 1.78500 12/14/2012HYDROCORTISONE AC/LIDOCAINE 1%-3%(7G) CREAM/APPL 0.00000 251.09000 12/14/2012HYDROCORTISONE AC/LIDOCAINE 2.5-3%(7G) GEL W/APPL 0.00000 251.09000 12/14/2012HYDROCORTISONE ACETATE POWDER 0.00000 3.23180 12/1/2012HYDROCORTISONE ACETATE 25 MG SUPP.RECT 1.44809 1.70599 9/20/2013HYDROCORTISONE ACETATE 30 MG SUPP.RECT 0.00000 3.95180 1/25/2013HYDROCORTISONE BUTYRATE 0.1 % CREAM (G) 0.00000 1.02530 2/15/2013HYDROCORTISONE BUTYRATE 0.1 % OINT. (G) 0.00000 0.85571 4/12/2013HYDROCORTISONE BUTYRATE 0.1 % SOLUTION 0.30030 0.29238 6/14/2013HYDROCORTISONE VALERATE 0.2 % CREAM (G) 0.00000 2.28761 9/20/2013HYDROCORTISONE/IODOQUINOL 1 %-1 % CREAM (G) 0.00000 0.43200 1/25/2013HYDROCORTISONE/LIDOCAINE/ALOE 2.5-3%(7G) KIT 0.00000 3.05119 12/14/2012HYDROCORTISONE/PRAMOXINE 2.5 %-1 % CREAM (G) 0.00000 1.30835 12/14/2012HYDROMORPHONE HCL 0.5MG/.5ML DISP SYRIN 0.00000 8.44200 6/21/2013HYDROMORPHONE HCL 1 MG/ML DISP SYRIN 0.00000 3.90600 1/25/2013HYDROMORPHONE HCL 1 MG/ML LIQUID 0.00000 0.27988 12/14/2012HYDROMORPHONE HCL 2 MG TABLET 0.00000 0.09250 3/22/2013HYDROMORPHONE HCL 2 MG/ML DISP SYRIN 0.00000 4.17900 1/25/2013HYDROMORPHONE HCL 2 MG/ML VIAL 1.74300 0.87780 6/7/2013HYDROMORPHONE HCL 3 MG SUPP.RECT 0.00000 8.58670 2/1/2013HYDROMORPHONE HCL 4 MG TABLET 0.00000 0.11269 5/24/2013HYDROMORPHONE HCL 4 MG/ML DISP SYRIN 0.00000 3.78000 1/25/2013HYDROMORPHONE HCL 8 MG TABLET 0.00000 0.28810 7/26/2013HYDROMORPHONE HCL/PF 1 MG/ML AMPUL 0.00000 0.87360 1/25/2013HYDROMORPHONE HCL/PF 10 MG/ML VIAL 0.00000 1.78538 10/11/2013HYDROMORPHONE HCL/PF 2 MG/ML AMPUL 0.00000 0.94080 1/25/2013HYDROMORPHONE HCL/PF 4 MG/ML AMPUL 0.00000 1.33560 1/25/2013HYDROQUINONE 4 % CREAM (G) 0.00000 0.35360 12/14/2012HYDROQUINONE MICROSPHERES 4 % CRM ER (G) 0.00000 2.49387 12/14/2012HYDROXOCOBALAMIN 1000MCG/ML VIAL 0.00000 0.89273 12/14/2012HYDROXYCHLOROQUINE SULFATE 200 MG TABLET 0.00000 0.10720 12/1/2012HYDROXYUREA 500 MG CAPSULE 0.00000 0.35730 5/17/2013HYDROXYZINE HCL 10 MG TABLET 0.07343 0.07338 9/27/2013HYDROXYZINE HCL 10 MG/5 ML SYRUP 0.00000 0.05982 10/4/2013HYDROXYZINE HCL 25 MG TABLET 0.08630 0.08632 5/31/2013HYDROXYZINE HCL 25 MG/ML VIAL 0.00000 0.51630 1/25/2013HYDROXYZINE HCL 50 MG TABLET 0.11020 0.11015 3/1/2013HYDROXYZINE HCL 50 MG/ML VIAL 0.00000 1.75000 12/14/2012HYDROXYZINE PAMOATE 100 MG CAPSULE 0.00000 0.31486 5/17/2013HYDROXYZINE PAMOATE 25 MG CAPSULE 0.00000 0.06620 12/1/2012HYDROXYZINE PAMOATE 50 MG CAPSULE 0.00000 0.08680 12/1/2012HYOSCYAMINE SULFATE 0.125 MG TAB RAPDIS 0.00000 0.27859 8/30/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

HYOSCYAMINE SULFATE 0.125 MG TAB SUBL 0.00000 0.44000 1/11/2013HYOSCYAMINE SULFATE 0.125 MG TABLET 0.00000 0.45942 8/30/2013HYOSCYAMINE SULFATE 0.125MG/ML DROPS 0.00000 1.05770 8/30/2013HYOSCYAMINE SULFATE 0.375 MG TAB ER 12H 0.00000 0.60697 3/15/2013HYOSCYAMINE SULFATE 125MCG/5ML ELIXIR 0.00000 0.04790 1/25/2013HYPROMELLOSE 0.3 % DROPS 0.33450 0.35978 5/3/2013HYPROMELLOSE 0.4 % DROPS 0.00000 0.17850 12/14/2012IBANDRONATE SODIUM 150 MG TABLET 0.00000 97.13590 1/25/2013IBUPROFEN 100 MG TAB CHEW 0.18350 0.12702 3/22/2013IBUPROFEN 100 MG TABLET 0.00000 0.18350 1/25/2013IBUPROFEN 100 MG/5ML ORAL SUSP 0.02337 0.02262 9/13/2013IBUPROFEN 200 MG CAPSULE 0.00000 0.05530 12/14/2012IBUPROFEN 200 MG TABLET 0.01469 0.01635 6/14/2013IBUPROFEN 400 MG TABLET 0.00000 0.03519 7/19/2013IBUPROFEN 50 MG/1.25 DROPS SUSP 0.00000 0.27347 3/1/2013IBUPROFEN 600 MG TABLET 0.00000 0.04556 10/11/2013IBUPROFEN 800 MG TABLET 0.00000 0.05515 7/19/2013IBUPROFEN/OXYCODONE HCL 400MG-5MG TABLET 0.00000 1.03130 1/25/2013IFOSFAMIDE 1 G/20 ML VIAL 5.07623 1.87005 8/23/2013IFOSFAMIDE 3 G VIAL 0.00000 88.61300 12/14/2012IFOSFAMIDE 3G/60ML VIAL 3.11430 1.92790 8/23/2013IFOSFAMIDE/MESNA 3G-1G KIT 0.00000 281.14725 12/14/2012IMIPENEM/CILASTATIN SODIUM 250 MG VIAL 0.00000 5.23320 3/29/2013IMIPENEM/CILASTATIN SODIUM 500 MG VIAL 0.00000 8.82000 8/9/2013IMIPRAMINE HCL 10 MG TABLET 0.00000 0.13202 4/12/2013IMIPRAMINE HCL 25 MG TABLET 0.00000 0.16830 4/12/2013IMIPRAMINE HCL 50 MG TABLET 0.00000 0.22962 5/24/2013IMIPRAMINE PAMOATE 100 MG CAPSULE 0.00000 11.65038 6/14/2013IMIPRAMINE PAMOATE 125 MG CAPSULE 0.00000 11.40705 12/14/2012IMIPRAMINE PAMOATE 150 MG CAPSULE 0.00000 10.62040 1/25/2013IMIPRAMINE PAMOATE 75 MG CAPSULE 0.00000 10.75614 8/2/2013IMIQUIMOD 5 % CREAM PACK 0.00000 10.97052 8/16/2013INDAPAMIDE 1.25 MG TABLET 0.00000 0.07660 1/25/2013INDAPAMIDE 2.5 MG TABLET 0.00000 0.08740 1/25/2013INDOMETHACIN 25 MG CAPSULE 0.00000 0.12627 10/11/2013INDOMETHACIN 50 MG CAPSULE 0.00000 0.16305 8/16/2013INDOMETHACIN 75 MG CAPSULE ER 0.00000 1.29820 4/19/2013INDOMETHACIN SODIUM 1 MG VIAL 0.00000 409.47900 12/14/2012IPRATROPIUM BROMIDE 0.2 MG/ML SOLUTION 0.06120 0.06124 3/1/2013IPRATROPIUM BROMIDE 21 MCG SPRAY 0.00000 0.21840 5/17/2013IPRATROPIUM BROMIDE 42MCG SPRAY 0.00000 0.43680 5/17/2013IPRATROPIUM/ALBUTEROL SULFATE 0.5-3MG/3 AMPUL-NEB 0.09619 0.09305 10/11/2013IRBESARTAN 150 MG TABLET 0.00000 0.19252 5/3/2013IRBESARTAN 300 MG TABLET 0.00000 0.31320 5/31/2013IRBESARTAN 75 MG TABLET 0.14564 0.14563 5/3/2013IRBESARTAN/HYDROCHLOROTHIAZIDE 150-12.5MG TABLET 0.19296 0.19206 4/19/2013IRBESARTAN/HYDROCHLOROTHIAZIDE 300-12.5MG TABLET 0.00000 0.66610 4/5/2013IRON FUMARATE/VIT C/VIT B12/FA 460-60MG CAPSULE 0.00000 0.43155 12/14/2012IRON POLYSACCH/IRON HEME POLYP 28 MG TABLET 0.00000 0.37090 1/25/2013IRON POLYSACCHARIDES COMPLEX 150 MG CAPSULE 0.00000 0.12990 1/25/2013IRON PS CMPLX/VIT B12/FA 150-25-1 CAPSULE 0.00000 0.18193 8/9/2013IRON PS/IRON HEM POLY/FA/B12 22-6-1-25 TABLET 0.00000 2.61148 1/25/2013IRON, CARB & GLUC/FA/B12/C/DSS 90-1-50 MG TABLET 0.00000 0.78945 5/3/2013IRON,CARB/DSS/B12IF/FA/MV-MN 150-50-1MG TAB ER 24H 0.00000 0.47055 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

IRON,CARBONYL 15 MG TAB CHEW 0.00000 0.42735 12/14/2012IRON,CARBONYL 15MG/1.25 ORAL SUSP 0.00000 0.12650 1/25/2013IRON,CARBONYL/FA/MULTIVITS-MIN 50-1.25MG TABLET 0.00000 1.05126 4/19/2013IRON,CARBONYL/VIT C/VIT B12/FA 100-250-1 TABLET 0.39480 0.21567 3/8/2013ISOMETHEPTENE/ACETAMINOPH/CAFF 130-500-20 TABLET 0.00000 2.71180 1/25/2013ISONIAZID 100 MG/ML VIAL 0.00000 63.03150 12/14/2012ISONIAZID 50 MG/5 ML SOLUTION 0.00000 0.09983 12/14/2012ISOPROPYL ALCOHOL/GLYCERIN 95%-5% DROPS 0.00000 0.07020 1/25/2013ISOSORBIDE DINITRATE 10 MG TABLET 0.00000 0.75849 3/29/2013ISOSORBIDE DINITRATE 2.5 MG TAB SUBL 0.00000 0.04410 1/25/2013ISOSORBIDE DINITRATE 30 MG TABLET 0.00000 0.75358 5/17/2013ISOSORBIDE DINITRATE 40 MG TABLET ER 0.00000 0.64714 6/14/2013ISOSORBIDE DINITRATE 5 MG TAB SUBL 0.00000 0.04407 12/14/2012ISOSORBIDE MONONITRATE 10 MG TABLET 0.00000 0.19730 1/25/2013ISOSORBIDE MONONITRATE 120 MG TAB ER 24H 0.00000 0.42893 9/27/2013ISOSORBIDE MONONITRATE 20 MG TABLET 0.00000 0.12251 10/11/2013ISOSORBIDE MONONITRATE 30 MG TAB ER 24H 0.00000 0.22032 10/4/2013ISOSORBIDE MONONITRATE 60 MG TAB ER 24H 0.00000 0.24348 9/13/2013ISOSULFAN BLUE 1 % VIAL 0.00000 102.04250 1/25/2013ISOTRETINOIN 10 MG CAPSULE 0.00000 12.20900 5/31/2013ISOTRETINOIN 20 MG CAPSULE 0.00000 14.43812 8/30/2013ISOTRETINOIN 30 MG CAPSULE 0.00000 11.51617 12/14/2012ISOTRETINOIN 40 MG CAPSULE 0.00000 16.54897 10/11/2013ISOXSUPRINE HCL 10 MG TABLET 0.00000 0.67470 1/25/2013ISRADIPINE 2.5 MG CAPSULE 0.00000 0.95543 12/14/2012ISRADIPINE 5 MG CAPSULE 0.00000 1.39713 12/14/2012ITRACONAZOLE 100 MG CAPSULE 0.00000 6.74400 5/17/2013KETOCONAZOLE 2 % CREAM (G) 0.16350 0.16348 7/26/2013KETOCONAZOLE 2 % SHAMPOO 0.00000 0.10040 1/25/2013KETOCONAZOLE 200 MG TABLET 0.00000 0.19757 3/1/2013KETOPROFEN 200 MG CAP24H PEL 0.00000 5.10170 2/8/2013KETOPROFEN 75 MG CAPSULE 0.00000 0.25233 9/27/2013KETOROLAC TROMETHAMINE 0.4 % DROPS 2.06890 2.08345 5/31/2013KETOROLAC TROMETHAMINE 0.5 % DROPS 1.29580 1.29534 8/9/2013KETOROLAC TROMETHAMINE 10 MG TABLET 0.00000 0.55620 9/20/2013KETOROLAC TROMETHAMINE 15 MG/ML VIAL 0.00000 0.92058 12/14/2012KETOROLAC TROMETHAMINE 30 MG/ML VIAL 0.00000 1.31943 12/14/2012KETOROLAC TROMETHAMINE 30MG/ML(1) VIAL 0.00000 0.70560 2/15/2013KETOROLAC TROMETHAMINE 60 MG/2 ML VIAL 0.00000 0.36960 3/1/2013KETOTIFEN FUMARATE 0.025 % DROPS 1.15457 1.19456 7/19/2013L-NORGEST-ETH ESTR/ETHIN ESTRA 100-20(84) TBDSPK 3MO 0.00000 2.06577 12/14/2012L-NORGEST-ETH ESTR/ETHIN ESTRA 150-30(84) TBDSPK 3MO 0.00000 2.06577 10/4/2013LABETALOL HCL 100 MG TABLET 0.00000 0.38550 11/1/2012LABETALOL HCL 20 MG/4 ML DISP SYRIN 0.00000 0.65310 1/25/2013LABETALOL HCL 200 MG TABLET 0.00000 0.47750 5/17/2013LABETALOL HCL 300 MG TABLET 0.00000 0.64820 12/1/2012LACTIC ACID 10 % CREAM (G) 0.00000 0.08303 12/14/2012LACTIC ACID 10 % LOTION 0.00000 0.04280 1/25/2013LACTULOSE 10 G/15 ML SOLUTION (LAXATIVE) 0.00000 0.01379 8/30/2013LACTULOSE 10 G/15 ML SOLUTION (MISC) 0.00000 0.01479 8/30/2013LACTULOSE 10 G/CUP SOLUTION 0.00000 0.04574 7/5/2013LAMIVUDINE 150 MG TABLET 0.00000 4.60763 9/20/2013LAMIVUDINE 300 MG TABLET 0.00000 8.79880 9/20/2013LAMIVUDINE/ZIDOVUDINE 150-300MG TABLET 0.00000 10.77206 6/28/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

LAMOTRIGINE 100 MG TAB ER 24 0.00000 9.25137 9/20/2013LAMOTRIGINE 100 MG TABLET 0.06850 0.06847 2/22/2013LAMOTRIGINE 150 MG TABLET 0.10390 0.10385 2/22/2013LAMOTRIGINE 200 MG TAB ER 24 0.00000 9.88540 10/11/2013LAMOTRIGINE 200 MG TABLET 0.11200 0.11202 2/22/2013LAMOTRIGINE 25 MG TAB ER 24 0.00000 4.58337 3/1/2013LAMOTRIGINE 25 MG TABLET 0.00000 0.06850 4/12/2013LAMOTRIGINE 25 MG TB CHW DSP 0.00000 0.29940 5/17/2013LAMOTRIGINE 250 MG TAB ER 24 0.00000 24.47409 4/26/2013LAMOTRIGINE 25MG (35) TAB DS PK 0.00000 2.90500 12/14/2012LAMOTRIGINE 300 MG TAB ER 24 0.00000 13.52610 9/20/2013LAMOTRIGINE 5 MG TB CHW DSP 0.00000 0.25904 8/2/2013LAMOTRIGINE 50 MG TAB ER 24 0.00000 9.03040 10/11/2013LANOLIN/MIN OIL/PETROLAT,WHT OINT. (G) 0.00000 0.91000 12/14/2012LANSOPRAZOLE 15 MG CAPSULE DR 0.49988 0.50161 8/30/2013LANSOPRAZOLE 30 MG CAPSULE DR 0.00000 1.19770 3/8/2013LANSOPRAZOLE/AMOXICILN/CLARITH 30-500-500 COMBO. PKG 0.00000 3.59300 9/27/2013LATANOPROST 0.005 % DROPS 0.00000 3.52733 8/16/2013LEFLUNOMIDE 10 MG TABLET 0.00000 0.68509 5/17/2013LEFLUNOMIDE 20 MG TABLET 0.70792 0.70790 1/25/2013LETROZOLE 2.5 MG TABLET 0.00000 0.15182 12/14/2012LEUCOVORIN CALCIUM 10 MG TABLET 0.00000 5.25150 1/25/2013LEUCOVORIN CALCIUM 10 MG/ML VIAL 0.00000 0.29460 1/25/2013LEUCOVORIN CALCIUM 15 MG TABLET 0.00000 5.85368 12/14/2012LEUCOVORIN CALCIUM 200 MG VIAL 18.73200 19.65600 10/11/2013LEUCOVORIN CALCIUM 25 MG TABLET 0.00000 7.83744 5/17/2013LEUCOVORIN CALCIUM 5 MG TABLET 0.00000 0.89690 8/16/2013LEUCOVORIN CALCIUM 50 MG VIAL 6.93000 5.85200 10/11/2013LEUCOVORIN CALCIUM 500 MG VIAL 0.00000 99.22500 12/14/2012LEUCOVORIN CALCIUM 500MG/50ML VIAL 0.00000 1.29948 12/14/2012LEUPROLIDE ACETATE 1MG/0.2ML KIT 0.00000 231.00000 2/15/2013LEVALBUTEROL HCL 0.31MG/3ML VIAL-NEB 0.00000 1.22344 4/19/2013LEVALBUTEROL HCL 0.63MG/3ML VIAL-NEB 0.00000 1.43806 8/30/2013LEVALBUTEROL HCL 1.25MG/0.5 VIAL-NEB 0.00000 4.68950 2/1/2013LEVALBUTEROL HCL 1.25MG/3ML VIAL-NEB 0.00000 1.39870 10/11/2013LEVETIRACETAM 100 MG/ML SOLUTION 0.06070 0.06076 6/14/2013LEVETIRACETAM 1000 MG TABLET 0.00000 0.32606 10/4/2013LEVETIRACETAM 250 MG TABLET 0.09900 0.09903 8/9/2013LEVETIRACETAM 500 MG TAB ER 24H 0.00000 0.39021 12/14/2012LEVETIRACETAM 500 MG TABLET 0.00000 0.16785 7/19/2013LEVETIRACETAM 500 MG/5ML SOLUTION 1.06820 1.06824 3/22/2013LEVETIRACETAM 500 MG/5ML VIAL 1.65800 1.65798 3/8/2013LEVETIRACETAM 750 MG TAB ER 24H 0.00000 0.59674 8/9/2013LEVETIRACETAM 750 MG TABLET 0.00000 0.23238 6/14/2013LEVETIRACETAM IN NACL (ISO-OS) 1000MG/100 PIGGYBACK 0.00000 0.59877 12/14/2012LEVETIRACETAM IN NACL (ISO-OS) 1500MG/100 PIGGYBACK 0.00000 0.77967 12/14/2012LEVETIRACETAM IN NACL (ISO-OS) 500MG/0.1L PIGGYBACK 0.00000 0.36284 12/14/2012LEVOBUNOLOL HCL 0.25 % DROPS 0.00000 1.24280 12/14/2012LEVOBUNOLOL HCL 0.5 % DROPS 0.00000 3.38520 4/5/2013LEVOCARNITINE (WITH SUGAR) 100 MG/ML SOLUTION 0.00000 0.17272 8/30/2013LEVOCARNITINE 330 MG TABLET 0.00000 0.60260 1/25/2013LEVOCARNITINE 500 MG TABLET 0.20201 0.21788 8/2/2013LEVOCETIRIZINE DIHYDROCHLORIDE 2.5 MG/5ML SOLUTION 0.00000 0.43653 12/14/2012LEVOCETIRIZINE DIHYDROCHLORIDE 5 MG TABLET 0.22244 0.22259 7/19/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

LEVOFLOXACIN 0.5 % DROPS 0.00000 7.88880 12/14/2012LEVOFLOXACIN 25 MG/ML VIAL 0.67200 0.71288 3/15/2013LEVOFLOXACIN 250 MG TABLET 0.14770 0.14767 4/12/2013LEVOFLOXACIN 250MG/10ML SOLUTION 0.88710 0.88900 8/2/2013LEVOFLOXACIN 500 MG TABLET 0.29530 0.29534 3/1/2013LEVOFLOXACIN 750 MG TABLET 0.00000 0.80941 10/11/2013LEVOFLOXACIN/D5W 250MG/50ML PIGGYBACK 0.11530 0.11656 8/2/2013LEVOFLOXACIN/D5W 500MG/0.1L PIGGYBACK 0.10563 0.10794 8/2/2013LEVOFLOXACIN/D5W 750MG/.15L PIGGYBACK 0.05200 0.05398 8/2/2013LEVOMEFOLATE CALCIUM 15 MG TABLET 0.00000 2.02070 1/25/2013LEVOMEFOLATE CALCIUM 7.5 MG TABLET 0.00000 2.02070 12/14/2012LEVONORGESTREL 0.75 MG TABLET 0.00000 12.79600 12/14/2012LEVONORGESTREL 1.5 MG TABLET 32.20550 27.30000 8/30/2013LEVONORGESTREL-ETH ESTRADIOL 0.1-0.02 TABLET 0.00000 0.67330 5/17/2013LEVONORGESTREL-ETH ESTRADIOL 0.15-0.03 TABLET 0.77320 0.77319 7/26/2013LEVONORGESTREL-ETH ESTRADIOL 0.15-0.03 TBDSPK 3MO 0.00000 1.11998 8/30/2013LEVONORGESTREL-ETH ESTRADIOL 6-5-10 TABLET 0.68717 0.68718 9/20/2013LEVORPHANOL TARTRATE 2 MG TABLET 0.00000 1.12600 1/25/2013LEVOTHYROXINE SODIUM 100 MCG TABLET 0.00000 0.30285 9/27/2013LEVOTHYROXINE SODIUM 100 MCG VIAL 0.00000 111.63600 12/14/2012LEVOTHYROXINE SODIUM 112 MCG TABLET 0.00000 0.35042 9/27/2013LEVOTHYROXINE SODIUM 125 MCG TABLET 0.00000 0.35530 9/27/2013LEVOTHYROXINE SODIUM 137 MCG TABLET 0.00000 0.36020 9/27/2013LEVOTHYROXINE SODIUM 150 MCG TABLET 0.00000 0.36558 9/27/2013LEVOTHYROXINE SODIUM 175MCG TABLET 0.00000 0.43460 9/27/2013LEVOTHYROXINE SODIUM 200 MCG TABLET 0.00000 0.43551 9/27/2013LEVOTHYROXINE SODIUM 25 MCG TABLET 0.00000 0.23563 9/27/2013LEVOTHYROXINE SODIUM 300 MCG TABLET 0.00000 0.58580 9/27/2013LEVOTHYROXINE SODIUM 50 MCG TABLET 0.00000 0.26733 9/27/2013LEVOTHYROXINE SODIUM 500 MCG VIAL 0.00000 44.60050 12/14/2012LEVOTHYROXINE SODIUM 75 MCG TABLET 0.00000 0.29548 9/27/2013LEVOTHYROXINE SODIUM 88 MCG TABLET 0.00000 0.30072 9/27/2013LIDOCAINE 5 % CREAM (G) 0.00000 1.01056 12/14/2012LIDOCAINE 5 % OINT. (G) 1.38446 1.38450 4/5/2013LIDOCAINE 5%(700MG) ADH. PATCH 0.00000 9.17627 9/27/2013LIDOCAINE HCL 2 % JEL (ML) 0.00000 0.29181 7/5/2013LIDOCAINE HCL 2 % JEL/PF APP 0.00000 0.49084 5/3/2013LIDOCAINE HCL 20 MG/ML SOLUTION 0.00000 0.02399 5/24/2013LIDOCAINE HCL 20 MG/ML VIAL 0.00000 0.06084 12/14/2012LIDOCAINE HCL 4 % SOLUTION 0.00000 1.05248 12/14/2012LIDOCAINE HCL 40 MG/ML SOLUTION 0.00000 0.07497 3/1/2013LIDOCAINE HCL/D5W/PF 4 MG/ML IV SOLN 0.00000 0.01280 1/25/2013LIDOCAINE HCL/D5W/PF 8 MG/ML IV SOLN 0.00000 0.02029 12/14/2012LIDOCAINE HCL/D7.5W/PF 5 % AMPUL 0.00000 6.05930 1/25/2013LIDOCAINE HCL/EPINEPHRINE 1%-1:100K VIAL 0.00000 0.06995 12/14/2012LIDOCAINE HCL/EPINEPHRINE 2 %-1:100K VIAL 0.00000 0.07910 1/25/2013LIDOCAINE HCL/EPINEPHRINE BIT 2 %-1:100K CARTRIDGE 0.00000 0.14933 12/14/2012LIDOCAINE HCL/EPINEPHRINE BIT 2%-1:50000 CARTRIDGE 0.00000 0.14933 12/14/2012LIDOCAINE HCL/EPINEPHRINE/PF 2%-1:200K VIAL 0.00000 0.35740 1/25/2013LIDOCAINE HCL/PF 10 MG/ML AMPUL 0.00000 0.35750 1/25/2013LIDOCAINE HCL/PF 100 MG/5ML DISP SYRIN 0.00000 0.66080 1/25/2013LIDOCAINE HCL/PF 15 MG/ML AMPUL 0.00000 0.66715 12/14/2012LIDOCAINE HCL/PF 20 MG/ML VIAL INJ 0.00000 0.34100 1/25/2013LIDOCAINE HCL/PF 20 MG/ML VIAL IV 0.00000 0.28224 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

LIDOCAINE HCL/PF 40 MG/ML AMPUL 0.00000 0.56780 1/25/2013LIDOCAINE HCL/PF 5 MG/ML VIAL 0.00000 0.11002 12/14/2012LIDOCAINE HCL/PF 50 MG/5 ML DISP SYRIN 0.00000 0.88790 1/25/2013LIDOCAINE/PRILOCAINE 2.5 %-2.5% CREAM (G) 0.00000 0.41718 10/11/2013LIDOCAINE/PRILOCAINE 2.5 %-2.5% KIT 0.00000 1.40764 12/14/2012LINDANE 1 % LOTION 0.00000 1.59670 2/8/2013LINDANE 1 % SHAMPOO 0.00000 1.59670 2/8/2013LIOTHYRONINE SODIUM 25 MCG TABLET 0.00000 0.58286 8/30/2013LIOTHYRONINE SODIUM 5 MCG TABLET 0.00000 0.49553 8/30/2013LIOTHYRONINE SODIUM 50 MCG TABLET 0.00000 1.04708 8/30/2013LISINOPRIL 10 MG TABLET 0.00000 0.02112 5/3/2013LISINOPRIL 2.5 MG TABLET 0.01809 0.01793 8/16/2013LISINOPRIL 20 MG TABLET 0.00000 0.03329 10/4/2013LISINOPRIL 30 MG TABLET 0.09045 0.09246 8/23/2013LISINOPRIL 40 MG TABLET 0.00000 0.06821 10/4/2013LISINOPRIL 5 MG TABLET 0.00000 0.01943 10/4/2013LISINOPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.03162 0.03157 7/26/2013LISINOPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.00000 0.04135 5/24/2013LISINOPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.05079 0.05076 7/26/2013LITHIUM CARBONATE 150 MG CAPSULE 0.00000 0.06553 10/4/2013LITHIUM CARBONATE 300 MG CAPSULE 0.00000 0.03216 5/17/2013LITHIUM CARBONATE 300 MG TABLET 0.00000 0.14910 1/25/2013LITHIUM CARBONATE 300 MG TABLET ER 0.00000 0.23699 10/11/2013LITHIUM CARBONATE 450 MG TABLET ER 0.26780 0.26764 4/19/2013LITHIUM CARBONATE 600 MG CAPSULE 0.00000 0.12860 1/25/2013LITHIUM CITRATE 8 MEQ/5 ML SOLUTION 0.00000 0.03921 12/14/2012LOPERAMIDE HCL 1MG/7.5ML LIQUID 0.02830 0.02772 2/15/2013LOPERAMIDE HCL 2 MG CAPSULE 0.00000 0.15512 8/16/2013LOPERAMIDE HCL 2 MG TABLET 0.08951 0.08953 4/19/2013LORATADINE 10 MG TAB RAPDIS 0.00000 0.38100 12/1/2012LORATADINE 10 MG TABLET 0.05132 0.05136 4/19/2013LORATADINE 5 MG/5 ML SOLUTION 0.00000 0.04500 5/17/2013LORATADINE/PSEUDOEPHEDRINE 10MG-240MG TAB ER 24H 0.00000 0.61293 8/30/2013LORAZEPAM 0.5 MG TABLET 0.00000 0.02718 5/24/2013LORAZEPAM 1 MG TABLET 0.00000 0.02921 5/17/2013LORAZEPAM 2 MG TABLET 0.00000 0.04875 7/26/2013LORAZEPAM 2 MG/ML DISP SYRIN 0.00000 1.76400 2/15/2013LORAZEPAM 2 MG/ML ORAL CONC 0.00000 0.98130 5/10/2013LORAZEPAM 2 MG/ML VIAL 0.00000 0.63000 3/1/2013LORAZEPAM 4 MG/ML DISP SYRIN 0.00000 2.46960 1/25/2013LORAZEPAM 4 MG/ML VIAL 0.00000 1.14324 12/14/2012LOSARTAN POTASSIUM 100 MG TABLET 0.00000 0.09759 10/4/2013LOSARTAN POTASSIUM 25 MG TABLET 0.00000 0.05289 10/4/2013LOSARTAN POTASSIUM 50 MG TABLET 0.00000 0.06700 9/13/2013LOSARTAN/HYDROCHLOROTHIAZIDE 100-12.5MG TABLET 0.11202 0.11197 4/26/2013LOSARTAN/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET 0.10180 0.10184 4/5/2013LOSARTAN/HYDROCHLOROTHIAZIDE 50-12.5 MG TABLET 0.00000 0.07450 1/25/2013LOVASTATIN 10 MG TABLET 0.00000 0.09447 3/15/2013LOVASTATIN 20 MG TABLET 0.00000 0.09759 4/26/2013LOVASTATIN 40 MG TABLET 0.00000 0.10910 5/24/2013LOXAPINE SUCCINATE 10 MG CAPSULE 0.00000 0.52984 8/16/2013LOXAPINE SUCCINATE 25 MG CAPSULE 0.00000 0.76755 8/16/2013LOXAPINE SUCCINATE 5 MG CAPSULE 0.00000 0.37150 1/25/2013LOXAPINE SUCCINATE 50 MG CAPSULE 0.00000 0.99683 8/16/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

MAFENIDE ACETATE 50 G PACKET 0.00000 112.55160 4/19/2013MAG CARB/AL HYDROX/ALGINIC AC 358-95/15 ORAL SUSP 0.00000 0.01253 12/14/2012MAG HYDROX/AL HYDROX/SIMETH 200-200-20 ORAL SUSP 0.00000 0.00590 12/14/2012MAG HYDROX/AL HYDROX/SIMETH 200-200-25 TAB CHEW 0.00000 0.03029 12/14/2012MAG HYDROX/AL HYDROX/SIMETH 400-400-40 ORAL SUSP 0.00000 0.00735 12/14/2012MAGNESIUM CHLORIDE 64 MG TABLET ER 0.00000 0.08364 12/14/2012MAGNESIUM HYDROXIDE 400 MG/5ML ORAL SUSP 0.00000 0.00415 3/15/2013MAGNESIUM OXIDE 400 MG CAPSULE 0.00000 0.08450 1/25/2013MAGNESIUM OXIDE 400 MG TABLET 0.02910 0.02908 3/8/2013MAGNESIUM SULFATE 2 G/50 ML PIGGYBACK 0.00000 0.24560 1/25/2013MAGNESIUM SULFATE 20 G/500ML IV SOLN 0.00000 0.01970 1/25/2013MAGNESIUM SULFATE 4 G/100 ML PIGGYBACK 0.00000 0.11860 1/25/2013MAGNESIUM SULFATE 4 G/50 ML PIGGYBACK 0.00000 0.23100 1/25/2013MAGNESIUM SULFATE 4 MEQ/ML DISP SYRIN 0.00000 0.63168 12/14/2012MAGNESIUM SULFATE 40G/1000ML IV SOLN 0.00000 0.01440 1/25/2013MAGNESIUM SULFATE/D5W 1 G/100 ML PIGGYBACK 0.00000 0.11630 1/25/2013MALATHION 0.5 % LOTION 0.00000 2.15921 2/15/2013MANGANESE CHLORIDE 0.1 MG/ML VIAL 0.00000 0.17390 1/25/2013MANGANESE SULFATE 0.1 MG/ML VIAL 0.00000 0.21874 12/14/2012MANNITOL 10 % IV SOLN 0.00000 0.01620 1/25/2013MANNITOL 20 % IV SOLN 0.00000 0.03980 12/14/2012MANNITOL 5 % IV SOLN 0.00000 0.00866 12/14/2012MANNITOL/SORBITOL SOLUTION 0.54G-2.7G IRRIG SOLN 0.00000 0.00569 12/14/2012MAPROTILINE HCL 25 MG TABLET 0.00000 0.59890 1/25/2013MAPROTILINE HCL 50 MG TABLET 0.00000 0.93980 2/8/2013MAPROTILINE HCL 75 MG TABLET 0.00000 1.28950 1/25/2013MECLIZINE HCL 12.5 MG TABLET 0.03140 0.03139 5/10/2013MECLIZINE HCL 25 MG TABLET 0.00000 0.28090 12/21/2012MECLOFENAMATE SODIUM 100 MG CAPSULE 0.00000 3.34760 1/25/2013MECLOFENAMATE SODIUM 50 MG CAPSULE 0.00000 1.91160 1/25/2013MEDROXYPROGESTERONE ACETATE 10 MG TABLET 0.00000 0.12690 12/1/2012MEDROXYPROGESTERONE ACETATE 2.5 MG TABLET 0.00000 0.06140 1/25/2013MEDROXYPROGESTERONE ACETATE 5 MG TABLET 0.00000 0.08240 1/25/2013MEFENAMIC ACID 250 MG CAPSULE 0.00000 10.93970 1/25/2013MEFLOQUINE HCL 250 MG TABLET 0.00000 3.74400 4/5/2013MEGESTROL ACETATE 20 MG TABLET 0.00000 0.15410 8/16/2013MEGESTROL ACETATE 40 MG TABLET 0.00000 0.19480 1/25/2013MEGESTROL ACETATE 400MG/10ML (10 ML) ORAL SUSP 0.00000 0.31675 4/26/2013MEGESTROL ACETATE 400MG/10ML (40 MG/ML) ORAL SUSP 0.00000 0.08509 8/30/2013MELATONIN 3 MG TABLET ER 0.00000 0.06370 12/14/2012MELOXICAM 15 MG TABLET 0.00000 0.03190 4/12/2013MELOXICAM 7.5 MG TABLET 0.00000 0.02541 8/30/2013MELOXICAM 7.5 MG/5ML ORAL SUSP 0.00000 1.21065 3/15/2013MENTHOL 10 % GEL (GRAM) 0.00000 0.11397 12/14/2012MENTHOL 3.5 % GEL (GRAM) 0.00000 0.10042 12/14/2012MENTHOL 8 MG LOZENGE 0.00000 0.06420 1/25/2013MEPERIDINE HCL 10 MG/ML CARTRIDGE 0.00000 0.49911 12/14/2012MEPERIDINE HCL 100 MG TABLET 0.00000 0.32670 2/15/2013MEPERIDINE HCL 50 MG TABLET 0.00000 0.20435 12/14/2012MEPERIDINE HCL 50 MG/5 ML SOLUTION 0.00000 0.14191 12/14/2012MEPERIDINE HCL/PF 100 MG/ML VIAL 0.00000 2.35200 12/14/2012MEPERIDINE HCL/PF 25 MG/ML VIAL 0.00000 2.12100 12/14/2012MEPERIDINE HCL/PF 50 MG/ML VIAL 0.00000 0.94080 12/14/2012MEPIVACAINE HCL/PF 30 MG/ML CARTRIDGE 0.00000 0.17730 1/25/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

MEPROBAMATE 200 MG TABLET 0.00000 1.83178 6/7/2013MEPROBAMATE 400 MG TABLET 0.00000 0.98070 1/25/2013MERCAPTOPURINE 50 MG TABLET 0.00000 1.91920 12/1/2012MEROPENEM 1 G VIAL 0.00000 8.99640 4/26/2013MEROPENEM 500 MG VIAL 0.00000 4.50240 2/15/2013MESALAMINE 4G/60ML ENEMA 0.00000 0.22922 7/5/2013MESALAMINE W/CLEANSING WIPES 4G/60ML KIT 0.00000 0.29920 12/14/2012METAPROTERENOL SULFATE 10 MG TABLET 0.00000 0.69965 12/14/2012METAPROTERENOL SULFATE 10 MG/5 ML SYRUP 0.00000 0.02460 1/25/2013METAPROTERENOL SULFATE 20 MG TABLET 0.00000 0.97496 12/14/2012METAXALONE 800 MG TABLET 0.00000 3.42370 1/25/2013METFORMIN HCL 1000 MG TAB ER 24 0.00000 7.32690 2/1/2013METFORMIN HCL 1000 MG TABLET 0.00000 0.04406 9/20/2013METFORMIN HCL 500 MG TAB ER 24 0.00000 4.02380 2/8/2013METFORMIN HCL 500 MG TAB ER 24H 0.00000 0.04516 9/20/2013METFORMIN HCL 500 MG TABLET 0.00000 0.02720 5/17/2013METFORMIN HCL 750 MG TAB ER 24H 0.00000 0.12958 5/17/2013METFORMIN HCL 850 MG TABLET 0.04167 0.04165 4/19/2013METHADONE HCL 10 MG TABLET 0.00000 0.09816 6/28/2013METHADONE HCL 10 MG/5 ML SOLUTION 0.00000 0.20658 12/14/2012METHADONE HCL 10 MG/ML ORAL CONC 0.00000 0.62300 12/1/2012METHADONE HCL 10 MG/ML VIAL 0.00000 6.01720 12/14/2012METHADONE HCL 40 MG TABLET SOL 0.00000 0.22381 12/14/2012METHADONE HCL 5 MG TABLET 0.00000 0.06042 4/5/2013METHADONE HCL 5 MG/5 ML SOLUTION 0.00000 0.12491 12/14/2012METHAMPHETAMINE HCL 5 MG TABLET 0.00000 3.02617 12/14/2012METHAZOLAMIDE 25 MG TABLET 0.00000 0.70710 1/25/2013METHAZOLAMIDE 50 MG TABLET 0.00000 2.25672 4/12/2013METHEN/M-BLUE/SAL/NA PHOS/HYOS 120-0.12MG TABLET 0.00000 2.09160 9/27/2013METHENAMINE HIPPURATE 1 G TABLET 0.00000 1.46649 8/16/2013METHENAMINE MANDELATE 1 G TABLET 0.00000 1.08069 8/9/2013METHENAMINE MANDELATE 500 MG TABLET 0.00000 0.62041 12/14/2012METHIMAZOLE 10 MG TABLET 0.00000 0.24912 8/9/2013METHIMAZOLE 5 MG TABLET 0.15680 0.15678 6/14/2013METHOCARBAMOL 500 MG TABLET 0.00000 0.07276 5/17/2013METHOCARBAMOL 750 MG TABLET 0.00000 0.15530 12/1/2012METHOTREXATE SODIUM 2.5 MG TABLET 0.00000 2.20323 10/11/2013METHOTREXATE SODIUM 25 MG/ML VIAL 0.00000 1.65075 4/12/2013METHOTREXATE SODIUM/PF 25 MG/ML VIAL 0.00000 0.60702 4/12/2013METHSCOPOLAMINE BROMIDE 2.5 MG TABLET 0.00000 1.54629 12/14/2012METHSCOPOLAMINE BROMIDE 5 MG TABLET 0.00000 2.38030 7/5/2013METHYCLOTHIAZIDE 5 MG TABLET 0.00000 1.21660 1/25/2013METHYL SALICYLATE OIL 0.00000 0.47540 1/25/2013METHYL-B12/L-MEFOLATE/B6 PHOS 2-3-35 MG TABLET 0.00000 1.01041 12/14/2012METHYLDOPA 250 MG TABLET 0.00000 0.10117 5/17/2013METHYLDOPA 500 MG TABLET 0.17650 0.17648 3/1/2013METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-15MG TABLET 0.00000 0.67180 1/25/2013METHYLDOPA/HYDROCHLOROTHIAZIDE 250MG-25MG TABLET 0.00000 0.79160 1/25/2013METHYLENE BLUE 1 % AMPUL 0.00000 2.76330 1/25/2013METHYLERGONOVINE MALEATE .2MG/ML(1) AMPUL 4.35610 4.75860 8/30/2013METHYLERGONOVINE MALEATE .2MG/ML(1) VIAL 0.00000 6.39450 12/14/2012METHYLERGONOVINE MALEATE 0.2 MG TABLET 0.00000 12.68875 8/30/2013METHYLPHENIDATE HCL 10 MG CPMP 30-70 0.00000 4.03956 4/5/2013METHYLPHENIDATE HCL 10 MG TABLET ER 0.00000 1.20337 7/5/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

METHYLPHENIDATE HCL 10 MG/5 ML SOLUTION 0.00000 1.91621 12/14/2012METHYLPHENIDATE HCL 18 MG TAB ER 24 0.00000 4.35526 3/15/2013METHYLPHENIDATE HCL 20 MG CPMP 30-70 0.00000 4.02091 5/3/2013METHYLPHENIDATE HCL 20 MG TABLET 0.00000 1.19790 9/13/2013METHYLPHENIDATE HCL 27 MG TAB ER 24 4.46446 4.46450 7/19/2013METHYLPHENIDATE HCL 30 MG CPMP 30-70 0.00000 4.00177 7/5/2013METHYLPHENIDATE HCL 36 MG TAB ER 24 0.00000 4.60502 12/14/2012METHYLPHENIDATE HCL 40 MG CPMP 30-70 0.00000 5.14002 5/31/2013METHYLPHENIDATE HCL 5 MG/5 ML SOLUTION 0.00000 1.34413 12/14/2012METHYLPHENIDATE HCL 50 MG CPMP 30-70 0.00000 6.70877 2/22/2013METHYLPHENIDATE HCL 54 MG TAB ER 24 0.00000 5.01081 12/14/2012METHYLPHENIDATE HCL 60 MG CPMP 30-70 0.00000 6.76633 5/3/2013METHYLPREDNISOLONE 16 MG TABLET 0.00000 2.17406 12/14/2012METHYLPREDNISOLONE 32 MG TABLET 0.00000 3.23736 12/14/2012METHYLPREDNISOLONE 4 MG TAB DS PK 0.00000 1.00070 2/8/2013METHYLPREDNISOLONE 4 MG TABLET 0.00000 1.24060 12/1/2012METHYLPREDNISOLONE 8 MG TABLET 0.00000 1.40728 12/14/2012METHYLPREDNISOLONE ACETATE 40 MG/ML VIAL 3.04720 3.47672 6/7/2013METHYLPREDNISOLONE ACETATE 80 MG/ML VIAL 6.81700 7.07957 7/19/2013METHYLPREDNISOLONE SOD SUCC 1000 MG VIAL 0.00000 17.05200 12/14/2012METHYLPREDNISOLONE SOD SUCC 125 MG VIAL 0.00000 4.08408 12/14/2012METHYLPREDNISOLONE SOD SUCC 40 MG VIAL 0.00000 3.53132 12/14/2012METIPRANOLOL 0.3 % DROPS 0.00000 2.91720 12/14/2012METOCLOPRAMIDE HCL 10 MG TABLET 0.00000 0.04228 9/27/2013METOCLOPRAMIDE HCL 10 MG/10ML SOLUTION 0.01351 0.04456 8/9/2013METOCLOPRAMIDE HCL 10 MG/2 ML DISP SYRIN 0.38640 0.66573 5/24/2013METOCLOPRAMIDE HCL 5 MG TABLET 0.04250 0.04248 4/26/2013METOCLOPRAMIDE HCL 5 MG/5 ML SOLUTION 0.00000 0.01351 5/17/2013METOLAZONE 10 MG TABLET 0.00000 0.84230 5/17/2013METOLAZONE 2.5 MG TABLET 0.00000 0.48610 5/17/2013METOLAZONE 5 MG TABLET 0.00000 0.55250 5/17/2013METOPROLOL SUCCINATE 100 MG TAB ER 24H 0.00000 0.90700 12/1/2012METOPROLOL SUCCINATE 200 MG TAB ER 24H 0.00000 1.80192 4/26/2013METOPROLOL SUCCINATE 25 MG TAB ER 24H 0.00000 0.45399 10/11/2013METOPROLOL SUCCINATE 50 MG TAB ER 24H 0.00000 0.73441 10/4/2013METOPROLOL TARTRATE 100 MG TABLET 0.00000 0.03109 6/14/2013METOPROLOL TARTRATE 25 MG TABLET 0.00000 0.02203 4/19/2013METOPROLOL TARTRATE 5 MG/5 ML AMPUL 0.00000 0.23020 1/25/2013METOPROLOL TARTRATE 5 MG/5 ML DISP SYRIN 0.00000 0.70560 1/25/2013METOPROLOL TARTRATE 50 MG TABLET 0.00000 0.02034 7/12/2013METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-25MG TABLET 0.00000 1.46036 7/26/2013METOPROLOL/HYDROCHLOROTHIAZIDE 100MG-50MG TABLET 0.00000 1.53410 2/8/2013METOPROLOL/HYDROCHLOROTHIAZIDE 50 MG-25MG TABLET 0.00000 0.92755 7/26/2013METRONIDAZOLE 0.75 % CREAM (G) 0.00000 2.72580 12/1/2012METRONIDAZOLE 0.75 % GEL (GRAM) 0.00000 2.65770 8/3/2012METRONIDAZOLE 0.75 % GEL W/APPL 0.00000 0.41004 12/14/2012METRONIDAZOLE 0.75 % LOTION 0.00000 2.93220 12/1/2012METRONIDAZOLE 250 MG TABLET 0.00000 0.30300 12/1/2012METRONIDAZOLE 500 MG TABLET 0.50366 0.50310 5/17/2013METRONIDAZOLE/SODIUM CHLORIDE 500MG/0.1L PIGGYBACK 0.00000 0.01400 4/5/2013MEXILETINE HCL 150 MG CAPSULE 0.29170 0.29172 8/9/2013MEXILETINE HCL 200 MG CAPSULE 0.40240 0.40235 8/9/2013MEXILETINE HCL 250 MG CAPSULE 0.48190 0.48191 8/9/2013MICONAZOLE NITRATE 100 MG SUPP.VAG 0.00000 0.44030 12/21/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

MICONAZOLE NITRATE 2 % CREAM (G) 0.00000 0.05700 4/19/2013MICONAZOLE NITRATE 2 % CREAM/APPL 0.09070 0.08640 5/10/2013MICONAZOLE NITRATE 2 % OINT. (G) 0.00000 0.08500 1/25/2013MICONAZOLE NITRATE 2 % TINCTURE 0.00000 0.39340 1/25/2013MICONAZOLE NITRATE 200 MG SUPP.VAG 0.00000 12.26633 12/14/2012MICONAZOLE NITRATE 200 MG-2 % KIT 0.00000 1.21793 12/14/2012MIDODRINE HCL 10 MG TABLET 0.00000 0.93010 1/25/2013MIDODRINE HCL 2.5 MG TABLET 0.00000 0.30992 5/17/2013MIDODRINE HCL 5 MG TABLET 0.00000 0.60470 2/8/2013MILRINONE LACTATE 1 MG/ML VIAL 0.00000 0.46056 12/14/2012MILRINONE LACTATE/D5W 20MG/100ML PIGGYBACK 0.00000 0.13280 1/25/2013MILRINONE LACTATE/D5W 40MG/200ML PIGGYBACK 0.00000 0.12430 1/25/2013MINERAL OIL LOTION 0.00480 0.01828 6/28/2013MINERAL OIL/PETROLATUM,WHITE 15 %-83 % OINT. (G) 0.00000 0.81740 1/25/2013MINERAL OIL/PETROLATUM,WHITE 15%-85% OINT. (G) 0.00000 4.48140 1/25/2013MINOCYCLINE HCL 100 MG CAPSULE 0.00000 0.28748 5/17/2013MINOCYCLINE HCL 100 MG TABLET 0.00000 2.40266 3/15/2013MINOCYCLINE HCL 135 MG TAB ER 24H 0.00000 3.56811 12/14/2012MINOCYCLINE HCL 45 MG TAB ER 24H 0.00000 3.56811 12/14/2012MINOCYCLINE HCL 50 MG CAPSULE 0.13594 0.13579 10/11/2013MINOCYCLINE HCL 50 MG TABLET 0.00000 1.44008 12/14/2012MINOCYCLINE HCL 75 MG CAPSULE 0.31020 0.31018 6/28/2013MINOCYCLINE HCL 75 MG TABLET 0.00000 1.69228 12/14/2012MINOCYCLINE HCL 90 MG TAB ER 24H 0.00000 3.56811 12/14/2012MINOXIDIL 10 MG TABLET 0.29735 0.29164 10/11/2013MINOXIDIL 2.5 MG TABLET 0.16710 0.16817 10/11/2013MIRTAZAPINE 15 MG TAB RAPDIS 0.00000 0.78702 10/11/2013MIRTAZAPINE 15 MG TABLET 0.00000 0.09156 7/12/2013MIRTAZAPINE 30 MG TAB RAPDIS 0.00000 0.79774 7/12/2013MIRTAZAPINE 30 MG TABLET 0.00000 0.13490 7/12/2013MIRTAZAPINE 45 MG TAB RAPDIS 0.00000 1.06427 2/22/2013MIRTAZAPINE 45 MG TABLET 0.00000 0.21614 3/15/2013MIRTAZAPINE 7.5 MG TABLET 0.00000 0.05985 3/1/2013MISOPROSTOL 100 MCG TABLET 0.56268 0.56252 7/26/2013MITOMYCIN 40 MG VIAL 0.00000 235.39125 12/14/2012MODAFINIL 100 MG TABLET 0.00000 11.07884 8/16/2013MODAFINIL 200 MG TABLET 0.00000 19.24640 3/22/2013MOEXIPRIL HCL 15 MG TABLET 0.00000 0.37580 2/8/2013MOEXIPRIL HCL 7.5 MG TABLET 0.00000 0.37580 1/25/2013MOEXIPRIL/HYDROCHLOROTHIAZIDE 15-12.5MG TABLET 0.00000 0.51310 1/25/2013MOEXIPRIL/HYDROCHLOROTHIAZIDE 15-25MG TABLET 0.00000 0.37076 12/14/2012MOEXIPRIL/HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET 0.00000 0.50960 12/14/2012MOLYBDENUM(AMMONIUM MOLYBDATE) 25 MCG/ML VIAL 0.00000 0.32672 12/14/2012MOMETASONE FUROATE 0.1 % CREAM (G) 0.00000 0.36894 7/19/2013MOMETASONE FUROATE 0.1 % OINT. (G) 0.00000 0.26293 7/19/2013MOMETASONE FUROATE 0.1 % SOLUTION 0.00000 0.22914 8/2/2013MONTELUKAST SODIUM 10 MG TABLET 0.00000 0.61330 8/17/2012MONTELUKAST SODIUM 4 MG TAB CHEW 0.00000 0.61330 8/17/2012MONTELUKAST SODIUM 5 MG TAB CHEW 0.00000 0.61330 8/17/2012MORPHINE SULFATE 10 MG CAP ER PEL 3.62712 3.31248 10/4/2013MORPHINE SULFATE 10 MG SUPP.RECT 0.00000 3.85880 1/25/2013MORPHINE SULFATE 10 MG/5 ML SOLUTION 0.00000 0.06164 12/14/2012MORPHINE SULFATE 10 MG/ML CARTRIDGE 0.00000 3.25500 1/25/2013MORPHINE SULFATE 10 MG/ML VIAL 0.00000 0.74480 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

MORPHINE SULFATE 100 MG CAP ER PEL 13.29374 13.29147 8/30/2013MORPHINE SULFATE 100 MG TABLET ER 0.00000 3.60620 10/11/2013MORPHINE SULFATE 100 MG/4ML VIAL PORT 0.00000 4.96650 1/25/2013MORPHINE SULFATE 100 MG/5ML SOLUTION 0.00000 0.29011 12/14/2012MORPHINE SULFATE 15 MG TABLET 0.00000 0.08606 2/22/2013MORPHINE SULFATE 15 MG TABLET ER 0.00000 0.62553 10/11/2013MORPHINE SULFATE 15 MG/ML CARTRIDGE 0.00000 3.25500 1/25/2013MORPHINE SULFATE 15 MG/ML VIAL 0.00000 0.69440 1/25/2013MORPHINE SULFATE 2 MG/ML CARTRIDGE 0.00000 3.25500 1/25/2013MORPHINE SULFATE 20 MG CAP ER PEL 3.65672 3.65617 8/16/2013MORPHINE SULFATE 20 MG SUPP.RECT 0.00000 5.25000 12/14/2012MORPHINE SULFATE 20 MG/5 ML SOLUTION 0.00000 0.09460 3/1/2013MORPHINE SULFATE 200 MG TABLET ER 0.00000 6.25263 10/11/2013MORPHINE SULFATE 25 MG/ML VIAL 0.00000 1.33770 7/26/2013MORPHINE SULFATE 250MG/10ML VIAL PORT 0.00000 1.99080 1/25/2013MORPHINE SULFATE 30 MG CAP ER PEL 0.00000 3.97649 12/14/2012MORPHINE SULFATE 30 MG SUPP.RECT 0.00000 6.56250 12/14/2012MORPHINE SULFATE 30 MG TABLET 0.00000 0.12130 2/8/2013MORPHINE SULFATE 30 MG TABLET ER 0.00000 0.32428 8/30/2013MORPHINE SULFATE 30 MG/30ML PCA SYRING 0.00000 0.43749 2/15/2013MORPHINE SULFATE 4 MG/ML CARTRIDGE 0.00000 3.25500 1/25/2013MORPHINE SULFATE 5 MG SUPP.RECT 0.00000 3.50000 12/14/2012MORPHINE SULFATE 5 MG/ML VIAL 0.00000 0.83160 12/14/2012MORPHINE SULFATE 50 MG CAP ER PEL 0.00000 6.64531 12/14/2012MORPHINE SULFATE 50 MG/ML VIAL 0.00000 0.87665 3/29/2013MORPHINE SULFATE 60 MG CAP ER PEL 7.95280 7.95284 3/15/2013MORPHINE SULFATE 60 MG TABLET ER 0.00000 2.31330 10/11/2013MORPHINE SULFATE 8 MG/ML CARTRIDGE 0.00000 2.98200 12/14/2012MORPHINE SULFATE 8 MG/ML VIAL 0.00000 0.94080 12/14/2012MORPHINE SULFATE 80 MG CAP ER PEL 10.60283 11.11482 8/16/2013MORPHINE SULFATE/PF 0.5 MG/ML AMPUL 0.00000 2.23713 12/14/2012MORPHINE SULFATE/PF 0.5 MG/ML VIAL 0.00000 0.42080 1/25/2013MORPHINE SULFATE/PF 1 MG/ML AMPUL 0.00000 3.80940 12/14/2012MORPHINE SULFATE/PF 1 MG/ML VIAL 0.00000 0.41240 1/25/2013MORPHINE SULFATE/PF 150MG/30ML PCA VIAL 0.00000 0.61320 12/14/2012MORPHINE SULFATE/PF 30 MG/30ML PCA VIAL 0.00000 0.50469 12/14/2012MTH/ME BLUE/SOD PHOS/PHEN/HYOS 81.6-10.8 TABLET 0.00000 0.91000 12/14/2012MULTIVITAMIN TABLET 0.00000 0.01474 5/10/2013MULTIVITAMIN W-MINERALS/LUTEIN TABLET 0.00000 0.04780 1/25/2013MULTIVITAMINS WITH IRON TABLET 0.01580 0.01954 8/16/2013MULTIVITAMINS WITH MIN NO.7/FA 1 MG CAPSULE 0.00000 0.17550 2/15/2013MULTIVITAMINS,THER W-MINERALS CAPSULE 0.00000 0.05780 1/25/2013MULTIVITAMINS,THERAPEUTIC TABLET 0.00000 0.02440 1/25/2013MULTIVITS W-MIN/FERROUS GLUC 9 MG/15 ML LIQUID 0.00000 0.01368 4/5/2013MULTIVITS,CA,MINERALS/IRON/FA 9MG-400MCG TABLET 0.00000 0.03497 12/14/2012MULTIVITS,STRESS FORMULA/ZINC TABLET 0.00000 0.04810 12/14/2012MULTIVITS-MIN/FA/LYCOPENE/LUT .4-300-250 TABLET 0.04527 0.05523 8/23/2013MULTIVITS-MIN/FA/LYCOPENE/LUT 500-300MCG TABLET 0.04800 0.05011 7/19/2013MULTIVITS-MINERALS/FA/LYCOPENE 0.4MG-600 TABLET 0.00000 0.04620 5/31/2013MUPIROCIN 2 % OINT. (G) 0.00000 0.47610 12/1/2012MUPIROCIN CALCIUM 2 % CREAM (G) 0.00000 3.22800 8/16/2013MV,MIN #10/FA/D3/ALIP ACID/LUT 1-1000-5 TABLET 0.00000 0.53985 6/21/2013MYCOPHENOLATE MOFETIL 250 MG CAPSULE 0.28970 0.28971 8/9/2013MYCOPHENOLATE MOFETIL 500 MG TABLET 0.00000 0.46854 9/20/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

NA PHOS,M-B/NA PHOS,DI-BA 19G-7G/118 ENEMA 0.00622 0.00578 8/30/2013NABUMETONE 500 MG TABLET 0.00000 0.25447 5/17/2013NABUMETONE 750 MG TABLET 0.00000 0.21132 3/15/2013NADOLOL 20 MG TABLET 0.00000 1.13470 2/22/2013NADOLOL 40 MG TABLET 0.00000 2.78610 8/16/2013NADOLOL/BENDROFLUMETHIAZIDE 40 MG-5 MG TABLET 0.00000 1.72368 12/14/2012NADOLOL/BENDROFLUMETHIAZIDE 80 MG-5 MG TABLET 0.00000 2.25914 12/14/2012NAFCILLIN IN DEXTROSE,ISO-OSM 1 G/50 ML FROZ.PIGGY 0.00000 0.25511 12/14/2012NAFCILLIN IN DEXTROSE,ISO-OSM 2 G/100 ML FROZ.PIGGY 0.00000 0.17407 12/14/2012NAFCILLIN SODIUM 1 G VIAL 9.54200 9.96450 4/26/2013NAFCILLIN SODIUM 1 G VIAL PORT 0.00000 12.56750 1/25/2013NAFCILLIN SODIUM 10 G VIAL 0.00000 97.14110 12/14/2012NAFCILLIN SODIUM 2 G VIAL 0.00000 19.41240 10/11/2013NAFCILLIN SODIUM 2 G VIAL PORT 0.00000 26.14500 3/29/2013NALBUPHINE HCL 10 MG/ML VIAL 0.00000 1.19280 1/25/2013NALBUPHINE HCL 20 MG/ML AMPUL 0.00000 3.45670 1/25/2013NALBUPHINE HCL 20 MG/ML VIAL 0.00000 1.70020 1/25/2013NALOXONE HCL 0.4 MG/ML DISP SYRIN 0.00000 3.15000 1/25/2013NALOXONE HCL 1 MG/ML DISP SYRIN 0.00000 7.11900 12/14/2012NALTREXONE HCL 50 MG TABLET 1.16580 1.00054 9/20/2013NAPHAZOLINE HCL 0.1 % DROPS 0.00000 0.11787 12/14/2012NAPHAZOLINE HCL/GLYCERIN 0.012-0.2% DROPS 0.00000 0.13640 1/25/2013NAPROXEN 125 MG/5ML ORAL SUSP 0.00000 0.09332 8/2/2013NAPROXEN 250 MG TABLET 0.04368 0.04355 5/31/2013NAPROXEN 375 MG TABLET 0.00000 0.05119 4/26/2013NAPROXEN 375 MG TABLET DR 0.00000 0.14755 3/1/2013NAPROXEN 500 MG TABLET 0.00000 0.06321 4/26/2013NAPROXEN 500 MG TABLET DR 0.00000 0.16965 8/16/2013NAPROXEN SODIUM 220 MG TABLET 0.05775 0.06206 6/21/2013NAPROXEN SODIUM 275 MG TABLET 0.08544 0.08189 8/16/2013NAPROXEN SODIUM 550 MG TABLET 0.00000 0.11254 5/24/2013NARATRIPTAN HCL 1 MG TABLET 0.00000 5.59223 9/13/2013NARATRIPTAN HCL 2.5 MG TABLET 0.00000 5.29830 1/25/2013NATEGLINIDE 120 MG TABLET 0.00000 0.84591 5/31/2013NATEGLINIDE 60 MG TABLET 0.00000 0.85197 5/10/2013NEFAZODONE HCL 100 MG TABLET 0.00000 0.57850 12/1/2012NEFAZODONE HCL 150 MG TABLET 0.00000 0.60800 1/25/2013NEFAZODONE HCL 200 MG TABLET 0.00000 0.63680 1/25/2013NEFAZODONE HCL 250 MG TABLET 0.66580 0.66582 8/23/2013NEFAZODONE HCL 50 MG TABLET 0.00000 0.52117 12/14/2012NEO/POLYMYX B SULF/DEXAMETH 0.1 % DROPS SUSP 3.76220 3.75440 9/6/2013NEO/POLYMYX B SULF/DEXAMETH 3.5-10K-.1 OINT. (G) 0.00000 4.73550 2/1/2013NEOMY SULF/BACITRA/POLYMYXIN B PACKET 0.00000 0.19440 1/25/2013NEOMY SULF/BACITRA/POLYMYXIN B 3.5MG-400 OINT. (G) 0.00000 8.35200 12/14/2012NEOMY SULF/BACITRAC ZN/POLY 3.5-400-5K OINT. (G) 0.00000 0.08536 1/25/2013NEOMY SULF/BACITRAC ZN/POLY/HC 3.5-10K-1 OINT. (G) 0.00000 12.81000 12/1/2012NEOMY SULF/POLYMYXIN B SULFATE 40-200K/ML AMPUL 0.00000 7.53960 4/12/2013NEOMY SULF/POLYMYXIN B SULFATE 40-200K/ML VIAL 0.00000 5.02645 12/14/2012NEOMYCIN SULFATE 500 MG TABLET 0.00000 0.90848 10/11/2013NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-1 DROPS SUSP 2.15600 2.15657 2/1/2013NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-1 SOLUTION 0.00000 1.65100 12/1/2012NEOMYCIN/POLYMYXIN B SULF/HC 3.5-10K-10 DROPS SUSP 0.00000 13.05287 3/8/2013NEOMYCIN/POLYMYXN B/GRAMICIDIN 1.75MG-10K DROPS 0.00000 4.33580 5/24/2013NEOMYCN/BACI ZN/PMYX BS/PRAMOX 3.5-10K-10 OINT. (G) 0.00000 0.16978 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

NEVIRAPINE 200 MG TABLET 0.00000 0.19200 1/25/2013NEVIRAPINE 50 MG/5 ML ORAL SUSP 0.00000 0.40225 12/14/2012NIACIN 100 MG TABLET 0.00000 0.01270 1/25/2013NIACIN 1000 MG TABLET ER 0.00000 0.05775 12/14/2012NIACIN 250 MG CAPSULE ER 0.00000 0.04147 12/14/2012NIACIN 250 MG TABLET ER 0.03660 0.03662 2/8/2013NIACIN 50 MG TABLET 0.00000 0.01274 12/14/2012NIACIN 500 MG CAPSULE ER 0.00000 0.04930 1/25/2013NIACIN 500 MG TABLET 0.00000 0.02000 1/25/2013NIACIN 500 MG TABLET ER 0.03296 0.03081 10/11/2013NIACIN 750 MG TABLET ER 0.00000 0.05020 1/25/2013NIACINAMIDE 500 MG TABLET 0.00000 0.02737 4/5/2013NICARDIPINE HCL 20 MG CAPSULE 0.00000 0.34500 2/8/2013NICARDIPINE HCL 30 MG CAPSULE 0.00000 0.35170 1/25/2013NICOTINE 14MG/24HR PATCH TD24 0.00000 1.71921 8/30/2013NICOTINE 21 MG/24HR PATCH TD24 0.00000 1.49950 8/23/2013NICOTINE 7MG/24HR PATCH TD24 0.00000 1.60985 10/11/2013NICOTINE POLACRILEX 2 MG GUM 0.00000 0.20868 8/30/2013NICOTINE POLACRILEX 4 MG GUM 0.00000 0.26813 8/30/2013NIFEDIPINE 10 MG CAPSULE 0.00000 0.82691 8/9/2013NIFEDIPINE 20 MG CAPSULE 1.61180 1.61182 8/9/2013NIFEDIPINE 30 MG TAB ER 24 0.00000 0.40522 6/14/2013NIFEDIPINE 30 MG TABLET ER 0.46632 0.46637 7/19/2013NIFEDIPINE 60 MG TAB ER 24 0.58800 0.58799 3/1/2013NIFEDIPINE 60 MG TABLET ER 0.00000 1.78434 8/9/2013NIFEDIPINE 90 MG TAB ER 24 0.00000 1.02510 8/16/2013NIFEDIPINE 90 MG TABLET ER 1.85478 1.88509 8/30/2013NIMODIPINE 30 MG CAPSULE 0.00000 6.55030 1/25/2013NISOLDIPINE 17 MG TAB ER 24H 0.00000 5.38832 12/14/2012NISOLDIPINE 20 MG TAB ER 24H 0.00000 6.85510 8/9/2013NISOLDIPINE 25.5 MG TAB ER 24H 0.00000 5.87636 12/14/2012NISOLDIPINE 30 MG TAB ER 24H 0.00000 7.05270 2/8/2013NISOLDIPINE 34 MG TAB ER 24H 0.00000 5.87636 12/14/2012NISOLDIPINE 40 MG TAB ER 24H 0.00000 6.65350 1/25/2013NISOLDIPINE 8.5MG TAB ER 24H 0.00000 4.29926 12/14/2012NITROFURANTOIN 25 MG/5 ML ORAL SUSP 0.00000 2.05244 8/30/2013NITROFURANTOIN MACROCRYSTAL 100 MG CAPSULE 0.00000 1.56470 5/17/2013NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE 0.95840 0.95835 6/14/2013NITROFURANTOIN MONOHYD/M-CRYST 100 MG CAPSULE 0.00000 2.39112 8/30/2013NITROGLYCERIN 0.1MG/HR PATCH TD24 0.00000 0.66430 1/25/2013NITROGLYCERIN 0.2MG/HR PATCH TD24 0.00000 0.61550 10/11/2013NITROGLYCERIN 0.4MG/DOSE SPRAY (AEROSOL) 0.00000 27.46701 1/4/2013NITROGLYCERIN 0.4MG/DOSE SPRAY (NON-AEROSOL) 0.00000 19.55100 7/12/2013NITROGLYCERIN 0.4MG/HR PATCH TD24 0.00000 0.67358 10/11/2013NITROGLYCERIN 0.6MG/HR PATCH TD24 0.00000 1.11309 10/11/2013NITROGLYCERIN 2.5 MG CAPSULE ER 0.00000 0.33267 5/17/2013NITROGLYCERIN 50 MG/10ML VIAL 0.00000 0.47040 12/14/2012NITROGLYCERIN 6.5 MG CAPSULE ER 0.00000 0.32960 2/15/2013NITROGLYCERIN 9 MG CAPSULE ER 0.00000 0.17330 1/25/2013NITROGLYCERIN/D5W 200MG/500 INFUS. BTL 0.00000 0.01110 1/25/2013NITROGLYCERIN/D5W 50MG/500ML INFUS. BTL 0.00000 0.02260 1/25/2013NIZATIDINE 150 MG CAPSULE 0.00000 0.27223 5/17/2013NIZATIDINE 150MG/10ML SOLUTION 0.00000 0.49300 6/28/2013NIZATIDINE 300 MG CAPSULE 0.00000 0.85582 8/30/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

NORETH A-ET ESTRA/FE FUMARATE 1.5-0.03MG TABLET 0.00000 0.72337 4/26/2013NORETH A-ET ESTRA/FE FUMARATE 1MG-20MCG TABLET 0.71640 0.71641 7/26/2013NORETH A-ET ESTRA/FE FUMARATE 5-7-9-7 TABLET 1.42880 1.42884 10/4/2013NORETH-ETHINYL ESTRADIOL/IRON 0.4-35(21) TAB CHEW 1.82948 1.82950 1/25/2013NORETHINDRONE 0.35 MG TABLET 0.00000 0.85114 8/30/2013NORETHINDRONE A-E ESTRADIOL 1.5-0.03MG TABLET 0.96454 0.96456 7/26/2013NORETHINDRONE A-E ESTRADIOL 1MG-20MCG TABLET 0.00000 0.95522 12/14/2012NORETHINDRONE ACETATE 5 MG TABLET 1.85400 1.85402 7/12/2013NORETHINDRONE-ETHINYL ESTRAD 0.4-0.035 TABLET 0.00000 0.91215 8/30/2013NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET 0.00000 0.80140 1/25/2013NORETHINDRONE-ETHINYL ESTRAD 1 MG-35MCG TABLET 0.74476 0.74378 7/12/2013NORETHINDRONE-ETHINYL ESTRAD 7 DAYS X 3 TABLET 0.81449 0.81737 7/26/2013NORETHINDRONE-ETHINYL ESTRAD 7-9-5 TABLET 0.00000 0.98375 12/14/2012NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 TABLET 0.00000 0.51223 8/30/2013NORGESTIMATE-ETHINYL ESTRADIOL 7DAYSX3 28 TABLET 0.00000 0.51223 8/30/2013NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET 0.00000 0.76300 2/8/2013NORTRIPTYLINE HCL 10 MG CAPSULE 0.09920 0.09916 3/22/2013NORTRIPTYLINE HCL 10 MG/5 ML SOLUTION 0.00000 0.20683 12/14/2012NORTRIPTYLINE HCL 25 MG CAPSULE 0.00000 0.13600 1/25/2013NORTRIPTYLINE HCL 50 MG CAPSULE 0.00000 0.16640 1/25/2013NORTRIPTYLINE HCL 75 MG CAPSULE 0.00000 0.23060 1/25/2013NYSTATIN 100000/G CREAM (G) 0.00000 0.57262 8/16/2013NYSTATIN 100000/G OINT. (G) 0.00000 0.95120 12/1/2012NYSTATIN 100000/G POWDER 0.00000 1.01120 2/1/2013NYSTATIN 10B UNIT POWDER(EA) 0.00000 ########## 12/14/2012NYSTATIN 150MM UNIT POWDER(EA) MISC (bulk) 0.00000 98.76650 1/25/2013NYSTATIN 150MM UNIT POWDER(EA) ORAL 0.00000 70.10500 12/14/2012NYSTATIN 1B UNIT POWDER(EA) 0.00000 404.56500 1/25/2013NYSTATIN 2B UNIT POWDER(EA) 0.00000 459.38450 12/14/2012NYSTATIN 500K UNIT TABLET 0.00000 0.51621 8/2/2013NYSTATIN 500MM UNIT POWDER(EA) MISC (bulk) 0.00000 156.49700 12/14/2012NYSTATIN 500MM UNIT POWDER(EA) ORAL 0.00000 203.31500 8/30/2013NYSTATIN 50MM UNIT POWDER(EA) MISC (bulk) 0.00000 47.31300 12/14/2012NYSTATIN 50MM UNIT POWDER(EA) ORAL 0.00000 3.91430 12/14/2012NYSTATIN 5B UNIT POWDER(EA) 0.00000 742.07950 12/14/2012OCTREOTIDE ACETATE 100 MCG/ML AMPUL 0.00000 5.70960 12/14/2012OCTREOTIDE ACETATE 100 MCG/ML DISP SYRIN 0.00000 10.04850 12/14/2012OCTREOTIDE ACETATE 100 MCG/ML VIAL 0.00000 5.54190 5/17/2013OCTREOTIDE ACETATE 1000MCG/ML VIAL 0.00000 30.52860 12/14/2012OCTREOTIDE ACETATE 200 MCG/ML VIAL 0.00000 7.30800 12/14/2012OCTREOTIDE ACETATE 50 MCG/ML AMPUL 0.00000 2.84310 12/14/2012OCTREOTIDE ACETATE 50 MCG/ML DISP SYRIN 0.00000 5.98920 12/14/2012OCTREOTIDE ACETATE 50 MCG/ML VIAL 0.00000 3.08850 1/25/2013OCTREOTIDE ACETATE 500 MCG/ML AMPUL 0.00000 29.90650 12/14/2012OCTREOTIDE ACETATE 500 MCG/ML DISP SYRIN 0.00000 45.22560 12/14/2012OCTREOTIDE ACETATE 500 MCG/ML VIAL 0.00000 16.18890 12/14/2012OFLOXACIN 0.3 % DROPS OPHTHALMIC 0.37252 0.38726 8/9/2013OFLOXACIN 0.3 % DROPS OTIC 0.00000 2.58116 7/12/2013OFLOXACIN 200 MG TABLET 0.00000 3.34859 12/14/2012OFLOXACIN 300 MG TABLET 0.00000 3.98503 12/14/2012OFLOXACIN 400 MG TABLET 0.00000 4.20250 1/25/2013OLANZAPINE 10 MG TAB RAPDIS 0.00000 8.72300 12/1/2012OLANZAPINE 10 MG TABLET 0.00000 1.29440 12/1/2012OLANZAPINE 10 MG VIAL 0.00000 29.05000 12/1/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

OLANZAPINE 15 MG TAB RAPDIS 0.00000 12.86570 12/1/2012OLANZAPINE 15 MG TABLET 0.00000 1.94180 12/1/2012OLANZAPINE 2.5 MG TABLET 0.00000 0.40630 12/1/2012OLANZAPINE 20 MG TAB RAPDIS 0.00000 17.00830 12/1/2012OLANZAPINE 20 MG TABLET 0.00000 2.58900 12/1/2012OLANZAPINE 5 MG TAB RAPDIS 0.00000 5.93670 12/1/2012OLANZAPINE 5 MG TABLET 0.00000 0.85890 12/1/2012OLANZAPINE 7.5 MG TABLET 0.00000 0.54020 12/1/2012OLANZAPINE/FLUOXETINE HCL 12MG-25MG CAPSULE 0.00000 15.27470 12/14/2012OLANZAPINE/FLUOXETINE HCL 12MG-50MG CAPSULE 0.00000 15.27470 12/14/2012OLANZAPINE/FLUOXETINE HCL 3MG-25MG CAPSULE 0.00000 7.72543 4/5/2013OLANZAPINE/FLUOXETINE HCL 6MG-25MG CAPSULE 0.00000 10.13740 12/14/2012OLANZAPINE/FLUOXETINE HCL 6MG-50MG CAPSULE 0.00000 10.13740 12/14/2012OMEGA-3/DHA/EPA/FISH OIL 1000 MG CAPSULE 0.04020 0.03652 8/9/2013OMEGA-3/DHA/EPA/FISH OIL 500-1000MG CAPSULE 0.00000 0.10952 12/14/2012OMEPRAZOLE 10 MG CAPSULE DR 0.00000 0.26318 9/27/2013OMEPRAZOLE 20 MG CAPSULE DR 0.00000 0.08670 9/6/2013OMEPRAZOLE 20 MG TABLET DR 0.00000 0.60836 12/14/2012OMEPRAZOLE 40 MG CAPSULE DR 0.00000 0.20730 9/20/2013OMEPRAZOLE/SODIUM BICARBONATE 20MG-1.1G CAPSULE 0.00000 0.48869 12/14/2012OMEPRAZOLE/SODIUM BICARBONATE 40MG-1.1G CAPSULE 0.00000 8.77497 6/14/2013ONDANSETRON 4 MG TAB RAPDIS 0.00000 0.74283 9/13/2013ONDANSETRON 8 MG TAB RAPDIS 0.00000 1.03672 10/11/2013ONDANSETRON HCL 4 MG TABLET 0.00000 0.14696 8/16/2013ONDANSETRON HCL 4 MG/5 ML SOLUTION 0.00000 1.94420 2/8/2013ONDANSETRON HCL 8 MG TABLET 0.00000 0.18894 5/17/2013ONDANSETRON HCL/PF 4 MG/2 ML AMPUL 0.00000 8.31950 12/14/2012ONDANSETRON HCL/PF 4 MG/2 ML DISP SYRIN 1.10670 0.56277 8/30/2013ONDANSETRON HCL/PF 4 MG/2 ML VIAL 0.00000 0.31460 5/10/2013OPIUM TINCTURE 10 MG/ML TINCTURE 0.00000 3.65310 8/2/2013OPIUM/BELLADONNA ALKALOIDS 30-16.2MG SUPP.RECT 0.00000 17.83542 4/5/2013OPIUM/BELLADONNA ALKALOIDS 60-16.2MG SUPP.RECT 0.00000 21.68192 4/5/2013ORPHENADRINE CITRATE 100 MG TABLET ER 0.00000 0.48990 7/19/2013ORPHENADRINE/ASPIRIN/CAFFEINE 50-770-60 TABLET 0.00000 1.83323 12/14/2012OXACILLIN SODIUM 1 G VIAL 9.75910 10.07977 2/1/2013OXACILLIN SODIUM 1 G VIAL PORT 0.00000 0.86301 12/14/2012OXACILLIN SODIUM 10 G VIAL 88.62910 90.95850 2/1/2013OXACILLIN SODIUM 2 G VIAL 18.87810 18.97980 2/1/2013OXACILLIN SODIUM 2 G VIAL PORT 0.00000 2.23201 12/14/2012OXACILLIN SODIUM/DEXTROSE,ISO 1 G/50 ML FROZ.PIGGY 0.00000 0.25790 1/25/2013OXACILLIN SODIUM/DEXTROSE,ISO 2 G/50 ML FROZ.PIGGY 0.00000 0.21527 12/14/2012OXANDROLONE 10 MG TABLET 0.00000 9.27840 12/14/2012OXANDROLONE 2.5 MG TABLET 2.99290 3.00096 6/14/2013OXAPROZIN 600 MG TABLET 0.00000 2.56480 2/22/2013OXAZEPAM 10 MG CAPSULE 0.00000 0.73300 12/1/2012OXAZEPAM 15 MG CAPSULE 0.00000 1.20600 12/1/2012OXCARBAZEPINE 150 MG TABLET 0.13740 0.13730 9/20/2013OXCARBAZEPINE 300 MG TABLET 0.00000 0.27459 6/14/2013OXCARBAZEPINE 300 MG/5ML ORAL SUSP 0.00000 0.57900 1/25/2013OXCARBAZEPINE 600 MG TABLET 0.00000 0.54703 10/11/2013OXYBUTYNIN CHLORIDE 10 MG TAB ER 24 0.00000 1.28700 4/12/2013OXYBUTYNIN CHLORIDE 15 MG TAB ER 24 0.00000 2.15890 1/25/2013OXYBUTYNIN CHLORIDE 5 MG TAB ER 24 0.00000 1.28700 4/12/2013OXYBUTYNIN CHLORIDE 5 MG TABLET 0.00000 0.42780 7/19/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

OXYBUTYNIN CHLORIDE 5 MG/5 ML SYRUP 0.00000 0.02124 5/17/2013OXYCODONE HCL 10 MG TABLET 0.00000 0.26460 12/21/2012OXYCODONE HCL 15 MG TABLET 0.00000 0.16080 12/1/2012OXYCODONE HCL 20 MG/ML ORAL CONC 0.00000 6.18140 5/31/2013OXYCODONE HCL 30 MG TABLET 0.00000 0.32160 12/1/2012OXYCODONE HCL 5 MG CAPSULE 0.00000 1.00437 10/11/2013OXYCODONE HCL 5 MG TABLET 0.00000 0.10720 12/1/2012OXYCODONE HCL/ACETAMINOPHEN 10MG-325MG TABLET 0.00000 0.28762 9/13/2013OXYCODONE HCL/ACETAMINOPHEN 10MG-650MG TABLET 0.00000 0.37370 2/15/2013OXYCODONE HCL/ACETAMINOPHEN 2.5-325MG TABLET 0.00000 1.43437 9/20/2013OXYCODONE HCL/ACETAMINOPHEN 5MG-325MG TABLET 0.04860 0.04864 3/8/2013OXYCODONE HCL/ACETAMINOPHEN 7.5-325MG TABLET 0.00000 0.30820 8/30/2013OXYCODONE HCL/ACETAMINOPHEN 7.5-500MG TABLET 0.00000 0.45240 12/1/2012OXYMORPHONE HCL 10 MG TABLET 0.00000 3.94550 9/6/2013OXYMORPHONE HCL 5 MG TABLET 0.00000 2.19465 10/11/2013P-EPHED HCL/CODEINE/GUAIFEN 30-10-100 SYRUP 0.00000 0.04770 12/14/2012P-EPHED HCL/TRIPROLIDINE HCL 10-0.938/1 LIQUID 0.00000 1.59900 1/25/2013P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP 0.00000 0.05830 1/25/2013P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET 0.00000 0.05247 12/14/2012PAMIDRONATE DISODIUM 30 MG VIAL 0.00000 15.22500 12/14/2012PAMIDRONATE DISODIUM 30MG/10ML VIAL 0.00000 1.51688 12/14/2012PAMIDRONATE DISODIUM 60 MG/10ML VIAL 0.00000 4.62000 12/14/2012PAMIDRONATE DISODIUM 90 MG VIAL 0.00000 56.47750 12/14/2012PAMIDRONATE DISODIUM 90 MG/10ML VIAL 0.00000 4.14700 12/14/2012PANTOPRAZOLE SODIUM 20 MG TABLET DR 0.00000 0.12179 8/16/2013PANTOPRAZOLE SODIUM 40 MG TABLET DR 0.00000 0.10079 4/19/2013PANTOPRAZOLE SODIUM 40 MG VIAL 3.94100 2.53400 7/19/2013PAREGORIC 2 MG/5 ML LIQUID 0.00000 0.46388 4/26/2013PAROMOMYCIN SULFATE 250 MG CAPSULE 0.00000 2.95152 6/14/2013PAROXETINE HCL 10 MG TABLET 0.11390 0.11361 10/11/2013PAROXETINE HCL 12.5 MG TAB ER 24H 0.00000 2.53190 1/25/2013PAROXETINE HCL 20 MG TABLET 0.00000 0.09581 7/12/2013PAROXETINE HCL 25 MG TAB ER 24H 0.00000 2.64470 1/25/2013PAROXETINE HCL 30 MG TABLET 0.00000 0.16840 1/25/2013PAROXETINE HCL 37.5 MG TAB ER 24H 0.00000 2.72360 1/25/2013PAROXETINE HCL 40 MG TABLET 0.00000 0.16962 10/11/2013PEANUT OIL OIL 0.00000 0.09990 1/25/2013PEG 3350/NA SULF,BICARB,CL/KCL 236-22.74G SOLN RECON 0.00000 0.00313 7/12/2013PEG 3350/NA SULF,BICARB,CL/KCL 240-22.72G SOLN RECON 0.00000 0.00220 2/8/2013PEG 400/HYPROMELLOSE/GLYCERIN 1-0.2-0.2% DROPS 0.00000 0.06720 1/25/2013PEN G POT/DEXTROSE-WATER 1MM/50ML FROZ.PIGGY 0.00000 0.19490 12/14/2012PEN G POT/DEXTROSE-WATER 2MM/50ML FROZ.PIGGY 0.00000 0.21880 12/14/2012PEN G POT/DEXTROSE-WATER 3MM/50ML FROZ.PIGGY 0.00000 0.13440 1/25/2013PENICILLIN G POTASSIUM 20MM UNIT VIAL 0.00000 95.11250 1/25/2013PENICILLIN G POTASSIUM 5MM UNIT VIAL 0.00000 21.69720 1/25/2013PENICILLIN G PROCAINE 1.2MM/2 ML DISP SYRIN 0.00000 11.84540 1/25/2013PENICILLIN G PROCAINE 600000/ML DISP SYRIN 0.00000 13.05360 1/25/2013PENICILLIN G SODIUM 5MM UNIT VIAL 0.00000 40.12055 8/9/2013PENICILLIN V POTASSIUM 125 MG/5ML SOLN RECON 0.00000 0.02349 4/5/2013PENICILLIN V POTASSIUM 250 MG TABLET 0.00000 0.07303 7/12/2013PENICILLIN V POTASSIUM 250 MG/5ML SOLN RECON 0.00000 0.02513 5/31/2013PENICILLIN V POTASSIUM 500 MG TABLET 0.00000 0.10601 6/28/2013PENTAZOCINE HCL/ACETAMINOPHEN 25-650MG TABLET 0.00000 0.86338 6/28/2013PENTAZOCINE HCL/NALOXONE HCL 50MG-0.5MG TABLET 0.00000 0.99360 8/30/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

PENTOXIFYLLINE 400 MG TABLET ER 0.00000 0.17535 9/20/2013PERINDOPRIL ERBUMINE 2 MG TABLET 0.00000 0.85163 12/14/2012PERINDOPRIL ERBUMINE 4 MG TABLET 0.00000 0.75205 12/14/2012PERINDOPRIL ERBUMINE 8 MG TABLET 0.00000 0.85631 12/14/2012PERMETHRIN 5 % CREAM (G) 0.00000 1.40446 6/28/2013PERPHENAZINE 16 MG TABLET 0.00000 1.67330 7/26/2013PERPHENAZINE 2 MG TABLET 0.00000 0.80915 9/27/2013PERPHENAZINE 4 MG TABLET 0.00000 1.11510 10/4/2013PERPHENAZINE 8 MG TABLET 0.00000 1.38698 5/31/2013PERPHENAZINE/AMITRIPTYLINE HCL 2 MG-10 MG TABLET 0.00000 0.45060 2/8/2013PERPHENAZINE/AMITRIPTYLINE HCL 2 MG-25 MG TABLET 0.00000 0.60030 12/1/2012PERPHENAZINE/AMITRIPTYLINE HCL 4 MG-25 MG TABLET 0.00000 0.66233 7/19/2013PERPHENAZINE/AMITRIPTYLINE HCL 4MG-10MG TABLET 0.00000 0.47570 1/25/2013PETROLATUM,WHITE/WATER LOTION 0.00000 0.00860 1/25/2013PHENAZOPYRIDINE HCL 100 MG TABLET 0.00000 0.08680 1/25/2013PHENAZOPYRIDINE HCL 200 MG TABLET 0.00000 0.21310 12/1/2012PHENDIMETRAZINE TARTRATE 35 MG TABLET 0.13900 0.13746 6/14/2013PHENELZINE SULFATE 15 MG TABLET 0.00000 0.58450 12/14/2012PHENOBARBITAL 100 MG TABLET 0.00000 0.22053 4/19/2013PHENOBARBITAL 15 MG TABLET 0.00000 0.11231 4/12/2013PHENOBARBITAL 16.2 MG TABLET 0.00000 0.12684 4/19/2013PHENOBARBITAL 20 MG/5 ML ELIXIR 0.00000 0.14799 6/14/2013PHENOBARBITAL 30 MG TABLET 0.00000 0.12320 3/22/2013PHENOBARBITAL 32.4MG TABLET 0.15959 0.15935 6/28/2013PHENOBARBITAL 64.8MG TABLET 0.00000 0.20327 4/19/2013PHENOBARBITAL 97.2MG TABLET 0.00000 0.29154 4/19/2013PHENOBARBITAL SODIUM 130MG/ML VIAL 0.00000 13.60800 1/25/2013PHENOBARBITAL SODIUM 65 MG/ML VIAL 0.00000 10.58400 7/26/2013PHENTERMINE HCL 15 MG CAPSULE 0.76600 0.76603 2/22/2013PHENTERMINE HCL 30 MG CAPSULE 0.00000 0.20502 12/14/2012PHENTERMINE HCL 37.5 MG CAPSULE 0.00000 0.31195 12/14/2012PHENTERMINE HCL 37.5 MG TABLET 0.00000 0.10693 12/14/2012PHENTOLAMINE MESYLATE 5 MG VIAL 0.00000 59.45000 12/14/2012PHENTOLAMINE MESYLATE 5 MG/ML(1) VIAL 0.00000 257.37180 12/14/2012PHENYLEPHRINE HCL 10 % DROPS 0.00000 0.88140 12/14/2012PHENYLEPHRINE HCL 10 MG TABLET 0.00000 0.03575 12/14/2012PHENYLEPHRINE HCL 2.5 % DROPS 0.93706 0.93710 6/14/2013PHENYLEPHRINE HCL 2.5 MG/5ML SOLUTION 0.00000 0.04150 1/25/2013PHENYLEPHRINE HCL/PROMETH HCL 5-6.25MG/5 SYRUP 0.06050 0.06227 5/31/2013PHENYLEPHRINE/BROMPHENIRAMINE 10-4MG/5ML LIQUID 0.00000 0.15294 12/14/2012PHENYLEPHRINE/BROMPHENIRAMINE 10MG-6MG/5 ORAL SUSP 0.00000 0.25513 12/14/2012PHENYLEPHRINE/CHLOPHEDIANOL/GG 5-12.5-120 LIQUID 0.00000 0.08960 1/25/2013PHENYLEPHRINE/CHLORPHENIRAMINE 10-4MG/5ML LIQUID 0.00000 0.02660 1/25/2013PHENYLEPHRINE/CHLORPHENIRAMINE 2MG-1MG/ML DROPS 0.00000 0.45951 12/14/2012PHENYLEPHRINE/CHLORPHENIRAMINE 3.5-1MG/ML DROPS 0.00000 0.37660 1/25/2013PHENYLEPHRINE/PYRILAMINE 5-16MG/5ML ORAL SUSP 0.00000 0.40980 1/25/2013PHENYTOIN 100 MG/4ML ORAL SUSP 0.24360 0.27300 9/6/2013PHENYTOIN 125 MG/5ML ORAL SUSP 0.00000 0.10191 5/31/2013PHENYTOIN 50 MG TAB CHEW 0.00000 0.36841 3/29/2013PHENYTOIN SODIUM 50 MG/ML AMPUL 0.00000 0.57670 1/25/2013PHENYTOIN SODIUM 50 MG/ML DISP SYRIN 0.00000 0.68460 1/25/2013PHENYTOIN SODIUM 50 MG/ML VIAL 0.33999 0.37563 5/10/2013PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE 0.00000 0.08985 5/24/2013PHENYTOIN SODIUM EXTENDED 200 MG CAPSULE 0.00000 0.55990 1/25/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

PHENYTOIN SODIUM EXTENDED 300 MG CAPSULE 0.00000 0.83864 12/14/2012PHOSP ACID/DEXTROSE/FRUCTOSE SOLUTION 0.02023 0.03038 7/12/2013PHOSPHORUS #1 250 MG TABLET 0.00000 0.13195 8/30/2013PHYTONADIONE 10 MG/ML AMPUL 0.00000 7.53480 1/25/2013PHYTONADIONE 100 MCG TABLET 0.00000 0.02140 1/25/2013PILOCARPINE HCL 1 % DROPS 0.00000 4.34000 4/26/2013PILOCARPINE HCL 2 % DROPS 0.00000 4.43940 4/26/2013PILOCARPINE HCL 4 % DROPS 0.00000 4.65220 4/26/2013PILOCARPINE HCL 5 MG TABLET 0.00000 0.21420 7/26/2013PILOCARPINE HCL 7.5 MG TABLET 0.00000 1.32821 7/26/2013PINDOLOL 10 MG TABLET 0.00000 0.98950 1/25/2013PINDOLOL 5 MG TABLET 0.00000 0.72630 2/8/2013PIOGLITAZONE HCL 15 MG TABLET 0.00000 0.21363 4/26/2013PIOGLITAZONE HCL 30 MG TABLET 0.00000 0.28364 4/19/2013PIOGLITAZONE HCL 45 MG TABLET 0.00000 0.31415 10/11/2013PIOGLITAZONE HCL/GLIMEPIRIDE 30 MG-2 MG TABLET 0.00000 21.94569 3/1/2013PIOGLITAZONE HCL/GLIMEPIRIDE 30 MG-4 MG TABLET 0.00000 21.94569 3/1/2013PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G VIAL 4.08720 4.41090 6/21/2013PIPERACILLIN SODIUM/TAZOBACTAM 2.25 G VIAL PORT 0.00000 8.32230 12/14/2012PIPERACILLIN SODIUM/TAZOBACTAM 3.375 G VIAL 0.00000 11.98000 7/19/2013PIPERACILLIN SODIUM/TAZOBACTAM 3.375 G VIAL PORT 0.00000 11.57100 12/14/2012PIPERACILLIN SODIUM/TAZOBACTAM 4.5G VIAL 0.00000 15.01360 7/19/2013PIPERACILLIN SODIUM/TAZOBACTAM 4.5G VIAL PORT 0.00000 15.73320 12/14/2012PIPERACILLIN SODIUM/TAZOBACTAM 40.5G VIAL 0.00000 54.97700 9/20/2013PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% SHAMPOO 0.03610 0.03613 5/3/2013PIROXICAM 10 MG CAPSULE 0.98560 1.05404 7/26/2013PIROXICAM 20 MG CAPSULE 0.00000 1.80000 2/8/2013PN W-CA64/IRON CB&GL/FA/DSS/DH 90-1-300MG COMBO. PKG 0.76697 0.78400 7/5/2013PNV #8/IRON PS CMP&ASPG/FA/DHA 22-6-1-200 COMBO. PKG 0.00000 0.51920 1/25/2013PNV 11-IRON FUM-FOLIC ACID-OM3 28-1-200MG CAPSULE 1.71267 1.55634 3/15/2013PNV CMB#21/IRON/FOLIC ACID 14 MG-400 TABLET 0.00000 0.06411 12/14/2012PNV CMB#95/FERROUS FUMARATE/FA 28MG-0.8MG TABLET 0.00000 0.05040 2/15/2013PNV COMBO #19/IRON/FOL AC/DHA 22-6-1-200 CAPSULE 0.00000 2.08973 5/3/2013PNV COMBO #22/IRON/FA/OM3/DHA 28-6-1-203 COMBO. PKG 0.00000 0.62148 1/25/2013PNV COMBO#47/IRON/FA #1/DHA 27-1-300MG CAPSULE 0.00000 1.59290 1/25/2013PNV NO.15/IRON FUM & PS CMP/FA 85 MG-1 MG CAPSULE 0.00000 1.15359 12/14/2012PNV NO.22/IRON CBN&GLUC/FA/DSS 27-1-50MG TABLET 0.00000 0.34913 12/14/2012PNV NO.23-IRON PS COMPLEX-FA 155 MG-1MG CAPSULE 0.00000 0.20689 12/14/2012PNV NO.25/IRON FUMARATE/FA/DHA 30-975-200 CAPSULE 0.00000 0.55977 4/19/2013PNV W-CA #40/IRON FUM/FA CMB#1 27 MG-1 MG TABLET 0.00000 1.49072 9/27/2013PNV W-CA NO.37/IRON/FA/OMEGA-3 27-1-330MG CAPSULE 0.00000 1.00684 8/9/2013PNV W-O IRON/FA/CALCIUM/B6/B12 1-200-75 TBMP 24HR 0.00000 0.70590 12/14/2012PNV WITH CA #68/IRON/FA#1/DHA 28-1-300MG CAPSULE 0.00000 1.68677 12/14/2012PNV WITH CA,NO.71/IRON/FA 27 MG-1 MG TABLET 0.00000 0.06240 12/14/2012PNV WITH CA,NO.72/IRON,CARB/FA 29 MG-1 MG TABLET 0.00000 0.13210 1/25/2013PNV WITH CA,NO.72/IRON/FA 27 MG-1 MG TABLET 0.00000 0.06606 6/14/2013PNV#16/IRON FUM & PS/FA/OM-3 35-1-200MG CAPSULE 0.00000 1.28451 8/30/2013PNV#20/IRON/FA/DS/FISH/DHA/EPA 27-1-500MG CAPSULE 0.00000 1.34404 5/31/2013PNV#24/IRON AA CHEL/FA/DHA 30-975-300 COMBO. PKG 0.00000 0.41988 4/19/2013PNV#26/IRON POLY/FA/DHA 29-1-200MG CAPSULE 0.00000 1.56287 6/7/2013PNV#79/IRON/FA/LMFOLATE CA/DHA 27-1.13 MG CAPSULE 0.00000 1.81370 1/25/2013PNV/FA/B6/CALCIUM PHOS/GINGER 1.2-40-100 TABLET 0.00000 0.72360 12/14/2012PNV17/IRON/FA/FISH OIL/DHA/OM 35-5-1.2MG CAPSULE 0.00000 1.61980 12/14/2012PNV2/IRON B-G SUC-P/FA/OMEGA-3 29-1-250MG COMBO. PKG 0.00000 0.36225 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

PNV22/IRON CBN&GLUC/FA/DSS/DHA 27-1-50MG COMBO. PKG 0.00000 0.63047 12/14/2012PNV34/IRON,CARBONYL/FA/DSS/DHA 30-1-50 MG CAPSULE 0.00000 1.58305 12/14/2012PNV38/IRON CBN&GLUC/FA/DSS/DHA 35-1-50MG COMBO. PKG 0.78493 0.81655 7/5/2013PNV51/IRON FUM/FA/OM-3/DHA/EPA 27-800-228 CAPSULE 0.12028 0.11428 5/24/2013PNV53/IRON B-G HCL-P/FA/OMEGA3 29-1-400MG COMBO. PKG 0.00000 0.43260 12/14/2012PNV54/IRON B-G HCL-P/FA/OMEGA3 29-1-430MG COMBO. PKG 0.00000 0.43260 12/14/2012PNV66/IRON FUMARATE/FA/DSS/DHA 27-1.25-55 CAPSULE 0.00000 1.36056 12/14/2012PNV80/IRON FUMARATE/FA/DSS/DHA 29-1.25-55 CAPSULE 0.00000 1.98769 12/14/2012PNV81/SOD IRON EDTA& PS/FA/OM3 27-1-430MG CMBPKGDRCP 0.00000 0.86509 12/14/2012PNV94/SOD IRON EDTA& PS/FA/OM3 26-1-374MG CMBPKGDRCP 0.00000 1.13225 12/14/2012PODOFILOX 0.5 % SOLUTION 0.00000 16.47695 3/29/2013POLYETHYLENE GLYCOL 3350 17G POWD PACK 0.00000 1.43752 6/14/2013POLYETHYLENE GLYCOL 3350 17G/DOSE POWDER 0.00000 0.04100 12/1/2012POLYMYXIN B SULF/TRIMETHOPRIM 10K/ML-0.1 DROPS 0.00000 0.89840 12/1/2012POLYVINYL ALCOHOL 1.4 % DROPS 0.00000 0.13400 12/14/2012POT CHLORIDE/POT BICARB/CIT AC 25 MEQ TABLET EFF 0.00000 0.68997 12/14/2012POTASSIUM ACETATE 4 MEQ/ML VIAL 0.00000 0.08796 4/5/2013POTASSIUM BICARBONATE/CIT AC 25 MEQ TABLET EFF 0.00000 0.21200 2/15/2013POTASSIUM CHLORIDE 10 MEQ CAPSULE ER 0.00000 0.58893 9/6/2013POTASSIUM CHLORIDE 10 MEQ TAB ER PRT 0.00000 0.38638 8/30/2013POTASSIUM CHLORIDE 10MEQ/0.1L PIGGYBACK 0.00000 0.02218 12/14/2012POTASSIUM CHLORIDE 10MEQ/50ML PIGGYBACK 0.00000 0.06570 1/25/2013POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN 0.00000 0.02806 12/14/2012POTASSIUM CHLORIDE 2 MEQ/ML VIAL 0.00000 0.02303 4/19/2013POTASSIUM CHLORIDE 20 MEQ TAB ER PRT 0.00000 0.39663 8/30/2013POTASSIUM CHLORIDE 20MEQ/0.1L PIGGYBACK 0.00000 0.02180 1/25/2013POTASSIUM CHLORIDE 20MEQ/15ML LIQUID 0.00000 0.01350 12/1/2012POTASSIUM CHLORIDE 20MEQ/50ML PIGGYBACK 0.00000 0.10610 1/25/2013POTASSIUM CHLORIDE 30MEQ/0.1L PIGGYBACK 0.00000 0.04528 12/14/2012POTASSIUM CHLORIDE 40MEQ/0.1L PIGGYBACK 0.00000 0.04897 12/14/2012POTASSIUM CHLORIDE 40MEQ/15ML LIQUID 0.00000 0.03955 8/2/2013POTASSIUM CHLORIDE 8 MEQ CAPSULE ER 0.00000 0.65780 2/1/2013POTASSIUM CHLORIDE IN 0.9%NACL 20 MEQ/L IV SOLN 0.00000 0.00283 4/19/2013POTASSIUM CHLORIDE IN 0.9%NACL 40 MEQ/L IV SOLN 0.00000 0.00510 1/25/2013POTASSIUM CHLORIDE IN D5W 20 MEQ/L IV SOLN 0.00000 0.00310 1/25/2013POTASSIUM CHLORIDE IN D5W 30 MEQ/L IV SOLN 0.00000 0.00266 12/14/2012POTASSIUM CHLORIDE IN D5W 40 MEQ/L IV SOLN 0.00000 0.00209 12/14/2012POTASSIUM CHLORIDE IN LR-D5 20 MEQ/L IV SOLN 0.00000 0.00610 1/25/2013POTASSIUM CHLORIDE IN LR-D5 40 MEQ/L IV SOLN 0.00000 0.00403 12/14/2012POTASSIUM CHLORIDE-0.45% NACL 20 MEQ/L IV SOLN 0.00000 0.00410 1/25/2013POTASSIUM CHLORIDE/D5-0.2%NACL 10 MEQ/L IV SOLN 0.00000 0.00234 12/14/2012POTASSIUM CHLORIDE/D5-0.2%NACL 20 MEQ/L IV SOLN 0.00000 0.00322 12/14/2012POTASSIUM CHLORIDE/D5-0.2%NACL 30 MEQ/L IV SOLN 0.00000 0.00200 1/25/2013POTASSIUM CHLORIDE/D5-0.2%NACL 40 MEQ/L IV SOLN 0.00000 0.00227 12/14/2012POTASSIUM CHLORIDE/D5-0.3%NACL 20 MEQ/L IV SOLN 0.00000 0.00322 12/14/2012POTASSIUM CHLORIDE/D5-0.45NACL 10 MEQ/L IV SOLN 0.00000 0.00320 1/25/2013POTASSIUM CHLORIDE/D5-0.45NACL 20 MEQ/L IV SOLN 0.00000 0.00230 1/25/2013POTASSIUM CHLORIDE/D5-0.45NACL 30 MEQ/L IV SOLN 0.00000 0.00236 12/14/2012POTASSIUM CHLORIDE/D5-0.45NACL 40 MEQ/L IV SOLN 0.00000 0.00228 12/14/2012POTASSIUM CHLORIDE/D5-0.9%NACL 20 MEQ/L IV SOLN 0.00000 0.00320 1/25/2013POTASSIUM CHLORIDE/D5-0.9%NACL 40 MEQ/L IV SOLN 0.00000 0.00540 1/25/2013POTASSIUM CITRATE 10 MEQ TABLET ER 0.00000 1.09486 4/12/2013POTASSIUM CITRATE 5 MEQ TABLET ER 0.00000 0.78130 4/12/2013POVIDONE-IODINE 0.3 % SOLUTION 0.00000 0.00990 1/25/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

POVIDONE-IODINE 10 % MED. SWAB 0.12643 0.15276 7/12/2013POVIDONE-IODINE 10 % OINT. (G) 0.00000 0.06258 12/14/2012POVIDONE-IODINE 10 % SOLUTION 0.00643 0.00639 8/30/2013PRAMIPEXOLE DI-HCL 0.125 MG TABLET 0.00000 0.09800 5/17/2013PRAMIPEXOLE DI-HCL 0.25 MG TABLET 0.00000 0.06919 8/30/2013PRAMIPEXOLE DI-HCL 0.5 MG TABLET 0.08631 0.08913 9/6/2013PRAMIPEXOLE DI-HCL 0.75 MG TABLET 0.17139 0.12212 9/6/2013PRAMIPEXOLE DI-HCL 1 MG TABLET 0.00000 0.12893 8/16/2013PRAMIPEXOLE DI-HCL 1.5 MG TABLET 0.09701 0.12893 9/6/2013PRAMOXINE HCL 1 % TOWELETTE 0.00000 0.35233 12/14/2012PRAVASTATIN SODIUM 10 MG TABLET 0.00000 0.47258 9/6/2013PRAVASTATIN SODIUM 20 MG TABLET 0.00000 0.58175 10/11/2013PRAVASTATIN SODIUM 40 MG TABLET 0.00000 0.75588 10/11/2013PRAVASTATIN SODIUM 80 MG TABLET 0.00000 0.76587 10/11/2013PRAZOSIN HCL 1 MG CAPSULE 0.00000 0.13570 5/17/2013PRAZOSIN HCL 2 MG CAPSULE 0.00000 0.31306 7/19/2013PRAZOSIN HCL 5 MG CAPSULE 0.00000 0.42850 5/17/2013PREDNICARBATE 0.1 % CREAM (G) 0.00000 0.86964 12/14/2012PREDNICARBATE 0.1 % OINT. (G) 0.00000 1.17750 1/25/2013PREDNISOLONE 15 MG/5 ML SOLUTION 0.00000 0.03992 5/24/2013PREDNISOLONE ACETATE 1 % DROPS SUSP 0.00000 3.27340 10/4/2013PREDNISOLONE SOD PHOSPHATE 1 % DROPS 0.00000 4.19720 2/8/2013PREDNISOLONE SOD PHOSPHATE 15 MG/5 ML SOLUTION 0.06980 0.06969 6/7/2013PREDNISOLONE SOD PHOSPHATE 25 MG/5 ML SOLUTION 0.00000 1.31101 12/14/2012PREDNISONE 1 MG TABLET 0.00000 0.15812 9/13/2013PREDNISONE 10 MG TAB DS PK 0.00000 0.17809 12/14/2012PREDNISONE 10 MG TABLET 0.00000 0.03377 5/17/2013PREDNISONE 2.5 MG TABLET 0.00000 0.14040 9/13/2013PREDNISONE 20 MG TABLET 0.00000 0.17820 10/4/2013PREDNISONE 5 MG TAB DS PK 0.00000 0.09568 3/29/2013PREDNISONE 5 MG TABLET 0.00000 0.02680 8/23/2013PREDNISONE 5 MG/5 ML SOLUTION 0.00000 0.14241 3/8/2013PREDNISONE 50 MG TABLET 0.28611 0.28608 9/6/2013PRENAT VIT COMB.10/IRON/FA/DHA 65-1-250MG COMBO. PKG 0.00000 0.80348 6/7/2013PRENATAL #57/IRON/FA/DSS/DHA 29-1.25-55 CAPSULE 0.00000 1.99010 1/11/2013PRENATAL CMB#95/IRON/FA/DHA 28-800-200 COMBO. PKG 0.00000 0.10500 4/19/2013PRENATAL VIT #60/IRON FUM/FA 27 MG-1 MG TABLET 0.00000 0.13125 3/15/2013PRENATAL VIT #76/IRON,CARB/FA 29 MG-1 MG TABLET 0.00000 0.11903 12/14/2012PRENATAL VIT #91/FE FUM/FA/DHA 28-975-200 COMBO. PKG 0.00000 0.16328 4/19/2013PRENATAL VIT 15/IRON CB/FA/DSS 90-1-50 MG TABLET 0.00000 0.11584 3/1/2013PRENATAL VIT 16/IRON CB/FA/DSS 90-1-50 MG TABLET 0.00000 0.21984 12/14/2012PRENATAL VIT 18/IRON CB/FA/DSS 90-1-50 MG TABLET 0.00000 0.08180 1/25/2013PRENATAL VIT NO.73/IRON/FA 28 MG-1 MG TABLET 0.00000 0.18018 12/14/2012PRENATAL VIT#96/FERROUS FUM/FA 27MG-0.8MG TABLET 0.00000 0.06840 12/14/2012PRENATAL VIT/FE FUM/DOSS/FA 29 MG-1 MG TABLET 0.00000 0.22000 3/8/2013PRENATAL VIT/FE FUMARATE/FA/SE 27 MG-1 MG TABLET 0.00000 0.15301 12/14/2012PRENATAL VIT/IRON FUMARATE/FA 27MG-0.8MG TABLET 0.00000 0.04257 4/12/2013PRENATAL VIT/IRON FUMARATE/FA 28MG-0.8MG TABLET 0.05604 0.04810 8/16/2013PRENATAL VIT/IRON FUMARATE/FA 29 MG-1 MG TAB CHEW 0.00000 0.27640 3/8/2013PRENATAL VIT/IRON FUMARATE/FA 65 MG-1 MG TABLET 0.00000 0.07504 12/14/2012PRENATAL VIT27&CALCIUM/IRON/FA 60 MG-1 MG TABLET 0.00000 0.20146 5/17/2013PRENATAL VITAMINS#21, IRON, FA 28-6-1 MG TABLET 0.00000 1.46985 1/25/2013PRENATAL VITS #33/IRON/FA/DHA 29-1-250MG COMBO. PKG 0.00000 0.78528 6/7/2013PRENATAL VITS #90/IRON FUM/FA 9 MG-0.5MG TABLET 0.00000 0.08394 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

PRENATAL VITS #93/IRON FUM/FA 9MG-267MCG TABLET 0.00000 0.05495 4/19/2013PRENATAL VITS W-CA,FE,FA(<1MG) TABLET 0.00000 0.04207 4/5/2013PRIMAQUINE PHOSPHATE 26.3 MG TABLET 0.00000 1.25286 12/14/2012PRIMIDONE 250 MG TABLET 0.18430 0.18425 6/28/2013PRIMIDONE 50 MG TABLET 0.00000 0.08940 1/25/2013PROBENECID 500 MG TABLET 0.00000 0.51720 1/25/2013PROCAINAMIDE HCL 100 MG/ML VIAL 0.00000 1.98490 1/25/2013PROCAINAMIDE HCL 500 MG/ML VIAL 0.00000 8.23200 1/25/2013PROCHLORPERAZINE EDISYLATE 10 MG/2 ML VIAL 0.00000 1.44060 1/25/2013PROCHLORPERAZINE EDISYLATE 5 MG/ML VIAL 0.00000 1.68000 1/25/2013PROCHLORPERAZINE MALEATE 10 MG TABLET 0.00000 0.07129 7/12/2013PROCHLORPERAZINE MALEATE 25 MG SUPP.RECT 9.25974 9.33313 8/30/2013PROCHLORPERAZINE MALEATE 5 MG TABLET 0.05960 0.05963 7/26/2013PROGESTERONE 50 MG/ML VIAL 0.00000 2.02150 1/25/2013PROGESTERONE,MICRONIZED 100 MG CAPSULE 1.48624 1.48263 8/23/2013PROGESTERONE,MICRONIZED 200 MG CAPSULE 0.00000 2.81679 9/27/2013PROMETHAZINE HCL 12.5 MG SUPP.RECT 0.00000 3.15330 1/25/2012PROMETHAZINE HCL 12.5 MG TABLET 0.00000 0.07735 5/17/2013PROMETHAZINE HCL 25 MG SUPP.RECT 0.00000 8.60160 7/5/2013PROMETHAZINE HCL 25 MG TABLET 0.00000 0.09320 12/1/2012PROMETHAZINE HCL 25 MG/ML AMPUL 0.00000 1.10880 12/14/2012PROMETHAZINE HCL 25 MG/ML DISP SYRIN 0.00000 1.04160 12/14/2012PROMETHAZINE HCL 25 MG/ML VIAL 0.00000 0.72153 7/5/2013PROMETHAZINE HCL 50 MG TABLET 0.00000 0.12177 6/28/2013PROMETHAZINE HCL 50 MG/ML AMPUL 1.55400 1.79970 3/15/2013PROMETHAZINE HCL 50 MG/ML VIAL 1.94330 1.91280 5/31/2013PROMETHAZINE HCL 6.25MG/5ML SYRUP 0.01500 0.01499 8/23/2013PROMETHAZINE HCL/CODEINE 6.25-10/5 SYRUP 0.01530 0.01528 2/1/2013PROMETHAZINE/PHENYLEPH/CODEINE 6.25-5-10 SYRUP 0.00000 0.08490 1/25/2013PROPAFENONE HCL 150 MG TABLET 0.00000 0.21533 7/5/2013PROPAFENONE HCL 225 MG CAP ER 12H 0.00000 4.78090 2/8/2013PROPAFENONE HCL 225 MG TABLET 0.00000 0.34879 5/31/2013PROPAFENONE HCL 300 MG TABLET 0.00000 1.00960 1/25/2013PROPAFENONE HCL 325 MG CAP ER 12H 0.00000 6.05700 2/1/2013PROPAFENONE HCL 425 MG CAP ER 12H 0.00000 6.05700 2/8/2013PROPANTHELINE BROMIDE 15 MG TABLET 0.00000 0.51177 3/15/2013PROPARACAINE HCL 0.5 % DROPS 0.00000 0.81433 4/5/2013PROPRANOLOL HCL POWDER 0.00000 17.22364 8/23/2013PROPRANOLOL HCL 10 MG TABLET 0.00000 0.02090 12/1/2012PROPRANOLOL HCL 120 MG CAP SA 24H 0.00000 1.00035 6/21/2013PROPRANOLOL HCL 160 MG CAP SA 24H 0.00000 1.33536 9/27/2013PROPRANOLOL HCL 20 MG TABLET 0.02210 0.02204 5/24/2013PROPRANOLOL HCL 20 MG/5 ML SOLUTION 0.00000 0.14456 3/15/2013PROPRANOLOL HCL 40 MG TABLET 0.00000 0.02640 12/1/2012PROPRANOLOL HCL 40MG/5ML SOLUTION 0.00000 0.20614 3/15/2013PROPRANOLOL HCL 60 MG CAP SA 24H 0.00000 0.69318 8/16/2013PROPRANOLOL HCL 60 MG TABLET 0.00000 0.54770 1/25/2013PROPRANOLOL HCL 80 MG CAP SA 24H 0.00000 0.81807 8/16/2013PROPRANOLOL HCL 80 MG TABLET 0.00000 0.04210 1/25/2013PROPRANOLOL/HYDROCHLOROTHIAZID 40 MG-25MG TABLET 0.00000 0.71600 1/25/2013PROPRANOLOL/HYDROCHLOROTHIAZID 80 MG-25MG TABLET 0.00000 0.87940 1/25/2013PROTAMINE SULFATE 10 MG/ML VIAL 0.00000 0.75770 1/25/2013PROTECT CMB2/CERAMIDE 1,3,6-11 CREAM (G) 0.00000 1.87360 1/25/2013PROTRIPTYLINE HCL 10 MG TABLET 0.00000 1.39594 3/1/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

PROTRIPTYLINE HCL 5 MG TABLET 0.00000 1.07682 9/13/2013PSEUDOEPH/CHLOPHEDIANOL/GG 30-12.5/5 LIQUID 0.00000 0.08600 1/25/2013PSEUDOEPHED/CHLORPHENIRAMINE 60 MG-4 MG TABLET 0.00000 0.05310 1/25/2013PSEUDOEPHEDRINE HCL 30 MG TABLET 0.02210 0.02205 2/15/2013PSEUDOEPHEDRINE HCL 60 MG TABLET 0.04790 0.02105 7/26/2013PSEUDOEPHEDRINE/BROMPHENIRAMIN 20-4MG/5ML LIQUID 0.00000 0.19210 1/25/2013PSYLLIUM HUSK (WITH SUGAR) 3.4 G/7 G POWDER 0.00000 0.01170 1/25/2013PSYLLIUM SEED POWDER 0.00000 0.01780 1/25/2013PSYLLIUM SEED (WITH DEXTROSE) POWDER 0.00000 0.01140 1/25/2013PSYLLIUM SEED (WITH SUGAR) PACKET 0.00000 0.22940 1/25/2013PSYLLIUM SEED (WITH SUGAR) POWDER 0.00000 0.00920 1/25/2013PSYLLIUM SEED/ASPARTAME POWDER 0.00000 0.01710 1/25/2013PYRANTEL PAMOATE 50 MG/ML ORAL SUSP 0.00000 0.16310 1/25/2013PYRAZINAMIDE 500 MG TABLET 0.00000 0.71150 1/25/2013PYRIDOSTIGMINE BROMIDE 60 MG TABLET 0.00000 0.27404 9/6/2013PYRIDOXINE HCL 100 MG TABLET 0.02399 0.02559 8/9/2013PYRIDOXINE HCL 100 MG/ML VIAL 0.00000 7.86632 12/14/2012PYRIDOXINE HCL 25 MG TABLET 0.00000 0.02190 1/25/2013PYRIDOXINE HCL 50 MG TABLET 0.00000 0.01407 12/14/2012QUETIAPINE FUMARATE 100 MG TABLET 0.00000 0.37260 12/1/2012QUETIAPINE FUMARATE 200 MG TABLET 0.00000 0.70330 12/1/2012QUETIAPINE FUMARATE 25 MG TABLET 0.00000 0.21760 12/1/2012QUETIAPINE FUMARATE 300 MG TABLET 0.00000 0.92200 12/1/2012QUETIAPINE FUMARATE 400 MG TABLET 0.00000 1.14370 12/1/2012QUETIAPINE FUMARATE 50 MG TABLET 0.00000 0.35700 12/1/2012QUINAPRIL HCL 10 MG TABLET 0.00000 0.17571 7/12/2013QUINAPRIL HCL 20 MG TABLET 0.00000 0.19930 4/19/2013QUINAPRIL HCL 40 MG TABLET 0.17384 0.17170 8/16/2013QUINAPRIL HCL 5 MG TABLET 0.18690 0.17976 7/12/2013QUINAPRIL/HYDROCHLOROTHIAZIDE 10-12.5MG TABLET 0.00000 0.78317 4/19/2013QUINAPRIL/HYDROCHLOROTHIAZIDE 20-12.5 MG TABLET 0.00000 0.79774 8/16/2013QUINAPRIL/HYDROCHLOROTHIAZIDE 20-25MG TABLET 0.00000 0.66927 9/27/2013QUINIDINE GLUCONATE 324 MG TABLET ER 0.00000 0.84810 1/25/2013QUINIDINE GLUCONATE 80 MG/ML VIAL 0.00000 3.64770 12/14/2012QUINIDINE SULFATE 200 MG TABLET 0.00000 0.09930 1/25/2013QUINIDINE SULFATE 300 MG TABLET 0.00000 0.18360 1/25/2013QUINIDINE SULFATE 300 MG TABLET ER 0.00000 0.67330 1/25/2013QUININE SULFATE 324 MG CAPSULE 0.00000 5.12820 12/14/2012RAMIPRIL 1.25 MG CAPSULE 0.00000 0.17732 8/9/2013RAMIPRIL 10 MG CAPSULE 0.05840 0.05842 7/19/2013RAMIPRIL 2.5 MG CAPSULE 0.00000 0.09500 4/19/2013RAMIPRIL 5 MG CAPSULE 0.00000 0.10440 4/19/2013RANITIDINE HCL 15 MG/ML SYRUP 0.00000 0.02023 8/16/2013RANITIDINE HCL 150 MG CAPSULE 0.00000 0.89980 1/25/2013RANITIDINE HCL 150 MG TABLET 0.02731 0.02862 9/27/2013RANITIDINE HCL 25 MG/ML VIAL 0.00000 0.86997 12/14/2012RANITIDINE HCL 300 MG CAPSULE 0.00000 1.63719 8/30/2013RANITIDINE HCL 300 MG TABLET 0.00000 0.06151 8/30/2013RANITIDINE HCL 75 MG TABLET 0.00000 0.08884 12/14/2012REPAGLINIDE 1 MG TABLET 0.00000 2.56165 8/2/2013REPAGLINIDE 2 MG TABLET 0.00000 2.56165 8/2/2013RIBAVIRIN 200 MG CAPSULE 0.00000 0.37791 8/30/2013RIBAVIRIN 200 MG TABLET 0.00000 0.62030 1/25/2013RIBOFLAVIN 25 MG TABLET 0.00000 0.02310 1/25/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

RIFAMPIN 150 MG CAPSULE 0.00000 1.02820 5/17/2013RIFAMPIN 300 MG CAPSULE 0.00000 0.70390 12/1/2012RILUZOLE 50 MG TABLET 3.18837 3.14860 10/4/2013RIMANTADINE HCL 100 MG TABLET 0.00000 1.70880 1/25/2013RINGERS SOLUTION IRRIG SOLN 0.00000 0.00710 1/25/2013RINGERS SOLUTION IV SOLN 0.00000 0.00250 1/25/2013RINGERS SOLUTION,LACTATED IRRIG SOLN 0.00000 0.00220 12/14/2012RINGERS SOLUTION,LACTATED IV SOLN 0.00000 0.00172 5/17/2013RISPERIDONE 0.25 MG TAB RAPDIS 0.00000 5.90310 12/14/2012RISPERIDONE 0.25 MG TABLET 0.00000 0.06231 8/16/2013RISPERIDONE 0.5 MG TAB RAPDIS 0.00000 1.70085 9/20/2013RISPERIDONE 0.5 MG TABLET 0.00000 0.07638 8/16/2013RISPERIDONE 1 MG TAB RAPDIS 0.00000 2.47023 6/7/2013RISPERIDONE 1 MG TABLET 0.00000 0.09410 1/25/2013RISPERIDONE 1 MG/ML SOLUTION 0.00000 0.55000 5/31/2013RISPERIDONE 2 MG TAB RAPDIS 0.00000 3.13350 2/22/2013RISPERIDONE 2 MG TABLET 0.00000 0.10160 1/25/2013RISPERIDONE 3 MG TAB RAPDIS 0.00000 6.19397 7/26/2013RISPERIDONE 3 MG TABLET 0.00000 0.09249 8/16/2013RISPERIDONE 4 MG TAB RAPDIS 0.00000 7.23401 8/16/2013RISPERIDONE 4 MG TABLET 0.00000 0.18358 8/16/2013RIVASTIGMINE TARTRATE 1.5 MG CAPSULE 0.00000 2.05087 12/14/2012RIVASTIGMINE TARTRATE 3 MG CAPSULE 0.00000 2.05087 12/14/2012RIVASTIGMINE TARTRATE 4.5 MG CAPSULE 0.00000 2.05087 12/14/2012RIVASTIGMINE TARTRATE 6 MG CAPSULE 0.00000 2.05087 12/14/2012RIZATRIPTAN BENZOATE 10 MG TAB RAPDIS 0.00000 23.25010 2/22/2013RIZATRIPTAN BENZOATE 10 MG TABLET 0.00000 1.71350 8/2/2013RIZATRIPTAN BENZOATE 5 MG TAB RAPDIS 0.00000 22.15008 7/12/2013RIZATRIPTAN BENZOATE 5 MG TABLET 0.00000 5.14855 3/29/2013ROPINIROLE HCL 0.25 MG TABLET 0.00000 0.15370 8/30/2013ROPINIROLE HCL 0.5 MG TABLET 0.00000 0.15370 8/30/2013ROPINIROLE HCL 1 MG TABLET 0.00000 0.15370 8/30/2013ROPINIROLE HCL 12 MG TAB ER 24H 0.00000 9.57763 12/14/2012ROPINIROLE HCL 2 MG TAB ER 24H 0.00000 1.91454 12/14/2012ROPINIROLE HCL 2 MG TABLET 0.00000 0.15718 8/30/2013ROPINIROLE HCL 3 MG TABLET 0.00000 0.15718 8/30/2013ROPINIROLE HCL 4 MG TAB ER 24H 3.82900 3.82911 8/23/2013ROPINIROLE HCL 4 MG TABLET 0.00000 0.14976 5/17/2013ROPINIROLE HCL 5 MG TABLET 0.14976 0.15233 9/27/2013ROPINIROLE HCL 6 MG TAB ER 24H 0.00000 4.97944 10/11/2013ROPINIROLE HCL 8 MG TAB ER 24H 0.00000 5.74373 12/14/2012SALICYLIC ACID 26 % LIQUID 0.00000 6.03610 12/14/2012SALICYLIC ACID 27.5 % LIQ-FILM 0.00000 7.24360 12/14/2012SALICYLIC ACID/COAL TAR/SULFUR 2 %-1 %-2% SHAMPOO 0.00000 0.20597 12/14/2012SALSALATE 500 MG TABLET 0.24620 0.24120 6/21/2013SALSALATE 750 MG TABLET 0.00000 0.32160 6/21/2013SCOPOLAMINE HYDROBROMIDE 0.4 MG/ML VIAL 0.00000 3.78000 1/25/2013SELEGILINE HCL 5 MG CAPSULE 0.00000 1.61280 2/8/2013SELEGILINE HCL 5 MG TABLET 0.00000 1.25200 1/25/2013SELENIUM 200 MCG TABLET 0.05760 0.05611 8/2/2013SELENIUM 40MCG/ML VIAL 0.00000 0.24063 12/14/2012SELENIUM SULFIDE 2.5 % SUSPENSION 0.00000 0.07595 5/10/2013SENNOSIDES 8.6 MG TABLET 0.00978 0.01059 9/20/2013SENNOSIDES 8.8MG/5ML SYRUP 0.04077 0.03933 5/10/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

SENNOSIDES/DOCUSATE SODIUM 8.6MG-50MG TABLET 0.01872 0.18687 8/23/2013SERTRALINE HCL 100 MG TABLET 0.00000 0.07310 3/8/2013SERTRALINE HCL 25 MG TABLET 0.04543 0.04548 5/24/2013SERTRALINE HCL 50 MG TABLET 0.00000 0.05250 3/8/2013SILDENAFIL CITRATE 20 MG TABLET 0.57580 0.57576 6/7/2013SILVER GEL ER(ML) 0.00000 48.44700 12/14/2012SILVER NITRATE 0.5 % SOLUTION 0.00000 0.03476 12/14/2012SILVER SULFADIAZINE 1 % CREAM (G) 0.00000 0.23000 12/1/2012SIMETHICONE 125 MG CAPSULE 0.09826 0.10676 7/5/2013SIMETHICONE 125 MG TAB CHEW 0.00000 0.07236 12/14/2012SIMETHICONE 180 MG CAPSULE 0.13147 0.07816 8/30/2013SIMETHICONE 40MG/0.6ML DROPS SUSP 0.00000 0.08040 12/14/2012SIMETHICONE 80 MG TAB CHEW 0.00000 0.02425 12/14/2012SIMVASTATIN 10 MG TABLET 0.00000 0.03473 9/20/2013SIMVASTATIN 20 MG TABLET 0.00000 0.04000 4/19/2013SIMVASTATIN 40 MG TABLET 0.00000 0.06240 4/19/2013SIMVASTATIN 5 MG TABLET 0.04167 0.04169 7/12/2013SIMVASTATIN 80 MG TABLET 0.00000 0.10413 8/16/2013SOD/POT/K CIT/SOD CIT/CIT ACID 500-550/5 SOLUTION 0.00000 0.04724 8/9/2013SODIUM BENZOATE POWDER 0.00000 0.04664 12/14/2012SODIUM BICARBONATE 0.5MEQ/ML DISP SYRIN 0.00000 0.44100 1/25/2013SODIUM BICARBONATE 0.5MEQ/ML VIAL 0.00000 0.42840 3/1/2013SODIUM BICARBONATE 0.9MEQ/ML DISP SYRIN 0.00000 0.12734 12/14/2012SODIUM BICARBONATE 1 MEQ/ML DISP SYRIN 0.00000 0.09770 1/25/2013SODIUM BICARBONATE 1 MEQ/ML VIAL 0.00000 0.02654 8/9/2013SODIUM BICARBONATE 10MEQ/10ML DISP SYRIN 0.00000 0.74256 12/14/2012SODIUM BICARBONATE 325 MG TABLET 0.00000 0.02155 12/14/2012SODIUM BICARBONATE 650 MG TABLET 0.00000 0.00953 3/22/2013SODIUM CHLORIDE 0.45 % PGGYBK PRT 0.00000 0.03640 1/25/2013SODIUM CHLORIDE 0.45 % 0.45 % IV SOLN 0.00000 0.00146 4/19/2013SODIUM CHLORIDE 0.65 % SPRAY 0.02466 0.02590 6/7/2013SODIUM CHLORIDE 2.5 MEQ/ML VIAL 0.00000 0.02780 4/5/2013SODIUM CHLORIDE 3 % 3 % IV SOLN 0.00000 0.00878 4/19/2013SODIUM CHLORIDE 4 MEQ/ML VIAL 0.00000 0.02077 12/14/2012SODIUM CHLORIDE 5 % 5 % IV SOLN 0.00000 0.00770 1/25/2013SODIUM CHLORIDE 5 % OINT. (G) 0.00000 2.36194 4/5/2013SODIUM CHLORIDE FOR INHALATION 0.9 % VIAL-NEB 0.00000 0.02980 3/1/2013SODIUM CHLORIDE FOR INHALATION 10 % VIAL-NEB 0.00000 0.04183 3/1/2013SODIUM CHLORIDE FOR INHALATION 3 % VIAL-NEB 0.00000 0.04285 8/9/2013SODIUM CHLORIDE FOR INHALATION 7 % VIAL-NEB 0.00000 0.07000 12/14/2012SODIUM CHLORIDE IRRIG SOLUTION 0.9 % IRRIG SOLN 0.00000 0.00580 1/25/2013SODIUM CHLORIDE/NAHCO3/KCL/PEG 420G SOLN RECON 0.00390 0.00376 8/9/2013SODIUM FERRIC GLUCONAT/SUCROSE 62.5MG/5ML VIAL 0.00000 5.15216 12/14/2012SODIUM FLUORIDE 0.25(0.55) TAB CHEW 0.00000 0.03738 3/1/2013SODIUM FLUORIDE 0.5 MG/ML DROPS 0.00000 0.17316 7/19/2013SODIUM FLUORIDE 0.5(1.1)MG TAB CHEW 0.00000 0.03740 2/22/2013SODIUM FLUORIDE 1.1 % CREAM (G) 0.00000 0.08013 8/30/2013SODIUM FLUORIDE 1.1 % GEL (GRAM) 0.00000 0.06890 2/22/2013SODIUM FLUORIDE 1MG(2.2MG) TAB CHEW 0.00000 0.03852 4/19/2013SODIUM HYPOCHLORITE 0.125 % SOLUTION 0.00000 9.54390 1/25/2013SODIUM HYPOCHLORITE 0.25 % SOLUTION 0.00000 0.04024 12/14/2012SODIUM HYPOCHLORITE 0.5 % SOLUTION 0.00000 0.04024 12/14/2012SODIUM LACTATE 5 MEQ/ML VIAL 0.00000 0.39992 12/14/2012SODIUM MORRHUATE 50 MG/ML VIAL 0.00000 1.96000 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

SODIUM POLYSTYRENE SULFONATE POWDER 0.00000 0.21960 8/30/2013SODIUM POLYSTYRENE SULFONATE 15G/60ML ORAL SUSP 0.00000 0.09336 8/9/2013SODIUM POLYSTYRENE SULFONATE 30G/120ML ENEMA 0.00000 0.25725 7/26/2013SODIUM POLYSTYRENE SULFONATE 50G/200ML ENEMA 0.00000 0.15435 7/26/2013SORBITOL SOLUTION 3 % IRRIG SOLN 0.00000 0.00351 12/14/2012SORBITOL SOLUTION 3.3% IRRIG SOLN 0.00000 0.00332 12/14/2012SOTALOL HCL 120 MG TABLET 0.00000 0.26813 8/16/2013SOTALOL HCL 150MG/10ML VIAL 0.00000 5.68750 1/25/2013SOTALOL HCL 160 MG TABLET 0.00000 0.35564 5/17/2013SOTALOL HCL 240 MG TABLET 0.00000 0.35321 3/29/2013SOTALOL HCL 80 MG TABLET 0.00000 0.09779 8/16/2013SPINOSAD 0.9 % SUSPENSION 0.00000 1.13995 3/8/2013SPIRONOLACT/HYDROCHLOROTHIAZID 25 MG-25MG TABLET 0.00000 0.72829 4/26/2013SPIRONOLACTONE 100 % POWDER 0.00000 18.81550 1/25/2013SPIRONOLACTONE 100 MG TABLET 0.00000 0.45212 4/26/2013SPIRONOLACTONE 25 MG TABLET 0.00000 0.06464 4/26/2013SPIRONOLACTONE 50 MG TABLET 0.00000 0.24616 4/26/2013SPIRONOLACTONE, MICRONIZED 100 % POWDER 0.00000 9.66880 1/25/2013STAVUDINE 1 MG/ML SOLN RECON 0.00000 0.27563 12/14/2012STAVUDINE 15 MG CAPSULE 0.00000 1.32500 1/25/2013STAVUDINE 20 MG CAPSULE 0.00000 1.31140 1/25/2013STAVUDINE 30 MG CAPSULE 0.00000 1.09200 9/27/2013STAVUDINE 40 MG CAPSULE 0.00000 1.43330 5/17/2013STREPTOMYCIN SULFATE 1 G VIAL 0.00000 11.16500 12/14/2012SUCRALFATE 1 G TABLET 0.22280 0.22284 8/16/2013SUCRALFATE 1 G/10 ML ORAL SUSP 0.00000 0.42069 6/28/2013SULFACETAMIDE SOD/SULFUR/UREA 10%-4%-10% CLEANSER 0.00000 0.15690 12/14/2012SULFACETAMIDE SOD/SULFUR/UREA 10%-5%-10% CLEANSER 0.00000 0.49178 12/14/2012SULFACETAMIDE SODIUM 10 % CLEANSER 0.35504 0.39051 9/27/2013SULFACETAMIDE SODIUM 10 % DROPS 0.00000 2.76010 2/1/2013SULFACETAMIDE SODIUM 10 % OINT. (G) 0.00000 13.17200 12/14/2012SULFACETAMIDE SODIUM 10 % SUSPENSION 0.00000 0.61247 12/14/2012SULFACETAMIDE SODIUM/SULFUR 10 %-1 % CLEANSER 0.00000 0.12531 12/14/2012SULFACETAMIDE SODIUM/SULFUR 10 %-5 % MED. PAD 0.00000 4.47784 8/16/2013SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) CLEANSER 0.00000 0.11587 6/28/2013SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) CREAM (G) 3.96704 4.47804 10/4/2013SULFACETAMIDE SODIUM/SULFUR 8 %-4 % SUSPENSION 0.00000 0.20795 12/14/2012SULFACETAMIDE SODIUM/SULFUR 9 %-4 % CLEANSER 0.00000 0.22315 12/14/2012SULFACETAMIDE SODIUM/SULFUR 9 %-4.5 % CLEANSER 0.24900 0.26751 3/15/2013SULFACETAMIDE/PREDNISOLONE SP 10 %-0.23% DROPS 0.00000 2.56476 2/15/2013SULFADIAZINE 500 MG TABLET 0.00000 3.00100 2/8/2013SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ORAL SUSP 0.00000 0.07070 1/25/2013SULFAMETHOXAZOLE/TRIMETHOPRIM 400MG-80MG TABLET 0.00000 0.07992 5/3/2013SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML VIAL 0.00000 0.45860 1/25/2013SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160 MG TABLET 0.00000 0.06180 1/25/2013SULFASALAZINE 500 MG TABLET 0.00000 0.15600 8/30/2013SULFASALAZINE 500 MG TABLET DR 0.00000 0.23850 1/25/2013SULINDAC 150 MG TABLET 0.00000 0.12532 5/17/2013SULINDAC 200 MG TABLET 0.16308 0.16310 1/25/2013SUMATRIPTAN 20 MG SPRAY 0.00000 34.47850 5/17/2013SUMATRIPTAN 5 MG SPRAY 0.00000 34.47850 5/17/2013SUMATRIPTAN SUCCINATE 100 MG TABLET 0.00000 0.84326 7/19/2013SUMATRIPTAN SUCCINATE 25 MG TABLET 0.00000 0.84366 4/19/2013SUMATRIPTAN SUCCINATE 4 MG/0.5ML CARTRIDGE 0.00000 142.35900 12/14/2012

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

SUMATRIPTAN SUCCINATE 4 MG/0.5ML PEN INJCTR 0.00000 150.29700 12/14/2012SUMATRIPTAN SUCCINATE 50 MG TABLET 0.00000 0.70574 7/12/2013SUMATRIPTAN SUCCINATE 6 MG/0.5ML CARTRIDGE 0.00000 129.12200 12/14/2012SUMATRIPTAN SUCCINATE 6 MG/0.5ML PEN INJCTR 0.00000 136.48620 1/25/2013SUMATRIPTAN SUCCINATE 6 MG/0.5ML VIAL 63.78575 62.39175 9/13/2013TACROLIMUS 0.5 MG CAPSULE 0.00000 1.18024 10/4/2013TACROLIMUS 1 MG CAPSULE 0.00000 2.02426 10/4/2013TACROLIMUS 5 MG CAPSULE 0.00000 12.32952 8/30/2013TAMOXIFEN CITRATE 10 MG TABLET 0.00000 0.15800 1/25/2013TAMOXIFEN CITRATE 20 MG TABLET 0.00000 0.42045 5/31/2013TAMSULOSIN HCL 0.4 MG CAP ER 24H 0.00000 0.17084 6/14/2013TEA TREE OIL 100 % OIL 0.23180 0.25509 7/26/2013TEMAZEPAM 15 MG CAPSULE 0.06960 0.06955 6/28/2013TEMAZEPAM 22.5 MG CAPSULE 0.00000 6.10781 12/14/2012TEMAZEPAM 30 MG CAPSULE 0.00000 0.08362 4/19/2013TEMAZEPAM 7.5 MG CAPSULE 0.00000 5.57707 4/26/2013TENIPOSIDE 50 MG/5 ML AMPUL 0.00000 56.11060 8/16/2013TERAZOSIN HCL 1 MG CAPSULE 0.00000 0.05410 1/25/2013TERAZOSIN HCL 10 MG CAPSULE 0.00000 0.06940 1/25/2013TERAZOSIN HCL 2 MG CAPSULE 0.06100 0.05574 9/27/2013TERAZOSIN HCL 5 MG CAPSULE 0.06270 0.06266 8/16/2013TERBINAFINE HCL 1 % CREAM (G) 0.29480 0.32428 5/31/2013TERBINAFINE HCL 250 MG TABLET 0.16844 0.16823 8/30/2013TERBUTALINE SULFATE 2.5 MG TABLET 0.00000 0.27990 5/17/2013TERBUTALINE SULFATE 5 MG TABLET 0.00000 0.40990 5/17/2013TERCONAZOLE 0.4 % CREAM/APPL 0.00000 0.67269 7/26/2013TERCONAZOLE 0.8 % CREAM/APPL 0.00000 1.43255 7/5/2013TERCONAZOLE 80 MG SUPP.VAG 0.00000 22.83867 4/12/2013TESTOSTERONE CYPIONATE 100 MG/ML VIAL 0.00000 4.13980 12/1/2012TESTOSTERONE ENANTHATE 200 MG/ML VIAL 0.00000 11.89300 4/19/2013TETANUS & DIPHTHERIA TOX,ADULT 2-2LF/0.5 VIAL 0.00000 30.27570 1/25/2013TETANUS,DIPHTHERIA TOXD PED/PF 5-25/0.5ML VIAL 0.00000 75.04140 1/25/2013TETRACAINE HCL 0.5 % DROPS 0.00000 0.49187 12/14/2012TETRACAINE HCL/PF 0.5 % DROPS 0.00000 8.12960 1/25/2013TETRACYCLINE HCL POWDER 0.59426 0.63044 9/27/2013TETRACYCLINE HCL 250 MG CAPSULE 0.00000 0.03000 1/25/2013TETRACYCLINE HCL 500 MG CAPSULE 0.00000 0.05521 12/14/2012THEOPHYLLINE ANHYDROUS 100 MG TAB ER 12H 0.00000 0.12830 1/25/2013THEOPHYLLINE ANHYDROUS 200 MG TAB ER 12H 0.00000 0.15509 4/26/2013THEOPHYLLINE ANHYDROUS 300 MG TAB ER 12H 0.00000 0.19349 5/3/2013THEOPHYLLINE ANHYDROUS 400 MG TABLET ER 0.00000 0.95030 2/1/2013THEOPHYLLINE ANHYDROUS 450 MG TAB ER 12H 0.00000 0.47789 12/14/2012THEOPHYLLINE ANHYDROUS 600 MG TABLET ER 0.00000 1.37320 2/1/2013THEOPHYLLINE ANHYDROUS 80 MG/15ML ELIXIR 0.13875 0.58429 7/5/2013THEOPHYLLINE ANHYDROUS 80 MG/15ML SOLUTION 0.13875 0.19140 5/17/2013THEOPHYLLINE/D5W 200MG/0.1L IV SOLN 0.00000 0.03335 12/14/2012THEOPHYLLINE/D5W 200MG/50ML IV SOLN 0.00000 0.09490 1/25/2013THEOPHYLLINE/D5W 400MG/.25L IV SOLN 0.00000 0.01852 12/14/2012THEOPHYLLINE/D5W 400MG/0.5L IV SOLN 0.00000 0.00730 12/14/2012THEOPHYLLINE/D5W 800MG/.25L IV SOLN 0.00000 0.01890 1/25/2013THIAMINE HCL 100 MG TABLET 0.01380 0.01375 7/19/2013THIAMINE HCL 100 MG/ML VIAL 0.00000 4.35316 3/29/2013THIAMINE HCL 50 MG TABLET 0.00000 0.01586 12/14/2012THIAMINE MONONITRATE 100 MG TABLET 0.02940 0.02455 7/26/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

THIORIDAZINE HCL 10 MG TABLET 0.00000 0.20589 3/1/2013THIORIDAZINE HCL 100 MG TABLET 0.00000 0.43590 8/16/2013THIORIDAZINE HCL 25 MG TABLET 0.00000 0.24040 2/15/2013THIORIDAZINE HCL 50 MG TABLET 0.00000 0.35333 5/3/2013THIOTEPA 15 MG VIAL 0.00000 111.46363 12/14/2012THIOTHIXENE 2 MG CAPSULE 0.00000 0.25892 7/26/2013THIOTHIXENE 5 MG CAPSULE 0.00000 0.39106 7/26/2013THYROID,PORK 30 MG TABLET 0.00000 0.09114 12/14/2012THYROID,PORK 60 MG TABLET 0.00000 0.10129 12/14/2012THYROID,PORK 90 MG TABLET 0.00000 0.15974 12/14/2012TIAGABINE HCL 2 MG TABLET 4.67694 4.67690 1/25/2013TIAGABINE HCL 4 MG TABLET 4.67694 4.67690 1/25/2013TICLOPIDINE HCL 250 MG TABLET 0.65360 0.65364 8/2/2013TIMOLOL MALEATE 0.25 % DROPS 0.00000 0.65258 3/22/2013TIMOLOL MALEATE 0.25 % SOL-GEL 0.00000 6.93000 12/14/2012TIMOLOL MALEATE 0.5 % DROPS 0.00000 0.75330 12/1/2012TIMOLOL MALEATE 0.5 % SOL-GEL 0.00000 8.19000 2/1/2013TIMOLOL MALEATE 10 MG TABLET 0.00000 0.55130 1/25/2013TIMOLOL MALEATE 20 MG TABLET 0.00000 1.01710 1/25/2013TIMOLOL MALEATE 5 MG TABLET 0.00000 0.44560 1/25/2013TINIDAZOLE 250 MG TABLET 0.00000 3.68381 12/14/2012TINIDAZOLE 500 MG TABLET 0.00000 3.68550 8/30/2013TIZANIDINE HCL 2 MG CAPSULE 1.72990 1.72987 3/15/2013TIZANIDINE HCL 2 MG TABLET 0.00000 0.28165 9/20/2013TIZANIDINE HCL 4 MG CAPSULE 0.00000 2.19301 12/14/2012TIZANIDINE HCL 4 MG TABLET 0.00000 0.32000 6/21/2013TIZANIDINE HCL 6 MG CAPSULE 0.00000 3.28900 3/15/2013TOBRAMYCIN 0.3 % DROPS 0.00000 2.11500 2/15/2013TOBRAMYCIN SULFATE 1.2 G VIAL 0.00000 74.31250 12/14/2012TOBRAMYCIN SULFATE 10 MG/ML VIAL 0.00000 1.10250 1/25/2013TOBRAMYCIN SULFATE 40 MG/ML VIAL 0.00000 0.56843 12/14/2012TOBRAMYCIN/DEXAMETHASONE 0.3 %-0.1% DROPS SUSP 0.00000 13.95800 4/26/2013TOBRAMYCIN/SODIUM CHLORIDE 60 MG/50ML PIGGYBACK 0.00000 0.31870 12/14/2012TOBRAMYCIN/SODIUM CHLORIDE 80MG/100ML PIGGYBACK 0.00000 0.18270 12/14/2012TOLAZAMIDE 250 MG TABLET 0.00000 2.22090 1/25/2013TOLAZAMIDE 500 MG TABLET 0.00000 1.52140 1/25/2013TOLBUTAMIDE 500 MG TABLET 0.00000 0.73440 1/25/2013TOLMETIN SODIUM 200 MG TABLET 0.00000 0.52500 2/8/2013TOLMETIN SODIUM 400 MG CAPSULE 0.00000 1.16584 12/14/2012TOLMETIN SODIUM 600 MG TABLET 0.00000 2.47650 1/25/2013TOLNAFTATE 1 % AERO POWD 0.00000 0.02769 12/14/2012TOLNAFTATE 1 % CREAM (G) 0.00000 0.10090 12/1/2012TOLNAFTATE 1 % POWDER 0.00000 0.04750 1/25/2013TOLTERODINE TARTRATE 1 MG TABLET 0.00000 1.07090 1/25/2013TOLTERODINE TARTRATE 2 MG TABLET 0.00000 1.09920 1/25/2013TOPIRAMATE 100 MG TABLET 0.00000 0.09235 6/14/2013TOPIRAMATE 15 MG CAP SPRINK 0.00000 0.52930 8/30/2013TOPIRAMATE 200 MG TABLET 0.00000 0.11890 1/25/2013TOPIRAMATE 25 MG CAP SPRINK 0.00000 0.64745 8/16/2013TOPIRAMATE 25 MG TABLET 0.03240 0.03243 2/15/2013TOPIRAMATE 50 MG TABLET 0.00000 0.06275 6/14/2013TOPOTECAN HCL 4 MG VIAL 138.71330 113.93900 8/16/2013TOPOTECAN HCL 4 MG/4 ML VIAL 124.05225 119.60550 5/24/2013TORSEMIDE 10 MG TABLET 0.00000 0.12600 5/17/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

TORSEMIDE 100 MG TABLET 0.00000 0.34440 5/17/2013TORSEMIDE 20 MG TABLET 0.00000 0.12636 5/17/2013TORSEMIDE 20 MG/2 ML VIAL 0.00000 4.31340 12/14/2012TORSEMIDE 5 MG TABLET 0.00000 0.11160 5/17/2013TORSEMIDE 50 MG/5 ML VIAL 0.00000 2.34654 12/14/2012TRAMADOL HCL 100 MG TAB ER 24H 0.00000 1.88500 5/31/2013TRAMADOL HCL 100 MG TBMP 24HR 0.00000 1.86080 1/25/2013TRAMADOL HCL 200 MG TAB ER 24H 0.00000 4.21009 3/22/2013TRAMADOL HCL 200 MG TBMP 24HR 0.00000 2.95290 1/25/2013TRAMADOL HCL 300 MG TAB ER 24H 0.00000 7.09800 8/30/2013TRAMADOL HCL 300 MG TBMP 24HR 0.00000 3.77000 12/14/2012TRAMADOL HCL 50 MG TABLET 0.02133 0.02131 8/23/2013TRAMADOL HCL/ACETAMINOPHEN 37.5-325MG TABLET 0.18140 0.18144 3/15/2013TRANDOLAPRIL 1 MG TABLET 0.25060 0.25064 8/23/2013TRANDOLAPRIL 2 MG TABLET 0.27370 0.27372 8/23/2013TRANDOLAPRIL 4 MG TABLET 0.27360 0.25133 8/23/2013TRANEXAMIC ACID 1000 MG/10 AMPUL 0.00000 3.94380 12/14/2012TRANEXAMIC ACID 1000 MG/10 VIAL 6.09656 5.59402 8/23/2013TRANEXAMIC ACID 650 MG TABLET 0.00000 3.65202 1/25/2013TRANYLCYPROMINE SULFATE 10 MG TABLET 0.00000 1.80076 12/14/2012TRAVOPROST (BENZALKONIUM) 0.004 % DROPS 0.00000 29.13400 5/3/2013TRAZODONE HCL 100 MG TABLET 0.00000 0.04700 1/25/2013TRAZODONE HCL 150 MG TABLET 0.00000 0.10498 10/11/2013TRAZODONE HCL 300 MG TABLET 0.00000 3.39183 12/14/2012TRAZODONE HCL 50 MG TABLET 0.00000 0.02440 1/25/2013TRETINOIN 0.01 % GEL (GRAM) 0.00000 0.84224 5/31/2013TRETINOIN 0.025 % CREAM (G) 0.00000 0.72259 6/28/2013TRETINOIN 0.025 % GEL (GRAM) 0.00000 1.07311 4/26/2013TRETINOIN 0.05 % CREAM (G) 0.00000 1.50816 6/7/2013TRETINOIN 0.1 % CREAM (G) 0.00000 1.73860 6/7/2013TRETINOIN 10 MG CAPSULE 0.00000 20.32926 12/14/2012TRIAMCINOLONE ACETONIDE 0.025 % CREAM (G) 0.00000 0.09310 1/25/2013TRIAMCINOLONE ACETONIDE 0.025 % LOTION 0.00000 0.73030 5/31/2013TRIAMCINOLONE ACETONIDE 0.025 % OINT. (G) 0.00000 0.09310 1/25/2013TRIAMCINOLONE ACETONIDE 0.1 % CREAM (G) 0.00000 0.21180 2/1/2013TRIAMCINOLONE ACETONIDE 0.1 % LOTION 0.00000 1.05000 5/17/2013TRIAMCINOLONE ACETONIDE 0.1 % OINT. (G) 0.04860 0.04864 2/1/2013TRIAMCINOLONE ACETONIDE 0.1 % PASTE (G) 0.00000 8.65310 8/2/2013TRIAMCINOLONE ACETONIDE 0.5 % CREAM (G) 0.00000 0.47180 2/22/2013TRIAMCINOLONE ACETONIDE 0.5 % OINT. (G) 0.47130 0.47133 7/19/2013TRIAMCINOLONE ACETONIDE 55MCG SPRAY 0.00000 4.80847 7/12/2013TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25 MG CAPSULE 0.00000 0.21575 10/11/2013TRIAMTERENE/HYDROCHLOROTHIAZID 37.5-25 MG TABLET 0.19700 0.19698 2/15/2013TRIAMTERENE/HYDROCHLOROTHIAZID 75 MG-50MG TABLET 0.21910 0.21909 4/12/2013TRIAZOLAM 0.125 MG TABLET 0.00000 0.20980 3/1/2013TRIAZOLAM 0.25 MG TABLET 0.00000 0.72108 8/30/2013TRIFLUOPERAZINE HCL 1 MG TABLET 0.00000 0.25948 4/5/2013TRIFLUOPERAZINE HCL 10 MG TABLET 0.00000 1.67825 9/20/2013TRIFLUOPERAZINE HCL 2 MG TABLET 0.00000 0.36440 2/15/2013TRIFLUOPERAZINE HCL 5 MG TABLET 0.00000 1.11338 9/20/2013TRIFLURIDINE 1 % DROPS 0.00000 16.63947 8/16/2013TRIHEXYPHENIDYL HCL 2 MG TABLET 0.00000 0.05410 1/25/2013TRIHEXYPHENIDYL HCL 2 MG/5 ML ELIXIR 0.00000 0.03920 2/8/2013TRIHEXYPHENIDYL HCL 5 MG TABLET 0.00000 0.11100 1/25/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

TRIMETHOBENZAMIDE HCL 100 MG/ML VIAL 0.00000 4.38990 1/25/2013TRIMETHOBENZAMIDE HCL 300 MG CAPSULE 0.00000 1.14618 4/12/2013TRIMETHOPRIM 100 MG TABLET 0.28926 0.28984 9/27/2013TROPICAMIDE 0.5 % DROPS 0.00000 0.64860 1/25/2013TROPICAMIDE 1 % DROPS 0.46107 0.52737 6/28/2013TROSPIUM CHLORIDE 20 MG TABLET 1.92680 1.92682 6/14/2013TROSPIUM CHLORIDE 60 MG CAP ER 24H 0.00000 4.71567 12/14/2012UREA 39 % CREAM (G) 0.00000 1.08841 6/21/2013UREA 40 % LOTION 0.00000 0.06890 1/25/2013UREA 40 % NL FM SUSP 0.00000 11.93033 12/14/2012UREA 45 % GEL/PF APP 0.00000 5.82575 12/14/2012UREA 45 % LOTION 0.00000 0.17003 12/14/2012UREA/HYALURONATE SODIUM 40%-0.2% KIT 0.00000 282.72300 12/14/2012URSODIOL 250 MG TABLET 0.00000 1.87768 5/17/2013URSODIOL 300 MG CAPSULE 0.00000 0.32674 5/17/2013URSODIOL 500 MG TABLET 0.00000 3.32738 12/14/2012VALACYCLOVIR HCL 1000 MG TABLET 0.00000 1.41370 8/30/2013VALACYCLOVIR HCL 500 MG TABLET 0.00000 0.90628 8/30/2013VALPROATE SODIUM 100 % POWDER 0.00000 4.63400 5/17/2013VALPROATE SODIUM 250 MG/5ML SOLUTION 0.00000 0.01420 5/17/2013VALPROATE SODIUM 250 MG/CUP SOLUTION 0.00000 0.30250 1/25/2013VALPROATE SODIUM 500MG/10ML SOLUTION 0.00000 0.07088 12/14/2012VALPROIC ACID 250 MG CAPSULE 0.00000 0.16253 9/27/2013VALSARTAN/HYDROCHLOROTHIAZIDE 160-12.5MG TABLET 0.00000 0.73040 4/19/2013VALSARTAN/HYDROCHLOROTHIAZIDE 160-25MG TABLET 0.00000 0.82920 4/19/2013VALSARTAN/HYDROCHLOROTHIAZIDE 320-12.5MG TABLET 0.00000 3.79428 5/10/2013VALSARTAN/HYDROCHLOROTHIAZIDE 320MG-25MG TABLET 4.30415 4.30406 9/20/2013VALSARTAN/HYDROCHLOROTHIAZIDE 80-12.5MG TABLET 0.00000 0.67110 4/19/2013VANCOMYCIN HCL 1 G VIAL 0.00000 4.31940 3/1/2013VANCOMYCIN HCL 1 G VIAL PORT 0.00000 4.40160 2/15/2013VANCOMYCIN HCL 10 G VIAL 0.00000 35.96050 2/22/2013VANCOMYCIN HCL 125 MG CAPSULE 21.92457 21.92673 4/19/2013VANCOMYCIN HCL 250 MG CAPSULE 0.00000 40.40096 8/2/2013VANCOMYCIN HCL 5 G VIAL 0.00000 19.20450 3/22/2013VANCOMYCIN HCL 500 MG VIAL 0.00000 2.58848 6/28/2013VANCOMYCIN HCL 500 MG VIAL PORT 0.00000 2.74260 1/25/2013VANCOMYCIN HCL 750 MG VIAL 0.00000 6.69900 1/25/2013VANCOMYCIN HCL 750 MG VIAL PORT 0.00000 10.90110 12/14/2012VANCOMYCIN HCL/D5W 1G/200ML FROZ.PIGGY 0.00000 0.29790 1/25/2013VANCOMYCIN HCL/D5W 500MG/0.1L FROZ.PIGGY 0.00000 0.10933 12/14/2012VANCOMYCIN IN DEXTROSE,ISO-OSM 750MG/.15L FROZ.PIGGY 0.00000 0.17722 12/14/2012VASOPRESSIN 20 UNIT/ML VIAL 0.00000 1.97529 12/14/2012VENLAFAXINE HCL 100 MG TABLET 0.00000 0.36640 1/25/2013VENLAFAXINE HCL 150 MG CAP ER 24H 0.00000 0.27365 9/13/2013VENLAFAXINE HCL 150 MG TAB ER 24 0.00000 1.46640 12/14/2012VENLAFAXINE HCL 225 MG TAB ER 24 0.00000 10.83870 1/25/2013VENLAFAXINE HCL 25 MG TABLET 0.00000 0.38378 7/5/2013VENLAFAXINE HCL 37.5 MG CAP ER 24H 0.00000 0.14428 10/11/2013VENLAFAXINE HCL 37.5 MG TAB ER 24 0.00000 2.37658 12/14/2012VENLAFAXINE HCL 37.5 MG TABLET 0.32470 0.32468 3/22/2013VENLAFAXINE HCL 50 MG TABLET 0.00000 0.34585 3/1/2013VENLAFAXINE HCL 75 MG CAP ER 24H 0.19309 0.19296 8/2/2013VENLAFAXINE HCL 75 MG TAB ER 24 0.00000 2.38475 10/11/2013VENLAFAXINE HCL 75 MG TABLET 0.32590 0.32589 3/22/2013

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Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

VERAPAMIL HCL 100 MG CAP24H PCT 0.00000 1.23213 12/14/2012VERAPAMIL HCL 120 MG CAP24H PEL 0.00000 0.63239 9/20/2013VERAPAMIL HCL 120 MG TABLET 0.00000 0.07726 5/17/2013VERAPAMIL HCL 120 MG TABLET ER 0.00000 0.27215 6/7/2013VERAPAMIL HCL 180 MG CAP24H PEL 0.00000 0.66547 9/20/2013VERAPAMIL HCL 180 MG TABLET ER 0.16910 0.16911 8/30/2013VERAPAMIL HCL 2.5 MG/ML AMPUL 0.00000 1.65480 1/25/2013VERAPAMIL HCL 2.5 MG/ML DISP SYRIN 0.00000 4.46460 1/25/2013VERAPAMIL HCL 2.5 MG/ML VIAL 0.00000 2.14400 1/25/2013VERAPAMIL HCL 200 MG CAP24H PCT 0.00000 1.58723 12/14/2012VERAPAMIL HCL 240 MG CAP24H PEL 0.00000 0.76343 9/20/2013VERAPAMIL HCL 240 MG TABLET ER 0.00000 0.14490 1/25/2013VERAPAMIL HCL 300 MG CAP24H PCT 0.00000 1.81821 7/19/2013VERAPAMIL HCL 360 MG CAP24H PEL 0.00000 1.46958 12/14/2012VERAPAMIL HCL 40 MG TABLET 0.00000 0.17650 1/25/2013VERAPAMIL HCL 80 MG TABLET 0.00000 0.05600 1/25/2013VINBLASTINE SULFATE 1 MG/ML VIAL 0.00000 2.22600 12/14/2012VINBLASTINE SULFATE 10 MG VIAL 0.00000 1.81350 12/14/2012VIT A,C & E/LUTEIN/MINERALS 1000-60-2 TABLET 0.05410 0.06145 3/29/2013VIT A/VIT C/VIT E/ZINC/COPPER 14320-226 CAPSULE 0.00000 0.16420 1/25/2013VIT A/VIT C/VIT E/ZINC/COPPER 7160-113 TABLET 0.00000 0.06620 1/25/2013VIT B CMPLX 3/FA/VIT C/BIOTIN 1MG-60MG TABLET 0.00000 0.12810 1/25/2013VIT B COMP/C/FA/IRON/VIT E 500-400-18 TABLET 0.00000 0.05547 12/14/2012VIT B12/LMEFOLATE CA/VIT B6/B2 1-6-50-5MG TABLET 0.00000 1.43640 1/25/2013VITAMIN A/VIT C/ZINC/PROPOLIS 15 MG LOZENGE 0.00000 0.02440 1/25/2013VITAMIN B COMPLEX/LYSINE 790MG/15ML LIQUID 0.00000 0.03270 1/25/2013VITAMIN E 100 UNIT CAPSULE 0.00000 0.02028 12/14/2012VITAMIN E 1000 UNIT CAPSULE 0.00000 0.12857 12/14/2012VITAMIN E 200 UNIT CAPSULE 0.00000 0.02860 1/25/2013VITAMIN E 400 UNIT CAPSULE 0.00000 0.04540 1/25/2013VITAMIN E 50 UNIT/ML DROPS 0.00000 1.89350 1/25/2013VITAMIN E MIXED 400 UNIT CAPSULE 0.05030 0.05369 7/12/2013VITAMINS B1,B2,B3,B5,& B6 100-2MG/ML VIAL 0.00000 1.31319 12/14/2012VITS A & D/WHITE PET/LANOLIN OINT PACK 0.00000 0.03450 1/25/2013VORICONAZOLE 200 MG TABLET 0.00000 26.11905 7/19/2013VORICONAZOLE 200 MG VIAL 87.18650 44.58750 7/19/2013VORICONAZOLE 50 MG TABLET 0.00000 7.61796 12/14/2012WARFARIN SODIUM 1 MG TABLET 0.00000 0.06280 4/12/2013WARFARIN SODIUM 10 MG TABLET 0.00000 0.07125 5/17/2013WARFARIN SODIUM 2 MG TABLET 0.00000 0.06017 8/30/2013WARFARIN SODIUM 2.5 MG TABLET 0.00000 0.06280 4/12/2013WARFARIN SODIUM 3 MG TABLET 0.00000 0.05601 9/20/2013WARFARIN SODIUM 4 MG TABLET 0.00000 0.05415 9/20/2013WARFARIN SODIUM 5 MG TABLET 0.00000 0.06280 4/12/2013WARFARIN SODIUM 6 MG TABLET 0.00000 0.07125 8/9/2013WARFARIN SODIUM 7.5 MG TABLET 0.00000 0.07142 5/17/2013WATER LIQUID 0.00000 0.01291 12/14/2012WATER FOR INJ.,BACTERIOSTATIC VIAL 0.00000 0.02210 1/25/2013WATER FOR INJECTION,STERILE AMPUL 0.00000 0.08820 1/25/2013WATER FOR INJECTION,STERILE IV SOLN 0.00000 0.00210 1/25/2013WATER FOR INJECTION,STERILE VIAL 0.00000 0.03430 1/25/2013WATER FOR IRRIGATION,STERILE IRRIG SOLN 0.00000 0.00580 1/25/2013WATER/ME-PARABEN/PROPYLPARABEN VIAL 0.00000 0.10643 12/14/2012WHEAT GERM OIL OIL 0.00000 0.26600 12/14/2012

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Page 57: westva mastersmac Oct 11 2013 - dhhr.wv.gov Pharmacy/Documents... · acetylcysteine 200 mg/ml vial 0.00000 5.26400 12/14/2012 acitretin 10 mg capsule 0.00000 21.82892 8/2/2013 acitretin

Generic_NameOld SMAC

PriceCurrent

SMAC Price Effective_Date

0.9 % SODIUM CHLORIDE PGGYBK PRT 0.00000 0.03440 1/25/2013

Disclaimer: Price listing does not guarantee coverage

West Virginia MedicaidState Maximum Allowable Cost (SMAC) List

Effective Oct 11, 2013 ‑ Version 2013.42

WITCH HAZEL 50 % MED. PAD 0.07611 0.07692 6/14/2013ZAFIRLUKAST 10 MG TABLET 0.00000 1.19188 12/14/2012ZAFIRLUKAST 20 MG TABLET 1.19188 1.25253 6/14/2013ZALEPLON 10 MG CAPSULE 0.00000 0.24951 5/17/2013ZALEPLON 5 MG CAPSULE 0.00000 0.21208 2/22/2013ZIDOVUDINE 10 MG/ML SYRUP 0.00000 0.12787 5/10/2013ZIDOVUDINE 100 MG CAPSULE 0.84773 0.73593 8/16/2013ZIDOVUDINE 300 MG TABLET 0.40279 0.39449 8/16/2013ZINC CHLORIDE 1 MG/ML VIAL 0.00000 0.17050 1/25/2013ZINC SULFATE 1 MG/ML VIAL 0.00000 0.21874 12/14/2012ZINC SULFATE 5 MG/ML VIAL 0.00000 0.65343 12/14/2012ZIPRASIDONE HCL 20 MG CAPSULE 0.00000 2.69450 5/17/2013ZIPRASIDONE HCL 40 MG CAPSULE 0.00000 2.69450 5/17/2013ZIPRASIDONE HCL 60 MG CAPSULE 0.00000 3.08300 5/17/2013ZIPRASIDONE HCL 80 MG CAPSULE 0.00000 3.08300 5/17/2013ZOLEDRONIC ACID/MANNITOL&WATER 4 MG/100ML PIGGYBACK 0.00000 10.14930 8/16/2013ZOLMITRIPTAN 2.5 MG TAB RAPDIS 0.00000 35.08983 5/31/2013ZOLMITRIPTAN 2.5 MG TABLET 0.00000 35.08983 5/31/2013ZOLMITRIPTAN 5 MG TAB RAPDIS 0.00000 38.79167 5/31/2013ZOLMITRIPTAN 5 MG TABLET 0.00000 38.79167 5/31/2013ZOLPIDEM TARTRATE 10 MG TABLET 0.00000 0.02669 8/16/2013ZOLPIDEM TARTRATE 12.5 MG TAB MPHASE 0.00000 2.76720 1/11/2013ZOLPIDEM TARTRATE 5 MG TABLET 0.00000 0.02565 4/19/2013ZOLPIDEM TARTRATE 6.25 MG TAB MPHASE 0.00000 1.39053 8/16/2013ZONISAMIDE 100 MG CAPSULE 0.00000 0.22022 8/23/2013ZONISAMIDE 25 MG CAPSULE 0.00000 0.10005 6/21/2013ZONISAMIDE 50 MG CAPSULE 0.00000 0.33031 8/23/2013

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