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Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
0.9 % SODIUM CHLORIDE INJECTION VIAL (ML) 0.9 % 0.05712 08/12/2014
0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 0.9 % 0.00196 03/06/2015 0.00196 08/21/2015
0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK WITH THREADED PORT (ML)
0.03505 01/30/2015 0.03505 08/21/2015
0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK WITH VIAL PORT (NON-THREADED)
0.04175 07/18/2014
ABACAVIR SULFATE ORAL TABLET 300 MG 1.77633 11/25/2017 0.36867 05/22/2020
ABIRATERONE ACETATE ORAL TABLET 250 MG 3.78000 02/21/2020 4.56040 02/24/2020
ACAMPROSATE CALCIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 333 MG
0.74145 04/09/2020 0.70192 06/19/2020
ACARBOSE ORAL TABLET 100 MG 0.18990 03/02/2018 0.13000 11/16/2018
ACARBOSE ORAL TABLET 25 MG 0.23329 08/21/2015 0.13994 08/25/2017
ACARBOSE ORAL TABLET 50 MG 0.14640 05/25/2018 0.12500 11/16/2018
ACEBUTOLOL HCL ORAL CAPSULE 200 MG 0.40001 06/04/2019 0.60776 10/07/2019
ACEBUTOLOL HCL ORAL CAPSULE 400 MG 0.26000 03/27/2015 0.26000 08/21/2015
ACETAMINOPHEN ORAL CAPSULE 500 MG 0.01093 08/12/2014
ACETAMINOPHEN ORAL DROPS 80MG/0.8ML 0.17160 10/11/2013 0.17160 08/21/2015
ACETAMINOPHEN ORAL LIQUID (ML) 160 MG/5ML 0.00932 09/27/2013 0.00932 08/21/2015
ACETAMINOPHEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 160 MG/5ML
0.02137 08/21/2015 0.02033 02/17/2017
ACETAMINOPHEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 160 MG/5ML
0.01083 06/09/2017 0.02033 03/02/2018
ACETAMINOPHEN ORAL TABLET 325 MG 0.00830 06/20/2014 0.00830 08/21/2015
ACETAMINOPHEN ORAL TABLET 500 MG 0.01040 04/03/2015 0.01040 08/21/2015
ACETAMINOPHEN ORAL TABLET,CHEWABLE 80 MG 0.04651 04/03/2015 0.04651 08/21/2015
ACETAMINOPHEN ORAL TABLET,DISINTEGRATING 80 MG 0.05113 08/21/2015
ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 120 MG 0.20324 08/22/2014 0.20324 08/21/2015
ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 325 MG 0.46400 08/22/2014 0.46400 08/21/2015
ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 650 MG 0.21762 08/22/2014 0.21762 08/21/2015
ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 120-12MG/5
0.01332 01/30/2015 0.01332 08/21/2015
ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 120-12MG/5
0.21394 03/27/2015 0.21394 08/21/2015
ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL SOLUTION, ORAL 300MG/12.5
0.10079 03/27/2015 0.10079 08/21/2015
ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-15MG
0.14344 09/19/2014 0.14344 08/21/2015
ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-30MG
0.10480 10/20/2017 0.09167 12/22/2017
ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-60MG
0.19101 05/20/2016 0.17150 08/17/2018
ACETAMINOPHEN/DIPHENHYDRAMINE HCL ORAL TABLET 500MG-25MG 0.04047 04/24/2015 0.04047 08/21/2015
ACETAZOLAMIDE ORAL CAPSULE, EXTENDED RELEASE 500 MG 0.94140 09/22/2017 0.70000 11/16/2018
ACETAZOLAMIDE ORAL TABLET 125 MG 1.52593 08/21/2015 1.29790 11/16/2018
ACETAZOLAMIDE ORAL TABLET 250 MG 1.02880 02/22/2019 0.69948 05/17/2019
ACETIC ACID IRRIGATION SOLUTION, IRRIGATION 0.25 % 0.00350 03/01/2013
ACETIC ACID OTIC SOLUTION, NON-ORAL 2 % 1.81591 08/21/2015 1.65333 02/21/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
ACETIC ACID/ALUMINUM ACETATE DROPS 2 % 0.84000 01/25/2013 0.84000 08/21/2015
ACETYLCYSTEINE INTRAVENOUS VIAL (ML) 200 MG/ML 5.26400 03/06/2015 5.26400 08/21/2015
ACETYLCYSTEINE MISCELLANEOUS VIAL (ML) 100 MG/ML 0.45068 08/21/2015 0.35144 02/21/2020
ACETYLCYSTEINE MISCELLANEOUS VIAL (ML) 200 MG/ML 0.19900 02/21/2020 0.34100 03/27/2020
ACETYLCYSTEINE/MECOBALAMIN/LEVOMEFOLATE CALCIUM ORAL TABLET 600-2-6 MG
1.89794 02/20/2015 1.89794 08/21/2015
ACITRETIN ORAL CAPSULE 10 MG 6.66667 11/24/2017 9.53166 12/18/2017
ACITRETIN ORAL CAPSULE 17.5 MG 42.31920 03/21/2014
ACITRETIN ORAL CAPSULE 25 MG 12.56000 01/25/2019 9.33333 05/17/2019
ACYCLOVIR ORAL CAPSULE 200 MG 0.08844 08/21/2015 0.05480 09/22/2017
ACYCLOVIR ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200 MG/5ML 0.37206 11/16/2018 0.40698 01/19/2020
ACYCLOVIR ORAL TABLET 400 MG 0.06655 07/14/2017 0.05351 11/16/2018
ACYCLOVIR ORAL TABLET 800 MG 0.13520 12/22/2017 0.11600 08/16/2019
ACYCLOVIR SODIUM INTRAVENOUS VIAL (EA) 500 MG 31.20600 08/22/2014 31.20600 08/21/2015
ACYCLOVIR SODIUM INTRAVENOUS VIAL (ML) 50 MG/ML 1.40750 07/25/2014
ACYCLOVIR TOPICAL OINTMENT (GRAM) 5 % 1.94109 11/15/2019 0.89933 05/22/2020
ADAPALENE TOPICAL CREAM (GRAM) 0.1 % 3.51289 04/26/2013
ADAPALENE TOPICAL GEL (GRAM) 0.1 % 1.82556 06/22/2018 1.58578 11/15/2019
ADAPALENE TOPICAL GEL (GRAM) 0.3 % 4.68580 08/21/2015 3.41117 06/16/2017
ADAPALENE TOPICAL GEL WITH PUMP (GRAM) 0.3 % 4.61985 04/10/2015 4.61985 08/21/2015
ADEFOVIR DIPIVOXIL ORAL TABLET 10 MG 26.52627 09/27/2013
ALBUMIN HUMAN INTRAVENOUS INTRAVENOUS SOLUTION 25 % 1.51200 05/01/2015 1.51200 08/21/2015
ALBUMIN HUMAN INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.21588 09/19/2014 0.21588 08/21/2015
ALBUTEROL SULFATE INHALATION SOLUTION, NON-ORAL 5 MG/ML 1.45230 10/23/2017 2.12250 12/27/2019
ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (EA) 2.5 MG/0.5 0.43876 08/01/2014
ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 0.63MG/3ML 0.15441 11/16/2018 0.11333 11/15/2019
ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 1.25MG/3ML 0.19073 06/21/2019 0.15240 12/20/2019
ALBUTEROL SULFATE INHALATION VIAL, NEBULIZER (ML) 2.5 MG/3ML 0.05253 08/21/2015 0.03400 01/19/2018
ALBUTEROL SULFATE ORAL SYRUP 2 MG/5 ML 0.01277 08/21/2015 0.03571 08/28/2019
ALBUTEROL SULFATE ORAL TABLET 2 MG 4.56651 08/21/2015 4.05000 12/25/2015
ALBUTEROL SULFATE ORAL TABLET 4 MG 4.11250 08/21/2015 3.62765 12/25/2015
ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 4 MG 1.18451 04/25/2014
ALBUTEROL SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 8 MG 1.71821 04/05/2013
ALCLOMETASONE DIPROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.88300 08/16/2019 0.62717 03/20/2020
ALCLOMETASONE DIPROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 0.58692 06/28/2013
ALENDRONATE SODIUM ORAL SOLUTION, ORAL 70 MG/75ML 2.45700 09/27/2013
ALENDRONATE SODIUM ORAL TABLET 10 MG 0.18750 08/21/2015 0.13200 10/20/2017
ALENDRONATE SODIUM ORAL TABLET 35 MG 0.35333 08/17/2018 0.23750 05/17/2019
ALENDRONATE SODIUM ORAL TABLET 40 MG 2.80060 03/27/2015
ALENDRONATE SODIUM ORAL TABLET 5 MG 0.18110 08/12/2014 0.18110 08/21/2015
ALENDRONATE SODIUM ORAL TABLET 70 MG 0.27875 10/20/2017 0.23250 09/21/2018
ALFUZOSIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.11326 03/16/2018 0.05870 05/22/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
ALLOPURINOL ORAL TABLET 100 MG 0.07267 11/16/2018 0.04709 01/25/2019
ALLOPURINOL ORAL TABLET 300 MG 0.11998 10/19/2018 0.09110 07/26/2019
ALMOTRIPTAN MALATE ORAL TABLET 12.5 MG 25.31000 08/25/2017 16.33370 10/19/2018
ALPHA LIPOIC ACID ORAL CAPSULE 200 MG 0.12771 08/08/2014 0.12771 08/21/2015
ALPHA LIPOIC ACID ORAL CAPSULE 50 MG 0.10210 08/12/2014 0.10210 08/21/2015
ALPRAZOLAM ORAL TABLET 0.25 MG 0.01509 05/16/2014 0.01509 08/21/2015
ALPRAZOLAM ORAL TABLET 0.5 MG 0.01780 04/17/2015 0.01780 08/21/2015
ALPRAZOLAM ORAL TABLET 1 MG 0.01970 02/06/2015 0.01970 08/21/2015
ALPRAZOLAM ORAL TABLET 2 MG 0.07213 09/28/2015 0.04891 12/22/2017
ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 0.5 MG 0.36136 08/21/2015 0.18083 09/22/2017
ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 1 MG 0.44913 08/21/2015 0.21717 09/22/2017
ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 0.41600 08/21/2015 0.40200 08/17/2018
ALPRAZOLAM ORAL TABLET, EXTENDED RELEASE 24 HR 3 MG 0.55483 11/20/2015 0.35500 09/22/2017
ALPRAZOLAM ORAL TABLET,DISINTEGRATING 0.25 MG 1.36123 03/01/2013 1.36123 08/21/2015
ALPRAZOLAM ORAL TABLET,DISINTEGRATING 0.5 MG 1.51669 01/25/2013 1.51669 08/21/2015
ALPRAZOLAM ORAL TABLET,DISINTEGRATING 1 MG 2.02358 01/25/2013 2.02358 08/21/2015
ALPRAZOLAM ORAL TABLET,DISINTEGRATING 2 MG 3.00202 01/25/2013 3.00202 08/21/2015
ALUMINUM HYDROXIDE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 320 MG/5ML
0.00813 08/21/2015
AMANTADINE HCL ORAL CAPSULE 100 MG 0.43730 12/22/2017 0.24644 08/17/2018
AMANTADINE HCL ORAL SOLUTION, ORAL 50 MG/5 ML 0.01733 04/03/2015 0.01733 08/21/2015
AMANTADINE HCL ORAL TABLET 100 MG 1.07830 09/21/2018 0.13100 08/16/2019
AMBRISENTAN ORAL TABLET 10 MG 38.40000 02/21/2020
AMBRISENTAN ORAL TABLET 5 MG 38.40000 02/21/2020
AMCINONIDE TOPICAL CREAM (GRAM) 0.1 % 2.82140 08/12/2014
AMCINONIDE TOPICAL LOTION (ML) 0.1 % 1.90000 08/12/2014
AMCINONIDE TOPICAL OINTMENT (GRAM) 0.1 % 4.53600 08/30/2013
AMIKACIN SULFATE INJECTION VIAL (ML) 1000MG/4ML 3.14373 12/05/2014 3.14373 08/21/2015
AMIKACIN SULFATE INJECTION VIAL (ML) 500 MG/2ML 2.95555 12/05/2014 2.95555 08/21/2015
AMILORIDE HCL ORAL TABLET 5 MG 0.14880 11/15/2019 0.13230 05/22/2020
AMILORIDE HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5 MG-50 MG 0.42250 05/30/2014 0.42250 08/21/2015
AMINO ACIDS ORAL POWDER (GRAM) 0.25540 08/12/2014
AMINOCAPROIC ACID INTRAVENOUS VIAL (ML) 250 MG/ML 0.08148 02/06/2015 0.08148 08/21/2015
AMINOCAPROIC ACID ORAL TABLET 1000 MG 18.30610 08/12/2014 18.30610 08/21/2015
AMINOCAPROIC ACID ORAL TABLET 500 MG 5.37896 10/11/2013 5.37896 08/21/2015
AMINOPHYLLINE INTRAVENOUS VIAL (ML) 250MG/10ML 0.30912 01/30/2015 0.30912 08/21/2015
AMINOPHYLLINE INTRAVENOUS VIAL (ML) 500MG/20ML 0.07270 08/12/2014
AMIODARONE HCL INTRAVENOUS AMPUL (ML) 50 MG/ML 0.33600 01/25/2013
AMIODARONE HCL ORAL TABLET 100 MG 2.16500 11/24/2017 1.97100 03/20/2020
AMIODARONE HCL ORAL TABLET 200 MG 0.12724 09/30/2016 0.09890 11/16/2018
AMIODARONE HCL ORAL TABLET 400 MG 3.19526 08/22/2014 2.81936 12/02/2016
AMITRIPTYLINE HCL ORAL TABLET 10 MG 0.05742 11/16/2018 0.03550 08/16/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
AMITRIPTYLINE HCL ORAL TABLET 100 MG 0.34700 08/16/2019 0.38720 09/13/2019
AMITRIPTYLINE HCL ORAL TABLET 150 MG 0.63350 01/24/2020 0.53600 06/19/2020
AMITRIPTYLINE HCL ORAL TABLET 25 MG 0.09537 11/16/2018 0.06874 05/22/2020
AMITRIPTYLINE HCL ORAL TABLET 50 MG 0.18572 03/20/2020 0.15000 06/19/2020
AMITRIPTYLINE HCL ORAL TABLET 75 MG 0.25740 11/15/2019 0.12500 04/17/2020
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE ORAL TABLET 12.5MG-5MG 1.07296 08/01/2014
AMITRIPTYLINE HCL/CHLORDIAZEPOXIDE ORAL TABLET 25 MG-10MG 1.51380 05/02/2014
AMLODIPINE BESYLATE ORAL TABLET 10 MG 0.02527 08/21/2015 0.01238 09/21/2018
AMLODIPINE BESYLATE ORAL TABLET 2.5 MG 0.05960 08/21/2015 0.01756 07/14/2017
AMLODIPINE BESYLATE ORAL TABLET 5 MG 0.06240 08/21/2015 0.01300 08/25/2017
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG-10MG
3.63000 09/30/2016 1.46667 11/15/2019
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG-20MG
3.93004 04/10/2015 3.93004 08/21/2015
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG-40MG
3.69400 05/25/2018 2.50000 09/20/2019
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 10 MG-80MG
6.55993 08/21/2015 5.53825 06/16/2017
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 2.5MG-10MG
5.07347 08/12/2014 5.07347 08/21/2015
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 2.5MG-20MG
3.01200 09/22/2017 2.46833 03/20/2020
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 2.5MG-40MG
6.55993 08/21/2015 5.92000 09/30/2016
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG-10 MG
4.55853 08/21/2015 3.16379 06/16/2017
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG-20 MG
3.93250 08/21/2015 2.74000 05/25/2018
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG-40 MG
3.35767 09/22/2017 3.09133 02/21/2020
AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM ORAL TABLET 5 MG-80 MG
5.92000 09/30/2016 3.28900 05/17/2019
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 10 MG-20MG 0.22277 09/30/2016 0.10120 08/25/2017
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 10 MG-40MG 0.14950 11/24/2017 0.09950 07/26/2019
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 2.5MG-10MG 0.46372 03/25/2016 0.08560 09/22/2017
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 5 MG-10 MG 0.14570 08/25/2017 0.07450 08/17/2018
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 5 MG-20 MG 0.17815 08/25/2017 0.10380 09/22/2017
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE 5 MG-40 MG 0.17283 11/24/2017 0.09000 04/27/2018
AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 10 MG-20MG
0.52000 11/24/2017 0.31333 11/15/2019
AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 10 MG-40MG
0.69044 03/17/2017 0.49867 05/17/2019
AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 5 MG-20 MG
0.65033 10/20/2017 0.44433 12/22/2017
AMLODIPINE BESYLATE/OLMESARTAN MEDOXOMIL ORAL TABLET 5 MG-40 MG
0.72933 11/16/2018 0.35000 05/22/2020
AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 10MG-160MG 0.47493 04/22/2016 0.35000 03/15/2019
AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 10MG-320MG 0.53089 05/20/2016 0.43333 11/24/2017
AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 5 MG-160MG 0.42633 10/21/2019 0.33484 12/20/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
AMLODIPINE BESYLATE/VALSARTAN ORAL TABLET 5 MG-320MG 0.45034 03/03/2017 0.37667 11/15/2019
AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 10-160-25
4.40212 01/01/2017 0.91533 05/25/2018
AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 10-320-25
1.41000 05/25/2018 0.94467 05/17/2019
AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 10MG-160MG
4.40212 01/01/2017 1.15000 03/15/2019
AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 5-160-12.5
3.88023 01/01/2017 1.74210 08/25/2017
AMLODIPINE BESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 5-160-25MG
3.88023 08/21/2015 3.88023 01/01/2017
AMMONIUM CHLORIDE VIAL (ML) 5 MEQ/ML 0.42630 01/25/2013
AMMONIUM LACTATE TOPICAL CREAM (GRAM) 12 % 0.03021 04/26/2019 0.05714 06/05/2019
AMMONIUM LACTATE TOPICAL LOTION (GRAM) 12 % 0.07500 03/25/2016 0.01588 05/22/2020
AMOXAPINE ORAL TABLET 100 MG 1.16865 11/22/2013
AMOXAPINE ORAL TABLET 150 MG 1.28830 01/25/2013
AMOXAPINE ORAL TABLET 25 MG 0.27027 01/25/2013
AMOXAPINE ORAL TABLET 50 MG 0.69923 11/22/2013
AMOXICILLIN ORAL CAPSULE 250 MG 0.04730 04/10/2015 0.04730 08/21/2015
AMOXICILLIN ORAL CAPSULE 500 MG 0.06941 08/21/2015 0.05236 06/16/2017
AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML
0.01420 04/24/2015 0.01420 08/21/2015
AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 MG/5ML
0.05684 08/21/2015 0.02500 08/25/2017
AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML
0.02291 10/20/2017 0.01825 07/26/2019
AMOXICILLIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 400 MG/5ML
0.02680 08/21/2015 0.01901 07/26/2019
AMOXICILLIN ORAL TABLET 500 MG 0.25550 08/17/2018 0.13125 05/17/2019
AMOXICILLIN ORAL TABLET 875 MG 0.12230 06/16/2017 0.08590 12/22/2017
AMOXICILLIN ORAL TABLET,CHEWABLE 125 MG 0.15067 01/25/2013
AMOXICILLIN ORAL TABLET,CHEWABLE 250 MG 0.26748 10/03/2014 0.26748 08/21/2015
AMOXICILLIN ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 775 MG
11.26813 12/26/2014 11.26813 08/21/2015
AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200-28.5/5
0.11239 08/21/2015 0.03290 11/24/2017
AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250-62.5/5
0.55083 03/20/2020 0.30000 05/22/2020
AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 400-57MG/5
0.08554 03/03/2017 0.06173 11/15/2019
AMOXICILLIN/POTASSIUM CLAVULANATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 600-42.9/5
0.08168 03/03/2017 0.06436 11/16/2018
AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET 250-125 MG 4.14283 08/21/2015 3.35700 08/17/2018
AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET 500-125 MG 0.26356 11/24/2017 0.25000 09/21/2018
AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET 875-125 MG 0.24750 09/21/2018 0.23428 01/24/2020
AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET, EXTENDED RELEASE 12 HR 1000-62.5
3.37383 10/31/2014
AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET,CHEWABLE 200-28.5MG
1.00222 03/01/2013 1.00222 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
AMOXICILLIN/POTASSIUM CLAVULANATE ORAL TABLET,CHEWABLE 400-57MG
1.51840 08/22/2014 3.77335 04/22/2016
AMPHOTERICIN B INJECTION VIAL (EA) 50 MG 20.87400 05/30/2014
AMPICILLIN SODIUM INJECTION VIAL (EA) 1 G 2.89120 01/25/2013
AMPICILLIN SODIUM INJECTION VIAL (EA) 10 G 36.92358 12/26/2014 36.92358 08/21/2015
AMPICILLIN SODIUM INJECTION VIAL (EA) 125 MG 3.50250 08/12/2014
AMPICILLIN SODIUM INJECTION VIAL (EA) 2 G 6.57000 11/08/2013 6.49900 05/17/2019
AMPICILLIN SODIUM INJECTION VIAL (EA) 250 MG 1.41638 01/25/2013
AMPICILLIN SODIUM INJECTION VIAL (EA) 500 MG 1.62006 01/25/2013
AMPICILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 G
12.17907 08/12/2014
AMPICILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2 G
23.62640 01/25/2013
AMPICILLIN SODIUM/SULBACTAM SODIUM INJECTION VIAL (EA) 1.5 G 2.57012 07/18/2014 2.57012 08/21/2015
AMPICILLIN SODIUM/SULBACTAM SODIUM INJECTION VIAL (EA) 15 G 20.70600 08/12/2014 20.70600 08/21/2015
AMPICILLIN SODIUM/SULBACTAM SODIUM INJECTION VIAL (EA) 3 G 6.47640 08/23/2013 6.47640 08/21/2015
AMPICILLIN SODIUM/SULBACTAM SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1.5 G
3.24240 01/25/2013
AMPICILLIN SODIUM/SULBACTAM SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 3 G
5.22060 01/25/2013 5.22060 08/21/2015
AMPICILLIN TRIHYDRATE ORAL CAPSULE 250 MG 0.09000 08/12/2014 0.09000 08/21/2015
AMPICILLIN TRIHYDRATE ORAL CAPSULE 500 MG 0.14370 08/21/2015 0.46990 05/15/2020
AMPICILLIN TRIHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML
0.03950 02/08/2013 0.03950 08/21/2015
AMPICILLIN TRIHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML
0.06860 02/08/2013 0.06860 08/21/2015
ANAGRELIDE HCL ORAL CAPSULE 0.5 MG 0.60112 05/16/2014
ANAGRELIDE HCL ORAL CAPSULE 1 MG 1.29259 05/16/2014
ANASTROZOLE ORAL TABLET 1 MG 0.08533 06/16/2017 0.04100 08/16/2019
ANTIPYRINE/BENZOCAINE DROPS 5.4 %-1.4% 0.43271 02/06/2015 0.43271 08/21/2015
ANTIPYRINE/BENZOCAINE DROPS 5.5 %-1.4% 10.70600 12/26/2014 10.70600 08/21/2015
ANTIVENIN,LATRODECTUS MACTANS INJECTION VIAL (EA) 6000 UNIT 57.33000 12/12/2014 57.33000 08/21/2015
ANTIVENIN,MICRURUS FULVIUS INJECTION VIAL (EA) 1496.32000 01/25/2013
APRACLONIDINE HCL OPHTHALMIC DROPS 0.5 % 12.32550 08/21/2015 10.34900 08/16/2019
ARGATROBAN IN 0.9 % SODIUM CHLORIDE INTRAVENOUS VIAL (ML) 125 MG/125
11.61817 01/25/2013
ARGATROBAN IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS VIAL (ML) 50 MG/50ML
3.85000 08/12/2014
ARGATROBAN INTRAVENOUS VIAL (ML) 100 MG/ML 412.36020 05/01/2015 412.36020 08/21/2015
ARGININE HCL ORAL TABLET 1000 MG 0.14760 08/12/2014
ARGININE ORAL CAPSULE 500 MG 0.08386 08/12/2014 0.08386 08/21/2015
ARIPIPRAZOLE ORAL SOLUTION, ORAL 1 MG/ML 2.79055 03/17/2017 2.75841 04/21/2017
ARIPIPRAZOLE ORAL TABLET 10 MG 0.17992 03/20/2020 0.15550 05/22/2020
ARIPIPRAZOLE ORAL TABLET 15 MG 0.27900 04/26/2019 0.18774 11/15/2019
ARIPIPRAZOLE ORAL TABLET 2 MG 0.18274 05/17/2019 0.06467 04/17/2020
ARIPIPRAZOLE ORAL TABLET 20 MG 0.30522 06/21/2019 0.27600 09/20/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
ARIPIPRAZOLE ORAL TABLET 30 MG 0.26417 05/17/2019 0.22500 11/15/2019
ARIPIPRAZOLE ORAL TABLET 5 MG 0.19485 05/17/2019 0.14460 06/19/2020
ARMODAFINIL ORAL TABLET 150 MG 1.03341 08/01/2018
ARMODAFINIL ORAL TABLET 200 MG 1.37000 08/25/2017 1.27067 02/21/2020
ARMODAFINIL ORAL TABLET 250 MG 1.19665 08/01/2018 1.09333 01/25/2019
ASCORBIC ACID ORAL TABLET 1000 MG 0.05352 08/12/2014 0.05352 08/21/2015
ASCORBIC ACID ORAL TABLET 250 MG 0.01807 08/12/2014 0.01807 08/21/2015
ASCORBIC ACID ORAL TABLET 500 MG 0.02550 08/12/2014 0.02550 08/21/2015
ASCORBIC ACID ORAL TABLET, EXTENDED RELEASE 1000 MG 0.07311 08/12/2014 0.07311 08/21/2015
ASCORBIC ACID ORAL TABLET,CHEWABLE 250 MG 0.02510 01/25/2013
ASCORBIC ACID ORAL TABLET,CHEWABLE 500 MG 0.04768 08/12/2014 0.04768 08/21/2015
ASPIRIN ORAL TABLET 325 MG 0.00616 03/27/2015 0.00616 08/21/2015
ASPIRIN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 325 MG 0.00872 05/01/2015 0.00872 08/21/2015
ASPIRIN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 81 MG 0.00804 04/03/2015 0.00804 08/21/2015
ASPIRIN ORAL TABLET,CHEWABLE 81 MG 0.02048 05/01/2015 0.02048 08/21/2015
ASPIRIN/ACETAMINOPHEN/CAFFEINE ORAL TABLET 250-250-65 0.04476 04/24/2015 0.04476 08/21/2015
ASPIRIN/CALCIUM CARBONATE/MAGNESIUM ORAL TABLET 325 MG 0.02015 03/07/2014 0.02015 08/21/2015
ASPIRIN/SODIUM BICARBONATE/CITRIC ACID ORAL TABLET, EFFERVESCENT 325-1916MG
0.09644 08/12/2014 0.09644 08/21/2015
ATAZANAVIR SULFATE ORAL CAPSULE 150 MG 4.58000 02/21/2020
ATAZANAVIR SULFATE ORAL CAPSULE 200 MG 4.48000 02/21/2020
ATAZANAVIR SULFATE ORAL CAPSULE 300 MG 6.89000 02/21/2020
ATENOLOL ORAL TABLET 100 MG 0.03400 08/21/2015 0.01518 09/22/2017
ATENOLOL ORAL TABLET 25 MG 0.02659 04/03/2015 0.02659 08/21/2015
ATENOLOL ORAL TABLET 50 MG 0.01640 04/17/2015 0.01640 08/21/2015
ATENOLOL/CHLORTHALIDONE ORAL TABLET 100MG-25MG 0.45970 11/24/2017 0.39948 03/02/2018
ATENOLOL/CHLORTHALIDONE ORAL TABLET 50 MG-25MG 0.35135 03/02/2018 0.32495 11/16/2018
ATOMOXETINE HCL ORAL CAPSULE 10 MG 2.33485 10/24/2019 1.79000 05/22/2020
ATOMOXETINE HCL ORAL CAPSULE 100 MG 2.81100 05/17/2019 2.47000 12/20/2019
ATOMOXETINE HCL ORAL CAPSULE 18 MG 1.62233 02/21/2020 0.82333 06/19/2020
ATOMOXETINE HCL ORAL CAPSULE 25 MG 1.41167 01/24/2020 1.98117 05/22/2020
ATOMOXETINE HCL ORAL CAPSULE 40 MG 1.70867 03/20/2020 1.64600 05/22/2020
ATOMOXETINE HCL ORAL CAPSULE 60 MG 1.95000 06/21/2019 2.41600 07/17/2019
ATOMOXETINE HCL ORAL CAPSULE 80 MG 1.96534 09/20/2019 1.66667 11/15/2019
ATORVASTATIN CALCIUM ORAL TABLET 10 MG 0.05920 08/17/2018 0.04039 11/15/2019
ATORVASTATIN CALCIUM ORAL TABLET 20 MG 0.06926 02/22/2019 0.06114 07/26/2019
ATORVASTATIN CALCIUM ORAL TABLET 40 MG 0.09629 10/25/2019 0.05800 04/17/2020
ATORVASTATIN CALCIUM ORAL TABLET 80 MG 0.11409 10/20/2017 0.10064 11/15/2019
ATOVAQUONE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 750 MG/5ML
2.21000 12/21/2018 1.42857 11/15/2019
ATOVAQUONE/PROGUANIL HCL ORAL TABLET 250-100 MG 2.23250 05/17/2019 2.19550 11/15/2019
ATOVAQUONE/PROGUANIL HCL ORAL TABLET 62.5-25 MG 1.85045 06/06/2014 0.92151 01/13/2017
ATROPINE SULFATE INJECTION SYRINGE (ML) 0.05 MG/ML 2.23272 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
ATROPINE SULFATE INJECTION SYRINGE (ML) 0.1 MG/ML 0.43014 01/25/2013 0.43014 08/21/2015
ATROPINE SULFATE INJECTION VIAL (ML) 0.4 MG/ML 0.85480 08/12/2014 0.85480 08/21/2015
ATROPINE SULFATE INJECTION VIAL (ML) 1 MG/ML 1.50320 08/12/2014
ATROPINE SULFATE OPHTHALMIC DROPS 1 % 8.17320 08/22/2015 9.81029 01/31/2020
ATROPINE SULFATE OPHTHALMIC OINTMENT (GRAM) 1 % 3.98000 02/08/2013
AZATHIOPRINE ORAL TABLET 50 MG 0.21600 04/26/2019 0.18135 11/15/2019
AZELASTINE HCL NASAL AEROSOL, SPRAY WITH PUMP (ML) 137 MCG 0.33442 11/16/2018 0.27345 07/26/2019
AZELASTINE HCL NASAL AEROSOL, SPRAY WITH PUMP (ML) 205.5 MCG 1.16607 08/16/2019 1.02000 02/21/2020
AZELASTINE HCL OPHTHALMIC DROPS 0.05 % 2.20055 11/24/2017 1.31000 12/21/2018
AZITHROMYCIN INTRAVENOUS VIAL (EA) 500 MG 3.77260 08/12/2014 3.77260 08/21/2015
AZITHROMYCIN INTRAVENOUS VIAL WITH THREADED PORT (EA) 500 MG 12.68820 01/25/2013
AZITHROMYCIN ORAL PACKET (EA) 1 G 20.29440 01/17/2014 20.29440 08/21/2015
AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100 MG/5ML
0.58000 08/16/2019 0.42933 05/22/2020
AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 MG/5ML
0.56816 02/21/2020 0.55000 04/17/2020
AZITHROMYCIN ORAL TABLET 250 MG 0.29000 10/20/2017 0.27106 01/19/2018
AZITHROMYCIN ORAL TABLET 500 MG 0.97640 03/03/2017 0.56111 06/16/2017
AZITHROMYCIN ORAL TABLET 600 MG 1.49833 05/17/2019 1.25500 09/20/2019
AZTREONAM INJECTION VIAL (EA) 1 G 27.67800 08/15/2014
AZTREONAM INJECTION VIAL (EA) 2 G 39.02640 01/30/2015 39.02640 08/21/2015
B-COMPLEX WITH VITAMIN C ORAL TABLET 0.02618 08/15/2014 0.02618 08/21/2015
BACITRACIN OPHTHALMIC OINTMENT (GRAM) 500 UNIT/G 13.86800 08/21/2015 27.98908 08/15/2018
BACITRACIN TOPICAL OINTMENT (GRAM) 500 UNIT/G 0.06722 04/19/2013 0.06722 08/21/2015
BACITRACIN ZINC TOPICAL OINTMENT (GRAM) 500 UNIT/G 0.10676 04/17/2015 0.10676 08/21/2015
BACITRACIN/POLYMYXIN B SULFATE OPHTHALMIC OINTMENT (GRAM) 500-10K/G
2.81450 08/21/2015 2.05714 08/16/2019
BACITRACIN/POLYMYXIN B SULFATE TOPICAL OINTMENT (GRAM) 500-10K/G
0.27376 01/25/2013 0.27376 08/21/2015
BACLOFEN MISCELLANEOUS POWDER (GRAM) 100 % 2.61831 02/13/2015 2.61831 08/21/2015
BACLOFEN ORAL TABLET 10 MG 0.07070 01/25/2019 0.05757 01/24/2020
BACLOFEN ORAL TABLET 20 MG 0.19580 02/04/2020 0.14090 05/22/2020
BALSALAZIDE DISODIUM ORAL CAPSULE 750 MG 0.35921 09/22/2017 0.22496 03/02/2018
BCG LIVE INTRAVESICAL VIAL (EA) 50 MG 291.39600 01/25/2013
BENAZEPRIL HCL ORAL TABLET 10 MG 0.03800 10/20/2017 0.01900 11/16/2018
BENAZEPRIL HCL ORAL TABLET 20 MG 0.05197 03/27/2015 0.05197 08/21/2015
BENAZEPRIL HCL ORAL TABLET 40 MG 0.06427 08/25/2017 0.04368 10/20/2017
BENAZEPRIL HCL ORAL TABLET 5 MG 0.05199 08/21/2015 0.03583 11/16/2018
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.63132 06/16/2017 0.60520 12/22/2017
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20 MG-25MG 0.87187 03/03/2017 0.49535 06/16/2017
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG 0.19990 08/17/2018 0.68974 08/25/2018
BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 5-6.25MG 0.45890 08/21/2015
BENZOCAINE/MENTHOL MUCOUS MEMBRANE LOZENGE 15MG-3.6MG 0.09806 02/13/2015 0.09806 08/21/2015
BENZONATATE ORAL CAPSULE 100 MG 0.09980 11/16/2018 0.08282 11/15/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
BENZONATATE ORAL CAPSULE 200 MG 0.14064 09/30/2016 0.08920 08/16/2019
BENZOYL PEROXIDE TOPICAL CLEANSER (GRAM) 10 % 0.04197 05/01/2015 0.04197 08/21/2015
BENZOYL PEROXIDE TOPICAL CLEANSER (GRAM) 5 % 0.04075 08/09/2013 0.04075 08/21/2015
BENZOYL PEROXIDE TOPICAL FOAM (GRAM) 5.3% 2.00832 08/12/2014
BENZOYL PEROXIDE TOPICAL FOAM (GRAM) 9.8 % 1.60318 08/12/2014
BENZOYL PEROXIDE TOPICAL GEL (GRAM) 10 % 0.21574 03/20/2015 0.21574 08/21/2015
BENZOYL PEROXIDE TOPICAL GEL (GRAM) 2.5 % 0.23088 08/16/2013
BENZOYL PEROXIDE TOPICAL GEL (GRAM) 5 % 0.18789 02/27/2015 0.18789 08/21/2015
BENZPHETAMINE HCL ORAL TABLET 50 MG 0.43389 11/07/2014 0.43389 08/21/2015
BENZTROPINE MESYLATE INJECTION AMPUL (ML) 2 MG/2 ML 23.40625 08/12/2014
BENZTROPINE MESYLATE INJECTION VIAL (ML) 2 MG/2 ML 40.39560 01/25/2013 40.39560 08/21/2015
BENZTROPINE MESYLATE ORAL TABLET 0.5 MG 0.08100 09/22/2017 0.05221 07/26/2019
BENZTROPINE MESYLATE ORAL TABLET 1 MG 0.09106 08/25/2017 0.05550 09/21/2018
BENZTROPINE MESYLATE ORAL TABLET 2 MG 0.09210 02/22/2019 0.07071 08/16/2019
BETA-CAROTENE(A) W-C AND E/LUTEIN/MINERALS ORAL TABLET 1000-60-2
0.06145 08/12/2014 0.06145 08/21/2015
BETA-CAROTENE/ASCORBIC ACID/VITE AC/ZINC OXIDE/CUPRIC OXIDE ORAL CAPSULE 14320-226
0.16420 08/12/2014 0.16420 08/21/2015
BETA-CAROTENE/ASCORBIC ACID/VITE AC/ZINC OXIDE/CUPRIC OXIDE ORAL TABLET 7160-113
0.06620 08/12/2014
BETAMETHASONE ACETATE/BETAMETHASONE SODIUM PHOSPHATE INJECTION VIAL (ML) 6 MG/ML
5.60000 01/25/2013 5.60000 08/21/2015
BETAMETHASONE DIPROPIONATE TOPICAL CREAM (GRAM) 0.05 % 1.08858 11/15/2019 1.02000 05/22/2020
BETAMETHASONE DIPROPIONATE TOPICAL GEL (GRAM) 0.05 % 1.21450 01/25/2013
BETAMETHASONE DIPROPIONATE TOPICAL LOTION (ML) 0.05 % 0.23117 08/16/2019 0.45600 02/07/2020
BETAMETHASONE DIPROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 1.57591 03/29/2013 1.57591 08/21/2015
BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL TOPICAL CREAM (GRAM) 0.05 %
0.34930 08/21/2015 0.17260 01/25/2019
BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL TOPICAL LOTION (ML) 0.05 %
1.77637 08/16/2013
BETAMETHASONE DIPROPIONATE/PROPYLENE GLYCOL TOPICAL OINTMENT (GRAM) 0.05 %
1.66174 06/16/2017 0.86311 08/16/2019
BETAMETHASONE VALERATE TOPICAL CREAM (GRAM) 0.1 % 0.56720 07/08/2016 0.16667 02/21/2020
BETAMETHASONE VALERATE TOPICAL FOAM (GRAM) 0.12 % 3.31660 08/21/2015 2.50000 10/25/2019
BETAMETHASONE VALERATE TOPICAL LOTION (ML) 0.1 % 0.79430 03/29/2013 0.79430 08/21/2015
BETAMETHASONE VALERATE TOPICAL OINTMENT (GRAM) 0.1 % 0.69422 09/04/2018 0.56667 02/21/2020
BETAXOLOL HCL OPHTHALMIC DROPS 0.5 % 7.27680 01/25/2013
BETAXOLOL HCL ORAL TABLET 10 MG 0.51160 08/16/2019
BETHANECHOL CHLORIDE ORAL TABLET 10 MG 0.29680 08/25/2017 0.11950 05/17/2019
BETHANECHOL CHLORIDE ORAL TABLET 25 MG 0.27150 09/22/2017 0.17580 08/16/2019
BETHANECHOL CHLORIDE ORAL TABLET 5 MG 0.14400 09/22/2017 0.12190 11/15/2019
BETHANECHOL CHLORIDE ORAL TABLET 50 MG 0.28034 12/02/2016 0.25990 11/16/2018
BICALUTAMIDE ORAL TABLET 50 MG 0.21667 08/25/2017 0.10180 08/17/2018
BIOFLAVONOID, LEMON/VITAMIN B COMP AND C ORAL TABLET 200-100 MG
0.14285 05/03/2013
BIOTIN ORAL CAPSULE 2500 MCG 0.09390 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
BISACODYL ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 5 MG 0.00996 01/16/2015 0.00996 08/21/2015
BISACODYL RECTAL SUPPOSITORY, RECTAL 10 MG 0.09491 08/12/2014 0.09491 08/21/2015
BISMUTH SUBSALICYLATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 262MG/15ML
0.00732 03/20/2015 0.00732 08/21/2015
BISMUTH SUBSALICYLATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 525MG/15ML
0.01095 04/24/2015 0.01095 08/21/2015
BISMUTH SUBSALICYLATE ORAL TABLET,CHEWABLE 262 MG 0.09120 08/21/2015 0.05733 01/25/2019
BISOPROLOL FUMARATE ORAL TABLET 10 MG 0.42566 11/15/2019 0.52457 03/24/2020
BISOPROLOL FUMARATE ORAL TABLET 5 MG 0.56161 10/24/2019 0.38074 02/21/2020
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 10-6.25MG
0.06432 04/17/2015 0.06432 08/21/2015
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 2.5-6.25MG
0.04920 10/20/2017 0.03462 03/02/2018
BISOPROLOL FUMARATE/HYDROCHLOROTHIAZIDE ORAL TABLET 5-6.25MG
0.42720 10/25/2019 0.33813 02/21/2020
BRIMONIDINE TARTRATE OPHTHALMIC DROPS 0.15 % 16.27762 08/21/2015 16.27762 04/22/2016
BRIMONIDINE TARTRATE OPHTHALMIC DROPS 0.2 % 0.51810 02/22/2019 0.42067 06/19/2020
BROMFENAC SODIUM OPHTHALMIC DROPS 0.09 % 39.30875 09/26/2014 39.30875 08/21/2015
BROMOCRIPTINE MESYLATE ORAL CAPSULE 5 MG 6.00042 03/25/2016 4.25000 10/19/2018
BROMOCRIPTINE MESYLATE ORAL TABLET 2.5 MG 2.15134 05/28/2019 1.06633 11/15/2019
BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL ORAL LIQUID (ML) 4-10MG/5ML
0.15294 01/25/2013 0.15294 08/21/2015
BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 4-10-20/5
0.11830 09/13/2013 0.11830 08/21/2015
BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 4-7.5-15/5
0.09960 12/12/2014 0.09960 08/21/2015
BROMPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/DEXTROMETHORPHAN ORAL SOLUTION, ORAL 1-2.5-5/5
0.01700 02/06/2015 0.01700 08/21/2015
BROMPHENIRAMINE MALEATE/PSEUDOEPHEDRINE HCL/DEXTROMETHORPHAN ORAL ELIXIR 1-15-5MG/5
0.01880 03/27/2015
BROMPHENIRAMINE MALEATE/PSEUDOEPHEDRINE HCL/DEXTROMETHORPHAN ORAL SYRUP 2-30-10/5
0.12883 09/20/2017 0.05776 11/16/2018
BUDESONIDE INHALATION AMPUL FOR NEBULIZATION (ML) 0.25MG/2ML 2.80662 12/02/2016 0.51467 11/15/2019
BUDESONIDE INHALATION AMPUL FOR NEBULIZATION (ML) 0.5 MG/2ML 0.93000 06/21/2019 0.74983 11/15/2019
BUDESONIDE INHALATION AMPUL FOR NEBULIZATION (ML) 1 MG/2 ML 4.43100 11/15/2019 4.11367 06/19/2020
BUDESONIDE ORAL CAPSULE, DELAYED, AND EXTENDED RELEASE 3 MG
0.89630 08/16/2019 0.48290 04/17/2020
BUMETANIDE INJECTION VIAL (ML) 0.25 MG/ML 0.26572 01/25/2013 0.26572 08/21/2015
BUMETANIDE ORAL TABLET 0.5 MG 0.15517 02/20/2015 0.15517 08/21/2015
BUMETANIDE ORAL TABLET 1 MG 0.37153 05/17/2019 0.27990 05/22/2020
BUMETANIDE ORAL TABLET 2 MG 0.99030 05/24/2016 0.64435 03/03/2017
BUPIVACAINE HCL INJECTION VIAL (ML) 2.5 MG/ML 0.04200 04/25/2014
BUPIVACAINE HCL INJECTION VIAL (ML) 5 MG/ML 0.05090 04/25/2014 0.05090 08/21/2015
BUPIVACAINE HCL/EPINEPHRINE BITARTRATE INJECTION CARTRIDGE (ML) 0.5-1:200K
0.26130 08/12/2014
BUPIVACAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 0.25-.0005 0.12253 01/25/2013
BUPIVACAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 0.5-1:200K 0.11900 01/25/2013
BUPIVACAINE HCL/EPINEPHRINE/PF INJECTION VIAL (ML) 0.25-.0005 0.27733 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
BUPIVACAINE HCL/EPINEPHRINE/PF INJECTION VIAL (ML) 0.5-1:200K 0.25992 01/25/2013
BUPIVACAINE HCL/PF INJECTION AMPUL (ML) 2.5 MG/ML 0.11790 08/12/2014
BUPIVACAINE HCL/PF INJECTION AMPUL (ML) 5 MG/ML 0.08690 08/12/2014
BUPIVACAINE HCL/PF INJECTION AMPUL (ML) 7.5 MG/ML 0.10478 01/25/2013 0.10478 08/21/2015
BUPIVACAINE HCL/PF INJECTION VIAL (ML) 2.5 MG/ML 0.06089 08/12/2014
BUPIVACAINE HCL/PF INJECTION VIAL (ML) 5 MG/ML 0.06736 08/12/2014
BUPIVACAINE HCL/PF INJECTION VIAL (ML) 7.5 MG/ML 0.13428 08/12/2014
BUPRENORPHINE HCL INJECTION CARTRIDGE (ML) 0.3 MG/ML 12.18000 01/25/2013
BUPRENORPHINE HCL SUBLINGUAL TABLET, SUBLINGUAL 2 MG 1.05933 06/16/2017 0.43600 09/22/2017
BUPRENORPHINE HCL SUBLINGUAL TABLET, SUBLINGUAL 8 MG 0.95666 06/25/2019 0.65800 09/20/2019
BUPRENORPHINE HCL/NALOXONE HCL SUBLINGUAL TABLET, SUBLINGUAL 2 MG-0.5MG
2.60728 06/16/2017 1.19133 11/15/2019
BUPRENORPHINE HCL/NALOXONE HCL SUBLINGUAL TABLET, SUBLINGUAL 8 MG-2 MG
2.31650 09/21/2018 1.75693 11/15/2019
BUPROPION HCL ORAL TABLET 100 MG 0.18600 09/22/2017 0.11485 08/16/2019
BUPROPION HCL ORAL TABLET 75 MG 0.14167 11/15/2019 0.08950 05/22/2020
BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 12 HR 150 MG 0.44367 03/25/2016 0.20967 07/14/2017
BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 24 HR 150 MG 0.15723 11/15/2019 0.14598 06/19/2020
BUPROPION HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 0.22833 01/25/2019 0.19016 05/22/2020
BUPROPION HCL ORAL TABLET,SUSTAINED-RELEASE 12 HR 100 MG 0.07644 03/02/2018 0.12200 07/23/2018
BUPROPION HCL ORAL TABLET,SUSTAINED-RELEASE 12 HR 150 MG 0.09350 06/16/2017 0.07500 06/19/2020
BUPROPION HCL ORAL TABLET,SUSTAINED-RELEASE 12 HR 200 MG 0.19271 07/14/2017 0.08490 02/22/2019
BUSPIRONE HCL ORAL TABLET 10 MG 0.03984 10/20/2017 0.04536 11/29/2018
BUSPIRONE HCL ORAL TABLET 15 MG 0.06612 11/14/2018 0.05500 07/26/2019
BUSPIRONE HCL ORAL TABLET 30 MG 0.26383 05/17/2019 0.21300 07/26/2019
BUSPIRONE HCL ORAL TABLET 5 MG 0.04020 08/21/2015 0.02551 11/16/2018
BUSPIRONE HCL ORAL TABLET 7.5 MG 0.35967 05/17/2019 0.33000 11/15/2019
BUTALBITAL/ACETAMINOPHEN ORAL TABLET 50MG-325MG 0.86233 03/14/2014 1.09000 08/07/2015
BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL CAPSULE 50-300-40 2.36850 08/03/2018 1.86500 10/19/2018
BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL CAPSULE 50-325-40 1.35905 03/27/2015
BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL TABLET 50-325-40 0.22890 12/20/2019 0.15773 05/22/2020
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE ORAL CAPSULE 50-300-30
4.30822 03/06/2015
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE PHOSPHATE ORAL CAPSULE 50-325-30
1.04965 08/21/2015 1.01795 03/02/2018
BUTALBITAL/ASPIRIN/CAFFEINE ORAL CAPSULE 50-325-40 0.88420 01/24/2020 1.00000 05/04/2020
BUTALBITAL/ASPIRIN/CAFFEINE ORAL TABLET 50-325-40 0.29110 12/17/2018
BUTENAFINE HCL TOPICAL CREAM (GRAM) 1 % 0.40179 08/21/2015 0.40179 01/01/2019
BUTORPHANOL TARTRATE INJECTION VIAL (ML) 1 MG/ML 1.94300 01/25/2013 1.94300 08/21/2015
BUTORPHANOL TARTRATE INJECTION VIAL (ML) 2 MG/ML 1.94300 01/25/2013 1.94300 08/21/2015
BUTORPHANOL TARTRATE NASAL AEROSOL, SPRAY (ML) 10 MG/ML 16.32960 08/21/2015 12.19584 06/16/2017
CABERGOLINE ORAL TABLET 0.5 MG 2.93000 06/21/2019 2.12000 07/26/2019
CAFFEINE CITRATE INTRAVENOUS VIAL (ML) 60 MG/3 ML 3.35400 04/03/2015 3.35400 08/21/2015
CAFFEINE CITRATE ORAL SOLUTION, ORAL 60 MG/3 ML 6.70190 08/21/2015 6.66666 01/25/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CAFFEINE/SODIUM BENZOATE INJECTION VIAL (ML) 250 MG/ML 2.73000 01/25/2013
CALCIPOTRIENE TOPICAL CREAM (GRAM) 0.005 % 1.70100 04/26/2019 0.88683 01/24/2020
CALCIPOTRIENE TOPICAL OINTMENT (GRAM) 0.005 % 4.22790 08/12/2014
CALCIPOTRIENE TOPICAL SOLUTION, NON-ORAL 0.005 % 2.64568 06/16/2017 1.56000 05/25/2018
CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE TOPICAL OINTMENT (GRAM) 0.005-.064
8.11932 06/16/2017 8.11932 01/01/2018
CALCITONIN,SALMON,SYNTHETIC NASAL AEROSOL, SPRAY WITH PUMP (ML) 200/SPRAY
10.40270 09/25/2015 9.78378 09/30/2016
CALCITRIOL INTRAVENOUS AMPUL (ML) 1 MCG/ML 4.68130 05/10/2013
CALCITRIOL ORAL CAPSULE 0.25 MCG 0.17150 11/16/2018 0.13009 08/16/2019
CALCITRIOL ORAL CAPSULE 0.5 MCG 0.50783 02/08/2018 0.20400 11/16/2018
CALCITRIOL ORAL SOLUTION, ORAL 1 MCG/ML 5.49667 08/26/2016 4.59200 08/16/2019
CALCITRIOL TOPICAL OINTMENT (GRAM) 3 MCG/G 6.43120 01/09/2015 6.43120 01/01/2018
CALCIUM ACETATE ORAL CAPSULE 667 MG 0.09543 08/16/2019 0.51577 03/31/2020
CALCIUM ACETATE ORAL TABLET 667 MG 0.36813 01/03/2014 0.30825 11/16/2018
CALCIUM ACETATE/ALUMINUM SULFATE TOPICAL POWDER IN PACKET (EA) 952-1347MG
0.72740 01/25/2013
CALCIUM CARBONATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 500 MG/5ML
0.01799 01/25/2013
CALCIUM CARBONATE ORAL TABLET 500(1250) 0.01434 06/21/2013 0.01434 08/21/2015
CALCIUM CARBONATE ORAL TABLET 600 MG 0.02144 07/26/2013 0.02144 08/21/2015
CALCIUM CARBONATE ORAL TABLET,CHEWABLE 200(500)MG 0.01357 02/06/2015 0.01357 08/21/2015
CALCIUM CARBONATE ORAL TABLET,CHEWABLE 300MG(750) 0.02554 02/27/2015 0.02554 08/21/2015
CALCIUM CARBONATE ORAL TABLET,CHEWABLE 400(1000) 0.04240 08/21/2015 0.02986 08/17/2018
CALCIUM CARBONATE ORAL TABLET,CHEWABLE 500(1250) 0.03420 08/12/2014
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 600 MG-400
0.04855 08/12/2014
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 250 MG-125
0.01032 01/25/2013 0.01032 08/21/2015
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 250 MG-125
0.02170 08/12/2014 0.02170 08/21/2015
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 500 MG-200
0.01599 08/12/2014 0.01599 08/21/2015
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 500 MG-400
0.03507 08/12/2014 0.03507 08/21/2015
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 600 MG-200
0.01899 01/25/2013 0.01899 08/21/2015
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 600 MG-400
0.01956 02/27/2015 0.01956 08/21/2015
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 600 MG-800
0.05873 02/13/2015 0.05873 08/21/2015
CALCIUM CARBONATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET,CHEWABLE 500 MG-100
0.03420 08/21/2015
CALCIUM CARBONATE/ERGOCALCIFEROL (VITAMIN D2) TABLET 250 MG-125
0.02170 08/12/2014 0.02170 08/21/2015
CALCIUM CARBONATE/MAGNESIUM HYDROXIDE ORAL TABLET,CHEWABLE 675-135 MG
0.01352 08/21/2015
CALCIUM CHLORIDE INTRAVENOUS SYRINGE (ML) 100 MG/ML 0.47124 08/12/2014 0.47124 08/21/2015
CALCIUM CHLORIDE INTRAVENOUS VIAL (ML) 100 MG/ML 0.17500 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CALCIUM CITRATE ORAL TABLET 200(950)MG 0.03070 08/12/2014 0.03070 08/21/2015
CALCIUM CITRATE ORAL TABLET 250 MG 0.05565 01/25/2013
CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 200 MG-250
0.04005 08/12/2014
CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 315 MG-200
0.05724 08/12/2014 0.05724 08/21/2015
CALCIUM CITRATE/CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 315 MG-250
0.04615 11/21/2014 0.04615 08/21/2015
CALCIUM POLYCARBOPHIL ORAL TABLET 625 MG 0.06417 08/12/2014 0.06417 08/21/2015
CANDESARTAN CILEXETIL ORAL TABLET 16 MG 1.34663 05/17/2019 1.17100 11/15/2019
CANDESARTAN CILEXETIL ORAL TABLET 32 MG 1.54000 04/27/2018 1.06144 09/20/2019
CANDESARTAN CILEXETIL ORAL TABLET 4 MG 1.45322 11/15/2019 1.20000 02/21/2020
CANDESARTAN CILEXETIL ORAL TABLET 8 MG 1.45333 08/17/2018 1.25400 08/16/2019
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE ORAL TABLET 16-12.5MG
1.87708 11/07/2014 1.87708 08/21/2015
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE ORAL TABLET 32-12.5MG
2.91948 01/25/2013 2.91948 08/21/2015
CANDESARTAN CILEXETIL/HYDROCHLOROTHIAZIDE ORAL TABLET 32MG-25MG
3.15984 08/12/2014 3.15984 08/21/2015
CAPECITABINE ORAL TABLET 150 MG 8.21479 04/24/2015 8.21479 08/21/2015
CAPECITABINE ORAL TABLET 500 MG 5.07000 11/24/2017 3.86667 11/15/2019
CAPSAICIN TOPICAL CREAM (GRAM) 0.025 % 0.06709 04/05/2013 0.06709 08/21/2015
CAPSAICIN TOPICAL CREAM (GRAM) 0.075 % 0.09338 08/12/2014 0.09338 08/21/2015
CAPSAICIN/METHYL SALICYLATE/MENTHOL TOPICAL LOTION (GRAM) 0.002%-20%
2.36327 01/25/2013
CAPTOPRIL MISCELLANEOUS POWDER (GRAM) 100 % 56.85764 02/22/2013 56.85764 08/21/2015
CAPTOPRIL ORAL TABLET 100 MG 1.12780 05/09/2014 1.12780 08/21/2015
CAPTOPRIL ORAL TABLET 12.5 MG 0.46645 08/15/2014 0.46645 08/21/2015
CAPTOPRIL ORAL TABLET 25 MG 0.99791 08/21/2015 0.75000 08/25/2017
CAPTOPRIL ORAL TABLET 50 MG 0.99970 02/22/2019 0.77990 11/15/2019
CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-15MG 0.33384 12/27/2013 0.33384 08/21/2015
CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-25MG 1.10214 05/30/2014 1.10214 08/21/2015
CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG-15MG 1.89163 05/30/2014 1.89163 08/21/2015
CAPTOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG-25MG 1.89163 05/30/2014 1.89163 08/21/2015
CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 100 MG
1.26909 06/06/2019 1.25017 03/20/2020
CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 200 MG
1.25113 08/21/2015
CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 200 MG
1.55500 10/17/2019 1.45789 05/22/2020
CARBAMAZEPINE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 12HR 300 MG
0.93459 11/15/2019 1.46300 11/16/2019
CARBAMAZEPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 MG/5ML
0.11631 07/18/2014 0.11631 01/01/2020
CARBAMAZEPINE ORAL TABLET 200 MG 0.22000 12/20/2019 0.32256 03/02/2020
CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 100 MG 0.49080 11/15/2019 0.63951 01/21/2020
CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 200 MG 0.90340 11/15/2019 0.88980 04/17/2020
CARBAMAZEPINE ORAL TABLET, EXTENDED RELEASE 12 HR 400 MG 2.17370 02/03/2020 1.81858 05/22/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CARBAMAZEPINE ORAL TABLET,CHEWABLE 100 MG 0.28300 02/24/2019 0.23768 09/20/2019
CARBAMIDE PEROXIDE OTIC DROPS 6.5 % 0.11614 08/21/2015 0.06800 08/25/2017
CARBIDOPA ORAL TABLET 25 MG 5.19620 10/19/2018 3.86500 01/25/2019
CARBIDOPA/LEVODOPA ORAL TABLET 10MG-100MG 0.09610 09/22/2017 0.06610 05/22/2020
CARBIDOPA/LEVODOPA ORAL TABLET 25MG-100MG 0.09799 07/14/2017 0.08025 03/16/2018
CARBIDOPA/LEVODOPA ORAL TABLET 25MG-250MG 0.12267 03/16/2018 0.09850 05/22/2020
CARBIDOPA/LEVODOPA ORAL TABLET, EXTENDED RELEASE 25MG-100MG
0.18200 08/17/2018 0.11510 10/19/2018
CARBIDOPA/LEVODOPA ORAL TABLET, EXTENDED RELEASE 50MG-200MG
0.42000 09/11/2019 0.31670 05/22/2020
CARBIDOPA/LEVODOPA ORAL TABLET,DISINTEGRATING 10MG-100MG 0.77305 01/25/2013 0.77305 08/21/2015
CARBIDOPA/LEVODOPA ORAL TABLET,DISINTEGRATING 25MG-100MG 0.94146 04/10/2015 0.94146 08/21/2015
CARBIDOPA/LEVODOPA ORAL TABLET,DISINTEGRATING 25MG-250MG 1.10100 01/25/2013 1.10100 08/21/2015
CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 12.5-50 MG 2.13334 08/21/2015 2.13334 04/22/2016
CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 18.75-75MG 2.62496 08/12/2014 2.62496 04/22/2016
CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 25-100-200 1.37907 03/03/2017 0.83370 09/22/2017
CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 31.25-125 2.62481 04/22/2016 1.13280 02/22/2019
CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 37.5-150MG 0.84205 11/15/2019 0.62336 02/21/2020
CARBIDOPA/LEVODOPA/ENTACAPONE ORAL TABLET 50-200-200 0.83370 09/22/2017 0.54950 05/17/2019
CARBINOXAMINE MALEATE ORAL LIQUID (ML) 4 MG/5 ML 0.09112 03/15/2013 0.09112 08/21/2015
CARBINOXAMINE MALEATE ORAL TABLET 4 MG 0.49602 05/10/2013 0.49602 08/21/2015
CARBOXYMETHYLCELLULOSE SODIUM OPHTHALMIC DROPPERETTE, GEL 1 %
0.32162 03/29/2013
CARBOXYMETHYLCELLULOSE SODIUM OPHTHALMIC DROPPERETTE, SINGLE-USE DROP DISPENSER 0.5 %
0.20828 08/12/2014 0.20828 08/21/2015
CARBOXYMETHYLCELLULOSE SODIUM OPHTHALMIC DROPS 0.5 % 0.33524 08/12/2014 0.33524 08/21/2015
CARISOPRODOL ORAL TABLET 250 MG 2.31410 02/08/2013 1.93208 06/16/2017
CARISOPRODOL ORAL TABLET 350 MG 0.07909 08/21/2015 0.05359 07/14/2017
CARISOPRODOL/ASPIRIN ORAL TABLET 200-325 MG 1.52430 08/12/2014 1.52430 08/21/2015
CARISOPRODOL/ASPIRIN/CODEINE PHOSPHATE ORAL TABLET 200-325-16
1.94250 01/25/2013 1.94250 08/21/2015
CARTEOLOL HCL OPHTHALMIC DROPS 1 % 1.17210 01/25/2013
CARVEDILOL ORAL TABLET 12.5 MG 0.04968 08/21/2015 0.01920 06/16/2017
CARVEDILOL ORAL TABLET 25 MG 0.03886 08/21/2015 0.02489 11/16/2018
CARVEDILOL ORAL TABLET 3.125 MG 0.03629 08/21/2015 0.02240 10/20/2017
CARVEDILOL ORAL TABLET 6.25 MG 0.04950 08/21/2015 0.02150 07/14/2017
CASTOR OIL ORAL OIL (ML) 0.05545 01/25/2013
CEFACLOR ORAL CAPSULE 250 MG 1.39260 02/01/2013 1.39260 08/21/2015
CEFACLOR ORAL CAPSULE 500 MG 1.61040 08/12/2014 1.61040 08/21/2015
CEFACLOR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML
0.68231 01/25/2013
CEFACLOR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML
1.36453 01/25/2013 1.36453 08/21/2015
CEFACLOR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 375 MG/5ML
2.04680 01/25/2013
CEFACLOR ORAL TABLET, EXTENDED RELEASE 12 HR 500 MG 3.48600 01/25/2013 3.48600 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CEFADROXIL ORAL CAPSULE 500 MG 0.16550 03/16/2018 0.12410 02/22/2019
CEFADROXIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML
0.36218 02/06/2015 0.20630 11/15/2019
CEFADROXIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 500 MG/5ML
0.50605 02/06/2015 0.24250 11/16/2018
CEFADROXIL ORAL TABLET 1 G 2.32518 01/25/2013
CEFAZOLIN SODIUM INJECTION VIAL (EA) 1 G 5.80360 09/26/2014 5.80360 08/21/2015
CEFAZOLIN SODIUM INJECTION VIAL (EA) 10 G 6.55920 09/26/2014 6.55920 08/21/2015
CEFAZOLIN SODIUM INJECTION VIAL (EA) 500 MG 1.03662 01/25/2013
CEFAZOLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 G 4.26300 01/25/2013
CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML
0.20427 01/25/2013
CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML
17.93574 01/25/2013
CEFAZOLIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML
0.07526 07/18/2014
CEFDINIR ORAL CAPSULE 300 MG 0.40142 08/17/2018 0.33556 11/16/2018
CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML 0.12375 11/16/2018 0.11329 05/22/2020
CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML 0.12749 05/17/2019 0.08000 12/20/2019
CEFDITOREN PIVOXIL ORAL TABLET 200 MG 10.31835 11/28/2014 10.31835 08/21/2015
CEFDITOREN PIVOXIL ORAL TABLET 400 MG 10.31835 11/28/2014 10.31835 08/21/2015
CEFEPIME HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML
0.55476 01/25/2013
CEFEPIME HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML
14.59910 08/12/2014
CEFEPIME HCL IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML
1.09878 11/07/2014
CEFEPIME HCL IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2 G/100 ML
0.88078 07/25/2014
CEFEPIME HCL INJECTION VIAL (EA) 1 G 4.04600 08/16/2019 3.99900 03/20/2020
CEFEPIME HCL INJECTION VIAL (EA) 2 G 3.93300 03/02/2018 6.00500 06/20/2018
CEFIXIME ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100 MG/5ML 3.56300 05/01/2015 3.56300 08/21/2015
CEFIXIME ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 MG/5ML 7.12610 05/01/2015 7.12610 08/21/2015
CEFOTAXIME SODIUM INJECTION VIAL (EA) 1 G 2.12524 09/06/2013 2.12524 08/21/2015
CEFOTAXIME SODIUM INJECTION VIAL (EA) 10 G 18.35400 01/25/2013
CEFOTAXIME SODIUM INJECTION VIAL (EA) 2 G 4.12516 08/12/2014 4.12516 08/21/2015
CEFOTAXIME SODIUM INJECTION VIAL (EA) 500 MG 1.26000 10/04/2013 1.26000 08/21/2015
CEFOTETAN DISODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML
12.81880 08/12/2014
CEFOTETAN DISODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML
17.59800 01/25/2013
CEFOTETAN DISODIUM INJECTION VIAL (EA) 1 G 9.55920 01/25/2013
CEFOTETAN DISODIUM INJECTION VIAL (EA) 2 G 19.91500 01/25/2013
CEFOTETAN DISODIUM INTRAVENOUS VIAL (EA) 10 G 98.60200 01/25/2013
CEFOXITIN SODIUM INTRAVENOUS VIAL (EA) 1 G 4.45484 03/20/2015 4.45484 08/21/2015
CEFOXITIN SODIUM INTRAVENOUS VIAL (EA) 10 G 32.13068 01/25/2013
CEFOXITIN SODIUM INTRAVENOUS VIAL (EA) 2 G 7.94256 03/20/2015 7.94256 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML
0.45037 04/19/2013
CEFOXITIN SODIUM/DEXTROSE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML
0.92383 01/25/2013
CEFPODOXIME PROXETIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100 MG/5ML
1.14772 03/29/2013
CEFPODOXIME PROXETIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 50 MG/5 ML
0.52444 08/12/2014
CEFPODOXIME PROXETIL ORAL TABLET 100 MG 4.71590 05/03/2013 3.61735 06/16/2017
CEFPODOXIME PROXETIL ORAL TABLET 200 MG 2.46500 10/19/2018 2.20000 05/22/2020
CEFPROZIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML
0.29385 08/22/2014 0.14400 02/22/2019
CEFPROZIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML
0.23730 09/22/2017 0.21875 11/16/2018
CEFPROZIL ORAL TABLET 250 MG 0.98670 08/21/2015 0.65800 06/16/2017
CEFPROZIL ORAL TABLET 500 MG 1.19535 06/16/2017 1.07200 02/21/2020
CEFTAZIDIME IN DEXTROSE 5% AND WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML
9.03846 01/25/2013
CEFTAZIDIME IN DEXTROSE 5% AND WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML
13.01154 01/25/2013
CEFTAZIDIME INJECTION VIAL (EA) 1 G 4.82560 11/08/2013 4.82560 08/21/2015
CEFTAZIDIME INJECTION VIAL (EA) 2 G 10.56045 11/01/2013 10.56045 08/21/2015
CEFTAZIDIME INJECTION VIAL (EA) 6 G 24.35825 08/12/2014 24.35825 08/21/2015
CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 1 G/50 ML
0.54291 01/25/2013
CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (EA) 2 G/50 ML
0.94697 01/25/2013
CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML
0.23839 07/18/2014
CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2 G/50 ML
0.56464 04/04/2014
CEFTRIAXONE SODIUM INJECTION VIAL (EA) 1 G 1.40413 03/02/2018 0.92998 08/16/2019
CEFTRIAXONE SODIUM INJECTION VIAL (EA) 10 G 16.22880 08/21/2015 14.68000 08/17/2018
CEFTRIAXONE SODIUM INJECTION VIAL (EA) 2 G 2.30600 03/20/2020 0.21605 05/22/2020
CEFTRIAXONE SODIUM INJECTION VIAL (EA) 250 MG 0.63100 08/17/2018 0.12600 05/17/2019
CEFTRIAXONE SODIUM INJECTION VIAL (EA) 500 MG 1.32048 08/21/2015 0.85100 08/25/2017
CEFTRIAXONE SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 G
3.51120 02/15/2013
CEFTRIAXONE SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2 G
6.39660 01/25/2013
CEFUROXIME AXETIL ORAL TABLET 250 MG 0.34339 08/16/2019 0.26250 05/22/2020
CEFUROXIME AXETIL ORAL TABLET 500 MG 0.42400 01/24/2020 0.38067 06/19/2020
CEFUROXIME SODIUM INJECTION VIAL (EA) 1.5 G 4.35422 08/12/2014 4.35422 08/21/2015
CEFUROXIME SODIUM INJECTION VIAL (EA) 750 MG 2.72428 11/14/2014 2.72428 08/21/2015
CEFUROXIME SODIUM INTRAVENOUS VIAL (EA) 1.5 G 4.35422 08/12/2014 4.35422 08/21/2015
CEFUROXIME SODIUM INTRAVENOUS VIAL (EA) 7.5 G 17.79645 08/12/2014 17.79645 08/21/2015
CELECOXIB ORAL CAPSULE 100 MG 0.15240 11/16/2018 0.12000 01/25/2019
CELECOXIB ORAL CAPSULE 200 MG 0.15090 06/21/2019 0.12861 05/22/2020
CELECOXIB ORAL CAPSULE 400 MG 1.25000 09/30/2016 0.71400 07/26/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CELECOXIB ORAL CAPSULE 50 MG 0.28033 10/20/2017 0.06583 05/17/2019
CEPHALEXIN ORAL CAPSULE 250 MG 0.07390 09/22/2017 0.06050 03/16/2018
CEPHALEXIN ORAL CAPSULE 500 MG 0.10023 08/21/2015 0.08687 12/22/2017
CEPHALEXIN ORAL CAPSULE 750 MG 6.15000 04/17/2019 5.49950 05/22/2020
CEPHALEXIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML
0.14563 08/21/2015 0.09450 11/24/2017
CEPHALEXIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML
0.09433 11/16/2018 0.08460 10/25/2019
CEPHALEXIN ORAL TABLET 250 MG 0.40092 01/25/2013
CEPHALEXIN ORAL TABLET 500 MG 0.80132 01/25/2013
CETIRIZINE HCL ORAL SOLUTION, ORAL 1 MG/ML 0.03306 08/21/2015 0.01500 12/21/2018
CETIRIZINE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.03306 07/07/2017
CETIRIZINE HCL ORAL TABLET 10 MG 0.04666 09/22/2017 0.03192 11/15/2019
CETIRIZINE HCL ORAL TABLET 5 MG 0.07567 08/21/2015 0.02870 11/15/2019
CETIRIZINE HCL ORAL TABLET,CHEWABLE 10 MG 1.66170 06/06/2014 1.66170 08/21/2015
CETIRIZINE HCL ORAL TABLET,CHEWABLE 5 MG 2.74179 08/21/2015 1.66166 01/25/2019
CETIRIZINE HCL/PSEUDOEPHEDRINE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 5 MG-120MG
0.50458 01/25/2019 0.65776 03/05/2019
CEVIMELINE HCL ORAL CAPSULE 30 MG 0.98965 12/10/2019 0.90460 03/20/2020
CHLORAMPHENICOL SOD SUCCINATE INTRAVENOUS VIAL (EA) 1 G 2.64689 01/25/2013
CHLORDIAZEPOXIDE HCL ORAL CAPSULE 10 MG 0.08863 08/21/2015 0.05930 12/22/2017
CHLORDIAZEPOXIDE HCL ORAL CAPSULE 25 MG 0.08949 08/21/2015 0.06297 03/02/2018
CHLORDIAZEPOXIDE HCL ORAL CAPSULE 5 MG 0.10875 08/15/2014 0.10875 08/21/2015
CHLORDIAZEPOXIDE/CLIDINIUM BROMIDE ORAL CAPSULE 5 MG-2.5MG 0.27604 02/27/2015 0.27604 08/21/2015
CHLORHEXIDINE GLUCONATE MUCOUS MEMBRANE MOUTHWASH 0.12 %
0.00598 03/13/2015 0.00598 08/21/2015
CHLOROQUINE PHOSPHATE ORAL TABLET 250 MG 0.86970 03/01/2013 0.86970 08/21/2015
CHLOROQUINE PHOSPHATE ORAL TABLET 500 MG 3.44058 08/12/2014 3.44058 08/21/2015
CHLOROTHIAZIDE ORAL TABLET 250 MG 0.15141 12/13/2013 0.15141 08/21/2015
CHLOROTHIAZIDE SODIUM INTRAVENOUS VIAL (EA) 500 MG 98.11300 04/17/2015 98.11300 08/21/2015
CHLORPHENIRAMINE MALEATE ORAL SYRUP 2 MG/5 ML 0.01798 01/25/2013 0.01798 08/21/2015
CHLORPHENIRAMINE MALEATE ORAL TABLET 4 MG 0.00634 02/06/2015 0.00634 08/21/2015
CHLORPHENIRAMINE MALEATE ORAL TABLET, EXTENDED RELEASE 12 MG
0.34709 08/21/2015
CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE HCL ORAL LIQUID (ML) 4-10MG/5ML
0.02660 08/12/2014
CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 2-5-15MG/5
0.06860 08/12/2014 0.06860 08/21/2015
CHLORPHENIRAMINE MALEATE/PHENYLEPHRINE HCL/DEXTROMETHORPHAN ORAL LIQUID (ML) 4-10-15/5
0.04500 08/12/2014
CHLORPHENIRAMINE MALEATE/PSEUDOEPHEDRINE HCL ORAL TABLET 4 MG-60 MG
0.05310 08/12/2014
CHLORPHENIRAMINE MALEATE/PSEUDOEPHEDRINE/DEXTROMETHORPHAN ORAL LIQUID (ML) 1-15-5MG/5
0.01868 01/25/2013 0.01868 08/21/2015
CHLORPROMAZINE HCL INJECTION AMPUL (ML) 25 MG/ML 18.81600 11/08/2013
CHLORPROMAZINE HCL ORAL TABLET 10 MG 2.65000 01/22/2016 1.55000 05/22/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CHLORPROMAZINE HCL ORAL TABLET 100 MG 3.26785 05/17/2019 5.06490 06/13/2019
CHLORPROMAZINE HCL ORAL TABLET 200 MG 6.35000 10/25/2019 7.16716 12/16/2019
CHLORPROMAZINE HCL ORAL TABLET 25 MG 2.39250 05/17/2019 1.85000 02/21/2020
CHLORPROMAZINE HCL ORAL TABLET 50 MG 4.07080 11/16/2018 2.95200 04/26/2019
CHLORPROPAMIDE TABLET 100 MG 0.84154 06/27/2014 0.84154 08/21/2015
CHLORPROPAMIDE TABLET 250 MG 0.85230 08/12/2014
CHLORTHALIDONE ORAL TABLET 25 MG 0.32970 01/24/2020 0.21557 05/22/2020
CHLORTHALIDONE ORAL TABLET 50 MG 0.59540 01/25/2019 0.35950 08/16/2019
CHLORZOXAZONE ORAL TABLET 500 MG 0.23400 04/10/2015 0.23400 08/21/2015
CHOLECALCIFEROL (VIT D3)/FOLIC ACID ORAL CAPSULE 3775 UNIT 15.16153 05/01/2015
CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 10 MCG 0.03240 05/01/2015 0.03240 08/21/2015
CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 100 MCG 0.06993 02/08/2013
CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 1250 MCG 0.14700 09/26/2014
CHOLECALCIFEROL (VITAMIN D3) ORAL CAPSULE 250 MCG 0.64783 12/26/2014 0.64783 08/21/2015
CHOLECALCIFEROL (VITAMIN D3) ORAL DROPS 125 MCG/ML 0.07303 08/12/2014
CHOLECALCIFEROL (VITAMIN D3) ORAL LIQUID (ML) 10MCG/5ML 0.02914 01/25/2013
CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 10 MCG 0.01786 04/17/2015 0.01786 08/21/2015
CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 125 MCG 0.05258 05/01/2015 0.05258 08/21/2015
CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 25 MCG 0.01997 08/12/2014 0.01997 08/21/2015
CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 50 MCG 0.02861 12/05/2014 0.02861 08/21/2015
CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET 75 MCG 0.05516 01/25/2013
CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET,CHEWABLE 10 MCG 0.02509 01/25/2013 0.02509 08/21/2015
CHOLECALCIFEROL (VITAMIN D3) ORAL TABLET,CHEWABLE 25 MCG 0.06098 08/12/2014 0.06098 08/21/2015
CHOLECALCIFEROL (VITAMIN D3) SUBLINGUAL SPRAY, SUSPENSION (ML) 25MCG/SPRY
0.30847 01/25/2013
CHOLESTYRAMINE (WITH SUGAR) ORAL POWDER (GRAM) 4 G 0.17550 07/26/2019 0.14794 10/25/2019
CHOLESTYRAMINE (WITH SUGAR) ORAL POWDER IN PACKET (EA) 4 G 1.33367 08/25/2017 1.21063 02/21/2020
CHOLESTYRAMINE/ASPARTAME ORAL POWDER (GRAM) 4 G 0.23748 04/22/2019 0.19459 06/19/2020
CHOLESTYRAMINE/ASPARTAME ORAL POWDER IN PACKET (EA) 4 G 1.58483 02/22/2019 1.30321 11/15/2019
CHOLINE SALICYLATE/MAGNESIUM SALICYLATE ORAL LIQUID (ML) 500 MG/5ML
0.12848 01/25/2013
CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR VIAL (EA) 10000 UNIT
184.04000 07/12/2013
CICLOPIROX OLAMINE TOPICAL CREAM (GRAM) 0.77 % 0.14964 08/12/2014 0.10611 01/24/2020
CICLOPIROX OLAMINE TOPICAL SUSPENSION, TOPICAL (ML) 0.77 % 0.37748 01/25/2013
CICLOPIROX TOPICAL GEL (GRAM) 0.77 % 1.12739 06/16/2017 0.89877 11/15/2019
CICLOPIROX TOPICAL SHAMPOO 1 % 0.39030 05/25/2018 0.24717 11/15/2019
CICLOPIROX TOPICAL SOLUTION, NON-ORAL 8 % 1.49242 04/26/2019 1.45000 05/22/2020
CICLOPIROX/UREA/CAMPHOR/MENTHOL/EUCALYPTOL TOPICAL SOLUTION, NON-ORAL 8 %
266.99400 01/25/2013
CIDOFOVIR INTRAVENOUS VIAL (ML) 75 MG/ML 118.10400 08/12/2014
CILOSTAZOL ORAL TABLET 100 MG 0.11183 03/02/2018 0.08000 02/22/2019
CILOSTAZOL ORAL TABLET 50 MG 0.10087 11/16/2018 0.08083 04/17/2020
CIMETIDINE HCL ORAL SOLUTION, ORAL 300 MG/5ML 0.06283 05/17/2013 0.06283 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CIMETIDINE ORAL TABLET 200 MG 0.23684 08/21/2015 0.19530 06/19/2020
CIMETIDINE ORAL TABLET 300 MG 0.26286 08/21/2015 0.22900 08/25/2017
CIMETIDINE ORAL TABLET 400 MG 0.31057 08/21/2015 0.44250 08/24/2016
CIMETIDINE ORAL TABLET 800 MG 1.28479 08/21/2015 0.74363 06/16/2017
CINACALCET HCL ORAL TABLET 30 MG 5.76000 02/21/2020
CINACALCET HCL ORAL TABLET 60 MG 11.16000 02/21/2020
CINACALCET HCL ORAL TABLET 90 MG 13.00000 02/21/2020
CIPROFLOXACIN HCL OPHTHALMIC DROPS 0.3 % 0.56000 10/19/2018 2.30160 06/06/2019
CIPROFLOXACIN HCL ORAL TABLET 100 MG 10.65167 09/26/2014
CIPROFLOXACIN HCL ORAL TABLET 250 MG 0.10750 07/14/2017 0.09120 08/17/2018
CIPROFLOXACIN HCL ORAL TABLET 500 MG 0.20001 03/03/2017 0.09234 06/16/2017
CIPROFLOXACIN HCL ORAL TABLET 750 MG 0.34599 08/21/2015 0.23220 08/17/2018
CIPROFLOXACIN HCL OTIC DROPPERETTE, SINGLE-USE DROP DISPENSER 0.2 %
12.61951 08/01/2014
CIPROFLOXACIN LACTATE VIAL (ML) 200MG/20ML 0.08890 01/25/2013
CIPROFLOXACIN LACTATE VIAL (ML) 400MG/40ML 0.06320 08/12/2014
CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 200MG/0.1L
0.01697 01/25/2013 0.01697 08/21/2015
CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 400MG/0.2L
0.01204 03/01/2013
CIPROFLOXACIN ORAL SUSPENSION, MICROCAPSULE RECONSTITUTED 250 MG/5ML
0.85323 08/22/2014
CIPROFLOXACIN ORAL SUSPENSION, MICROCAPSULE RECONSTITUTED 500 MG/5ML
0.99890 08/22/2014
CIPROFLOXACIN/CIPROFLOXACIN HCL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 1000 MG
7.79233 01/25/2013 7.79233 08/21/2015
CIPROFLOXACIN/CIPROFLOXACIN HCL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 500 MG
6.85916 01/25/2013 6.85916 08/21/2015
CISATRACURIUM BESYLATE INTRAVENOUS VIAL (ML) 10 MG/ML 11.95425 01/16/2015 11.95425 08/21/2015
CISATRACURIUM BESYLATE INTRAVENOUS VIAL (ML) 2 MG/ML 2.36880 08/12/2014 2.36880 08/21/2015
CITALOPRAM HYDROBROMIDE ORAL SOLUTION, ORAL 10 MG/5 ML 0.42456 04/12/2018 0.24500 01/25/2019
CITALOPRAM HYDROBROMIDE ORAL TABLET 10 MG 0.02661 05/01/2015 0.02661 08/21/2015
CITALOPRAM HYDROBROMIDE ORAL TABLET 20 MG 0.03382 08/21/2015 0.02364 01/19/2018
CITALOPRAM HYDROBROMIDE ORAL TABLET 40 MG 0.04139 08/21/2015 0.02900 11/16/2018
CITRATE PHOSPHATE DEXTROS SOLN MISCELLANEOUS SOLUTION, NON-ORAL 2.63 G/100
0.08318 01/25/2013
CITRIC ACID/SODIUM CITRATE ORAL SOLUTION, ORAL 334-500MG 0.02013 11/14/2014 0.02013 08/21/2015
CLARITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125 MG/5ML
0.36569 05/17/2013
CLARITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250 MG/5ML
1.14740 12/11/2017 1.22798 04/16/2018
CLARITHROMYCIN ORAL TABLET 250 MG 2.64794 08/21/2015 0.34333 06/16/2017
CLARITHROMYCIN ORAL TABLET 500 MG 0.45686 03/03/2017 0.40642 05/22/2020
CLARITHROMYCIN ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 3.50443 08/21/2015 3.18447 06/16/2017
CLINDAMYCIN HCL ORAL CAPSULE 150 MG 0.08641 08/21/2015 0.07460 09/21/2018
CLINDAMYCIN HCL ORAL CAPSULE 300 MG 0.25661 08/21/2015 0.19938 03/03/2017
CLINDAMYCIN HCL ORAL CAPSULE 75 MG 0.41720 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CLINDAMYCIN PALMITATE HCL ORAL SOLUTION, RECONSTITUTED, ORAL 75 MG/5 ML
0.19640 09/22/2017 0.23180 02/15/2018
CLINDAMYCIN PHOSPHATE INJECTION VIAL (ML) 150 MG/ML 0.35600 08/12/2014
CLINDAMYCIN PHOSPHATE INTRAVENOUS VIAL WITH THREADED PORT (ML) 300 MG/2ML
2.99418 01/25/2013
CLINDAMYCIN PHOSPHATE INTRAVENOUS VIAL WITH THREADED PORT (ML) 600 MG/4ML
1.60881 01/25/2013
CLINDAMYCIN PHOSPHATE INTRAVENOUS VIAL WITH THREADED PORT (ML) 900MG/6ML
1.51899 01/25/2013
CLINDAMYCIN PHOSPHATE TOPICAL FOAM (GRAM) 1 % 3.71476 08/21/2015 3.56290 11/15/2019
CLINDAMYCIN PHOSPHATE TOPICAL GEL (GRAM) 1 % 1.04700 01/11/2020 0.87733 05/22/2020
CLINDAMYCIN PHOSPHATE TOPICAL LOTION (ML) 1 % 1.00375 03/20/2020 0.89300 05/22/2020
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION, NON-ORAL 1 % 0.31316 06/16/2017 0.20259 02/22/2019
CLINDAMYCIN PHOSPHATE TOPICAL SWAB, MEDICATED 1 % 0.32269 03/19/2019 0.29097 11/15/2019
CLINDAMYCIN PHOSPHATE VAGINAL CREAM WITH APPLICATOR 2 % 1.37550 08/16/2019 1.71925 08/23/2019
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE TOPICAL GEL (GRAM) 1 %-5 %
2.44740 02/22/2019 1.52390 03/20/2020
CLINDAMYCIN PHOSPHATE/BENZOYL PEROXIDE TOPICAL GEL (GRAM) 1.2(1)%-5%
3.16462 08/12/2014 1.13000 08/16/2019
CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 300MG/50ML
0.11749 08/12/2014
CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 600MG/50ML
0.16505 11/07/2014 0.16505 08/21/2015
CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 900MG/50ML
0.21492 10/24/2014 0.21492 08/21/2015
CLOBAZAM ORAL TABLET 20 MG 0.80000 04/17/2020
CLOBETASOL PROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.89179 02/13/2020 0.63767 05/22/2020
CLOBETASOL PROPIONATE TOPICAL FOAM (GRAM) 0.05 % 1.24600 03/20/2020 1.03090 05/22/2020
CLOBETASOL PROPIONATE TOPICAL GEL (GRAM) 0.05 % 2.30000 05/25/2018 1.25150 08/16/2019
CLOBETASOL PROPIONATE TOPICAL LOTION (ML) 0.05 % 1.57000 12/21/2018 0.67797 11/15/2019
CLOBETASOL PROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 0.39284 01/24/2020 0.20242 06/19/2020
CLOBETASOL PROPIONATE TOPICAL SHAMPOO 0.05 % 1.53000 05/26/2018 1.47407 11/15/2019
CLOBETASOL PROPIONATE TOPICAL SOLUTION, NON-ORAL 0.05 % 0.63510 10/25/2019 0.51260 06/19/2020
CLOBETASOL PROPIONATE TOPICAL SPRAY, NON-AEROSOL (ML) 0.05 % 4.33264 03/06/2015
CLOBETASOL PROPIONATE/EMOLLIENT BASE TOPICAL CREAM (GRAM) 0.05 %
1.20000 12/20/2019 0.66483 03/20/2020
CLOBETASOL PROPIONATE/EMOLLIENT BASE TOPICAL FOAM (GRAM) 0.05 %
3.64100 08/12/2014 3.64100 08/21/2015
CLOCORTOLONE PIVALATE TOPICAL CREAM (GRAM) 0.1 % 5.01620 03/07/2014
CLOMIPHENE CITRATE ORAL TABLET 50 MG 1.01394 08/21/2015 0.58467 09/22/2017
CLOMIPRAMINE HCL ORAL CAPSULE 25 MG 3.50000 02/22/2019 2.85000 02/21/2020
CLOMIPRAMINE HCL ORAL CAPSULE 50 MG 3.40000 01/25/2019 1.98650 10/25/2019
CLOMIPRAMINE HCL ORAL CAPSULE 75 MG 2.72010 02/22/2019 1.58230 11/15/2019
CLONAZEPAM ORAL TABLET 0.5 MG 0.01635 12/12/2014 0.01635 08/21/2015
CLONAZEPAM ORAL TABLET 1 MG 0.02613 02/06/2015 0.02613 08/21/2015
CLONAZEPAM ORAL TABLET 2 MG 0.04039 08/21/2015 0.02645 11/16/2018
CLONAZEPAM ORAL TABLET,DISINTEGRATING 0.125 MG 0.72847 09/19/2014 0.70200 11/15/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CLONAZEPAM ORAL TABLET,DISINTEGRATING 0.25 MG 0.62800 09/22/2017 0.51183 11/15/2019
CLONAZEPAM ORAL TABLET,DISINTEGRATING 0.5 MG 0.51100 11/15/2019 0.54183 03/02/2020
CLONAZEPAM ORAL TABLET,DISINTEGRATING 1 MG 0.58810 03/16/2018 0.74870 03/18/2020
CLONAZEPAM ORAL TABLET,DISINTEGRATING 2 MG 1.09330 01/25/2013
CLONIDINE HCL ORAL TABLET 0.1 MG 0.02704 08/21/2015 0.01272 09/21/2018
CLONIDINE HCL ORAL TABLET 0.2 MG 0.05338 08/21/2015 0.02868 08/25/2017
CLONIDINE HCL ORAL TABLET 0.3 MG 0.04301 08/21/2015 0.02763 04/27/2018
CLONIDINE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 0.1 MG 0.88817 07/26/2019 0.69150 05/22/2020
CLONIDINE HCL/PF EPIDURAL VIAL (ML) 1000MCG/10 2.29944 08/12/2014
CLONIDINE HCL/PF EPIDURAL VIAL (ML) 5000MCG/10 10.09700 08/12/2014 10.09700 08/21/2015
CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.1MG/24HR 8.79250 11/15/2019 4.99750 05/22/2020
CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.2MG/24HR 14.26950 11/15/2019 12.69000 12/20/2019
CLONIDINE TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.3MG/24HR 21.24500 11/15/2019 18.23000 12/20/2019
CLOPIDOGREL BISULFATE ORAL TABLET 300 MG 14.71960 04/17/2015 14.71960 08/21/2015
CLOPIDOGREL BISULFATE ORAL TABLET 75 MG 0.05800 06/16/2017 0.05198 10/25/2019
CLORAZEPATE DIPOTASSIUM ORAL TABLET 15 MG 0.26100 08/21/2015 2.39650 09/19/2016
CLORAZEPATE DIPOTASSIUM ORAL TABLET 3.75 MG 0.19698 08/15/2014 0.19698 08/21/2015
CLORAZEPATE DIPOTASSIUM ORAL TABLET 7.5 MG 0.30128 08/01/2014 0.30128 08/21/2015
CLOTRIMAZOLE MUCOUS MEMBRANE TROCHE 10 MG 0.97392 03/27/2015
CLOTRIMAZOLE TOPICAL CREAM (GRAM) 1 % 0.10907 08/21/2015 0.07533 06/19/2020
CLOTRIMAZOLE TOPICAL SOLUTION, NON-ORAL 1 % 0.32656 01/25/2013
CLOTRIMAZOLE VAGINAL CREAM WITH APPLICATOR 1 % 0.07865 03/01/2013 0.07865 08/21/2015
CLOTRIMAZOLE VAGINAL CREAM WITH APPLICATOR 2 % 0.32760 08/12/2014 0.32760 08/21/2015
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE TOPICAL CREAM (GRAM) 1 %-0.05 %
0.20951 02/22/2019 0.19625 05/22/2020
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE TOPICAL LOTION (ML) 1 %-0.05 %
3.46640 05/31/2013
CLOZAPINE ORAL TABLET 100 MG 0.25570 11/15/2019 0.32882 03/03/2020
CLOZAPINE ORAL TABLET 200 MG 0.93590 02/21/2020 0.87220 05/22/2020
CLOZAPINE ORAL TABLET 25 MG 0.28170 01/06/2020 0.18130 05/22/2020
CLOZAPINE ORAL TABLET 50 MG 0.59637 02/26/2020 0.46890 06/19/2020
CLOZAPINE ORAL TABLET,DISINTEGRATING 100 MG 4.61480 08/17/2018 4.51730 08/16/2019
CLOZAPINE ORAL TABLET,DISINTEGRATING 12.5 MG 1.55925 01/25/2013
CLOZAPINE ORAL TABLET,DISINTEGRATING 25 MG 2.09823 01/25/2013
COAL TAR TOPICAL SHAMPOO 1 % 0.03020 08/12/2014
COCAINE HCL SOLUTION, NON-ORAL 4 % 15.19980 01/25/2013
CODEINE PHOSPHATE/BUTALBITAL/ASPIRIN/CAFFEINE ORAL CAPSULE 30-50-325
1.89262 08/21/2015 1.23660 09/22/2017
CODEINE PHOSPHATE/GUAIFENESIN ORAL LIQUID (ML) 10-100MG/5 0.05079 08/21/2015 0.02594 08/25/2017
CODEINE PHOSPHATE/GUAIFENESIN ORAL LIQUID (ML) 6.3-100/5 0.03518 08/12/2014
CODEINE PHOSPHATE/GUAIFENESIN ORAL LIQUID (ML) 7.5-225/5 0.04970 08/12/2014
CODEINE SULFATE ORAL TABLET 15 MG 0.36736 03/01/2013
CODEINE SULFATE ORAL TABLET 30 MG 0.44059 09/19/2014 0.44059 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CODEINE SULFATE ORAL TABLET 60 MG 0.79681 09/19/2014 0.79681 08/21/2015
COLCHICINE ORAL CAPSULE 0.6 MG 4.16383 05/17/2019 3.83870 07/26/2019
COLCHICINE ORAL TABLET 0.6 MG 5.02150 03/20/2020 4.29990 06/19/2020
COLESTIPOL HCL ORAL GRANULES (GRAM) 5 G 0.20871 01/25/2013
COLESTIPOL HCL ORAL PACKET (EA) 5 G 2.75100 01/16/2015
COLESTIPOL HCL ORAL TABLET 1 G 0.66658 02/25/2020 0.57208 05/22/2020
COLISTIN (AS COLISTIMETHATE SODIUM) INJECTION VIAL (EA) 150 MG 26.57000 06/24/2019 22.52000 10/25/2019
CORTISONE ACETATE ORAL TABLET 25 MG 3.04785 02/20/2015 3.04785 08/21/2015
COSYNTROPIN INJECTION VIAL (EA) 0.25 MG 64.39973 04/19/2013 64.39973 08/21/2015
COSYNTROPIN VIAL (ML) 0.25 MG/ML 151.55280 01/25/2013
CROMOLYN SODIUM INHALATION AMPUL FOR NEBULIZATION (ML) 20 MG/2 ML
1.16380 10/03/2014
CROMOLYN SODIUM NASAL AEROSOL, SPRAY WITH PUMP (ML) 5.2 MG 0.33554 01/25/2013 0.33554 08/21/2015
CROMOLYN SODIUM OPHTHALMIC DROPS 4 % 0.67817 08/21/2015 0.46600 09/30/2016
CROMOLYN SODIUM ORAL CONCENTRATE, ORAL 20 MG/ML 0.87906 08/21/2015 0.25000 03/15/2019
CUPRIC CHLORIDE INTRAVENOUS VIAL (ML) 0.4 MG/ML 0.15460 08/12/2014
CYANOCOBALAMIN (VITAMIN B-12) ORAL TABLET 100 MCG 0.01365 02/13/2015 0.01365 08/21/2015
CYANOCOBALAMIN (VITAMIN B-12) ORAL TABLET 500 MCG 0.02101 02/13/2015 0.02101 08/21/2015
CYANOCOBALAMIN (VITAMIN B-12) ORAL TABLET, EXTENDED RELEASE 1000 MCG
0.03872 08/12/2014 0.03872 08/21/2015
CYANOCOBALAMIN (VITAMIN B-12) SUBLINGUAL TABLET, SUBLINGUAL 1000 MCG
0.05332 08/12/2014 0.05332 08/21/2015
CYANOCOBALAMIN (VITAMIN B-12) SUBLINGUAL TABLET, SUBLINGUAL 5000 MCG
0.10737 03/08/2013
CYANOCOBALAMIN/FOLIC ACID ORAL TABLET 0.5 MG-1MG 0.12600 01/25/2013
CYANOCOBALAMIN/FOLIC ACID/PYRIDOXINE ORAL TABLET 2-2.5-25MG 0.43177 03/20/2015 0.43177 08/21/2015
CYANOCOBALAMIN/LEVOMEFOLATE CALCIUM/PYRIDOXINE HCL (B6) ORAL TABLET 2-1.13-25
0.89950 07/18/2014
CYANOCOBALAMIN/LEVOMEFOLATE CALCIUM/PYRIDOXINE/RIBOFLAVIN ORAL TABLET 1-6-50-5MG
2.02075 02/20/2015 2.02075 08/21/2015
CYCLOBENZAPRINE HCL ORAL TABLET 10 MG 0.02680 08/21/2015 0.01476 11/16/2018
CYCLOBENZAPRINE HCL ORAL TABLET 5 MG 0.03457 10/20/2017 0.02130 01/24/2020
CYCLOBENZAPRINE HCL ORAL TABLET 7.5 MG 3.36504 08/21/2015 1.79990 05/17/2019
CYCLOPENTOLATE HCL OPHTHALMIC DROPS 1 % 1.65266 05/10/2013 1.65266 08/21/2015
CYCLOPENTOLATE HCL OPHTHALMIC DROPS 2 % 3.33840 02/08/2013
CYCLOPHOSPHAMIDE INTRAVENOUS VIAL (EA) 1 G 432.93460 12/12/2014
CYCLOPHOSPHAMIDE INTRAVENOUS VIAL (EA) 2 G 1063.88300 12/12/2014 1063.88300 08/21/2015
CYCLOPHOSPHAMIDE INTRAVENOUS VIAL (EA) 500 MG 266.22500 12/12/2014 266.22500 08/21/2015
CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG 8.29164 09/05/2014 5.41000 09/21/2018
CYCLOSPORINE ORAL CAPSULE 100 MG 5.25882 05/23/2014
CYCLOSPORINE ORAL CAPSULE 25 MG 3.39817 09/27/2018 1.82000 01/25/2019
CYCLOSPORINE, MODIFIED ORAL CAPSULE 100 MG 2.20106 02/27/2015 1.21667 03/03/2017
CYCLOSPORINE, MODIFIED ORAL CAPSULE 25 MG 0.51042 05/20/2016 0.23923 03/03/2017
CYCLOSPORINE, MODIFIED ORAL CAPSULE 50 MG 1.20163 07/25/2014
CYCLOSPORINE, MODIFIED ORAL SOLUTION, ORAL 100 MG/ML 2.00000 09/22/2017 1.76740 02/22/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
CYPROHEPTADINE HCL ORAL SYRUP 2 MG/5 ML 0.08798 02/27/2015 0.06816 03/02/2018
CYPROHEPTADINE HCL ORAL TABLET 4 MG 0.23460 08/16/2019 0.14405 11/15/2019
CYTARABINE INJECTION VIAL (ML) 20 MG/ML 0.40080 08/12/2014 0.40080 08/21/2015
CYTARABINE/PF INJECTION VIAL (ML) 100 MG/5ML 1.97106 01/25/2013 1.97106 08/21/2015
CYTARABINE/PF INJECTION VIAL (ML) 2 G/20 ML 0.82997 08/12/2014 0.82997 08/21/2015
CYTARABINE/PF INJECTION VIAL (ML) 20 MG/ML 0.76440 01/16/2015 0.76440 08/21/2015
DACARBAZINE INTRAVENOUS VIAL (EA) 100 MG 7.93800 01/25/2013
DANAZOL ORAL CAPSULE 100 MG 3.38527 02/13/2015
DANAZOL ORAL CAPSULE 200 MG 4.80198 03/20/2015 4.80198 08/21/2015
DANAZOL ORAL CAPSULE 50 MG 2.25628 02/13/2015
DANTROLENE SODIUM INTRAVENOUS VIAL (EA) 20 MG 68.04000 01/25/2013
DANTROLENE SODIUM ORAL CAPSULE 100 MG 1.51750 02/08/2013 0.82590 03/20/2020
DANTROLENE SODIUM ORAL CAPSULE 25 MG 0.60000 08/30/2018 0.35000 11/16/2018
DANTROLENE SODIUM ORAL CAPSULE 50 MG 1.21009 03/22/2013 0.63900 05/25/2018
DAPSONE ORAL TABLET 100 MG 1.25033 01/25/2019 1.17600 03/20/2020
DARIFENACIN HYDROBROMIDE ORAL TABLET, EXTENDED RELEASE 24 HR 7.5 MG
2.60744 11/15/2019 2.41867 02/21/2020
DAUNORUBICIN HCL INTRAVENOUS VIAL (ML) 5 MG/ML 18.76077 08/12/2014 18.76077 08/21/2015
DECITABINE INTRAVENOUS VIAL (EA) 50 MG 1375.39150 12/12/2014 1375.39150 08/21/2015
DEFEROXAMINE MESYLATE INJECTION VIAL (EA) 2 G 26.33481 01/25/2013 26.33481 08/21/2015
DEMECLOCYCLINE HCL ORAL TABLET 150 MG 2.95730 03/16/2018 2.71000 11/16/2018
DEMECLOCYCLINE HCL ORAL TABLET 300 MG 7.13944 02/27/2015 7.13944 08/21/2015
DESIPRAMINE HCL ORAL TABLET 10 MG 0.71980 05/17/2019 0.57533 11/15/2019
DESIPRAMINE HCL ORAL TABLET 100 MG 2.97528 08/21/2015 1.78620 03/20/2020
DESIPRAMINE HCL ORAL TABLET 150 MG 4.38839 08/12/2014
DESIPRAMINE HCL ORAL TABLET 25 MG 0.96739 08/21/2015 0.42950 01/24/2020
DESIPRAMINE HCL ORAL TABLET 50 MG 1.74170 02/21/2018 1.31850 05/25/2018
DESIPRAMINE HCL ORAL TABLET 75 MG 2.22992 08/12/2014 1.19400 09/22/2017
DESLORATADINE ORAL TABLET 5 MG 0.33544 11/24/2017 0.25470 10/25/2019
DESLORATADINE ORAL TABLET,DISINTEGRATING 2.5 MG 10.07649 01/24/2014 10.07649 08/21/2015
DESLORATADINE ORAL TABLET,DISINTEGRATING 5 MG 4.07750 01/25/2013 4.07750 08/21/2015
DESMOPRESSIN ACETATE (NON-REFRIGERATED) NASAL AEROSOL, SPRAY WITH PUMP (ML) 10/SPRAY
14.44800 04/26/2019 13.10000 02/21/2020
DESMOPRESSIN ACETATE INJECTION AMPUL (ML) 4 MCG/ML 16.22800 08/30/2013
DESMOPRESSIN ACETATE INJECTION VIAL (ML) 4 MCG/ML 8.62810 05/16/2014
DESMOPRESSIN ACETATE NASAL AEROSOL, SPRAY WITH PUMP (ML) 10/SPRAY
28.62300 02/06/2015
DESMOPRESSIN ACETATE NASAL SOLUTION, NON-ORAL 0.1 MG/ML 25.31760 03/08/2013
DESMOPRESSIN ACETATE ORAL TABLET 0.1 MG 0.41720 11/15/2019 0.23400 06/19/2020
DESMOPRESSIN ACETATE ORAL TABLET 0.2 MG 0.50930 10/25/2019 0.44210 03/20/2020
DESOGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.15-0.03 0.21696 03/02/2018 0.10127 03/20/2020
DESOGESTREL-ETHINYL ESTRADIOL ORAL TABLET 7 DAYS X 3 0.81931 08/21/2015 0.52119 06/16/2017
DESOGESTREL-ETHINYL ESTRADIOL/ETHINYL ESTRADIOL ORAL TABLET 21-5 (28)
0.46310 03/03/2017 0.37988 03/02/2018
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
DESONIDE TOPICAL CREAM (GRAM) 0.05 % 1.15112 06/21/2019 0.91650 03/20/2020
DESONIDE TOPICAL LOTION (ML) 0.05 % 1.83560 12/05/2014 1.66017 11/15/2019
DESONIDE TOPICAL OINTMENT (GRAM) 0.05 % 1.28900 08/16/2019 0.70000 10/25/2019
DESOXIMETASONE TOPICAL CREAM (GRAM) 0.05 % 3.19548 02/07/2014
DESOXIMETASONE TOPICAL CREAM (GRAM) 0.25 % 0.73085 06/16/2017 0.57933 03/20/2020
DESOXIMETASONE TOPICAL GEL (GRAM) 0.05 % 2.73169 01/25/2013
DESOXIMETASONE TOPICAL OINTMENT (GRAM) 0.05 % 5.41981 02/07/2014 5.41981 08/21/2015
DESOXIMETASONE TOPICAL OINTMENT (GRAM) 0.25 % 3.72602 06/16/2017 0.79000 12/20/2019
DESVENLAFAXINE FUMARATE TABLET, EXTENDED RELEASE 24 HR 100 MG
4.64370 04/04/2014
DESVENLAFAXINE FUMARATE TABLET, EXTENDED RELEASE 24 HR 50 MG
4.64370 04/04/2014
DESVENLAFAXINE SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG
0.50550 11/15/2019 0.77253 02/06/2020
DESVENLAFAXINE SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 25 MG
0.82000 04/27/2018 0.76900 08/16/2019
DESVENLAFAXINE SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 50 MG
0.75488 01/25/2019 0.71833 05/17/2019
DEXAMETHASONE ORAL ELIXIR 0.5 MG/5ML 0.14107 04/21/2017 0.06692 09/22/2017
DEXAMETHASONE ORAL SOLUTION, ORAL 0.5 MG/5ML 0.03446 08/22/2014
DEXAMETHASONE ORAL TABLET 1.5 MG 0.09841 02/07/2014 0.09841 08/21/2015
DEXAMETHASONE ORAL TABLET 4 MG 0.34200 04/06/2018 0.93000 05/28/2019
DEXAMETHASONE SODIUM PHOSPHATE INJECTION VIAL (ML) 10 MG/ML 0.80490 08/12/2014 0.80490 08/21/2015
DEXAMETHASONE SODIUM PHOSPHATE INJECTION VIAL (ML) 4 MG/ML 0.28517 08/12/2014 0.28517 08/21/2015
DEXAMETHASONE SODIUM PHOSPHATE OPHTHALMIC DROPS 0.1 % 3.31265 08/21/2015 9.46200 04/16/2018
DEXAMETHASONE SODIUM PHOSPHATE/PF INJECTION VIAL (ML) 10 MG/ML
6.35376 01/25/2013
DEXCHLORPHENIRAMINE MALEATE/PSEUDOEPHEDRINE/CHLOPHEDIANOL ORAL LIQUID (ML) 1-30-12.5
0.08050 08/12/2014
DEXMETHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 50-50 10 MG
6.50059 03/27/2015 5.84742 12/02/2016
DEXMETHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 50-50 5 MG
5.46315 03/27/2015
DEXMETHYLPHENIDATE HCL ORAL TABLET 10 MG 0.41200 08/16/2019 0.39990 10/25/2019
DEXMETHYLPHENIDATE HCL ORAL TABLET 2.5 MG 0.47427 12/02/2016 0.19260 09/22/2017
DEXMETHYLPHENIDATE HCL ORAL TABLET 5 MG 0.31590 11/15/2019 0.20000 01/24/2020
DEXRAZOXANE HCL INTRAVENOUS VIAL (EA) 250 MG 165.25050 01/16/2015
DEXRAZOXANE HCL INTRAVENOUS VIAL (EA) 500 MG 286.43625 01/16/2015
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 10 MG
1.42000 01/22/2020 1.42000 01/23/2020
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 15 MG
1.80000 01/22/2020 1.69990 05/22/2020
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 20 MG
1.57007 01/28/2020 1.38000 05/22/2020
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 25 MG
1.89020 11/15/2019 1.89020 01/22/2020
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 30 MG
1.51574 11/15/2019 1.51574 01/22/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL CAPSULE, EXT RELEASE 24 HR 5 MG
3.82332 01/22/2020 2.02485 03/20/2020
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL TABLET 10 MG
0.42600 06/25/2019 0.33058 11/15/2019
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL TABLET 12.5 MG
0.23110 09/22/2017 0.52690 01/08/2018
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL TABLET 15 MG
0.50545 03/16/2019 0.37100 09/20/2019
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL TABLET 20 MG
0.56320 03/08/2019 0.37150 09/20/2019
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL TABLET 30 MG
0.21010 03/20/2020 0.36280 05/16/2020
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL TABLET 5 MG
0.40500 06/22/2018 0.25450 11/16/2018
DEXTROAMPHETAMINE SULF-SACCHARATE/AMPHETAMINE SULF-ASPARTATE ORAL TABLET 7.5 MG
0.69359 12/02/2016 0.54333 03/03/2017
DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 10 MG
0.46820 03/20/2020 1.19950 04/17/2020
DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 15 MG
1.85122 11/14/2017 0.88868 09/21/2018
DEXTROAMPHETAMINE SULFATE ORAL CAPSULE, EXTENDED RELEASE 5 MG
2.62825 01/01/2017 2.06516 06/16/2017
DEXTROAMPHETAMINE SULFATE ORAL SOLUTION, ORAL 5 MG/5 ML 1.27716 01/24/2014 1.27716 08/21/2015
DEXTROAMPHETAMINE SULFATE ORAL TABLET 10 MG 0.42930 01/24/2020 0.40200 03/20/2020
DEXTROAMPHETAMINE SULFATE ORAL TABLET 5 MG 0.64600 03/22/2019 0.34350 05/17/2019
DEXTROMETHORPHAN HBR/ACETAMINOPHEN/DOXYLAMINE ORAL LIQUID (ML) 15-325/15
0.01469 08/22/2014 0.01469 08/21/2015
DEXTROMETHORPHAN HBR/PHENYLEPHRINE HCL/DEXBROMPHENIRAMINE ORAL SYRUP 20-10-2/5
0.05168 08/12/2014 0.05168 08/21/2015
DEXTROMETHORPHAN POLISTIREX ORAL SUSPENSION, EXTENDED RELEASE 12 HR 30 MG/5 ML
0.08530 03/20/2015 0.08530 08/21/2015
DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS DEHP-FREE BAG, INJECTION (ML) 10 %-0.2 %
0.04179 01/25/2013
DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 10 %-0.2 %
0.03704 01/25/2013
DEXTROSE 10 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 10%-0.45%
0.01077 01/25/2013
DEXTROSE 10 % IN WATER INTRAVENOUS DEHP-FREE BAG, INJECTION (ML) 10 %
0.00819 01/25/2013
DEXTROSE 10 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 10 %
0.00207 04/05/2013
DEXTROSE 2.5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 2.5%-0.45%
0.00250 08/12/2014 0.00250 08/21/2015
DEXTROSE 20 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 20 %
0.00864 01/25/2013
DEXTROSE 25 % IN WATER INTRAVENOUS SYRINGE (ML) 25 % 0.38140 08/12/2014
DEXTROSE 30 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 30 %
0.00877 01/25/2013 0.00877 08/21/2015
DEXTROSE 40 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 40 %
0.00870 08/12/2014
DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 5 %-0.2 %
0.00228 01/25/2013
DEXTROSE 5 % AND 0.3 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 5 %-0.3 %
0.00230 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 5 %-0.45 %
0.00181 08/22/2014 0.00181 08/21/2015
DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 5 %-0.9 %
0.00274 01/09/2015 0.00274 08/21/2015
DEXTROSE 5 % IN LACTATED RINGERS INTRAVENOUS INTRAVENOUS SOLUTION 5 %
0.00214 01/25/2013
DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.00275 07/25/2014 0.00275 08/21/2015
DEXTROSE 5 % IN WATER INTRAVENOUS PIGGYBACK WITH THREADED PORT (ML)
0.02997 01/30/2015 0.02997 08/21/2015
DEXTROSE 5 % IN WATER INTRAVENOUS PIGGYBACK WITH VIAL PORT (NON-THREADED)
0.07096 01/25/2013
DEXTROSE 5 % IN WATER INTRAVENOUS VIAL (ML) 5 % 0.53214 01/25/2013
DEXTROSE 50 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 50 %
0.00630 01/25/2013 0.00630 08/21/2015
DEXTROSE 50 % IN WATER INTRAVENOUS SYRINGE (ML) 50 % 0.09475 04/05/2013 0.09475 08/21/2015
DEXTROSE 50 % IN WATER INTRAVENOUS VIAL (ML) 50 % 0.02540 08/12/2014
DEXTROSE 70 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 70 %
0.00532 04/19/2013 0.00532 08/21/2015
DEXTROSE ORAL SOLUTION, ORAL 5 % 0.01679 01/16/2015 0.01679 08/21/2015
DIAZEPAM INJECTION SYRINGE (ML) 5 MG/ML 3.71280 01/25/2013
DIAZEPAM INJECTION VIAL (ML) 5 MG/ML 1.36920 07/12/2013
DIAZEPAM ORAL CONCENTRATE, ORAL 5 MG/ML 1.83609 01/16/2015
DIAZEPAM ORAL SOLUTION, ORAL 5 MG/5 ML 0.10010 05/09/2014
DIAZEPAM ORAL TABLET 10 MG 0.02396 09/19/2014 0.02396 08/21/2015
DIAZEPAM ORAL TABLET 2 MG 0.02372 04/17/2015 0.02372 08/21/2015
DIAZEPAM ORAL TABLET 5 MG 0.02230 01/23/2015 0.02230 08/21/2015
DIAZEPAM RECTAL KIT 12.5-15-20 234.84300 04/01/2019 232.00000 10/25/2019
DIAZEPAM RECTAL KIT 2.5 MG 197.11300 08/22/2014 197.11300 04/01/2019
DIAZEPAM RECTAL KIT 5-7.5-10MG 245.00000 10/25/2019 234.39000 11/15/2019
DICLOFENAC POTASSIUM ORAL TABLET 50 MG 0.42767 03/16/2018 0.25630 11/16/2018
DICLOFENAC SODIUM OPHTHALMIC DROPS 0.1 % 1.02376 05/02/2014 1.02376 08/21/2015
DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 25 MG
0.99526 03/28/2014
DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 50 MG
0.09565 03/03/2017 0.08500 01/24/2020
DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 75 MG
0.09565 07/14/2017 0.08230 01/24/2020
DICLOFENAC SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG 0.66130 12/19/2018 1.60000 06/04/2019
DICLOFENAC SODIUM TOPICAL DROPS 1.5 % 0.90000 04/27/2018 0.11873 11/15/2019
DICLOFENAC SODIUM TOPICAL GEL (GRAM) 1 % 0.17595 11/15/2019 0.14776 05/22/2020
DICLOFENAC SODIUM TOPICAL GEL (GRAM) 3 % 1.49000 05/25/2018 0.68850 03/20/2020
DICLOFENAC SODIUM/MISOPROSTOL ORAL TABLET,IMMEDIATE,DELAY RELEASE,BIPHASE 50 MG-200
2.34693 08/21/2015 1.56576 06/16/2017
DICLOFENAC SODIUM/MISOPROSTOL ORAL TABLET,IMMEDIATE,DELAY RELEASE,BIPHASE 75 MG-200
1.94983 03/03/2017 1.59850 05/22/2020
DICLOXACILLIN SODIUM ORAL CAPSULE 250 MG 0.33183 09/26/2014 0.33183 08/21/2015
DICLOXACILLIN SODIUM ORAL CAPSULE 500 MG 0.67080 09/26/2014 0.67080 08/21/2015
DICYCLOMINE HCL ORAL CAPSULE 10 MG 0.14349 11/15/2019 0.11241 04/17/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
DICYCLOMINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.21028 04/03/2015
DICYCLOMINE HCL ORAL TABLET 20 MG 0.14933 09/20/2019 0.18270 10/04/2019
DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 125 MG
2.70223 01/25/2013
DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 200 MG
4.32270 02/08/2013
DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 250 MG
5.50853 01/25/2013
DIDANOSINE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 400 MG
8.60350 02/08/2013
DIETHYLPROPION HCL ORAL TABLET 25 MG 0.23090 08/21/2015 0.18070 11/24/2017
DIETHYLPROPION HCL ORAL TABLET, EXTENDED RELEASE 75 MG 0.88524 08/22/2014 0.88524 08/21/2015
DIFLORASONE DIACETATE TOPICAL CREAM (GRAM) 0.05 % 3.29067 08/21/2015
DIFLORASONE DIACETATE TOPICAL OINTMENT (GRAM) 0.05 % 2.47670 08/12/2014 2.47670 08/21/2015
DIFLUNISAL ORAL TABLET 500 MG 1.18611 05/17/2013 1.18611 08/21/2015
DIGOXIN INJECTION SYRINGE (ML) 250 MCG/ML 1.58760 01/25/2013
DIGOXIN ORAL SOLUTION, ORAL 50 MCG/ML 0.56138 04/17/2015 0.68654 08/24/2017
DIGOXIN ORAL TABLET 125 MCG 0.24247 05/17/2019 0.21936 03/20/2020
DIGOXIN ORAL TABLET 250 MCG 0.29347 08/16/2019 0.17780 10/25/2019
DIHYDROERGOTAMINE MESYLATE INJECTION AMPUL (ML) 1 MG/ML 104.81800 03/13/2015
DIHYDROERGOTAMINE MESYLATE INJECTION VIAL (ML) 1 MG/ML 37.55430 01/25/2013
DIHYDROERGOTAMINE MESYLATE NASAL AEROSOL, SPRAY WITH PUMP (ML) 0.5MG/SPRY
296.65500 07/05/2017 324.99800 09/24/2019
DILTIAZEM HCL INTRAVENOUS VIAL WITH THREADED PORT (EA) 100 MG 14.71680 01/25/2013
DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 120 MG 0.18874 10/19/2018 0.13167 05/17/2019
DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 180 MG 0.16256 10/25/2019 0.12444 04/17/2020
DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 240 MG 0.25000 04/27/2018 0.23078 02/22/2019
DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 300 MG 0.41122 10/20/2017 0.28339 11/16/2018
DILTIAZEM HCL ORAL CAPSULE, EXT RELEASE 24 HR 360 MG 4.13262 01/07/2019 2.89000 10/25/2019
DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 60 MG 1.97040 04/10/2015
DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 90 MG 1.05763 05/16/2014 2.33360 07/24/2018
DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 120 MG 0.31426 08/21/2015 0.23822 03/02/2018
DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 180 MG 0.32000 03/02/2018 0.26189 08/17/2018
DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 240 MG 0.51111 07/14/2017 0.41667 11/24/2017
DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 300 MG 0.64937 07/14/2017 0.33644 05/22/2020
DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 360 MG 0.39467 02/22/2019 0.35344 11/15/2019
DILTIAZEM HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 420 MG 1.49711 09/30/2016 1.16224 06/16/2017
DILTIAZEM HCL ORAL CAPSULE,EXTENDED-RELEASE 24HR DEGRADABLE 120 MG
0.44907 09/30/2016 0.35690 09/22/2017
DILTIAZEM HCL ORAL CAPSULE,EXTENDED-RELEASE 24HR DEGRADABLE 180 MG
0.58869 08/21/2015 0.41490 03/17/2017
DILTIAZEM HCL ORAL CAPSULE,EXTENDED-RELEASE 24HR DEGRADABLE 240 MG
0.45397 03/02/2018 0.42815 03/16/2018
DILTIAZEM HCL ORAL TABLET 120 MG 0.28520 11/16/2018 0.26220 02/22/2019
DILTIAZEM HCL ORAL TABLET 30 MG 0.09900 08/21/2015 0.07598 09/22/2017
DILTIAZEM HCL ORAL TABLET 60 MG 0.21057 04/28/2016 0.14363 07/14/2017
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
DILTIAZEM HCL ORAL TABLET 90 MG 0.24125 09/22/2017 0.22950 05/22/2020
DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 180 MG 2.04560 08/21/2015 1.63333 05/17/2019
DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 240 MG 2.33427 08/21/2015 1.94733 03/20/2020
DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 2.97603 12/19/2014 2.97603 08/21/2015
DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 360 MG 2.40333 11/16/2018 2.18554 06/21/2019
DILTIAZEM HCL ORAL TABLET, EXTENDED RELEASE 24 HR 420 MG 3.54216 03/21/2014 3.13330 06/16/2017
DILUENT FOR EPOPROSTENOL SODIUM (GLYCINE) INTRAVENOUS VIAL (ML)
0.14700 01/25/2013
DIMENHYDRINATE INJECTION VIAL (ML) 50 MG/ML 4.98960 01/25/2013
DIMENHYDRINATE ORAL TABLET 50 MG 0.01809 01/25/2013 0.01809 08/21/2015
DIMETHICONE TOPICAL CREAM (ML) 5 % 0.03918 04/10/2015 0.03918 08/21/2015
DIMETHICONE TOPICAL SPRAY, NON-AEROSOL (ML) 2 % 0.03000 08/12/2014
DIPHENHYDRAMINE HCL INJECTION VIAL (ML) 50 MG/ML 0.59000 08/16/2019
DIPHENHYDRAMINE HCL ORAL CAPSULE 25 MG 0.03163 08/21/2015 0.02020 10/20/2017
DIPHENHYDRAMINE HCL ORAL CAPSULE 50 MG 0.01743 08/12/2014 0.01743 08/21/2015
DIPHENHYDRAMINE HCL ORAL CAPSULE 50 MG 0.17282 08/21/2015 0.01743 11/17/2017
DIPHENHYDRAMINE HCL ORAL ELIXIR 12.5MG/5ML 0.00512 01/25/2013 0.00512 08/21/2015
DIPHENHYDRAMINE HCL ORAL LIQUID (ML) 12.5MG/5ML 0.00578 01/16/2015 0.00578 08/21/2015
DIPHENHYDRAMINE HCL ORAL SYRUP 12.5MG/5ML 0.01260 08/12/2014
DIPHENHYDRAMINE HCL ORAL TABLET 25 MG 0.02104 02/06/2015 0.02104 08/21/2015
DIPHENOXYLATE HCL/ATROPINE SULFATE ORAL LIQUID (ML) 2.5-.025/5 0.10803 01/25/2013
DIPHENOXYLATE HCL/ATROPINE SULFATE ORAL TABLET 2.5-.025MG 0.29000 02/22/2019 0.21900 11/15/2019
DIPYRIDAMOLE ORAL TABLET 25 MG 0.05708 02/13/2015 0.05708 08/21/2015
DIPYRIDAMOLE ORAL TABLET 50 MG 0.10810 08/12/2014 0.10810 08/21/2015
DIPYRIDAMOLE ORAL TABLET 75 MG 0.13680 08/12/2014 0.13680 08/21/2015
DISOPYRAMIDE PHOSPHATE ORAL CAPSULE 100 MG 0.34801 05/01/2015 0.34801 08/21/2015
DISOPYRAMIDE PHOSPHATE ORAL CAPSULE 150 MG 0.35458 08/21/2015
DISULFIRAM ORAL TABLET 250 MG 0.78000 01/25/2019 1.50849 04/09/2019
DISULFIRAM ORAL TABLET 500 MG 3.76000 01/08/2018 0.87360 03/02/2018
DIVALPROEX SODIUM ORAL CAPSULE, DELAYED RELEASE SPRINKLE 125 MG
0.29874 03/20/2020 0.23220 06/19/2020
DIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 125 MG
0.05896 08/21/2015 0.04414 03/02/2018
DIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 250 MG
0.10366 08/21/2015 0.06000 08/25/2017
DIVALPROEX SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 500 MG
0.10326 01/19/2018 0.07662 12/20/2019
DIVALPROEX SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 250 MG 0.28108 04/01/2020 0.14808 06/19/2020
DIVALPROEX SODIUM ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.20742 12/20/2019 0.14998 04/17/2020
DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 1000MG/250
0.08730 08/12/2014
DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 250 MG/250
0.04960 08/12/2014
DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 500 MG/500
0.02810 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
DOBUTAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 500MG/250
0.05620 08/12/2014
DOBUTAMINE HCL INTRAVENOUS VIAL (ML) 250MG/20ML 0.15780 08/12/2014
DOBUTAMINE HCL INTRAVENOUS VIAL (ML) 500MG/40ML 0.15830 08/12/2014
DOCETAXEL INTRAVENOUS VIAL (ML) 140 MG/7ML 43.50599 01/23/2015 43.50599 08/21/2015
DOCETAXEL INTRAVENOUS VIAL (ML) 160 MG/8ML 675.67500 08/12/2014
DOCETAXEL INTRAVENOUS VIAL (ML) 160MG/16ML 67.85567 08/12/2014 67.85567 08/21/2015
DOCETAXEL INTRAVENOUS VIAL (ML) 20 MG/2 ML 60.99275 08/12/2014 60.99275 08/21/2015
DOCETAXEL INTRAVENOUS VIAL (ML) 200MG/20ML 42.61540 05/01/2015
DOCETAXEL INTRAVENOUS VIAL (ML) 20MG/ML(1) 53.07450 02/27/2015 53.07450 08/21/2015
DOCETAXEL INTRAVENOUS VIAL (ML) 80 MG/4 ML 50.41463 02/27/2015 50.41463 08/21/2015
DOCETAXEL INTRAVENOUS VIAL (ML) 80 MG/8 ML 61.30313 08/12/2014 61.30313 08/21/2015
DOCETAXEL INTRAVENOUS VIAL (ML) FNL 20MG/2 148.61475 01/25/2013 148.61475 08/21/2015
DOCETAXEL INTRAVENOUS VIAL (ML) FNL 80MG/8 297.22950 01/25/2013 297.22950 08/21/2015
DOCUSATE CALCIUM ORAL CAPSULE 240 MG 0.05135 08/12/2014 0.05135 08/21/2015
DOCUSATE SODIUM ORAL CAPSULE 100 MG 0.01474 01/30/2015 0.01474 08/21/2015
DOCUSATE SODIUM ORAL CAPSULE 250 MG 0.04068 03/27/2015 0.04068 08/21/2015
DOCUSATE SODIUM ORAL LIQUID (ML) 50 MG/5 ML 0.00902 08/12/2014 0.00902 08/21/2015
DOCUSATE SODIUM ORAL SYRUP 60 MG/15ML 0.00788 08/12/2014 0.00788 08/21/2015
DOCUSATE SODIUM ORAL TABLET 100 MG 0.02938 08/21/2015 0.01740 08/17/2018
DOCUSATE SODIUM RECTAL ENEMA (ML) 283 MG/5ML 3.28266 08/21/2015
DOCUSATE SODIUM/BENZOCAINE RECTAL ENEMA (ML) 283-20MG/5 2.68029 08/21/2015
DOFETILIDE ORAL CAPSULE 125 MCG 4.55000 08/25/2017 3.55783 09/22/2017
DOFETILIDE ORAL CAPSULE 500 MCG 2.61000 10/25/2019 1.71667 03/20/2020
DONEPEZIL HCL ORAL TABLET 10 MG 0.05607 08/25/2017 0.03508 09/22/2017
DONEPEZIL HCL ORAL TABLET 23 MG 0.76656 08/16/2019 0.24733 02/21/2020
DONEPEZIL HCL ORAL TABLET 5 MG 0.04100 07/26/2019 0.03500 10/25/2019
DONEPEZIL HCL ORAL TABLET,DISINTEGRATING 10 MG 0.27257 01/30/2015
DONEPEZIL HCL ORAL TABLET,DISINTEGRATING 5 MG 0.37252 08/21/2015 0.22000 03/20/2020
DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC BAG, INJECTION (ML) 200MG/.25L
0.02960 08/12/2014
DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC BAG, INJECTION (ML) 400MG/.25L
0.03690 08/12/2014
DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC BAG, INJECTION (ML) 400MG/0.5L
0.04060 08/12/2014
DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC BAG, INJECTION (ML) 800MG/.25L
0.08010 08/12/2014
DOPAMINE HCL IN DEXTROSE 5 % IN WATER INTRAVENOUS PLASTIC BAG, INJECTION (ML) 800MG/0.5L
0.05100 08/12/2014
DOPAMINE HCL INTRAVENOUS VIAL (ML) 400 MG/5ML 0.50263 01/25/2013
DOPAMINE HCL INTRAVENOUS VIAL (ML) 400MG/10ML 0.07980 01/25/2013
DOPAMINE HCL INTRAVENOUS VIAL (ML) 800MG/10ML 0.20101 01/25/2013
DOPAMINE HCL INTRAVENOUS VIAL (ML) 800MG/5ML 0.62837 01/25/2013
DORZOLAMIDE HCL OPHTHALMIC DROPS 2 % 0.81880 08/25/2017 0.78900 12/20/2019
DORZOLAMIDE HCL/TIMOLOL MALEATE OPHTHALMIC DROPS 22.3-6.8/1 0.78900 09/20/2019 1.73621 01/29/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
DOXAZOSIN MESYLATE ORAL TABLET 1 MG 0.13300 09/22/2017 0.05640 09/20/2019
DOXAZOSIN MESYLATE ORAL TABLET 2 MG 0.09930 11/24/2017 0.05640 01/24/2020
DOXAZOSIN MESYLATE ORAL TABLET 4 MG 0.18871 08/01/2019 0.08960 01/24/2020
DOXAZOSIN MESYLATE ORAL TABLET 8 MG 0.10930 11/24/2017 0.08800 06/19/2020
DOXEPIN HCL ORAL CAPSULE 10 MG 0.37514 08/21/2015 0.22778 05/17/2019
DOXEPIN HCL ORAL CAPSULE 100 MG 0.96692 09/30/2019 0.55000 05/22/2020
DOXEPIN HCL ORAL CAPSULE 150 MG 0.92954 03/20/2015
DOXEPIN HCL ORAL CAPSULE 25 MG 0.36040 08/25/2017 0.24400 06/19/2020
DOXEPIN HCL ORAL CAPSULE 50 MG 0.45428 05/17/2019 0.58570 08/06/2019
DOXEPIN HCL ORAL CAPSULE 75 MG 1.19520 09/18/2016 0.65458 05/17/2019
DOXEPIN HCL ORAL CONCENTRATE, ORAL 10 MG/ML 0.05720 08/12/2014
DOXERCALCIFEROL ORAL CAPSULE 0.5 MCG 11.21120 01/01/2017 11.21120 01/02/2017
DOXERCALCIFEROL ORAL CAPSULE 1 MCG 22.42149 01/01/2017 22.42149 01/02/2017
DOXERCALCIFEROL ORAL CAPSULE 2.5 MCG 25.97343 01/01/2017 25.97343 01/02/2017
DOXORUBICIN HCL INTRAVENOUS VIAL (EA) 10 MG 40.96400 08/08/2014 40.96400 08/21/2015
DOXORUBICIN HCL INTRAVENOUS VIAL (EA) 50 MG 29.40000 03/07/2014 29.40000 08/21/2015
DOXORUBICIN HCL PEGYLATED LIPOSOMAL INTRAVENOUS VIAL (ML) 2 MG/ML
80.99070 04/05/2013
DOXYCYCLINE HYCLATE INTRAVENOUS VIAL (EA) 100 MG 13.86000 11/14/2014 13.86000 08/21/2015
DOXYCYCLINE HYCLATE ORAL CAPSULE 100 MG 0.16900 12/21/2018 0.13096 05/22/2020
DOXYCYCLINE HYCLATE ORAL CAPSULE 50 MG 0.28216 04/08/2019 0.21890 11/15/2019
DOXYCYCLINE HYCLATE ORAL TABLET 100 MG 0.12565 08/16/2019 0.09980 04/17/2020
DOXYCYCLINE HYCLATE ORAL TABLET 20 MG 0.62690 08/21/2015 0.20961 07/08/2016
DOXYCYCLINE HYCLATE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 100 MG
9.19320 08/17/2018 5.36500 10/19/2018
DOXYCYCLINE HYCLATE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 150 MG
8.72316 04/24/2015 5.65000 06/21/2019
DOXYCYCLINE HYCLATE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 75 MG
7.15693 08/12/2014
DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 100 MG 0.16447 11/16/2018 0.14700 01/24/2020
DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 150 MG 17.25512 01/25/2013
DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 50 MG 0.20460 08/17/2018 0.12490 10/25/2019
DOXYCYCLINE MONOHYDRATE ORAL CAPSULE 75 MG 11.72204 01/30/2015 11.72204 08/21/2015
DOXYCYCLINE MONOHYDRATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 25 MG/5 ML
0.26565 03/20/2015 0.23433 05/17/2019
DOXYCYCLINE MONOHYDRATE ORAL TABLET 100 MG 0.56939 06/16/2017 0.22315 03/20/2020
DOXYCYCLINE MONOHYDRATE ORAL TABLET 150 MG 4.39361 01/25/2013 4.39361 08/21/2015
DOXYCYCLINE MONOHYDRATE ORAL TABLET 50 MG 0.65088 06/16/2017 0.32590 09/22/2017
DOXYCYCLINE MONOHYDRATE ORAL TABLET 75 MG 0.73370 08/12/2014 0.73370 08/21/2015
DOXYLAMINE SUCCINATE ORAL TABLET 25 MG 0.20563 08/21/2015
DRONABINOL ORAL CAPSULE 10 MG 9.55706 12/02/2016 7.63483 09/22/2017
DRONABINOL ORAL CAPSULE 2.5 MG 1.56000 12/21/2018 1.49667 11/15/2019
DRONABINOL ORAL CAPSULE 5 MG 3.24900 11/15/2019 2.50000 03/20/2020
DROPERIDOL INJECTION AMPUL (ML) 2.5 MG/ML 0.84840 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
DROPERIDOL INJECTION VIAL (ML) 2.5 MG/ML 1.48750 01/25/2013
DROSPIRENONE/ETHINYL ESTRADIOL/LEVOMEFOLATE CALCIUM ORAL TABLET 3-0.02(24)
3.80020 02/26/2019 3.28512 11/15/2019
DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 20 MG
0.19211 11/16/2018 0.15437 08/16/2019
DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 30 MG
0.15200 12/21/2018 0.10633 12/20/2019
DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 40 MG
2.98102 04/23/2019 2.25600 02/21/2020
DULOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 60 MG
0.11663 08/16/2019 0.10200 06/19/2020
DUTASTERIDE ORAL CAPSULE 0.5 MG 0.17067 09/21/2018 0.13530 08/16/2019
DUTASTERIDE/TAMSULOSIN HCL ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 0.5-0.4 MG
2.40833 11/16/2018 2.18600 08/16/2019
ECONAZOLE NITRATE TOPICAL CREAM (GRAM) 1 % 0.44717 11/15/2019 0.24988 05/22/2020
ELECTROLYTE-48 SOLUTION/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 5 %
0.00430 08/12/2014
ELECTROLYTES/DEXTROSE ORAL SOLUTION, ORAL 0.00517 02/27/2015 0.00517 08/21/2015
ELETRIPTAN HYDROBROMIDE ORAL TABLET 20 MG 9.80000 04/27/2018 5.01000 12/20/2019
ELETRIPTAN HYDROBROMIDE ORAL TABLET 40 MG 5.31750 05/17/2019 3.67667 09/20/2019
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION (GRAM) 0.44835 01/25/2013 0.44835 08/21/2015
EMOLLIENT COMBINATION NO.32 TOPICAL EMULSION (GRAM) 0.72194 08/29/2014 0.72194 08/21/2015
EMOLLIENT COMBINATION NO.44 TOPICAL FOAM (GRAM) 0.90811 01/25/2013
EMOLLIENT COMBINATION NO.53 TOPICAL CREAM (GRAM) 0.49685 08/12/2014
EMOLLIENT COMBINATION NO.53 TOPICAL FOAM (GRAM) 1.01001 01/25/2013
ENALAPRIL MALEATE MISCELLANEOUS POWDER (GRAM) 100 % 3.35240 08/12/2014 3.35240 08/21/2015
ENALAPRIL MALEATE ORAL TABLET 10 MG 0.07090 09/20/2019 0.05510 11/15/2019
ENALAPRIL MALEATE ORAL TABLET 2.5 MG 0.06000 08/25/2017 0.05650 07/26/2019
ENALAPRIL MALEATE ORAL TABLET 20 MG 0.11706 11/16/2018 0.07320 01/24/2020
ENALAPRIL MALEATE ORAL TABLET 5 MG 0.13023 08/25/2017 0.07035 11/16/2018
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE ORAL TABLET 10 MG-25MG
0.14036 08/21/2015 0.09050 06/16/2017
ENALAPRIL MALEATE/HYDROCHLOROTHIAZIDE ORAL TABLET 5MG-12.5MG
0.08740 05/31/2013 0.08740 08/21/2015
ENALAPRILAT DIHYDRATE INTRAVENOUS VIAL (ML) 1.25 MG/ML 1.78220 09/12/2014
ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 100 MG/ML 13.03766 04/21/2017 10.08000 08/01/2018
ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 120MG/.8ML 19.56825 02/26/2016 17.76502 04/21/2017
ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 150 MG/ML 12.95000 09/21/2018 11.45550 11/15/2019
ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 30MG/0.3ML 10.59000 08/22/2019 8.99667 03/20/2020
ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 40MG/0.4ML 9.79500 02/21/2020 11.98426 05/15/2020
ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 60MG/0.6ML 11.40870 03/17/2017 10.60666 06/19/2020
ENOXAPARIN SODIUM SUBCUTANEOUS SYRINGE (ML) 80MG/0.8ML 9.16000 12/27/2019 8.92000 05/22/2020
ENOXAPARIN SODIUM SUBCUTANEOUS VIAL (ML) 300MG/3ML 59.20133 03/06/2015 59.20133 08/21/2015
ENTACAPONE ORAL TABLET 200 MG 0.33480 11/15/2019 0.63276 12/27/2019
ENTECAVIR ORAL TABLET 0.5 MG 1.70800 05/17/2019 0.69967 11/15/2019
ENTECAVIR ORAL TABLET 1 MG 5.88033 09/22/2017 5.88030 09/23/2017
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
ENZYMES,DIGESTIVE ORAL CAPSULE 0.05940 08/12/2014 0.05940 08/21/2015
EPHEDRINE SULFATE VIAL (ML) 50 MG/ML 4.10130 01/25/2013 4.10130 08/21/2015
EPINASTINE HCL OPHTHALMIC DROPS 0.05 % 9.27130 08/21/2015 5.46126 06/16/2017
EPINEPHRINE HCL/PF INJECTION AMPUL (ML) 1 MG/ML(1) 682.71000 02/20/2015
EPINEPHRINE INJECTION SYRINGE (ML) 0.1 MG/ML 0.47910 08/12/2014 0.47910 08/21/2015
EPINEPHRINE INJECTION VIAL (ML) 1 MG/ML 0.20160 08/12/2014 0.20160 08/21/2015
EPIRUBICIN HCL INTRAVENOUS VIAL (EA) 200 MG 1992.09500 01/25/2013
EPLERENONE ORAL TABLET 25 MG 0.65000 05/22/2020 0.78922 05/28/2020
EPLERENONE ORAL TABLET 50 MG 1.26499 06/16/2017 0.98300 08/16/2019
EPOPROSTENOL SODIUM (GLYCINE) INTRAVENOUS VIAL (EA) 0.5 MG 12.85200 01/25/2013
EPOPROSTENOL SODIUM (GLYCINE) INTRAVENOUS VIAL (EA) 1.5 MG 24.45100 01/25/2013
EPROSARTAN MESYLATE ORAL TABLET 600 MG 2.39820 01/25/2013
ERGOCALCIFEROL (VITAMIN D2) ORAL CAPSULE 1250 MCG 0.16000 06/16/2017 0.09770 09/22/2017
ERGOCALCIFEROL (VITAMIN D2) ORAL TABLET 10 MCG 0.02380 02/08/2013
ERGOCALCIFEROL (VITAMIN D2) ORAL TABLET 50 MCG 0.05446 01/25/2013
ERGOLOID MESYLATES ORAL TABLET 1 MG 5.67287 02/06/2015
ERLOTINIB HCL ORAL TABLET 100 MG 12.50000 02/21/2020
ERLOTINIB HCL ORAL TABLET 150 MG 12.93000 02/21/2020
ERLOTINIB HCL ORAL TABLET 25 MG 9.50000 02/21/2020
ERYTHROMYCIN BASE IN ETHANOL TOPICAL GEL (GRAM) 2 % 2.23000 01/25/2019 1.68000 07/26/2019
ERYTHROMYCIN BASE IN ETHANOL TOPICAL SOLUTION, NON-ORAL 2 % 0.42017 06/21/2019 0.32978 11/15/2019
ERYTHROMYCIN BASE IN ETHANOL TOPICAL SWAB, MEDICATED 2 % 1.10370 02/08/2013
ERYTHROMYCIN BASE OPHTHALMIC OINTMENT (GRAM) 5 MG/GRAM 1.68401 06/16/2017 1.63247 02/22/2019
ERYTHROMYCIN BASE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 250 MG
2.41500 08/21/2015 4.82650 07/19/2019
ERYTHROMYCIN BASE ORAL TABLET 250 MG 9.39950 01/25/2019 7.81000 06/21/2019
ERYTHROMYCIN BASE ORAL TABLET 500 MG 9.78572 08/21/2015 12.26652 05/16/2016
ERYTHROMYCIN BASE/BENZOYL PEROXIDE TOPICAL GEL (GRAM) 3 %-5 %
2.91330 08/27/2019 1.97425 03/20/2020
ESCITALOPRAM OXALATE ORAL SOLUTION, ORAL 5 MG/5 ML 0.36009 02/26/2016 0.14983 04/26/2019
ESCITALOPRAM OXALATE ORAL TABLET 10 MG 0.06080 06/16/2017 0.04554 09/22/2017
ESCITALOPRAM OXALATE ORAL TABLET 20 MG 0.05913 02/22/2019 0.03570 10/25/2019
ESCITALOPRAM OXALATE ORAL TABLET 5 MG 0.06264 08/25/2017 0.03320 10/20/2017
ESOMEPRAZOLE MAGNESIUM ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 20 MG
0.23553 05/17/2019 0.19700 08/16/2019
ESOMEPRAZOLE MAGNESIUM ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 40 MG
0.22614 08/16/2019 0.15306 04/17/2020
ESOMEPRAZOLE SODIUM INTRAVENOUS VIAL (EA) 20 MG 9.22875 04/24/2015 9.22875 08/21/2015
ESOMEPRAZOLE SODIUM INTRAVENOUS VIAL (EA) 40 MG 10.43250 04/24/2015 10.43250 08/21/2015
ESTAZOLAM ORAL TABLET 1 MG 0.26770 08/12/2014
ESTAZOLAM ORAL TABLET 2 MG 0.29330 08/12/2014 0.29330 08/21/2015
ESTRADIOL ORAL TABLET 0.5 MG 0.10410 08/25/2017 0.06180 09/22/2017
ESTRADIOL ORAL TABLET 1 MG 0.11270 07/14/2017 0.07130 05/22/2020
ESTRADIOL ORAL TABLET 2 MG 0.13700 06/16/2017 0.11000 10/20/2017
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY .025MG/24H
8.45640 06/16/2017 7.60625 07/26/2019
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY .0375MG/24
7.27000 10/19/2018 6.67875 05/17/2019
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY .075MG/24H
6.63000 06/22/2018 5.61875 08/16/2019
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 0.05MG/24H
6.18000 12/21/2018 8.09043 11/26/2019
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL SEMIWEEKLY 0.1MG/24HR
5.94125 05/17/2019 7.76750 05/29/2020
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY .025MG/24H 15.92223 09/20/2013 13.00000 03/03/2017
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY .0375MG/24 12.39250 12/22/2017 11.07000 01/24/2020
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY .075MG/24H 10.55000 05/02/2014
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.05MG/24H 9.98000 05/17/2019 13.11750 11/06/2019
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.06MG/24H 15.47000 04/25/2014 12.05375 06/16/2017
ESTRADIOL TRANSDERMAL PATCH, TRANSDERMAL WEEKLY 0.1MG/24HR
14.16352 12/25/2015 12.42131 06/16/2017
ESTRADIOL VAGINAL TABLET 10 MCG 9.30000 12/20/2019 8.45065 05/22/2020
ESTRADIOL/NORETHINDRONE ACETATE ORAL TABLET 0.5-0.1 MG 1.73571 03/15/2019 2.26160 04/13/2020
ESTRADIOL/NORETHINDRONE ACETATE ORAL TABLET 1 MG-0.5MG 2.83847 03/25/2016 2.29848 06/16/2017
ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE ORAL TABLET 0.625-1.25
1.58654 08/12/2014 1.58654 08/21/2015
ESTROGENS,ESTERIFIED/METHYLTESTOSTERONE ORAL TABLET 1.25-2.5MG
1.74068 08/12/2014 1.74068 08/21/2015
ESTROPIPATE TABLET 0.75 MG 0.36322 04/25/2014 0.36322 08/21/2015
ESTROPIPATE TABLET 1.5 MG 0.50765 04/25/2014
ESTROPIPATE TABLET 3 MG 0.70270 08/12/2014
ESZOPICLONE ORAL TABLET 1 MG 0.29577 09/22/2017 0.26290 05/17/2019
ESZOPICLONE ORAL TABLET 2 MG 0.19400 09/22/2017 0.17820 11/16/2018
ESZOPICLONE ORAL TABLET 3 MG 0.34539 03/03/2017 0.20747 08/25/2017
ETHACRYNIC ACID ORAL TABLET 25 MG 5.52000 08/16/2019
ETHAMBUTOL HCL ORAL TABLET 100 MG 0.28000 11/24/2017 0.16920 08/17/2018
ETHINYL ESTRADIOL/DROSPIRENONE ORAL TABLET 0.02-3(28) 0.49000 03/15/2019 0.36702 08/16/2019
ETHINYL ESTRADIOL/DROSPIRENONE ORAL TABLET 0.03MG-3MG 0.49000 04/27/2018 0.39301 08/17/2018
ETHOSUXIMIDE ORAL CAPSULE 250 MG 1.08530 03/02/2018 0.70270 02/22/2019
ETHOSUXIMIDE ORAL SOLUTION, ORAL 250 MG/5ML 0.27221 01/25/2019 0.15389 06/19/2020
ETHYL ALCOHOL INJECTION AMPUL (ML) 98 % 7.48300 12/12/2014 7.48300 08/21/2015
ETHYL ALCOHOL INJECTION VIAL (ML) 98 % 12.09096 08/12/2014
ETHYNODIOL DIACETATE-ETHINYL ESTRADIOL ORAL TABLET 1 MG-35MCG
0.70226 03/03/2017 0.58262 11/24/2017
ETIDRONATE DISODIUM ORAL TABLET 200 MG 3.02458 01/24/2014
ETIDRONATE DISODIUM ORAL TABLET 400 MG 6.04777 11/22/2013 6.04777 08/21/2015
ETODOLAC ORAL CAPSULE 200 MG 0.89280 01/13/2017 0.84280 11/24/2017
ETODOLAC ORAL CAPSULE 300 MG 1.02950 11/24/2017 0.70490 03/02/2018
ETODOLAC ORAL TABLET 400 MG 0.42692 08/17/2018 0.34640 11/16/2018
ETODOLAC ORAL TABLET 500 MG 0.49930 08/25/2017 0.26330 11/15/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
ETODOLAC ORAL TABLET, EXTENDED RELEASE 24 HR 400 MG 2.03084 08/21/2015 1.21731 06/16/2017
ETODOLAC ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.96565 06/16/2017 0.16333 11/15/2019
ETODOLAC ORAL TABLET, EXTENDED RELEASE 24 HR 600 MG 2.29187 08/21/2015 1.36061 06/16/2017
ETOPOSIDE ORAL CAPSULE 50 MG 56.82120 02/15/2013
EXEMESTANE ORAL TABLET 25 MG 2.18833 07/25/2019 1.29833 11/15/2019
EZETIMIBE ORAL TABLET 10 MG 0.13771 01/15/2020 0.07384 04/17/2020
EZETIMIBE/SIMVASTATIN ORAL TABLET 10 MG-10MG 2.62000 04/27/2018 2.37300 11/16/2018
EZETIMIBE/SIMVASTATIN ORAL TABLET 10 MG-20MG 1.90000 06/21/2019
EZETIMIBE/SIMVASTATIN ORAL TABLET 10 MG-40MG 0.77689 03/20/2020 0.71933 05/22/2020
EZETIMIBE/SIMVASTATIN ORAL TABLET 10 MG-80MG 1.85700 10/02/2019 2.09682 11/26/2019
FAMCICLOVIR ORAL TABLET 125 MG 0.46454 08/21/2015 0.35833 11/16/2018
FAMCICLOVIR ORAL TABLET 250 MG 0.68028 08/21/2015 0.28887 06/16/2017
FAMCICLOVIR ORAL TABLET 500 MG 0.51583 11/16/2018 0.49467 11/15/2019
FAMOTIDINE IN SODIUM CHLORIDE, ISO-OSMOTIC/PF INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 20 MG/50ML
0.13650 01/25/2013
FAMOTIDINE INTRAVENOUS VIAL (ML) 10 MG/ML 0.26572 01/09/2015 0.26572 08/21/2015
FAMOTIDINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 40MG/5ML 1.14744 03/03/2020 1.99680 05/18/2020
FAMOTIDINE ORAL TABLET 10 MG 0.08920 03/27/2015 0.08920 08/21/2015
FAMOTIDINE ORAL TABLET 20 MG 0.02905 10/25/2019 0.19960 04/13/2020
FAMOTIDINE ORAL TABLET 40 MG 0.08659 08/21/2015 0.05563 03/02/2018
FAMOTIDINE/PF INTRAVENOUS VIAL (ML) 20 MG/2 ML 0.37429 08/12/2014 0.37429 08/21/2015
FEBUXOSTAT ORAL TABLET 40 MG 4.80000 02/21/2020
FEBUXOSTAT ORAL TABLET 80 MG 4.97000 02/21/2020
FELBAMATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 600 MG/5ML 1.58070 12/02/2016 1.10721 05/22/2020
FELBAMATE ORAL TABLET 400 MG 1.34690 10/20/2017 0.86430 08/16/2019
FELBAMATE ORAL TABLET 600 MG 1.48180 02/22/2019 1.41430 03/20/2020
FELODIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.34000 05/20/2016 0.09000 11/24/2017
FELODIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 2.5 MG 0.54257 08/21/2015 0.14760 09/22/2017
FELODIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 5 MG 0.19800 07/14/2017 0.07260 11/24/2017
FENOFIBRATE NANOCRYSTALLIZED ORAL TABLET 145 MG 0.16870 08/16/2019 0.15547 06/19/2020
FENOFIBRATE NANOCRYSTALLIZED ORAL TABLET 48 MG 0.14196 05/17/2019 0.10550 11/15/2019
FENOFIBRATE ORAL CAPSULE 150 MG 5.00920 01/23/2017 5.55870 09/05/2017
FENOFIBRATE ORAL CAPSULE 50 MG 1.73180 08/01/2014
FENOFIBRATE ORAL TABLET 160 MG 0.29844 02/11/2020 0.19590 04/17/2020
FENOFIBRATE ORAL TABLET 54 MG 0.18444 11/16/2018 0.16656 11/15/2019
FENOFIBRATE,MICRONIZED ORAL CAPSULE 130 MG 2.43400 08/17/2018 1.89200 10/19/2018
FENOFIBRATE,MICRONIZED ORAL CAPSULE 134 MG 0.19433 11/15/2019 0.14630 04/17/2020
FENOFIBRATE,MICRONIZED ORAL CAPSULE 200 MG 0.73900 02/14/2019 0.55315 08/16/2019
FENOFIBRATE,MICRONIZED ORAL CAPSULE 43 MG 1.64500 08/21/2015 0.58033 09/22/2017
FENOFIBRATE,MICRONIZED ORAL CAPSULE 67 MG 0.39699 08/24/2019 0.11000 11/15/2019
FENOFIBRIC ACID (CHOLINE) ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 135 MG
1.21444 08/01/2018 0.84544 02/22/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
FENOFIBRIC ACID (CHOLINE) ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 45 MG
0.41211 09/22/2017 0.37988 01/25/2019
FENOFIBRIC ACID ORAL TABLET 105 MG 2.10232 05/30/2014 2.03967 08/25/2017
FENOFIBRIC ACID ORAL TABLET 35 MG 0.70070 08/12/2014
FENOPROFEN CALCIUM ORAL TABLET 600 MG 1.53587 02/07/2014 1.53587 08/21/2015
FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 1200 MCG 31.46500 01/25/2013
FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 1600 MCG 38.80683 01/25/2013
FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 200 MCG 13.16280 01/25/2013 7.47933 09/22/2017
FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 400 MCG 16.67657 01/25/2013
FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 600 MCG 20.42600 01/25/2013
FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 800 MCG 24.20180 10/25/2013
FENTANYL CITRATE/PF INTRAVENOUS SYRINGE (ML) 100MCG/2ML 0.65520 01/25/2013 0.65520 08/21/2015
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 100 MCG/HR
7.70600 08/17/2018 6.41480 02/22/2019
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 12 MCG/HR
7.16254 01/13/2020 7.60912 02/20/2020
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 25 MCG/HR
2.22000 10/25/2019 2.16000 05/22/2020
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 37.5MCG/HR
42.45400 05/01/2015
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 50MCG/HR 3.05057 11/15/2019 2.49800 01/24/2020
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 62.5MCG/HR
61.68800 05/01/2015
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 75MCG/HR 4.63650 11/15/2019 7.43407 02/12/2020
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 87.5MCG/HR
83.99000 05/01/2015
FERROUS FUMARATE/ASCORBIC ACID/B12-IF/FOLIC ACID ORAL CAPSULE 110-0.5MG
0.18226 08/30/2013
FERROUS GLUCONATE ORAL TABLET 240(27)MG 0.03859 08/12/2014
FERROUS SULFATE ORAL DROPS 15 MG/ML 0.06072 03/06/2015 0.06072 08/21/2015
FERROUS SULFATE ORAL SOLUTION, ORAL 220 (44)/5 0.00626 04/10/2015 0.00626 08/21/2015
FERROUS SULFATE ORAL TABLET 325(65) MG 0.00838 04/10/2015 0.00838 08/21/2015
FEXOFENADINE HCL ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 30 MG/5 ML
0.05664 02/27/2015
FEXOFENADINE HCL ORAL TABLET 180 MG 0.19000 11/16/2018 0.15500 08/16/2019
FEXOFENADINE HCL ORAL TABLET 60 MG 0.31707 08/21/2015 0.24340 08/16/2019
FEXOFENADINE HCL/PSEUDOEPHEDRINE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 60MG-120MG
0.66733 08/21/2015
FINASTERIDE ORAL TABLET 1 MG 0.31250 03/25/2016 0.09000 08/25/2017
FINASTERIDE ORAL TABLET 5 MG 0.13871 03/03/2017 0.05049 09/22/2017
FISH OIL/BORAGE OIL/FLAXSEED OIL/OMEGA 3,6,9 COMBINATION NO1 ORAL CAPSULE 400-400 MG
0.06168 08/12/2014
FISH OIL/DOCOSAHEXAENOIC ACID/EICOSAPENTAENOIC ACID ORAL CAPSULE 1200-144MG
0.01579 01/25/2013
FLAVOXATE HCL ORAL TABLET 100 MG 0.80990 08/21/2015 0.45341 06/16/2017
FLECAINIDE ACETATE ORAL TABLET 100 MG 0.20830 11/16/2018 0.17710 08/16/2019
FLECAINIDE ACETATE ORAL TABLET 150 MG 0.58174 08/21/2015 0.19130 08/17/2018
FLECAINIDE ACETATE ORAL TABLET 50 MG 0.14900 07/26/2019 0.13700 01/24/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS SOLUTION, PIGGYBACK (ML) 200MG/0.1L
0.09824 04/24/2015 0.09824 08/21/2015
FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS SOLUTION, PIGGYBACK (ML) 400MG/0.2L
0.05315 04/24/2015 0.05315 08/21/2015
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 200MG/0.1L
0.01660 08/25/2017 0.03849 03/27/2020
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 400MG/0.2L
0.03369 04/24/2015 0.03369 08/21/2015
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS IV SOLUTION, PIGGYBACK, BOTTLE (ML) 200MG/0.1L
0.05285 03/06/2015 0.05285 08/21/2015
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS IV SOLUTION, PIGGYBACK, BOTTLE (ML) 400MG/0.2L
0.09450 01/25/2013 0.09450 08/21/2015
FLUCONAZOLE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 10 MG/ML
0.32278 08/21/2015 0.23000 09/22/2017
FLUCONAZOLE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 40 MG/ML
0.49314 09/22/2017 0.47400 10/25/2019
FLUCONAZOLE ORAL TABLET 100 MG 0.54328 11/16/2018 0.46613 11/15/2019
FLUCONAZOLE ORAL TABLET 150 MG 0.72107 02/22/2019 0.62917 06/19/2020
FLUCONAZOLE ORAL TABLET 200 MG 0.55972 11/16/2018 0.48000 06/19/2020
FLUCONAZOLE ORAL TABLET 50 MG 0.89200 08/21/2015 0.53200 06/16/2017
FLUCYTOSINE ORAL CAPSULE 250 MG 57.44830 11/21/2014 57.44830 08/21/2015
FLUCYTOSINE ORAL CAPSULE 500 MG 111.16350 11/21/2014 111.16350 08/21/2015
FLUDROCORTISONE ACETATE ORAL TABLET 0.1 MG 0.37080 12/06/2016 0.30660 10/20/2017
FLUNISOLIDE NASAL AEROSOL, SPRAY (ML) 25 MCG 1.92500 03/13/2015 1.92500 08/21/2015
FLUOCINOLONE ACETONIDE OIL OTIC DROPS 0.01 % 6.56750 10/19/2018 4.81200 12/21/2018
FLUOCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.01 % 1.82185 08/12/2014 1.82185 08/21/2015
FLUOCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.025 % 1.39143 08/21/2015 1.29967 02/21/2020
FLUOCINOLONE ACETONIDE TOPICAL OIL (ML) 0.01 % 1.30643 08/21/2015 0.55000 02/22/2019
FLUOCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.025 % 1.18650 08/22/2014
FLUOCINOLONE ACETONIDE TOPICAL SOLUTION, NON-ORAL 0.01 % 1.56983 08/16/2019 0.90000 11/15/2019
FLUOCINOLONE ACETONIDE/SHOWER CAP TOPICAL OIL (ML) 0.01 % 1.31863 08/21/2015 0.50719 03/20/2020
FLUOCINONIDE TOPICAL CREAM (GRAM) 0.05 % 0.79753 11/24/2017 0.53592 10/25/2019
FLUOCINONIDE TOPICAL CREAM (GRAM) 0.1 % 13.23945 02/27/2015 11.07021 12/02/2016
FLUOCINONIDE TOPICAL GEL (GRAM) 0.05 % 1.04867 01/24/2020 1.50566 03/04/2020
FLUOCINONIDE TOPICAL OINTMENT (GRAM) 0.05 % 0.78790 08/30/2013 0.42932 07/08/2016
FLUOCINONIDE TOPICAL SOLUTION, NON-ORAL 0.05 % 1.13388 05/02/2014 0.79333 02/21/2020
FLUOCINONIDE/EMOLLIENT BASE TOPICAL CREAM (GRAM) 0.05 % 0.25684 06/07/2013 0.25684 08/21/2015
FLUORIDE (SODIUM) DENTAL CREAM (GRAM) 1.1 % 0.08013 08/21/2015 0.06294 10/25/2019
FLUORIDE (SODIUM) DENTAL GEL (GRAM) 1.1 % 0.06890 09/27/2013 0.06890 08/21/2015
FLUORIDE (SODIUM) ORAL DROPS 0.5 MG/ML 0.17316 08/21/2015 0.10320 11/24/2017
FLUORIDE (SODIUM) ORAL TABLET,CHEWABLE 0.25(0.55) 0.03738 03/01/2013 0.03738 08/21/2015
FLUORIDE (SODIUM) ORAL TABLET,CHEWABLE 0.5(1.1)MG 0.03740 02/22/2013 0.03740 08/21/2015
FLUORIDE (SODIUM) ORAL TABLET,CHEWABLE 1MG(2.2MG) 0.03852 04/19/2013 0.03852 08/21/2015
FLUOROMETHOLONE OPHTHALMIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 0.1 %
10.37820 02/20/2015 12.54792 04/27/2019
FLUOROURACIL INTRAVENOUS VIAL (ML) 1 G/20 ML 0.25200 03/27/2015 0.25200 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
FLUOROURACIL INTRAVENOUS VIAL (ML) 2.5 G/50ML 0.19859 03/27/2015
FLUOROURACIL INTRAVENOUS VIAL (ML) 5 G/100 ML 0.12840 09/22/2017 0.11050 03/20/2020
FLUOROURACIL INTRAVENOUS VIAL (ML) 500MG/10ML 0.25200 03/27/2015 0.25200 08/21/2015
FLUOROURACIL TOPICAL CREAM (GRAM) 0.5 % 41.44770 12/26/2014
FLUOROURACIL TOPICAL CREAM (GRAM) 5 % 4.05885 08/21/2015 4.05885 04/15/2016
FLUOROURACIL TOPICAL SOLUTION, NON-ORAL 2 % 4.95080 08/12/2014
FLUOROURACIL TOPICAL SOLUTION, NON-ORAL 5 % 7.93170 05/17/2013
FLUOXETINE HCL ORAL CAPSULE 10 MG 0.02814 05/01/2015 0.02814 08/21/2015
FLUOXETINE HCL ORAL CAPSULE 20 MG 0.02988 05/01/2015 0.02988 08/21/2015
FLUOXETINE HCL ORAL CAPSULE 40 MG 0.10783 02/01/2018 0.06800 01/25/2019
FLUOXETINE HCL ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 90 MG
29.33500 02/21/2014 29.33500 08/21/2015
FLUOXETINE HCL ORAL SOLUTION, ORAL 20 MG/5 ML 0.41658 07/27/2019 0.49922 04/23/2020
FLUOXETINE HCL ORAL TABLET 10 MG 0.05507 03/20/2015 0.05507 08/21/2015
FLUOXETINE HCL ORAL TABLET 20 MG 0.67167 07/26/2019 0.56167 11/15/2019
FLUOXETINE HCL ORAL TABLET 60 MG 2.97158 07/05/2013
FLUPHENAZINE DECANOATE INJECTION VIAL (ML) 25 MG/ML 13.83300 08/17/2018 16.70660 11/06/2019
FLUPHENAZINE HCL INJECTION VIAL (ML) 2.5 MG/ML 10.58000 03/01/2013
FLUPHENAZINE HCL ORAL CONCENTRATE, ORAL 5 MG/ML 0.81136 01/25/2013
FLUPHENAZINE HCL ORAL ELIXIR 2.5 MG/5ML 0.26710 01/25/2013
FLUPHENAZINE HCL ORAL TABLET 1 MG 3.20310 03/11/2019 2.52000 02/21/2020
FLUPHENAZINE HCL ORAL TABLET 10 MG 7.36791 01/06/2020 6.63180 06/19/2020
FLUPHENAZINE HCL ORAL TABLET 2.5 MG 0.47850 06/12/2018 3.16710 08/23/2019
FLUPHENAZINE HCL ORAL TABLET 5 MG 2.92200 08/17/2018 6.89950 11/27/2018
FLURAZEPAM HCL ORAL CAPSULE 15 MG 0.19583 08/22/2014 0.19583 08/21/2015
FLURAZEPAM HCL ORAL CAPSULE 30 MG 0.35100 08/22/2014 0.35100 08/21/2015
FLURBIPROFEN ORAL TABLET 100 MG 0.36823 02/20/2015 0.36823 08/21/2015
FLURBIPROFEN ORAL TABLET 50 MG 0.22113 09/19/2014 0.22113 08/21/2015
FLURBIPROFEN SODIUM OPHTHALMIC DROPS 0.03 % 1.57114 08/21/2015 1.14467 06/16/2017
FLUTAMIDE ORAL CAPSULE 125 MG 0.63643 08/21/2015 0.49639 11/24/2017
FLUTICASONE PROPIONATE NASAL SPRAY, SUSPENSION 50 MCG 0.32375 12/02/2016 0.15892 01/27/2017
FLUTICASONE PROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.23000 08/25/2017 0.18317 08/16/2019
FLUTICASONE PROPIONATE TOPICAL LOTION (ML) 0.05 % 4.54942 08/30/2013 4.54942 08/21/2015
FLUTICASONE PROPIONATE TOPICAL OINTMENT (GRAM) 0.005 % 0.48681 03/01/2013
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE INHALATION BLISTER, WITH INHALATION DEVICE 250-50 MCG
2.45000 04/17/2020 3.04950 05/02/2020
FLUVASTATIN SODIUM ORAL CAPSULE 20 MG 2.64600 03/27/2015 2.64600 04/22/2016
FLUVASTATIN SODIUM ORAL CAPSULE 40 MG 2.64297 08/23/2013 2.64297 04/22/2016
FLUVOXAMINE MALEATE ORAL CAPSULE, EXT RELEASE 24 HR 100 MG 7.12857 10/10/2014
FLUVOXAMINE MALEATE ORAL CAPSULE, EXT RELEASE 24 HR 150 MG 7.65030 10/10/2014
FLUVOXAMINE MALEATE ORAL TABLET 100 MG 0.42683 08/16/2019 0.33360 02/21/2020
FLUVOXAMINE MALEATE ORAL TABLET 25 MG 0.23769 08/21/2015 0.16767 08/25/2017
FLUVOXAMINE MALEATE ORAL TABLET 50 MG 0.31590 08/16/2019 0.23950 11/15/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
FOLIC ACID INJECTION VIAL (ML) 5 MG/ML 1.79410 02/15/2013
FOLIC ACID ORAL TABLET 0.4 MG 0.01380 02/06/2015 0.01380 08/21/2015
FOLIC ACID ORAL TABLET 1 MG 0.02320 08/21/2015 0.00800 03/02/2018
FOLIC ACID/ARGININE HCL/CYANOCOBALAMIN/VIT B6/BLACK PEPPER TABLET 2-500-500
0.56210 01/25/2013
FOLIC ACID/MULTIVIT WITH MINERALS/LUTEIN ORAL TABLET 0.4MG-250 0.03600 01/25/2013
FOLIC ACID/PYRIDOXINE HCL/CA PHOS DIBASIC & TRIBASIC/GINGER ORAL TABLET 1.2-40-100
0.72360 01/25/2013 0.72360 08/21/2015
FOLIC ACID/VITAMIN B COMPLEX AND VITAMIN C ORAL TABLET 0.8 MG 0.09960 08/12/2014 0.09960 08/21/2015
FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 10MG/0.8ML 94.71000 01/09/2015 94.71000 08/21/2015
FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 2.5 MG/0.5 83.02000 08/21/2015 28.20200 02/21/2020
FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 5MG/0.4ML 110.40650 01/09/2015 110.40650 08/21/2015
FONDAPARINUX SODIUM SUBCUTANEOUS SYRINGE (ML) 7.5MG/0.6 129.37800 01/09/2015 129.37800 08/21/2015
FORMALDEHYDE SOLUTION WITH APPLICATOR (ML) 10 % 0.36953 01/25/2013
FOSCARNET SODIUM INTRAVENOUS INFUSION BOTTLE (ML) 24 MG/ML 0.25326 01/30/2015 0.25326 08/21/2015
FOSINOPRIL SODIUM ORAL TABLET 10 MG 0.15448 08/21/2015 0.11000 12/21/2018
FOSINOPRIL SODIUM ORAL TABLET 20 MG 0.14428 08/21/2015 0.09833 02/22/2019
FOSINOPRIL SODIUM ORAL TABLET 40 MG 0.19096 08/21/2015 0.14144 02/22/2019
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.74360 08/12/2014 0.74360 08/21/2015
FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG
1.06964 08/12/2014 1.06964 08/21/2015
FOSPHENYTOIN SODIUM INJECTION VIAL (ML) 100MG PE/2 0.91763 01/30/2015 0.91763 08/21/2015
FOSPHENYTOIN SODIUM INJECTION VIAL (ML) 500 PE/10 0.75985 01/30/2015 0.75985 08/21/2015
FUROSEMIDE INJECTION VIAL (ML) 10 MG/ML 0.40508 08/21/2015 0.36590 08/16/2019
FUROSEMIDE ORAL SOLUTION, ORAL 10 MG/ML 0.11127 05/17/2013
FUROSEMIDE ORAL SOLUTION, ORAL 40MG/5ML 0.14150 01/25/2013
FUROSEMIDE ORAL TABLET 20 MG 0.01363 04/24/2015 0.01363 08/21/2015
FUROSEMIDE ORAL TABLET 40 MG 0.02141 04/24/2015 0.02141 08/21/2015
FUROSEMIDE ORAL TABLET 80 MG 0.03476 08/21/2015 0.02408 10/20/2017
GABAPENTIN MISCELLANEOUS POWDER (GRAM) 100 % 1.14400 08/21/2015
GABAPENTIN ORAL CAPSULE 100 MG 0.03654 08/21/2015 0.02447 10/20/2017
GABAPENTIN ORAL CAPSULE 300 MG 0.05614 04/18/2019 0.04300 06/21/2019
GABAPENTIN ORAL CAPSULE 400 MG 0.06516 12/06/2019 0.04698 04/17/2020
GABAPENTIN ORAL SOLUTION, ORAL 250 MG/5ML 0.29166 01/25/2013
GABAPENTIN ORAL SOLUTION, ORAL 250 MG/5ML 0.15513 03/29/2019 0.11517 08/16/2019
GABAPENTIN ORAL SOLUTION, ORAL 300 MG/6ML 0.29164 01/25/2013
GABAPENTIN ORAL TABLET 600 MG 0.08738 01/27/2017 0.06198 04/17/2020
GABAPENTIN ORAL TABLET 800 MG 0.12078 07/14/2017 0.10138 12/22/2017
GALANTAMINE HBR ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 16 MG
1.31666 08/16/2019 1.18400 09/20/2019
GALANTAMINE HBR ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 24 MG
2.00142 06/16/2017 0.83300 03/02/2018
GALANTAMINE HBR ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 8 MG
1.22142 09/21/2018 0.43700 08/16/2019
GALANTAMINE HBR ORAL SOLUTION, ORAL 4 MG/ML 2.95575 01/25/2013 2.95575 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
GALANTAMINE HBR ORAL TABLET 12 MG 0.65067 09/22/2017 0.15067 08/16/2019
GALANTAMINE HBR ORAL TABLET 4 MG 0.89375 03/02/2018 0.76000 11/15/2019
GALANTAMINE HBR ORAL TABLET 8 MG 0.69000 04/22/2016 0.60633 03/16/2018
GANCICLOVIR SODIUM INTRAVENOUS VIAL (EA) 500 MG 62.00208 02/27/2015
GANIRELIX ACETATE SUBCUTANEOUS SYRINGE (ML) 250MCG/0.5 243.87300 01/25/2013
GATIFLOXACIN OPHTHALMIC DROPS 0.5 % 24.56800 05/25/2018 20.80000 10/19/2018
GEMCITABINE HCL INTRAVENOUS VIAL (EA) 1 G 39.64700 01/23/2015 39.64700 08/21/2015
GEMCITABINE HCL INTRAVENOUS VIAL (EA) 2 G 96.93425 08/08/2014 96.93425 08/21/2015
GEMCITABINE HCL INTRAVENOUS VIAL (EA) 200 MG 9.28800 01/23/2015 9.28800 08/21/2015
GEMCITABINE HCL INTRAVENOUS VIAL (ML) 1 G/26.3ML 2.87559 08/12/2014
GEMCITABINE HCL INTRAVENOUS VIAL (ML) 2 G/52.6ML 3.25580 08/12/2014
GEMCITABINE HCL INTRAVENOUS VIAL (ML) 200MG/5.26 3.55320 08/12/2014
GEMFIBROZIL ORAL TABLET 600 MG 0.07726 06/16/2017 0.06021 12/22/2017
GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 100MG/50ML
0.13213 01/25/2013
GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 120MG/0.1L
0.06630 01/25/2013
GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 70 MG/50ML
0.15469 01/25/2013
GENTAMICIN SULFATE IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 90MG/100ML
0.07491 01/25/2013
GENTAMICIN SULFATE INJECTION VIAL (ML) 20 MG/2 ML 1.45158 01/25/2013
GENTAMICIN SULFATE INJECTION VIAL (ML) 40 MG/ML 0.51161 08/12/2014 1.35660 01/16/2017
GENTAMICIN SULFATE OPHTHALMIC DROPS 0.3 % 0.68286 11/24/2017 0.62300 06/21/2019
GENTAMICIN SULFATE OPHTHALMIC OINTMENT (GRAM) 0.3 % 3.99600 08/21/2015 8.10000 10/23/2019
GENTAMICIN SULFATE TOPICAL CREAM (GRAM) 0.1 % 1.86566 07/18/2018
GENTAMICIN SULFATE TOPICAL OINTMENT (GRAM) 0.1 % 2.52733 02/07/2019 2.02650 03/20/2020
GENTAMICIN SULFATE/PF INJECTION VIAL (ML) 20 MG/2 ML 1.09954 08/12/2014
GENTAMICIN SULFATE/PF INTRAVENOUS VIAL WITH THREADED PORT (ML) 100MG/10ML
0.29434 01/25/2013
GENTAMICIN SULFATE/PF INTRAVENOUS VIAL WITH THREADED PORT (ML) 60 MG/6 ML
0.39255 01/25/2013
GLIMEPIRIDE ORAL TABLET 1 MG 0.03490 12/22/2017 0.01800 01/25/2019
GLIMEPIRIDE ORAL TABLET 2 MG 0.06095 09/22/2017 0.03695 12/22/2017
GLIMEPIRIDE ORAL TABLET 4 MG 0.08041 03/03/2017 0.04760 09/22/2017
GLIPIZIDE ORAL TABLET 10 MG 0.05265 08/21/2015 0.02000 08/25/2017
GLIPIZIDE ORAL TABLET 5 MG 0.03000 08/21/2015 0.01935 10/20/2017
GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG 0.19510 07/26/2019 0.14525 12/20/2019
GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 2.5 MG 0.15400 12/22/2017 0.10667 03/15/2019
GLIPIZIDE ORAL TABLET, EXTENDED RELEASE 24 HR 5 MG 0.10660 03/16/2018 0.07990 10/25/2019
GLIPIZIDE/METFORMIN HCL ORAL TABLET 2.5-250 MG 0.34151 11/08/2013 0.34151 08/21/2015
GLIPIZIDE/METFORMIN HCL ORAL TABLET 2.5-500 MG 0.43480 05/20/2016 0.23690 05/17/2019
GLIPIZIDE/METFORMIN HCL ORAL TABLET 5 MG-500MG 0.24565 11/24/2017 0.21777 11/16/2018
GLUCOSAMINE SULFATE ORAL TABLET 750 MG 0.33095 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
GLUCOSAMINE SULFATE/CHONDROITIN SULFATE/METHYLSULFONYLMETHAN ORAL TABLET 500-200 MG
1.20120 01/25/2013
GLYBURIDE ORAL TABLET 1.25 MG 0.07710 03/02/2018 0.06020 02/22/2019
GLYBURIDE ORAL TABLET 2.5 MG 0.13169 08/21/2015 0.03220 09/22/2017
GLYBURIDE ORAL TABLET 5 MG 0.11240 08/25/2017 0.04420 09/22/2017
GLYBURIDE,MICRONIZED ORAL TABLET 1.5 MG 0.02590 08/12/2014 0.02590 08/21/2015
GLYBURIDE,MICRONIZED ORAL TABLET 3 MG 0.02840 08/12/2014 0.02840 08/21/2015
GLYBURIDE,MICRONIZED ORAL TABLET 6 MG 0.09900 05/17/2013 0.09900 08/21/2015
GLYBURIDE/METFORMIN HCL ORAL TABLET 1.25-250MG 0.09353 08/21/2015 0.03860 11/16/2018
GLYBURIDE/METFORMIN HCL ORAL TABLET 2.5-500 MG 0.08911 08/21/2015 0.05000 08/25/2017
GLYBURIDE/METFORMIN HCL ORAL TABLET 5 MG-500MG 0.04340 08/25/2017 0.02658 02/22/2019
GLYCINE ORAL POWDER (GRAM) 0.21190 08/12/2014
GLYCINE UROLOGIC SOLUTION IRRIGATION SOLUTION, IRRIGATION 1.5 %
0.00291 08/12/2014
GLYCOPYRROLATE INJECTION VIAL (ML) 0.2 MG/ML 0.22100 08/21/2015
GLYCOPYRROLATE ORAL TABLET 1 MG 0.11360 05/17/2019 0.06940 03/20/2020
GLYCOPYRROLATE ORAL TABLET 2 MG 0.26900 09/22/2017 0.17170 03/02/2018
GRANISETRON HCL INTRAVENOUS VIAL (ML) 1 MG/ML 4.71250 01/25/2013 4.71250 08/21/2015
GRANISETRON HCL INTRAVENOUS VIAL (ML) 1 MG/ML(1) 7.21995 01/25/2013 6.71000 05/17/2019
GRANISETRON HCL ORAL TABLET 1 MG 1.52404 02/27/2015 1.52404 08/21/2015
GRANISETRON HCL/PF INTRAVENOUS VIAL (ML) 100 MCG/ML 3.21880 08/12/2014
GRISEOFULVIN ULTRAMICROSIZE ORAL TABLET 125 MG 3.68837 10/17/2014 3.68837 08/21/2015
GRISEOFULVIN ULTRAMICROSIZE ORAL TABLET 250 MG 4.28393 08/21/2015 2.81345 06/16/2017
GRISEOFULVIN, MICROSIZE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 125 MG/5ML
0.12406 01/31/2014 0.12406 08/21/2015
GRISEOFULVIN, MICROSIZE ORAL TABLET 500 MG 5.95588 12/05/2014
GUAIFENESIN ORAL LIQUID (ML) 100 MG/5ML 0.00603 09/19/2014 0.00603 08/21/2015
GUAIFENESIN ORAL TABLET 200 MG 0.04248 10/31/2014 0.04248 08/21/2015
GUAIFENESIN ORAL TABLET 400 MG 0.05655 08/12/2014 0.05655 08/21/2015
GUAIFENESIN ORAL TABLET, EXTENDED RELEASE 12 HR 600 MG 0.31161 08/21/2015
GUAIFENESIN/DEXTROMETHORPHAN HBR ORAL LIQUID (ML) 100-10MG/5
0.01776 11/07/2014 0.01776 08/21/2015
GUAIFENESIN/DEXTROMETHORPHAN HBR ORAL SYRUP 100-10MG/5 0.00801 08/12/2014 0.00801 08/21/2015
GUAIFENESIN/DEXTROMETHORPHAN HBR ORAL TABLET 400MG-20MG 0.07778 08/21/2015
GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL DROPS 5-2.5MG/ML
0.15389 10/10/2014
GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL LIQUID (ML) 100-10-5MG
0.01987 04/24/2015 0.01987 08/21/2015
GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL LIQUID (ML) 100-15-5/5
0.03941 08/12/2014 0.03941 08/21/2015
GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL LIQUID (ML) 200-10-5/5
0.02590 08/12/2014
GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL LIQUID (ML) 200-20-10
0.07980 08/12/2014 0.07980 08/21/2015
GUAIFENESIN/DEXTROMETHORPHAN HBR/PHENYLEPHRINE ORAL TABLET 380-15-10
0.47192 12/12/2014 0.47192 08/21/2015
GUAIFENESIN/PHENYLEPHRINE HCL ORAL TABLET 380MG-10MG 0.43170 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1 MG 0.32400 07/26/2019 0.29290 12/20/2019
GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 0.31610 07/26/2019 0.24000 11/15/2019
GUANFACINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 3 MG 0.58000 08/25/2017 0.36520 01/25/2019
GUANIDINE HCL ORAL TABLET 125 MG 0.17724 01/25/2013
HALOBETASOL PROPIONATE TOPICAL CREAM (GRAM) 0.05 % 0.92200 08/16/2019 0.79908 11/15/2019
HALOBETASOL PROPIONATE TOPICAL OINTMENT (GRAM) 0.05 % 2.05920 06/16/2017 1.65860 03/20/2020
HALOPERIDOL DECANOATE INTRAMUSCULAR AMPUL (ML) 100 MG/ML 43.21000 04/15/2019 35.04600 05/17/2019
HALOPERIDOL DECANOATE INTRAMUSCULAR AMPUL (ML) 50 MG/ML 21.74667 01/25/2013
HALOPERIDOL DECANOATE INTRAMUSCULAR VIAL (ML) 100 MG/ML 43.24600 10/13/2015 38.75000 12/21/2018
HALOPERIDOL DECANOATE INTRAMUSCULAR VIAL (ML) 50 MG/ML 22.14000 08/21/2015 22.00000 01/25/2019
HALOPERIDOL LACTATE INJECTION AMPUL (ML) 5 MG/ML 5.15760 01/25/2013
HALOPERIDOL LACTATE INJECTION VIAL (ML) 5 MG/ML 1.02376 08/21/2015 0.63747 08/17/2018
HALOPERIDOL LACTATE ORAL CONCENTRATE, ORAL 2 MG/ML 0.03924 08/17/2018 0.06721 05/23/2019
HALOPERIDOL ORAL TABLET 0.5 MG 0.21117 10/11/2013 0.15250 08/25/2017
HALOPERIDOL ORAL TABLET 1 MG 0.33160 02/22/2018 0.28000 05/25/2018
HALOPERIDOL ORAL TABLET 10 MG 0.72503 01/04/2020 0.68650 03/20/2020
HALOPERIDOL ORAL TABLET 2 MG 0.31198 12/28/2017 0.50550 06/04/2020
HALOPERIDOL ORAL TABLET 20 MG 1.18740 03/02/2018 0.95065 08/16/2019
HALOPERIDOL ORAL TABLET 5 MG 0.46260 05/13/2019 0.44668 11/15/2019
HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 12500/250
0.04754 04/10/2015 0.04754 08/21/2015
HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 25000/250
0.02356 04/10/2015 0.02356 08/21/2015
HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 25000/500
0.01978 04/10/2015 0.01978 08/21/2015
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM CHLORIDE/PF INTRAVENOUS INTRAVENOUS SOLUTION 1000/500ML
0.00720 01/25/2013 0.00720 08/21/2015
HEPARIN SODIUM,PORCINE IN 0.9 % SODIUM CHLORIDE/PF INTRAVENOUS INTRAVENOUS SOLUTION 2K/1000ML
0.00440 08/12/2014 0.00440 08/21/2015
HEPARIN SODIUM,PORCINE INJECTION CARTRIDGE (ML) 5000/ML(1) 3.65400 01/25/2013
HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 1000/ML 0.20739 11/28/2014 0.20739 08/21/2015
HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 10000/ML 2.31659 05/01/2015 2.31659 08/21/2015
HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 20000/ML 8.04388 04/03/2015
HEPARIN SODIUM,PORCINE INJECTION VIAL (ML) 5000/ML 1.04000 08/25/2017 0.70240 08/16/2019
HEPARIN SODIUM,PORCINE INTRAVENOUS SYRINGE (ML) 500/5 ML 0.32928 11/15/2013
HEPARIN SODIUM,PORCINE INTRAVENOUS VIAL (ML) 100/ML 0.03983 04/05/2013 0.03983 08/21/2015
HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 12500/250
0.05431 04/24/2015 0.05431 08/21/2015
HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 20K/500ML
0.01097 04/17/2015 0.01097 08/21/2015
HEPARIN SODIUM,PORCINE/PF INJECTION CARTRIDGE (ML) 5000/0.5ML 3.99840 05/01/2015 3.99840 08/21/2015
HEPARIN SODIUM,PORCINE/PF INJECTION VIAL (ML) 1000/ML 3.64676 08/12/2014
HEPARIN SODIUM,PORCINE/PF INJECTION VIAL (ML) 5000/0.5ML 9.36923 01/25/2013
HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 1 UNIT/ML 0.53235 05/31/2013 0.53235 08/21/2015
HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 10 UNIT/ML 0.15678 05/31/2013 0.15678 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 100/ML (1) 0.14740 05/31/2013
HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 1000/10 ML 0.14740 05/31/2013
HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 200/2 ML 0.14740 05/31/2013
HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 300/3 ML 0.15513 07/25/2014 0.15513 08/21/2015
HEPARIN SODIUM,PORCINE/PF INTRAVENOUS SYRINGE (ML) 500/5 ML 0.09299 03/07/2014 0.09299 08/21/2015
HEPARIN SODIUM,PORCINE/PF INTRAVENOUS VIAL (ML) 10 UNIT/ML 1.27250 08/12/2014
HEPARIN SODIUM,PORCINE/PF INTRAVENOUS VIAL (ML) 100/ML (1) 1.63384 01/25/2013
HYDRALAZINE HCL INJECTION VIAL (ML) 20 MG/ML 4.60408 07/19/2013
HYDRALAZINE HCL ORAL TABLET 10 MG 0.05309 08/21/2015 0.03468 08/25/2017
HYDRALAZINE HCL ORAL TABLET 100 MG 0.11896 05/20/2016 0.06535 09/30/2016
HYDRALAZINE HCL ORAL TABLET 25 MG 0.05000 03/17/2017 0.03020 09/22/2017
HYDRALAZINE HCL ORAL TABLET 50 MG 0.05113 09/22/2017 0.03105 12/22/2017
HYDROCHLOROTHIAZIDE ORAL CAPSULE 12.5 MG 0.05352 08/21/2015 0.02000 08/25/2017
HYDROCHLOROTHIAZIDE ORAL TABLET 12.5 MG 0.08000 08/25/2017 0.05327 11/15/2019
HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG 0.02250 08/21/2015 0.00892 10/20/2017
HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG 0.04931 08/21/2015 0.01144 08/25/2017
HYDROCODONE BITARTRATE MISCELLANEOUS POWDER (GRAM) 100 % 7.56450 08/21/2015
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 2.5-108/5
0.56630 05/30/2014
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 2.5-167/5
0.47191 01/25/2013
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 5-217MG/10
0.59709 08/01/2014
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 7.5-325/15
0.16755 08/12/2014
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL SOLUTION, ORAL 7.5-325/15
0.07831 07/11/2017 0.04658 11/24/2017
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 10MG-300MG
1.78019 10/17/2014 0.60510 09/22/2017
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 10MG-325MG
0.16477 05/19/2017 0.10886 06/16/2017
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 2.5-325 MG
0.69069 04/03/2015
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 5 MG-300MG
0.65450 09/22/2017 0.32970 05/22/2020
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 5 MG-325MG
0.14569 03/03/2017 0.06500 08/25/2017
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 7.5-300 MG
1.07550 06/16/2017 0.70230 09/22/2017
HYDROCODONE BITARTRATE/ACETAMINOPHEN ORAL TABLET 7.5-325 MG
0.09087 01/25/2019 0.07087 08/16/2019
HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE ORAL SYRUP 5-1.5 MG/5
0.52500 01/25/2013
HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE ORAL SYRUP 5-1.5 MG/5
0.06580 08/12/2014
HYDROCODONE BITARTRATE/HOMATROPINE METHYLBROMIDE ORAL TABLET 5 MG-1.5MG
0.71674 01/30/2015 0.71674 08/21/2015
HYDROCODONE POLISTIREX/CHLORPHENIRAMINE POLISTIREX ORAL SUSPENSION, EXTENDED RELEASE 12 HR 10-8MG/5ML
0.40047 11/24/2017 0.38226 10/19/2018
HYDROCODONE/IBUPROFEN ORAL TABLET 10MG-200MG 3.99069 04/10/2015 3.99069 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
HYDROCODONE/IBUPROFEN ORAL TABLET 2.5-200 MG 2.04491 01/25/2013 2.04491 08/21/2015
HYDROCODONE/IBUPROFEN ORAL TABLET 5MG-200MG 2.49634 08/21/2015 2.23740 09/22/2017
HYDROCODONE/IBUPROFEN ORAL TABLET 7.5-200 MG 0.25323 05/20/2016 0.15400 07/14/2017
HYDROCORTISONE ACETATE MISCELLANEOUS POWDER (GRAM) 3.23180 01/25/2013 3.23180 08/21/2015
HYDROCORTISONE ACETATE RECTAL SUPPOSITORY, RECTAL 25 MG 2.93375 08/16/2019 2.38958 03/20/2020
HYDROCORTISONE ACETATE RECTAL SUPPOSITORY, RECTAL 30 MG 3.95180 08/12/2014
HYDROCORTISONE ACETATE/LIDOCAINE HCL/ALOE VERA RECTAL KIT 2.5-3%(7G)
251.09000 07/18/2014
HYDROCORTISONE ACETATE/PRAMOXINE HCL TOPICAL CREAM (GRAM) 2.5 %-1 %
1.29675 05/01/2015 1.29675 08/21/2015
HYDROCORTISONE BUTYRATE TOPICAL CREAM (GRAM) 0.1 % 1.02530 02/15/2013 1.02530 08/21/2015
HYDROCORTISONE BUTYRATE TOPICAL OINTMENT (GRAM) 0.1 % 1.88020 05/09/2014 1.88020 08/21/2015
HYDROCORTISONE BUTYRATE TOPICAL SOLUTION, NON-ORAL 0.1 % 0.21870 07/25/2014 0.21870 08/21/2015
HYDROCORTISONE BUTYRATE/EMOLLIENT BASE TOPICAL CREAM (GRAM) 0.1 %
6.29588 12/27/2013
HYDROCORTISONE MISCELLANEOUS POWDER (GRAM) 2.18774 08/12/2014 2.18774 08/21/2015
HYDROCORTISONE ORAL TABLET 10 MG 0.28362 05/20/2016 0.21970 09/22/2017
HYDROCORTISONE ORAL TABLET 20 MG 0.45000 11/24/2017 0.13960 08/17/2018
HYDROCORTISONE ORAL TABLET 5 MG 0.16140 09/22/2017 0.15020 11/16/2018
HYDROCORTISONE RECTAL ENEMA (ML) 100MG/60ML 0.06885 12/05/2014 0.06885 08/21/2015
HYDROCORTISONE TOPICAL CREAM (GRAM) 0.5 % 0.08224 04/05/2013 0.08224 08/21/2015
HYDROCORTISONE TOPICAL CREAM (GRAM) 1 % 0.05060 01/30/2015 0.05060 08/21/2015
HYDROCORTISONE TOPICAL CREAM (GRAM) 2.5 % 0.08792 10/25/2019 0.07675 05/22/2020
HYDROCORTISONE TOPICAL CREAM WITH PERINEAL APPLICATOR 1 % 0.66820 01/25/2013
HYDROCORTISONE TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 % 0.42190 12/23/2019 0.34234 05/22/2020
HYDROCORTISONE TOPICAL LOTION (GRAM) 1 % 0.04414 08/12/2014
HYDROCORTISONE TOPICAL LOTION (ML) 1 % 0.03153 08/12/2014 0.03153 08/21/2015
HYDROCORTISONE TOPICAL LOTION (ML) 2.5 % 0.23863 04/12/2013
HYDROCORTISONE TOPICAL OINTMENT (GRAM) 1 % 0.10490 01/30/2015 0.10490 08/21/2015
HYDROCORTISONE TOPICAL OINTMENT (GRAM) 2.5 % 0.11200 08/12/2014 0.11200 08/21/2015
HYDROCORTISONE VALERATE TOPICAL CREAM (GRAM) 0.2 % 1.43182 11/15/2019 1.04733 05/22/2020
HYDROCORTISONE VALERATE TOPICAL OINTMENT (GRAM) 0.2 % 4.59200 07/25/2014 4.59200 08/21/2015
HYDROCORTISONE/ACETIC ACID OTIC DROPS 1 %-2 % 9.82215 08/21/2015 8.85454 01/13/2017
HYDROCORTISONE/ALOE VERA TOPICAL CREAM (GRAM) 1 % 0.08883 08/21/2015 0.04374 01/25/2019
HYDROCORTISONE/IODOQUINOL TOPICAL CREAM (GRAM) 1 %-1 % 0.43200 08/12/2014
HYDROCORTISONE/MINERAL OIL/PETROLATUM,WHITE OINTMENT (GRAM) 1 %
0.12564 01/25/2013
HYDROMORPHONE HCL INJECTION AMPUL (ML) 1 MG/ML 0.87360 01/25/2013
HYDROMORPHONE HCL INJECTION AMPUL (ML) 4 MG/ML 1.33560 01/25/2013
HYDROMORPHONE HCL INJECTION SYRINGE (ML) 0.5MG/.5ML 8.44200 06/21/2013
HYDROMORPHONE HCL INJECTION SYRINGE (ML) 1 MG/ML 3.90600 01/25/2013
HYDROMORPHONE HCL INJECTION SYRINGE (ML) 2 MG/ML 1.88160 12/26/2014
HYDROMORPHONE HCL INJECTION SYRINGE (ML) 4 MG/ML 3.78000 01/25/2013
HYDROMORPHONE HCL INJECTION VIAL (ML) 2 MG/ML 0.87780 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
HYDROMORPHONE HCL ORAL LIQUID (ML) 1 MG/ML 0.27988 01/25/2013
HYDROMORPHONE HCL ORAL TABLET 2 MG 0.07780 08/25/2017 0.05790 05/22/2020
HYDROMORPHONE HCL ORAL TABLET 4 MG 0.08770 09/22/2017 0.07870 07/26/2019
HYDROMORPHONE HCL ORAL TABLET 8 MG 0.21960 02/22/2019 0.20310 03/20/2020
HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 12 MG
14.29670 08/01/2014 14.29670 08/21/2015
HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 16 MG
19.06219 08/21/2015 15.75000 05/25/2018
HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 32 MG
37.91137 08/01/2014
HYDROMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 8 MG 9.53110 08/01/2014 9.53110 08/21/2015
HYDROMORPHONE HCL RECTAL SUPPOSITORY, RECTAL 3 MG 8.58670 02/01/2013
HYDROMORPHONE HCL/PF INJECTION AMPUL (ML) 1 MG/ML 0.87360 01/25/2013
HYDROMORPHONE HCL/PF INJECTION AMPUL (ML) 2 MG/ML 0.94080 01/25/2013
HYDROMORPHONE HCL/PF INJECTION AMPUL (ML) 4 MG/ML 1.33560 01/25/2013
HYDROMORPHONE HCL/PF INJECTION SYRINGE (ML) 4 MG/ML 3.78000 01/25/2013
HYDROMORPHONE HCL/PF INJECTION VIAL (ML) 10 MG/ML 1.90750 01/30/2015 1.61638 12/02/2016
HYDROQUINONE MICROSPHERES TOPICAL CREAM, EXTENDED RELEASE (GRAM) 4 %
2.49387 01/25/2013
HYDROQUINONE TOPICAL CREAM (GRAM) 4 % 2.30566 08/21/2015 0.83056 11/15/2019
HYDROXOCOBALAMIN INTRAMUSCULAR VIAL (ML) 1000MCG/ML 0.89273 01/25/2013
HYDROXYUREA ORAL CAPSULE 500 MG 0.21423 11/24/2017 0.18352 03/02/2018
HYDROXYZINE HCL INTRAMUSCULAR VIAL (ML) 50 MG/ML 1.75000 01/25/2013 1.75000 08/21/2015
HYDROXYZINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.05916 08/21/2015 0.03692 03/02/2018
HYDROXYZINE HCL ORAL TABLET 10 MG 0.07338 08/21/2015 0.03772 09/22/2017
HYDROXYZINE HCL ORAL TABLET 25 MG 0.04000 08/25/2017 0.04986 06/06/2019
HYDROXYZINE HCL ORAL TABLET 50 MG 0.08702 10/03/2019 0.04500 06/19/2020
HYDROXYZINE PAMOATE ORAL CAPSULE 100 MG 0.52378 08/15/2014 0.52378 08/21/2015
HYDROXYZINE PAMOATE ORAL CAPSULE 25 MG 0.08300 02/25/2019 0.06010 10/25/2019
HYDROXYZINE PAMOATE ORAL CAPSULE 50 MG 0.08144 09/03/2019 0.06434 11/15/2019
HYOSCYAMINE SULFATE ORAL DROPS 0.125MG/ML 1.29622 04/24/2015 1.29622 08/21/2015
HYOSCYAMINE SULFATE ORAL ELIXIR 125MCG/5ML 0.04790 12/26/2014
HYOSCYAMINE SULFATE ORAL TABLET 0.125 MG 0.13030 09/22/2017 0.11025 08/16/2019
HYOSCYAMINE SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 0.375 MG
0.60697 07/18/2014 0.60697 08/21/2015
HYOSCYAMINE SULFATE ORAL TABLET,DISINTEGRATING 0.125 MG 0.18450 03/16/2018 0.12900 05/17/2019
HYOSCYAMINE SULFATE SUBLINGUAL TABLET, SUBLINGUAL 0.125 MG 0.19432 12/25/2015 0.07000 07/14/2017
HYPROMELLOSE OPHTHALMIC DROPS 0.3 % 0.35978 08/12/2014
HYPROMELLOSE OPHTHALMIC DROPS 0.4 % 0.17850 01/25/2013
IBANDRONATE SODIUM INTRAVENOUS SYRINGE (ML) 3 MG/3 ML 74.36375 11/14/2014
IBANDRONATE SODIUM ORAL TABLET 150 MG 4.66000 06/22/2018 4.34278 11/15/2019
IBUPROFEN ORAL CAPSULE 200 MG 0.10261 04/10/2015 0.10261 08/21/2015
IBUPROFEN ORAL SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 50 MG/1.25
0.22167 01/30/2015 0.22167 08/21/2015
IBUPROFEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 MG/5ML 0.02262 04/17/2015 0.02262 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
IBUPROFEN ORAL TABLET 200 MG 0.01635 01/16/2015 0.01635 08/21/2015
IBUPROFEN ORAL TABLET 400 MG 0.06240 08/21/2015 0.04002 08/25/2017
IBUPROFEN ORAL TABLET 600 MG 0.06700 08/21/2015 0.03420 07/14/2017
IBUPROFEN ORAL TABLET 800 MG 0.07263 08/21/2015 0.03474 07/14/2017
IBUPROFEN ORAL TABLET,CHEWABLE 100 MG 0.12702 08/21/2015 0.12802 05/03/2019
IBUPROFEN/OXYCODONE HCL ORAL TABLET 400 MG-5MG 1.03130 08/12/2014 1.03130 08/21/2015
IFOSFAMIDE INTRAVENOUS VIAL (EA) 3 G 88.61300 01/25/2013
IFOSFAMIDE INTRAVENOUS VIAL (ML) 1 G/20 ML 2.09300 02/27/2015 2.09300 08/21/2015
IFOSFAMIDE INTRAVENOUS VIAL (ML) 3 G/60 ML 1.93007 10/17/2014 1.93007 08/21/2015
IFOSFAMIDE/MESNA KIT 3G-1G 281.14725 01/25/2013
IMIPENEM/CILASTATIN SODIUM INTRAVENOUS VIAL (EA) 250 MG 4.41000 08/12/2014 4.41000 08/21/2015
IMIPENEM/CILASTATIN SODIUM INTRAVENOUS VIAL (EA) 500 MG 8.82000 04/18/2014 8.82000 08/21/2015
IMIPRAMINE HCL ORAL TABLET 10 MG 0.10780 08/25/2017 0.06140 11/24/2017
IMIPRAMINE HCL ORAL TABLET 25 MG 0.10686 03/03/2017 0.06370 11/24/2017
IMIPRAMINE HCL ORAL TABLET 50 MG 0.13870 03/20/2020 0.10530 05/22/2020
IMIPRAMINE PAMOATE ORAL CAPSULE 100 MG 5.97100 03/07/2014
IMIPRAMINE PAMOATE ORAL CAPSULE 125 MG 8.87087 04/10/2015
IMIPRAMINE PAMOATE ORAL CAPSULE 150 MG 11.22875 04/10/2015
IMIPRAMINE PAMOATE ORAL CAPSULE 75 MG 7.95000 12/27/2013
IMIQUIMOD TOPICAL CREAM IN PACKET (EA) 5 % 2.07408 06/16/2017 1.89000 12/20/2019
INDAPAMIDE ORAL TABLET 1.25 MG 0.30448 08/01/2014 0.17220 09/22/2017
INDAPAMIDE ORAL TABLET 2.5 MG 0.17880 09/22/2017 0.14820 01/24/2020
INDOMETHACIN ORAL CAPSULE 25 MG 0.07340 12/22/2017 0.02910 11/16/2018
INDOMETHACIN ORAL CAPSULE 50 MG 0.09440 03/02/2018 0.07690 09/21/2018
INDOMETHACIN ORAL CAPSULE, EXTENDED RELEASE 75 MG 0.32783 07/14/2017 0.27750 03/02/2018
INDOMETHACIN SODIUM INTRAVENOUS VIAL (EA) 1 MG 365.86025 08/12/2014
IPRATROPIUM BROMIDE INHALATION SOLUTION, NON-ORAL 0.2 MG/ML 0.06013 08/21/2015 0.03720 07/26/2019
IPRATROPIUM BROMIDE NASAL AEROSOL, SPRAY (ML) 21 MCG 0.62500 12/25/2015 0.59969 04/21/2017
IPRATROPIUM BROMIDE NASAL AEROSOL, SPRAY (ML) 42 MCG 1.17400 03/03/2017 2.39930 05/03/2019
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE INHALATION AMPUL FOR NEBULIZATION (ML) 0.5-3MG/3
0.05553 03/03/2017 0.04815 07/26/2019
IRBESARTAN ORAL TABLET 150 MG 0.13666 08/25/2017 0.11244 10/20/2017
IRBESARTAN ORAL TABLET 75 MG 0.14563 08/21/2015 0.08700 09/22/2017
IRBESARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 150-12.5MG 0.18022 03/02/2018 0.15667 08/17/2018
IRBESARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 300-12.5MG 0.19011 09/22/2017 0.17176 11/16/2018
IRON CARBONYL,GLUC/FOLIC ACID/VIT B12/VIT C/DOCUSATE SODIUM ORAL TABLET 90-1-50 MG
0.78945 08/21/2015 2.02566 12/13/2018
IRON POLYSACCHAR COMPLX/IRON HEME POLYPEPTIDE/FOLIC ACID/B12 ORAL TABLET 22-6-1-25
2.61148 01/25/2013 2.61148 08/21/2015
IRON POLYSACCHARIDE COMPLEX ORAL CAPSULE 150 MG 0.12990 08/16/2013 0.12990 08/21/2015
IRON POLYSACCHARIDE COMPLEX/CYANOCOBALAMIN/FOLIC ACID ORAL CAPSULE 150-25-1
0.19524 02/20/2015 0.19524 08/21/2015
IRON POLYSACCHARIDE COMPLEX/IRON HEME POLYPEPTIDE ORAL TABLET 28 MG
0.37090 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
IRON,CARBONYL ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 15MG/1.25
0.12650 08/12/2014
IRON,CARBONYL/ASCORBIC ACID/CYANOCOBALAMIN/FOLIC ACID ORAL TABLET 100-250-1
0.80738 08/12/2014
IRON,CARBONYL/DOCUSATE SODIUM/B12-IF/FOLIC ACID/MULTIVIT-MIN ORAL TABLET, EXTENDED RELEASE 24 HR 150-50-1MG
0.47055 01/25/2013
ISOMETHEPTENE MUCATE/DICHLORALPHENAZONE/ACETAMINOPHEN CAPSULE 65-100-325
4.71877 09/19/2014 4.71877 08/21/2015
ISONIAZID INJECTION VIAL (ML) 100 MG/ML 63.03150 01/25/2013
ISONIAZID ORAL SOLUTION, ORAL 50 MG/5 ML 0.09983 01/25/2013
ISONIAZID ORAL TABLET 100 MG 0.04221 12/13/2013 0.04221 08/21/2015
ISONIAZID ORAL TABLET 300 MG 0.06993 11/28/2014 0.06993 08/21/2015
ISOPROPYL ALCOHOL IN GLYCERIN OTIC DROPS 95 %-5 % 0.07020 08/12/2014 0.07020 08/21/2015
ISOSORBIDE DINITRATE ORAL TABLET 10 MG 0.68863 08/21/2015 0.22376 09/30/2016
ISOSORBIDE DINITRATE ORAL TABLET 20 MG 0.41250 03/02/2018 0.18870 09/21/2018
ISOSORBIDE DINITRATE ORAL TABLET 30 MG 0.83200 10/10/2014 0.83200 08/21/2015
ISOSORBIDE DINITRATE ORAL TABLET 5 MG 0.39000 12/21/2018 0.09160 02/21/2020
ISOSORBIDE DINITRATE ORAL TABLET, EXTENDED RELEASE 40 MG 1.24501 12/05/2014 1.24501 08/21/2015
ISOSORBIDE MONONITRATE ORAL TABLET 10 MG 0.19730 01/25/2013 0.19730 08/21/2015
ISOSORBIDE MONONITRATE ORAL TABLET 20 MG 0.12251 10/11/2013 0.09070 01/19/2018
ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 120 MG
0.31550 09/22/2017 0.24000 11/24/2017
ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 30 MG
0.10900 11/16/2018 0.07058 05/17/2019
ISOSORBIDE MONONITRATE ORAL TABLET, EXTENDED RELEASE 24 HR 60 MG
0.08680 01/24/2020 0.06790 03/20/2020
ISOSULFAN BLUE SUBCUTANEOUS VIAL (ML) 1 % 110.57218 04/03/2015 110.57218 08/21/2015
ISOTRETINOIN ORAL CAPSULE 10 MG 6.52054 01/22/2016 3.70100 10/19/2018
ISOTRETINOIN ORAL CAPSULE 20 MG 1.92767 08/16/2019 3.46933 02/07/2020
ISOTRETINOIN ORAL CAPSULE 30 MG 3.55000 12/20/2019 5.11994 04/08/2020
ISOTRETINOIN ORAL CAPSULE 40 MG 3.19000 10/25/2019 2.13833 01/24/2020
ISOXSUPRINE HCL ORAL TABLET 10 MG 0.80892 04/03/2015 0.80892 08/21/2015
ISRADIPINE ORAL CAPSULE 2.5 MG 0.95543 02/13/2015 0.95543 08/21/2015
ISRADIPINE ORAL CAPSULE 5 MG 1.39713 03/27/2015 1.39713 08/21/2015
ITRACONAZOLE ORAL CAPSULE 100 MG 1.62600 09/20/2019 1.09133 11/15/2019
IVERMECTIN ORAL TABLET 3 MG 7.57155 01/16/2015
KETOCONAZOLE ORAL TABLET 200 MG 0.98460 12/22/2017 0.93167 03/02/2018
KETOCONAZOLE TOPICAL CREAM (GRAM) 2 % 0.55784 11/15/2019 0.46671 02/21/2020
KETOCONAZOLE TOPICAL SHAMPOO 2 % 0.07500 03/17/2017 0.05789 08/25/2017
KETOPROFEN ORAL CAPSULE 75 MG 0.40169 03/06/2015 0.40169 08/21/2015
KETOPROFEN ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 200 MG
5.64648 03/13/2015 5.64648 08/21/2015
KETOROLAC TROMETHAMINE INJECTION SYRINGE (ML) 30 MG/ML 1.81000 04/25/2014
KETOROLAC TROMETHAMINE INJECTION VIAL (ML) 15 MG/ML 1.01304 02/13/2015 1.01304 08/21/2015
KETOROLAC TROMETHAMINE INJECTION VIAL (ML) 30 MG/ML 1.31943 01/25/2013
KETOROLAC TROMETHAMINE INJECTION VIAL (ML) 30MG/ML(1) 1.08696 02/13/2015 1.08696 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
KETOROLAC TROMETHAMINE INTRAMUSCULAR VIAL (ML) 60 MG/2 ML 0.97981 02/13/2015 0.97981 08/21/2015
KETOROLAC TROMETHAMINE OPHTHALMIC DROPS 0.4 % 7.81600 03/27/2015 7.81600 08/21/2015
KETOROLAC TROMETHAMINE OPHTHALMIC DROPS 0.5 % 1.29534 08/21/2015 1.13433 08/25/2017
KETOROLAC TROMETHAMINE ORAL TABLET 10 MG 0.69950 11/16/2018 0.58960 05/22/2020
KETOTIFEN FUMARATE OPHTHALMIC DROPS 0.025 % 0.92080 03/27/2015 0.92080 08/21/2015
LABETALOL HCL INTRAVENOUS SYRINGE (ML) 20 MG/4 ML 0.65310 01/25/2013 0.65310 08/21/2015
LABETALOL HCL ORAL TABLET 100 MG 0.14153 05/17/2019 0.10450 09/20/2019
LABETALOL HCL ORAL TABLET 200 MG 0.18547 12/22/2017 0.12920 07/26/2019
LABETALOL HCL ORAL TABLET 300 MG 0.27700 11/24/2017 0.18370 09/20/2019
LACTIC ACID CREAM (GRAM) 10 % 0.08303 01/25/2013
LACTIC ACID LOTION (ML) 10 % 0.04280 08/12/2014
LACTULOSE ORAL SOLUTION, ORAL 10 G/15 ML 0.03407 04/03/2015
LACTULOSE ORAL SOLUTION, ORAL 10 G/15 ML 0.01396 04/24/2015
LACTULOSE ORAL SOLUTION, ORAL 10 G/15 ML 0.01301 11/21/2014 0.01301 08/21/2015
LACTULOSE ORAL SOLUTION, ORAL 20 G/30 ML 0.02205 02/07/2014 0.02205 08/21/2015
LAMIVUDINE ORAL SOLUTION, ORAL 10 MG/ML 0.34922 03/13/2015 0.27563 11/24/2017
LAMIVUDINE ORAL TABLET 150 MG 1.72083 03/17/2017 0.65500 11/15/2019
LAMIVUDINE ORAL TABLET 300 MG 1.61000 11/24/2017 1.31000 11/15/2019
LAMIVUDINE/ZIDOVUDINE ORAL TABLET 150-300 MG 0.91667 09/22/2017 0.33467 05/22/2020
LAMOTRIGINE ORAL TABLET 100 MG 0.05167 08/25/2017 0.03960 12/22/2017
LAMOTRIGINE ORAL TABLET 150 MG 0.10385 08/21/2015 0.06512 08/25/2017
LAMOTRIGINE ORAL TABLET 200 MG 0.08236 08/21/2015 0.06122 08/25/2017
LAMOTRIGINE ORAL TABLET 25 MG 0.03110 07/14/2017 0.02605 07/26/2019
LAMOTRIGINE ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG 0.13440 02/21/2020 0.20031 04/08/2020
LAMOTRIGINE ORAL TABLET, CHEWABLE DISPERSIBLE 5 MG 0.08870 02/22/2019 0.17130 05/21/2019
LAMOTRIGINE ORAL TABLET, DOSE PACK 25MG (35) 2.90500 01/25/2013
LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG 1.92966 01/25/2019 1.72650 06/21/2019
LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 200 MG 2.06266 01/25/2019 2.01533 03/20/2020
LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 25 MG 1.75000 06/22/2018 1.55055 06/21/2019
LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 250 MG 7.24667 11/16/2018 8.57000 12/20/2018
LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 4.42467 06/22/2018 2.83067 10/25/2019
LAMOTRIGINE ORAL TABLET, EXTENDED RELEASE 24 HR 50 MG 1.94367 11/15/2019 1.60000 05/22/2020
LAMOTRIGINE ORAL TABLET,DISINTEGRATING 100 MG 5.81000 08/17/2018 3.93467 05/22/2020
LAMOTRIGINE ORAL TABLET,DISINTEGRATING 200 MG 23.77830 08/21/2015 6.30000 03/15/2019
LAMOTRIGINE ORAL TABLET,DISINTEGRATING 25 MG 5.75000 08/17/2018 4.72000 01/25/2019
LAMOTRIGINE ORAL TABLET,DISINTEGRATING 50 MG 18.68721 08/21/2015 3.33933 11/24/2017
LANOLIN/MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT (GRAM)
0.91000 01/25/2013 0.91000 08/21/2015
LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 15 MG
0.28500 06/16/2017 0.13167 05/17/2019
LANSOPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 30 MG
0.15656 07/14/2017 0.08467 03/15/2019
LANSOPRAZOLE/AMOXICILLIN TRIHYDRATE/CLARITHROMYCIN ORAL COMBINATION PACKAGE (EA) 30-500-500
3.59300 03/20/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
LATANOPROST OPHTHALMIC DROPS 0.005 % 1.67400 10/19/2018 1.62800 04/17/2020
LEFLUNOMIDE ORAL TABLET 10 MG 0.76500 02/22/2019 0.66667 05/17/2019
LEFLUNOMIDE ORAL TABLET 20 MG 1.34389 08/16/2019 1.03800 03/20/2020
LETROZOLE ORAL TABLET 2.5 MG 0.10433 07/14/2017 0.08978 04/17/2020
LEUCOVORIN CALCIUM INJECTION VIAL (EA) 200 MG 16.25400 08/12/2014 16.25400 08/21/2015
LEUCOVORIN CALCIUM INJECTION VIAL (EA) 50 MG 5.85200 08/12/2014 5.85200 08/21/2015
LEUCOVORIN CALCIUM INJECTION VIAL (EA) 500 MG 99.22500 01/25/2013
LEUCOVORIN CALCIUM INJECTION VIAL (ML) 10 MG/ML 0.29460 08/12/2014 0.29460 08/21/2015
LEUCOVORIN CALCIUM ORAL TABLET 10 MG 5.25150 08/12/2014
LEUCOVORIN CALCIUM ORAL TABLET 15 MG 5.85368 01/25/2013
LEUCOVORIN CALCIUM ORAL TABLET 25 MG 7.83744 05/17/2013 4.84400 03/02/2018
LEUCOVORIN CALCIUM ORAL TABLET 5 MG 0.64904 12/02/2016 0.60030 08/17/2018
LEUPROLIDE ACETATE SUBCUTANEOUS KIT 1 MG/0.2ML 129.30375 03/13/2015 129.30375 08/21/2015
LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (EA) 1.25MG/0.5 4.52639 12/26/2014 4.52639 08/21/2015
LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (ML) 0.31MG/3ML 0.78893 08/21/2015 0.54096 03/17/2017
LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (ML) 0.63MG/3ML 0.30400 05/17/2019 0.25156 11/15/2019
LEVALBUTEROL HCL INHALATION VIAL, NEBULIZER (ML) 1.25MG/3ML 0.38012 03/02/2018 0.29673 08/17/2018
LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 1000MG/100
0.59877 01/25/2013
LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 1500MG/100
0.77967 01/25/2013
LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 500MG/0.1L
0.36284 01/25/2013
LEVETIRACETAM INTRAVENOUS VIAL (ML) 500 MG/5ML 1.29524 08/12/2014 1.29524 08/21/2015
LEVETIRACETAM ORAL SOLUTION, ORAL 100 MG/ML 0.04966 08/21/2015 0.03332 10/20/2017
LEVETIRACETAM ORAL SOLUTION, ORAL 500 MG/5ML 1.06824 08/21/2015 0.05210 09/30/2016
LEVETIRACETAM ORAL TABLET 1000 MG 0.22030 03/22/2019 0.21650 07/26/2019
LEVETIRACETAM ORAL TABLET 250 MG 0.07448 08/21/2015 0.06112 05/22/2020
LEVETIRACETAM ORAL TABLET 500 MG 0.10089 05/19/2017 0.07706 08/01/2018
LEVETIRACETAM ORAL TABLET 750 MG 0.16433 03/04/2019 0.12917 07/26/2019
LEVETIRACETAM ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.23278 11/16/2018 0.16667 07/26/2019
LEVETIRACETAM ORAL TABLET, EXTENDED RELEASE 24 HR 750 MG 0.27750 05/17/2019 0.21650 05/22/2020
LEVOBUNOLOL HCL OPHTHALMIC DROPS 0.5 % 2.15200 09/30/2016 0.58000 12/21/2018
LEVOCARNITINE (WITH SUGAR) ORAL SOLUTION, ORAL 100 MG/ML 0.27042 06/22/2018 0.19661 11/15/2019
LEVOCARNITINE ORAL TABLET 330 MG 0.53495 04/24/2015 0.72599 05/25/2018
LEVOCARNITINE ORAL TABLET 500 MG 0.24450 10/24/2014 0.24450 08/21/2015
LEVOCETIRIZINE DIHYDROCHLORIDE ORAL SOLUTION, ORAL 2.5 MG/5ML
0.43651 08/12/2014 0.43651 08/21/2015
LEVOCETIRIZINE DIHYDROCHLORIDE ORAL TABLET 5 MG 0.07215 11/16/2018 0.06111 04/26/2019
LEVOFLOXACIN INTRAVENOUS VIAL (ML) 25 MG/ML 0.55298 08/12/2014
LEVOFLOXACIN OPHTHALMIC DROPS 0.5 % 7.88880 01/25/2013
LEVOFLOXACIN ORAL SOLUTION, ORAL 250MG/10ML 0.88900 08/12/2014
LEVOFLOXACIN ORAL TABLET 250 MG 0.14767 08/21/2015 0.05240 03/15/2019
LEVOFLOXACIN ORAL TABLET 500 MG 0.12400 11/16/2018 0.10300 07/26/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
LEVOFLOXACIN ORAL TABLET 750 MG 0.24150 03/02/2018 0.22400 04/26/2019
LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 250MG/50ML
0.11258 08/12/2014
LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 500MG/0.1L
0.06601 08/12/2014 0.02228 11/24/2017
LEVOFLOXACIN/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 750MG/.15L
0.05357 08/12/2014 0.01569 11/24/2017
LEVOMEFOLATE CALCIUM ORAL TABLET 15 MG 2.04831 01/23/2015 2.04831 08/21/2015
LEVOMEFOLATE CALCIUM ORAL TABLET 7.5 MG 2.05620 02/20/2015 2.05620 08/21/2015
LEVONORGESTREL ORAL TABLET 0.75 MG 12.79600 01/25/2013 12.79600 08/21/2015
LEVONORGESTREL ORAL TABLET 1.5 MG 10.22000 05/17/2019 8.50000 12/20/2019
LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL ORAL TABLET, DOSE PACK, 3 MONTHS 100-20(84)
0.99800 12/21/2018 0.41879 01/25/2019
LEVONORGESTREL/ETHINYL ESTRADIOL AND ETHINYL ESTRADIOL ORAL TABLET, DOSE PACK, 3 MONTHS 150-30(84)
0.31610 03/20/2020 0.56003 05/12/2020
LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET 0.1-0.02MG 0.27345 08/17/2018 0.21078 03/15/2019
LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET 0.15-0.03 0.19619 09/30/2016 0.11607 03/02/2018
LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET 6-5-10 0.68718 08/12/2014 0.18904 07/08/2016
LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET 90-20 MCG 1.48500 04/24/2015
LEVONORGESTREL/ETHINYL ESTRADIOL ORAL TABLET, DOSE PACK, 3 MONTHS 0.15-0.03
0.40699 05/23/2018 0.32100 11/16/2018
LEVORPHANOL TARTRATE ORAL TABLET 2 MG 1.12600 08/12/2014 1.12600 08/21/2015
LEVOTHYROXINE SODIUM INTRAVENOUS VIAL (EA) 100 MCG 77.11900 11/07/2014 77.11900 08/21/2015
LEVOTHYROXINE SODIUM INTRAVENOUS VIAL (EA) 500 MCG 44.60050 01/25/2013 44.60050 08/21/2015
LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG 0.20882 07/14/2017 0.32886 03/17/2020
LEVOTHYROXINE SODIUM ORAL TABLET 112 MCG 0.37767 10/19/2018 0.31907 06/21/2019
LEVOTHYROXINE SODIUM ORAL TABLET 125 MCG 0.39235 06/14/2019 0.36510 05/22/2020
LEVOTHYROXINE SODIUM ORAL TABLET 137 MCG 0.40522 05/19/2017 0.35260 10/20/2017
LEVOTHYROXINE SODIUM ORAL TABLET 150 MCG 0.38550 02/22/2019 0.24822 01/24/2020
LEVOTHYROXINE SODIUM ORAL TABLET 175 MCG 0.42570 12/20/2019 0.37844 05/22/2020
LEVOTHYROXINE SODIUM ORAL TABLET 200 MCG 0.49196 01/27/2017 0.33885 07/14/2017
LEVOTHYROXINE SODIUM ORAL TABLET 25 MCG 0.22294 11/16/2018 0.17105 04/17/2020
LEVOTHYROXINE SODIUM ORAL TABLET 300 MCG 0.59100 03/30/2019 0.55480 05/22/2020
LEVOTHYROXINE SODIUM ORAL TABLET 50 MCG 0.27192 07/14/2017 0.20082 12/20/2019
LEVOTHYROXINE SODIUM ORAL TABLET 75 MCG 0.30045 07/14/2017 0.22038 04/17/2020
LEVOTHYROXINE SODIUM ORAL TABLET 88 MCG 0.26722 07/14/2017 0.23539 04/17/2020
LIDOCAINE HCL IN DEXTROSE 5% IN WATER/PF INTRAVENOUS INTRAVENOUS SOLUTION 4 MG/ML
0.01280 08/12/2014
LIDOCAINE HCL IN DEXTROSE 5% IN WATER/PF INTRAVENOUS INTRAVENOUS SOLUTION 8 MG/ML
0.02029 01/25/2013
LIDOCAINE HCL IN DEXTROSE 7.5 % IN WATER/PF INTRATHECAL AMPUL (ML) 5 %
6.05930 08/12/2014
LIDOCAINE HCL INJECTION VIAL (ML) 10 MG/ML 0.05802 02/07/2014 0.05802 08/21/2015
LIDOCAINE HCL INJECTION VIAL (ML) 20 MG/ML 0.06084 01/25/2013
LIDOCAINE HCL MUCOUS MEMBRANE JELLY (ML) 2 % 0.27545 02/14/2014 0.27545 08/21/2015
LIDOCAINE HCL MUCOUS MEMBRANE JELLY WITH PREFILLED APPLICATOR (ML) 2 %
0.34943 12/12/2014 0.34943 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
LIDOCAINE HCL MUCOUS MEMBRANE SOLUTION, NON-ORAL 40 MG/ML 0.06266 08/12/2014 0.06266 08/21/2015
LIDOCAINE HCL MUCOUS MEMBRANE SOLUTION, ORAL 2 % 0.02375 08/21/2015 0.07917 05/21/2018
LIDOCAINE HCL TOPICAL SOLUTION, ORAL 4 % 1.05248 01/25/2013
LIDOCAINE HCL/EPINEPHRINE BITARTRATE INJECTION CARTRIDGE (ML) 2 %-1:100K
0.14933 01/25/2013
LIDOCAINE HCL/EPINEPHRINE BITARTRATE INJECTION CARTRIDGE (ML) 2%-1:50000
0.14933 01/25/2013
LIDOCAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 1%-1:100K 0.06995 01/25/2013 0.06995 08/21/2015
LIDOCAINE HCL/EPINEPHRINE INJECTION VIAL (ML) 2 %-1:100K 0.07910 08/12/2014 0.07910 08/21/2015
LIDOCAINE HCL/EPINEPHRINE/PF INJECTION VIAL (ML) 2%-1:200K 0.35740 08/12/2014 0.35740 08/21/2015
LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL CREAM (GRAM) 3 %-0.5 %
1.78500 03/13/2015
LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL CREAM WITH APPLICATOR 3 %-0.5 %
1.37036 02/06/2015 1.37036 08/21/2015
LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL CREAM WITH APPLICATOR 3%-1%(7 G)
251.09000 01/25/2013
LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL GEL WITH APPLICATOR (GRAM) 3-2.5%(7G)
251.09000 01/25/2013
LIDOCAINE HCL/HYDROCORTISONE ACETATE RECTAL KIT 3 %-0.5 % 7.69340 08/21/2015
LIDOCAINE HCL/PF INJECTION AMPUL (ML) 10 MG/ML 0.35751 12/20/2013 0.35751 08/21/2015
LIDOCAINE HCL/PF INJECTION AMPUL (ML) 15 MG/ML 0.66715 01/25/2013
LIDOCAINE HCL/PF INJECTION AMPUL (ML) 20 MG/ML 1.01535 12/27/2013
LIDOCAINE HCL/PF INJECTION AMPUL (ML) 40 MG/ML 0.56780 08/12/2014
LIDOCAINE HCL/PF INJECTION VIAL (ML) 20 MG/ML 0.48516 08/12/2014
LIDOCAINE HCL/PF INJECTION VIAL (ML) 5 MG/ML 0.11002 01/25/2013
LIDOCAINE HCL/PF INTRAVENOUS SYRINGE (ML) 100 MG/5ML 0.66080 01/25/2013 0.66080 08/21/2015
LIDOCAINE HCL/PF INTRAVENOUS SYRINGE (ML) 50 MG/5 ML 0.88790 08/12/2014
LIDOCAINE HCL/PF INTRAVENOUS VIAL (ML) 20 MG/ML 0.28224 01/25/2013
LIDOCAINE MISCELLANEOUS POWDER (GRAM) 0.19471 08/21/2015
LIDOCAINE TOPICAL ADHESIVE PATCH, MEDICATED 5 % 2.15204 02/21/2020 2.46633 05/14/2020
LIDOCAINE TOPICAL CREAM (GRAM) 4 % 0.79667 08/16/2019 0.31433 02/21/2020
LIDOCAINE TOPICAL CREAM (GRAM) 5 % 1.05645 12/26/2014 1.05645 08/21/2015
LIDOCAINE TOPICAL OINTMENT (GRAM) 5 % 0.26639 11/15/2019 0.22550 01/24/2020
LIDOCAINE/PRILOCAINE TOPICAL CREAM (GRAM) 2.5 %-2.5% 0.19392 11/15/2019 0.17500 05/22/2020
LIDOCAINE/PRILOCAINE TOPICAL KIT 2.5 %-2.5% 1.40764 01/25/2013 1.40764 08/21/2015
LINDANE TOPICAL LOTION (ML) 1 % 1.59670 02/08/2013 1.59670 08/21/2015
LINDANE TOPICAL SHAMPOO 1 % 1.59670 02/08/2013 1.59670 08/21/2015
LINEZOLID IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 600MG/300
0.50400 03/13/2015 0.50400 08/21/2015
LINEZOLID ORAL TABLET 600 MG 1.51000 02/21/2020 2.34734 03/04/2020
LIOTHYRONINE SODIUM ORAL TABLET 25 MCG 0.65000 03/17/2017 0.42480 07/14/2017
LIOTHYRONINE SODIUM ORAL TABLET 5 MCG 0.32485 05/19/2017 0.29155 07/14/2017
LIOTHYRONINE SODIUM ORAL TABLET 50 MCG 1.01491 04/24/2015 0.47406 03/03/2017
LISINOPRIL ORAL TABLET 10 MG 0.02112 04/17/2015 0.02112 08/21/2015
LISINOPRIL ORAL TABLET 2.5 MG 0.01635 05/01/2015 0.01635 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
LISINOPRIL ORAL TABLET 20 MG 0.02086 10/20/2017 0.02569 04/06/2020
LISINOPRIL ORAL TABLET 30 MG 0.07504 08/21/2015 0.03142 06/16/2017
LISINOPRIL ORAL TABLET 40 MG 0.02100 08/25/2017 0.02610 07/25/2019
LISINOPRIL ORAL TABLET 5 MG 0.01809 08/21/2015 0.00832 10/20/2017
LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.02693 03/06/2015 0.02693 08/21/2015
LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 20 MG-25MG 0.05186 08/21/2015 0.02920 10/20/2017
LISINOPRIL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG 0.04063 08/21/2015 0.02670 04/27/2018
LITHIUM CARBONATE ORAL CAPSULE 150 MG 0.06052 02/13/2015 0.06052 08/21/2015
LITHIUM CARBONATE ORAL CAPSULE 300 MG 0.03114 04/24/2015 0.03114 08/21/2015
LITHIUM CARBONATE ORAL CAPSULE 600 MG 0.14351 08/21/2015 0.08414 07/14/2017
LITHIUM CARBONATE ORAL TABLET 300 MG 0.14961 04/17/2015 0.14961 08/21/2015
LITHIUM CARBONATE ORAL TABLET, EXTENDED RELEASE 300 MG 0.14970 03/03/2017 0.12000 09/21/2018
LITHIUM CARBONATE ORAL TABLET, EXTENDED RELEASE 450 MG 0.17713 02/22/2019 0.10100 05/17/2019
LITHIUM CITRATE ORAL SOLUTION, ORAL 8 MEQ/5 ML 0.03921 01/25/2013
LOPERAMIDE HCL ORAL CAPSULE 2 MG 0.28182 03/10/2019 0.22363 11/15/2019
LOPERAMIDE HCL ORAL LIQUID (ML) 1MG/7.5ML 0.03361 08/12/2014 0.03361 08/21/2015
LOPERAMIDE HCL ORAL TABLET 2 MG 0.08953 08/12/2014 0.08953 08/21/2015
LORATADINE ORAL SOLUTION, ORAL 5 MG/5 ML 0.04500 08/21/2015 0.03325 11/16/2018
LORATADINE ORAL TABLET 10 MG 0.05136 08/21/2015 0.03157 10/20/2017
LORATADINE ORAL TABLET,DISINTEGRATING 10 MG 0.38100 02/01/2013 0.38100 08/21/2015
LORATADINE/PSEUDOEPHEDRINE SULFATE ORAL TABLET, EXTENDED RELEASE 12 HR 5 MG-120MG
0.58500 04/07/2017 0.75400 07/16/2018
LORATADINE/PSEUDOEPHEDRINE SULFATE ORAL TABLET, EXTENDED RELEASE 24 HR 10MG-240MG
0.36808 11/16/2018 0.30533 05/22/2020
LORAZEPAM INJECTION SYRINGE (ML) 2 MG/ML 1.76400 02/15/2013 1.76400 08/21/2015
LORAZEPAM INJECTION SYRINGE (ML) 4 MG/ML 2.46960 01/25/2013
LORAZEPAM INJECTION VIAL (ML) 2 MG/ML 0.59480 03/02/2018 0.46840 11/15/2019
LORAZEPAM INJECTION VIAL (ML) 4 MG/ML 1.14324 01/25/2013
LORAZEPAM ORAL CONCENTRATE, ORAL 2 MG/ML 0.29067 09/21/2018 0.26900 11/15/2019
LORAZEPAM ORAL TABLET 0.5 MG 0.03047 08/21/2015 0.02030 10/20/2017
LORAZEPAM ORAL TABLET 1 MG 0.03287 08/21/2015 0.01735 12/22/2017
LORAZEPAM ORAL TABLET 2 MG 0.05247 08/21/2015 0.03950 08/17/2018
LOSARTAN POTASSIUM ORAL TABLET 100 MG 0.06386 06/16/2017 0.04114 10/20/2017
LOSARTAN POTASSIUM ORAL TABLET 25 MG 0.03245 10/20/2017 0.02177 10/25/2019
LOSARTAN POTASSIUM ORAL TABLET 50 MG 0.42866 09/04/2019 0.09600 02/21/2020
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 100-12.5MG
0.08772 08/25/2017 0.07169 12/22/2017
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 100MG-25MG
0.06639 04/27/2018 0.19126 03/16/2020
LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE ORAL TABLET 50-12.5 MG
0.07450 08/21/2015 0.05099 11/16/2018
LOVASTATIN ORAL TABLET 10 MG 0.05820 09/22/2017 0.04733 05/22/2020
LOVASTATIN ORAL TABLET 20 MG 0.05223 06/16/2017 0.03900 10/20/2017
LOVASTATIN ORAL TABLET 40 MG 0.04717 09/22/2017 0.01901 11/16/2018
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
LOXAPINE SUCCINATE ORAL CAPSULE 10 MG 0.26000 03/02/2018 0.66531 06/03/2019
LOXAPINE SUCCINATE ORAL CAPSULE 25 MG 0.76809 08/21/2015 0.56280 08/25/2017
LOXAPINE SUCCINATE ORAL CAPSULE 5 MG 0.37172 08/21/2015 0.28570 03/02/2018
LOXAPINE SUCCINATE ORAL CAPSULE 50 MG 0.66820 08/17/2018 0.62000 08/16/2019
MAGNESIUM CARBONATE/ALUMINUM HYDROXIDE/ALGINIC ACID ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 358-95/15
0.01253 01/25/2013
MAGNESIUM CHLORIDE ORAL TABLET, EXTENDED RELEASE 64 MG 0.08364 01/25/2013
MAGNESIUM HYDROXIDE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 400 MG/5ML
0.00419 08/12/2014 0.00419 08/21/2015
MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200-200-20
0.00592 09/19/2014 0.00592 08/21/2015
MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 400-400-40
0.00967 12/26/2014 0.00967 08/21/2015
MAGNESIUM HYDROXIDE/ALUMINUM HYDROXIDE/SIMETHICONE ORAL TABLET,CHEWABLE 200-200-25
0.03062 08/12/2014 0.03062 08/21/2015
MAGNESIUM OXIDE ORAL CAPSULE 400 MG 0.08450 08/12/2014
MAGNESIUM OXIDE ORAL TABLET 400 MG 0.02077 02/06/2015 0.02077 08/21/2015
MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS INTRAVENOUS SOLUTION 20 G/500ML
0.01970 08/12/2014
MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS INTRAVENOUS SOLUTION 40G/1000ML
0.01440 08/12/2014
MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 2 G/50 ML
0.24560 08/12/2014
MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 4 G/100 ML
0.13419 07/25/2014
MAGNESIUM SULFATE IN STERILE WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 4 G/50 ML
0.23100 08/12/2014
MAGNESIUM SULFATE INJECTION SYRINGE (ML) 4 MEQ/ML 0.63168 01/25/2013
MAGNESIUM SULFATE/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 1 G/100 ML
0.11630 08/12/2014
MALATHION TOPICAL LOTION (ML) 0.5 % 2.54547 08/21/2015 3.71143 08/12/2019
MANGANESE CHLORIDE INTRAVENOUS VIAL (ML) 0.1 MG/ML 0.17390 08/12/2014
MANNITOL INTRAVENOUS INTRAVENOUS SOLUTION 10 % 0.01620 08/12/2014
MANNITOL INTRAVENOUS INTRAVENOUS SOLUTION 20 % 0.03980 01/25/2013
MANNITOL INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.00866 01/25/2013
MANNITOL/SORBITOL SOLUTION URETHRAL SOLUTION, IRRIGATION 0.54G-2.7G
0.00569 01/25/2013
MAPROTILINE HCL ORAL TABLET 25 MG 0.59890 08/12/2014
MAPROTILINE HCL ORAL TABLET 50 MG 0.93980 02/08/2013
MAPROTILINE HCL ORAL TABLET 75 MG 1.28950 08/12/2014
MECLIZINE HCL ORAL TABLET 12.5 MG 0.03685 02/27/2015 0.03685 08/21/2015
MECLIZINE HCL ORAL TABLET 25 MG 0.12062 03/03/2017 0.04200 11/15/2019
MECLOFENAMATE SODIUM ORAL CAPSULE 100 MG 3.34760 08/12/2014 3.34760 08/21/2015
MECLOFENAMATE SODIUM ORAL CAPSULE 50 MG 1.91160 08/12/2014
MECOBALAMIN/LEVOMEFOLATE CALCIUM/PYRIDOXAL PHOSPHATE ORAL TABLET 2-3-35 MG
0.88358 03/27/2015 0.88358 08/21/2015
MEDROXYPROGESTERONE ACETATE INTRAMUSCULAR VIAL (ML) 150 MG/ML
42.38726 11/13/2019 35.40500 05/22/2020
MEDROXYPROGESTERONE ACETATE ORAL TABLET 10 MG 0.12690 08/21/2015 0.09842 07/14/2017
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
MEDROXYPROGESTERONE ACETATE ORAL TABLET 2.5 MG 0.10570 08/25/2017 0.07140 03/20/2020
MEDROXYPROGESTERONE ACETATE ORAL TABLET 5 MG 0.21370 05/19/2017 0.11870 03/02/2018
MEFENAMIC ACID ORAL CAPSULE 250 MG 6.03867 08/17/2018 1.46000 10/19/2018
MEFLOQUINE HCL ORAL TABLET 250 MG 3.74400 04/05/2013 3.74400 08/21/2015
MEGESTROL ACETATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 400MG/10ML
0.29429 08/08/2014 0.29429 08/21/2015
MEGESTROL ACETATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 400MG/10ML
0.08856 11/19/2019 0.07566 03/20/2020
MEGESTROL ACETATE ORAL TABLET 20 MG 0.11377 06/27/2014
MEGESTROL ACETATE ORAL TABLET 40 MG 0.14931 07/14/2017 0.10500 08/16/2019
MELATONIN ORAL TABLET, EXTENDED RELEASE 3 MG 0.06370 01/25/2013
MELATONIN/TRYPTOPHAN ORAL CAPSULE 3 MG-100MG 5.05750 01/31/2014
MELOXICAM ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 7.5 MG/5ML 1.33161 02/21/2014
MELOXICAM ORAL TABLET 15 MG 0.03190 08/21/2015 0.01655 08/17/2018
MELOXICAM ORAL TABLET 7.5 MG 0.02466 05/01/2015 0.02466 08/21/2015
MEMANTINE HCL ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 21 MG
2.50450 08/16/2019 2.41733 05/22/2020
MEMANTINE HCL ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 28 MG
1.93938 11/15/2019 0.97767 06/19/2020
MEMANTINE HCL ORAL TABLET 10 MG 0.08633 11/16/2018 0.06912 12/20/2019
MEMANTINE HCL ORAL TABLET 5 MG 0.18583 08/25/2017 0.09917 09/22/2017
MENTHOL MUCOUS MEMBRANE LOZENGE 8 MG 0.06420 08/12/2014
MENTHOL TOPICAL GEL (GRAM) 10 % 0.11397 01/25/2013
MEPERIDINE HCL INJECTION CARTRIDGE (ML) 10 MG/ML 0.49911 01/25/2013
MEPERIDINE HCL ORAL SOLUTION, ORAL 50 MG/5 ML 0.14191 01/25/2013
MEPERIDINE HCL ORAL TABLET 100 MG 0.32670 03/06/2015
MEPERIDINE HCL ORAL TABLET 50 MG 1.31433 08/21/2015 0.41454 06/16/2017
MEPERIDINE HCL/PF INJECTION VIAL (ML) 100 MG/ML 2.35200 01/25/2013
MEPERIDINE HCL/PF INJECTION VIAL (ML) 25 MG/ML 2.12100 01/25/2013
MEPERIDINE HCL/PF INJECTION VIAL (ML) 50 MG/ML 0.94080 01/25/2013
MEPIVACAINE HCL/PF INJECTION CARTRIDGE (ML) 30 MG/ML 0.17730 08/12/2014
MEPROBAMATE ORAL TABLET 200 MG 4.81285 10/17/2014 4.81285 08/21/2015
MEPROBAMATE ORAL TABLET 400 MG 0.98070 01/25/2013 0.98070 08/21/2015
MERCAPTOPURINE ORAL TABLET 50 MG 0.88334 09/22/2017 0.76000 05/17/2019
MEROPENEM INTRAVENOUS VIAL (EA) 1 G 11.34682 08/21/2015 16.85013 01/23/2017
MEROPENEM INTRAVENOUS VIAL (EA) 500 MG 4.50240 12/26/2014 4.50240 08/21/2015
MESALAMINE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 1.2 G
3.19075 01/29/2020 2.22400 04/17/2020
MESALAMINE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 800 MG
4.25000 11/15/2019 4.25000 01/01/2020
MESALAMINE RECTAL ENEMA (ML) 4 G/60 ML 0.19094 04/21/2017 0.16262 03/02/2018
MESALAMINE WITH CLEANSING WIPES RECTAL ENEMA KIT 4 G/60 ML 119.73500 12/26/2014 110.04250 06/16/2017
METAPROTERENOL SULFATE ORAL SYRUP 10 MG/5 ML 0.02460 08/12/2014 0.02460 08/21/2015
METAPROTERENOL SULFATE ORAL TABLET 10 MG 0.69965 01/25/2013 0.69965 08/21/2015
METAPROTERENOL SULFATE ORAL TABLET 20 MG 0.97496 01/25/2013 0.97496 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
METAXALONE ORAL TABLET 800 MG 0.52160 04/26/2019 0.45990 05/22/2020
METFORMIN HCL ORAL TABLET 1000 MG 0.03664 08/21/2015 0.02659 10/20/2017
METFORMIN HCL ORAL TABLET 500 MG 0.01932 08/21/2015 0.01435 07/26/2019
METFORMIN HCL ORAL TABLET 850 MG 0.02986 05/01/2015 0.02986 08/21/2015
METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1000 MG 3.80000 05/17/2019 3.67350 11/15/2019
METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 3.60978 12/26/2014 3.41667 11/24/2017
METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.04020 08/21/2015 0.02600 01/25/2019
METFORMIN HCL ORAL TABLET, EXTENDED RELEASE 24 HR 750 MG 0.06915 08/17/2018 0.04510 04/17/2020
METHADONE HCL INJECTION VIAL (ML) 10 MG/ML 6.01720 01/25/2013
METHADONE HCL ORAL CONCENTRATE, ORAL 10 MG/ML 0.62300 02/01/2013
METHADONE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.09670 07/18/2014
METHADONE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.12491 01/25/2013
METHADONE HCL ORAL TABLET 10 MG 0.10562 05/19/2017 0.08790 11/16/2018
METHADONE HCL ORAL TABLET 5 MG 0.11840 10/25/2019 0.10660 01/24/2020
METHADONE HCL ORAL TABLET, SOLUBLE 40 MG 0.22381 01/25/2013 0.22381 08/21/2015
METHAMPHETAMINE HCL ORAL TABLET 5 MG 4.11749 05/01/2015 4.11749 08/21/2015
METHAZOLAMIDE ORAL TABLET 25 MG 2.68163 03/13/2015
METHAZOLAMIDE ORAL TABLET 50 MG 2.59840 12/05/2014
METHENAMINE HIPPURATE ORAL TABLET 1 G 0.63990 01/24/2020 0.59990 03/20/2020
METHENAMINE MANDELATE ORAL TABLET 500 MG 0.62041 01/25/2013
METHENAMINE/METHYLENE BLUE/SOD PHOS/P.SALICYLATE/HYOSCYAMINE ORAL CAPSULE 118-10-36
1.80978 03/06/2015 1.80978 08/21/2015
METHENAMINE/METHYLENE BLUE/SOD PHOS/P.SALICYLATE/HYOSCYAMINE ORAL TABLET 81-0.12MG
4.27272 03/06/2015 4.27272 08/21/2015
METHENAMINE/METHYLENE BLUE/SOD PHOS/P.SALICYLATE/HYOSCYAMINE ORAL TABLET 81.6-10.8
0.91000 09/12/2014
METHENAMINE/SOD PHOSPH,MONOBASIC/METHYLENE BLUE/HYOSCYAMINE ORAL TABLET 81.6-.12MG
2.26793 03/06/2015
METHIMAZOLE ORAL TABLET 10 MG 0.15839 08/21/2015 0.09155 03/03/2017
METHIMAZOLE ORAL TABLET 5 MG 0.08482 02/27/2015 0.04940 09/22/2017
METHOCARBAMOL INJECTION VIAL (ML) 100 MG/ML 4.14861 02/13/2015
METHOCARBAMOL ORAL TABLET 500 MG 0.05895 08/25/2017 0.03100 11/16/2018
METHOCARBAMOL ORAL TABLET 750 MG 0.05730 12/22/2017 0.10932 08/23/2019
METHOTREXATE SODIUM INJECTION VIAL (ML) 25 MG/ML 3.00720 01/30/2015
METHOTREXATE SODIUM ORAL TABLET 2.5 MG 0.38159 11/15/2019 0.35990 06/19/2020
METHOTREXATE SODIUM/PF INJECTION VIAL (ML) 25 MG/ML 0.58357 08/21/2015 2.87500 10/02/2019
METHOXSALEN ORAL CAPSULE, LIQUID-FILLED, RAPID RELEASE 10 MG 66.75860 09/05/2014
METHSCOPOLAMINE BROMIDE ORAL TABLET 2.5 MG 1.53056 08/21/2015 0.31450 08/17/2018
METHSCOPOLAMINE BROMIDE ORAL TABLET 5 MG 2.17750 05/20/2016 0.86350 09/22/2017
METHYCLOTHIAZIDE TABLET 5 MG 1.21660 01/25/2013
METHYL SALICYLATE MISCELLANEOUS OIL (ML) 0.47540 08/12/2014
METHYLDOPA ORAL TABLET 250 MG 0.12359 07/14/2017 0.06990 03/02/2018
METHYLDOPA ORAL TABLET 500 MG 0.32656 08/21/2015 0.16892 05/19/2017
METHYLDOPA/HYDROCHLOROTHIAZIDE ORAL TABLET 250MG-15MG 0.67180 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
METHYLDOPA/HYDROCHLOROTHIAZIDE ORAL TABLET 250MG-25MG 1.51046 12/26/2014
METHYLERGONOVINE MALEATE INJECTION AMPUL (ML) .2MG/ML(1) 4.75860 08/12/2014
METHYLERGONOVINE MALEATE INJECTION VIAL (ML) .2MG/ML(1) 6.39450 01/25/2013
METHYLERGONOVINE MALEATE ORAL TABLET 0.2 MG 53.75250 01/25/2019 27.26667 05/22/2020
METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 30-70 10 MG
4.03956 12/09/2017 2.29720 07/26/2019
METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 30-70 20 MG
2.94350 12/08/2017 2.94350 12/09/2017
METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 30-70 30 MG
2.96640 12/09/2017 3.27270 05/16/2018
METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 30-70 40 MG
4.30300 12/08/2017 4.30300 12/09/2017
METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 30-70 50 MG
4.55740 12/09/2017 4.24000 07/26/2019
METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 30-70 60 MG
6.76633 12/08/2017 6.76633 12/09/2017
METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 50-50 20 MG
3.68500 10/19/2018 3.59850 05/17/2019
METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 50-50 30 MG
4.36506 04/25/2014 3.78000 07/26/2019
METHYLPHENIDATE HCL ORAL CAPSULE,EXTENDED RELEASE BIPHASIC 50-50 40 MG
4.27230 11/24/2017 3.85000 06/22/2018
METHYLPHENIDATE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.90135 04/10/2015
METHYLPHENIDATE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.73600 02/27/2015 0.73600 03/02/2016
METHYLPHENIDATE HCL ORAL TABLET 10 MG 0.27063 08/17/2018 0.18500 01/25/2019
METHYLPHENIDATE HCL ORAL TABLET 20 MG 0.23000 01/25/2019 0.27814 04/18/2019
METHYLPHENIDATE HCL ORAL TABLET 5 MG 0.17340 08/17/2018 0.15000 01/25/2019
METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 10 MG 2.31000 05/25/2018 1.67990 08/16/2019
METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 20 MG 2.23490 03/16/2018 1.70023 08/17/2018
METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 18 MG
7.32227 01/05/2018 4.56290 11/15/2019
METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 27 MG
6.98215 01/05/2018 5.31480 11/15/2019
METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 36 MG
6.58990 07/09/2019 6.27617 11/15/2019
METHYLPHENIDATE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 54 MG
4.40970 11/15/2019 5.65671 12/05/2019
METHYLPREDNISOLONE ACETATE INJECTION VIAL (ML) 40 MG/ML 3.47672 08/12/2014 3.47672 08/21/2015
METHYLPREDNISOLONE ACETATE INJECTION VIAL (ML) 80 MG/ML 7.07957 08/12/2014 7.07957 08/21/2015
METHYLPREDNISOLONE ORAL TABLET 16 MG 2.47842 04/03/2015 1.95015 06/16/2017
METHYLPREDNISOLONE ORAL TABLET 32 MG 3.62572 04/03/2015
METHYLPREDNISOLONE ORAL TABLET 4 MG 0.31030 01/19/2018 0.21648 05/17/2019
METHYLPREDNISOLONE ORAL TABLET 8 MG 1.15600 11/24/2017 1.09220 11/15/2019
METHYLPREDNISOLONE ORAL TABLET, DOSE PACK 4 MG 0.20571 04/17/2020 0.19148 05/22/2020
METHYLPREDNISOLONE SODIUM SUCCINATE INJECTION VIAL (EA) 125 MG
4.08408 01/25/2013
METHYLPREDNISOLONE SODIUM SUCCINATE INJECTION VIAL (EA) 40 MG
3.53132 01/25/2013
METHYLPREDNISOLONE SODIUM SUCCINATE INTRAVENOUS VIAL (EA) 1000 MG
17.05200 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
METIPRANOLOL OPHTHALMIC DROPS 0.3 % 2.91720 01/25/2013
METOCLOPRAMIDE HCL INJECTION SYRINGE (ML) 10 MG/2 ML 0.66573 05/24/2013 0.66573 08/21/2015
METOCLOPRAMIDE HCL INJECTION VIAL (ML) 5 MG/ML 0.37728 02/13/2015 0.37728 08/21/2015
METOCLOPRAMIDE HCL ORAL SOLUTION, ORAL 10 MG/10ML 0.04456 08/09/2013 0.04456 08/21/2015
METOCLOPRAMIDE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.01217 08/21/2015 0.03870 07/16/2018
METOCLOPRAMIDE HCL ORAL TABLET 10 MG 0.04069 08/21/2015 0.02797 11/16/2018
METOCLOPRAMIDE HCL ORAL TABLET 5 MG 0.04126 08/21/2015 0.02200 09/22/2017
METOLAZONE ORAL TABLET 10 MG 0.84230 05/17/2013
METOLAZONE ORAL TABLET 2.5 MG 0.12540 05/22/2020 1.17600 06/06/2020
METOLAZONE ORAL TABLET 5 MG 0.68220 01/24/2020 1.11320 02/25/2020
METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG
0.20520 09/21/2018 0.17251 05/22/2020
METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 200 MG
0.43860 12/20/2019 0.32643 02/21/2020
METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 25 MG
0.15329 11/24/2017 0.10200 06/21/2019
METOPROLOL SUCCINATE ORAL TABLET, EXTENDED RELEASE 24 HR 50 MG
0.18560 06/16/2017 0.09250 09/21/2018
METOPROLOL TARTRATE INTRAVENOUS AMPUL (ML) 5 MG/5 ML 0.23020 08/12/2014 0.23020 08/21/2015
METOPROLOL TARTRATE INTRAVENOUS SYRINGE (ML) 5 MG/5 ML 0.70560 01/25/2013
METOPROLOL TARTRATE ORAL TABLET 100 MG 0.03114 08/21/2015 0.02070 05/22/2020
METOPROLOL TARTRATE ORAL TABLET 25 MG 0.02399 05/01/2015 0.02399 08/21/2015
METOPROLOL TARTRATE ORAL TABLET 50 MG 0.02097 12/26/2014 0.02097 08/21/2015
METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE ORAL TABLET 100MG-25MG
0.84850 06/16/2017 0.63568 06/21/2019
METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE ORAL TABLET 100MG-50MG
1.53410 02/08/2013
METOPROLOL TARTRATE/HYDROCHLOROTHIAZIDE ORAL TABLET 50 MG-25MG
0.70970 11/24/2017 0.67570 03/02/2018
METRONIDAZOLE IN SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 500MG/0.1L
0.01400 04/05/2013 0.01400 08/21/2015
METRONIDAZOLE ORAL CAPSULE 375 MG 3.91048 01/31/2014 3.91048 08/21/2015
METRONIDAZOLE ORAL TABLET 250 MG 0.17910 12/22/2017 0.07480 08/16/2019
METRONIDAZOLE ORAL TABLET 500 MG 0.14590 09/22/2017 0.11483 11/16/2018
METRONIDAZOLE TOPICAL CREAM (GRAM) 0.75 % 1.18465 10/07/2019 0.88756 05/22/2020
METRONIDAZOLE TOPICAL GEL (GRAM) 0.75 % 1.23346 06/16/2017 0.81000 12/21/2018
METRONIDAZOLE TOPICAL LOTION (ML) 0.75 % 2.93220 01/17/2014 2.39124 06/16/2017
METRONIDAZOLE VAGINAL GEL WITH APPLICATOR (GRAM) 0.75 % 0.72500 06/26/2019 1.04743 06/04/2020
MEXILETINE HCL ORAL CAPSULE 150 MG 0.55042 01/30/2015 0.55042 08/21/2015
MEXILETINE HCL ORAL CAPSULE 200 MG 0.70746 10/03/2014
MEXILETINE HCL ORAL CAPSULE 250 MG 0.48191 08/09/2013
MICONAZOLE NITRATE TOPICAL CREAM (GRAM) 2 % 0.05700 03/07/2014 0.05700 08/21/2015
MICONAZOLE NITRATE TOPICAL OINTMENT (GRAM) 2 % 0.08500 08/12/2014
MICONAZOLE NITRATE TOPICAL TINCTURE 2 % 0.39340 08/12/2014
MICONAZOLE NITRATE VAGINAL CREAM WITH APPLICATOR 2 % 0.09470 04/24/2015 0.09470 08/21/2015
MICONAZOLE NITRATE VAGINAL KIT 200 MG-2 % 7.83470 08/21/2015 7.64000 01/25/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
MICONAZOLE NITRATE VAGINAL SUPPOSITORY, VAGINAL 100 MG 0.44030 01/25/2013 0.44030 08/21/2015
MICONAZOLE NITRATE VAGINAL SUPPOSITORY, VAGINAL 200 MG 12.26633 01/25/2013
MIDODRINE HCL ORAL TABLET 10 MG 0.71570 08/05/2019 0.55753 02/21/2020
MIDODRINE HCL ORAL TABLET 2.5 MG 0.31350 12/04/2018 0.28820 11/15/2019
MIDODRINE HCL ORAL TABLET 5 MG 0.35870 08/16/2019 0.31930 10/25/2019
MILRINONE LACTATE INTRAVENOUS VIAL (ML) 1 MG/ML 0.29545 08/25/2017 0.27241 05/22/2020
MILRINONE LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 20MG/100ML
0.13280 08/12/2014 0.13280 08/21/2015
MILRINONE LACTATE/DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 40MG/200ML
0.16676 10/03/2014 0.16676 08/21/2015
MINERAL OIL RECTAL ENEMA (ML) 0.01182 08/21/2015
MINERAL OIL TOPICAL LOTION (ML) 0.01828 08/12/2014
MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT (GRAM) 15 %-83 %
0.81740 08/12/2014
MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT (GRAM) 15%-85%
1.90107 01/16/2015 1.90107 08/21/2015
MINERAL OIL/PETROLATUM,WHITE OPHTHALMIC OINTMENT (GRAM) 3 %-94 %
4.48140 08/21/2015
MINOCYCLINE HCL ORAL CAPSULE 100 MG 0.30445 04/17/2015 0.30445 08/21/2015
MINOCYCLINE HCL ORAL CAPSULE 50 MG 0.19068 03/03/2017 0.13650 03/15/2019
MINOCYCLINE HCL ORAL CAPSULE 75 MG 0.35403 08/12/2014
MINOCYCLINE HCL ORAL TABLET 100 MG 2.20000 05/25/2018 1.80620 11/16/2018
MINOCYCLINE HCL ORAL TABLET 50 MG 1.14200 09/22/2017 1.03750 11/15/2019
MINOCYCLINE HCL ORAL TABLET 75 MG 1.69228 01/25/2013 1.69228 08/21/2015
MINOCYCLINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 135 MG 3.56811 01/25/2013 3.56811 08/21/2015
MINOCYCLINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 45 MG 3.56811 01/25/2013 3.56811 08/21/2015
MINOCYCLINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 90 MG 3.56811 01/25/2013 3.56811 08/21/2015
MINOXIDIL ORAL TABLET 10 MG 0.20050 11/24/2017 0.12250 11/16/2018
MINOXIDIL ORAL TABLET 2.5 MG 0.01538 08/25/2017 0.04230 09/05/2019
MIRTAZAPINE ORAL TABLET 15 MG 0.08134 06/16/2017 0.06475 11/15/2019
MIRTAZAPINE ORAL TABLET 30 MG 0.13332 05/19/2017 0.07067 06/16/2017
MIRTAZAPINE ORAL TABLET 45 MG 0.11133 11/15/2019 0.07467 05/22/2020
MIRTAZAPINE ORAL TABLET 7.5 MG 0.70950 02/21/2020 0.66000 04/17/2020
MIRTAZAPINE ORAL TABLET,DISINTEGRATING 15 MG 0.58000 08/25/2017 0.47533 11/24/2017
MIRTAZAPINE ORAL TABLET,DISINTEGRATING 30 MG 0.65247 03/03/2017 0.53400 09/22/2017
MIRTAZAPINE ORAL TABLET,DISINTEGRATING 45 MG 0.92063 06/03/2019 0.76367 11/15/2019
MISOPROSTOL ORAL TABLET 100 MCG 0.42254 09/19/2014 0.42254 08/21/2015
MISOPROSTOL ORAL TABLET 200 MCG 0.77996 07/29/2016 0.69441 03/03/2017
MITOMYCIN INTRAVENOUS VIAL (EA) 40 MG 256.23975 08/21/2015 990.94800 11/05/2015
MODAFINIL ORAL TABLET 100 MG 1.82967 03/02/2018 0.49100 10/19/2018
MODAFINIL ORAL TABLET 200 MG 0.35717 11/15/2019 0.63463 11/29/2019
MOEXIPRIL HCL ORAL TABLET 15 MG 0.37580 02/08/2013 0.37580 08/21/2015
MOEXIPRIL HCL ORAL TABLET 7.5 MG 0.37580 08/12/2014 0.37580 08/21/2015
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE TABLET 15-12.5MG 0.51310 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE TABLET 15-25MG 0.37076 01/25/2013 0.37076 08/21/2015
MOEXIPRIL HCL/HYDROCHLOROTHIAZIDE TABLET 7.5-12.5MG 0.50960 01/25/2013 0.50960 08/21/2015
MOLYBDENUM (AMMONIUM MOLYBDATE) VIAL (ML) 25 MCG/ML 0.32672 01/25/2013
MOMETASONE FUROATE NASAL AEROSOL, SPRAY WITH PUMP (GRAM) 50 MCG
2.67456 08/16/2019 2.32029 02/21/2020
MOMETASONE FUROATE TOPICAL CREAM (GRAM) 0.1 % 0.49044 06/25/2019 0.18611 08/16/2019
MOMETASONE FUROATE TOPICAL OINTMENT (GRAM) 0.1 % 0.20169 11/15/2019 0.18244 03/20/2020
MOMETASONE FUROATE TOPICAL SOLUTION, NON-ORAL 0.1 % 0.22914 08/21/2015 0.30258 10/16/2019
MONTELUKAST SODIUM ORAL GRANULES IN PACKET (EA) 4 MG 2.29967 10/19/2018 1.78811 02/22/2019
MONTELUKAST SODIUM ORAL TABLET 10 MG 0.12093 03/03/2017 0.05967 06/16/2017
MONTELUKAST SODIUM ORAL TABLET,CHEWABLE 4 MG 0.12956 03/02/2018 0.10275 08/17/2018
MONTELUKAST SODIUM ORAL TABLET,CHEWABLE 5 MG 0.08100 06/21/2019 0.06795 06/19/2020
MORPHINE SULFATE INJECTION SYRINGE (ML) 10 MG/ML 1.83954 05/23/2014 1.83954 08/21/2015
MORPHINE SULFATE INJECTION SYRINGE (ML) 2 MG/ML 1.83954 04/25/2014 1.83954 08/21/2015
MORPHINE SULFATE INJECTION SYRINGE (ML) 4 MG/ML 1.83954 05/23/2014 1.83954 08/21/2015
MORPHINE SULFATE INJECTION SYRINGE (ML) 5 MG/ML 1.83954 05/23/2014
MORPHINE SULFATE INJECTION SYRINGE (ML) 8 MG/ML 1.83954 05/23/2014 1.83954 08/21/2015
MORPHINE SULFATE INJECTION VIAL (ML) 10 MG/ML 0.74480 01/25/2013
MORPHINE SULFATE INJECTION VIAL (ML) 15 MG/ML 0.69440 01/25/2013
MORPHINE SULFATE INJECTION VIAL (ML) 5 MG/ML 0.83160 01/25/2013
MORPHINE SULFATE INJECTION VIAL (ML) 8 MG/ML 0.94080 01/25/2013
MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 10 MG/ML 3.25500 01/25/2013
MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 15 MG/ML 3.25500 01/25/2013
MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 2 MG/ML 3.25500 01/25/2013
MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 4 MG/ML 3.25500 01/25/2013
MORPHINE SULFATE INTRAVENOUS CARTRIDGE (ML) 8 MG/ML 2.98200 01/25/2013
MORPHINE SULFATE INTRAVENOUS PATIENT CONTROLLED ANALGESIA SYRINGE 30 MG/30ML
0.33600 11/08/2013 0.33600 08/21/2015
MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 10 MG/ML 1.80600 12/26/2014
MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 2 MG/ML 1.80600 03/28/2014
MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 4 MG/ML 1.80600 03/28/2014
MORPHINE SULFATE INTRAVENOUS SYRINGE (ML) 8 MG/ML 1.80600 12/26/2014
MORPHINE SULFATE INTRAVENOUS VIAL (ML) 25 MG/ML 1.33770 07/26/2013
MORPHINE SULFATE INTRAVENOUS VIAL (ML) 50 MG/ML 1.03719 06/27/2014
MORPHINE SULFATE INTRAVENOUS VIAL WITH THREADED PORT (ML) 100 MG/4ML
4.96650 01/25/2013
MORPHINE SULFATE INTRAVENOUS VIAL WITH THREADED PORT (ML) 250MG/10ML
1.99080 01/25/2013
MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 10 MG
2.38833 09/22/2017 2.16080 11/24/2017
MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 100 MG
12.63000 08/21/2015 11.91976 12/02/2016
MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 20 MG
2.41414 06/16/2017 1.25730 09/22/2017
MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 30 MG
3.44336 06/16/2017 1.18850 11/15/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 50 MG
6.65266 08/21/2015 4.71535 06/16/2017
MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 60 MG
7.95944 08/21/2015 5.37753 01/27/2017
MORPHINE SULFATE ORAL CAPSULE, EXTENDED RELEASE PELLETS 80 MG
10.60675 08/21/2015 8.45051 06/16/2017
MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 120 MG
13.81709 02/21/2014
MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 30 MG
4.01072 02/21/2014
MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 45 MG
5.94685 02/21/2014
MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 60 MG
7.78841 02/21/2014
MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 75 MG
9.91130 02/21/2014
MORPHINE SULFATE ORAL CAPSULE,EXTENDED RELEASE MULTIPHASE 24HR 90 MG
11.71044 02/21/2014
MORPHINE SULFATE ORAL SOLUTION, ORAL 10 MG/5 ML 0.05473 08/21/2015 0.04420 08/17/2018
MORPHINE SULFATE ORAL SOLUTION, ORAL 100 MG/5ML 0.23910 09/30/2016 0.22056 08/16/2019
MORPHINE SULFATE ORAL SOLUTION, ORAL 20 MG/5 ML 0.08307 01/16/2015 0.08307 08/21/2015
MORPHINE SULFATE ORAL TABLET 15 MG 0.11466 04/03/2015
MORPHINE SULFATE ORAL TABLET 30 MG 0.17240 04/11/2014 0.49746 11/05/2018
MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 100 MG 0.98200 11/24/2017 1.07226 04/09/2018
MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 15 MG 0.21670 03/07/2020 0.20054 05/22/2020
MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 200 MG 2.23770 03/02/2018 1.86820 01/24/2020
MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 30 MG 0.23720 04/17/2020 0.35780 05/21/2020
MORPHINE SULFATE ORAL TABLET, EXTENDED RELEASE 60 MG 0.63607 09/22/2017 0.54275 11/16/2018
MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 10 MG 3.85880 08/12/2014
MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 20 MG 5.25000 01/25/2013
MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 30 MG 6.56250 01/25/2013
MORPHINE SULFATE RECTAL SUPPOSITORY, RECTAL 5 MG 3.50000 01/25/2013
MORPHINE SULFATE/PF INJECTION AMPUL (ML) 0.5 MG/ML 2.23713 01/25/2013
MORPHINE SULFATE/PF INJECTION AMPUL (ML) 1 MG/ML 3.80940 01/25/2013
MORPHINE SULFATE/PF INJECTION VIAL (ML) 0.5 MG/ML 0.42080 08/12/2014
MORPHINE SULFATE/PF INJECTION VIAL (ML) 1 MG/ML 0.41240 08/12/2014
MORPHINE SULFATE/PF INTRAVENOUS PATIENT CONTROLLED ANALGESIA VIAL 150MG/30ML
0.61320 01/25/2013
MORPHINE SULFATE/PF INTRAVENOUS PATIENT CONTROLLED ANALGESIA VIAL 30 MG/30ML
0.50469 01/25/2013
MOXIFLOXACIN HCL ORAL TABLET 400 MG 1.78867 03/15/2019 1.33333 11/15/2019
multivit no.49/ferrous fumarate/folic acid/levomefolate/dha CAPSULE 27-1.13 MG
1.81370 01/25/2013 1.81370 08/21/2015
multivitamin comb no.48/ferrous fumarate/folic acid/dha CAPSULE 28-1-250MG 3.34740 09/26/2014
MULTIVITAMIN COMBINATION NO.47/FERROUS FUM/FOLATE NO.1/DHA ORAL CAPSULE 27-1-300MG
1.43085 04/24/2015 0.81153 06/16/2017
multivitamin combination no.50/iron ps complex/folic acid CAPSULE 155 MG-1MG
0.20689 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
MULTIVITAMIN COMBINATION NO.51/FERROUS FUMARATE/FOLIC ACID ORAL CAPSULE 106.5-1MG
0.60753 01/23/2015 0.60753 08/21/2015
multivitamin combo no.52/iron/iron asparto gly/folic/omega-3 CAPSULE 27-1-330MG
0.98583 12/26/2014 0.98583 08/21/2015
MULTIVITAMIN ORAL TABLET 0.01441 02/20/2015 0.01441 08/21/2015
MULTIVITAMIN WITH IRON ORAL TABLET 0.01954 08/12/2014 0.01954 08/21/2015
MULTIVITAMIN WITH MINERALS NO.69/IRON,CARBONYL/FOLIC ACID ORAL TABLET 50-1.25 MG
1.05126 04/19/2013
MULTIVITAMIN WITH MINERALS NO.7/FOLIC ACID ORAL CAPSULE 1 MG 0.17550 02/15/2013
MULTIVITAMIN WITH MINERALS/FERROUS GLUCONATE ORAL LIQUID (ML) 9 MG/15 ML
0.01674 08/12/2014 0.01674 08/21/2015
MULTIVITAMIN WITH MINERALS/FOLIC ACID ORAL TABLET 0.4 MG 0.80780 08/12/2014 0.80780 08/21/2015
MULTIVITAMIN WITH MINERALS/FOLIC ACID/LYCOPENE/LUTEIN ORAL TABLET .4-300-250
0.04317 03/27/2015 0.04317 08/21/2015
MULTIVITAMIN WITH MINERALS/FOLIC ACID/LYCOPENE/LUTEIN ORAL TABLET 500-300MCG
0.05011 08/12/2014
MULTIVITAMIN WITH MINERALS/LUTEIN ORAL TABLET 0.04780 08/12/2014 0.04780 08/21/2015
MULTIVITAMIN,STRESS FORMULA/ZINC ORAL TABLET 0.04810 05/02/2014 0.04810 08/21/2015
MULTIVITAMIN,THERAPEUTIC ORAL TABLET 0.02440 08/12/2014
MULTIVITAMIN-MINERALS NO.71/IRON FUMARAT/FOLIC ACID NO.1/DHA ORAL CAPSULE 28-1-300MG
1.28123 10/10/2014
MULTIVITS WITH CALCIUM AND MINERALS/IRON FUMARATE/FOLIC ACID ORAL TABLET 9MG-400MCG
0.03495 08/12/2014
MUPIROCIN CALCIUM TOPICAL CREAM (GRAM) 2 % 2.58284 02/06/2015 2.58284 08/21/2015
MUPIROCIN TOPICAL OINTMENT (GRAM) 2 % 0.20477 11/24/2017 0.17500 12/21/2018
MV-MIN 75/FERROUS FUM/IRON PS CPLX/FOLIC AC/OMEGA-3/DHA/EPA ORAL CAPSULE 35-1-200MG
0.74013 04/10/2015
MV-MINS NO.74/FERROUS FUMARATE/IRON PS CPLX/FOLIC ACID ORAL CAPSULE 85 MG-1 MG
1.15359 01/25/2013
MYCOPHENOLATE MOFETIL ORAL CAPSULE 250 MG 0.19250 11/24/2017 0.12520 01/19/2018
MYCOPHENOLATE MOFETIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 MG/ML
4.24000 07/26/2019 5.06388 03/31/2020
MYCOPHENOLATE MOFETIL ORAL TABLET 500 MG 0.20142 03/03/2017 0.16100 06/21/2019
MYCOPHENOLATE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 180 MG
1.39966 03/03/2017 0.82950 11/16/2018
MYCOPHENOLATE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 360 MG
2.89000 03/15/2019 2.80967 09/20/2019
NABUMETONE ORAL TABLET 500 MG 0.14920 08/01/2018 0.12800 05/22/2020
NABUMETONE ORAL TABLET 750 MG 0.20923 05/19/2017 0.15891 09/22/2017
NADOLOL ORAL TABLET 20 MG 1.25218 01/08/2018 0.29000 11/15/2019
NADOLOL ORAL TABLET 40 MG 0.80040 01/01/2018 0.44895 06/19/2020
NADOLOL ORAL TABLET 80 MG 3.31195 12/02/2016 3.31195 01/01/2018
NADOLOL/BENDROFLUMETHIAZIDE ORAL TABLET 40 MG-5 MG 1.72368 01/25/2013
NADOLOL/BENDROFLUMETHIAZIDE ORAL TABLET 80 MG-5 MG 2.25914 01/25/2013
NAFCILLIN IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML
0.25511 01/25/2013
NAFCILLIN IN DEXTROSE, ISO-OSMOTIC INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2 G/100 ML
0.53762 07/25/2014
NAFCILLIN SODIUM INJECTION VIAL (EA) 1 G 11.78070 01/16/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
NAFCILLIN SODIUM INJECTION VIAL (EA) 10 G 69.68850 03/06/2015
NAFCILLIN SODIUM INJECTION VIAL (EA) 2 G 11.96470 03/06/2015 11.96470 08/21/2015
NAFCILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 G 12.56750 08/12/2014
NAFCILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2 G 26.14500 03/29/2013
NALBUPHINE HCL INJECTION AMPUL (ML) 20 MG/ML 3.45670 01/25/2013
NALBUPHINE HCL INJECTION VIAL (ML) 10 MG/ML 1.19280 01/25/2013 1.19280 08/21/2015
NALBUPHINE HCL INJECTION VIAL (ML) 20 MG/ML 1.70020 08/12/2014
NALOXONE HCL INJECTION SYRINGE (ML) 0.4 MG/ML 3.15000 01/25/2013
NALOXONE HCL INJECTION SYRINGE (ML) 1 MG/ML 7.11900 11/15/2013 7.11900 08/21/2015
NALTREXONE HCL ORAL TABLET 50 MG 0.71722 10/25/2019 0.66875 11/15/2019
NAPHAZOLINE HCL DROPS 0.1 % 0.11787 01/25/2013 0.11787 08/21/2015
NAPHAZOLINE HCL/GLYCERIN OPHTHALMIC DROPS 0.012-0.25 0.13090 04/03/2015
NAPROXEN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 125 MG/5ML 0.81200 05/04/2018 0.85722 08/24/2018
NAPROXEN ORAL TABLET 250 MG 0.04181 08/12/2014 0.04181 08/21/2015
NAPROXEN ORAL TABLET 375 MG 0.05065 11/21/2014 0.05065 08/21/2015
NAPROXEN ORAL TABLET 500 MG 0.06330 08/21/2015 0.04180 10/20/2017
NAPROXEN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 375 MG
0.12990 12/22/2017 0.11150 11/15/2019
NAPROXEN ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 500 MG
0.17979 08/21/2015 0.13450 03/15/2019
NAPROXEN SODIUM ORAL TABLET 220 MG 0.04739 04/03/2015 0.04739 08/21/2015
NAPROXEN SODIUM ORAL TABLET 275 MG 1.20510 08/01/2018 0.99950 11/16/2018
NAPROXEN SODIUM ORAL TABLET 550 MG 0.46647 11/15/2019 0.32180 05/22/2020
NARATRIPTAN HCL ORAL TABLET 1 MG 4.82300 09/30/2016 3.92785 06/16/2017
NARATRIPTAN HCL ORAL TABLET 2.5 MG 1.10278 11/15/2019 2.12614 05/07/2020
NATEGLINIDE ORAL TABLET 120 MG 0.36656 08/16/2019 0.14756 02/21/2020
NATEGLINIDE ORAL TABLET 60 MG 0.28945 08/16/2019 0.26967 05/22/2020
NEFAZODONE HCL ORAL TABLET 100 MG 1.09937 10/03/2014 1.09937 08/21/2015
NEFAZODONE HCL ORAL TABLET 150 MG 1.18018 02/13/2015 1.18018 08/21/2015
NEFAZODONE HCL ORAL TABLET 200 MG 1.18438 10/17/2014 1.18438 08/21/2015
NEFAZODONE HCL ORAL TABLET 250 MG 0.66582 08/23/2013
NEFAZODONE HCL ORAL TABLET 50 MG 0.56680 08/12/2014
NEOMYCIN SULF/BACITRACIN ZINC/POLYMYXIN B SULF/PRAMOXINE HCL TOPICAL OINTMENT (GRAM) 3.5-10K-10
0.16974 08/21/2015 0.07183 08/17/2018
NEOMYCIN SULFATE ORAL TABLET 500 MG 0.50000 11/24/2017 0.61422 08/18/2018
NEOMYCIN SULFATE/BACITRACIN ZINC/POLYMYXIN B TOPICAL OINTMENT (GRAM) 3.5-400-5K
0.08442 02/13/2015 0.08442 08/21/2015
NEOMYCIN SULFATE/BACITRACIN ZINC/POLYMYXIN B/HYDROCORTISONE OPHTHALMIC OINTMENT (GRAM) 3.5-10K-1
12.81263 08/21/2015 12.16571 03/02/2018
NEOMYCIN SULFATE/BACITRACIN/POLYMYXIN B OPHTHALMIC OINTMENT (GRAM) 3.5MG-400
8.09100 08/21/2015 3.90000 02/22/2019
NEOMYCIN SULFATE/POLYMYXIN B SULFATE IRRIGATION AMPUL (ML) 40-200K/ML
7.53960 04/12/2013
NEOMYCIN SULFATE/POLYMYXIN B SULFATE IRRIGATION VIAL (ML) 40-200K/ML
5.02645 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
NEOMYCIN SULFATE/POLYMYXIN B SULFATE/GRAMICIDIN D OPHTHALMIC DROPS 1.75MG-10K
4.33580 05/24/2013 4.33580 08/21/2015
NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE OPHTHALMIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 3.5-10K-10
13.05287 03/08/2013
NEOMYCIN SULFATE/POLYMYXIN B SULFATE/HYDROCORTISONE OTIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 3.5-10K-1
2.05680 08/21/2015 7.04760 09/22/2015
NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE OPHTHALMIC OINTMENT (GRAM) 3.5-10K-.1
2.52857 08/16/2019 1.53143 09/20/2019
NEOMYCIN/POLYMYXIN B SULFATE/DEXAMETHASONE OPHTHALMIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 0.1 %
2.83000 03/03/2017 2.60900 06/22/2018
NEVIRAPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 50 MG/5 ML 0.40225 01/25/2013
NEVIRAPINE ORAL TABLET 200 MG 0.19200 08/21/2015 0.10617 09/22/2017
NEVIRAPINE ORAL TABLET, EXTENDED RELEASE 24 HR 400 MG 15.82373 08/21/2015 3.59633 11/24/2017
NIACIN (INOSITOL NIACINATE) ORAL TABLET 500 MG 0.02737 08/21/2015
NIACIN ORAL CAPSULE, EXTENDED RELEASE 250 MG 0.04147 02/01/2013
NIACIN ORAL CAPSULE, EXTENDED RELEASE 500 MG 0.04930 08/12/2014
NIACIN ORAL TABLET 100 MG 0.01270 08/12/2014 0.01270 08/21/2015
NIACIN ORAL TABLET 50 MG 0.01274 01/25/2013
NIACIN ORAL TABLET 500 MG 0.02000 08/12/2014 0.02000 08/21/2015
NIACIN ORAL TABLET, EXTENDED RELEASE 1000 MG 0.05775 01/25/2013
NIACIN ORAL TABLET, EXTENDED RELEASE 24 HR 1000 MG 1.24189 10/20/2017 0.81100 11/15/2019
NIACIN ORAL TABLET, EXTENDED RELEASE 24 HR 500 MG 0.33656 07/26/2019 0.08178 11/15/2019
NIACIN ORAL TABLET, EXTENDED RELEASE 250 MG 0.03662 02/08/2013
NIACIN ORAL TABLET, EXTENDED RELEASE 500 MG 0.03081 08/12/2014 0.03081 08/21/2015
NIACIN ORAL TABLET, EXTENDED RELEASE 750 MG 0.05020 08/12/2014
NIACINAMIDE ORAL TABLET 500 MG 0.02737 04/05/2013
NICARDIPINE HCL ORAL CAPSULE 20 MG 0.34500 02/08/2013
NICARDIPINE HCL ORAL CAPSULE 30 MG 0.35170 08/12/2014
NICOTINE POLACRILEX BUCCAL GUM 2 MG 0.17264 11/16/2018 0.20629 04/02/2019
NICOTINE POLACRILEX BUCCAL GUM 4 MG 0.14927 01/19/2018 0.21527 05/15/2019
NICOTINE POLACRILEX BUCCAL LOZENGE 2 MG 0.36791 08/21/2015
NICOTINE POLACRILEX BUCCAL LOZENGE 4 MG 0.33277 05/26/2017 0.29250 08/16/2019
NICOTINE POLACRILEX BUCCAL MINI LOZENGE 4 MG 0.38277 05/26/2017
NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 14MG/24HR 1.24071 08/16/2019 1.16303 02/21/2020
NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 21 MG/24HR
1.36143 11/16/2018 1.30714 02/22/2019
NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 7MG/24HR 1.46910 06/21/2019 1.29714 11/15/2019
NIFEDIPINE MISCELLANEOUS POWDER (GRAM) 2.02800 08/21/2015
NIFEDIPINE ORAL CAPSULE 10 MG 0.43570 11/24/2017 0.40990 02/22/2019
NIFEDIPINE ORAL CAPSULE 20 MG 1.61182 08/21/2015 1.31822 06/16/2017
NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 30 MG 0.16274 08/17/2018 0.10000 12/20/2019
NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 60 MG 0.23630 12/22/2017 0.20292 08/17/2018
NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 90 MG 0.34796 03/19/2019 0.28610 10/25/2019
NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 30 MG 0.13326 08/25/2017 0.11185 11/16/2018
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 60 MG 0.30939 02/22/2019 0.16950 05/17/2019
NIFEDIPINE ORAL TABLET, EXTENDED RELEASE 90 MG 0.39300 05/17/2019 0.20555 08/16/2019
NIMODIPINE ORAL CAPSULE 30 MG 13.27890 08/21/2015 2.09000 05/17/2019
NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 17 MG 4.66057 04/22/2016 3.86000 05/20/2016
NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 20 MG 10.97514 03/13/2015
NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 25.5 MG 5.87636 01/25/2013
NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 30 MG 7.05270 02/08/2013
NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 34 MG 5.87636 01/25/2013
NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 40 MG 6.65350 01/25/2013
NISOLDIPINE ORAL TABLET, EXTENDED RELEASE 24 HR 8.5MG 3.94911 12/02/2016 3.89950 11/16/2018
NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE 100 MG 0.91780 07/14/2017 0.74480 03/02/2018
NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE 50 MG 0.47000 10/25/2019 0.39193 02/21/2020
NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS ORAL CAPSULE 100 MG
0.52928 04/17/2020 0.46800 05/22/2020
NITROFURANTOIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 25 MG/5 ML
1.31539 03/02/2018 9.40983 04/23/2019
NITROGLYCERIN IN 5 % DEXTROSE IN WATER INTRAVENOUS INFUSION BOTTLE (ML) 200MG/500
0.01110 08/12/2014
NITROGLYCERIN IN 5 % DEXTROSE IN WATER INTRAVENOUS INFUSION BOTTLE (ML) 50MG/500ML
0.02260 08/12/2014
NITROGLYCERIN INTRAVENOUS VIAL (ML) 50 MG/10ML 0.47040 01/25/2013
NITROGLYCERIN ORAL CAPSULE, EXTENDED RELEASE 2.5 MG 0.33267 05/17/2013 0.33267 08/21/2015
NITROGLYCERIN ORAL CAPSULE, EXTENDED RELEASE 6.5 MG 0.32960 02/15/2013 0.32960 08/21/2015
NITROGLYCERIN ORAL CAPSULE, EXTENDED RELEASE 9 MG 0.17330 08/12/2014 0.17330 08/21/2015
NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.1MG/HR
0.69594 08/21/2015 0.52033 08/16/2019
NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.2MG/HR
0.43967 03/03/2017 0.35275 11/24/2017
NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.4MG/HR
0.43334 09/30/2016 0.39678 02/22/2019
NITROGLYCERIN TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 0.6MG/HR
0.97601 08/21/2015 0.54533 10/20/2017
NITROGLYCERIN TRANSLINGUAL AEROSOL, SPRAY (GRAM) 400MCG/SPR
27.46701 01/25/2013
NITROGLYCERIN TRANSLINGUAL SPRAY, NON-AEROSOL (GRAM) 400MCG/SPR
31.99165 01/05/2018 23.27500 01/25/2019
NIZATIDINE ORAL CAPSULE 150 MG 0.26336 08/21/2015 0.18833 08/25/2017
NIZATIDINE ORAL CAPSULE 300 MG 0.56236 08/21/2015 0.36667 11/16/2018
NIZATIDINE ORAL SOLUTION, ORAL 150MG/10ML 0.49300 08/21/2015 1.00143 10/26/2019
NORETHINDRONE ACETATE ORAL TABLET 5 MG 0.65960 06/21/2019 0.99460 08/08/2019
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 0.5MG-2.5
2.00956 04/27/2018
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1.5-0.03MG
0.57873 09/22/2017 0.42460 05/22/2020
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1MG-20MCG
0.20508 01/24/2020 0.13889 05/22/2020
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL ORAL TABLET 1MG-5MCG
1.65878 04/03/2019 1.33988 05/17/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE ORAL TABLET 1.5-30(21)
0.16679 11/15/2019 0.15557 05/22/2020
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE ORAL TABLET 1MG-20(21)
0.19802 02/22/2019 0.14387 06/21/2019
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE ORAL TABLET 1MG-20(24)
1.05273 11/24/2017 0.73809 01/25/2019
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE ORAL TABLET 5-7-9-7
1.42880 08/21/2015 0.91503 06/16/2017
NORETHINDRONE ACETATE-ETHINYL ESTRADIOL/FERROUS FUMARATE ORAL TABLET,CHEWABLE 1MG-20(24)
1.88500 04/17/2020
NORETHINDRONE ORAL TABLET 0.35 MG 0.10917 03/16/2018 0.07500 11/15/2019
NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 0.4-0.035 0.39583 06/16/2017 0.24429 02/21/2020
NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 0.5-0.035 0.70263 02/26/2016 0.66000 04/27/2018
NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 1 MG-35MCG 0.60029 03/25/2016 0.28925 06/16/2017
NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 7 DAYS X 3 0.37448 06/16/2017 0.15179 11/15/2019
NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 7-9-5 0.98375 01/25/2013 0.59237 06/16/2017
NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE ORAL TABLET,CHEWABLE 0.4-35(21)
1.86241 08/21/2015 1.46607 10/20/2017
NORETHINDRONE-ETHINYL ESTRADIOL/FERROUS FUMARATE ORAL TABLET,CHEWABLE 0.8-25(24)
1.60596 04/27/2018
NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 0.25-0.035 0.21536 11/16/2018 0.12787 03/15/2019
NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 7DAYSX3 28 0.19123 11/16/2018 0.10250 03/15/2019
NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 7DAYSX3 LO 0.17845 01/24/2020 0.15456 06/19/2020
NORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.3-0.03MG 0.41253 10/20/2017 0.26161 11/16/2018
NORTRIPTYLINE HCL ORAL CAPSULE 10 MG 0.07000 08/25/2017 0.05556 10/25/2019
NORTRIPTYLINE HCL ORAL CAPSULE 25 MG 0.06686 11/16/2018 0.05334 11/15/2019
NORTRIPTYLINE HCL ORAL CAPSULE 50 MG 0.11622 06/16/2017 0.07750 05/22/2020
NORTRIPTYLINE HCL ORAL CAPSULE 75 MG 0.15800 08/25/2017 0.12989 09/22/2017
NORTRIPTYLINE HCL ORAL SOLUTION, ORAL 10 MG/5 ML 0.26055 02/27/2015 0.26055 08/21/2015
NYSTATIN MISCELLANEOUS POWDER (EA) 10B UNIT 17265.36000 01/25/2013
NYSTATIN MISCELLANEOUS POWDER (EA) 150MM UNIT 98.76650 01/25/2013
NYSTATIN MISCELLANEOUS POWDER (EA) 1B UNIT 404.56500 01/25/2013
NYSTATIN MISCELLANEOUS POWDER (EA) 2B UNIT 459.38450 01/25/2013
NYSTATIN MISCELLANEOUS POWDER (EA) 500MM UNIT 156.49700 01/25/2013 156.49700 08/21/2015
NYSTATIN MISCELLANEOUS POWDER (EA) 50MM UNIT 47.31300 01/25/2013 47.31300 08/21/2015
NYSTATIN MISCELLANEOUS POWDER (EA) 5B UNIT 742.07950 01/25/2013
NYSTATIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100000/ML 0.06036 06/16/2017 0.04816 08/17/2018
NYSTATIN ORAL TABLET 500K UNIT 0.40617 05/19/2017 0.34870 08/17/2018
NYSTATIN TOPICAL CREAM (GRAM) 100000/G 0.17875 11/15/2019 0.16033 01/24/2020
NYSTATIN TOPICAL OINTMENT (GRAM) 100000/G 0.32875 11/16/2018 0.28593 06/21/2019
NYSTATIN TOPICAL POWDER (GRAM) 100000/G 0.29656 07/26/2019 0.26384 11/15/2019
NYSTATIN/TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 100000-0.1
0.95666 04/26/2019 0.38408 02/21/2020
NYSTATIN/TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 100000-0.1
0.55533 02/22/2019 0.18333 09/20/2019
OCTREOTIDE ACETATE INJECTION AMPUL (ML) 100 MCG/ML 4.02220 03/07/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
OCTREOTIDE ACETATE INJECTION AMPUL (ML) 50 MCG/ML 2.84310 01/25/2013
OCTREOTIDE ACETATE INJECTION AMPUL (ML) 500 MCG/ML 21.50330 12/26/2014
OCTREOTIDE ACETATE INJECTION SYRINGE (ML) 100 MCG/ML 15.96000 03/21/2014
OCTREOTIDE ACETATE INJECTION SYRINGE (ML) 50 MCG/ML 5.98920 01/25/2013
OCTREOTIDE ACETATE INJECTION SYRINGE (ML) 500 MCG/ML 45.22560 01/25/2013
OCTREOTIDE ACETATE INJECTION VIAL (ML) 100 MCG/ML 5.15580 05/01/2015 5.15580 08/21/2015
OCTREOTIDE ACETATE INJECTION VIAL (ML) 1000MCG/ML 34.03343 02/27/2015 34.03343 08/21/2015
OCTREOTIDE ACETATE INJECTION VIAL (ML) 200 MCG/ML 8.03760 08/12/2014 8.03760 08/21/2015
OCTREOTIDE ACETATE INJECTION VIAL (ML) 50 MCG/ML 2.83010 09/05/2014 2.83010 08/21/2015
OCTREOTIDE ACETATE INJECTION VIAL (ML) 500 MCG/ML 20.95800 05/01/2015 20.95800 08/21/2015
OFLOXACIN OPHTHALMIC DROPS 0.3 % 2.10000 02/22/2019 1.83240 11/15/2019
OFLOXACIN OTIC DROPS 0.3 % 14.24520 06/04/2015 2.52000 05/22/2020
OLANZAPINE INTRAMUSCULAR VIAL (EA) 10 MG 29.05000 02/01/2013
OLANZAPINE ORAL TABLET 10 MG 0.13334 11/16/2018 0.10867 04/17/2020
OLANZAPINE ORAL TABLET 15 MG 0.15220 09/22/2017 0.11167 04/17/2020
OLANZAPINE ORAL TABLET 2.5 MG 0.10093 08/25/2017 0.07267 03/02/2018
OLANZAPINE ORAL TABLET 20 MG 0.16876 11/15/2019 0.10000 01/24/2020
OLANZAPINE ORAL TABLET 5 MG 0.09611 08/25/2017 0.07497 08/16/2019
OLANZAPINE ORAL TABLET 7.5 MG 0.10995 05/17/2019 0.08533 08/16/2019
OLANZAPINE ORAL TABLET,DISINTEGRATING 10 MG 0.35333 11/16/2018 0.76425 03/19/2020
OLANZAPINE ORAL TABLET,DISINTEGRATING 15 MG 0.57400 05/17/2019 0.55533 05/22/2020
OLANZAPINE ORAL TABLET,DISINTEGRATING 20 MG 3.18610 08/21/2015 0.61067 11/24/2017
OLANZAPINE ORAL TABLET,DISINTEGRATING 5 MG 0.72000 03/04/2019 0.18167 03/20/2020
OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 12MG-25MG 15.27470 08/15/2014
OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 12MG-50MG 15.27773 08/12/2014
OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 3 MG-25 MG 7.51917 11/14/2014 7.51917 08/21/2015
OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 6MG-25MG 10.13740 08/01/2014 10.13740 08/21/2015
OLANZAPINE/FLUOXETINE HCL ORAL CAPSULE 6MG-50MG 10.13740 08/01/2014 7.04000 01/25/2019
OLMESARTAN MEDOXOMIL ORAL TABLET 20 MG 0.10100 04/27/2018 0.08956 06/19/2020
OLMESARTAN MEDOXOMIL ORAL TABLET 40 MG 0.16863 04/27/2018
OLMESARTAN MEDOXOMIL ORAL TABLET 5 MG 0.08550 11/16/2018 0.05067 07/26/2019
OLMESARTAN MEDOXOMIL/AMLODIPINE BESYLATE/HYDROCHLOROTHIAZIDE ORAL TABLET 20-5-12.5
1.37855 11/15/2019 1.37855 01/01/2020
OLMESARTAN MEDOXOMIL/AMLODIPINE BESYLATE/HYDROCHLOROTHIAZIDE ORAL TABLET 40-10-12.5
1.82389 11/15/2019 1.82389 01/01/2020
OLMESARTAN MEDOXOMIL/AMLODIPINE BESYLATE/HYDROCHLOROTHIAZIDE ORAL TABLET 40-10-25MG
1.61800 11/16/2018 1.61800 01/01/2020
OLMESARTAN MEDOXOMIL/AMLODIPINE BESYLATE/HYDROCHLOROTHIAZIDE ORAL TABLET 40-5-12.5
1.00133 05/17/2019 1.00133 01/01/2020
OLMESARTAN MEDOXOMIL/AMLODIPINE BESYLATE/HYDROCHLOROTHIAZIDE ORAL TABLET 40-5-25 MG
1.71000 11/16/2018 1.71000 01/01/2020
OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG
0.13000 08/17/2018 0.08333 03/15/2019
OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE ORAL TABLET 40 MG-25MG
0.20000 04/27/2018 0.17600 02/22/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
OLMESARTAN MEDOXOMIL/HYDROCHLOROTHIAZIDE ORAL TABLET 40-12.5 MG
0.12000 04/27/2018
OLOPATADINE HCL NASAL AEROSOL, SPRAY WITH PUMP (GRAM) 0.6 % 2.15000 06/21/2019 2.35611 06/24/2019
OLOPATADINE HCL OPHTHALMIC DROPS 0.1 % 2.57629 11/15/2019 2.39000 05/22/2020
OMEGA-3 ACID ETHYL ESTERS ORAL CAPSULE 1 G 0.21378 01/01/2019 0.18871 05/22/2020
OMEGA-3 FATTY ACIDS/DOCOSAHEXAENOIC ACID/EPA/FISH OIL ORAL CAPSULE 1000 MG
0.05283 08/12/2014
OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 10 MG
0.11633 08/25/2017 0.02056 08/17/2018
OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 20 MG
0.08682 08/21/2015 0.03862 07/14/2017
OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 40 MG
0.05675 04/26/2019 0.04480 01/24/2020
OMEPRAZOLE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 20 MG
0.47857 08/25/2017 0.19321 02/21/2020
OMEPRAZOLE/SODIUM BICARBONATE ORAL CAPSULE 20MG-1.1G 6.58183 09/22/2017 1.95000 10/25/2019
OMEPRAZOLE/SODIUM BICARBONATE ORAL CAPSULE 40MG-1.1G 1.85000 10/25/2019 1.28050 11/15/2019
ONDANSETRON HCL INTRAVENOUS VIAL (ML) 2 MG/ML 0.07865 01/16/2015 0.07865 08/21/2015
ONDANSETRON HCL ORAL SOLUTION, ORAL 4 MG/5 ML 0.25940 07/26/2019 0.23744 11/15/2019
ONDANSETRON HCL ORAL TABLET 4 MG 0.07664 11/16/2018 0.05643 05/22/2020
ONDANSETRON HCL ORAL TABLET 8 MG 0.12277 11/16/2018 0.09415 05/22/2020
ONDANSETRON HCL/PF INJECTION AMPUL (ML) 4 MG/2 ML 8.31950 01/25/2013
ONDANSETRON HCL/PF INJECTION SYRINGE (ML) 4 MG/2 ML 0.93551 05/01/2015 0.93551 08/21/2015
ONDANSETRON HCL/PF INJECTION VIAL (ML) 4 MG/2 ML 0.25000 11/16/2018 0.14720 03/20/2020
ONDANSETRON ORAL TABLET,DISINTEGRATING 4 MG 0.24667 10/19/2018 0.22616 11/15/2019
ONDANSETRON ORAL TABLET,DISINTEGRATING 8 MG 0.24400 07/26/2019 0.22773 11/15/2019
OPIUM TINCTURE ORAL TINCTURE 10 MG/ML 3.65310 08/02/2013 2.38890 03/02/2018
OPIUM/BELLADONNA ALKALOIDS RECTAL SUPPOSITORY, RECTAL 30-16.2 MG
19.61500 07/18/2014
OPIUM/BELLADONNA ALKALOIDS RECTAL SUPPOSITORY, RECTAL 60-16.2 MG
23.41675 10/24/2014
ORPHENADRINE CITRATE ORAL TABLET, EXTENDED RELEASE 100 MG 0.18230 09/22/2017 0.14850 11/16/2018
OSELTAMIVIR PHOSPHATE ORAL CAPSULE 30 MG 5.33000 01/25/2019
OSELTAMIVIR PHOSPHATE ORAL CAPSULE 45 MG 5.55000 01/25/2019
OSELTAMIVIR PHOSPHATE ORAL CAPSULE 75 MG 2.92000 03/20/2020 1.84057 05/22/2020
OSELTAMIVIR PHOSPHATE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 6 MG/ML
1.02317 11/15/2019 0.63350 05/22/2020
OXACILLIN SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1 G/50 ML
0.25790 01/25/2013
OXACILLIN SODIUM IN ISO-OSMOTIC DEXTROSE INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2 G/50 ML
0.23003 09/26/2014
OXACILLIN SODIUM INJECTION VIAL (EA) 1 G 8.82240 08/22/2014 8.82240 08/21/2015
OXACILLIN SODIUM INJECTION VIAL (EA) 10 G 86.55715 08/22/2014
OXACILLIN SODIUM INJECTION VIAL (EA) 2 G 15.23550 08/22/2014 15.23550 08/21/2015
OXACILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 1 G 0.86301 01/25/2013
OXACILLIN SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2 G 2.23201 01/25/2013
OXANDROLONE ORAL TABLET 10 MG 9.27840 01/25/2013 9.27840 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
OXANDROLONE ORAL TABLET 2.5 MG 3.00096 08/12/2014 3.00096 08/21/2015
OXAPROZIN ORAL TABLET 600 MG 0.89000 10/19/2018 0.76500 03/20/2020
OXAZEPAM ORAL CAPSULE 10 MG 0.56183 01/13/2017 0.51416 01/27/2017
OXAZEPAM ORAL CAPSULE 15 MG 0.77475 12/02/2016 0.74047 04/21/2017
OXAZEPAM ORAL CAPSULE 30 MG 1.11314 04/24/2015
OXCARBAZEPINE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 300 MG/5ML
0.25400 12/21/2018 0.31168 01/07/2019
OXCARBAZEPINE ORAL TABLET 150 MG 0.09147 08/17/2018 0.07880 07/26/2019
OXCARBAZEPINE ORAL TABLET 300 MG 0.14390 11/16/2018 0.12910 07/26/2019
OXCARBAZEPINE ORAL TABLET 600 MG 0.30876 05/19/2017 0.27511 08/25/2017
OXYBUTYNIN CHLORIDE ORAL SYRUP 5 MG/5 ML 0.02124 05/17/2013 0.02124 08/21/2015
OXYBUTYNIN CHLORIDE ORAL TABLET 5 MG 0.11303 06/21/2019 0.07000 05/22/2020
OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 10 MG
0.22747 11/15/2019 0.21537 05/22/2020
OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 15 MG
0.28120 05/17/2019 0.20670 05/22/2020
OXYBUTYNIN CHLORIDE ORAL TABLET, EXTENDED RELEASE 24 HR 5 MG
0.31306 11/15/2019 0.18040 01/24/2020
OXYCODONE HCL ORAL CAPSULE 5 MG 1.29200 08/21/2015 0.41790 06/16/2017
OXYCODONE HCL ORAL CONCENTRATE, ORAL 20 MG/ML 3.73320 09/30/2016 2.80000 05/25/2018
OXYCODONE HCL ORAL SOLUTION, ORAL 5 MG/5 ML 0.15271 09/20/2019 0.09998 11/15/2019
OXYCODONE HCL ORAL TABLET 10 MG 0.15800 07/14/2017 0.13000 03/02/2018
OXYCODONE HCL ORAL TABLET 15 MG 0.14173 03/03/2017 0.11260 03/02/2018
OXYCODONE HCL ORAL TABLET 20 MG 0.24678 01/27/2017 0.19825 08/25/2017
OXYCODONE HCL ORAL TABLET 30 MG 0.25736 03/15/2019 0.19490 03/20/2020
OXYCODONE HCL ORAL TABLET 5 MG 0.09012 03/03/2017 0.07130 08/25/2017
OXYCODONE HCL ORAL TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 40 MG
5.78530 03/03/2017 5.78530 03/04/2017
OXYCODONE HCL ORAL TABLET,ORAL ONLY,EXTENDED RELEASE 12 HR 80 MG
9.41957 03/03/2017 9.41957 03/04/2017
OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 10MG-325MG 0.27202 07/17/2019 0.25078 08/16/2019
OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 2.5-325 MG 1.43437 05/01/2015 1.24120 11/24/2017
OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 5 MG-325MG 0.09991 03/03/2017 0.06530 09/21/2018
OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 7.5-325 MG 0.22515 05/17/2019 0.16020 11/15/2019
OXYCODONE HCL/ASPIRIN ORAL TABLET 4.8355-325 0.40759 11/07/2014 0.40759 08/21/2015
OXYMORPHONE HCL ORAL TABLET 10 MG 2.46947 07/14/2017 1.92770 11/24/2017
OXYMORPHONE HCL ORAL TABLET 5 MG 1.64692 08/21/2015 1.36790 11/24/2017
OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 10 MG 2.43642 08/21/2015 2.81100 01/29/2018
OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 15 MG 3.54294 04/03/2015
OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 20 MG 5.11420 07/10/2017 5.38900 05/17/2018
OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 30 MG 6.21979 08/21/2015 6.32123 07/13/2017
OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 40 MG 8.11845 05/16/2014 8.11845 08/21/2015
OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 5 MG 1.26886 05/16/2014 1.26886 08/21/2015
OXYMORPHONE HCL ORAL TABLET, EXTENDED RELEASE 12 HR 7.5 MG 1.91827 05/16/2014
PALIPERIDONE ORAL TABLET, EXTENDED RELEASE 24 HR 6 MG 17.55344 01/03/2017 8.99000 06/21/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
PALIPERIDONE ORAL TABLET, EXTENDED RELEASE 24 HR 9 MG 13.28867 12/27/2019 12.64833 02/21/2020
PAMIDRONATE DISODIUM INTRAVENOUS VIAL (EA) 30 MG 10.37300 02/27/2015 10.37300 08/21/2015
PAMIDRONATE DISODIUM INTRAVENOUS VIAL (EA) 90 MG 26.85500 02/27/2015 26.85500 08/21/2015
PAMIDRONATE DISODIUM INTRAVENOUS VIAL (ML) 30MG/10ML 1.47400 08/12/2014 1.47400 08/21/2015
PAMIDRONATE DISODIUM INTRAVENOUS VIAL (ML) 60 MG/10ML 4.62000 01/25/2013
PAMIDRONATE DISODIUM INTRAVENOUS VIAL (ML) 90 MG/10ML 4.54740 08/08/2014 4.54740 08/21/2015
PANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 20 MG
0.05756 12/22/2017 0.04411 01/19/2018
PANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 40 MG
0.11779 08/21/2015 0.05189 06/16/2017
PAREGORIC LIQUID (ML) 2 MG/5 ML 0.46388 04/26/2013
PARICALCITOL INJECTION VIAL (ML) 2 MCG/ML 3.52800 03/27/2015
PARICALCITOL INJECTION VIAL (ML) 5 MCG/ML 8.82000 01/30/2015
PARICALCITOL ORAL CAPSULE 1 MCG 2.80000 05/25/2018 0.94067 08/17/2018
PARICALCITOL ORAL CAPSULE 2 MCG 15.52623 07/04/2014 8.23334 03/03/2017
PARICALCITOL ORAL CAPSULE 4 MCG 31.05270 07/04/2014
PAROMOMYCIN SULFATE ORAL CAPSULE 250 MG 2.95152 06/14/2013
PAROXETINE HCL ORAL TABLET 10 MG 0.05431 12/22/2017 0.04078 11/16/2018
PAROXETINE HCL ORAL TABLET 20 MG 0.05879 07/14/2017 0.04100 09/22/2017
PAROXETINE HCL ORAL TABLET 30 MG 0.14156 08/21/2015 0.08967 09/22/2017
PAROXETINE HCL ORAL TABLET 40 MG 0.17420 08/21/2015 0.07622 07/14/2017
PAROXETINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 25 MG 1.44307 05/17/2019 1.27800 03/20/2020
PEANUT OIL MISCELLANEOUS OIL (ML) 0.09990 08/12/2014 0.09990 08/21/2015
PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM CHLORIDE ORAL SOLUTION, RECONSTITUTED, ORAL 236-22.74G
0.00288 12/05/2014
PEG 3350/SOD SULF/SOD BICARB/SOD CHLORIDE/POTASSIUM CHLORIDE ORAL SOLUTION, RECONSTITUTED, ORAL 240-22.72G
0.00219 08/22/2014 0.00219 08/21/2015
PENICILLIN G POTASSIUM INJECTION VIAL (EA) 20MM UNIT 24.80100 08/12/2014
PENICILLIN G POTASSIUM INJECTION VIAL (EA) 5MM UNIT 26.68167 04/17/2015 26.68167 08/21/2015
PENICILLIN G POTASSIUM/DEXTROSE-WATER INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1MM/50ML
0.19490 01/25/2013
PENICILLIN G POTASSIUM/DEXTROSE-WATER INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 2MM/50ML
0.21880 01/25/2013
PENICILLIN G POTASSIUM/DEXTROSE-WATER INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 3MM/50ML
0.13440 01/25/2013
PENICILLIN G PROCAINE INTRAMUSCULAR SYRINGE (ML) 1.2MM/2 ML 11.84540 01/25/2013 11.84540 08/21/2015
PENICILLIN G PROCAINE INTRAMUSCULAR SYRINGE (ML) 600000/ML 13.05360 01/25/2013
PENICILLIN G SODIUM INJECTION VIAL (EA) 5MM UNIT 40.12055 08/09/2013
PENICILLIN V POTASSIUM ORAL SOLUTION, RECONSTITUTED, ORAL 125 MG/5ML
0.02349 04/05/2013
PENICILLIN V POTASSIUM ORAL SOLUTION, RECONSTITUTED, ORAL 250 MG/5ML
0.05111 04/03/2015
PENICILLIN V POTASSIUM ORAL TABLET 250 MG 0.17072 08/21/2015 0.07000 11/24/2017
PENICILLIN V POTASSIUM ORAL TABLET 500 MG 0.07250 11/15/2019 0.05740 01/24/2020
PENTAZOCINE HCL/NALOXONE HCL ORAL TABLET 50MG-0.5MG 2.10324 04/03/2015 2.10324 08/21/2015
PENTOXIFYLLINE ORAL TABLET, EXTENDED RELEASE 400 MG 0.14637 08/25/2017 0.12795 11/16/2018
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
PERINDOPRIL ERBUMINE ORAL TABLET 2 MG 0.85163 01/25/2013
PERINDOPRIL ERBUMINE ORAL TABLET 4 MG 0.61627 08/21/2015 0.58980 11/15/2019
PERINDOPRIL ERBUMINE ORAL TABLET 8 MG 0.70278 08/29/2014 0.70278 08/21/2015
PERMETHRIN TOPICAL CREAM (GRAM) 5 % 0.45460 03/20/2019 0.29678 02/21/2020
PERMETHRIN TOPICAL LIQUID (ML) 1 % 0.04372 12/13/2013 0.04372 08/21/2015
PERPHENAZINE ORAL TABLET 16 MG 1.67330 10/24/2014 1.53480 09/22/2017
PERPHENAZINE ORAL TABLET 2 MG 0.45370 03/16/2018 0.31250 01/25/2019
PERPHENAZINE ORAL TABLET 4 MG 0.46600 01/25/2019 0.34360 02/22/2019
PERPHENAZINE ORAL TABLET 8 MG 0.52100 07/26/2019 0.29300 03/20/2020
PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 2 MG-10 MG 0.85974 03/13/2015
PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 2 MG-25 MG 1.09466 04/03/2015
PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 4 MG-25 MG 1.19224 03/13/2015
PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 4 MG-50 MG 1.96854 03/13/2015 2.47290 03/06/2018
PERPHENAZINE/AMITRIPTYLINE HCL ORAL TABLET 4MG-10MG 0.47570 08/12/2014
PETROLATUM,WHITE TOPICAL OINTMENT IN PACKET (GRAM) 13.09140 08/21/2015
PETROLATUM,WHITE/WATER TOPICAL LOTION (ML) 0.00860 08/12/2014
PHENAZOPYRIDINE HCL ORAL TABLET 100 MG 0.51200 11/24/2017 0.26500 06/21/2019
PHENAZOPYRIDINE HCL ORAL TABLET 200 MG 0.68905 11/16/2018 0.40000 05/22/2020
PHENDIMETRAZINE TARTRATE ORAL TABLET 35 MG 0.13406 08/12/2014 0.13406 08/21/2015
PHENELZINE SULFATE ORAL TABLET 15 MG 0.58450 01/25/2013 0.44016 09/30/2016
PHENOBARBITAL ORAL ELIXIR 20 MG/5 ML 0.12828 01/30/2015 0.11000 07/26/2019
PHENOBARBITAL ORAL TABLET 100 MG 0.22053 04/19/2013
PHENOBARBITAL ORAL TABLET 15 MG 0.11231 04/12/2013
PHENOBARBITAL ORAL TABLET 16.2 MG 0.16065 08/21/2015 0.37408 09/23/2015
PHENOBARBITAL ORAL TABLET 30 MG 0.12320 08/29/2014
PHENOBARBITAL ORAL TABLET 32.4 MG 0.50000 08/25/2017 0.36000 11/16/2018
PHENOBARBITAL ORAL TABLET 64.8 MG 0.58906 05/06/2019 0.49250 08/16/2019
PHENOBARBITAL ORAL TABLET 97.2MG 0.90673 03/01/2018 0.85000 05/25/2018
PHENOBARBITAL SODIUM INJECTION VIAL (ML) 130MG/ML 13.60800 01/25/2013
PHENOBARBITAL SODIUM INJECTION VIAL (ML) 65 MG/ML 10.58400 07/26/2013
PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE SULF/SCOPOLAMINE HB ORAL ELIXIR 16.2MG/5ML
0.11741 08/21/2015
PHENOBARBITAL/HYOSCYAMINE SULF/ATROPINE SULF/SCOPOLAMINE HB ORAL TABLET 16.2 MG
0.02701 08/21/2015
PHENTERMINE HCL ORAL CAPSULE 15 MG 0.76603 08/21/2015 0.16000 09/22/2017
PHENTERMINE HCL ORAL CAPSULE 30 MG 0.19443 08/21/2015 0.14830 08/25/2017
PHENTERMINE HCL ORAL CAPSULE 37.5 MG 0.32924 08/21/2015 0.10540 09/22/2017
PHENTERMINE HCL ORAL TABLET 37.5 MG 0.08429 08/21/2015 0.06571 04/26/2019
PHENYLEPHRINE HCL OPHTHALMIC DROPS 10 % 6.86000 02/27/2015 6.86000 08/21/2015
PHENYLEPHRINE HCL OPHTHALMIC DROPS 2.5 % 6.61924 02/27/2015 6.61924 08/21/2015
PHENYLEPHRINE HCL ORAL SOLUTION, ORAL 2.5 MG/5ML 0.04150 08/12/2014
PHENYLEPHRINE HCL ORAL TABLET 10 MG 0.04135 09/19/2014 0.04135 08/21/2015
PHENYLEPHRINE HCL/PROMETHAZINE HCL ORAL SYRUP 5-6.25MG/5 0.23791 10/31/2014 0.23791 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
PHENYTOIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 100 MG/4ML 0.27300 08/12/2014
PHENYTOIN ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 125 MG/5ML 0.08026 03/17/2017 0.06283 08/17/2018
PHENYTOIN ORAL TABLET,CHEWABLE 50 MG 0.19360 08/17/2018 0.29720 12/18/2019
PHENYTOIN SODIUM EXTENDED ORAL CAPSULE 100 MG 0.17390 03/15/2019 0.16530 10/25/2019
PHENYTOIN SODIUM EXTENDED ORAL CAPSULE 200 MG 0.55990 08/12/2014
PHENYTOIN SODIUM INTRAVENOUS AMPUL (ML) 50 MG/ML 0.57670 08/12/2014
PHENYTOIN SODIUM INTRAVENOUS SYRINGE (ML) 50 MG/ML 0.68460 01/25/2013
PHENYTOIN SODIUM INTRAVENOUS VIAL (ML) 50 MG/ML 0.37563 08/12/2014
PHOSPHORATED CARBOHYDRATE (DEXTROSE AND FRUCTOSE) ORAL SOLUTION, ORAL
0.03038 08/12/2014
PHYTONADIONE (VIT K1) INJECTION AMPUL (ML) 10 MG/ML 26.38440 08/22/2014
PHYTONADIONE (VIT K1) ORAL TABLET 100 MCG 0.02140 08/12/2014 0.02140 08/21/2015
PHYTONADIONE (VIT K1) ORAL TABLET 5 MG 44.17600 08/16/2019
PILOCARPINE HCL OPHTHALMIC DROPS 1 % 4.34000 04/26/2013 4.34000 08/21/2015
PILOCARPINE HCL OPHTHALMIC DROPS 2 % 4.43940 08/21/2015 4.22200 05/22/2020
PILOCARPINE HCL OPHTHALMIC DROPS 4 % 4.65220 08/21/2015 4.14400 02/21/2020
PILOCARPINE HCL ORAL TABLET 5 MG 0.74470 02/22/2019 0.28990 11/15/2019
PILOCARPINE HCL ORAL TABLET 7.5 MG 1.15570 05/20/2016 1.04620 11/16/2018
PINDOLOL ORAL TABLET 10 MG 0.97925 06/16/2017 0.79990 02/22/2019
PINDOLOL ORAL TABLET 5 MG 0.85750 03/02/2018 0.65800 01/25/2019
PIOGLITAZONE HCL ORAL TABLET 15 MG 0.07000 08/25/2017 0.05857 11/16/2018
PIOGLITAZONE HCL ORAL TABLET 30 MG 0.12456 08/25/2017 0.07133 11/16/2018
PIOGLITAZONE HCL ORAL TABLET 45 MG 0.14678 03/16/2018 0.03389 11/16/2018
PIOGLITAZONE HCL/GLIMEPIRIDE ORAL TABLET 30 MG-2 MG 21.94569 03/01/2013 6.57850 06/16/2017
PIOGLITAZONE HCL/GLIMEPIRIDE ORAL TABLET 30 MG-4 MG 21.94569 03/01/2013 10.75527 06/16/2017
PIOGLITAZONE HCL/METFORMIN HCL ORAL TABLET 15MG-500MG 1.12650 08/17/2018 1.11033 03/20/2020
PIOGLITAZONE HCL/METFORMIN HCL ORAL TABLET 15MG-850MG 1.02022 11/24/2017 0.61100 02/21/2020
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 2.25 G
3.74530 08/21/2015 4.62000 10/05/2016
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 3.375 G
11.98000 08/21/2015 3.25000 05/22/2020
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 4.5 G
15.01360 07/19/2013 4.35700 05/22/2020
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL (EA) 40.5 G
95.66330 08/21/2015 72.90000 01/25/2019
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 2.25 G
8.32230 01/25/2013
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 3.375 G
12.66720 01/31/2014
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INTRAVENOUS VIAL WITH THREADED PORT (EA) 4.5 G
15.73320 01/25/2013
PIPERONYL BUTOXIDE/PYRETHRINS TOPICAL SHAMPOO 4%-0.33% 0.03613 05/03/2013 0.03613 08/21/2015
PIROXICAM ORAL CAPSULE 10 MG 0.53490 11/24/2017 0.44020 03/15/2019
PIROXICAM ORAL CAPSULE 20 MG 0.57000 10/19/2018 0.23350 11/16/2018
PODOFILOX TOPICAL SOLUTION, NON-ORAL 0.5 % 16.47695 04/22/2016 12.20500 09/30/2016
POLYDIMETHYLSILOXANES/SILICON DIOXIDE TOPICAL GEL (GRAM) 3.96690 04/03/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
POLYETHYLENE GLYCOL 3350 ORAL POWDER (GRAM) 17G/DOSE 0.04100 08/21/2015 0.02099 05/19/2017
POLYETHYLENE GLYCOL 3350 ORAL POWDER IN PACKET (EA) 17G 1.48370 03/04/2020 1.03071 06/19/2020
POLYETHYLENE GLYCOL 400/HYPROMELLOSE/GLYCERIN OPHTHALMIC DROPS 1-0.2-0.2%
0.06720 01/25/2013
POLYMYXIN B SULFATE/TRIMETHOPRIM OPHTHALMIC DROPS 10000-1/ML
0.41400 12/22/2017 0.38700 09/20/2019
POLYVINYL ALCOHOL OPHTHALMIC DROPS 1.4 % 0.13400 01/25/2013 0.13400 08/21/2015
POTASSIUM ALUM/SALICYLIC ACID/TALC/BENTONITE TOPICAL POWDER (GRAM)
0.06740 08/12/2014
POTASSIUM ALUM/TALC/BENTONITE TOPICAL POWDER (GRAM) 0.07530 08/12/2014
POTASSIUM BICARBONATE/CITRIC ACID ORAL TABLET, EFFERVESCENT 25 MEQ
0.21200 05/01/2015 0.18200 08/17/2018
POTASSIUM CHLORIDE IN 0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L
0.00410 08/12/2014
POTASSIUM CHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L
0.00283 04/19/2013
POTASSIUM CHLORIDE IN 0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L
0.00510 01/25/2013
POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L
0.00310 08/12/2014
POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 30 MEQ/L
0.00266 01/25/2013
POTASSIUM CHLORIDE IN 5 % DEXTROSE IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L
0.00209 01/25/2013 0.00209 08/21/2015
POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L
0.00320 08/12/2014
POTASSIUM CHLORIDE IN DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L
0.00540 08/12/2014
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 10 MEQ/L
0.00234 01/25/2013
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L
0.00322 01/25/2013
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 30 MEQ/L
0.00200 01/25/2013
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L
0.00227 01/25/2013
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 10 MEQ/L
0.00320 08/12/2014
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L
0.00230 08/12/2014
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 30 MEQ/L
0.00236 01/25/2013
POTASSIUM CHLORIDE IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L
0.00228 01/25/2013
POTASSIUM CHLORIDE IN DEXTROSE 5% AND 0.3 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L
0.00322 01/25/2013 0.00322 08/21/2015
POTASSIUM CHLORIDE IN LACTATED RINGERS AND 5 % DEXTROSE INTRAVENOUS INTRAVENOUS SOLUTION 20 MEQ/L
0.00610 08/12/2014
POTASSIUM CHLORIDE IN LACTATED RINGERS AND 5 % DEXTROSE INTRAVENOUS INTRAVENOUS SOLUTION 40 MEQ/L
0.00403 01/25/2013
POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 10MEQ/0.1L
0.02218 01/25/2013
POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 10MEQ/50ML
0.06570 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
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Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 20MEQ/0.1L
0.02180 01/25/2013
POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 20MEQ/50ML
0.10610 08/12/2014
POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 30MEQ/0.1L
0.04528 01/25/2013 0.04528 08/21/2015
POTASSIUM CHLORIDE IN WATER FOR INJECTION, STERILE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 40MEQ/0.1L
0.04897 01/25/2013
POTASSIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION 2 MEQ/ML
0.02779 08/22/2014
POTASSIUM CHLORIDE INTRAVENOUS VIAL (ML) 2 MEQ/ML 0.02303 04/19/2013 0.02303 08/21/2015
POTASSIUM CHLORIDE ORAL CAPSULE, EXTENDED RELEASE 10 MEQ 0.27000 08/25/2017 0.09794 09/22/2017
POTASSIUM CHLORIDE ORAL CAPSULE, EXTENDED RELEASE 8 MEQ 0.41723 02/26/2016 0.15000 08/16/2019
POTASSIUM CHLORIDE ORAL LIQUID (ML) 20MEQ/15ML 0.23230 10/25/2019 0.28252 12/09/2019
POTASSIUM CHLORIDE ORAL LIQUID (ML) 40MEQ/15ML 0.83849 07/19/2017 0.38055 11/16/2018
POTASSIUM CHLORIDE ORAL PACKET (EA) 20 MEQ 4.03333 11/15/2019 4.93300 01/13/2020
POTASSIUM CHLORIDE ORAL TABLET, EXT RELEASE, PARTICLES/CRYSTALS 10 MEQ
0.19245 11/16/2018 0.16745 08/16/2019
POTASSIUM CHLORIDE ORAL TABLET, EXT RELEASE, PARTICLES/CRYSTALS 20 MEQ
0.18912 02/22/2019 0.18056 10/25/2019
POTASSIUM CHLORIDE ORAL TABLET, EXTENDED RELEASE 10 MEQ 0.14650 12/21/2018 0.13899 07/26/2019
POTASSIUM CHLORIDE ORAL TABLET, EXTENDED RELEASE 8 MEQ 0.35868 08/21/2015 0.15500 08/25/2017
POTASSIUM CHLORIDE/POTASSIUM BICARBONATE/CITRIC ACID TABLET, EFFERVESCENT 25 MEQ
0.68997 01/25/2013
POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 10 MEQ 0.65371 04/25/2019 0.52180 07/26/2019
POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 15 MEQ 1.19990 09/20/2019 1.06610 03/20/2020
POTASSIUM CITRATE ORAL TABLET, EXTENDED RELEASE 5 MEQ 0.92685 09/30/2016 0.52180 11/15/2019
POVIDONE-IODINE TOPICAL OINTMENT (GRAM) 10 % 0.06258 01/25/2013 0.06258 08/21/2015
POVIDONE-IODINE TOPICAL SOLUTION, NON-ORAL 10 % 0.00639 04/17/2015 0.00639 08/21/2015
POVIDONE-IODINE TOPICAL SWAB, MEDICATED 10 % 0.15276 08/12/2014
POVIDONE-IODINE VAGINAL SOLUTION, NON-ORAL 0.3 % 0.00990 08/12/2014
PRAMIPEXOLE DI-HCL ORAL TABLET 0.125 MG 0.06600 08/25/2017 0.03978 09/22/2017
PRAMIPEXOLE DI-HCL ORAL TABLET 0.25 MG 0.04338 07/14/2017 0.03074 11/16/2018
PRAMIPEXOLE DI-HCL ORAL TABLET 0.5 MG 0.04834 08/25/2017 0.02844 12/20/2019
PRAMIPEXOLE DI-HCL ORAL TABLET 0.75 MG 0.09654 02/06/2015 0.09654 08/21/2015
PRAMIPEXOLE DI-HCL ORAL TABLET 1 MG 0.04395 08/25/2017 0.03333 05/22/2020
PRAMIPEXOLE DI-HCL ORAL TABLET 1.5 MG 0.06322 09/22/2017 0.04000 04/27/2018
PRAMIPEXOLE DI-HCL ORAL TABLET, EXTENDED RELEASE 24 HR 0.375 MG
11.95470 05/01/2015
PRAMIPEXOLE DI-HCL ORAL TABLET, EXTENDED RELEASE 24 HR 0.75 MG
11.29637 04/24/2015
PRAMIPEXOLE DI-HCL ORAL TABLET, EXTENDED RELEASE 24 HR 1.5 MG 11.29637 04/24/2015
PRAMOXINE HCL TOPICAL TOWELETTE (EA) 1 % 0.35233 01/25/2013
PRASUGREL HCL ORAL TABLET 10 MG 0.41000 04/17/2020 0.27733 05/22/2020
PRASUGREL HCL ORAL TABLET 5 MG 0.21000 01/25/2019 0.69533 04/06/2020
PRAVASTATIN SODIUM ORAL TABLET 10 MG 0.06264 09/20/2019 0.04363 03/20/2020
PRAVASTATIN SODIUM ORAL TABLET 20 MG 0.08000 08/25/2017 0.06396 05/22/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
PRAVASTATIN SODIUM ORAL TABLET 40 MG 0.14067 09/22/2017 0.06651 01/19/2018
PRAVASTATIN SODIUM ORAL TABLET 80 MG 0.21211 09/22/2017 0.11322 12/22/2017
PRAZOSIN HCL ORAL CAPSULE 1 MG 0.25364 11/15/2019 0.22789 05/22/2020
PRAZOSIN HCL ORAL CAPSULE 2 MG 0.44780 11/23/2019 0.27003 02/21/2020
PRAZOSIN HCL ORAL CAPSULE 5 MG 0.60000 11/15/2019 0.36400 04/17/2020
PREDNICARBATE TOPICAL CREAM (GRAM) 0.1 % 1.10483 12/26/2014 1.10483 08/21/2015
PREDNICARBATE TOPICAL OINTMENT (GRAM) 0.1 % 1.13044 04/24/2015 1.13044 08/21/2015
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 1 %
5.55440 02/21/2020 4.86400 05/22/2020
PREDNISOLONE ORAL SOLUTION, ORAL 15 MG/5 ML 0.03992 08/30/2013 0.03992 08/21/2015
PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC DROPS 1 % 4.19720 02/08/2013 4.19720 08/21/2015
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION, ORAL 15 MG/5 ML
0.08044 12/26/2014 0.08044 08/21/2015
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION, ORAL 25 MG/5 ML
1.48119 12/05/2014
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION, ORAL 5 MG/5 ML 0.57224 02/21/2014 0.57224 08/21/2015
PREDNISOLONE SODIUM PHOSPHATE ORAL TABLET,DISINTEGRATING 10 MG
10.06877 02/13/2015 10.06877 08/21/2015
PREDNISOLONE SODIUM PHOSPHATE ORAL TABLET,DISINTEGRATING 15 MG
16.78133 02/13/2015
PREDNISOLONE SODIUM PHOSPHATE ORAL TABLET,DISINTEGRATING 30 MG
21.57604 02/13/2015
PREDNISONE ORAL SOLUTION, ORAL 5 MG/5 ML 0.25220 02/07/2018 0.58034 07/03/2018
PREDNISONE ORAL TABLET 1 MG 0.19015 03/27/2015 0.09709 09/30/2016
PREDNISONE ORAL TABLET 10 MG 0.11202 08/25/2017 0.07950 09/22/2017
PREDNISONE ORAL TABLET 2.5 MG 0.14040 08/21/2015 0.10130 11/15/2019
PREDNISONE ORAL TABLET 20 MG 0.11890 01/19/2018 0.07974 09/21/2018
PREDNISONE ORAL TABLET 5 MG 0.05260 09/22/2017 0.04580 10/25/2019
PREDNISONE ORAL TABLET 50 MG 0.28608 08/12/2014
PREDNISONE ORAL TABLET, DOSE PACK 10 MG 0.78000 02/06/2015 0.78000 08/21/2015
PREDNISONE ORAL TABLET, DOSE PACK 5 MG 0.45000 10/24/2014 0.45000 08/21/2015
PREGABALIN ORAL CAPSULE 100 MG 0.15800 02/21/2020
PREGABALIN ORAL CAPSULE 150 MG 0.19717 11/15/2019 0.16000 04/01/2020
PREGABALIN ORAL CAPSULE 200 MG 0.17000 02/21/2020
PREGABALIN ORAL CAPSULE 225 MG 0.17000 02/21/2020
PREGABALIN ORAL CAPSULE 25 MG 0.11111 11/15/2019
PREGABALIN ORAL CAPSULE 300 MG 0.28689 11/15/2019 0.17767 04/01/2020
PREGABALIN ORAL CAPSULE 50 MG 0.41000 11/15/2019 0.11222 04/01/2020
PREGABALIN ORAL CAPSULE 75 MG 0.16844 04/01/2020 0.11233 05/22/2020
PRENATAL VIT 17/IRON/FOLIC ACID/FISH OIL/DHA/OMEGA 3,6 NO.1 CAPSULE 35-5-1.2MG
1.61980 01/25/2013 1.61980 08/21/2015
PRENATAL VIT NO.21/IRON POLYSACCH,HEME POLYPEP/FOLIC ACID TABLET 28-6-1 MG
1.47032 08/12/2014
PRENATAL VIT NO.22/IRON CBN,GLUCON/FOLIC ACID/DOCUSATE/DHA COMBINATION PACKAGE (EA) 27-1-50 MG
0.63047 07/05/2013 0.63047 08/21/2015
PRENATAL VIT NO.81/SOD.FEREDETATE-IRON PS/FOLIC ACID/OMEGA-3 ORAL COMBINATION PACKAGE, TABLET AND DR CAP 27-1-430MG
0.86509 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
PRENATAL VIT WITH CALCIUM 15/IRON/FOLIC ACID/DOCUSATE SODIUM ORAL TABLET 90-1-50 MG
0.11873 08/29/2014 0.11873 08/21/2015
PRENATAL VIT WITH CALCIUM 16/IRON/FOLIC ACID/DOCUSATE SODIUM TABLET 90-1-50 MG
0.13967 08/29/2014 0.13967 08/21/2015
PRENATAL VIT WITH CALCIUM 18/IRON/FOLIC ACID/DOCUSATE SODIUM TABLET 90-1-50 MG
0.08180 08/12/2014 0.08180 08/21/2015
PRENATAL VIT WITH CALCIUM 53/IRON BIS,S-P/FOLIC ACID/OMEGA-3 ORAL COMBINATION PACKAGE (EA) 29-1-400MG
0.43260 01/25/2013
PRENATAL VIT WITH CALCIUM 95/FERROUS FUMARATE/FOLIC ACID/DHA ORAL COMBINATION PACKAGE (EA) 28-800-200
0.10500 04/19/2013
PRENATAL VIT WITH CALCIUM NO.126/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 28MG-0.8MG
0.04810 01/25/2016
PRENATAL VIT WITH CALCIUM NO.128/FERROUS FUMARATE/FOLIC ACID TABLET 28MG-0.8MG
0.04207 01/25/2016
PRENATAL VIT WITH CALCIUM NO.129/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 27MG-0.8MG
0.04257 01/25/2016
PRENATAL VIT WITH CALCIUM NO.130/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 27MG-0.8MG
0.04207 01/25/2016
PRENATAL VIT WITH CALCIUM NO.131/FERROUS FUMARATE/FOLIC ACID TABLET 28MG-0.8MG
0.04810 01/25/2016
PRENATAL VIT WITH CALCIUM NO.40/IRON FUMARATE/FOLATE NO.1 ORAL TABLET 27 MG-1 MG
1.33925 05/02/2014
PRENATAL VIT WITH CALCIUM NO.69/IRON/FOLIC ACID/DOCUSATE/DHA ORAL CAPSULE 28-1-50 MG
1.38343 01/31/2014
PRENATAL VITAMIN 27 WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 60 MG-1 MG
0.20146 05/17/2013
PRENATAL VITAMIN CALCIUM,IRON,FOLIC ACID (LESS THAN 1 MG) ORAL TABLET
0.04207 04/05/2013 0.04207 08/21/2015
PRENATAL VITAMIN COMBO NO.22/IRON/FOLIC ACID/OMEGA-3/DHA COMBINATION PACKAGE (EA) 28-6-1-203
0.62446 08/12/2014
PRENATAL VITAMIN NO.19/IRON POLYSAC,IRON HEME/FOLIC ACID/DHA CAPSULE 22-6-1-200
2.08973 05/03/2013 2.08973 08/21/2015
PRENATAL VITAMIN NO.52/IRON/FOLIC ACID/OMEGA-3/DHA ORAL COMBINATION PACKAGE (EA) 29-1-200MG
0.36225 01/25/2013
PRENATAL VITAMIN NO.59/IRON CARB,FUM/FOLIC ACID/DOCUSATE/DHA ORAL CAPSULE 27-1-50 MG
4.46109 12/12/2014
PRENATAL VITAMIN NO.86/IRON BIS-GLYCINATE/FOLIC ACID ORAL TABLET 32 MG-1 MG
0.83875 09/05/2014 0.83875 08/21/2015
PRENATAL VITAMIN WITH CALCIUM NO.76/IRON,CARBONYL/FOLIC ACID ORAL TABLET 29 MG-1 MG
0.22547 08/12/2014 0.22547 08/21/2015
PRENATAL VITAMINS NO.11/FERROUS FUMARATE/FOLIC ACID/OMEGA-3 ORAL CAPSULE 28-1-200MG
2.01177 04/03/2015
PRENATAL VITAMINS NO.25/FERROUS FUMARATE/FOLIC ACID/DHA CAPSULE 30-975-200
0.55977 04/19/2013
PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 27MG-0.8MG
0.04257 04/12/2013 0.04257 08/21/2015
PRENATAL VITAMINS WITH CALCIUM/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 28MG-0.8MG
0.04810 08/12/2014 0.04810 08/21/2015
PRENATAL VITS NO.115/IRON FUMARATE/FOLIC ACID/DOCUSATE SOD. ORAL TABLET 29-1-25 MG
0.61940 04/04/2014 0.61940 08/21/2015
PRENATAL VITS NO.119/IRON FUMARATE/FOLIC ACID/DOCUSATE SOD. ORAL TABLET 29-1-25 MG
0.44586 01/31/2014 0.44586 08/21/2015
PRENATAL VITS NO.151/IRON FUM/FOLIC ACID/OMEGA3/DHA/EPA/FISH ORAL CAPSULE 27-800-228
0.11428 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
PRENATAL VITS NO.24/IRON AMINO ACID CHELATE/FOLIC ACID/DHA COMBINATION PACKAGE (EA) 30-975-300
0.41988 04/19/2013
PRENATAL VITS NO.34/IRON,CARB/FOLIC ACID/DOCUSATE SODIUM/DHA ORAL CAPSULE 30-1-50 MG
1.58305 01/25/2013 1.58305 08/21/2015
PRENATAL VITS WITH CALCIUM 118/FERROUS FUMARATE/FOLIC ACID ORAL TABLET,CHEWABLE 29 MG-1 MG
0.60102 11/08/2013 0.60102 08/21/2015
PRENATAL VITS WITH CALCIUM 95/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 28MG-0.8MG
0.05924 12/19/2014 0.05924 08/21/2015
PRENATAL VITS WITH CALCIUM NO.21/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 14 MG-400
0.06411 01/25/2013
PRENATAL VITS WITH CALCIUM NO.72/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 27 MG-1 MG
0.06606 03/13/2015 0.06606 08/21/2015
PRENATAL VITS WITH CALCIUM NO.73/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 28 MG-1 MG
0.26832 08/29/2014 0.26832 08/21/2015
PRENATAL VITS WITH CALCIUM NO.74/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 27 MG-1 MG
0.02170 08/21/2015
PRENATAL VITS WITH CALCIUM NO.80/IRON FUM/FOLIC ACID/DSS/DHA ORAL CAPSULE 29-1.25-55
1.98769 01/25/2013 1.98769 08/21/2015
PRENATAL VITS WITH CALCIUM NO.87/IRON BISGLY/FOLIC ACID/DHA ORAL COMBINATION PACKAGE (EA) 32-1-230MG
0.59733 01/17/2014 0.59733 08/21/2015
PRENATAL VITS WITH CALCIUM NO.90/FERROUS FUMARATE/FOLIC ACID TABLET 9 MG-0.5MG
0.08394 01/25/2013
PRENATAL VITS WITH CALCIUM NO.93/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 9MG-267MCG
0.05495 04/19/2013
PRENATAL VITS WITH CALCIUM NO.96/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 27MG-0.8MG
0.06924 08/12/2014
PRENATAL VITS, CALCIUM NO.91/FERROUS FUMARATE/FOLIC ACID/DHA ORAL COMBINATION PACKAGE (EA) 28-975-200
0.16328 04/19/2013
PRENATAL VITS,CALCIUM NO.66/IRON FUM/FOLIC ACID/DOCUSATE/DHA ORAL CAPSULE 26-1.2-55
1.21550 08/29/2014 1.21550 08/21/2015
PRENATAL VITS,CALCIUM NO.66/IRON FUM/FOLIC ACID/DOCUSATE/DHA ORAL CAPSULE 27-1.25-55
0.45240 09/26/2014 0.45240 08/21/2015
PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG 1.17327 11/07/2014 1.17327 08/21/2015
PRIMIDONE ORAL TABLET 250 MG 0.16411 08/21/2015 0.14150 08/25/2017
PRIMIDONE ORAL TABLET 50 MG 0.08737 08/21/2015 0.06000 08/25/2017
PROBENECID ORAL TABLET 500 MG 0.51720 08/21/2015 0.79640 07/18/2019
PROBENECID/COLCHICINE ORAL TABLET 500-0.5 MG 0.67760 10/10/2014
PROCAINAMIDE HCL INJECTION VIAL (ML) 100 MG/ML 1.98490 08/12/2014
PROCAINAMIDE HCL INJECTION VIAL (ML) 500 MG/ML 8.23200 01/25/2013
PROCHLORPERAZINE EDISYLATE INJECTION VIAL (ML) 10 MG/2 ML 2.63900 01/17/2014 2.63900 08/21/2015
PROCHLORPERAZINE EDISYLATE INJECTION VIAL (ML) 5 MG/ML 1.68000 01/25/2013
PROCHLORPERAZINE MALEATE ORAL TABLET 10 MG 0.05210 10/20/2017 0.34730 12/05/2019
PROCHLORPERAZINE MALEATE ORAL TABLET 5 MG 0.24370 07/05/2019 0.18950 11/15/2019
PROCHLORPERAZINE RECTAL SUPPOSITORY, RECTAL 25 MG 8.90000 08/08/2014 8.90000 08/21/2015
PROGESTERONE INTRAMUSCULAR VIAL (ML) 50 MG/ML 2.02150 01/25/2013 1.55900 03/02/2018
PROGESTERONE MISCELLANEOUS POWDER (GRAM) 100 % 0.47840 08/21/2015
PROGESTERONE, MICRONIZED MISCELLANEOUS POWDER (GRAM) 100 %
0.37440 08/21/2015
PROGESTERONE, MICRONIZED ORAL CAPSULE 100 MG 0.24402 06/21/2019 0.19990 03/20/2020
PROGESTERONE, MICRONIZED ORAL CAPSULE 200 MG 0.96465 08/16/2019 0.71130 09/20/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
PROMETHAZINE HCL INJECTION AMPUL (ML) 25 MG/ML 1.67584 10/24/2014
PROMETHAZINE HCL INJECTION AMPUL (ML) 50 MG/ML 1.79970 08/12/2014
PROMETHAZINE HCL INJECTION VIAL (ML) 25 MG/ML 0.76113 11/22/2013 0.76113 08/21/2015
PROMETHAZINE HCL INJECTION VIAL (ML) 50 MG/ML 1.91280 08/12/2014
PROMETHAZINE HCL ORAL SYRUP 6.25MG/5ML 0.01454 02/27/2015 0.01454 08/21/2015
PROMETHAZINE HCL ORAL TABLET 12.5 MG 0.05630 09/22/2017 0.04160 12/22/2017
PROMETHAZINE HCL ORAL TABLET 25 MG 0.09320 08/21/2015 0.03140 07/14/2017
PROMETHAZINE HCL ORAL TABLET 50 MG 0.14740 08/21/2015 0.10467 04/21/2017
PROMETHAZINE HCL RECTAL SUPPOSITORY, RECTAL 12.5 MG 8.24914 01/13/2017 7.87258 06/16/2017
PROMETHAZINE HCL RECTAL SUPPOSITORY, RECTAL 25 MG 5.25000 02/21/2020 4.35583 05/22/2020
PROMETHAZINE HCL RECTAL SUPPOSITORY, RECTAL 50 MG 25.03550 10/17/2014
PROMETHAZINE HCL/CODEINE ORAL SYRUP 6.25-10/5 0.01528 01/25/2013 0.01528 08/21/2015
PROMETHAZINE HCL/DEXTROMETHORPHAN HBR ORAL SYRUP 6.25-15/5 0.04860 10/21/2019 0.06227 12/11/2019
PROMETHAZINE/PHENYLEPHRINE HCL/CODEINE ORAL SYRUP 6.25-5-10 0.08490 08/21/2015 0.01101 11/24/2017
PROPAFENONE HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 225 MG
3.07683 03/20/2020 1.88000 05/22/2020
PROPAFENONE HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 325 MG
5.37947 04/21/2017 3.30000 12/20/2019
PROPAFENONE HCL ORAL CAPSULE, EXTENDED RELEASE 12 HR 425 MG
6.99942 10/31/2014 5.15292 06/16/2017
PROPAFENONE HCL ORAL TABLET 150 MG 0.21963 08/21/2015 0.11450 08/25/2017
PROPAFENONE HCL ORAL TABLET 225 MG 0.29990 03/02/2018 0.19070 02/22/2019
PROPAFENONE HCL ORAL TABLET 300 MG 0.95600 07/29/2016 0.45365 06/16/2017
PROPANTHELINE BROMIDE ORAL TABLET 15 MG 0.59475 03/20/2015 0.59475 08/21/2015
PROPARACAINE HCL OPHTHALMIC DROPS 0.5 % 0.81433 04/05/2013 0.81433 08/21/2015
PROPRANOLOL HCL MISCELLANEOUS POWDER (GRAM) 17.22364 08/23/2013 17.22364 08/21/2015
PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 120 MG 0.54990 01/24/2020 0.48840 03/20/2020
PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 160 MG 1.30000 11/16/2018 0.79800 12/21/2018
PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 60 MG 0.32273 08/16/2019 0.24880 10/25/2019
PROPRANOLOL HCL ORAL CAPSULE, EXTENDED RELEASE 24HR 80 MG 0.27910 09/20/2019 0.49490 02/26/2020
PROPRANOLOL HCL ORAL SOLUTION, ORAL 20 MG/5 ML 0.15914 07/18/2014
PROPRANOLOL HCL ORAL SOLUTION, ORAL 40MG/5ML 0.20614 03/15/2013
PROPRANOLOL HCL ORAL TABLET 10 MG 0.10768 01/24/2019 0.07170 04/26/2019
PROPRANOLOL HCL ORAL TABLET 20 MG 0.12333 11/16/2018 0.08990 09/20/2019
PROPRANOLOL HCL ORAL TABLET 40 MG 0.21556 03/03/2017 0.14630 02/22/2019
PROPRANOLOL HCL ORAL TABLET 60 MG 0.60253 01/13/2017 0.55290 03/02/2018
PROPRANOLOL HCL ORAL TABLET 80 MG 0.27250 11/16/2018 0.17910 01/24/2020
PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 40 MG-25MG
0.71600 08/12/2014
PROPRANOLOL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 80 MG-25MG
0.87940 08/12/2014
PROTAMINE SULFATE INTRAVENOUS VIAL (ML) 10 MG/ML 1.17782 08/12/2014
PROTECTIVES COMBINATION NO.2/CERAMIDES 1,3,6-11 TOPICAL CREAM (GRAM)
1.87360 08/12/2014
PROTRIPTYLINE HCL ORAL TABLET 10 MG 1.94520 08/21/2015 1.23085 06/16/2017
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
PROTRIPTYLINE HCL ORAL TABLET 5 MG 1.43575 07/29/2016 1.10701 12/02/2016
PSEUDOEPHEDRINE HCL ORAL TABLET 30 MG 0.02680 11/21/2014 0.02680 08/21/2015
PSEUDOEPHEDRINE HCL ORAL TABLET 60 MG 0.02105 08/12/2014 0.02105 08/21/2015
PSEUDOEPHEDRINE HCL/CHLOPHEDIANOL HCL/GUAIFENESIN ORAL LIQUID (ML) 30-12.5/5
0.08600 08/12/2014
PSEUDOEPHEDRINE HCL/CODEINE PHOSPHATE/GUAIFENESIN ORAL SYRUP 30-10-100
0.15863 01/30/2015 0.15863 08/21/2015
PSYLLIUM HUSK (WITH SUGAR) ORAL POWDER (GRAM) 3.4 G/7 G 0.01464 12/26/2014 0.01464 08/21/2015
PSYLLIUM SEED (WITH SUGAR) ORAL POWDER (GRAM) 0.00920 08/12/2014 0.00920 08/21/2015
PSYLLIUM SEED ORAL POWDER (GRAM) 0.01780 01/25/2013 0.01780 08/21/2015
PYRANTEL PAMOATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 50 MG/ML
0.16310 01/25/2013
PYRAZINAMIDE ORAL TABLET 500 MG 1.88174 07/25/2014
PYRIDOSTIGMINE BROMIDE ORAL TABLET 60 MG 0.24830 01/24/2020 0.34550 02/17/2020
PYRIDOXINE HCL (VITAMIN B6) INJECTION VIAL (ML) 100 MG/ML 7.86632 01/25/2013
PYRIDOXINE HCL (VITAMIN B6) ORAL TABLET 100 MG 0.02559 08/12/2014 0.02559 08/21/2015
PYRIDOXINE HCL (VITAMIN B6) ORAL TABLET 25 MG 0.02190 08/12/2014
PYRIDOXINE HCL (VITAMIN B6) ORAL TABLET 50 MG 0.01407 09/27/2013 0.01407 08/21/2015
QUETIAPINE FUMARATE ORAL TABLET 100 MG 0.03670 09/21/2018 0.03110 07/26/2019
QUETIAPINE FUMARATE ORAL TABLET 200 MG 0.08270 06/16/2017 0.06540 06/19/2020
QUETIAPINE FUMARATE ORAL TABLET 25 MG 0.03890 09/22/2017 0.02259 03/16/2018
QUETIAPINE FUMARATE ORAL TABLET 300 MG 0.13924 03/03/2017 0.12517 09/21/2018
QUETIAPINE FUMARATE ORAL TABLET 400 MG 0.27326 01/13/2017 0.09749 01/27/2017
QUETIAPINE FUMARATE ORAL TABLET 50 MG 0.06000 11/24/2017 0.04945 05/22/2020
QUETIAPINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 HR 150 MG
0.32842 11/15/2019 0.10817 03/20/2020
QUETIAPINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 HR 200 MG
0.46666 01/25/2019 0.25400 11/15/2019
QUETIAPINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG
0.53330 07/26/2019 0.46206 11/15/2019
QUETIAPINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 HR 400 MG
0.65533 04/11/2019 0.46000 06/21/2019
QUETIAPINE FUMARATE ORAL TABLET, EXTENDED RELEASE 24 HR 50 MG
0.28000 11/16/2018 0.11959 05/17/2019
QUINAPRIL HCL ORAL TABLET 10 MG 0.15690 08/21/2015 0.13756 12/22/2017
QUINAPRIL HCL ORAL TABLET 20 MG 0.08945 08/25/2017 0.07100 11/15/2019
QUINAPRIL HCL ORAL TABLET 40 MG 0.12089 10/20/2017 0.07200 08/17/2018
QUINAPRIL HCL ORAL TABLET 5 MG 0.14511 06/16/2017 0.09400 09/22/2017
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 10-12.5MG 0.56012 07/04/2014 0.56012 08/21/2015
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20 MG-25MG 0.49945 08/21/2015 0.35755 11/16/2018
QUINAPRIL HCL/HYDROCHLOROTHIAZIDE ORAL TABLET 20-12.5 MG 0.42731 08/21/2015 0.36578 11/16/2018
QUINIDINE GLUCONATE ORAL TABLET, EXTENDED RELEASE 324 MG 0.84810 08/12/2014 0.84810 08/21/2015
QUINIDINE GLUCONATE VIAL (ML) 80 MG/ML 3.64770 01/25/2013
QUINIDINE SULFATE ORAL TABLET 200 MG 0.09930 01/25/2013
QUINIDINE SULFATE ORAL TABLET 300 MG 0.18360 08/12/2014
QUINIDINE SULFATE ORAL TABLET, EXTENDED RELEASE 300 MG 0.67330 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
QUININE SULFATE ORAL CAPSULE 324 MG 3.07125 08/21/2015 1.83367 09/22/2017
RABEPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 20 MG
0.31567 10/20/2017 0.19089 03/20/2020
RALOXIFENE HCL ORAL TABLET 60 MG 0.54147 11/16/2018 0.32133 05/17/2019
RAMELTEON ORAL TABLET 8 MG 3.03167 01/01/2020 2.79767 05/22/2020
RAMIPRIL ORAL CAPSULE 1.25 MG 0.12030 12/21/2018 0.09855 11/15/2019
RAMIPRIL ORAL CAPSULE 10 MG 0.05856 08/21/2015 0.03852 10/20/2017
RAMIPRIL ORAL CAPSULE 2.5 MG 0.09500 08/21/2015 0.04723 11/24/2017
RAMIPRIL ORAL CAPSULE 5 MG 0.06081 11/16/2018 0.02720 07/26/2019
RANITIDINE HCL CAPSULE 150 MG 0.31000 06/21/2019 0.41255 10/11/2019
RANITIDINE HCL CAPSULE 300 MG 1.03000 10/19/2018 0.81033 11/16/2018
RANITIDINE HCL SYRUP 15 MG/ML 0.03000 06/21/2019 0.05891 12/17/2019
RANITIDINE HCL TABLET 150 MG 0.04560 05/01/2015 0.04560 08/21/2015
RANITIDINE HCL TABLET 300 MG 0.10192 10/20/2017 0.08896 10/25/2019
RANITIDINE HCL TABLET 75 MG 0.09782 08/21/2015 0.05750 11/24/2017
RANITIDINE HCL VIAL (ML) 25 MG/ML 1.01383 02/20/2015 1.01383 08/21/2015
RANOLAZINE ORAL TABLET, EXTENDED RELEASE 12 HR 1000 MG 0.71411 01/24/2020
RANOLAZINE ORAL TABLET, EXTENDED RELEASE 12 HR 500 MG 0.37763 01/24/2020
RASAGILINE MESYLATE ORAL TABLET 1 MG 4.40000 11/15/2019 5.08438 11/27/2019
REPAGLINIDE ORAL TABLET 0.5 MG 0.17060 11/24/2017 0.08777 11/16/2018
REPAGLINIDE ORAL TABLET 1 MG 0.13355 11/16/2018 0.11823 05/22/2020
REPAGLINIDE ORAL TABLET 2 MG 0.18605 12/22/2017 0.10198 08/17/2018
RIBAVIRIN ORAL CAPSULE 200 MG 0.79060 03/13/2015 0.79060 08/21/2015
RIBAVIRIN ORAL TABLET 200 MG 0.72584 08/21/2015 0.61089 10/23/2015
RIBOFLAVIN (VITAMIN B2) ORAL TABLET 25 MG 0.02310 08/12/2014
RIFABUTIN ORAL CAPSULE 150 MG 12.24594 08/12/2014
RIFAMPIN ORAL CAPSULE 150 MG 1.02820 12/13/2013 0.91689 11/20/2015
RIFAMPIN ORAL CAPSULE 300 MG 0.48100 11/24/2017 0.47600 07/26/2019
RILUZOLE ORAL TABLET 50 MG 0.85000 09/21/2018 0.28500 04/17/2020
RIMANTADINE HCL ORAL TABLET 100 MG 1.70880 08/12/2014 1.70880 08/21/2015
RINGER'S SOLUTION INTRAVENOUS INTRAVENOUS SOLUTION 0.00250 08/12/2014
RINGER'S SOLUTION IRRIGATION SOLUTION, IRRIGATION 0.00710 08/12/2014
RINGER'S SOLUTION,LACTATED INTRAVENOUS INTRAVENOUS SOLUTION
0.03400 08/21/2015 0.00364 04/21/2017
RINGER'S SOLUTION,LACTATED IRRIGATION SOLUTION, IRRIGATION 0.00220 01/25/2013
RISEDRONATE SODIUM ORAL TABLET 150 MG 31.25000 03/15/2019 28.95000 06/21/2019
RISEDRONATE SODIUM ORAL TABLET 30 MG 29.56000 03/25/2016
RISEDRONATE SODIUM ORAL TABLET 35 MG 5.21000 03/15/2019 5.21000 10/25/2019
RISEDRONATE SODIUM ORAL TABLET 5 MG 3.95000 01/25/2019 2.33300 04/17/2020
RISPERIDONE ORAL SOLUTION, ORAL 1 MG/ML 0.21474 11/15/2019 0.16267 06/19/2020
RISPERIDONE ORAL TABLET 0.25 MG 0.04949 08/25/2017 0.02047 03/20/2020
RISPERIDONE ORAL TABLET 0.5 MG 0.04150 10/20/2017 0.02083 01/24/2020
RISPERIDONE ORAL TABLET 1 MG 0.06372 08/25/2017 0.03897 09/22/2017
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
RISPERIDONE ORAL TABLET 2 MG 0.05984 05/14/2019 0.04430 11/15/2019
RISPERIDONE ORAL TABLET 3 MG 0.06627 08/25/2017 0.04333 12/22/2017
RISPERIDONE ORAL TABLET 4 MG 0.07709 09/22/2017 0.06578 05/22/2020
RISPERIDONE ORAL TABLET,DISINTEGRATING 0.25 MG 5.90310 03/22/2013
RISPERIDONE ORAL TABLET,DISINTEGRATING 0.5 MG 0.67437 06/16/2017 0.50000 04/27/2018
RISPERIDONE ORAL TABLET,DISINTEGRATING 1 MG 0.93124 01/27/2017 0.48786 03/02/2018
RISPERIDONE ORAL TABLET,DISINTEGRATING 2 MG 1.77337 12/25/2015 0.97357 03/17/2017
RISPERIDONE ORAL TABLET,DISINTEGRATING 3 MG 1.24500 11/16/2018 1.15500 11/15/2019
RISPERIDONE ORAL TABLET,DISINTEGRATING 4 MG 6.09630 02/06/2015
RIVASTIGMINE TARTRATE ORAL CAPSULE 1.5 MG 0.15325 11/16/2018 0.11583 05/17/2019
RIVASTIGMINE TARTRATE ORAL CAPSULE 3 MG 0.20075 11/16/2018 0.11583 05/17/2019
RIVASTIGMINE TARTRATE ORAL CAPSULE 4.5 MG 0.26333 09/22/2017 0.11583 05/17/2019
RIVASTIGMINE TARTRATE ORAL CAPSULE 6 MG 0.45891 09/22/2017 0.10250 08/16/2019
RIVASTIGMINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 13.3MG/24H
3.94122 08/16/2019 3.66667 03/20/2020
RIVASTIGMINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 4.6MG/24HR
3.44000 12/20/2019 2.53000 02/21/2020
RIVASTIGMINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 9.5MG/24HR
3.99967 11/15/2019 3.57000 02/21/2020
RIZATRIPTAN BENZOATE ORAL TABLET 10 MG 0.51667 03/15/2019 0.37778 07/26/2019
RIZATRIPTAN BENZOATE ORAL TABLET 5 MG 0.57750 03/20/2020 0.43333 04/17/2020
RIZATRIPTAN BENZOATE ORAL TABLET,DISINTEGRATING 10 MG 0.83889 09/22/2017 0.49000 12/21/2018
RIZATRIPTAN BENZOATE ORAL TABLET,DISINTEGRATING 5 MG 0.85000 09/21/2018 0.55500 08/16/2019
ROPINIROLE HCL ORAL TABLET 0.25 MG 0.10162 08/21/2015 0.06306 07/14/2017
ROPINIROLE HCL ORAL TABLET 0.5 MG 0.05230 03/16/2018 0.04000 12/20/2019
ROPINIROLE HCL ORAL TABLET 1 MG 0.05854 07/14/2017 0.04490 04/27/2018
ROPINIROLE HCL ORAL TABLET 2 MG 0.13261 08/21/2015 0.05812 07/14/2017
ROPINIROLE HCL ORAL TABLET 3 MG 0.08220 08/25/2017 0.06620 05/22/2020
ROPINIROLE HCL ORAL TABLET 4 MG 0.08150 10/20/2017 0.06920 01/19/2018
ROPINIROLE HCL ORAL TABLET 5 MG 0.14000 01/25/2019 0.08350 08/16/2019
ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 12 MG 7.95362 08/21/2015 4.25900 08/17/2018
ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 2 MG 1.09254 08/21/2015 0.74883 11/15/2019
ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 4 MG 1.15000 06/22/2018 0.40520 10/19/2018
ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 6 MG 4.97944 08/21/2015 1.06633 09/22/2017
ROPINIROLE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 8 MG 3.22530 08/12/2014 3.22530 08/21/2015
ROPIVACAINE HCL/PF INJECTION VIAL (ML) 10 MG/ML 0.49701 10/17/2014 0.49701 08/21/2015
ROPIVACAINE HCL/PF INJECTION VIAL (ML) 2 MG/ML 0.23912 12/05/2014
ROPIVACAINE HCL/PF INJECTION VIAL (ML) 5 MG/ML 0.29748 10/17/2014
ROPIVACAINE HCL/PF INJECTION VIAL (ML) 7.5 MG/ML 0.42672 12/05/2014
ROSUVASTATIN CALCIUM ORAL TABLET 10 MG 0.08622 03/16/2018 0.06033 09/21/2018
ROSUVASTATIN CALCIUM ORAL TABLET 20 MG 0.12200 10/20/2017 0.06520 12/21/2018
ROSUVASTATIN CALCIUM ORAL TABLET 40 MG 0.12344 09/21/2018 0.10000 12/21/2018
ROSUVASTATIN CALCIUM ORAL TABLET 5 MG 0.06722 11/15/2019 0.05389 04/17/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
SACCHAROMYCES BOULARDII ORAL CAPSULE 250 MG 0.55650 10/10/2014
SALICYLIC ACID TOPICAL FILM-FORMING LIQUID WITH APPLICATOR 27.5 %
7.24360 01/31/2014
SALICYLIC ACID TOPICAL LIQUID (ML) 26 % 6.03610 01/25/2013
SALICYLIC ACID/COAL TAR/SULFUR SHAMPOO 2 %-1 %-2% 0.20597 01/25/2013
SALSALATE ORAL TABLET 500 MG 0.24147 11/07/2014 0.24147 08/21/2015
SALSALATE ORAL TABLET 750 MG 1.38136 06/16/2017 0.60680 05/25/2018
SCOPOLAMINE HYDROBROMIDE VIAL (ML) 0.4 MG/ML 3.78000 01/25/2013
SELEGILINE HCL ORAL CAPSULE 5 MG 1.61219 08/12/2014 1.61219 08/21/2015
SELEGILINE HCL ORAL TABLET 5 MG 1.25290 11/28/2014 1.25290 08/21/2015
SELENIUM INTRAVENOUS VIAL (ML) 40 MCG/ML 0.24063 01/25/2013
SELENIUM ORAL TABLET 200 MCG 0.05669 08/12/2014 0.05669 08/21/2015
SELENIUM SULFIDE TOPICAL SHAMPOO 2.5 % 0.07952 09/19/2014 0.07952 08/21/2015
SENNOSIDES ORAL SYRUP 8.8MG/5ML 0.04146 08/12/2014 0.04146 08/21/2015
SENNOSIDES ORAL TABLET 8.6 MG 0.00978 05/01/2015 0.00978 08/21/2015
SENNOSIDES/DOCUSATE SODIUM ORAL TABLET 8.6MG-50MG 0.01946 11/07/2014 0.01946 08/21/2015
SERTRALINE HCL ORAL CONCENTRATE, ORAL 20 MG/ML 0.68521 05/19/2017 0.65250 08/16/2019
SERTRALINE HCL ORAL TABLET 100 MG 0.07310 08/21/2015 0.04255 10/20/2017
SERTRALINE HCL ORAL TABLET 25 MG 0.03430 10/20/2017 0.02144 01/25/2019
SERTRALINE HCL ORAL TABLET 50 MG 0.05250 08/21/2015 0.03376 06/16/2017
SILDENAFIL CITRATE ORAL TABLET 20 MG 0.18128 01/24/2020 0.10600 03/20/2020
SILVER NITRATE TOPICAL SOLUTION, NON-ORAL 0.5 % 0.03476 01/25/2013
SILVER SULFADIAZINE TOPICAL CREAM (GRAM) 1 % 0.08520 03/15/2019 0.07140 12/20/2019
SILVER TOPICAL GEL, EXTENDED RELEASE (ML) 48.44700 01/25/2013
SIMETHICONE ORAL CAPSULE 125 MG 0.08754 03/13/2015 0.08754 08/21/2015
SIMETHICONE ORAL CAPSULE 180 MG 0.07370 08/21/2015 0.03333 03/02/2018
SIMETHICONE ORAL SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 40MG/0.6ML
0.08040 08/21/2015 0.05634 11/16/2018
SIMETHICONE ORAL TABLET,CHEWABLE 125 MG 0.07236 02/06/2015 0.07236 08/21/2015
SIMETHICONE ORAL TABLET,CHEWABLE 80 MG 0.02452 11/21/2014 0.02452 08/21/2015
SIMVASTATIN ORAL TABLET 10 MG 0.03578 08/21/2015 0.02311 10/20/2017
SIMVASTATIN ORAL TABLET 20 MG 0.04000 08/21/2015 0.01895 09/22/2017
SIMVASTATIN ORAL TABLET 40 MG 0.06240 08/21/2015 0.03117 06/16/2017
SIMVASTATIN ORAL TABLET 5 MG 0.05868 08/21/2015 0.02917 11/24/2017
SIMVASTATIN ORAL TABLET 80 MG 0.09991 08/21/2015 0.05544 11/24/2017
SIROLIMUS ORAL TABLET 0.5 MG 3.99000 09/21/2018 5.70661 11/21/2019
SIROLIMUS ORAL TABLET 1 MG 7.15000 12/20/2019 7.77140 01/21/2020
SIROLIMUS ORAL TABLET 2 MG 22.65484 12/08/2017 16.95000 09/21/2018
SODIUM BENZOATE MISCELLANEOUS POWDER (GRAM) 0.04664 01/25/2013 0.04664 08/21/2015
SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 0.5MEQ/ML 0.44100 01/25/2013
SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 0.9MEQ/ML 0.12734 01/25/2013
SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 1 MEQ/ML 0.09770 08/12/2014 0.09770 08/21/2015
SODIUM BICARBONATE INTRAVENOUS SYRINGE (ML) 10MEQ/10ML 0.74256 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
SODIUM BICARBONATE INTRAVENOUS VIAL (ML) 0.5MEQ/ML 0.42840 03/01/2013
SODIUM BICARBONATE INTRAVENOUS VIAL (ML) 1 MEQ/ML 0.13238 11/07/2014
SODIUM BICARBONATE ORAL TABLET 325 MG 0.02155 01/25/2013 0.02155 08/21/2015
SODIUM BICARBONATE ORAL TABLET 650 MG 0.00953 03/22/2013 0.00953 08/21/2015
SODIUM CHLORIDE 0.45 % INTRAVENOUS INTRAVENOUS SOLUTION 0.45 %
0.00260 03/07/2014
SODIUM CHLORIDE 0.45 % INTRAVENOUS PIGGYBACK WITH THREADED PORT (ML)
0.04345 01/30/2015 0.04345 08/21/2015
SODIUM CHLORIDE 3 % INTRAVENOUS INTRAVENOUS SOLUTION 3 % 0.00878 04/19/2013
SODIUM CHLORIDE 5 % INTRAVENOUS INTRAVENOUS SOLUTION 5 % 0.00770 08/12/2014
SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 0.9 %
0.05389 03/06/2015 0.05389 08/21/2015
SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 10 %
0.04183 03/01/2013
SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 3 %
0.04633 04/03/2015 0.04980 03/28/2018
SODIUM CHLORIDE FOR INHALATION INHALATION VIAL, NEBULIZER (ML) 7 %
0.07000 11/01/2013
SODIUM CHLORIDE INTRAVENOUS VIAL (ML) 2.5 MEQ/ML 0.02780 04/05/2013 0.02780 08/21/2015
SODIUM CHLORIDE INTRAVENOUS VIAL (ML) 4 MEQ/ML 0.03239 11/22/2013
SODIUM CHLORIDE IRRIGATING SOLUTION IRRIGATION SOLUTION, IRRIGATION 0.9 %
0.00764 08/12/2014 0.00764 08/21/2015
SODIUM CHLORIDE MISCELLANEOUS TABLET, SOLUBLE 1000 MG 0.09895 12/26/2014
SODIUM CHLORIDE NASAL AEROSOL, SPRAY (ML) 0.65 % 0.02561 02/13/2015 0.02561 08/21/2015
SODIUM CHLORIDE OPHTHALMIC OINTMENT (GRAM) 5 % 2.49240 08/12/2014 1.85007 06/16/2017
SODIUM CHLORIDE/SODIUM BICARBONATE/POTASSIUM CHLORIDE/PEG ORAL SOLUTION, RECONSTITUTED, ORAL 420G
0.00401 06/27/2014 0.00401 08/21/2015
SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INTRAVENOUS VIAL (ML) 62.5MG/5ML
5.15944 05/01/2015 5.15944 08/21/2015
SODIUM HYPOCHLORITE MISCELLANEOUS SOLUTION, NON-ORAL 0.125 %
9.54390 08/12/2014
SODIUM HYPOCHLORITE MISCELLANEOUS SOLUTION, NON-ORAL 0.25 %
0.04024 01/25/2013
SODIUM HYPOCHLORITE MISCELLANEOUS SOLUTION, NON-ORAL 0.5 % 0.04024 01/25/2013
SODIUM LACTATE VIAL (ML) 5 MEQ/ML 0.39992 01/25/2013
SODIUM MORRHUATE VIAL (ML) 50 MG/ML 1.96000 01/25/2013
SODIUM PHOSPHATE,DIBASIC/POT PHOS,MONOB/SOD PHOSPHATE MONO ORAL TABLET 250 MG
0.21890 11/24/2017 0.16750 03/20/2020
SODIUM PHOSPHATE,MONOBASIC/SODIUM PHOSPHATE,DIBASIC RECTAL ENEMA (ML) 19G-7G/118
0.00578 08/12/2014 0.00578 08/21/2015
SODIUM POLYSTYRENE SULFONATE ENEMA (ML) 30 G/120ML 0.25725 07/26/2013
SODIUM POLYSTYRENE SULFONATE ENEMA (ML) 50 G/200ML 0.15435 07/26/2013
SODIUM POLYSTYRENE SULFONATE ORAL POWDER (GRAM) 0.19415 08/21/2015 0.08976 02/22/2019
SODIUM POLYSTYRENE SULFONATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 15 G/60 ML
0.11988 10/10/2014
SODIUM/POTASSIUM/POTASSIUM CITRATE/SODIUM CITRATE/CIT AC ORAL SOLUTION, ORAL 500-550/5
0.02493 01/23/2015 0.02493 08/21/2015
SOLIFENACIN SUCCINATE ORAL TABLET 10 MG 0.30000 04/17/2020 0.15733 06/19/2020
SORBITOL SOLUTION IRRIGATION SOLUTION, IRRIGATION 3 % 0.00351 01/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
SORBITOL SOLUTION IRRIGATION SOLUTION, IRRIGATION 3.3 % 0.00332 01/25/2013
SOTALOL HCL INTRAVENOUS VIAL (ML) 150MG/10ML 5.68750 01/25/2013
SOTALOL HCL ORAL TABLET 120 MG 0.09290 11/15/2019 0.07900 01/24/2020
SOTALOL HCL ORAL TABLET 160 MG 0.20247 08/12/2014 0.20247 08/21/2015
SOTALOL HCL ORAL TABLET 240 MG 0.35321 03/29/2013 0.35321 08/21/2015
SOTALOL HCL ORAL TABLET 80 MG 0.06730 09/22/2017 0.05260 12/22/2017
SPINOSAD TOPICAL SUSPENSION, TOPICAL (ML) 0.9 % 1.59301 08/18/2017 1.59301 01/01/2018
SPIRONOLACTONE MISCELLANEOUS POWDER (GRAM) 100 % 4.24580 08/12/2014 4.24580 08/21/2015
SPIRONOLACTONE ORAL TABLET 100 MG 0.23410 08/16/2019 0.16950 09/20/2019
SPIRONOLACTONE ORAL TABLET 25 MG 0.06122 08/21/2015 0.04580 11/16/2018
SPIRONOLACTONE ORAL TABLET 50 MG 0.14490 08/25/2017 0.12350 10/25/2019
SPIRONOLACTONE, MICRONIZED MISCELLANEOUS POWDER (GRAM) 100 %
9.66880 08/12/2014
SPIRONOLACTONE/HYDROCHLOROTHIAZIDE ORAL TABLET 25 MG-25MG 0.90011 03/29/2018 0.72980 08/17/2018
STAVUDINE ORAL CAPSULE 15 MG 1.32500 08/12/2014
STAVUDINE ORAL CAPSULE 20 MG 1.31140 08/12/2014
STAVUDINE ORAL CAPSULE 30 MG 1.09200 09/27/2013
STAVUDINE ORAL CAPSULE 40 MG 0.98233 02/26/2016 0.91833 11/24/2017
STAVUDINE ORAL SOLUTION, RECONSTITUTED, ORAL 1 MG/ML 0.27563 01/25/2013
STREPTOMYCIN SULFATE INTRAMUSCULAR VIAL (EA) 1 G 11.16500 01/25/2013
SUCRALFATE ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 1 G/10 ML 0.40574 03/04/2020 0.42860 04/06/2020
SUCRALFATE ORAL TABLET 1 G 0.19994 01/04/2018 0.15950 05/22/2020
SULFACETAMIDE SODIUM OPHTHALMIC DROPS 10 % 2.74986 08/21/2015 1.92000 12/21/2018
SULFACETAMIDE SODIUM OPHTHALMIC OINTMENT (GRAM) 10 % 13.17200 05/23/2014 13.17200 08/21/2015
SULFACETAMIDE SODIUM TOPICAL CLEANSER (ML) 10 % 0.37761 08/12/2014 0.37761 08/21/2015
SULFACETAMIDE SODIUM TOPICAL CLEANSER, GEL (ML) 10 % 1.02906 02/13/2015
SULFACETAMIDE SODIUM TOPICAL CLEANSER, GEL EXTENDED RELEASE 10 %
0.85753 10/25/2013
SULFACETAMIDE SODIUM TOPICAL SUSPENSION, TOPICAL (ML) 10 % 0.61247 01/25/2013 0.61247 08/21/2015
SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC DROPS 10 %-0.23%
2.56476 02/15/2013 2.56476 08/21/2015
SULFACETAMIDE SODIUM/SULFUR TOPICAL CLEANSER (GRAM) 10-5%(W/W)
0.07523 02/20/2015 0.07523 08/21/2015
SULFACETAMIDE SODIUM/SULFUR TOPICAL CLEANSER (GRAM) 9 %-4.5 %
0.26751 08/21/2015 0.09064 11/15/2019
SULFACETAMIDE SODIUM/SULFUR TOPICAL CLEANSER (ML) 9 %-4 % 0.22315 01/25/2013
SULFACETAMIDE SODIUM/SULFUR TOPICAL CREAM (GRAM) 10-5%(W/W) 4.86785 08/22/2014 4.86785 08/21/2015
SULFACETAMIDE SODIUM/SULFUR TOPICAL PADS, MEDICATED (EA) 10 %-5 %
4.47784 03/20/2015 4.47784 08/21/2015
SULFACETAMIDE SODIUM/SULFUR TOPICAL SUSPENSION, TOPICAL (GRAM) 10-5%(W/W)
1.58340 05/02/2014
SULFACETAMIDE SODIUM/SULFUR TOPICAL SUSPENSION, TOPICAL (ML) 8 %-4 %
0.20782 08/12/2014
SULFACETAMIDE SODIUM/SULFUR/AVOBENZONE/OCTINOXATE/OCTYL SAL TOPICAL COMBINATION PACKAGE, CLEANSER AND CREAM 9 %-4.5 %
0.47020 11/21/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
SULFACETAMIDE SODIUM/SULFUR/UREA TOPICAL CLEANSER (ML) 10%-5%-10%
0.49178 01/25/2013
SULFADIAZINE ORAL TABLET 500 MG 3.21496 12/05/2014 3.21496 08/21/2015
SULFAMETHOXAZOLE/TRIMETHOPRIM INTRAVENOUS VIAL (ML) 80-16MG/ML
0.78029 11/07/2014
SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL SUSPENSION, ORAL (FINAL DOSE FORM) 200-40MG/5
0.13732 11/16/2018 0.12203 07/26/2019
SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL TABLET 400MG-80MG 0.06393 08/17/2018 0.04490 08/16/2019
SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL TABLET 800-160 MG 0.07643 08/25/2017 0.04090 12/22/2017
SULFASALAZINE ORAL TABLET 500 MG 0.15600 02/27/2015 0.15600 08/21/2015
SULFASALAZINE ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 500 MG
0.22563 09/30/2016 0.12670 08/25/2017
SULINDAC ORAL TABLET 150 MG 0.15930 08/21/2015 0.12100 09/22/2017
SULINDAC ORAL TABLET 200 MG 0.19673 03/02/2018 0.13438 08/17/2018
SUMATRIPTAN NASAL SPRAY, NON-AEROSOL (EA) 20 MG 45.17086 06/16/2017 40.67000 06/22/2018
SUMATRIPTAN NASAL SPRAY, NON-AEROSOL (EA) 5 MG 46.82000 04/05/2019 38.32500 05/22/2020
SUMATRIPTAN SUCCINATE ORAL TABLET 100 MG 0.44444 06/16/2017 0.36778 03/02/2018
SUMATRIPTAN SUCCINATE ORAL TABLET 25 MG 0.46722 11/15/2019 0.37556 03/20/2020
SUMATRIPTAN SUCCINATE ORAL TABLET 50 MG 0.46667 07/14/2017 0.36556 11/16/2018
SUMATRIPTAN SUCCINATE SUBCUTANEOUS CARTRIDGE (ML) 6 MG/0.5ML
129.12200 01/25/2013 129.12200 08/21/2015
SUMATRIPTAN SUCCINATE SUBCUTANEOUS PEN INJECTOR (ML) 6 MG/0.5ML
91.25000 01/25/2019 86.52000 06/21/2019
SUMATRIPTAN SUCCINATE SUBCUTANEOUS VIAL (ML) 6 MG/0.5ML 39.30000 10/19/2018 32.50000 01/25/2019
TACROLIMUS ORAL CAPSULE 0.5 MG 0.11703 03/03/2017 0.08055 08/17/2018
TACROLIMUS ORAL CAPSULE 1 MG 0.18660 03/03/2017 0.13478 11/16/2018
TACROLIMUS ORAL CAPSULE 5 MG 0.39610 09/21/2018 5.46000 01/17/2020
TACROLIMUS TOPICAL OINTMENT (GRAM) 0.03 % 5.17608 11/24/2017 4.11000 12/20/2019
TACROLIMUS TOPICAL OINTMENT (GRAM) 0.1 % 4.83523 11/24/2017 3.49000 05/22/2020
TADALAFIL ORAL TABLET 10 MG 1.05000 06/21/2019
TADALAFIL ORAL TABLET 20 MG 1.05000 06/21/2019 0.42967 08/16/2019
TADALAFIL ORAL TABLET 5 MG 0.28400 01/24/2020 0.25900 05/22/2020
TAMOXIFEN CITRATE ORAL TABLET 10 MG 0.24955 08/21/2015 0.15000 11/24/2017
TAMOXIFEN CITRATE ORAL TABLET 20 MG 0.24500 04/17/2020 0.46024 05/13/2020
TAMSULOSIN HCL ORAL CAPSULE 0.4 MG 0.09815 11/24/2017 0.06065 11/16/2018
TEA TREE OIL TOPICAL OIL (ML) 100 % 0.25509 08/12/2014
TELMISARTAN ORAL TABLET 20 MG 0.70000 01/01/2017 0.13809 06/16/2017
TELMISARTAN ORAL TABLET 40 MG 0.26333 09/22/2017 0.12822 11/16/2018
TELMISARTAN ORAL TABLET 80 MG 0.28902 06/16/2017 0.26433 08/17/2018
TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 40 MG-10MG 3.87707 08/21/2015 3.87707 01/01/2020
TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 40 MG-5 MG 3.87707 10/03/2014 3.87707 08/21/2015
TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 80 MG-10MG 3.87707 08/21/2015 3.87707 01/01/2020
TELMISARTAN/AMLODIPINE BESYLATE ORAL TABLET 80 MG-5 MG 3.87707 08/21/2015 3.87707 01/01/2020
TELMISARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 40-12.5 MG 2.39935 06/16/2017 0.73000 05/25/2018
TELMISARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 80 MG-25MG 1.23867 08/17/2018 0.56667 11/15/2019
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
TELMISARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 80-12.5MG 1.28950 09/21/2018 1.17000 02/22/2019
TEMAZEPAM ORAL CAPSULE 15 MG 0.06445 08/21/2015 0.04590 03/02/2018
TEMAZEPAM ORAL CAPSULE 22.5 MG 4.17825 06/16/2017 3.96400 04/17/2020
TEMAZEPAM ORAL CAPSULE 30 MG 0.08040 03/06/2015 0.08040 08/21/2015
TEMAZEPAM ORAL CAPSULE 7.5 MG 3.36810 06/16/2017 1.55470 09/22/2017
TEMOZOLOMIDE ORAL CAPSULE 100 MG 96.94428 10/28/2016 42.23000 09/21/2018
TEMOZOLOMIDE ORAL CAPSULE 140 MG 128.55828 07/29/2016
TEMOZOLOMIDE ORAL CAPSULE 180 MG 127.00000 09/22/2017 60.22000 05/22/2020
TEMOZOLOMIDE ORAL CAPSULE 20 MG 21.53000 07/29/2016
TEMOZOLOMIDE ORAL CAPSULE 250 MG 241.19000 07/29/2016
TEMOZOLOMIDE ORAL CAPSULE 5 MG 8.05000 07/29/2016
TENIPOSIDE INTRAVENOUS AMPUL (ML) 50 MG/5 ML 56.11060 08/16/2013 56.11060 08/21/2015
TERAZOSIN HCL ORAL CAPSULE 1 MG 0.05574 08/29/2014 0.05574 08/21/2015
TERAZOSIN HCL ORAL CAPSULE 10 MG 0.06888 08/21/2015 0.04130 08/25/2017
TERAZOSIN HCL ORAL CAPSULE 2 MG 0.05574 08/12/2014 0.05574 08/21/2015
TERAZOSIN HCL ORAL CAPSULE 5 MG 0.06266 08/21/2015 0.05040 12/22/2017
TERBINAFINE HCL ORAL TABLET 250 MG 0.10367 08/25/2017 0.08000 12/20/2019
TERBINAFINE HCL TOPICAL CREAM (GRAM) 1 % 0.39135 04/10/2015 0.39135 08/21/2015
TERBUTALINE SULFATE ORAL TABLET 2.5 MG 0.27990 12/26/2014 1.26973 10/01/2015
TERCONAZOLE VAGINAL CREAM WITH APPLICATOR 0.4 % 0.48888 03/03/2017 0.71068 01/16/2020
TERCONAZOLE VAGINAL CREAM WITH APPLICATOR 0.8 % 1.43255 07/05/2013 1.43255 08/21/2015
TERCONAZOLE VAGINAL SUPPOSITORY, VAGINAL 80 MG 22.83867 04/12/2013 22.83867 08/21/2015
TESTOSTERONE CYPIONATE INTRAMUSCULAR VIAL (ML) 100 MG/ML 4.13840 08/12/2014
TESTOSTERONE CYPIONATE INTRAMUSCULAR VIAL (ML) 200 MG/ML 15.27368 01/22/2020 16.21857 04/24/2020
TESTOSTERONE ENANTHATE INTRAMUSCULAR VIAL (ML) 200 MG/ML 11.89300 04/19/2013 11.89300 08/21/2015
TESTOSTERONE MISCELLANEOUS POWDER (GRAM) 0.19136 08/21/2015
TESTOSTERONE PROPIONATE MISCELLANEOUS POWDER (GRAM) 1.55480 08/21/2015
TESTOSTERONE TRANSDERMAL GEL (GRAM) 50 MG (1%) 1.92771 04/22/2016 1.28256 06/16/2017
TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG (2%)
13.97550 11/14/2014 4.85000 10/25/2019
TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 12.5/1.25G
1.92710 03/06/2015 1.92710 08/21/2015
TESTOSTERONE TRANSDERMAL GEL IN PACKET (GRAM) 25MG(1%) 4.08296 03/06/2015
TESTOSTERONE TRANSDERMAL GEL IN PACKET (GRAM) 50 MG (1%) 1.98413 01/01/2017 1.98413 01/03/2017
TETANUS AND DIPHTHERIA TOXOIDS, ADULT INTRAMUSCULAR VIAL (ML) 2-2 LF/0.5
30.27570 01/25/2013 30.27570 08/21/2015
TETANUS,DIPHTHERIA TOXOID PED/PF INTRAMUSCULAR VIAL (ML) 5-25/0.5ML
150.18360 11/07/2014 150.18360 08/21/2015
TETRACAINE HCL OPHTHALMIC DROPS 0.5 % 0.49187 01/25/2013 0.49187 08/21/2015
TETRACAINE HCL/PF OPHTHALMIC DROPS 0.5 % 8.12960 08/12/2014
TETRACYCLINE HCL MISCELLANEOUS POWDER (GRAM) 0.66757 05/01/2015 0.66757 08/21/2015
TETRACYCLINE HCL ORAL CAPSULE 250 MG 4.62950 08/21/2015 3.20000 09/21/2018
TETRACYCLINE HCL ORAL CAPSULE 500 MG 3.86019 09/21/2018 2.19010 11/15/2019
THEOPHYLLINE ANHYDROUS ORAL ELIXIR 80 MG/15ML 0.58429 07/05/2013 0.58429 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
THEOPHYLLINE ANHYDROUS ORAL SOLUTION, ORAL 80 MG/15ML 0.15122 08/12/2014 0.15122 08/21/2015
THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 100 MG
0.31010 01/30/2015 0.31010 08/21/2015
THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 200 MG
0.39893 01/30/2015 0.39893 08/21/2015
THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 300 MG
2.59756 03/14/2018 2.59756 06/08/2018
THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 12 HR 450 MG
2.63490 07/12/2017 4.55210 01/11/2018
THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 400 MG
0.95030 02/01/2013
THEOPHYLLINE ANHYDROUS ORAL TABLET, EXTENDED RELEASE 600 MG
1.37320 02/01/2013
THEOPHYLLINE IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 200MG/0.1L
0.03335 01/25/2013
THEOPHYLLINE IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 200MG/50ML
0.09490 08/12/2014
THEOPHYLLINE IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 400MG/.25L
0.01852 01/25/2013
THEOPHYLLINE IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 400MG/0.5L
0.00730 01/25/2013
THEOPHYLLINE IN DEXTROSE 5 % IN WATER INTRAVENOUS INTRAVENOUS SOLUTION 800MG/.25L
0.01890 08/12/2014
THIAMINE HCL INJECTION VIAL (ML) 100 MG/ML 3.68193 08/12/2014
THIAMINE HCL ORAL TABLET 100 MG 0.01375 08/12/2014 0.01375 08/21/2015
THIAMINE HCL ORAL TABLET 50 MG 0.01586 01/25/2013
THIAMINE HCL/RIBOFLAVIN/NIACINAMIDE/DEXPANTHENOL/PYRIDOXINE INJECTION VIAL (ML) 100-2MG/ML
1.31319 01/25/2013
THIAMINE MONONITRATE (VIT B1) ORAL TABLET 100 MG 0.02524 04/24/2015 0.02524 08/21/2015
THIORIDAZINE HCL ORAL TABLET 10 MG 0.35490 05/30/2014
THIORIDAZINE HCL ORAL TABLET 100 MG 0.79650 07/21/2016 0.83510 01/20/2017
THIORIDAZINE HCL ORAL TABLET 25 MG 0.24040 02/15/2013
THIORIDAZINE HCL ORAL TABLET 50 MG 0.59970 05/19/2017 0.56010 11/16/2018
THIOTHIXENE ORAL CAPSULE 1 MG 0.44352 12/26/2014 0.44352 08/21/2015
THIOTHIXENE ORAL CAPSULE 10 MG 1.88013 04/10/2015 1.88013 08/21/2015
THIOTHIXENE ORAL CAPSULE 2 MG 0.85163 03/13/2015 0.85163 08/21/2015
THIOTHIXENE ORAL CAPSULE 5 MG 1.29668 08/21/2015 1.90520 01/02/2020
TIAGABINE HCL ORAL TABLET 2 MG 4.68720 03/27/2015 4.68720 08/21/2015
TIAGABINE HCL ORAL TABLET 4 MG 4.68720 03/27/2015 4.68720 08/21/2015
TICLOPIDINE HCL TABLET 250 MG 1.31502 11/14/2014 1.31502 08/21/2015
TIMOLOL MALEATE OPHTHALMIC DROPS 0.25 % 0.45600 11/24/2017 0.42400 02/22/2019
TIMOLOL MALEATE OPHTHALMIC DROPS 0.5 % 0.56636 02/22/2019 0.51000 04/26/2019
TIMOLOL MALEATE OPHTHALMIC GEL-FORMING SOLUTION 0.25 % 19.30600 06/27/2014
TIMOLOL MALEATE OPHTHALMIC GEL-FORMING SOLUTION 0.5 % 19.15060 07/18/2014
TIMOLOL MALEATE ORAL TABLET 10 MG 0.99344 06/06/2014
TIMOLOL MALEATE ORAL TABLET 20 MG 1.83281 06/06/2014
TIMOLOL MALEATE ORAL TABLET 5 MG 0.44560 08/12/2014
TINIDAZOLE ORAL TABLET 250 MG 0.87620 08/22/2014 0.87620 01/01/2017
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
TINIDAZOLE ORAL TABLET 500 MG 2.65000 06/22/2018 1.67000 06/21/2019
TIZANIDINE HCL ORAL CAPSULE 2 MG 0.60000 12/21/2018 0.29733 02/21/2020
TIZANIDINE HCL ORAL CAPSULE 4 MG 0.78350 06/16/2017 0.40807 02/21/2020
TIZANIDINE HCL ORAL CAPSULE 6 MG 2.02220 05/20/2016 1.53533 12/22/2017
TIZANIDINE HCL ORAL TABLET 2 MG 0.02233 11/16/2018 0.07180 04/07/2020
TIZANIDINE HCL ORAL TABLET 4 MG 0.06003 08/21/2015 0.03761 05/22/2020
TOBRAMYCIN OPHTHALMIC DROPS 0.3 % 1.09667 06/16/2017 0.82800 11/24/2017
TOBRAMYCIN SULFATE INJECTION VIAL (EA) 1.2 G 67.77984 08/01/2014
TOBRAMYCIN SULFATE INJECTION VIAL (ML) 10 MG/ML 1.10250 01/25/2013
TOBRAMYCIN SULFATE INJECTION VIAL (ML) 40 MG/ML 0.57335 10/03/2014 0.57335 08/21/2015
TOBRAMYCIN SULFATE/SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 60 MG/50ML
0.31870 01/25/2013
TOBRAMYCIN SULFATE/SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 80MG/100ML
0.18270 01/25/2013
TOBRAMYCIN/DEXAMETHASONE OPHTHALMIC SUSPENSION, DROPS(FINAL DOSAGE FORM)(ML) 0.3 %-0.1%
12.90400 08/25/2017 12.90400 01/01/2018
TOLAZAMIDE TABLET 250 MG 2.22090 08/12/2014 2.22090 08/21/2015
TOLAZAMIDE TABLET 500 MG 1.52140 08/12/2014
TOLBUTAMIDE TABLET 500 MG 0.73440 08/12/2014
TOLMETIN SODIUM ORAL CAPSULE 400 MG 1.16584 01/25/2013 1.16584 08/21/2015
TOLMETIN SODIUM ORAL TABLET 200 MG 0.52500 02/08/2013
TOLMETIN SODIUM ORAL TABLET 600 MG 2.47650 08/12/2014 2.47650 08/21/2015
TOLNAFTATE TOPICAL AEROSOL, POWDER (GRAM) 1 % 0.04750 08/21/2015
TOLNAFTATE TOPICAL CREAM (GRAM) 1 % 0.11078 01/09/2015 0.11078 08/21/2015
TOLNAFTATE TOPICAL POWDER (GRAM) 1 % 0.04750 08/12/2014 0.04750 08/21/2015
TOLTERODINE TARTRATE ORAL CAPSULE, EXT RELEASE 24 HR 2 MG 1.42833 09/20/2019 1.23116 03/20/2020
TOLTERODINE TARTRATE ORAL CAPSULE, EXT RELEASE 24 HR 4 MG 1.12667 05/17/2019 0.90000 05/22/2020
TOLTERODINE TARTRATE ORAL TABLET 1 MG 0.72917 11/16/2018 0.43100 11/15/2019
TOLTERODINE TARTRATE ORAL TABLET 2 MG 0.58475 05/17/2019 0.38750 05/22/2020
TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 100 MG
12.64551 09/19/2014 16.13817 04/05/2019
TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 150 MG
15.54000 09/19/2014 16.10700 05/21/2018
TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 200 MG
20.06300 05/09/2019 22.09013 03/07/2020
TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 25 MG
4.87551 09/19/2014 5.74233 09/12/2018
TOPIRAMATE ORAL CAPSULE SPRINKLE, EXTENDED RELEASE 24 HR 50 MG
6.72182 04/20/2018 7.40912 09/12/2018
TOPIRAMATE ORAL CAPSULE, SPRINKLE 15 MG 0.23103 04/21/2017 0.48250 03/10/2020
TOPIRAMATE ORAL CAPSULE, SPRINKLE 25 MG 0.46055 09/30/2016 0.44733 08/17/2018
TOPIRAMATE ORAL TABLET 100 MG 0.06500 08/25/2017 0.03583 02/22/2019
TOPIRAMATE ORAL TABLET 200 MG 0.09788 03/03/2017 0.08528 11/16/2018
TOPIRAMATE ORAL TABLET 25 MG 0.04470 08/21/2015 0.02750 06/16/2017
TOPIRAMATE ORAL TABLET 50 MG 0.03750 09/22/2017 0.02333 05/22/2020
TOPOTECAN HCL INTRAVENOUS VIAL (EA) 4 MG 81.26200 01/23/2015 81.26200 08/21/2015
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
TOPOTECAN HCL INTRAVENOUS VIAL (ML) 4 MG/4 ML 30.38490 01/09/2015 30.38490 08/21/2015
TORSEMIDE ORAL TABLET 10 MG 0.06650 10/20/2017 0.04670 11/15/2019
TORSEMIDE ORAL TABLET 100 MG 0.25220 03/02/2018 0.12655 11/16/2018
TORSEMIDE ORAL TABLET 20 MG 0.07950 07/14/2017 0.06643 11/16/2018
TORSEMIDE ORAL TABLET 5 MG 0.09400 09/22/2017 0.05660 11/16/2018
TORSEMIDE VIAL (ML) 20 MG/2 ML 4.31340 01/25/2013
TORSEMIDE VIAL (ML) 50 MG/5 ML 2.34654 01/25/2013
TRAMADOL HCL ORAL TABLET 50 MG 0.01510 04/27/2018 0.01627 09/18/2018
TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 100 MG 1.65067 05/25/2018 1.49967 03/20/2020
TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 200 MG 4.20992 08/21/2015 1.30933 09/22/2017
TRAMADOL HCL ORAL TABLET, EXTENDED RELEASE 24 HR 300 MG 4.04500 09/30/2016 3.23534 06/16/2017
TRAMADOL HCL ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 100 MG
1.86080 08/12/2014 1.86080 08/21/2015
TRAMADOL HCL ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 200 MG
5.44880 08/15/2014 5.44880 08/21/2015
TRAMADOL HCL ORAL TABLET,EXTENDED RELEASE MULTIPHASE 24 HR 300 MG
3.77000 01/25/2013 3.77000 08/21/2015
TRAMADOL HCL/ACETAMINOPHEN ORAL TABLET 37.5-325MG 0.21668 08/21/2015 0.08010 09/22/2017
TRANDOLAPRIL ORAL TABLET 1 MG 0.25064 08/21/2015 0.21120 08/25/2017
TRANDOLAPRIL ORAL TABLET 2 MG 0.27372 08/21/2015 0.23910 06/16/2017
TRANDOLAPRIL ORAL TABLET 4 MG 0.25133 08/12/2014 0.25133 08/21/2015
TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND REL BIPHASE 24HR 1MG-240 MG
3.70321 05/01/2015
TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND REL BIPHASE 24HR 2 MG-180MG
3.70321 05/01/2015
TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND REL BIPHASE 24HR 2MG-240 MG
3.70321 05/01/2015
TRANDOLAPRIL/VERAPAMIL HCL ORAL TABLET,IMMED AND EXTEND REL BIPHASE 24HR 4MG-240 MG
3.70321 05/01/2015
TRANEXAMIC ACID INTRAVENOUS AMPUL (ML) 1000 MG/10 4.94036 04/10/2015 4.94036 08/21/2015
TRANEXAMIC ACID INTRAVENOUS VIAL (ML) 1000 MG/10 4.18675 02/13/2015 4.18675 08/21/2015
TRANEXAMIC ACID ORAL TABLET 650 MG 1.07400 05/17/2019 1.81496 05/09/2020
TRANYLCYPROMINE SULFATE ORAL TABLET 10 MG 1.49220 03/02/2018 1.01000 10/25/2019
TRAVOPROST (BENZALKONIUM) DROPS 0.004 % 29.13400 05/03/2013
TRAZODONE HCL ORAL TABLET 100 MG 0.10300 04/20/2016 0.06178 07/14/2017
TRAZODONE HCL ORAL TABLET 150 MG 0.13590 02/22/2019 0.08990 03/20/2020
TRAZODONE HCL ORAL TABLET 300 MG 2.76314 08/21/2015 2.19000 10/19/2018
TRAZODONE HCL ORAL TABLET 50 MG 0.08541 10/02/2015 0.03200 08/25/2017
TRETINOIN ORAL CAPSULE 10 MG 18.81170 12/05/2014
TRETINOIN TOPICAL CREAM (GRAM) 0.025 % 2.08949 03/20/2020 2.39910 03/30/2020
TRETINOIN TOPICAL CREAM (GRAM) 0.05 % 3.20000 10/25/2019 3.60262 03/23/2020
TRETINOIN TOPICAL CREAM (GRAM) 0.1 % 4.55930 04/01/2019 3.89489 07/26/2019
TRETINOIN TOPICAL GEL (GRAM) 0.01 % 1.51858 04/01/2019 3.77480 10/08/2019
TRETINOIN TOPICAL GEL (GRAM) 0.025 % 3.33916 08/19/2019 2.89600 03/20/2020
TRIAMCINOLONE ACETONIDE DENTAL PASTE (GRAM) 0.1 % 5.58000 12/21/2018 5.19600 03/20/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
TRIAMCINOLONE ACETONIDE INJECTION VIAL (ML) 10 MG/ML 1.52320 08/01/2014 1.52320 08/21/2015
TRIAMCINOLONE ACETONIDE INJECTION VIAL (ML) 40 MG/ML 2.89400 08/01/2014 2.89400 08/21/2015
TRIAMCINOLONE ACETONIDE NASAL AEROSOL, SPRAY (GRAM) 55 MCG 4.71467 03/27/2015 4.71467 08/21/2015
TRIAMCINOLONE ACETONIDE TOPICAL AEROSOL (GRAM) 0.147MG/G 2.72467 05/01/2015 2.64159 03/20/2020
TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.025 % 0.09310 08/12/2014 0.09310 08/21/2015
TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.1 % 0.05888 06/16/2017 0.04281 01/25/2019
TRIAMCINOLONE ACETONIDE TOPICAL CREAM (GRAM) 0.5 % 0.33419 07/14/2017 0.31333 10/25/2019
TRIAMCINOLONE ACETONIDE TOPICAL LOTION (ML) 0.025 % 0.76647 08/12/2014
TRIAMCINOLONE ACETONIDE TOPICAL LOTION (ML) 0.1 % 0.40833 11/24/2017 0.38000 11/15/2019
TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.025 % 0.28560 08/21/2015 0.13286 08/16/2019
TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.1 % 0.11910 02/20/2015 0.11910 08/21/2015
TRIAMCINOLONE ACETONIDE TOPICAL OINTMENT (GRAM) 0.5 % 0.38333 06/21/2019 0.35000 03/20/2020
TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL CAPSULE 37.5-25 MG 0.11056 03/03/2017 0.04697 12/22/2017
TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL TABLET 37.5-25 MG 0.15561 05/19/2017 0.07000 08/25/2017
TRIAMTERENE/HYDROCHLOROTHIAZIDE ORAL TABLET 75 MG-50MG 0.18148 08/21/2015 0.05500 09/22/2017
TRIAZOLAM ORAL TABLET 0.125 MG 0.20980 03/01/2013 0.20980 08/21/2015
TRIAZOLAM ORAL TABLET 0.25 MG 0.86737 02/13/2015 0.86737 08/21/2015
TRIFLUOPERAZINE HCL ORAL TABLET 1 MG 0.61215 04/24/2015 0.55090 11/24/2017
TRIFLUOPERAZINE HCL ORAL TABLET 10 MG 1.67825 04/24/2015 1.46378 06/21/2019
TRIFLUOPERAZINE HCL ORAL TABLET 2 MG 0.72000 08/17/2018 0.69000 11/16/2018
TRIFLUOPERAZINE HCL ORAL TABLET 5 MG 0.97490 01/19/2018 0.95030 03/02/2018
TRIFLURIDINE OPHTHALMIC DROPS 1 % 21.31330 07/09/2018 21.91752 04/15/2019
TRIHEXYPHENIDYL HCL ORAL ELIXIR 2 MG/5 ML 0.06175 02/13/2015
TRIHEXYPHENIDYL HCL ORAL TABLET 2 MG 0.05735 11/22/2013
TRIHEXYPHENIDYL HCL ORAL TABLET 5 MG 0.09110 08/25/2017 0.06878 01/19/2018
TRIMETHOBENZAMIDE HCL ORAL CAPSULE 300 MG 1.14618 04/12/2013
TRIMETHOPRIM ORAL TABLET 100 MG 0.27023 02/13/2015 0.16520 09/22/2017
TRIPROLIDINE HCL/PSEUDOEPHEDRINE HCL ORAL LIQUID (ML) 0.938-10/1
1.59900 08/12/2014 1.59900 08/21/2015
TRIPROLIDINE HCL/PSEUDOEPHEDRINE HCL ORAL SYRUP 1.25-30/5 0.05830 08/12/2014
TRIPROLIDINE HCL/PSEUDOEPHEDRINE HCL ORAL TABLET 2.5MG-60MG 0.05247 01/25/2013 0.05247 08/21/2015
TROPICAMIDE OPHTHALMIC DROPS 0.5 % 0.64860 08/12/2014
TROPICAMIDE OPHTHALMIC DROPS 1 % 0.52737 08/12/2014 0.34733 11/24/2017
TROSPIUM CHLORIDE ORAL CAPSULE, EXT RELEASE 24 HR 60 MG 4.06176 12/02/2016 3.77843 06/16/2017
TROSPIUM CHLORIDE ORAL TABLET 20 MG 0.37433 09/22/2017 0.25217 05/17/2019
UREA TOPICAL CREAM (GRAM) 40 % 0.16364 08/21/2015 1.75937 03/06/2019
UREA TOPICAL FOAM (GRAM) 35 % 0.88531 09/05/2014
UREA TOPICAL GEL WITH PREFILLED APPLICATOR (ML) 45 % 5.82575 01/25/2013
UREA TOPICAL KIT 40%-0.2% 282.72300 01/25/2013
UREA TOPICAL LOTION (GRAM) 45 % 0.17003 01/25/2013 0.17003 08/21/2015
UREA TOPICAL LOTION (ML) 40 % 0.07492 09/26/2014 0.07492 08/21/2015
UREA TOPICAL NAIL FILM SUSPENSION (ML) 40 % 11.93033 02/14/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
UREA/HYALURONATE SODIUM KIT 40%-0.2% 282.72300 01/25/2013
URSODIOL MISCELLANEOUS POWDER (GRAM) 100 % 1.52880 08/21/2015
URSODIOL ORAL CAPSULE 300 MG 1.28215 08/16/2019 0.79510 09/20/2019
URSODIOL ORAL TABLET 250 MG 0.89760 10/15/2018 0.71540 01/24/2020
URSODIOL ORAL TABLET 500 MG 1.05000 11/24/2017 0.63240 05/17/2019
VALACYCLOVIR HCL ORAL TABLET 1000 MG 0.37833 01/19/2018 0.34233 09/21/2018
VALACYCLOVIR HCL ORAL TABLET 500 MG 0.21606 06/21/2019 0.18200 07/26/2019
VALGANCICLOVIR HCL ORAL TABLET 450 MG 19.10000 09/22/2017 5.24417 11/15/2019
VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) MISCELLANEOUS POWDER (GRAM) 100 %
0.69225 08/12/2014
VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) ORAL SOLUTION, ORAL 250 MG/5ML
0.15149 05/01/2015 0.15149 08/21/2015
VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) ORAL SOLUTION, ORAL 250 MG/5ML
0.01420 05/17/2013 0.01897 02/14/2020
VALPROIC ACID (AS SODIUM SALT) (VALPROATE SODIUM) ORAL SOLUTION, ORAL 500MG/10ML
0.08532 08/12/2014
VALPROIC ACID ORAL CAPSULE 250 MG 0.22504 04/12/2018 0.14010 02/22/2019
VALSARTAN ORAL TABLET 160 MG 0.46207 11/15/2019 0.32845 05/22/2020
VALSARTAN ORAL TABLET 320 MG 0.48608 10/02/2019 0.40033 04/17/2020
VALSARTAN ORAL TABLET 40 MG 0.05556 11/24/2017 0.18770 10/02/2019
VALSARTAN ORAL TABLET 80 MG 0.12753 05/19/2017 0.07372 03/02/2018
VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 160-12.5MG 0.11778 03/16/2018 0.66866 03/14/2020
VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 160-25MG 0.20035 03/03/2017 0.14689 03/16/2018
VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 320-12.5MG 0.25178 03/03/2017 0.20556 08/17/2018
VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 320MG-25MG 0.43524 12/19/2019 0.32422 05/22/2020
VALSARTAN/HYDROCHLOROTHIAZIDE ORAL TABLET 80-12.5MG 0.21031 03/03/2017 0.13678 08/25/2017
VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 1 G 3.85000 05/17/2019 2.93100 03/20/2020
VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 10 G 41.89000 09/16/2016 40.99000 08/17/2018
VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 5 G 21.82000 07/04/2016 21.43000 08/17/2018
VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 500 MG 2.11680 08/12/2014 2.11680 08/21/2015
VANCOMYCIN HCL INTRAVENOUS VIAL (EA) 750 MG 6.69900 01/25/2013
VANCOMYCIN HCL INTRAVENOUS VIAL WITH THREADED PORT (EA) 750 MG
10.90110 01/25/2013
VANCOMYCIN HCL ORAL CAPSULE 125 MG 2.25000 11/16/2018 2.10033 02/21/2020
VANCOMYCIN HCL ORAL CAPSULE 250 MG 7.23600 11/24/2017 6.49950 05/17/2019
VANCOMYCIN IN 5 % DEXTROSE IN WATER INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 1G/200ML
0.29786 07/25/2014
VANCOMYCIN IN 5 % DEXTROSE IN WATER INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 500MG/0.1L
0.18969 11/07/2014
VANCOMYCIN IN 5 % DEXTROSE IN WATER INTRAVENOUS IV SOLUTION, PIGGYBACK PREMIX FROZEN(ML) 750MG/.15L
0.17722 07/25/2014
VASOPRESSIN VIAL (ML) 20 UNIT/ML 3.14184 08/12/2014 3.14184 08/21/2015
VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 150 MG 0.14709 03/02/2018 0.14250 07/26/2019
VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 37.5 MG 0.10578 01/19/2018 0.09175 05/22/2020
VENLAFAXINE HCL ORAL CAPSULE, EXT RELEASE 24 HR 75 MG 0.15843 11/15/2019 0.09733 04/17/2020
VENLAFAXINE HCL ORAL TABLET 100 MG 0.09980 08/16/2019 0.05010 06/19/2020
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
VENLAFAXINE HCL ORAL TABLET 25 MG 0.19030 08/25/2017 0.11520 11/16/2018
VENLAFAXINE HCL ORAL TABLET 37.5 MG 0.14520 08/17/2018 0.11380 07/26/2019
VENLAFAXINE HCL ORAL TABLET 50 MG 0.23880 09/22/2017 0.14160 08/17/2018
VENLAFAXINE HCL ORAL TABLET 75 MG 0.09780 12/22/2017 0.04630 05/22/2020
VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 150 MG 3.19458 08/21/2015 2.62298 12/02/2016
VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 225 MG 5.77550 01/09/2015 7.38620 12/11/2018
VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 37.5 MG 3.22698 03/27/2015
VENLAFAXINE HCL ORAL TABLET, EXTENDED RELEASE 24 HR 75 MG 3.51130 03/27/2015 4.74492 12/31/2019
VERAPAMIL HCL INTRAVENOUS AMPUL (ML) 2.5 MG/ML 1.65480 01/25/2013
VERAPAMIL HCL INTRAVENOUS SYRINGE (ML) 2.5 MG/ML 4.46460 01/25/2013
VERAPAMIL HCL INTRAVENOUS VIAL (ML) 2.5 MG/ML 2.14400 01/25/2013 2.14400 08/21/2015
VERAPAMIL HCL MISCELLANEOUS POWDER (GRAM) 100 % 0.53976 08/21/2015
VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 120 MG
1.35700 09/21/2016 0.86929 06/16/2017
VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 180 MG
0.70015 04/10/2015 0.70015 08/21/2015
VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 240 MG
0.89550 05/15/2015 0.89550 08/21/2015
VERAPAMIL HCL ORAL CAPSULE, EXTENDED RELEASE PELLETS 24 HR 360 MG
2.54807 04/10/2015 2.54807 08/21/2015
VERAPAMIL HCL ORAL CAPSULE,24HR EXTENDED RELEASE PELLET CT 100 MG
1.23210 08/12/2014 1.23210 08/21/2015
VERAPAMIL HCL ORAL CAPSULE,24HR EXTENDED RELEASE PELLET CT 200 MG
1.58723 01/25/2013 1.58723 08/21/2015
VERAPAMIL HCL ORAL CAPSULE,24HR EXTENDED RELEASE PELLET CT 300 MG
2.09080 02/27/2015 2.09080 08/21/2015
VERAPAMIL HCL ORAL TABLET 120 MG 0.06180 09/22/2017 0.04790 10/25/2019
VERAPAMIL HCL ORAL TABLET 40 MG 0.18824 05/30/2014
VERAPAMIL HCL ORAL TABLET 80 MG 0.05600 08/12/2014 0.05600 08/21/2015
VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 120 MG 0.16750 03/16/2018 0.11030 08/17/2018
VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 180 MG 0.16830 08/21/2015 0.10355 09/22/2017
VERAPAMIL HCL ORAL TABLET, EXTENDED RELEASE 240 MG 0.12965 10/20/2017 0.07657 03/02/2018
VINBLASTINE SULFATE INTRAVENOUS VIAL (ML) 1 MG/ML 2.22600 01/25/2013
VIT B COMPLEX/VIT C/FOLIC ACID/FERROUS FUMARATE/VIT E ACET ORAL TABLET 500-400-18
0.05547 01/25/2013
VITAMIN A/ASCORBIC ACID/ZINC/PROPOLIS (BEE GLUE) ORAL LOZENGE 15 MG
0.02440 08/12/2014
VITAMIN B COMPLEX AND VITAMIN C NO.20/FOLIC ACID ORAL CAPSULE 1 MG
0.16037 08/21/2015 0.09490 11/24/2017
VITAMIN B COMPLEX NO.3/FOLIC ACID/ASCORBIC ACID(VITC)/BIOTIN ORAL TABLET 1MG-60MG
0.12810 08/12/2014 0.12810 08/21/2015
VITAMIN B COMPLEX/LYSINE ORAL LIQUID (ML) 790MG/15ML 0.03270 01/25/2013
VITAMIN E (DL-ALPHA TOCOPHERYL ACETATE) ORAL CAPSULE 400 UNIT 0.04540 08/21/2015
VITAMIN E MIXED ORAL CAPSULE 400 UNIT 0.05369 08/12/2014 0.05369 08/21/2015
VITAMIN E ORAL CAPSULE 100 UNIT 0.02028 01/25/2013 0.02028 08/21/2015
VITAMIN E ORAL CAPSULE 1000 UNIT 0.12857 01/25/2013 0.12857 08/21/2015
VITAMIN E ORAL CAPSULE 200 UNIT 0.02860 08/12/2014
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
VITAMIN E ORAL CAPSULE 400 UNIT 0.04540 08/12/2014 0.04540 08/21/2015
VITAMIN E ORAL DROPS 50 UNIT/ML 0.94477 01/31/2014
VITAMINS A AND D/WHITE PETROLATUM/LANOLIN TOPICAL OINTMENT IN PACKET (GRAM)
0.03450 08/12/2014
VORICONAZOLE INTRAVENOUS VIAL (EA) 200 MG 44.58750 08/12/2014
VORICONAZOLE ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200 MG/5ML
9.84947 12/27/2013
VORICONAZOLE ORAL TABLET 200 MG 5.00600 08/17/2018 3.00000 05/17/2019
VORICONAZOLE ORAL TABLET 50 MG 5.86000 07/08/2016 4.93290 09/21/2018
WARFARIN SODIUM ORAL TABLET 1 MG 0.14230 01/19/2018 0.09226 08/16/2019
WARFARIN SODIUM ORAL TABLET 10 MG 0.21998 08/21/2015 0.12355 08/16/2019
WARFARIN SODIUM ORAL TABLET 2 MG 0.11277 08/16/2019 0.07090 05/22/2020
WARFARIN SODIUM ORAL TABLET 2.5 MG 0.20194 08/21/2015 0.06420 08/16/2019
WARFARIN SODIUM ORAL TABLET 3 MG 0.20206 08/21/2015 0.10730 07/26/2019
WARFARIN SODIUM ORAL TABLET 4 MG 0.10000 08/16/2019 0.08291 05/22/2020
WARFARIN SODIUM ORAL TABLET 5 MG 0.08184 06/21/2019 0.07560 07/26/2019
WARFARIN SODIUM ORAL TABLET 6 MG 0.23115 08/21/2015 0.07290 08/16/2019
WARFARIN SODIUM ORAL TABLET 7.5 MG 0.17462 08/21/2015 0.06695 08/16/2019
WATER FOR INJ.,BACTERIOSTATIC INJECTION VIAL (ML) 0.02828 03/20/2015 0.02828 08/21/2015
WATER FOR INJECTION,STERILE INJECTION AMPUL (ML) 0.08820 01/25/2013 0.08820 08/21/2015
WATER FOR INJECTION,STERILE INJECTION VIAL (ML) 0.07489 08/21/2015 0.05462 02/22/2019
WATER FOR INJECTION,STERILE INTRAVENOUS INTRAVENOUS SOLUTION
0.00226 05/01/2015 0.00226 08/21/2015
WATER FOR IRRIGATION,STERILE IRRIGATION SOLUTION, IRRIGATION 0.00545 08/12/2014 0.00545 08/21/2015
WATER ORAL LIQUID (ML) 0.01165 01/16/2015 0.01165 08/21/2015
WITCH HAZEL TOPICAL PADS, MEDICATED (EA) 50 % 0.07692 08/12/2014 0.07692 08/21/2015
ZAFIRLUKAST ORAL TABLET 10 MG 1.19188 01/25/2013 1.19188 01/01/2017
ZAFIRLUKAST ORAL TABLET 20 MG 1.11667 02/21/2020 0.82500 04/17/2020
ZALEPLON ORAL CAPSULE 10 MG 0.21311 08/21/2015 0.13820 09/22/2017
ZALEPLON ORAL CAPSULE 5 MG 0.21208 08/21/2015 0.17120 08/17/2018
ZIDOVUDINE ORAL CAPSULE 100 MG 0.82839 11/08/2013 0.82839 08/21/2015
ZIDOVUDINE ORAL SYRUP 10 MG/ML 0.12787 05/10/2013 0.09521 11/24/2017
ZIDOVUDINE ORAL TABLET 300 MG 0.37007 08/21/2015 0.30183 11/24/2017
ZINC CHLORIDE INTRAVENOUS VIAL (ML) 1 MG/ML 0.17050 08/12/2014
ZINC SULFATE INTRAVENOUS VIAL (ML) 1 MG/ML 0.21874 01/25/2013
ZINC SULFATE INTRAVENOUS VIAL (ML) 5 MG/ML 0.65343 01/25/2013
ZIPRASIDONE HCL ORAL CAPSULE 20 MG 0.22400 12/20/2019 0.19433 05/22/2020
ZIPRASIDONE HCL ORAL CAPSULE 40 MG 0.39000 11/16/2018 0.26000 12/21/2018
ZIPRASIDONE HCL ORAL CAPSULE 60 MG 0.43250 06/22/2018 0.24917 05/17/2019
ZIPRASIDONE HCL ORAL CAPSULE 80 MG 0.28483 03/20/2020 0.25617 05/22/2020
ZOLEDRONIC ACID IN MANNITOL AND 0.9 % SODIUM CHLORIDE INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 4 MG/100ML
10.14930 08/16/2013
ZOLEDRONIC ACID IN MANNITOL AND WATER FOR INJECTION INTRAVENOUS INTRAVENOUS SOLUTION, PIGGYBACK (ML) 5 MG/100ML
8.37592 10/25/2013
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
Generic Name Prev. SMAC Price Prev. Effective Date
Current SMAC Price
Current Effective Date
ZOLMITRIPTAN ORAL TABLET 2.5 MG 5.62000 06/16/2017 0.96500 09/21/2018
ZOLMITRIPTAN ORAL TABLET 5 MG 2.88000 02/21/2020 2.65000 04/17/2020
ZOLMITRIPTAN ORAL TABLET,DISINTEGRATING 2.5 MG 7.56000 06/16/2017 5.64000 06/22/2018
ZOLMITRIPTAN ORAL TABLET,DISINTEGRATING 5 MG 5.50481 06/16/2017 3.89667 09/22/2017
ZOLPIDEM TARTRATE ORAL TABLET 10 MG 0.02680 03/27/2015 0.02680 08/21/2015
ZOLPIDEM TARTRATE ORAL TABLET 5 MG 0.02680 03/13/2015 0.02680 08/21/2015
ZOLPIDEM TARTRATE ORAL TABLET, EXTENDED RELEASE MULTIPHASE 12.5 MG
0.52530 12/22/2017 0.48879 03/16/2018
ZOLPIDEM TARTRATE ORAL TABLET, EXTENDED RELEASE MULTIPHASE 6.25 MG
0.38000 10/19/2018 0.18852 06/21/2019
ZONISAMIDE ORAL CAPSULE 100 MG 0.14126 04/05/2019 0.10150 03/20/2020
ZONISAMIDE ORAL CAPSULE 25 MG 0.12974 04/21/2017 0.07950 07/14/2017
ZONISAMIDE ORAL CAPSULE 50 MG 0.15682 04/28/2016 0.12410 08/25/2017
West Virginia MedicaidState Maximum Allowable Cost (SMAC) List
Disclaimer: Price listing does not guarantee coverage
Effective 6/19/2020
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