Wymedicaid.org

Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
ACEBUTOLOL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 400MG" ACETAMINOPHEN ORAL TABLET, CHEWABLE 80MG" ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 325MG" ALBUTEROL SULFATE INHALATION SOLUTION, NON-ORAL 5MG/ML" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 10MG-20MG" AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 2.5MG-10MG" AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5-10MG" AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5MG-20MG" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
ANAGRELIDE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 1MG" AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100MG/5ML" AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200MG/5ML" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
BENZONATATE ORAL CAPSULE (HARD, SOFT, ETC.) 200MG" BENZOYL PEROXIDE TOPICAL CLEANSER (GM) 10% BENZOYL PEROXIDE TOPICAL CLEANSER (GM) 5% Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
BUPROPION HCL ORAL TABLET, SUSTAINED RELEASE 24HR 150MG" BUPROPION HCL ORAL TABLET, SUSTAINED RELEASE 24HR 300MG" BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL TABLET 50-500-40 BUTALBITAL/CAF/APAP/COD 50/40/325/30 MG CAP CAPTOPRIL/HYDROCHLOROTHIAZIDE 50/25 MG TAB Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
CEFDINIR ORAL CAPSULE (HARD, SOFT, ETC.) 300MG" CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125MG/5ML" CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250MG/5ML" CEFTRIAXONE SODIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 1G" CEFTRIAXONE SODIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 250MG" CEFTRIAXONE SODIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 500MG" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
CYANOCOBALAMIN INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 1000MCG/ML" DEXTROMETHORPHAN HBR/PROMETHAZINE HCL ORAL SYRUP 15-6.25/5 Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 50MG" DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 75MG" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
DIVALPROEX SODIUM ORAL TABLET, SUSTAINED RELEASE 24HR 250MG" DIVALPROEX SODIUM ORAL TABLET, SUSTAINED RELEASE 24HR 500MG" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
ETH E/NOR 30/40/30MCG-0.05/.075/.125MG TAB Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 100MCG/HR" FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 50MCG/HR" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
FLUTICASONE PROPIONATE NASAL SPRAY, SUSPENSION 50MCG" FOSINOPRIL-HYDROCHLOROTHIAZIDE 20/12.5 MG Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 10MG-650MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 2.5-500MG HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 7.5-650MG Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
HYDROMORPHONE HCL/PF INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 10MG/ML" HYDROXYCHLOROQUINE SULFATE ORAL TABLET 200MG HYDROXYZINE PAMOATE ORAL CAPSULE (HARD, SOFT, ETC.) 100MG" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
ISOTRETINOIN ORAL CAPSULE (HARD, SOFT, ETC.) 10MG" ISOTRETINOIN ORAL CAPSULE (HARD, SOFT, ETC.) 20MG" ISOTRETINOIN ORAL CAPSULE (HARD, SOFT, ETC.) 40MG" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
LAMOTRIGINE ORAL TABLET, DISPERSIBLE 25MG" LAMOTRIGINE ORAL TABLET, DISPERSIBLE 5MG" LEVETIRACETAM ORAL SOLUTION, ORAL 100MG/ML" LEVONORGESTREL-ETH ESTRA ORAL TABLET 0.1-0.02 Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
MICONAZOLE NITRATE VAGINAL CREAM WITH APPLICATOR 2% MIRTAZAPINE ORAL TABLET, RAPID DISSOLVE 15MG" MIRTAZAPINE ORAL TABLET, RAPID DISSOLVE 45MG" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
MORPHINE SULFATE ORAL TABLET, SUSTAINED ACTION 200MG" NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 14MG/24HR" NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 21MG/24HR" NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 7MG/24HR" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE (HARD, SOFT, ETC.) 100MG" NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE (HARD, SOFT, ETC.) 50MG" NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 0.4-0.035 NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 0.25-0.035 NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 7DAYSX3 28 NORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.3-0.03MG Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 40MG" ONDANSETRON ORAL TABLET, RAPID DISSOLVE 4MG" ONDANSETRON ORAL TABLET, RAPID DISSOLVE 8MG" OXYBUTYNIN CHLORIDE ORAL TABLET, SR OSMOTIC PUSH 24HR 10MG" OXYBUTYNIN CHLORIDE ORAL TABLET, SR OSMOTIC PUSH 24HR 15MG" OXYBUTYNIN CHLORIDE ORAL TABLET, SR OSMOTIC PUSH 24HR 5MG" OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 7.5-500MG Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
PAROXETINE HCL ORAL TABLET, SUSTAINED RELEASE 24HR 12.5MG" PAROXETINE HCL ORAL TABLET, SUSTAINED RELEASE 24HR 25MG" PENTAZOCINE HCL/NALOXONE HCL 50-0.5MG TAB PHENYTOIN SODIUM EXTENDED ORAL CAPSULE (HARD, SOFT, ETC.) 100MG" PIPERONYL BUTOXIDE/PYRETHRINS TOPICAL SHAMPOO 3-0.3% PIPERONYL BUTOXIDE/PYRETHRINS TOPICAL SHAMPOO 4%-0.33% POTASSIUM CHLORIDE ORAL LIQUID (ML) 20MEQ/15ML POTASSIUM CHLORIDE ORAL LIQUID (ML) 40MEQ/15ML Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
PROPRANOLOL/HYDROCHLOROTHIAZIDE 40/25 MG T PROPRANOLOL/HYDROCHLOROTHIAZIDE 80/25 MG T PSEUDOEPHEDRINE SULFATE/LORATADINE ORAL TABLET, SUSTAINED RELEASE 12HR 120-5MG"PSEUDOEPHEDRINE SULFATE/LORATADINE ORAL TABLET, SUSTAINED RELEASE 24HR Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
RIBAVIRIN ORAL CAPSULE (HARD, SOFT, ETC.) 200MG" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
STAVUDINE ORAL CAPSULE (HARD, SOFT, ETC.) 15MG" STAVUDINE ORAL CAPSULE (HARD, SOFT, ETC.) 20MG" STAVUDINE ORAL CAPSULE (HARD, SOFT, ETC.) 30MG" STAVUDINE ORAL CAPSULE (HARD, SOFT, ETC.) 40MG" Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of August 12, 2009
Effective
Generic Name
SMAC Price
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC ACID/BIOTIN ORAL TABLET 1MG-60MG ZALEPLON ORAL CAPSULE (HARD, SOFT, ETC.) 10MG" ZALEPLON ORAL CAPSULE (HARD, SOFT, ETC.) 5MG" ZONISAMIDE ORAL CAPSULE (HARD, SOFT, ETC.) 25MG" ZONISAMIDE ORAL CAPSULE (HARD, SOFT, ETC.) 50MG"

Source: http://www.wymedicaid.org/uploads/Mi/M0/MiM0_V5t2kcLEIJIiWUZSw/wyoming_master_smac_aug12_2009.pdf