wyoming medicaid office of pharmacy services 2.5 mg tab 1.90488 01/01/2009 bumetanide 0.5 mg tablet...
TRANSCRIPT
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
ACEBUTOLOL 200 MG CAP 0.20828 01/01/2009
ACEBUTOLOL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 400MG" 0.33096 0.31234 08/12/2009
ACETAMINOPHEN ORAL TABLET, CHEWABLE 80MG" 0.03683 08/12/2009
ACETAMINOPHEN RECTAL SUPPOSITORY, RECTAL 325MG" 0.36400 08/12/2009
ACETAMINOPHEN/COD 300/30 MG TAB 0.07164 01/01/2009
ACETAMINOPHEN/COD 300/60 MG TAB 0.14952 01/01/2009
ACETAMINOPHEN/COD ELIX 0.01529 01/01/2009
ACETAZOLAMIDE 250 MG TAB 0.36200 01/01/2009
ACETIC ACID 2% EAR SOLN 2.21880 01/01/2009
ACETIC ACID W/HC EAR DROP 1.88616 01/01/2009
ACETIC ACID/ALUMINUM DROPS 0.08830 06/01/2006
ACETYLCYSTEINE 10% VIAL 0.54360 06/01/2006
ACETYLCYSTEINE 20% VIAL 0.44120 01/28/2008
ACYCLOVIR 200 MG CAP 0.07601 01/01/2009
ACYCLOVIR 200 MG/5 ML SUSP 0.26340 01/01/2009
ACYCLOVIR 400 MG TAB 0.08508 01/01/2009
ACYCLOVIR 800 MG TAB 0.18774 01/01/2009
ALBUTEROL 0.83 MG/ML SOLN 0.06056 01/01/2009
ALBUTEROL 90 MCG INHALER 1.12643 10/29/2007
ALBUTEROL 90 MCG INHALER 1.12643 10/29/2007
ALBUTEROL SUL 1.25 MG/3 ML SOLN 0.61659 01/01/2009
ALBUTEROL SULF 2 MG/5 ML SYRP 0.01640 01/28/2008
ALBUTEROL SULFATE 2 MG TAB 0.09320 01/01/2007
ALBUTEROL SULFATE 4 MG TAB 0.12920 01/01/2007
ALBUTEROL SULFATE ER 4 MG TAB 1.42449 01/01/2009
ALBUTEROL SULFATE INHALATION SOLUTION, NON-ORAL 5MG/ML" 0.17393 0.15470 08/12/2009
ALENDRONATE SODIUM 10 MG TAB 2.35506 01/01/2009
ALENDRONATE SODIUM ORAL TABLET 35MG 5.91545 2.43750 03/01/2009
ALENDRONATE SODIUM ORAL TABLET 5MG 0.37206 0.25475 04/01/2009
ALENDRONATE SODIUM ORAL TABLET 70MG 5.64236 1.76475 03/01/2009
ALLOPURINOL 100 MG TAB 0.04833 01/01/2009
ALLOPURINOL 300 MG TAB 0.08691 01/01/2009
ALPRAZOLAM 0.25 MG TAB 0.03788 01/01/2009
ALPRAZOLAM 0.5 MG TAB 0.04590 01/01/2009
Page 1 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
ALPRAZOLAM 1 MG TAB 0.04962 01/01/2009
ALPRAZOLAM 2 MG TAB 0.10758 01/01/2009
ALPRAZOLAM XR 0.5 MG TAB 0.74073 01/01/2009
ALPRAZOLAM XR 1 MG TAB 0.76235 01/01/2009
ALPRAZOLAM XR 2 MG TAB 0.91475 01/01/2009
AMANTADINE 100 MG CAP 0.49728 01/01/2009
AMILORIDE HCL/HCTZ 5/50 MG TAB 0.05805 01/01/2009
AMIODARONE HCL ORAL TABLET 200MG 0.24150 0.21255 10/01/2009
AMITRIP-CDP 25-10 TABLET 0.85530 01/01/2007
AMITRIPTYLINE HCL 10 MG TAB 0.02468 01/01/2009
AMITRIPTYLINE HCL 100 MG TAB 0.06269 01/01/2009
AMITRIPTYLINE HCL 150 MG TAB 0.14111 01/01/2009
AMITRIPTYLINE HCL 25 MG TAB 0.02732 01/01/2009
AMITRIPTYLINE HCL 50 MG TAB 0.03378 01/01/2009
AMITRIPTYLINE HCL 75 MG TAB 0.05753 01/01/2009
AMLODIPINE BESYLATE 10 MG TAB 0.08885 01/01/2009
AMLODIPINE BESYLATE 2.5 MG TAB 0.07712 01/01/2009
AMLODIPINE BESYLATE 5 MG TAB 0.07437 01/01/2009
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 10MG-20MG" 1.69500 1.36755 08/12/2009
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 2.5MG-10MG" 1.39550 1.07555 08/12/2009
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5-10MG" 1.35050 1.09875 08/12/2009
AMLODIPINE BESYLATE/BENAZEPRIL HCL ORAL CAPSULE (HARD, SOFT, ETC.) 5MG-20MG" 1.55050 1.52653 08/12/2009
AMMONIUM LACTATE 12% CRM 0.05387 01/01/2009
AMMONIUM LACTATE 12% LOT 0.03918 01/01/2009
AMOX TR-K CLV 200-28.5 MG/5ML SUSP 0.19869 01/01/2009
AMOX TR-K CLV 400-57 MG/5 ML SUSP 0.28404 01/01/2009
AMOX TR-K CLV 500-125 MG TAB 1.03305 01/01/2009
AMOX TR-K CLV 600-42.9 MG/5 ML SUSP 0.29384 01/01/2009
AMOX TR-K CLV 875-125 MG TAB 1.08087 01/01/2009
AMOXICILLIN 125 MG/5 ML SUSP 0.01427 01/01/2009
AMOXICILLIN 200 MG/5 ML SUSP 0.06588 01/01/2009
AMOXICILLIN 250 MG CAP 0.05790 01/01/2009
AMOXICILLIN 250 MG TAB CHEW 0.16521 01/01/2009
AMOXICILLIN 250 MG/5 ML SUSP 0.01551 01/01/2009
Page 2 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
AMOXICILLIN 400 MG TAB CHEW 0.44300 01/28/2008
AMOXICILLIN 400 MG/5 ML SUSP 0.05324 01/01/2009
AMOXICILLIN 500 MG CAP 0.07301 01/01/2009
AMOXICILLIN TRIHYDRATE ORAL TABLET 875MG 0.34881 0.33150 04/01/2009
AMOXICILLIN TRIHYDRATE/POTASSIUM CLAVULANATE ORAL TABLET, CHEWABLE 400-57MG 1.37642 1.25550 10/01/2009
AMPHETAMINE SALTS 10 MG TAB 0.26312 01/01/2009
AMPHETAMINE SALTS 20 MG TAB 0.25700 01/01/2009
AMPHETAMINE SALTS 30 MG TAB 0.26066 01/01/2009
AMPHETAMINE SALTS 5 MG TAB 0.26166 01/01/2009
AMPICILLIN TR 250 MG CAP 0.11768 01/01/2009
AMPICILLIN TR 500 MG CAP 0.18488 01/01/2009
ANAGRELIDE HCL 0.5 MG CAP 0.21287 01/01/2009
ANAGRELIDE HCL ORAL CAPSULE (HARD, SOFT, ETC.) 1MG" 0.76180 08/12/2009
ANTIPYRINE/BENZOCAINE/GLYCERIN OTIC DROPS 5.4%-1.4% 0.83373 10/01/2009
ASA/BUTALB/CAFF/COD 325/50/40/30 MG CAP 0.89736 01/01/2009
ATENOLOL 100 MG TAB 0.05994 01/01/2009
ATENOLOL 25 MG TAB 0.02778 01/01/2009
ATENOLOL 50 MG TAB 0.03183 01/01/2009
ATENOLOL/CHLORTHALIDONE 100/25 MG TAB 0.12899 01/01/2009
ATENOLOL/CHLORTHALIDONE 50/25 MG TAB 0.07629 01/01/2009
AZATHIOPRINE 50 MG TAB 0.22755 01/01/2009
AZITHROMYCIN 250 MG TAB 1.41102 01/01/2009
AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 100MG/5ML" 1.55118 1.44554 04/01/2009
AZITHROMYCIN ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 200MG/5ML" 1.13786 1.06167 03/01/2009
AZITHROMYCIN ORAL TABLET 500MG 3.65733 2.05500 08/12/2009
AZITHROMYCIN ORAL TABLET 600MG 5.98693 07/01/2009
BACITRACIN-POLYMYXIN OINT 1.36056 01/01/2009
BACLOFEN 10 MG TAB 0.07428 01/01/2009
BACLOFEN 20 MG TAB 0.11654 01/01/2009
BACTERIOSTATIC SALINE VIAL 0.02190 01/01/2007
BALSALAZIDE DISODIUM 750 MG CAP 0.62090 01/01/2009
BENAZEPRIL HCL 10 MG TAB 0.09261 01/01/2009
BENAZEPRIL HCL 20 MG TAB 0.09134 01/01/2009
BENAZEPRIL HCL 40 MG TAB 0.10148 01/01/2009
Page 3 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
BENAZEPRIL HCL ORAL TABLET 5MG 0.10865 0.10300 04/01/2009
BENAZEPRIL/HCTZ 10/12.5 MG TAB 0.18674 01/01/2009
BENAZEPRIL/HCTZ 20/12.5 MG TAB 0.18801 01/01/2009
BENAZEPRIL/HCTZ 20/25 MG TAB 0.20046 01/01/2009
BENZONATATE ORAL CAPSULE (HARD, SOFT, ETC.) 100MG 0.24981 0.12155 10/01/2009
BENZONATATE ORAL CAPSULE (HARD, SOFT, ETC.) 200MG 0.32500 0.21320 10/01/2009
BENZOYL PEROXIDE TOPICAL CLEANSER (GM) 10% 0.09416 08/12/2009
BENZOYL PEROXIDE TOPICAL CLEANSER (GM) 5% 0.08801 08/12/2009
BENZTROPINE MES 0.5 MG TAB 0.07142 01/01/2009
BENZTROPINE MES 1 MG TAB 0.07110 01/01/2009
BENZTROPINE MES 2 MG TAB 0.10952 01/01/2009
BETAMETHASONE DP 0.05% AUGMTD CRM 0.61149 01/01/2009
BETAMETHASONE DP 0.05% AUGMTD OINT 0.21090 01/28/2008
BETAMETHASONE DP 0.05% CREAM 0.07130 01/01/2007
BETAMETHASONE DP 0.05% GEL 1.19430 06/01/2006
BETAMETHASONE DP 0.05% LOT 0.07083 01/01/2009
BETAMETHASONE DP 0.05% OINT 0.07460 01/28/2008
BETAMETHASONE VA 0.1% CREAM 0.06450 01/28/2008
BETAMETHASONE VA 0.1% LOTION 0.06450 01/28/2008
BETAMETHASONE VA 0.1% OINT 0.06740 01/28/2008
BETHANECHOL 10 MG TAB 0.38235 01/01/2009
BETHANECHOL 25 MG TAB 0.50441 01/01/2009
BISOPROLOL FUMARATE 10 MG TAB 0.98807 01/01/2009
BISOPROLOL FUMARATE 5 MG TAB 0.91196 01/01/2009
BISOPROLOL/HCTZ 10/6.25 MG TAB 0.08153 01/01/2009
BISOPROLOL/HCTZ 2.5/6.25 MG TAB 0.06462 01/01/2009
BISOPROLOL/HCTZ 5/6.25 MG TAB 0.06810 01/01/2009
BRIMONIDINE 0.2% EYE DROP 2.11415 01/01/2009
BROMOCRIPTINE 2.5 MG TAB 1.90488 01/01/2009
BUMETANIDE 0.5 MG TABLET 0.14250 01/01/2007
BUMETANIDE 1 MG TAB 0.23756 01/01/2009
BUMETANIDE 2 MG TAB 0.24804 01/01/2009
BUPIVACAINE 0.25% VIAL 0.11910 06/01/2006
BUPIVACAINE 0.5% VIAL 0.12570 06/01/2006
Page 4 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
BUPROPION HCL 100 MG TAB 0.25938 01/01/2009
BUPROPION HCL 75 MG TAB 0.22196 01/01/2009
BUPROPION HCL ER 100 MG TAB 0.87162 01/01/2009
BUPROPION HCL ER 200 MG TAB 1.47440 01/01/2009
BUPROPION HCL ORAL TABLET, SUSTAINED RELEASE 24HR 150MG" 3.26083 0.99552 07/01/2009
BUPROPION HCL ORAL TABLET, SUSTAINED RELEASE 24HR 300MG" 1.91115 1.45150 07/01/2009
BUPROPION HCL SR 150 MG TAB - AB1 0.86355 01/01/2009
BUPROPION HCL SR 150 MG TABLET - AB2 1.25720 01/28/2008
BUSPIRONE HCL 10 MG TAB 0.06489 01/01/2009
BUSPIRONE HCL 15 MG TAB 0.10541 01/01/2009
BUSPIRONE HCL 30 MG TAB 0.90503 01/01/2009
BUSPIRONE HCL 5 MG TAB 0.05049 01/01/2009
BUTAL/APAP/CAFF 50/325/40 MG TAB 0.08579 01/01/2009
BUTALBITAL/ACETAMINOPHEN/CAFFEINE ORAL TABLET 50-500-40 0.16900 0.15340 10/01/2009
BUTALBITAL/ASA/CAFF 50/325/40 MG TAB 0.13974 01/01/2009
BUTALBITAL/ASA/CAFFEINE 50/325/40 MG CAP 0.48180 01/28/2008
BUTALBITAL/CAF/APAP/COD 50/40/325/30 MG CAP 0.43205 01/01/2009
BUTORPHANOL 10 MG/ML SPRY 9.67070 01/01/2009
CABERGOLINE 0.5 MG TAB 28.42053 01/01/2009
CALCIPOTRIENE 0.005% SOLUTION 3.06360 01/01/2009
CALCITRIOL 0.25 MCG CAPSULE 1.19360 01/28/2008
CAPTOPRIL 100 MG TAB 0.08595 01/01/2009
CAPTOPRIL 12.5 MG TAB 0.01872 01/01/2009
CAPTOPRIL 25 MG TAB 0.02117 01/01/2009
CAPTOPRIL 50 MG TAB 0.03126 01/01/2009
CAPTOPRIL/HCTZ 25/15 MG TAB 0.08763 01/01/2009
CAPTOPRIL/HYDROCHLOROTHIAZIDE 50/25 MG TAB 0.17880 06/01/2006
CARBAMAZEPINE 100 MG TAB CHW 0.09066 01/01/2009
CARBAMAZEPINE 100 MG/5 ML SUSP 0.04149 01/01/2009
CARBAMAZEPINE 200 MG TAB 0.05934 01/01/2009
CARBIDOPA/LEVO 10/100 MG TAB 0.23586 01/01/2009
CARBIDOPA/LEVO 25/100 MG TAB 0.21920 01/01/2009
CARBIDOPA/LEVO 25/100 MG TAB SA 0.44769 01/01/2009
CARBIDOPA/LEVO 25/250 MG TAB 0.30693 01/01/2009
Page 5 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
CARBIDOPA/LEVO 50/200 MG TAB SA 0.55101 01/01/2009
CARISOPRODOL 350 MG TAB 0.06011 01/01/2009
CARTEOLOL HCL 1% EYE DROP 1.95332 01/01/2009
CARVEDILOL 12.5 MG TAB 0.06930 01/01/2009
CARVEDILOL 25 MG TAB 0.06747 01/01/2009
CARVEDILOL 3.125 MG TAB 0.06933 01/01/2009
CARVEDILOL 6.25 MG TAB 0.07040 01/01/2009
CEFACLOR 250 MG CAP 0.44133 01/01/2009
CEFACLOR 500 MG CAP 0.72872 01/01/2009
CEFADROXIL 500 MG CAP 0.62297 01/01/2009
CEFAZOLIN 1 GM VIAL 1.51580 01/28/2008
CEFDINIR ORAL CAPSULE (HARD, SOFT, ETC.) 300MG" 2.75167 1.15167 05/01/2009
CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125MG/5ML" 0.54002 0.48476 08/12/2009
CEFDINIR ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250MG/5ML" 1.28081 1.13347 03/01/2009
CEFPODOXIME 200 MG TAB 5.49812 01/01/2009
CEFPODOXIME PROXETIL ORAL TABLET 100MG 2.69550 08/12/2009
CEFPROZIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 125MG/5ML 0.27302 0.23750 10/01/2009
CEFPROZIL ORAL SUSPENSION, RECONSTITUTED, ORAL (ML) 250MG/5ML 0.38970 0.35750 10/01/2009
CEFPROZIL ORAL TABLET 250MG 2.66909 2.07467 03/01/2009
CEFPROZIL ORAL TABLET 500MG 3.98580 03/01/2009
CEFTRIAXONE SODIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 10G 45.22700 10/01/2009
CEFTRIAXONE SODIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 1G" 6.92196 4.64100 08/12/2009
CEFTRIAXONE SODIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 250MG" 1.80700 08/12/2009
CEFTRIAXONE SODIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 2G 7.80000 10/01/2009
CEFTRIAXONE SODIUM INJECTION VIAL (SDV,MDV OR ADDITIVE) (EA) 500MG 3.70500 3.57500 10/01/2009
CEFUROXIME AXETIL ORAL TABLET 250MG 0.42104 0.35334 08/12/2009
CEFUROXIME AXETIL ORAL TABLET 500MG 0.64890 0.61971 08/12/2009
CEPHALEXIN 125 MG/5 ML SUSP 0.05487 01/01/2009
CEPHALEXIN 250 MG CAP 0.13101 01/01/2009
CEPHALEXIN 250 MG/5 ML SUSP 0.06027 01/01/2009
CEPHALEXIN 500 MG CAP 0.15972 01/01/2009
CETIRIZINE HCL 1 MG/ML SYRUP 0.03834 01/01/2009
CETIRIZINE HCL ORAL TABLET 10MG 0.06529 03/01/2009
CETIRIZINE HCL ORAL TABLET 5MG 0.17290 03/01/2009
Page 6 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
CETIRIZINE HCL ORAL TABLET, CHEWABLE 10MG 0.57308 10/01/2009
CHLORDIAZEPOXIDE 10 MG CAP 0.07490 01/01/2009
CHLORDIAZEPOXIDE 25 MG CAP 0.09032 01/01/2009
CHLORDIAZEPOXIDE 5 MG CAP 0.09830 01/01/2009
CHLORHEXIDINE 0.12% RINSE 0.01059 01/01/2009
CHLOROTHIAZIDE 250 MG TAB 0.13499 01/01/2009
CHLOROTHIAZIDE 500 MG TAB 0.16569 01/01/2009
CHLORPROPAMIDE 250 MG TABLET 0.21460 06/01/2006
CHLORTHALIDONE 25 MG TAB 0.13344 01/01/2009
CHLORTHALIDONE 50 MG TABLET 0.19260 01/28/2008
CHLORZOXAZONE 500 MG TAB 0.05675 01/01/2009
CHOLESTYRAMINE LIGHT PACKET 1.59779 01/01/2009
CHOLESTYRAMINE LIGHT PWDR - PREVALITE 0.21299 01/01/2009
CHOLESTYRAMINE PACKET 1.92888 01/01/2009
CHOLESTYRAMINE PWDR -QUESTRAN 0.12629 01/01/2009
CICLOPIROX 0.77% CRM 0.54005 01/01/2009
CICLOPIROX 0.77% TOPICAL SUSP 0.84347 01/01/2009
CICLOPIROX 8% SOLN 1.78227 01/01/2009
CILOSTAZOL 100 MG TAB 0.25002 01/01/2009
CILOSTAZOL 50 MG TAB 0.24711 01/01/2009
CIMETIDINE 200 MG TABLET 0.28080 03/01/2009
CIMETIDINE 300 MG TAB 0.06335 01/01/2009
CIMETIDINE 300 MG/5 ML SOLN 0.06330 06/01/2006
CIMETIDINE 400 MG TAB 0.06293 01/01/2009
CIMETIDINE 800 MG TAB 0.12666 01/01/2009
CIPROFLOXACIN HCL 250 MG TAB 0.08058 01/01/2009
CIPROFLOXACIN HCL 500 MG TAB 0.08930 01/01/2009
CIPROFLOXACIN HCL 750 MG TAB 0.18041 01/01/2009
CIPROFLOXACIN HCL OPHTHALMIC DROPS 0.3% 1.93857 1.31950 10/01/2009
CITALOPRAM HBR 10 MG TAB 0.07556 01/01/2009
CITALOPRAM HBR 20 MG TAB 0.06899 01/01/2009
CITALOPRAM HBR 40 MG TAB 0.07209 01/01/2009
CLARITHROMYCIN 250 MG TABLET 0.78020 01/28/2008
CLARITHROMYCIN 500 MG TAB 0.56264 01/01/2009
Page 7 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
CLARITHROMYCIN ER 500 MG TAB 4.36779 01/01/2009
CLEMASTINE FUM 2.68 MG TAB 0.22980 01/01/2007
CLINDAMYCIN 2% VAG CRM 1.07390 01/01/2009
CLINDAMYCIN HCL 150 MG CAP 0.12212 01/01/2009
CLINDAMYCIN HCL 300 MG CAP 0.54729 01/01/2009
CLINDAMYCIN PH 1% GEL 0.35331 01/01/2009
CLINDAMYCIN PH 1% LOT 0.35625 01/01/2009
CLINDAMYCIN PH 1% PLEDGET 0.36402 01/01/2009
CLINDAMYCIN PH 1% SOLN 0.08375 01/01/2009
CLINDAMYCIN PH 150 MG/ML VIAL 0.73500 06/01/2006
CLOBETASOL 0.05% CRM 0.15669 01/01/2009
CLOBETASOL 0.05% GEL 0.55530 01/01/2009
CLOBETASOL 0.05% OINT 0.14858 01/01/2009
CLOBETASOL 0.05% SOLN 0.21114 01/01/2009
CLOBETASOL EMOLLIENT 0.05% CRM 0.30005 01/01/2009
CLOBETASOL PROP 0.05% FOAM 2.50283 01/01/2009
CLOMIPHENE CITRATE 50 MG TAB 1.72970 01/28/2008
CLOMIPRAMINE 25 MG CAP 0.10341 01/01/2009
CLOMIPRAMINE 50 MG CAP 0.15381 01/01/2009
CLOMIPRAMINE 75 MG CAP 0.22269 01/01/2009
CLONAZEPAM 0.25 MG DIS TAB 1.24413 01/01/2009
CLONAZEPAM ORAL TABLET 0.5MG 0.02556 0.02240 08/12/2009
CLONAZEPAM ORAL TABLET 1MG 0.04022 0.03640 08/12/2009
CLONAZEPAM ORAL TABLET 2MG 0.06044 0.05928 08/12/2009
CLONIDINE HCL 0.1 MG TAB 0.05061 01/01/2009
CLONIDINE HCL 0.2 MG TAB 0.07013 01/01/2009
CLONIDINE HCL 0.3 MG TAB 0.07565 01/01/2009
CLORAZEPATE 15 MG TABLET 0.23720 06/01/2006
CLORAZEPATE 3.75 MG TAB 0.11001 01/01/2009
CLORAZEPATE 7.5 MG TAB 0.12575 01/01/2009
CLOTRIMAZOLE 1% SOLN 0.34916 01/01/2009
CLOTRIMAZOLE 10 MG TROCHE 1.11210 01/01/2009
CLOTRIMAZOLE TOPICAL CREAM (GRAMS) 1% 0.59654 0.06386 08/12/2009
CLOTRIMAZOLE-BETAMETH CRM 0.24332 01/01/2009
Page 8 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
CLOTRIMAZOLE-BETAMETH LOT 0.79701 01/01/2009
CLOZAPINE 25 MG TAB 0.63126 01/01/2009
CLOZAPINE ORAL TABLET 100MG 1.41278 1.25755 08/12/2009
COLESTIPOL HCL 1 GM TAB 0.67245 01/01/2009
CROMOLYN SODIUM 4% EYE DROP 0.84593 01/01/2009
CYANOCOBALAMIN INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 1000MCG/ML" 0.92288 0.16250 03/01/2009
CYCLOBENZAPRINE 10 MG TAB 0.06299 01/01/2009
CYCLOBENZAPRINE 5 MG TAB 0.07605 01/01/2009
CYCLOPENTOLATE 1% EYE DROP 0.16289 01/01/2009
CYCLOSPORINE 100 MG SOFTGEL - AB1 4.12437 01/01/2009
CYCLOSPORINE 25 MG SOFTGEL - AB1 1.05144 01/01/2009
CYPROHEPTADINE 2 MG/5 ML SYRP 0.08756 01/01/2009
CYPROHEPTADINE 4 MG TAB 0.14667 01/01/2009
D-AMPHETAMINE 10 MG CAP SA 0.73260 01/01/2007
D-AMPHETAMINE 10 MG TAB 0.21698 01/01/2009
D-AMPHETAMINE 5 MG CAP SA 0.56660 06/01/2006
D-AMPHETAMINE 5 MG TAB 0.17564 01/01/2009
DESIPRAMINE 10 MG TAB 0.17889 01/01/2009
DESIPRAMINE 100 MG TAB 0.54386 2.10550 09/03/2009
DESIPRAMINE 25 MG TAB 0.22622 01/01/2009
DESIPRAMINE 50 MG TAB 0.33920 01/01/2009
DESMOPRESSIN 0.1 MG/ML SPRAY 16.91579 01/01/2009
DESMOPRESSIN 0.1 MG/ML SPRAY 16.91579 01/01/2009
DESMOPRESSIN ACET 0.2 MG TAB 2.12390 01/01/2009
DESMOPRESSIN ACETATE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 4MCG/ML 7.67000 10/01/2009
DESMOPRESSIN ACETATE ORAL TABLET 0.1MG 1.37700 08/12/2009
DESONIDE 0.05% CREAM 0.18020 01/28/2008
DESONIDE 0.05% LOT 0.19877 01/01/2009
DESONIDE 0.05% OINT 0.17993 01/01/2009
DESOXIMETASONE 0.25% CREAM 2.05500 06/01/2008
DEXAMETHASONE 0.1% EYE DROP 3.17250 01/01/2009
DEXAMETHASONE SP 4 MG/ML VIAL 0.87594 01/01/2009
DEXTROAMPHETAMINE 15 MG CAPSULE 0.96810 01/28/2008
DEXTROMETHORPHAN HBR/PROMETHAZINE HCL ORAL SYRUP 15-6.25/5 0.02100 0.01971 04/01/2009
Page 9 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
DIAZEPAM 10 MG TAB 0.04049 01/01/2009
DIAZEPAM 2 MG TAB 0.03539 01/01/2009
DIAZEPAM 5 MG TAB 0.03336 01/01/2009
DIAZEPAM 5 MG/ML SYRINGE 1.16750 06/01/2006
DICLOFENAC POT 50 MG TAB 0.18299 01/01/2009
DICLOFENAC SOD ER 100 MG TAB 0.59202 01/01/2009
DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 50MG" 0.49682 0.39911 03/01/2009
DICLOFENAC SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 75MG" 0.54561 0.48214 03/01/2009
DICLOXACILLIN 250 MG CAP 0.34745 01/01/2009
DICLOXACILLIN 500 MG CAP 0.66881 01/01/2009
DICYCLOMINE 10 MG CAP 0.04716 01/01/2009
DICYCLOMINE 20 MG TAB 0.05693 01/01/2009
DIFLORASONE 0.05% CRM 0.61064 01/01/2009
DIFLORASONE 0.05% OINT 0.47961 01/01/2009
DIGOXIN 125 MCG TAB 0.12689 01/01/2009
DIGOXIN 250 MCG TAB 0.14618 01/01/2009
DILTIAZEM 120 MG TAB 0.16206 01/01/2009
DILTIAZEM 30 MG TAB 0.04223 01/01/2009
DILTIAZEM 60 MG TAB 0.07346 01/01/2009
DILTIAZEM 90 MG TABLET 0.10980 06/01/2006
DILTIAZEM HCL 120 MG CAP SA - AB2 0.40086 01/01/2009
DILTIAZEM HCL 120 MG CAP SA - AB3 0.70757 01/01/2009
DILTIAZEM HCL 120 MG CAP SA - AB4 0.62342 01/01/2009
DILTIAZEM HCL 180 MG CAP SA - AB2 0.45579 01/01/2009
DILTIAZEM HCL 180 MG CAP SA - AB3 0.81371 01/01/2009
DILTIAZEM HCL 180 MG CAP SA - AB4 0.70217 01/01/2009
DILTIAZEM HCL 240 MG CAP SA - AB2 0.47361 01/01/2009
DILTIAZEM HCL 240 MG CAP SA - AB3 1.12785 01/01/2009
DILTIAZEM HCL 240 MG CAP SA - AB4 0.97538 01/01/2009
DILTIAZEM HCL 300 MG CAP SA - AB3 1.53552 01/01/2009
DILTIAZEM HCL 300 MG CAP SA - AB4 1.25234 01/01/2009
DILTIAZEM HCL 360 MG CAP SA - AB4 1.33580 01/01/2009
DILTIAZEM HCL 420 MG CAP SA 2.41830 01/28/2008
DIPHENHYDRAMINE 50 MG CAP 0.04400 01/01/2009
Page 10 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
DIPHENHYDRAMINE 50 MG/ML VIAL 1.12910 01/28/2008
DIPHENOXYLATE/ATROPINE 2.5/0.025 MG TAB 0.06225 01/01/2009
DIPIVEFRIN 0.1% EYE DROPS 0.39770 06/01/2006
DIPYRIDAMOLE 25 MG TABLET 0.27020 01/01/2007
DIPYRIDAMOLE 50 MG TAB 0.43179 01/01/2009
DIPYRIDAMOLE 75 MG TAB 0.58155 01/01/2009
DIVALPROEX SODIUM 125MG TABLET DR 0.11028 09/17/2008
DIVALPROEX SODIUM 250 MG TAB DR 0.14954 01/01/2009
DIVALPROEX SODIUM 500 MG TAB DR 0.26837 01/01/2009
DIVALPROEX SODIUM ORAL TABLET, SUSTAINED RELEASE 24HR 250MG" 1.37770 08/12/2009
DIVALPROEX SODIUM ORAL TABLET, SUSTAINED RELEASE 24HR 500MG" 2.27567 08/12/2009
DORZOLAMIDE HCL OPHTHALMIC DROPS 2% 6.47400 4.58700 10/01/2009
DORZOLAMIDE HCL/TIMOLOL MALEATE OPHTHALMIC DROPS 2%-0.5% 6.54500 10/01/2009
DOXAZOSIN MESYLATE 1 MG TAB 0.05861 01/01/2009
DOXAZOSIN MESYLATE 2 MG TAB 0.05660 01/01/2009
DOXAZOSIN MESYLATE 4 MG TAB 0.07205 01/01/2009
DOXAZOSIN MESYLATE 8 MG TAB 0.07928 01/01/2009
DOXEPIN 10 MG CAP 0.05447 01/01/2009
DOXEPIN 100 MG CAP 0.14510 01/01/2009
DOXEPIN 25 MG CAP 0.05976 01/01/2009
DOXEPIN 50 MG CAP 0.07184 01/01/2009
DOXEPIN 75 MG CAP 0.11843 01/01/2009
DOXYCYCLINE 100 MG CAP 0.07091 01/01/2009
DOXYCYCLINE 100 MG TAB 0.07886 01/01/2009
DOXYCYCLINE 20 MG TAB 0.88688 01/01/2009
DOXYCYCLINE 50 MG CAP 0.10545 01/01/2009
ECONAZOLE NITRATE 1% CRM 0.33204 01/01/2009
ENALAPRIL MALEATE 10 MG TAB 0.03785 01/01/2009
ENALAPRIL MALEATE 2.5 MG TAB 0.03084 01/01/2009
ENALAPRIL MALEATE 20 MG TAB 0.04922 01/01/2009
ENALAPRIL MALEATE 5 MG TAB 0.03239 01/01/2009
ENALAPRIL/HCTZ 10/25 MG TAB 0.13535 01/01/2009
ENALAPRIL/HCTZ 5/12.5 MG TAB 0.13553 01/01/2009
EPLERENONE ORAL TABLET 25MG 1.96650 10/01/2009
Page 11 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
EPLERENONE ORAL TABLET 50MG 1.96650 10/01/2009
ERGOTAMINE-CAFF 1/100 MG TAB 0.98009 01/01/2009
ERYTHROMYCIN 2% GEL 0.23327 01/01/2009
ERYTHROMYCIN 2% SOLN 0.18935 01/01/2009
ERYTHROMYCIN ES 400 MG TAB 0.22956 01/01/2009
ERYTHROMYCIN EYE OINT 0.50213 01/01/2009
ERYTHROMYCIN-BENZOYL GEL 1.45020 01/28/2008
ERYTHROMYCIN/SULFISOX SUSP 0.06090 01/01/2007
ESTAZOLAM 2 MG TABLET 0.43260 06/01/2006
ESTRADIOL 0.05 MG PATCH - AB1 6.50660 01/01/2007
ESTRADIOL 0.1 MG PATCH - AB1 6.83280 01/01/2007
ESTRADIOL 0.5 MG TAB 0.04655 01/01/2009
ESTRADIOL 1 MG TAB 0.05529 01/01/2009
ESTRADIOL 2 MG TAB 0.05831 01/01/2009
ESTROPIPATE 0.625 (0.75 MG) TAB 0.10509 01/01/2009
ESTROPIPATE 1.25 (1.5 MG) TAB 0.12800 01/01/2009
ETH E/NOR 30/40/30MCG-0.05/.075/.125MG TAB 0.94550 01/01/2009
ETH E/NORETH 20/30/35MCG-1/1/1MG FE TAB 2.08277 01/01/2009
ETH EST/LEVO 30/0.15 MG TAB 1.64982 01/01/2009
ETH EST/LEVO 30MCG/0.15MG TAB 1.08248 01/01/2009
ETH ESTRADIOL/DESOGEST 25/0.1/0.125/0.15 1.05280 06/01/2006
ETH ESTRADIOL/DESOGEST 30 MCG/0.15MG TAB 0.86133 01/01/2009
ETH ESTRADIOL/ETHYN 35MCG/1MG TAB 1.07094 01/01/2009
ETH ESTRADIOL/NORETH 20MCG/1MG TAB 1.30749 01/01/2009
ETH ESTRADIOL/NORETH 30MCG/1.5MG TAB 1.28378 01/01/2009
ETH ESTRADIOL/NORETH 35MCG/0.5MG TAB 1.06656 01/01/2009
ETH ESTRADIOL/NORETH 35MCG/1MG TAB 0.90066 01/01/2009
ETH ESTRADIOL/NORETH 7/7/7 TAB 1.12880 01/01/2007
ETH ESTRADIOL/NORETH FE 20MCG/1MG TAB 0.99606 01/01/2009
ETH ESTRADIOL/NORETH FE 30MCG/1.5MG TAB 0.98666 01/01/2009
ETHOSUXIMIDE 250 MG CAP 1.39358 01/01/2009
ETODOLAC 300 MG CAP 0.22421 01/01/2009
ETODOLAC 400 MG TAB 0.18162 01/01/2009
ETODOLAC 400 MG TABLET SA 0.94440 01/28/2008
Page 12 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
ETODOLAC 500 MG TAB 0.28941 01/01/2009
ETODOLAC 500 MG TAB SA 1.07057 01/01/2009
ETODOLAC 600 MG TABLET SA 2.07090 01/01/2007
FAMCICLOVIR ORAL TABLET 125MG 2.57885 08/12/2009
FAMCICLOVIR ORAL TABLET 250MG 2.86155 08/12/2009
FAMCICLOVIR ORAL TABLET 500MG 5.75533 08/12/2009
FAMOTIDINE 10 MG TABLET 0.13640 03/01/2009
FAMOTIDINE 20 MG TAB 0.06012 01/01/2009
FAMOTIDINE 40 MG TAB 0.09917 01/01/2009
FELODIPINE ER 10 MG TABLET 2.11460 01/01/2007
FELODIPINE ER 2.5 MG TABLET 1.20780 01/01/2007
FELODIPINE ER 5 MG TABLET 1.18100 01/01/2007
FENOFIBRATE 134 MG CAP 1.59429 01/01/2009
FENOPROFEN 600 MG TABLET 0.28040 06/01/2006
FENTANYL 0.05 MG/ML AMPUL 0.15690 01/28/2008
FENTANYL 0.05 MG/ML VIAL 0.35010 01/28/2008
FENTANYL 12MCG/HR PATCH 15.63240 01/28/2008
FENTANYL 25 MCG/HR PATCH 10.54928 01/01/2009
FENTANYL 75 MCG/HR PATCH 28.88457 01/01/2009
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 100MCG/HR" 37.81101 34.75751 04/01/2009
FENTANYL TRANSDERMAL PATCH, TRANSDERMAL 72 HOURS 50MCG/HR" 19.35143 14.65643 04/01/2009
FEXOFENADINE HCL 60 MG TAB 0.88044 01/01/2009
FEXOFENADINE HCL ORAL TABLET 180MG 1.34745 0.93757 08/12/2009
FEXOFENADINE HCL ORAL TABLET 30MG 0.52580 0.49881 03/01/2009
FINASTERIDE 5 MG TAB 1.47728 01/01/2009
FLAVOXATE HCL 100 MG TAB 1.43406 01/01/2009
FLECAINIDE ACETATE 100 MG TAB 0.41042 01/01/2009
FLECAINIDE ACETATE 150 MG TAB 0.82796 01/01/2009
FLECAINIDE ACETATE 50 MG TAB 0.28265 01/01/2009
FLUCONAZOLE 10 MG/ML SUSP 0.28830 01/01/2009
FLUCONAZOLE 100 MG TAB 0.17778 01/01/2009
FLUCONAZOLE 150 MG TAB 0.31733 01/01/2009
FLUCONAZOLE 200 MG TAB 0.36837 01/01/2009
FLUCONAZOLE 40 MG/ML SUSP 0.85920 01/28/2008
Page 13 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
FLUDROCORTISONE 0.1 MG TAB 0.68675 01/01/2009
FLUNISOLIDE 0.025% SPRAY 1.21395 01/01/2009
FLUOCINONIDE 0.05% CRM 0.05987 01/01/2009
FLUOCINONIDE 0.05% GEL 0.35376 01/01/2009
FLUOCINONIDE 0.05% OINT 0.18089 01/01/2009
FLUOCINONIDE 0.05% SOLN 0.10691 01/01/2009
FLUOCINONIDE-E 0.05% CRM 0.17721 01/01/2009
FLUOROMETHOLONE 0.1% DROPS 1.74780 01/01/2007
FLUOXETINE 10 MG CAP 0.04374 01/01/2009
FLUOXETINE 10 MG TAB 0.08040 01/01/2009
FLUOXETINE 20 MG CAP 0.03669 01/01/2009
FLUOXETINE 20 MG/5 ML SOLN 0.05255 01/01/2009
FLUOXETINE 40 MG CAP 0.68825 01/01/2009
FLUPHENAZINE 1 MG TABLET 0.09140 06/01/2006
FLUPHENAZINE 10 MG TAB 0.15317 01/01/2009
FLUPHENAZINE 5 MG TAB 0.11637 01/01/2009
FLUPHENAZINE DEC 25 MG/ML VL 1.65500 01/01/2007
FLURAZEPAM 15 MG CAP 0.07691 01/01/2009
FLURAZEPAM 30 MG CAP 0.09216 01/01/2009
FLURBIPROFEN 0.03% EYE DROP 2.61060 01/01/2007
FLURBIPROFEN 100 MG TAB 0.16619 01/01/2009
FLUTICASONE PROP 0.005% OINT 0.33285 01/01/2009
FLUTICASONE PROP 0.05% CRM 0.35606 01/01/2009
FLUTICASONE PROPIONATE NASAL SPRAY, SUSPENSION 50MCG" 0.63059 0.59598 08/12/2009
FLUVOXAMINE MAL 100 MG TAB 0.39548 01/01/2009
FLUVOXAMINE MAL 50 MG TAB 0.41202 01/01/2009
FOLIC ACID 1 MG TAB 0.01677 01/01/2009
FOSINOPRIL SODIUM 10 MG TAB 0.23354 01/01/2009
FOSINOPRIL SODIUM 20 MG TAB 0.22286 01/01/2009
FOSINOPRIL SODIUM 40 MG TAB 0.21225 01/01/2009
FOSINOPRIL-HYDROCHLOROTHIAZIDE 20/12.5 MG 1.10740 06/01/2006
FOSINOPRIL/HCTZ 10/12.5 MG TAB 1.03094 01/01/2009
FUROSEMIDE 10 MG/ML SOLN 0.07503 01/01/2009
FUROSEMIDE 10 MG/ML VIAL 0.17670 01/01/2007
Page 14 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
FUROSEMIDE 20 MG TAB 0.01761 01/01/2009
FUROSEMIDE 40 MG TAB 0.02234 01/01/2009
FUROSEMIDE 80 MG TAB 0.04077 01/01/2009
GABAPENTIN 100 MG CAP 0.05249 01/01/2009
GABAPENTIN 300 MG CAP 0.09543 01/01/2009
GABAPENTIN 400 MG CAP 0.11805 01/01/2009
GABAPENTIN 600 MG TAB 0.31938 01/01/2009
GABAPENTIN 800 MG TAB 0.43349 01/01/2009
GEMFIBROZIL 600 MG TAB 0.11303 01/01/2009
GENTAMICIN 0.1% CRM 0.09578 01/01/2009
GENTAMICIN 0.1% OINT 0.09695 01/01/2009
GENTAMICIN 3 MG/GM EYE OINT 4.21319 01/01/2009
GENTAMICIN 3 MG/ML EYE DROP 0.32424 01/01/2009
GENTAMICIN 40 MG/ML VIAL 0.49338 01/01/2009
GLIMEPIRIDE 1 MG TAB 0.03200 01/01/2009
GLIMEPIRIDE 2 MG TAB 0.05466 01/01/2009
GLIMEPIRIDE 4 MG TAB 0.08327 01/01/2009
GLIPIZIDE 10 MG TAB 0.06288 01/01/2009
GLIPIZIDE 5 MG TAB 0.03992 01/01/2009
GLIPIZIDE ER 10 MG TAB 0.34959 01/01/2009
GLIPIZIDE ER 2.5 MG TAB 0.27239 01/01/2009
GLIPIZIDE ER 5 MG TAB 0.19989 01/01/2009
GLIPIZIDE/METFORMIN 5/500 MG TAB 0.91488 01/01/2009
GLYBURIDE 1.25 MG TAB 0.06222 01/01/2009
GLYBURIDE 2.5 MG TAB 0.06603 01/01/2009
GLYBURIDE 5 MG TAB 0.06084 01/01/2009
GLYBURIDE MICRO 3 MG TAB 0.04037 01/01/2009
GLYBURIDE MICRO 6 MG TAB 0.08037 01/01/2009
GLYBURIDE/METFORMIN 1.25/250 MG TAB 0.14805 01/01/2009
GLYBURIDE/METFORMIN 2.5/500 MG TAB 0.15105 01/01/2009
GLYBURIDE/METFORMIN 5/500 MG TAB 0.14910 01/01/2009
GLYCOPYRROLATE 0.2 MG/ML VL 0.38930 06/01/2006
GLYCOPYRROLATE 1 MG TAB 0.84588 01/01/2009
GLYCOPYRROLATE 2 MG TABLET 1.90370 01/01/2007
Page 15 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
GRANISETRON HCL ORAL TABLET 1MG 15.06180 03/01/2009
GUANFACINE 1 MG TAB 0.10088 01/01/2009
GUANFACINE 2 MG TAB 0.15548 01/01/2009
HALOBETASOL PROP 0.05% CRM 0.69264 01/01/2009
HALOBETASOL PROP 0.05% OINT 0.56606 01/01/2009
HALOPERIDOL 0.5 MG TAB 0.07140 01/01/2009
HALOPERIDOL 1 MG TAB 0.11387 01/01/2009
HALOPERIDOL 10 MG TAB 1.43214 01/01/2009
HALOPERIDOL 2 MG TAB 0.15624 01/01/2009
HALOPERIDOL 5 MG TAB 0.17430 01/01/2009
HALOPERIDOL DEC 100 MG/ML VIAL 5.66420 01/01/2009
HALOPERIDOL DEC 50 MG/ML VIAL 5.16380 01/01/2009
HALOPERIDOL LAC 2 MG/ML CONC 0.07130 01/28/2008
HALOPERIDOL LAC 5 MG/ML VIAL 2.65007 01/01/2009
HEPARIN LOCK FLUSH 100 UNITS/ML VIAL 0.06240 01/28/2008
HYDRALAZINE 10 MG TAB 0.18530 01/01/2009
HYDRALAZINE 100 MG TAB 0.59723 01/01/2009
HYDRALAZINE 25 MG TAB 0.23765 01/01/2009
HYDRALAZINE 50 MG TAB 0.26208 01/01/2009
HYDROCHLOROTHIAZIDE 12.5 MG CAP 0.12704 01/01/2009
HYDROCHLOROTHIAZIDE 25 MG TAB 0.01796 01/01/2009
HYDROCHLOROTHIAZIDE 50 MG TAB 0.05858 01/01/2009
HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 10MG-650MG 0.08463 0.07965 04/01/2009
HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 2.5-500MG 0.12029 0.11182 04/01/2009
HYDROCODONE BIT/ACETAMINOPHEN ORAL TABLET 7.5-650MG 0.08337 0.07750 04/01/2009
HYDROCODONE BT/IBU 7.5/200 MG TAB 0.47264 01/01/2009
HYDROCODONE COMPOUND SYRUP 0.19328 06/01/2008
HYDROCODONE/APAP 10/325 MG TAB 0.22800 01/01/2009
HYDROCODONE/APAP 10/500 MG TAB 0.16484 01/01/2009
HYDROCODONE/APAP 10/660 MG TAB 0.21099 01/01/2009
HYDROCODONE/APAP 5/325 MG TAB 0.28661 01/01/2009
HYDROCODONE/APAP 5/500 MG TAB 0.04193 01/01/2009
HYDROCODONE/APAP 7.5/325 MG TAB 0.31476 01/01/2009
HYDROCODONE/APAP 7.5/500 MG TAB 0.06506 01/01/2009
Page 16 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
HYDROCODONE/APAP 7.5/750 MG TAB 0.06320 01/01/2009
HYDROCODONE/APAP SOLN 0.02637 01/01/2009
HYDROCORTISONE 0.2% CREAM 0.27770 01/01/2007
HYDROCORTISONE 1% CRM 0.04914 01/01/2009
HYDROCORTISONE 10 MG TABLET 0.46809 01/01/2009
HYDROCORTISONE 100 MG ENEMA 0.13060 06/01/2006
HYDROCORTISONE 2.5% CRM 0.09989 01/01/2009
HYDROCORTISONE 2.5% LOT 0.30866 01/01/2009
HYDROCORTISONE 2.5% OINT 0.10613 01/01/2009
HYDROCORTISONE 2.5% RECTAL CRM 0.19802 01/01/2009
HYDROCORTISONE 5 MG TAB 0.27404 01/01/2009
HYDROCORTISONE VALERATE TOPICAL OINTMENT(GM) 0.2% 0.67793 0.91585 10/01/2009
HYDROMORPHONE 2 MG TAB 0.11550 01/01/2009
HYDROMORPHONE 4 MG TAB 0.15825 01/01/2009
HYDROMORPHONE HCL 8 MG TAB 0.87372 01/01/2009
HYDROMORPHONE HCL/PF INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 10MG/ML" 1.72380 08/12/2009
HYDROXYCHLOROQUINE SULFATE ORAL TABLET 200MG 0.19688 0.19500 04/01/2009
HYDROXYUREA 500 MG CAP 0.34503 01/01/2009
HYDROXYZINE 10 MG/5 ML SYRUP 0.17138 08/28/2008
HYDROXYZINE 50 MG/ML VIAL 0.86610 01/28/2008
HYDROXYZINE HCL ORAL TABLET 10MG 0.28409 0.19500 03/01/2009
HYDROXYZINE HCL ORAL TABLET 25MG 0.31799 0.31200 03/01/2009
HYDROXYZINE HCL ORAL TABLET 50MG 0.42798 0.23400 03/01/2009
HYDROXYZINE PAM 25 MG CAP 0.07875 01/01/2009
HYDROXYZINE PAM 50 MG CAP 0.09383 01/01/2009
HYDROXYZINE PAMOATE ORAL CAPSULE (HARD, SOFT, ETC.) 100MG" 0.32552 08/12/2009
IBUPROFEN 100 MG TABLET 0.18440 03/01/2009
IBUPROFEN 100 MG/5 ML SUSP 0.03953 01/01/2009
IBUPROFEN 200 MG TABLET 0.04580 03/01/2009
IBUPROFEN 400 MG TAB 0.02996 01/01/2009
IBUPROFEN 600 MG TAB 0.03353 01/01/2009
IBUPROFEN 800 MG TAB 0.04856 01/01/2009
IBUPROFEN COLD SUSPENSION 0.04730 03/01/2009
IBUPROFEN IB 100MG CHEW TAB 0.14070 03/01/2009
Page 17 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
IBUPROFEN/PSEUDOEPHEDRINE CPLT 0.25230 03/01/2009
IMIPRAMINE HCL 10 MG TAB 0.16745 01/01/2009
IMIPRAMINE HCL 25 MG TAB 0.21360 01/01/2009
IMIPRAMINE HCL 50 MG TAB 0.32403 01/01/2009
INDAPAMIDE 1.25 MG TAB 0.04535 01/01/2009
INDAPAMIDE 2.5 MG TAB 0.05400 01/01/2009
INDOMETHACIN 25 MG CAP 0.21198 01/01/2009
INDOMETHACIN 50 MG CAP 0.26369 01/01/2009
IPRATR-ALBUTEROL 0.5-3 MG/3 ML SOLN 0.17886 01/01/2009
IPRATROPIUM 0.03% SPRAY 0.53268 01/01/2009
IPRATROPIUM 0.06% SPRAY 1.00281 01/01/2009
IPRATROPIUM BR 0.02% SOLN 0.07179 01/01/2009
ISONIAZID 300 MG TAB 0.10530 01/01/2009
ISOSORBIDE DN 10 MG TAB 0.03495 01/01/2009
ISOSORBIDE DN 20 MG TAB 0.03920 01/01/2009
ISOSORBIDE DN 30 MG TAB 0.19704 01/01/2009
ISOSORBIDE DN 40 MG TAB SA 0.76472 01/01/2009
ISOSORBIDE DN 5 MG TABLET 0.03080 06/01/2006
ISOSORBIDE MN 20 MG TABLET 0.14580 01/28/2008
ISOSORBIDE MONONITRATE ORAL TABLET, SUSTAINED RELEASE 24HR 120MG 0.15467 0.55445 10/01/2009
ISOSORBIDE MONONITRATE ORAL TABLET, SUSTAINED RELEASE 24HR 30MG 0.06411 0.33475 10/01/2009
ISOSORBIDE MONONITRATE ORAL TABLET, SUSTAINED RELEASE 24HR 60MG 0.06785 0.33240 10/01/2009
ISOTRETINOIN ORAL CAPSULE (HARD, SOFT, ETC.) 10MG" 4.25755 5.95250 09/15/2009
ISOTRETINOIN ORAL CAPSULE (HARD, SOFT, ETC.) 20MG" 4.90620 4.66750 08/12/2009
ISOTRETINOIN ORAL CAPSULE (HARD, SOFT, ETC.) 40MG" 6.31104 4.15700 08/12/2009
KETOCONAZOLE 2% CRM 0.40701 01/01/2009
KETOCONAZOLE 200 MG TAB 0.32178 01/01/2009
KETOPROFEN 200 MG CAPSULE SA 1.71630 06/01/2006
KETOPROFEN 50 MG CAPSULE 0.09900 06/01/2006
KETOPROFEN 75 MG CAP 0.12348 01/01/2009
KETOROLAC 10 MG TABLET 0.24510 01/28/2008
KETOROLAC 30 MG/ML VIAL 1.38050 01/28/2008
KETOROLAC 60 MG/2ML VIAL 0.81780 01/28/2008
LABETALOL HCL 100 MG TAB 0.13827 01/01/2009
Page 18 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
LABETALOL HCL 200 MG TAB 0.17405 01/01/2009
LABETALOL HCL 300 MG TAB 0.26466 01/01/2009
LACTULOSE 10 GM/15 ML SOLN-CON 0.01301 01/01/2009
LACTULOSE 10 GM/15 ML SOLN-ENU 0.01304 01/01/2009
LAMOTRIGINE ORAL TABLET 100MG 0.29141 0.21112 10/01/2009
LAMOTRIGINE ORAL TABLET 150MG 4.19500 0.19165 04/01/2009
LAMOTRIGINE ORAL TABLET 200MG 4.55500 0.20862 04/01/2009
LAMOTRIGINE ORAL TABLET 25MG 0.25514 0.15431 10/01/2009
LAMOTRIGINE ORAL TABLET, DISPERSIBLE 25MG" 0.59995 0.40995 07/01/2009
LAMOTRIGINE ORAL TABLET, DISPERSIBLE 5MG" 0.57278 0.39975 07/01/2009
LEFLUNOMIDE 10 MG TAB 0.55424 01/01/2009
LEFLUNOMIDE 20 MG TAB 0.55263 01/01/2009
LEUCOVORIN CALCIUM 5 MG TAB 1.28950 06/01/2006
LEVETIRACETAM ORAL SOLUTION, ORAL 100MG/ML" 0.30230 0.14330 08/12/2009
LEVETIRACETAM ORAL TABLET 1000MG 1.21961 1.14292 08/12/2009
LEVETIRACETAM ORAL TABLET 250MG 0.49555 03/01/2009
LEVETIRACETAM ORAL TABLET 500MG 0.55955 03/01/2009
LEVETIRACETAM ORAL TABLET 750MG 0.72555 03/01/2009
LEVOBUNOLOL 0.25% EYE DROPS 1.11430 06/01/2006
LEVOBUNOLOL 0.5% EYE DROP 0.44115 01/01/2009
LEVONORGESTREL-ETH ESTRA ORAL TABLET 0.1-0.02 0.97046 0.90076 04/01/2009
LEVOTHYROXINE 100 MCG TAB 0.17855 01/01/2009
LEVOTHYROXINE 112 MCG TAB 0.20502 01/01/2009
LEVOTHYROXINE 125 MCG TAB 0.20828 01/01/2009
LEVOTHYROXINE 137 MCG TAB 0.23636 01/01/2009
LEVOTHYROXINE 150 MCG TAB 0.21521 01/01/2009
LEVOTHYROXINE 175 MCG TABLET 0.25500 01/28/2008
LEVOTHYROXINE 200 MCG TAB 0.25827 01/01/2009
LEVOTHYROXINE 25 MCG TAB 0.13746 01/01/2009
LEVOTHYROXINE 300 MCG TAB 0.37443 01/01/2009
LEVOTHYROXINE 50 MCG TAB 0.15210 01/01/2009
LEVOTHYROXINE 75 MCG TAB 0.17303 01/01/2009
LEVOTHYROXINE 88 MCG TAB 0.17105 01/01/2009
LIDOCAINE 2% VISCOUS SOLN 0.03122 01/01/2009
Page 19 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
LIDOCAINE 5% OINT 0.30528 01/01/2009
LIDOCAINE HCL 1% VIAL 0.02750 01/28/2008
LIDOCAINE HCL 2% JELLY 0.39962 01/01/2009
LIDOCAINE-PRILOCAINE CRM 0.28016 01/01/2009
LISINOPRIL 10 MG TAB 0.04386 01/01/2009
LISINOPRIL 2.5 MG TAB 0.02757 01/01/2009
LISINOPRIL 20 MG TAB 0.06497 01/01/2009
LISINOPRIL 30 MG TAB 0.16517 01/01/2009
LISINOPRIL 40 MG TAB 0.12323 01/01/2009
LISINOPRIL 5 MG TAB 0.03758 01/01/2009
LISINOPRIL/HCTZ 10/12.5 MG TAB 0.08778 01/01/2009
LISINOPRIL/HCTZ 20/12.5 MG TAB 0.10371 01/01/2009
LISINOPRIL/HCTZ 20/25 MG TAB 0.13527 01/01/2009
LITHIUM CARBONATE 300 MG CAP 0.05631 01/01/2009
LITHIUM CARBONATE ER 300 MG TAB 0.29711 01/01/2009
LITHIUM ER 450 MG TAB 0.33708 01/01/2009
LOPERAMIDE 2 MG CAP 0.07469 01/01/2009
LORATADINE 10 MG DIS TAB 0.97260 03/01/2009
LORATADINE 5 MG/5 ML SYRUP 0.06980 03/01/2009
LORATADINE ORAL TABLET 10MG 0.23220 0.09200 03/01/2009
LORAZEPAM 0.5 MG TAB 0.04577 01/01/2009
LORAZEPAM 1 MG TAB 0.04907 01/01/2009
LORAZEPAM 2 MG TAB 0.09053 01/01/2009
LORAZEPAM 2 MG/ML VIAL 1.32080 01/01/2009
LOVASTATIN 10 MG TAB 0.22262 01/01/2009
LOVASTATIN 20 MG TAB 0.25347 01/01/2009
LOVASTATIN 40 MG TAB 0.37436 01/01/2009
MECLIZINE HCL ORAL TABLET 12.5MG 0.35459 0.02915 10/01/2009
MECLIZINE HCL ORAL TABLET 25MG 0.39806 0.04094 10/01/2009
MEDROXYPROGEST 150 MG/ML VIAL 47.88830 01/28/2008
MEDROXYPROGESTERONE 10 MG TB 0.09530 01/28/2008
MEDROXYPROGESTERONE 2.5 MG TAB 0.08270 01/28/2008
MEDROXYPROGESTERONE 5 MG TAB 0.10280 01/28/2008
MEFLOQUINE HCL 250 MG TAB 7.71056 01/01/2009
Page 20 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
MEGESTROL 20 MG TABLET 0.23660 01/01/2007
MEGESTROL 40 MG TAB 0.27786 01/01/2009
MEGESTROL ACET 40 MG/ML SUSP 0.13140 01/01/2009
MELOXICAM 15 MG TAB 0.05184 01/01/2009
MELOXICAM 7.5 MG TAB 0.03962 01/01/2009
MEPERIDINE 50 MG TAB 0.25590 01/01/2009
MERCAPTOPURINE 50 MG TAB 1.95903 01/01/2009
MESALAMINE 4G/60 ML RECT SUSP 0.17940 01/01/2009
METFORMIN HCL 1000 MG TAB 0.08072 01/01/2009
METFORMIN HCL 500 MG TAB 0.04374 01/01/2009
METFORMIN HCL 850 MG TAB 0.07631 01/01/2009
METFORMIN HCL ER 500 MG TAB 0.07571 01/01/2009
METFORMIN HCL ER 750 MG TAB 0.16749 01/01/2009
METHADONE HCL 10 MG TAB 0.10235 01/01/2009
METHADONE HCL 5 MG TAB 0.06713 01/01/2009
METHAZOLAMIDE 50 MG TAB 0.19032 01/01/2009
METHIMAZOLE 10 MG TAB 0.39575 01/01/2009
METHIMAZOLE 5 MG TAB 0.26399 01/01/2009
METHOCARBAMOL 500 MG TAB 0.08741 01/01/2009
METHOCARBAMOL 750 MG TAB 0.09591 01/01/2009
METHOTREXATE 2.5 MG TAB 0.28620 01/01/2009
METHOTREXATE 25 MG/ML VIAL 2.30780 01/28/2008
METHOTREXATE 25 MG/ML VIAL-PF 2.40620 01/28/2008
METHYLDOPA 250 MG TAB 0.14226 01/01/2009
METHYLDOPA 500 MG TAB 0.27386 01/01/2009
METHYLIN ER 10 MG TABLET SA 0.85253 01/01/2009
METHYLPHENIDATE 10 MG TAB 0.13317 01/01/2009
METHYLPHENIDATE 20 MG TAB 0.23619 01/01/2009
METHYLPHENIDATE 5 MG TAB 0.10703 01/01/2009
METHYLPHENIDATE HCL ORAL TABLET, SUSTAINED ACTION 20MG 0.44463 0.32604 10/01/2009
METHYLPRED 4 MG TAB DOSEPAK 0.11511 01/01/2009
METHYLPREDNISOLONE 4 MG TAB 0.09303 01/01/2009
METOCLOPRAMIDE 10 MG TAB 0.05870 01/01/2009
METOCLOPRAMIDE 5 MG TAB 0.06656 01/01/2009
Page 21 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
METOCLOPRAMIDE 5 MG/5 ML SYRP 0.02171 01/01/2009
METOLAZONE 2.5 MG TAB 0.56955 01/01/2009
METOLAZONE 5 MG TAB 0.91637 01/01/2009
METOPROLOL 100 MG TAB 0.05856 01/01/2009
METOPROLOL 25 MG TAB 0.04514 01/01/2009
METOPROLOL 50 MG TAB 0.03324 01/01/2009
METOPROLOL SUCCINATE ORAL TABLET, SUSTAINED RELEASE 24HR 100MG 1.23396 10/01/2009
METOPROLOL SUCCINATE ORAL TABLET, SUSTAINED RELEASE 24HR 200MG 1.96300 10/01/2009
METOPROLOL SUCCINATE ORAL TABLET, SUSTAINED RELEASE 24HR 25MG 0.92551 10/01/2009
METOPROLOL SUCCINATE ORAL TABLET, SUSTAINED RELEASE 24HR 50MG 0.92551 10/01/2009
METRONIDAZOLE 0.75% CRM 0.89271 01/01/2009
METRONIDAZOLE 250 MG TAB 0.05372 01/01/2009
METRONIDAZOLE 500 MG TAB 0.09446 01/01/2009
METRONIDAZOLE TOP 0.75% GEL 0.84909 01/01/2009
MEXILETINE 150 MG CAPSULE 0.24270 01/01/2009
MICONAZOLE NITRATE VAGINAL CREAM WITH APPLICATOR 2% 0.12277 08/12/2009
MIDAZOLAM HCL 1 MG/ML VIAL 0.40653 01/01/2009
MIDAZOLAM HCL 5 MG/ML VIAL 1.63353 01/01/2009
MIDODRINE HCL 10 MG TAB 1.98260 01/01/2009
MIDODRINE HCL 2.5 MG TAB 0.64353 01/01/2009
MIDODRINE HCL 5 MG TAB 1.09809 01/01/2009
MINOCYCLINE 100 MG CAP 0.40592 01/01/2009
MINOCYCLINE 50 MG CAP 0.21462 01/01/2009
MINOXIDIL 10 MG TAB 0.39027 01/01/2009
MINOXIDIL 2.5 MG TAB 0.21558 01/01/2009
MIRTAZAPINE 15 MG TAB 0.17738 01/01/2009
MIRTAZAPINE 30 MG RPD DISLV TAB 1.57769 01/01/2009
MIRTAZAPINE 30 MG TAB 0.24018 01/01/2009
MIRTAZAPINE 45 MG TAB 0.42725 01/01/2009
MIRTAZAPINE ORAL TABLET, RAPID DISSOLVE 15MG" 1.78200 1.68810 04/01/2009
MIRTAZAPINE ORAL TABLET, RAPID DISSOLVE 45MG" 3.19300 1.76854 04/01/2009
MISOPROSTOL 100 MCG TAB 0.57588 01/01/2009
MISOPROSTOL 200 MCG TABLET 0.68550 01/28/2008
MOEXIPRIL HCL 15 MG TAB 0.86198 01/01/2009
Page 22 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
MOEXIPRIL HCL 7.5 MG TAB 0.98226 01/01/2009
MOEXIPRIL-HCTZ 15/25 MG TAB 0.81192 01/01/2009
MOMETASONE FUROATE 0.1% CRM 0.63668 01/01/2009
MOMETASONE FUROATE 0.1% OINT 0.60929 01/01/2009
MOMETASONE FUROATE 0.1% SOLN 0.72833 01/01/2009
MORPHINE SULF 100 MG TAB SA 1.40799 01/01/2009
MORPHINE SULF 15 MG TAB SA 0.30795 01/01/2009
MORPHINE SULF 30 MG TAB SA 0.45419 01/01/2009
MORPHINE SULF 60 MG TAB SA 0.82262 01/01/2009
MORPHINE SULFATE ORAL TABLET, SUSTAINED ACTION 200MG" 2.77500 08/12/2009
MUPIROCIN 2% OINT 0.50997 01/01/2009
MYCOPHENOLATE MOFETIL ORAL CAPSULE (HARD, SOFT, ETC.) 250MG 0.59163 10/01/2009
MYCOPHENOLATE MOFETIL ORAL TABLET 500MG 1.29467 10/01/2009
NABUMETONE ORAL TABLET 500MG 0.48389 0.33534 08/12/2009
NABUMETONE ORAL TABLET 750MG 0.50361 0.38795 08/12/2009
NADOLOL 20 MG TAB 0.15965 01/01/2009
NADOLOL 40 MG TAB 0.25133 01/01/2009
NADOLOL 80 MG TABLET 0.42830 01/28/2008
NALTREXONE 50 MG TAB 1.72607 01/01/2009
NAPROXEN 250 MG TAB 0.05189 01/01/2009
NAPROXEN 375 MG TAB 0.06785 01/01/2009
NAPROXEN 500 MG TAB 0.05967 01/01/2009
NAPROXEN 500 MG TABLET EC 0.21810 01/28/2008
NAPROXEN SODIUM 220 MG TAB 0.12410 03/01/2009
NAPROXEN SODIUM 550 MG TAB 0.18321 01/01/2009
NEFAZODONE HCL 100 MG TAB 0.54552 01/01/2009
NEFAZODONE HCL 150 MG TAB 0.58781 01/01/2009
NEFAZODONE HCL 200 MG TAB 0.61607 01/01/2009
NEO/BACIT/POLY EYE OINTMENT 0.83490 01/01/2007
NEO/BACIT/POLY/HC EYE OINT 1.01560 06/01/2006
NEO/POLY/DEXAMET EYE OINT 0.72000 01/01/2009
NEO/POLYMYXIN/DEXAMETH DROP 0.50604 01/01/2009
NEO/POLYMYXIN/HC EAR SOLN 1.36740 01/01/2009
NEO/POLYMYXIN/HC EAR SUSP 1.29866 01/01/2009
Page 23 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
NEOMYCI/POLY/GRAM OPHTH SOL 2.52521 01/01/2009
NEOMYCIN 500 MG TAB 1.21268 01/01/2009
NICOTINE 2 MG LOZENGE 0.80160 03/01/2009
NICOTINE 4 MG LOZENGE 0.73740 03/01/2009
NICOTINE POLACRILEX BUCCAL GUM 2MG 0.34665 0.21805 08/12/2009
NICOTINE POLACRILEX BUCCAL GUM 4MG 0.36792 0.26792 08/12/2009
NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 14MG/24HR" 2.22764 2.07859 08/12/2009
NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 21MG/24HR" 2.22764 2.07859 08/12/2009
NICOTINE TRANSDERMAL PATCH, TRANSDERMAL 24 HOURS 7MG/24HR" 2.22764 2.07859 08/12/2009
NIFEDIPINE ER 30 MG TAB - AB1 0.73179 01/01/2009
NIFEDIPINE ER 30 MG TAB - AB2 0.83490 01/01/2009
NIFEDIPINE ER 60 MG TAB - AB1 1.40400 01/01/2009
NIFEDIPINE ER 60 MG TAB - AB2 1.46142 01/01/2009
NIFEDIPINE ER 90 MG TABLET 2.47670 06/01/2006
NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE (HARD, SOFT, ETC.) 100MG" 1.24034 0.88531 08/12/2009
NITROFURANTOIN MACROCRYSTAL ORAL CAPSULE (HARD, SOFT, ETC.) 50MG" 0.74337 0.58305 08/12/2009
NITROFURANTOIN MONOHYD 100 MG CAP 0.45698 01/01/2009
NITROGLYCERIN 0.1 MG/HR PATCH 0.69818 01/01/2009
NITROGLYCERIN 0.2 MG/HR PATCH 0.67956 01/01/2009
NITROGLYCERIN 0.4 MG/HR PATCH 0.74127 01/01/2009
NITROGLYCERIN 0.6 MG/HR PATCH 1.07760 01/28/2008
NIZATIDINE 150 MG CAP 0.40350 01/01/2009
NIZATIDINE 75 MG TABLET 0.36650 03/01/2009
NORETHINDRONE 0.35 MG TABLET 1.24170 01/28/2008
NORETHINDRONE 5 MG TABLET 1.94840 06/01/2006
NORETHINDRONE-ETHINYL ESTRADIOL ORAL TABLET 0.4-0.035 2.13776 0.99785 08/12/2009
NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 0.25-0.035 0.70236 0.67825 08/12/2009
NORGESTIMATE-ETHINYL ESTRADIOL ORAL TABLET 7DAYSX3 28 0.66746 0.52555 08/12/2009
NORGESTREL-ETHINYL ESTRADIOL ORAL TABLET 0.3-0.03MG 0.98835 0.74830 08/12/2009
NORTRIPTYLINE HCL 10 MG CAP 0.04502 01/01/2009
NORTRIPTYLINE HCL 25 MG CAP 0.05111 01/01/2009
NORTRIPTYLINE HCL 50 MG CAP 0.06434 01/01/2009
NORTRIPTYLINE HCL 75 MG CAP 0.10746 01/01/2009
NYSTATIN 100,000 UNIT/GM CRM" 0.07071 01/01/2009
Page 24 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
NYSTATIN 100,000 UNIT/GM OINT" 0.09291 01/01/2009
NYSTATIN 100,000 UNIT/GM PWDR" 0.67032 01/01/2009
NYSTATIN 100,000 UNIT/ML SUSP" 0.07406 01/01/2009
NYSTATIN 500,000 UNIT ORAL TAB" 0.64520 01/01/2007
NYSTATIN/TRIAMCINOLONE CRM 0.06593 01/01/2009
NYSTATIN/TRIAMCINOLONE OINT 0.08148 01/01/2009
OCTREOTIDE ACETATE INJECTION VIAL (SDV,MDV OR ADDITIVE) (ML) 50MCG/ML 5.72000 10/01/2009
OFLOXACIN OPHTHALMIC DROPS 0.3% 1.00308 0.72020 08/12/2009
OFLOXACIN OTIC DROPS 0.3% 2.39337 1.85751 08/12/2009
OMEPRAZOLE 10 MG CAP DR 0.66351 01/01/2009
OMEPRAZOLE 20 MG CAP 0.33332 01/01/2009
OMEPRAZOLE ORAL CAPSULE,DELAYED RELEASE (ENTERIC COATED) 40MG" 0.68500 08/12/2009
ONDANSETRON 4 MG/5 ML SOLN 4.22265 09/07/2007
ONDANSETRON HCL 2 MG/ML VIAL 0.45750 09/07/2007
ONDANSETRON HCL 24 MG TABLET 8.61000 09/07/2007
ONDANSETRON HCL 4 MG TAB 0.68132 01/01/2009
ONDANSETRON HCL 4 MG/2 ML VIAL 0.88550 01/28/2008
ONDANSETRON HCL 8 MG TAB 0.85548 01/01/2009
ONDANSETRON ORAL TABLET, RAPID DISSOLVE 4MG" 0.56711 0.55250 08/12/2009
ONDANSETRON ORAL TABLET, RAPID DISSOLVE 8MG" 1.01306 0.73450 08/12/2009
ORPHENADRINE 100 MG TAB SA 0.73634 01/01/2009
ORPHENGESIC FORTE TABLET 1.08430 06/01/2006
OXAPROZIN 600 MG TAB 0.15947 01/01/2009
OXAZEPAM 10 MG CAP 0.27495 01/01/2009
OXAZEPAM 15 MG CAP 0.48242 01/01/2009
OXAZEPAM 30 MG CAPSULE 1.18750 06/01/2006
OXCARBAZEPINE ORAL TABLET 150MG 0.54847 0.41000 07/01/2009
OXCARBAZEPINE ORAL TABLET 300MG 0.97015 0.67295 07/01/2009
OXCARBAZEPINE ORAL TABLET 600MG 1.58405 1.16953 07/01/2009
OXYBUTYNIN 5 MG TAB 0.04847 01/01/2009
OXYBUTYNIN 5 MG/5 ML SYRP 0.03138 01/01/2009
OXYBUTYNIN CHLORIDE ORAL TABLET, SR OSMOTIC PUSH 24HR 10MG" 2.79000 1.37500 07/01/2009
OXYBUTYNIN CHLORIDE ORAL TABLET, SR OSMOTIC PUSH 24HR 15MG" 2.28700 1.90500 08/12/2009
OXYBUTYNIN CHLORIDE ORAL TABLET, SR OSMOTIC PUSH 24HR 5MG" 2.71821 1.37500 07/01/2009
Page 25 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
OXYCODONE HCL 15 MG TAB 0.30591 01/01/2009
OXYCODONE HCL 30 MG TAB 0.52382 01/01/2009
OXYCODONE HCL 5 MG TAB 0.11085 01/01/2009
OXYCODONE HCL/ACETAMINOPHEN ORAL TABLET 7.5-500MG 0.49478 0.45671 04/01/2009
OXYCODONE-APAP 5-500 MG CAP 0.13709 01/01/2009
OXYCODONE/APAP 10/325 MG TAB 0.62762 01/01/2009
OXYCODONE/APAP 10/650 MG TAB 0.64634 01/01/2009
OXYCODONE/APAP 5/325 MG TAB 0.07977 01/01/2009
OXYCODONE/APAP 7.5/325 MG TAB 0.52491 01/01/2009
OXYCODONE/ASA 4.88/325 TAB 0.69360 06/01/2006
PANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 20MG 2.07500 10/01/2009
PANTOPRAZOLE SODIUM ORAL TABLET, DELAYED RELEASE (ENTERIC COATED) 40MG 2.07500 10/01/2009
PARCOPA 25 MG-100 MG TABLET 1.43787 01/01/2009
PAROXETINE HCL 10 MG TAB 0.21009 01/01/2009
PAROXETINE HCL 20 MG TAB 0.21939 01/01/2009
PAROXETINE HCL 30 MG TAB 0.26943 01/01/2009
PAROXETINE HCL 40 MG TAB 0.27077 01/01/2009
PAROXETINE HCL ORAL TABLET, SUSTAINED RELEASE 24HR 12.5MG" 3.62379 2.85671 03/01/2009
PAROXETINE HCL ORAL TABLET, SUSTAINED RELEASE 24HR 25MG" 3.83034 2.88865 03/01/2009
PEG 3350/ELECTROLYTE SOLN 0.00360 01/28/2008
PENICILLIN VK 250 MG TAB 0.11976 01/01/2009
PENICILLIN VK 250 MG/5 ML SOLN 0.02409 01/01/2009
PENICILLIN VK 500 MG TAB 0.21809 01/01/2009
PENTAZOCINE HCL/NALOXONE HCL 50-0.5MG TAB 1.07057 01/01/2009
PENTOXIFYLLINE 400 MG TAB SA 0.10604 01/01/2009
PERMETHRIN 5% CRM 0.13556 01/01/2009
PERPHENAZINE 2 MG TAB 0.21581 01/01/2009
PERPHENAZINE 4 MG TAB 0.28365 0.79950 09/10/2009
PERPHENAZINE 8 MG TAB 0.38979 01/01/2009
PHENTERMINE 15 MG CAPSULE 0.48560 01/28/2008
PHENTERMINE 30 MG CAPSULE 0.54230 01/28/2008
PHENTERMINE 37.5 MG TABLET 0.24080 01/28/2008
PHENYTOIN 125 MG/5 ML SUSP 0.11360 01/01/2009
PHENYTOIN SODIUM EXTENDED ORAL CAPSULE (HARD, SOFT, ETC.) 100MG" 0.28527 0.21372 04/01/2009
Page 26 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
PILOCARPINE HCL 5 MG TAB 0.46124 01/01/2009
PINDOLOL 10 MG TABLET 0.13190 06/01/2006
PINDOLOL 5 MG TABLET 0.10960 06/01/2006
PIPERONYL BUTOXIDE/PYRETHRINS TOPICAL SHAMPOO 3-0.3% 0.04323 08/12/2009
PIPERONYL BUTOXIDE/PYRETHRINS TOPICAL SHAMPOO 4%-0.33% 0.03030 08/12/2009
PIROXICAM 10 MG CAP 0.05483 01/01/2009
PIROXICAM 20 MG CAP 0.06458 01/01/2009
POLYETHYLENE GLYCOL 3350 POWD 0.05376 01/01/2009
POLYMYXIN B/TMP EYE DROPS 0.19640 01/28/2008
POTASSIUM CHLORIDE ORAL LIQUID (ML) 20MEQ/15ML 0.00523 08/12/2009
POTASSIUM CHLORIDE ORAL LIQUID (ML) 40MEQ/15ML 0.01100 08/12/2009
POTASSIUM CL 10 MEQ CAP SA 0.54848 01/01/2009
POTASSIUM CL 10 MEQ TAB SA 0.13899 01/01/2009
POTASSIUM CL 2 MEQ/ML VIAL 0.03240 01/01/2007
POTASSIUM CL 20 MEQ TAB SA 0.11639 01/01/2009
POTASSIUM CL 8 MEQ TABLET SA 0.08420 01/28/2008
PRAVASTATIN SODIUM 10 MG TAB 0.15183 01/01/2009
PRAVASTATIN SODIUM 20 MG TAB 0.17993 01/01/2009
PRAVASTATIN SODIUM 40 MG TAB 0.21980 01/01/2009
PRAVASTATIN SODIUM 80MG TABLET 0.41940 01/01/2009
PRAZOSIN 1 MG CAP 0.15671 01/01/2009
PRAZOSIN 2 MG CAP 0.28989 01/01/2009
PRAZOSIN HCL 5 MG CAP 0.50249 01/01/2009
PREDNISOLONE 15 MG/5 ML SOLN 0.11792 01/01/2009
PREDNISOLONE 15 MG/5 ML SYRP 0.03578 01/01/2009
PREDNISOLONE 6.7 MG/5 ML SOLN 0.05546 01/01/2009
PREDNISOLONE AC 1% EYE DROP 1.13700 01/28/2008
PREDNISOLONE SOD 1% EYE DROP 2.66460 06/01/2006
PREDNISONE 1 MG TAB 0.11724 01/01/2009
PREDNISONE 10 MG TAB 0.03684 01/01/2009
PREDNISONE 2.5 MG TAB 0.06393 01/01/2009
PREDNISONE 20 MG TAB 0.06095 01/01/2009
PREDNISONE 5 MG TAB 0.01973 01/01/2009
PRENATAL VITAMIN NO.15/IRON,CARBONYL/FOLIC ACID/DOCUSATE SOD ORAL TABLET
90-1-50MG
0.20083 10/01/2009
Page 27 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
PRENATAL VITAMINS/FERROUS FUMARATE/FOLIC ACID ORAL TABLET 27MG-1MG 0.04550 10/01/2009
PRIMIDONE 250 MG TAB 0.32972 01/01/2009
PRIMIDONE 50 MG TAB 0.22886 01/01/2009
PROBENECID 500 MG TAB 0.49398 01/01/2009
PROCHLORPERAZINE 10 MG TAB 0.07119 01/01/2009
PROCHLORPERAZINE 25 MG SUPP 1.10511 01/01/2009
PROCHLORPERAZINE 5 MG TAB 0.07769 01/01/2009
PROMETHAZINE 25 MG SUPP 0.70077 01/01/2009
PROMETHAZINE 25 MG TAB 0.26133 01/01/2009
PROMETHAZINE 25 MG/ML AMPUL 1.37550 01/01/2007
PROMETHAZINE 25 MG/ML VIAL 1.29300 01/28/2008
PROMETHAZINE 6.25/5 ML SYRP 0.02339 01/01/2009
PROMETHAZINE HCL 12.5 MG SUPP 0.68591 01/01/2009
PROMETHAZINE VC/COD SYRP 0.08886 01/01/2009
PROMETHAZINE/CODEINE SYRP 0.01853 01/01/2009
PROPAFENONE HCL 150 MG TAB 0.29633 01/01/2009
PROPAFENONE HCL 225 MG TAB 0.44223 01/01/2009
PROPAFENONE HCL 300 MG TAB 1.71720 06/01/2006
PROPARACAINE 0.5% EYE DROPS 0.51530 06/01/2006
PROPOXY-N/APAP 100/650 MG TAB 0.05622 01/01/2009
PROPOXYPHENE HCL 65 MG CAP 0.18951 01/01/2009
PROPRANOLOL 10 MG TAB 0.04250 01/01/2009
PROPRANOLOL 120 MG CAP SA 1.31181 01/01/2009
PROPRANOLOL 160 MG CAP SA 1.72452 01/01/2009
PROPRANOLOL 20 MG TAB 0.04275 01/01/2009
PROPRANOLOL 40 MG TAB 0.05918 01/01/2009
PROPRANOLOL 60 MG CAP SA 0.93603 01/01/2009
PROPRANOLOL 60 MG TAB 1.00839 01/01/2009
PROPRANOLOL 80 MG CAP SA 1.08339 01/01/2009
PROPRANOLOL 80 MG TAB 0.07625 01/01/2009
PROPRANOLOL/HYDROCHLOROTHIAZIDE 40/25 MG T 0.08040 06/01/2006
PROPRANOLOL/HYDROCHLOROTHIAZIDE 80/25 MG T 0.11800 06/01/2006
PSEUDOEPHEDRINE SULFATE/LORATADINE ORAL TABLET, SUSTAINED RELEASE 12HR
120-5MG"
0.58500 08/12/2009
PSEUDOEPHEDRINE SULFATE/LORATADINE ORAL TABLET, SUSTAINED RELEASE 24HR
240-10MG"
1.01330 0.58500 08/12/2009
Page 28 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
PYRIDOSTIGMINE BR 60 MG TAB 0.40284 01/01/2009
QUINAPRIL HCL 5 MG TABLET 0.24510 01/28/2008
QUINAPRIL HCL 10 MG TAB 0.15524 01/01/2009
QUINAPRIL HCL 20 MG TAB 0.13845 01/01/2009
QUINAPRIL HCL 40 MG TAB 0.15326 01/01/2009
QUINAPRIL/HCTZ 20/12.5 MG TAB 0.96719 01/01/2009
QUINAPRIL/HCTZ 20/25 MG TAB 1.25420 01/28/2008
QUINARETIC 10-12.5 MG TABLET 1.25270 06/01/2006
QUINIDINE SULFATE 200 MG TAB 0.18140 01/28/2008
RAMIPRIL 10 MG CAP 0.17042 01/01/2009
RAMIPRIL 2.5 MG CAP 0.13370 01/01/2009
RAMIPRIL 5 MG CAP 0.14925 01/01/2009
RANITIDINE 150 MG TAB 0.03095 01/01/2009
RANITIDINE 300 MG TAB 0.07245 01/01/2009
RANITIDINE HCL 75 MG TABLET 0.14010 03/01/2009
RANITIDINE HCL ORAL SYRUP 15MG/ML 0.25182 0.20613 03/01/2009
RIBAVIRIN ORAL CAPSULE (HARD, SOFT, ETC.) 200MG" 1.85718 1.49520 07/01/2009
RIBAVIRIN ORAL TABLET 200MG 1.64539 1.15565 07/01/2009
RIFAMPIN 300 MG CAP 2.41596 01/01/2009
RISPERIDONE ORAL TABLET 0.25MG 0.87550 0.38515 04/01/2009
RISPERIDONE ORAL TABLET 0.5MG 0.96750 0.42241 04/01/2009
RISPERIDONE ORAL TABLET 1MG 1.12100 0.45353 04/01/2009
RISPERIDONE ORAL TABLET 2MG 1.71250 0.68275 04/01/2009
RISPERIDONE ORAL TABLET 3MG 2.04600 0.83525 04/01/2009
RISPERIDONE ORAL TABLET 4MG 2.82500 0.99595 04/01/2009
ROPINIROLE HCL ORAL TABLET 0.25MG 0.65373 0.41500 08/12/2009
ROPINIROLE HCL ORAL TABLET 0.5MG 0.66254 0.43500 08/12/2009
ROPINIROLE HCL ORAL TABLET 1MG 0.64961 0.45500 08/12/2009
ROPINIROLE HCL ORAL TABLET 2MG 0.63834 0.46500 08/12/2009
ROPINIROLE HCL ORAL TABLET 3MG 0.63995 0.48500 08/12/2009
ROPINIROLE HCL ORAL TABLET 4MG 0.66711 0.49500 08/12/2009
ROPINIROLE HCL ORAL TABLET 5MG 0.65177 0.51500 08/12/2009
SELEGILINE HCL 5 MG CAP 0.34440 01/01/2009
SELEGILINE HCL 5 MG TABLET 0.12300 01/28/2008
Page 29 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
SELENIUM SULF 2.5% SHAMPOO 0.05067 01/01/2009
SERTRALINE 20 MG/ML ORAL CONC 0.94700 05/14/2007
SERTRALINE HCL 100 MG TAB 0.12717 01/01/2009
SERTRALINE HCL 25 MG TAB 0.11325 01/01/2009
SERTRALINE HCL 50 MG TAB 0.11261 01/01/2009
SILVER SULFADIAZINE 1% CRM 0.08810 01/01/2007
SIMVASTATIN 10 MG TAB 0.06261 01/01/2009
SIMVASTATIN 20 MG TAB 0.09062 01/01/2009
SIMVASTATIN 40 MG TAB 0.10601 01/01/2009
SIMVASTATIN 5 MG TAB 0.06296 01/01/2009
SIMVASTATIN 80 MG TAB 0.13697 01/01/2009
SODIUM BICARB 8.4% SYRINGE 0.09240 06/01/2006
SODIUM CHLORIDE 0.9% SOLN 0.00500 01/28/2008
SODIUM CHLORIDE 0.9% VIAL 0.02870 01/01/2007
SODIUM POLYSTYRENE SULF PWDR 0.32348 01/01/2009
SOTALOL HCL 120 MG TAB 0.21345 01/01/2009
SOTALOL HCL 160 MG TAB 0.25967 01/01/2009
SOTALOL HCL 80 MG TAB 0.12927 01/01/2009
SOTALOL HCL ORAL TABLET 240MG 0.85644 08/12/2009
SPIRONOLACT/HCTZ 25/25 MG TAB 0.27585 01/01/2009
SPIRONOLACTONE 25 MG TAB 0.14721 01/01/2009
SPIRONOLACTONE 50 MG TAB 0.45432 01/01/2009
SPIRONOLACTONE ORAL TABLET 100MG 0.93629 0.86598 04/01/2009
SPS 15 GM/60 ML SUSP 0.05892 01/01/2009
STAVUDINE ORAL CAPSULE (HARD, SOFT, ETC.) 15MG" 1.95477 04/01/2009
STAVUDINE ORAL CAPSULE (HARD, SOFT, ETC.) 20MG" 2.03298 04/01/2009
STAVUDINE ORAL CAPSULE (HARD, SOFT, ETC.) 30MG" 2.15908 04/01/2009
STAVUDINE ORAL CAPSULE (HARD, SOFT, ETC.) 40MG" 2.32917 04/01/2009
STERILE WATER,IRRIGATION" 0.00340 06/01/2006
SUCRALFATE 1 GM TAB 0.17210 01/01/2009
SULFACETAMIDE 10% EYE DROP 0.14420 01/01/2009
SULFAMETHOXAZOLE/TMP DS TAB 0.12309 01/01/2009
SULFAMETHOXAZOLE/TMP SS TAB 0.14538 01/01/2009
SULFAMETHOXAZOLE/TMP SUSP 0.03309 01/01/2009
Page 30 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
SULFASALAZINE 500 MG TAB 0.11648 01/01/2009
SULFASALAZINE DR 500 MG TAB 0.31950 01/28/2008
SULINDAC 150 MG TAB 0.19851 01/01/2009
SULINDAC 200 MG TAB 0.27911 01/01/2009
SUMATRIPTAN SUCCINATE ORAL TABLET 100MG 2.33489 10/01/2009
SUMATRIPTAN SUCCINATE ORAL TABLET 25MG 2.49811 10/01/2009
SUMATRIPTAN SUCCINATE ORAL TABLET 50MG 2.33489 10/01/2009
SUMYCIN 125 MG/5 ML ORAL SUSP 0.20820 06/01/2006
TAMOXIFEN 10 MG TAB 0.18054 01/01/2009
TAMOXIFEN 20 MG TAB 0.35837 01/01/2009
TEMAZEPAM 15 MG CAP 0.09153 01/01/2009
TEMAZEPAM 30 MG CAP 0.11762 01/01/2009
TERAZOSIN 1 MG CAP 0.11282 01/01/2009
TERAZOSIN 10 MG CAP 0.10622 01/01/2009
TERAZOSIN 2 MG CAP 0.10332 01/01/2009
TERAZOSIN 5 MG CAP 0.11000 01/01/2009
TERBINAFINE HCL 250 MG TAB 0.28499 01/01/2009
TERBUTALINE SULFATE 2.5 MG TAB 0.39950 01/28/2008
TERBUTALINE SULFATE 5 MG TAB 0.54633 01/01/2009
TERCONAZOLE 0.4% CRM 0.31703 01/01/2009
TERCONAZOLE 0.8% VAGINAL CREAM 1.07510 01/28/2008
TESTOSTERONE CYP 200 MG/ML VIAL 16.68923 01/01/2009
TESTOSTERONE ENAN 200 MG/ML VIAL 13.75827 01/01/2009
TETRACYCLINE 250 MG CAP 0.04541 01/01/2009
TETRACYCLINE 500 MG CAP 0.06888 01/01/2009
THEOPHYLLINE 100 MG TAB SA 0.17259 01/01/2009
THEOPHYLLINE 200 MG TAB SA 0.17477 01/01/2009
THEOPHYLLINE 300 MG TAB SA 0.20777 01/01/2009
THIORIDAZINE 10 MG TABLET 0.18310 06/01/2006
THIORIDAZINE 100 MG TAB 0.29963 01/01/2009
THIORIDAZINE 25 MG TAB 0.19193 01/01/2009
THIORIDAZINE 50 MG TAB 0.23642 01/01/2009
THIOTHIXENE 10 MG CAP 0.30062 01/01/2009
THIOTHIXENE 2 MG CAP 0.10752 01/01/2009
Page 31 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
THIOTHIXENE 5 MG CAP 0.21171 01/01/2009
TICLOPIDINE 250 MG TAB 0.18587 01/01/2009
TIMOLOL 0.25% EYE DROP 0.38234 01/01/2009
TIMOLOL 0.5% EYE DROP 0.33162 01/01/2009
TIZANIDINE HCL 2 MG TAB 0.08561 01/01/2009
TIZANIDINE HCL 4 MG TAB 0.09929 01/01/2009
TOBRAMYCIN 0.3% EYE DROP 0.39345 01/01/2009
TOLMETIN SODIUM 400 MG CAP 1.03170 06/01/2006
TOLNAFTATE TOPICAL CREAM (GRAMS) 1% 0.05287 08/12/2009
TOPIRAMATE 100 MG TABLET 0.23550 07/01/2009
TOPIRAMATE 200 MG TABLET 0.21755 07/01/2009
TOPIRAMATE ORAL TABLET 25MG 0.18500 0.12870 10/01/2009
TOPIRAMATE ORAL TABLET 50MG 0.20750 0.18720 10/01/2009
TORSEMIDE 10 MG TAB 0.18848 01/01/2009
TORSEMIDE 100 MG TAB 0.97310 01/01/2009
TORSEMIDE 20 MG TAB 0.25986 01/01/2009
TRAMADOL HCL 50 MG TAB 0.04154 01/01/2009
TRAMADOL/APAP 37.5/325 MG TAB 0.47244 01/01/2009
TRANDOLAPRIL 1 MG TAB 0.56901 01/01/2009
TRANDOLAPRIL 2 MG TAB 0.58350 01/01/2009
TRANDOLAPRIL 4 MG TAB 0.55739 01/01/2009
TRAZODONE 100 MG TAB 0.06051 01/01/2009
TRAZODONE 150 MG TAB 0.14621 01/01/2009
TRAZODONE 50 MG TAB 0.03437 01/01/2009
TRETINOIN 0.01% GEL 1.10910 01/28/2008
TRETINOIN 0.025% CRM 0.83333 01/01/2009
TRETINOIN 0.025% GEL 1.63764 01/01/2009
TRETINOIN 0.05% CRM 1.26828 01/01/2009
TRETINOIN 0.1% CRM 1.41650 01/01/2009
TRIAMCINOLONE 0.025% CRM 0.04265 01/01/2009
TRIAMCINOLONE 0.025% OINT 0.05951 01/01/2009
TRIAMCINOLONE 0.1% CRM 0.04425 01/01/2009
TRIAMCINOLONE 0.1% LOT 0.55584 01/01/2009
TRIAMCINOLONE 0.1% OINT 0.04898 01/01/2009
Page 32 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
TRIAMCINOLONE 0.5% CRM 0.12197 01/01/2009
TRIAMCINOLONE 0.5% OINT 0.20604 01/01/2009
TRIAMTERENE/HCTZ 37.5/25 MG CAP 0.05501 01/01/2009
TRIAMTERENE/HCTZ 37.5/25 MG TAB 0.05936 01/01/2009
TRIAMTERENE/HCTZ 50/25 MG CAP 0.41268 01/01/2009
TRIAMTERENE/HCTZ 75/50 MG TAB 0.04310 01/28/2008
TRIAZOLAM 0.125 MG TABLET 0.20610 01/28/2008
TRIAZOLAM 0.25 MG TABLET 0.20820 01/28/2008
TRIFLUOPERAZINE 2 MG TABLET 0.49130 06/01/2006
TRIFLUOPERAZINE 5 MG TABLET 0.61660 06/01/2006
TRIHEXYPHENIDYL 2 MG TAB 0.07470 01/01/2009
TRIHEXYPHENIDYL 5 MG TAB 0.18209 01/01/2009
TRIMETHOBENZAMIDE 300 MG CAP 0.77110 06/01/2006
TRIMETHOPRIM 100 MG TABLET 0.43350 01/01/2007
UREA TOPICAL CREAM (GRAMS) 40% 0.16364 08/12/2009
URSODIOL 300 MG CAP 0.56322 01/01/2009
VALPROIC ACID 250 MG CAP 0.24699 01/01/2009
VALPROIC ACID 250 MG/5 ML SYRP 0.02042 01/01/2009
VENLAFAXINE HCL ORAL TABLET 100MG 1.20393 0.57535 08/12/2009
VENLAFAXINE HCL ORAL TABLET 25MG 1.01036 0.57535 08/12/2009
VENLAFAXINE HCL ORAL TABLET 37.5MG 1.04026 0.57535 08/12/2009
VENLAFAXINE HCL ORAL TABLET 50MG 1.07172 0.57535 08/12/2009
VENLAFAXINE HCL ORAL TABLET 75MG 1.13620 0.57535 08/12/2009
VERAPAMIL 120 MG CAP PELLET 0.58722 01/01/2009
VERAPAMIL 120 MG TAB 0.08910 01/01/2009
VERAPAMIL 120 MG TAB SA 0.44123 01/01/2009
VERAPAMIL 180 MG CAP PELLET 0.60330 01/01/2007
VERAPAMIL 180 MG TAB SA 0.26907 01/01/2009
VERAPAMIL 240 MG CAP PELLET 0.57453 01/01/2009
VERAPAMIL 240 MG TAB SA 0.30920 01/01/2009
VERAPAMIL 80 MG TAB 0.07229 01/01/2009
VITAMIN B COMPLX NO.3/FOLIC ACID/ASCORBIC ACID/BIOTIN ORAL TABLET 1MG-60MG 0.24960 08/12/2009
WARFARIN SODIUM 1 MG TAB 0.16286 01/01/2009
WARFARIN SODIUM 10 MG TAB 0.21989 01/01/2009
Page 33 of 3410/26/2009
Generic Name
Wyoming Medicaid
Office of Pharmacy Services
State Maximum Allowable Cost (SMAC) List
as of October 26, 2009
Old SMAC
Price
Current
SMAC Price
Effective
Date
WARFARIN SODIUM 2 MG TAB 0.16392 01/01/2009
WARFARIN SODIUM 2.5 MG TAB 0.16298 01/01/2009
WARFARIN SODIUM 3 MG TAB 0.16319 01/01/2009
WARFARIN SODIUM 4 MG TAB 0.15848 01/01/2009
WARFARIN SODIUM 5 MG TAB 0.15345 01/01/2009
WARFARIN SODIUM 6 MG TAB 0.17613 01/01/2009
WARFARIN SODIUM 7.5 MG TAB 0.18375 01/01/2009
WATER FOR INJECTION VIAL 0.03350 01/01/2007
ZALEPLON ORAL CAPSULE (HARD, SOFT, ETC.) 10MG" 0.52761 0.41575 08/12/2009
ZALEPLON ORAL CAPSULE (HARD, SOFT, ETC.) 5MG" 0.56757 0.41575 08/12/2009
ZIDOVUDINE ORAL TABLET 300MG 0.78953 08/12/2009
ZOLPIDEM TARTRATE 10 MG TAB 0.05108 01/01/2009
ZOLPIDEM TARTRATE 5 MG TAB 0.04794 01/01/2009
ZONISAMIDE 100 MG CAP 0.29024 01/01/2009
ZONISAMIDE ORAL CAPSULE (HARD, SOFT, ETC.) 25MG" 0.16731 05/01/2009
ZONISAMIDE ORAL CAPSULE (HARD, SOFT, ETC.) 50MG" 0.18304 05/01/2009
Page 34 of 3410/26/2009