Alabama Medicaid Maximum Allowable Cost List
Alabama Medicaid Maximum Allowable Cost List
Alabama Medicaid Maximum Allowable Cost List
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
AMINOSYN II W/ELEC IN DEX W/CA AA 4.25%/CAL/D25W/LYTES 4.25% IV SOLN.<br />
CLINIMIX E AA 4.25%/CAL/D25W/LYTES 4.25% IV SOLN.<br />
AMINOSYN II 4.25% M/DEXT 10% AA 4.25%/D10W/ELECTROLYTE-TPN 4.25% IV SOLN.<br />
QUICK MIX W/LYTES AA 4.25%/D10W/ELECTROLYTE-TPN 4.25% IV SOLN.<br />
FREAMINE III W/ELECTROLYTES AA 8.5%/ELECTROLYTE-TPN SOLN 8.5% IV SOLN.<br />
ACEBUTOLOL HCL ACEBUTOLOL HCL 200MG CAPSULE<br />
ACEBUTOLOL HCL ACEBUTOLOL HCL 400MG CAPSULE<br />
SECTRAL ACEBUTOLOL HCL 200MG CAPSULE<br />
SECTRAL ACEBUTOLOL HCL 400MG CAPSULE<br />
ACEPHEN ACETAMINOPHEN 120MG SUPP.RECT<br />
ACEPHEN ACETAMINOPHEN 325MG SUPP.RECT<br />
ACEPHEN ACETAMINOPHEN 650MG SUPP.RECT<br />
ACETA ACETAMINOPHEN 160MG TAB CHEW<br />
ACETA ACETAMINOPHEN 325MG TABLET<br />
ACETA ACETAMINOPHEN 500MG CAPSULE<br />
ACETA ACETAMINOPHEN 500MG TABLET<br />
ACETAMINOPHEN ACETAMINOPHEN 100MG/ML DROPS<br />
ACETAMINOPHEN ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
ACETAMINOPHEN ACETAMINOPHEN 120MG SUPP.RECT<br />
ACETAMINOPHEN ACETAMINOPHEN 160MG TAB CHEW<br />
ACETAMINOPHEN ACETAMINOPHEN 160MG/5ML ELIXIR<br />
ACETAMINOPHEN ACETAMINOPHEN 160MG/5ML LIQUID<br />
ACETAMINOPHEN ACETAMINOPHEN 160MG/5ML SOLUTION<br />
ACETAMINOPHEN ACETAMINOPHEN 325MG SUPP.RECT<br />
ACETAMINOPHEN ACETAMINOPHEN 325MG TABLET<br />
ACETAMINOPHEN ACETAMINOPHEN 500MG CAPSULE<br />
ACETAMINOPHEN ACETAMINOPHEN 500MG TABLET<br />
ACETAMINOPHEN ACETAMINOPHEN 650MG SUPP.RECT<br />
ACETAMINOPHEN ACETAMINOPHEN 650MG TABLET<br />
ACETAMINOPHEN ACETAMINOPHEN 80MG TAB CHEW<br />
ACETAMINOPHEN JR ACETAMINOPHEN 160MG TAB CHEW<br />
ACETAMINOPHEN JUNIOR STRENGTH ACETAMINOPHEN 160MG TAB CHEW<br />
ACTAMIN ACETAMINOPHEN 500MG/5ML LIQUID<br />
ALTENOL ACETAMINOPHEN 160MG/5ML ELIXIR<br />
ANACIN ASPIRIN FREE ACETAMINOPHEN 500MG TABLET<br />
APAP ACETAMINOPHEN 100MG/ML DROPS<br />
APAP ACETAMINOPHEN 160MG/5ML ELIXIR<br />
APAP ACETAMINOPHEN 160MG/5ML SOLUTION<br />
APAP ACETAMINOPHEN 325MG TABLET<br />
APAP ACETAMINOPHEN 500MG TABLET<br />
APAP 500 ACETAMINOPHEN 500MG/5ML LIQUID<br />
APAP CHILDRENS ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
APAPEDYN ACETAMINOPHEN 160MG/5ML ELIXIR<br />
APAPEDYN ACETAMINOPHEN 500MG TABLET<br />
ARTHRITIS PAIN RELIEF ACETAMINOPHEN 650MG TABLET SA<br />
ASPIRIN FREE CHILD'S ACETAMINOPHEN 160MG/5ML ELIXIR<br />
ASPIRIN FREE CHILD'S ACETAMINOPHEN 80MG TAB CHEW<br />
ASPIRIN FREE EXTRA STRENGTH ACETAMINOPHEN 500MG TABLET<br />
CHILD APAP ACETAMINOPHEN 80MG TAB CHEW<br />
CHILD PAIN RELIEF ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
CHILD PAIN RELIEF ACETAMINOPHEN 160MG/5ML ELIXIR<br />
CHILD PAIN RELIEF ACETAMINOPHEN 80MG TAB CHEW<br />
CHILD PAIN RELIEF F ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
CHILDREN'S ACETAMINOPHEN ACETAMINOPHEN 80MG TAB CHEW<br />
CHILDREN'S NON ASPIRIN ACETAMINOPHEN 80MG TAB CHEW<br />
CHILDREN'S NON-ASPIRIN ACETAMINOPHEN 160MG/5ML ELIXIR<br />
CHILDREN'S NON-ASPIRIN ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
CHILDREN'S NON-ASPIRIN ACETAMINOPHEN 80MG TAB CHEW<br />
CHILDREN'S PAIN RELIEF ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
CHILDREN'S PAIN RELIEF ACETAMINOPHEN 80MG TAB CHEW<br />
CHILDREN'S PAIN RELIEVER ACETAMINOPHEN 160MG/5ML ELIXIR<br />
CHILDREN'S PAIN RELIEVER ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
CHILDREN'S PAIN RELIEVER ACETAMINOPHEN 80MG TAB CHEW<br />
CHILDRENS PAIN RELIEVER ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
CHILDREN'S SUSPENSION ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
CHILDREN'S TACTINAL ACETAMINOPHEN 80MG TAB CHEW<br />
CHILDREN'S TYLENOL ACETAMINOPHEN 80MG TAB CHEW<br />
DOLONO ACETAMINOPHEN 160MG/5ML ELIXIR<br />
DOLONO ACETAMINOPHEN 325MG TABLET<br />
DOLONO EXTRA STRENGTH ACETAMINOPHEN 500MG TABLET<br />
DOLONO INFANT'S ACETAMINOPHEN 100MG/ML DROPS<br />
ED-APAP ACETAMINOPHEN 160MG/5ML LIQUID<br />
EXTRA STRENGTH PAIN RELIEF ACETAMINOPHEN 500MG TABLET<br />
FEBROL ACETAMINOPHEN 167MG/5ML LIQUID<br />
FEVERALL ACETAMINOPHEN 120MG SUPP.RECT<br />
Page 1<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
FEVERALL ACETAMINOPHEN 325MG SUPP.RECT<br />
FEVERALL ACETAMINOPHEN 650MG SUPP.RECT<br />
GENAPAP ACETAMINOPHEN 100MG/ML DROPS<br />
GENAPAP ACETAMINOPHEN 160MG/5ML ELIXIR<br />
GENAPAP ACETAMINOPHEN 325MG TABLET<br />
GENAPAP ACETAMINOPHEN 500MG TABLET<br />
GENAPAP ACETAMINOPHEN 80MG TAB CHEW<br />
GENEBS ACETAMINOPHEN 325MG TABLET<br />
GENEBS ACETAMINOPHEN 500MG TABLET<br />
HM PAIN RELIEVER ACETAMINOPHEN 325MG TABLET<br />
HM PAIN RELIEVER ACETAMINOPHEN 500MG TABLET<br />
INFANT DROPS ACETAMINOPHEN 100MG/ML DROPS<br />
INFANT PAIN RELIEF ACETAMINOPHEN 100MG/ML DROPS<br />
INFANT SUSPENSION ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
INFANTOL ACETAMINOPHEN 100MG/ML DROPS<br />
INFANT'S NON-ASPIRIN ACETAMINOPHEN 100MG/ML DROPS<br />
INFANTS' NON-ASPIRIN ACETAMINOPHEN 100MG/ML DROPS<br />
INFANTS NON-ASPIRIN ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
INFANT'S PAIN RELIEVER ACETAMINOPHEN 100MG/ML DROPS<br />
INFANT'S PAIN RELIEVER ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
INFANTS PAIN RELIEVER ACETAMINOPHEN 100MG/ML DROPS<br />
INFANTS PAIN RELIEVER W/O ASA ACETAMINOPHEN 100MG/ML DROPS<br />
INFANT'S SUSPENSION ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
KOMAPHEN ACETAMINOPHEN 160MG/5ML ELIXIR<br />
KOSHER CARE ACETAMINOPHEN 160MG/5ML LIQUID<br />
MAPAP ACETAMINOPHEN 100MG/ML DROPS<br />
MAPAP ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
MAPAP ACETAMINOPHEN 120MG SUPP.RECT<br />
MAPAP ACETAMINOPHEN 160MG/5ML ELIXIR<br />
MAPAP ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
MAPAP ACETAMINOPHEN 325MG TABLET<br />
MAPAP ACETAMINOPHEN 500MG CAPSULE<br />
MAPAP ACETAMINOPHEN 500MG TABLET<br />
MAPAP ACETAMINOPHEN 650MG SUPP.RECT<br />
MAPAP ACETAMINOPHEN 80MG TAB CHEW<br />
MAPAP ARTHRITIS PAIN ACETAMINOPHEN 650MG TABLET SA<br />
MAPAP CHILDREN'S ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
MAPAP EXTRA STRENGTH ACETAMINOPHEN 500MG TABLET<br />
MAPAP JR STRENGTH ACETAMINOPHEN 160MG TABLET<br />
MARDOL ACETAMINOPHEN 100MG/ML DROPS<br />
MARDOL ACETAMINOPHEN 160MG/5ML ELIXIR<br />
MARDOL ACETAMINOPHEN 325MG TABLET<br />
MARDOL ACETAMINOPHEN 500MG TABLET<br />
MAXINOL ACETAMINOPHEN 325MG TABLET<br />
MAXINOL ACETAMINOPHEN 500MG TABLET<br />
NON ASPIRIN ACETAMINOPHEN 100MG/ML DROPS<br />
NON ASPIRIN ACETAMINOPHEN 500MG TABLET<br />
NON-ASA E/S ACETAMINOPHEN 500MG TABLET<br />
NON-ASPIRIN ACETAMINOPHEN 100MG/ML DROPS<br />
NON-ASPIRIN ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
NON-ASPIRIN ACETAMINOPHEN 120MG SUPP.RECT<br />
NON-ASPIRIN ACETAMINOPHEN 160MG TAB CHEW<br />
NON-ASPIRIN ACETAMINOPHEN 160MG/5ML ELIXIR<br />
NON-ASPIRIN ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
NON-ASPIRIN ACETAMINOPHEN 325MG TABLET<br />
NON-ASPIRIN ACETAMINOPHEN 500MG CAPSULE<br />
NON-ASPIRIN ACETAMINOPHEN 500MG TABLET<br />
NON-ASPIRIN ACETAMINOPHEN 80MG TAB CHEW<br />
NON-ASPIRIN EXTRA STRENGTH ACETAMINOPHEN 167MG/5ML LIQUID<br />
NON-ASPIRIN EXTRA STRENGTH ACETAMINOPHEN 500MG TABLET<br />
NON-ASPIRIN INFANT PAIN RELIEF ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
NON-ASPIRIN JR ACETAMINOPHEN 160MG TAB CHEW<br />
NON-ASPIRIN JR STRENGTH ACETAMINOPHEN 160MG TAB CHEW<br />
NON-ASPIRIN JUNIOR ACETAMINOPHEN 160MG TAB CHEW<br />
NON-ASPIRIN PAIN RELIEF ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
NON-ASPIRIN PAIN RELIEF ACETAMINOPHEN 325MG TABLET<br />
NON-ASPIRIN PAIN RELIEF ACETAMINOPHEN 500MG TABLET<br />
NON-ASPIRIN PAIN RELIEF ACETAMINOPHEN 80MG TAB CHEW<br />
NON-ASPIRIN PAIN RELIEVER ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
NON-ASPIRIN PAIN RELIEVER ACETAMINOPHEN 500MG TABLET<br />
NON-ASPIRIN PAIN RELIEVER ACETAMINOPHEN 80MG TAB CHEW<br />
NON-ASPIRIN SUSPENSION ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
NORTEMP ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
NORTEMP ACETAMINOPHEN 160MG/5ML SOLUTION<br />
PAIN RELIEF ACETAMINOPHEN 325MG TABLET<br />
Page 2<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
PAIN RELIEF ACETAMINOPHEN 500MG TABLET<br />
PAIN RELIEF EXTRA-STRENGTH ACETAMINOPHEN 500MG TABLET<br />
PAIN RELIEF JUNIOR STRENGTH ACETAMINOPHEN 160MG TAB CHEW<br />
PAIN RELIEVER ACETAMINOPHEN 100MG/ML DROPS<br />
PAIN RELIEVER ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
PAIN RELIEVER ACETAMINOPHEN 120MG SUPP.RECT<br />
PAIN RELIEVER ACETAMINOPHEN 160MG/5ML ELIXIR<br />
PAIN RELIEVER ACETAMINOPHEN 160MG/5ML LIQUID<br />
PAIN RELIEVER ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
PAIN RELIEVER ACETAMINOPHEN 325MG TABLET<br />
PAIN RELIEVER ACETAMINOPHEN 500MG TABLET<br />
PAIN RELIEVER ACETAMINOPHEN 80MG TAB CHEW<br />
PAIN RELIEVER CHILD ACETAMINOPHEN 160MG TAB CHEW<br />
PAIN RELIEVER JR ACETAMINOPHEN 160MG TAB CHEW<br />
PAIN RELIEVER JUNIOR STRENGTH ACETAMINOPHEN 160MG TAB CHEW<br />
PAIN RELIEVER NON-ASA EX STR ACETAMINOPHEN 500MG TABLET<br />
PAIN RELIEVER W/O ASPIRIN ACETAMINOPHEN 325MG TABLET<br />
PAIN RELIEVER W/O ASPIRIN ACETAMINOPHEN 500MG TABLET<br />
PAIN RELIEVER W/OUT ASPIRIN ACETAMINOPHEN 500MG TABLET<br />
Q-PAP ACETAMINOPHEN 100MG/ML DROPS<br />
Q-PAP ACETAMINOPHEN 160MG/5ML ELIXIR<br />
Q-PAP ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
Q-PAP ACETAMINOPHEN 325MG TABLET<br />
Q-PAP EXTRA STRENGTH ACETAMINOPHEN 500MG TABLET<br />
REGULAR STRENGTH PAIN RELIEF ACETAMINOPHEN 325MG TABLET<br />
SB NON-ASPIRIN ACETAMINOPHEN 160MG TAB CHEW<br />
SB NON-ASPIRIN ACETAMINOPHEN 325MG TABLET<br />
SILAPAP ACETAMINOPHEN 100MG/ML DROPS<br />
SILAPAP ACETAMINOPHEN 160MG/5ML LIQUID<br />
TACTINAL ACETAMINOPHEN 325MG TABLET<br />
TACTINAL ACETAMINOPHEN 500MG TABLET<br />
TYLENOL ACETAMINOPHEN 100MG/ML DROPS<br />
TYLENOL ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
TYLENOL ACETAMINOPHEN 160MG TAB CHEW<br />
TYLENOL ACETAMINOPHEN 160MG/5ML ELIXIR<br />
TYLENOL ACETAMINOPHEN 160MG/5ML ORAL SUSP<br />
TYLENOL ACETAMINOPHEN 167MG/5ML LIQUID<br />
TYLENOL ACETAMINOPHEN 325MG TABLET<br />
TYLENOL ACETAMINOPHEN 500MG TABLET<br />
TYLENOL ACETAMINOPHEN 650MG TABLET SA<br />
TYLENOL ARTHRITIS ACETAMINOPHEN 650MG TABLET SA<br />
TYLENOL EXTRA STRENGTH ACETAMINOPHEN 500MG TABLET<br />
TYLENOL SORE THROAT ACETAMINOPHEN 167MG/5ML LIQUID<br />
UNI-ACE ACETAMINOPHEN 500MG TABLET<br />
UNI-ACE CHILD ACETAMINOPHEN 160MG/5ML LIQUID<br />
V-R NON ASPIRIN ACETAMINOPHEN 500MG TABLET<br />
V-R NON-ASPIRIN ACETAMINOPHEN 100MG/ML DROPS SUSP<br />
V-R NON-ASPIRIN ACETAMINOPHEN 500MG TABLET<br />
YACEMOL EXTRA STRENGTH ACETAMINOPHEN 500MG TABLET<br />
ADDED STRENGTH PAIN RELIEF ACETAMINOPHEN/ASPIRIN/CAFFEINE TABLET<br />
ADDED STRENGTH PAIN RELIEF ACETAMINOPHEN/ASPIRIN/CAFFEINE 250-250-65 TABLET<br />
ADDED STRENGTH PAIN RELIEVER ACETAMINOPHEN/ASPIRIN/CAFFEINE 250-250-65 TABLET<br />
ANALGESIC ACETAMINOPHEN/ASPIRIN/CAFFEINE TABLET<br />
EXCEDRIN ACETAMINOPHEN/ASPIRIN/CAFFEINE 250-250-65 TABLET<br />
EXCEDRIN MIGRAINE ACETAMINOPHEN/ASPIRIN/CAFFEINE 250-250-65 TABLET<br />
EX-PAIN ACETAMINOPHEN/ASPIRIN/CAFFEINE TABLET<br />
GENACED ACETAMINOPHEN/ASPIRIN/CAFFEINE 250-250-65 TABLET<br />
HEADACHE PAIN ACETAMINOPHEN/ASPIRIN/CAFFEINE 250-250-65 TABLET<br />
MIGRAINE FORMULA ACETAMINOPHEN/ASPIRIN/CAFFEINE 250-250-65 TABLET<br />
MIGRAINE RELIEF ACETAMINOPHEN/ASPIRIN/CAFFEINE 250-250-65 TABLET<br />
PAIN RELIEF EXTRA STRENGTH ACETAMINOPHEN/ASPIRIN/CAFFEINE TABLET<br />
PAIN RELIEVER ACETAMINOPHEN/ASPIRIN/CAFFEINE TABLET<br />
PAIN RELIEVER ACETAMINOPHEN/ASPIRIN/CAFFEINE 250-250-65 TABLET<br />
PAIN RELIEVER PLUS ACETAMINOPHEN/ASPIRIN/CAFFEINE 250-250-65 TABLET<br />
ULTRA-GESIC ACETAMINOPHEN/ASPIRIN/CAFFEINE TABLET<br />
V-R ADDED STRENGTH HEADACHE ACETAMINOPHEN/ASPIRIN/CAFFEINE TABLET<br />
AMERICET ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 TABLET<br />
ANOLOR-300 ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
ARCET ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
BUTALBITAL/APAP/CAFFEINE ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
BUTALBITAL/APAP/CAFFEINE ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 TABLET<br />
BUTALBITAL/APAP/CAFFEINE ACETAMINOPHEN/BUTALB/CAFFEINE 500-40-50 TABLET<br />
BUTALBITAL-APAP-CAFFEINE ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 TABLET<br />
ENDOLOR ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
ESGIC ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
Page 3<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
ESGIC ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 TABLET<br />
ESGIC PLUS ACETAMINOPHEN/BUTALB/CAFFEINE 500-40-50 CAPSULE<br />
ESGIC-PLUS ACETAMINOPHEN/BUTALB/CAFFEINE 500-40-50 TABLET<br />
EZOL ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
FIORICET ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 TABLET<br />
GEONE ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
MARGESIC ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
MEDIGESIC ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
REPAN ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
REPAN ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 TABLET<br />
TENAKE ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
TRIAD ACETAMINOPHEN/BUTALB/CAFFEINE 325-40-50 CAPSULE<br />
ZEBUTAL ACETAMINOPHEN/BUTALB/CAFFEINE 500-40-50 CAPSULE<br />
ACETAMINOPHEN W/BUTALBITAL ACETAMINOPHEN/BUTALBITAL 325-50MG TABLET<br />
AXOCET ACETAMINOPHEN/BUTALBITAL 650-50MG CAPSULE<br />
AXOCET ACETAMINOPHEN/BUTALBITAL 650-50MG TABLET<br />
BUPAP ACETAMINOPHEN/BUTALBITAL 650-50MG TABLET<br />
BUTEX FORTE ACETAMINOPHEN/BUTALBITAL 650-50MG CAPSULE<br />
CEPHADYN ACETAMINOPHEN/BUTALBITAL 650-50MG TABLET<br />
DOLGIC ACETAMINOPHEN/BUTALBITAL 650-50MG TABLET<br />
MARTEN-TAB ACETAMINOPHEN/BUTALBITAL 325-50MG TABLET<br />
PHRENILIN FORTE ACETAMINOPHEN/BUTALBITAL 650-50MG CAPSULE<br />
PROMACET ACETAMINOPHEN/BUTALBITAL 650-50MG TABLET<br />
REPAN-CF ACETAMINOPHEN/BUTALBITAL 650-50MG TABLET<br />
SEDAPAP ACETAMINOPHEN/BUTALBITAL 650-50MG TABLET<br />
TENCON ACETAMINOPHEN/BUTALBITAL 650-50MG CAPSULE<br />
TENCON ACETAMINOPHEN/BUTALBITAL 650-50MG TABLET<br />
ACETAMINOPHEN W/CODEIN ACETAMINOPHEN/CODEINE PHOS 30-300MG TABLET<br />
ACETAMINOPHEN W/CODEIN ACETAMINOPHEN/CODEINE PHOS 60-300MG TABLET<br />
ACETAMINOPHEN W/CODEINE ACETAMINOPHEN/CODEINE PHOS 12-120MG/5 ELIXIR<br />
ACETAMINOPHEN W/CODEINE ACETAMINOPHEN/CODEINE PHOS 15-300MG TABLET<br />
ACETAMINOPHEN W/CODEINE ACETAMINOPHEN/CODEINE PHOS 30-300MG TABLET<br />
ACETAMINOPHEN W/CODEINE ACETAMINOPHEN/CODEINE PHOS 60-300MG TABLET<br />
ACETAMINOPHEN-CODEINE ACETAMINOPHEN/CODEINE PHOS 15-300MG TABLET<br />
ACETAMINOPHEN-CODEINE ACETAMINOPHEN/CODEINE PHOS 30-300MG TABLET<br />
ACETAMINOPHEN-CODEINE ACETAMINOPHEN/CODEINE PHOS 60-300MG TABLET<br />
TYLENOL W/CODEINE NO.3 ACETAMINOPHEN/CODEINE PHOS 30-300MG TABLET<br />
TYLENOL W/CODEINE NO.4 ACETAMINOPHEN/CODEINE PHOS 60-300MG TABLET<br />
TY-PAP W/CODEINE ACETAMINOPHEN/CODEINE PHOS 12-120MG/5 ELIXIR<br />
ANEXSIA ACETAMINOPHEN/HYDROCODONE BIT 5-325MG TABLET<br />
ANEXSIA ACETAMINOPHEN/HYDROCODONE BIT 7.5-650MG TABLET<br />
BANCAP HC ACETAMINOPHEN/HYDROCODONE BIT 5-500MG CAPSULE<br />
CETA-PLUS ACETAMINOPHEN/HYDROCODONE BIT 5-500MG CAPSULE<br />
CO-GESIC ACETAMINOPHEN/HYDROCODONE BIT 5-500MG TABLET<br />
DOLACET ACETAMINOPHEN/HYDROCODONE BIT 5-500MG CAPSULE<br />
HYCOMED ACETAMINOPHEN/HYDROCODONE BIT 10-650MG TABLET<br />
HYCOMED ACETAMINOPHEN/HYDROCODONE BIT 5-500MG TABLET<br />
HYDROCET ACETAMINOPHEN/HYDROCODONE BIT 5-500MG CAPSULE<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 10-500MG TABLET<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 10-650MG TABLET<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 10-660MG TABLET<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 2.5-167/5 ELIXIR<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 2.5-500MG TABLET<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 5-325MG TABLET<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 5-500MG CAPSULE<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 5-500MG TABLET<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 7.5-500MG TABLET<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 7.5-650MG TABLET<br />
HYDROCODONE W/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 7.5-750MG TABLET<br />
HYDROCODONE W/ACETAMINOPHEN HS ACETAMINOPHEN/HYDROCODONE BIT 2.5-500MG TABLET<br />
HYDROCODONE/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 10-325MG TABLET<br />
HYDROCODONE/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 10-500MG TABLET<br />
HYDROCODONE/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 10-650MG TABLET<br />
HYDROCODONE/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 10-660MG TABLET<br />
HYDROCODONE/ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 5-500MG TABLET<br />
HYDROCODONE-ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 5-325MG TABLET<br />
HYDROCODONE-ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 5-500MG TABLET<br />
HYDROCODONE-ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 7.5-325MG TABLET<br />
HYDROCODONE-ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 7.5-500MG TABLET<br />
HYDROCODONE-ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 7.5-650MG TABLET<br />
HYDROCODONE-ACETAMINOPHEN ACETAMINOPHEN/HYDROCODONE BIT 7.5-750MG TABLET<br />
HY-PHEN ACETAMINOPHEN/HYDROCODONE BIT 5-500MG TABLET<br />
LORCET 10/650 ACETAMINOPHEN/HYDROCODONE BIT 10-650MG TABLET<br />
LORCET PLUS ACETAMINOPHEN/HYDROCODONE BIT 7.5-650MG TABLET<br />
LORCET-HD ACETAMINOPHEN/HYDROCODONE BIT 5-500MG CAPSULE<br />
Page 4<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
LORTAB ACETAMINOPHEN/HYDROCODONE BIT 10-500MG TABLET<br />
LORTAB ACETAMINOPHEN/HYDROCODONE BIT 2.5-167/5 ELIXIR<br />
LORTAB ACETAMINOPHEN/HYDROCODONE BIT 2.5-500MG TABLET<br />
LORTAB ACETAMINOPHEN/HYDROCODONE BIT 5-500MG TABLET<br />
LORTAB ACETAMINOPHEN/HYDROCODONE BIT 7.5-500MG TABLET<br />
MARGESIC H ACETAMINOPHEN/HYDROCODONE BIT 5-500MG CAPSULE<br />
NORCO ACETAMINOPHEN/HYDROCODONE BIT 10-325MG TABLET<br />
NORCO ACETAMINOPHEN/HYDROCODONE BIT 5-325MG TABLET<br />
STAGESIC ACETAMINOPHEN/HYDROCODONE BIT 5-500MG CAPSULE<br />
VANACET ACETAMINOPHEN/HYDROCODONE BIT 5-500MG TABLET<br />
VICODIN ACETAMINOPHEN/HYDROCODONE BIT 5-500MG TABLET<br />
VICODIN ES ACETAMINOPHEN/HYDROCODONE BIT 7.5-750MG TABLET<br />
VICODIN HP ACETAMINOPHEN/HYDROCODONE BIT 10-660MG TABLET<br />
ENDOCET ACETAMINOPHEN/OXYCODONE HCL 10-650MG TABLET<br />
ENDOCET ACETAMINOPHEN/OXYCODONE HCL 5-325MG TABLET<br />
ENDOCET ACETAMINOPHEN/OXYCODONE HCL 7.5-500MG TABLET<br />
OXYCODONE W/ACETAMINOPHEN ACETAMINOPHEN/OXYCODONE HCL 5-325MG TABLET<br />
OXYCODONE W/ACETAMINOPHEN ACETAMINOPHEN/OXYCODONE HCL 5-500MG CAPSULE<br />
OXYCODONE/APAP ACETAMINOPHEN/OXYCODONE HCL 10-650MG TABLET<br />
OXYCODONE/APAP ACETAMINOPHEN/OXYCODONE HCL 7.5-500MG TABLET<br />
OXYCODONE-ACETAMINOPHEN ACETAMINOPHEN/OXYCODONE HCL 5-500MG CAPSULE<br />
PERCOCET ACETAMINOPHEN/OXYCODONE HCL 5-325MG TABLET<br />
ROXICET ACETAMINOPHEN/OXYCODONE HCL 5-325MG TABLET<br />
TYLOX ACETAMINOPHEN/OXYCODONE HCL 5-500MG CAPSULE<br />
PENTAZOCINE/ACETAMINOPHEN ACETAMINOPHEN/PENTAZOCINE HCL 25-650MG TABLET<br />
DOLOGESIC ACETAMINOPHEN/PHENYLTOLX CIT 500-30MG CAPSULE<br />
FLEXTRA-DS ACETAMINOPHEN/PHENYLTOLX CIT 500-50MG TABLET<br />
GENECAR ACETAMINOPHEN/PHENYLTOLX CIT 500-30MG TABLET<br />
HYFLEX-650 ACETAMINOPHEN/PHENYLTOLX CIT 650-60MG TABLET<br />
HYFLEX-DS ACETAMINOPHEN/PHENYLTOLX CIT 500-50MG TABLET<br />
RHINOFLEX ACETAMINOPHEN/PHENYLTOLX CIT 500-50MG TABLET<br />
DARVOCET-N 100 ACETAMINOPHEN/PROPOXYPHENE 100-650MG TABLET<br />
PROPOXYPHENE NAPSYLATE W/APAP ACETAMINOPHEN/PROPOXYPHENE 100-650MG TABLET<br />
PROPOXYPHENE NAPSYLATE W/APAP ACETAMINOPHEN/PROPOXYPHENE 50-325MG TABLET<br />
PROPOXYPHENE NAPSYLATE/APAP ACETAMINOPHEN/PROPOXYPHENE 100-650MG TABLET<br />
PROPOXYPHENE HCL W/APAP ACETAMINOPHEN/PROPOXYPHENE HCL 65-650MG TABLET<br />
PROPOXYPHENE HCL/APAP ACETAMINOPHEN/PROPOXYPHENE HCL 65-650MG TABLET<br />
LORSIN ACETAMINOPHN/CP/P-EPHED HCL 30-500-2MG TABLET<br />
ANABAR ACETAMINOPHN/P-TLOX/SAL-AMIDE 200-300-20 TABLET<br />
ASP ACETAMINOPHN/P-TLOX/SAL-AMIDE 200-300-20 CAPSULE<br />
CETAZONE-T ACETAMINOPHN/P-TLOX/SAL-AMIDE 200-300-20 TABLET<br />
ED-FLEX ACETAMINOPHN/P-TLOX/SAL-AMIDE 200-300-20 CAPSULE<br />
LOBAC ACETAMINOPHN/P-TLOX/SAL-AMIDE 200-300-20 CAPSULE<br />
ACETAZOLAMIDE ACETAZOLAMIDE 125MG TABLET<br />
ACETAZOLAMIDE ACETAZOLAMIDE 250MG TABLET<br />
DIAMOX ACETAZOLAMIDE 125MG TABLET<br />
DIAMOX ACETAZOLAMIDE 250MG TABLET<br />
ACETAZOLAMIDE SODIUM ACETAZOLAMIDE SODIUM 500MG VIAL<br />
ACIDIC VAGINAL ACETIC AC/OXYQUINOL/RICINOLEIC JELLY/APPL<br />
ACETASOL ACETIC ACID 2% SOLUTION<br />
ACETIC ACID ACETIC ACID 0.25% IRRIG SOLN<br />
ACETIC ACID ACETIC ACID 2% SOLUTION<br />
VASOLATE ACETIC ACID 2% SOLUTION<br />
VOSOL ACETIC ACID 2% SOLUTION<br />
ACETIC ACID/ALUMINUM ACETIC ACID/ALUMINUM ACETATE 2% DROPS<br />
BOROFAIR ACETIC ACID/ALUMINUM ACETATE 2% DROPS<br />
DOMEBORO ACETIC ACID/ALUMINUM ACETATE 2% DROPS<br />
ACETASOL HC ACETIC ACID/HYDROCORTISONE 2-1% DROPS<br />
ACETIC ACID/HYDROCORTISONE ACETIC ACID/HYDROCORTISONE 2-1% DROPS<br />
VOSOL HC ACETIC ACID/HYDROCORTISONE 2-1% DROPS<br />
ACETOHEXAMIDE ACETOHEXAMIDE 250MG TABLET<br />
ACETOHEXAMIDE ACETOHEXAMIDE 500MG TABLET<br />
ACETYLCYSTEINE ACETYLCYSTEINE 100MG/ML VIAL<br />
ACETYLCYSTEINE ACETYLCYSTEINE 100MG/ML VIAL-NEB.<br />
ACETYLCYSTEINE ACETYLCYSTEINE 200MG/ML VIAL<br />
MUCOMYST ACETYLCYSTEINE 200MG/ML VIAL<br />
MUCOMYST-10 ACETYLCYSTEINE 100MG/ML VIAL<br />
ACYCLOVIR ACYCLOVIR 200MG CAPSULE<br />
ACYCLOVIR ACYCLOVIR 200MG/5ML ORAL SUSP<br />
ACYCLOVIR ACYCLOVIR 400MG TABLET<br />
ACYCLOVIR ACYCLOVIR 800MG TABLET<br />
ZOVIRAX ACYCLOVIR 200MG CAPSULE<br />
ZOVIRAX ACYCLOVIR 400MG TABLET<br />
ZOVIRAX ACYCLOVIR 800MG TABLET<br />
ACYCLOVIR SODIUM ACYCLOVIR SODIUM 1000MG VIAL<br />
Page 5<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
ACYCLOVIR SODIUM ACYCLOVIR SODIUM 1G/40ML VIAL<br />
ACYCLOVIR SODIUM ACYCLOVIR SODIUM 500MG VIAL<br />
ACYCLOVIR SODIUM ACYCLOVIR SODIUM 500MG/20ML VIAL<br />
ACYCLOVIR SODIUM ACYCLOVIR SODIUM 50MG/ML VIAL<br />
ZOVIRAX ACYCLOVIR SODIUM 1000MG VIAL<br />
ZOVIRAX ACYCLOVIR SODIUM 500MG VIAL<br />
BUFFERED ASPIRIN AL AMINOACET/ASPIRIN/MAG CARB 325MG TABLET<br />
UNI-BUFF AL AMINOACET/ASPIRIN/MAG CARB 325MG TABLET<br />
ARTHRITIS PAIN FORMULA AL HYDROX/ASPIRIN/MAG HYDROX 325MG TABLET<br />
MAGNAPRIN AL HYDROX/ASPIRIN/MAG HYDROX 325MG TABLET<br />
ALAMAG PLUS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
ALMACONE AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
ALMACONE-2 AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
ANTACID AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
ANTACID AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
ANTACID ANTI-GAS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
ANTACID ANTI-GAS AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
ANTACID ANTI-GAS DOUBLE STR AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
ANTACID DOUBLE STRENGTH AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
ANTACID M AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
ANTACID M AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
ANTACID PLUS AL HYDROX/MAG HYDROX/SIMETH 200-200-25 TAB CHEW<br />
ANTACID W/SIMETHICONE AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
ANTACID W/SIMETHICONE AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
ANTACID/ANTI-GAS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
ANTACID/ANTIGAS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
ANTACID-ANTIGAS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
GELUSIL AL HYDROX/MAG HYDROX/SIMETH 200-200-25 TAB CHEW<br />
GERI-LANTA AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
HM ANTACID/ANTIGAS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
MAALOX MS AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
MAALOX QUICK DISSOLVE AL HYDROX/MAG HYDROX/SIMETH 200-200-25 TAB CHEW<br />
MASANTI AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
MASANTI AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
MASANTI II AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
MI ACID AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
MI-ACID II AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
MILANTEX AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
MINTOX PLUS AL HYDROX/MAG HYDROX/SIMETH 200-200-25 TAB CHEW<br />
MYLANTA AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
MYLANTA DOUBLE-STRENGTH AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
MYLANTEX DOUBLE-STRENGTH AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
RI-GEL AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
RI-GEL II AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
UNI-LAN AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
UNI-LAN II AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
URBAN AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP<br />
URBAN D.S. AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP<br />
ALAMAG AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP<br />
ANTACID AL HYDROX/MAGNESIUM HYDROXIDE 200-225 ORAL SUSP<br />
ANTACID AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP<br />
HM ANTACID AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP<br />
LIQUID ANTACID AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP<br />
MAALOX AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP<br />
MAGNESIUM HYDR/ALUMINUM HYDR AL HYDROX/MAGNESIUM HYDROXIDE 200-225 ORAL SUSP<br />
MALDROXAL AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP<br />
MINTOX AL HYDROX/MAGNESIUM HYDROXIDE 200-200 TAB CHEW<br />
MINTOX AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP<br />
RI-MOX AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP<br />
RULOX AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP<br />
RULOX NO.1 AL HYDROX/MAGNESIUM HYDROXIDE 200-200 TAB CHEW<br />
ALBUMARC ALBUMIN HUMAN 25% IV SOLN.<br />
ALBUMARC ALBUMIN HUMAN 5% IV SOLN.<br />
ALBUMIN ALBUMIN HUMAN 25% IV SOLN.<br />
ALBUMIN ALBUMIN HUMAN 25% VIAL<br />
ALBUMIN ALBUMIN HUMAN 5% IV SOLN.<br />
ALBUMINAR-25 ALBUMIN HUMAN 25% IV SOLN.<br />
ALBUMINAR-25 ALBUMIN HUMAN 25% VIAL<br />
ALBUMINAR-5 ALBUMIN HUMAN 5% IV SOLN.<br />
ALBURX ALBUMIN HUMAN 25% VIAL<br />
ALBURX ALBUMIN HUMAN 5% VIAL<br />
ALBUTEIN ALBUMIN HUMAN 25% IV SOLN.<br />
ALBUTEIN ALBUMIN HUMAN 25% VIAL<br />
ALBUTEIN ALBUMIN HUMAN 5% IV SOLN.<br />
BUMINATE ALBUMIN HUMAN 25% VIAL<br />
Page 6<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
BUMINATE ALBUMIN HUMAN 5% IV SOLN.<br />
BUMINATE W/ADMINISTRATION SET ALBUMIN HUMAN 25% IV SOLN.<br />
PLASBUMIN-25 ALBUMIN HUMAN 25% VIAL<br />
PLASBUMIN-5 ALBUMIN HUMAN 5% IV SOLN.<br />
PLASBUMIN-5 ALBUMIN HUMAN 5% VIAL<br />
ALBUMIN-SALINE ALBUMIN HUMAN/SODIUM CHLORIDE 0.03% VIAL<br />
ALBUTEROL ALBUTEROL 90MCG AER REFILL<br />
ALBUTEROL ALBUTEROL 90MCG AEROSOL<br />
PROVENTIL ALBUTEROL 90MCG AER REFILL<br />
PROVENTIL ALBUTEROL 90MCG AEROSOL<br />
VENTOLIN ALBUTEROL 90MCG AER REFILL<br />
VENTOLIN ALBUTEROL 90MCG AEROSOL<br />
AIRET ALBUTEROL SULFATE 0.83MG/ML SOLUTION<br />
ALBUTEROL SULFATE ALBUTEROL SULFATE 0.83MG/ML SOLUTION<br />
ALBUTEROL SULFATE ALBUTEROL SULFATE 2MG TABLET<br />
ALBUTEROL SULFATE ALBUTEROL SULFATE 2MG/5ML SYRUP<br />
ALBUTEROL SULFATE ALBUTEROL SULFATE 4MG TABLET<br />
ALBUTEROL SULFATE ALBUTEROL SULFATE 5MG/ML SOLUTION<br />
PROVENTIL ALBUTEROL SULFATE 0.83MG/ML SOLUTION<br />
PROVENTIL ALBUTEROL SULFATE 2MG TABLET<br />
PROVENTIL ALBUTEROL SULFATE 4MG TABLET<br />
PROVENTIL ALBUTEROL SULFATE 5MG/ML SOLUTION<br />
VOSPIRE ER ALBUTEROL SULFATE 4MG TAB.SR 12H<br />
VOSPIRE ER ALBUTEROL SULFATE 8MG TAB.SR 12H<br />
ALFENTANIL HYDROCHLORIDE ALFENTANIL HCL 500MCG/ML AMPUL<br />
ASCRIPTIN ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
ASCRIPTIN A/D ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
ASPIRIN W/ANTACID ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
ASPIRIN W/ANTACID A/D ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
ASPIR-MOX IB ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
ASPRIDROX ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
ASPRIMOX ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
ASPRIMOX ID ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
ASPRIMOX ID ALH/ASA/CALCIUM CARB/MAGNESIUM 500MG TABLET<br />
BUFFERIN ALH/ASA/CALCIUM CARB/MAGNESIUM 500MG TABLET<br />
ALLOPURINOL ALLOPURINOL 100MG TABLET<br />
ALLOPURINOL ALLOPURINOL 300MG TABLET<br />
ZYLOPRIM ALLOPURINOL 100MG TABLET<br />
ZYLOPRIM ALLOPURINOL 300MG TABLET<br />
CORTAID W/ALOE ALO VER/HYDROCORTISONE ACETATE 0.5% CREAM(GM)<br />
HYDROCORTISONE W/ALOE ALO VER/HYDROCORTISONE ACETATE 0.5% CREAM(GM)<br />
HYDROCORTISONE W/ALOE ALO VER/HYDROCORTISONE ACETATE 0.5% OINT.(GM)<br />
HYDROCORTISONE ALOE VERA/HYDROCORTISONE 0.5% CREAM(GM)<br />
HYDROCORTISONE PLUS ALOE VERA/HYDROCORTISONE 1% CREAM(GM)<br />
HYDROCORTISONE W/ALOE ALOE VERA/HYDROCORTISONE 0.5% CREAM(GM)<br />
HYDROCORTISONE W/ALOE ALOE VERA/HYDROCORTISONE 0.5% OINT.(GM)<br />
HYDROCORTISONE W/ALOE ALOE VERA/HYDROCORTISONE 1% CREAM(GM)<br />
HYDROCORTISONE W/ALOE ALOE VERA/HYDROCORTISONE 1% OINT.(GM)<br />
ALPROSTADIL ALPROSTADIL 500MCG/ML AMPUL<br />
ALPROSTADIL ALPROSTADIL 500MCG/ML VIAL<br />
EDEX ALPROSTADIL 10MCG VIAL<br />
EDEX ALPROSTADIL 20MCG VIAL<br />
EDEX ALPROSTADIL 40MCG VIAL<br />
ALUMINUM HYDROXIDE ALUMINUM HYDROXIDE 320MG/5ML ORAL SUSP<br />
M.T.E.-7 AM MB/CH/CU/MN/NAI/SE/ZSO4 HP VIAL<br />
AMANTADINE AMANTADINE HCL 100MG CAPSULE<br />
AMANTADINE HCL AMANTADINE HCL 100MG CAPSULE<br />
AMANTADINE HCL AMANTADINE HCL 50MG/5ML SYRUP<br />
SYMMETREL AMANTADINE HCL 50MG/5ML SYRUP<br />
AMCINONIDE AMCINONIDE 0.1% CREAM(GM)<br />
AMIKACIN SULFATE AMIKACIN SULFATE 250MG/ML VIAL<br />
AMIKACIN SULFATE AMIKACIN SULFATE 50MG/ML VIAL<br />
AMIKIN AMIKACIN SULFATE 250MG/ML DISP SYRIN<br />
AMIKIN AMIKACIN SULFATE 250MG/ML VIAL<br />
AMIKIN AMIKACIN SULFATE 50MG/ML VIAL<br />
AMIKIN PEDIATRIC AMIKACIN SULFATE 50MG/ML VIAL<br />
AMILORIDE HCL AMILORIDE HCL 5MG TABLET<br />
MIDAMOR AMILORIDE HCL 5MG TABLET<br />
AMILORIDE HCL W/HCTZ AMILORIDE HCL/HCTZ 5-50MG TABLET<br />
MODURETIC AMILORIDE HCL/HCTZ 5-50MG TABLET<br />
AMINO ACID CERVICAL AMINO AC/SODIUM PROPIONATE/URE CREAM/APPL<br />
CERVICAL AMINO ACID AMINO AC/SODIUM PROPIONATE/URE CREAM/APPL<br />
ELECARE AMINO ACIDS POWDER<br />
PHLEXY-10 AMINO ACIDS CAPSULE<br />
AMINOSYN AMINO ACIDS 10% 10% IV SOLN.<br />
Page 7<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
AMINOSYN II AMINO ACIDS 10% 10% IV SOLN.<br />
AMINOSYN-PF AMINO ACIDS 10% 10% IV SOLN.<br />
FREAMINE III AMINO ACIDS 10% 10% IV SOLN.<br />
TRAVASOL AMINO ACIDS 10% 10% IV SOLN.<br />
AMINOSYN II AMINO ACIDS 15% 15% IV SOLN.<br />
CLINISOL AMINO ACIDS 15% 15% IV SOLN.<br />
NOVAMINE AMINO ACIDS 15% 15% IV SOLN.<br />
AMINOSYN II IN DEXTROSE AMINO ACIDS 4.25%/D10W 4.25% IV SOLN.<br />
CLINIMIX AMINO ACIDS 4.25%/D10W 4.25% IV SOLN.<br />
AMINOSYN II IN DEXTROSE AMINO ACIDS 4.25%/D20W 4.25% IV SOLN.<br />
AMINOSYN II 4.25%/DEXTROSE 25% AMINO ACIDS 4.25%/D25W 4.25% IV SOLN.<br />
CLINIMIX AMINO ACIDS 4.25%/D25W 4.25% IV SOLN.<br />
AMINOSYN-HF AMINO ACIDS 8% 8% IV SOLN.<br />
HEPATAMINE AMINO ACIDS 8% 8% IV SOLN.<br />
HEPATASOL AMINO ACIDS 8% 8% IV SOLN.<br />
TRAVASOL AMINO ACIDS 8.5% 8.5% IV SOLN.<br />
GENETECT PLUS AMINO ACIDS/MV,FE,OTHER MIN CAPSULE<br />
AMICAR AMINOCAPROIC ACID 250MG/ML VIAL<br />
AMINOCAPROIC ACID AMINOCAPROIC ACID 250MG/ML SYRUP<br />
AMINOCAPROIC ACID AMINOCAPROIC ACID 250MG/ML VIAL<br />
AMINOCAPROIC ACID AMINOCAPROIC ACID 500MG TABLET<br />
AMINOPHYLLINE AMINOPHYLLINE 100MG TABLET<br />
AMINOPHYLLINE AMINOPHYLLINE 105MG/5ML LIQUID<br />
AMINOPHYLLINE AMINOPHYLLINE 200MG TABLET<br />
AMINOPHYLLINE AMINOPHYLLINE 250MG/10ML VIAL<br />
AMINOPHYLLINE AMINOPHYLLINE 500MG/20ML VIAL<br />
AMIODARONE HCL AMIODARONE HCL 200MG TABLET<br />
AMIODARONE HCL AMIODARONE HCL 50MG/ML AMPUL<br />
AMIODARONE HCL AMIODARONE HCL 50MG/ML VIAL<br />
CORDARONE AMIODARONE HCL 200MG TABLET<br />
PACERONE AMIODARONE HCL 200MG TABLET<br />
AMITRIPTYLINE/CHLORDIAZEPOXIDE AMITRIP HCL/CHLORDIAZEPOXIDE 12.5-5MG TABLET<br />
AMITRIPTYLINE/CHLORDIAZEPOXIDE AMITRIP HCL/CHLORDIAZEPOXIDE 25-10MG TABLET<br />
AMITRIPTYLINE HCL AMITRIPTYLINE HCL 100MG TABLET<br />
AMITRIPTYLINE HCL AMITRIPTYLINE HCL 10MG TABLET<br />
AMITRIPTYLINE HCL AMITRIPTYLINE HCL 150MG TABLET<br />
AMITRIPTYLINE HCL AMITRIPTYLINE HCL 25MG TABLET<br />
AMITRIPTYLINE HCL AMITRIPTYLINE HCL 50MG TABLET<br />
AMITRIPTYLINE HCL AMITRIPTYLINE HCL 75MG TABLET<br />
ELAVIL AMITRIPTYLINE HCL 100MG TABLET<br />
ELAVIL AMITRIPTYLINE HCL 10MG TABLET<br />
ELAVIL AMITRIPTYLINE HCL 150MG TABLET<br />
ELAVIL AMITRIPTYLINE HCL 25MG TABLET<br />
ELAVIL AMITRIPTYLINE HCL 50MG TABLET<br />
ELAVIL AMITRIPTYLINE HCL 75MG TABLET<br />
VANATRIP AMITRIPTYLINE HCL 50MG TABLET<br />
AMITRIPTYLINE W/PERPHENAZINE AMITRIPTYLINE HCL/PERPHENAZINE 10-2MG TABLET<br />
AMITRIPTYLINE W/PERPHENAZINE AMITRIPTYLINE HCL/PERPHENAZINE 10-4MG TABLET<br />
AMITRIPTYLINE W/PERPHENAZINE AMITRIPTYLINE HCL/PERPHENAZINE 25-2MG TABLET<br />
AMITRIPTYLINE W/PERPHENAZINE AMITRIPTYLINE HCL/PERPHENAZINE 25-4MG TABLET<br />
AMITRIPTYLINE W/PERPHENAZINE AMITRIPTYLINE HCL/PERPHENAZINE 50-4MG TABLET<br />
ETRAFON 2-10 AMITRIPTYLINE HCL/PERPHENAZINE 10-2MG TABLET<br />
ETRAFON 2-25 AMITRIPTYLINE HCL/PERPHENAZINE 25-2MG TABLET<br />
ETRAFON A 4-10 AMITRIPTYLINE HCL/PERPHENAZINE 10-4MG TABLET<br />
ETRAFON FORTE 4-25 AMITRIPTYLINE HCL/PERPHENAZINE 25-4MG TABLET<br />
TRIAVIL 10-2 AMITRIPTYLINE HCL/PERPHENAZINE 10-2MG TABLET<br />
TRIAVIL 25-2 AMITRIPTYLINE HCL/PERPHENAZINE 25-2MG TABLET<br />
TRIAVIL 25-4 AMITRIPTYLINE HCL/PERPHENAZINE 25-4MG TABLET<br />
AMOX TR/POTASSIUM CLAVULANATE AMOX TR/POTASSIUM CLAVULANATE 200-28.5/5 SUSP RECON<br />
AMOX TR/POTASSIUM CLAVULANATE AMOX TR/POTASSIUM CLAVULANATE 200-28.5MG TAB CHEW<br />
AMOX TR/POTASSIUM CLAVULANATE AMOX TR/POTASSIUM CLAVULANATE 400-57MG TAB CHEW<br />
AMOX TR/POTASSIUM CLAVULANATE AMOX TR/POTASSIUM CLAVULANATE 400-57MG/5 SUSP RECON<br />
AMOX TR/POTASSIUM CLAVULANATE AMOX TR/POTASSIUM CLAVULANATE 500-125MG TABLET<br />
AMOX TR/POTASSIUM CLAVULANATE AMOX TR/POTASSIUM CLAVULANATE 875-125MG TABLET<br />
AUGMENTIN AMOX TR/POTASSIUM CLAVULANATE 500-125MG TABLET<br />
AUGMENTIN AMOX TR/POTASSIUM CLAVULANATE 875-125MG TABLET<br />
AMOXAPINE AMOXAPINE 100MG TABLET<br />
AMOXAPINE AMOXAPINE 150MG TABLET<br />
AMOXAPINE AMOXAPINE 25MG TABLET<br />
AMOXAPINE AMOXAPINE 50MG TABLET<br />
AMOXICILLIN AMOXICILLIN TRIHYDRATE 125MG TAB CHEW<br />
AMOXICILLIN AMOXICILLIN TRIHYDRATE 125MG/5ML SUSP RECON<br />
AMOXICILLIN AMOXICILLIN TRIHYDRATE 200MG TAB CHEW<br />
AMOXICILLIN AMOXICILLIN TRIHYDRATE 250MG CAPSULE<br />
AMOXICILLIN AMOXICILLIN TRIHYDRATE 250MG TAB CHEW<br />
Page 8<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
AMOXICILLIN AMOXICILLIN TRIHYDRATE 250MG/5ML SUSP RECON<br />
AMOXICILLIN AMOXICILLIN TRIHYDRATE 400MG TAB CHEW<br />
AMOXICILLIN AMOXICILLIN TRIHYDRATE 500MG CAPSULE<br />
AMOXICILLIN AMOXICILLIN TRIHYDRATE 500MG TABLET<br />
AMOXICILLIN AMOXICILLIN TRIHYDRATE 875MG TABLET<br />
AMOXIL AMOXICILLIN TRIHYDRATE 125MG/5ML SUSP RECON<br />
AMOXIL AMOXICILLIN TRIHYDRATE 250MG CAPSULE<br />
AMOXIL AMOXICILLIN TRIHYDRATE 250MG/5ML SUSP RECON<br />
AMOXIL AMOXICILLIN TRIHYDRATE 500MG CAPSULE<br />
AMOXIL AMOXICILLIN TRIHYDRATE 50MG/ML DROP RECON<br />
TRIMOX AMOXICILLIN TRIHYDRATE 250MG CAPSULE<br />
TRIMOX AMOXICILLIN TRIHYDRATE 500MG CAPSULE<br />
TRIMOX 125 AMOXICILLIN TRIHYDRATE 125MG/5ML SUSP RECON<br />
TRIMOX 250 AMOXICILLIN TRIHYDRATE 250MG/5ML SUSP RECON<br />
ADDERALL AMPHET ASP/AMPHET/D-AMPHET 10MG TABLET<br />
ADDERALL AMPHET ASP/AMPHET/D-AMPHET 20MG TABLET<br />
ADDERALL AMPHET ASP/AMPHET/D-AMPHET 30MG TABLET<br />
ADDERALL AMPHET ASP/AMPHET/D-AMPHET 5MG TABLET<br />
AMPHETAMINE SALT COMBO AMPHET ASP/AMPHET/D-AMPHET 10MG TABLET<br />
AMPHETAMINE SALT COMBO AMPHET ASP/AMPHET/D-AMPHET 20MG TABLET<br />
AMPHETAMINE SALT COMBO AMPHET ASP/AMPHET/D-AMPHET 30MG TABLET<br />
AMPHETAMINE SALT COMBO AMPHET ASP/AMPHET/D-AMPHET 5MG TABLET<br />
AMPHOCIN AMPHOTERICIN B 50MG VIAL<br />
AMPHOTERICIN B AMPHOTERICIN B 50MG VIAL<br />
FUNGIZONE IV AMPHOTERICIN B 50MG VIAL<br />
AMPICILLIN SODIUM AMPICILLIN SODIUM 10G VIAL<br />
AMPICILLIN SODIUM AMPICILLIN SODIUM 125MG VIAL<br />
AMPICILLIN SODIUM AMPICILLIN SODIUM 1G VIAL<br />
AMPICILLIN SODIUM AMPICILLIN SODIUM 250MG VIAL<br />
AMPICILLIN SODIUM AMPICILLIN SODIUM 2G VIAL<br />
AMPICILLIN SODIUM AMPICILLIN SODIUM 500MG VIAL<br />
TOTACILLIN-N AMPICILLIN SODIUM 10G VIAL<br />
TOTACILLIN-N AMPICILLIN SODIUM 1G PIGGYBACK<br />
TOTACILLIN-N AMPICILLIN SODIUM 1G VIAL<br />
TOTACILLIN-N AMPICILLIN SODIUM 2G PIGGYBACK<br />
TOTACILLIN-N AMPICILLIN SODIUM 2G VIAL<br />
AMPICILLIN/SULBACTAM AMPICILLIN SODIUM/SULBACTAM NA 15G VIAL<br />
UNASYN AMPICILLIN SODIUM/SULBACTAM NA 1.5G VIAL<br />
UNASYN AMPICILLIN SODIUM/SULBACTAM NA 15G VIAL<br />
UNASYN AMPICILLIN SODIUM/SULBACTAM NA 3G VIAL<br />
AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE 125MG/5ML SUSP RECON<br />
AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE 250MG CAPSULE<br />
AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE 250MG/5ML SUSP RECON<br />
AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE 500MG CAPSULE<br />
PRINCIPEN AMPICILLIN TRIHYDRATE 500MG CAPSULE<br />
PRINCIPEN 125 AMPICILLIN TRIHYDRATE 125MG/5ML SUSP RECON<br />
PRINCIPEN 250 AMPICILLIN TRIHYDRATE 250MG CAPSULE<br />
PRINCIPEN 250 AMPICILLIN TRIHYDRATE 250MG/5ML SUSP RECON<br />
CYANIDE ANTIDOTE PACKAGE AMYL NIT/SOD NIT/SOD THIOSULF KIT<br />
AMYL NITRITE AMYL NITRITE 0.3ML AMPUL<br />
CREON 10 AMYLASE/LIPASE/PROTEASE 33.2-10-38 CAPSULE DR<br />
CREON 20 AMYLASE/LIPASE/PROTEASE 66.4-20-75 CAPSULE DR<br />
LIPRAM AMYLASE/LIPASE/PROTEASE 20-4.5-25 CAPSULE DR<br />
LIPRAM-CR 10 AMYLASE/LIPASE/PROTEASE 33.2-10-38 CAPSULE DR<br />
LIPRAM-CR20 AMYLASE/LIPASE/PROTEASE 66.4-20-75 CAPSULE DR<br />
LIPRAM-CR5 AMYLASE/LIPASE/PROTEASE 16.6-5-19 CAPSULE DR<br />
LIPRAM-PN10 AMYLASE/LIPASE/PROTEASE 30-10-30 CAPSULE DR<br />
LIPRAM-PN16 AMYLASE/LIPASE/PROTEASE 48-16-48 CAPSULE DR<br />
LIPRAM-PN20 AMYLASE/LIPASE/PROTEASE 56-20-44 CAPSULE DR<br />
LIPRAM-UL12 AMYLASE/LIPASE/PROTEASE 39-12-39 CAPSULE DR<br />
LIPRAM-UL18 AMYLASE/LIPASE/PROTEASE 59-18-59 CAPSULE DR<br />
LIPRAM-UL20 AMYLASE/LIPASE/PROTEASE 65-20-65 CAPSULE DR<br />
PALIPASE AMYLASE/LIPASE/PROTEASE 20-4.5-25 CAPSULE DR<br />
PALIPASE MT 16 AMYLASE/LIPASE/PROTEASE 48-16-48 CAPSULE DR<br />
PALIPASE MT 20 AMYLASE/LIPASE/PROTEASE 56-20-44 CAPSULE DR<br />
PALPEON DR 10 AMYLASE/LIPASE/PROTEASE 33.2-10-38 CAPSULE DR<br />
PALPEON DR 20 AMYLASE/LIPASE/PROTEASE 66.4-20-75 CAPSULE DR<br />
PALPEON MT 20 AMYLASE/LIPASE/PROTEASE 65-20-65 CAPSULE DR<br />
PALTRASE V8 AMYLASE/LIPASE/PROTEASE 30-8-30 TABLET<br />
PANCREASE AMYLASE/LIPASE/PROTEASE 20-4.5-25 CAPSULE DR<br />
PANCREASE MT 16 AMYLASE/LIPASE/PROTEASE 48-16-48 CAPSULE DR<br />
PANCRELIPASE AMYLASE/LIPASE/PROTEASE 20-4.5-25 CAPSULE DR<br />
PANCRELIPASE AMYLASE/LIPASE/PROTEASE 30-8-30 TABLET<br />
PANCRELIPASE 10000 AMYLASE/LIPASE/PROTEASE 33.2-10-38 CAPSULE DR<br />
PANCRELIPASE 16000 AMYLASE/LIPASE/PROTEASE 48-16-48 CAPSULE DR<br />
Page 9<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
PANCRELIPASE MT 16 AMYLASE/LIPASE/PROTEASE 48-16-48 CAPSULE DR<br />
PANCRELIPASE MT-16 AMYLASE/LIPASE/PROTEASE 48-16-48 CAPSULE DR<br />
PANCRON 10 AMYLASE/LIPASE/PROTEASE 33.2-10-38 CAPSULE DR<br />
PANCRON 20 AMYLASE/LIPASE/PROTEASE 66.4-20-75 CAPSULE DR<br />
PANGESTYME CN 10 AMYLASE/LIPASE/PROTEASE 33.2-10-38 CAPSULE DR<br />
PANGESTYME CN 20 AMYLASE/LIPASE/PROTEASE 66.4-20-75 CAPSULE DR<br />
PANGESTYME EC AMYLASE/LIPASE/PROTEASE 20-4.5-25 CAPSULE DR<br />
PANGESTYME MT 16 AMYLASE/LIPASE/PROTEASE 48-16-48 CAPSULE DR<br />
PANGESTYME UL 12 AMYLASE/LIPASE/PROTEASE 39-12-39 CAPSULE DR<br />
PANGESTYME UL 18 AMYLASE/LIPASE/PROTEASE 59-18-59 CAPSULE DR<br />
PANGESTYME UL 20 AMYLASE/LIPASE/PROTEASE 65-20-65 CAPSULE DR<br />
PANOKASE AMYLASE/LIPASE/PROTEASE 30-8-30 TABLET<br />
PLARETASE 8000 AMYLASE/LIPASE/PROTEASE 30-8-30 TABLET<br />
ULTRASE AMYLASE/LIPASE/PROTEASE 20-4.5-25 CAPSULE DR<br />
ULTRASE MT 20 AMYLASE/LIPASE/PROTEASE 65-20-65 CAPSULE DR<br />
VIOKASE AMYLASE/LIPASE/PROTEASE 30-8-30 TABLET<br />
ANTHRALIN ANTHRALIN 1% CREAM(GM)<br />
DRITHOCREME HP ANTHRALIN 1% CREAM(GM)<br />
BIOCLATE ANTIHEMOPHILIC FACTOR, HUM REC 1020(+/-)U VIAL<br />
BIOCLATE ANTIHEMOPHILIC FACTOR, HUM REC 310 (+/-)U VIAL<br />
BIOCLATE ANTIHEMOPHILIC FACTOR, HUM REC 600 (+/-)U VIAL<br />
KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 1000(+/-)U KIT<br />
KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 250 (+/-)U KIT<br />
KOATE-DVI ANTIHEMOPHILIC FACTOR,HUMAN 500 (+/-)U KIT<br />
KOATE-HP ANTIHEMOPHILIC FACTOR,HUMAN 1000(+/-)U KIT<br />
KOATE-HP ANTIHEMOPHILIC FACTOR,HUMAN 250 (+/-)U KIT<br />
KOATE-HP ANTIHEMOPHILIC FACTOR,HUMAN 500 (+/-)U KIT<br />
MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 1000(+/-)U KIT<br />
MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 250 (+/-)U KIT<br />
MONOCLATE-P ANTIHEMOPHILIC FACTOR,HUMAN 500 (+/-)U KIT<br />
EAR-GESIC ANTIPY/B-CAINE/PHENYLEPHRINE 0.25-5-5% DROPS<br />
A/B OTIC ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
ALLERGEN ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
ANTIBEN ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
ANTIPYRINE W/BENZOCAINE ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
AURALGAN ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
AURODEX EAR DROPS ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
AUROGUARD ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
AUROTO ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
BALAGAN ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
DOLOTIC ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
PRO-OTIC ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
RX-OTIC ANTIPYRINE/BENZOCAINE/GLYCERIN 5.4-1.4% DROPS<br />
BUTALBITAL/CAFF/APAP/CODEINE APAP/BUTALB/CAFFEIN/CODEINE 30MG CAPSULE<br />
FIORICET W/CODEINE APAP/BUTALB/CAFFEIN/CODEINE 30MG CAPSULE<br />
PHRENILIN W/CAFFEINE & CODEINE APAP/BUTALB/CAFFEIN/CODEINE 30MG CAPSULE<br />
ACETAMINOPHEN W/CODEINE APAP/CODEINE PHOSPHATE 30-300MG TABLET<br />
ACETAMINOPHEN W/CODEINE APAP/CODEINE PHOSPHATE 60-300MG TABLET<br />
CONTAC APAP/DM HB/GUAIFEN/P-EPHEDRINE LIQUID<br />
COUGH FORMULA 4-M APAP/DM HB/GUAIFEN/P-EPHEDRINE LIQUID<br />
MULTI SYMPTOM COUGH FORMULA APAP/DM HB/GUAIFEN/P-EPHEDRINE LIQUID<br />
MULTI-SYMPTOM APAP/DM HB/GUAIFEN/P-EPHEDRINE LIQUID<br />
MULTI-SYMPTOM COUGH FORMULA APAP/DM HB/GUAIFEN/P-EPHEDRINE LIQUID<br />
HYDROCODONE W/ACETAMINOPHEN APAP/HYDROCODONE BITARTRATE 5-500MG TABLET<br />
ASCOMP W/CODEINE ASA/BUTALB/CAFFEINE/CODEINE 30MG CAPSULE<br />
BUTALBITAL COMPOUND W/CODEINE ASA/BUTALB/CAFFEINE/CODEINE 30MG CAPSULE<br />
FIORINAL W/CODEINE #3 ASA/BUTALB/CAFFEINE/CODEINE 30MG CAPSULE<br />
DARVON COMPOUND-65 ASA/CAFFEINE/PROPOXYPHENE HCL 65MG CAPSULE<br />
PROPOXYPHENE HCL COMPOUND ASA/CAFFEINE/PROPOXYPHENE HCL 65MG CAPSULE<br />
CARISOPRODOL COMPOUND/CODEINE ASA/CARISOPRODOL/CODEINE PHOS 16-200-325 TABLET<br />
SOMA COMPOUND W/CODEINE ASA/CARISOPRODOL/CODEINE PHOS 16-200-325 TABLET<br />
ASCORBIC ACID ASCORBIC ACID 250MG/ML VIAL<br />
ASCORBIC ACID ASCORBIC ACID 500MG/ML VIAL<br />
VI-CERT C500 ASCORBIC ACID 500MG/ML VIAL<br />
VITAMIN C ASCORBIC ACID 250MG TABLET<br />
CHOLESTYRAMINE LIGHT ASPARTAME/CHOLESTYRAMINE POWDER<br />
CHOLESTYRAMINE LIGHT ASPARTAME/CHOLESTYRAMINE 4G PACKET<br />
PREVALITE ASPARTAME/CHOLESTYRAMINE POWDER<br />
PREVALITE ASPARTAME/CHOLESTYRAMINE 4G PACKET<br />
QUESTRAN LIGHT ASPARTAME/CHOLESTYRAMINE POWDER<br />
QUESTRAN LIGHT ASPARTAME/CHOLESTYRAMINE 4G PACKET<br />
ADULT ASPIRIN ASPIRIN 81MG TAB CHEW<br />
ASPIR 81 ASPIRIN 81MG TABLET DR<br />
ASPIRIN ASPIRIN 120MG SUPP.RECT<br />
ASPIRIN ASPIRIN 125MG SUPP.RECT<br />
Page 10<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
ASPIRIN ASPIRIN 130MG SUPP.RECT<br />
ASPIRIN ASPIRIN 195MG SUPP.RECT<br />
ASPIRIN ASPIRIN 300MG SUPP.RECT<br />
ASPIRIN ASPIRIN 325MG TABLET<br />
ASPIRIN ASPIRIN 325MG TABLET DR<br />
ASPIRIN ASPIRIN 325MG TABLET EC<br />
ASPIRIN ASPIRIN 500MG TABLET<br />
ASPIRIN ASPIRIN 500MG TABLET DR<br />
ASPIRIN ASPIRIN 500MG TABLET EC<br />
ASPIRIN ASPIRIN 600MG SUPP.RECT<br />
ASPIRIN ASPIRIN 650MG TABLET DR<br />
ASPIRIN ASPIRIN 800MG TABLET SA<br />
ASPIRIN ASPIRIN 81MG TAB CHEW<br />
ASPIRIN ASPIRIN 81MG TABLET<br />
ASPIRIN ASPIRIN 81MG TABLET DR<br />
ASPIRIN ASPIRIN 81MG TABLET EC<br />
ASPIRIN ASPIRIN 975MG TABLET DR<br />
ASPIRIN EC ASPIRIN 81MG TABLET DR<br />
ASPIRIN EC LOW DOSE ASPIRIN 81MG TABLET DR<br />
ASPIRIN ENTERIC COATED ASPIRIN 325MG TABLET DR<br />
ASPIRIN EXTRA STRENGTH EC ASPIRIN 500MG TABLET DR<br />
ASPIRIN LITE COAT ASPIRIN 325MG TABLET<br />
ASPIRIN LOW-STRENGTH ASPIRIN 81MG TAB CHEW<br />
ASPIRIN LOW-STRENGTH ASPIRIN 81MG TABLET DR<br />
ASPIR-LOW ASPIRIN 81MG TABLET DR<br />
CHILD ASPIRIN ASPIRIN 81MG TAB CHEW<br />
CHILDREN'S ASPIRIN ASPIRIN 81MG TAB CHEW<br />
CHILDREN'S CHEWABLE ASPIRIN ASPIRIN 81MG TAB CHEW<br />
EASPRIN ASPIRIN 975MG TABLET DR<br />
ECASPIRIN ASPIRIN 325MG TABLET DR<br />
ECO-10 ASPIRIN 650MG TABLET EC<br />
ECO-5 ASPIRIN 325MG TABLET EC<br />
ECOTRIN ASPIRIN 325MG TABLET DR<br />
ECOTRIN ASPIRIN 500MG TABLET DR<br />
ECOTRIN ASPIRIN 81MG TABLET DR<br />
ECPIRIN ASPIRIN 325MG TABLET DR<br />
ENTERIC COATED ASA ASPIRIN 325MG TABLET DR<br />
ENTERIC COATED ASPIRIN ASPIRIN 325MG TABLET DR<br />
GENACOTE ASPIRIN 325MG TABLET DR<br />
GENACOTE ASPIRIN 500MG TABLET DR<br />
HCA ASPIRIN ASPIRIN 500MG TABLET DR<br />
LITE COAT ASPIRIN ASPIRIN 325MG TABLET<br />
LOW DOSE ASPIRIN ASPIRIN 81MG TABLET DR<br />
ST. JOSEPH ASPIRIN ASPIRIN 81MG TAB CHEW<br />
ST. JOSEPH ASPIRIN ASPIRIN 81MG TABLET DR<br />
SUREPRIN 81 ASPIRIN 81MG TABLET DR<br />
TASPRIN ASPIRIN 325MG TABLET DR<br />
TASPRIN ASPIRIN 81MG TABLET DR<br />
V-R ASPIRIN ASPIRIN 325MG TABLET DR<br />
V-R ASPIRIN ASPIRIN 81MG TABLET DR<br />
V-R CHILDREN'S ASPIRIN ASPIRIN 81MG TAB CHEW<br />
ZORPRIN ASPIRIN 800MG TABLET SA<br />
BUTALBITAL COMPOUND ASPIRIN/BUTALBITAL/CAFFEINE 325-40-50 CAPSULE<br />
BUTALBITAL COMPOUND ASPIRIN/BUTALBITAL/CAFFEINE 325-40-50 TABLET<br />
FARBITAL ASPIRIN/BUTALBITAL/CAFFEINE 325-40-50 CAPSULE<br />
FARBITAL ASPIRIN/BUTALBITAL/CAFFEINE 325-40-50 TABLET<br />
FIORINAL ASPIRIN/BUTALBITAL/CAFFEINE 325-40-50 CAPSULE<br />
FORTABS ASPIRIN/BUTALBITAL/CAFFEINE 325-40-50 TABLET<br />
AA & C ASPIRIN/CAFFEINE 400-32MG TABLET<br />
ADULT STRENGTH ANALGESIC ASPIRIN/CAFFEINE 400-32MG TABLET<br />
ANACIN ASPIRIN/CAFFEINE 400-32MG TABLET<br />
ANALGESIC ASPIRIN/CAFFEINE 400-32MG TABLET<br />
AS-CAFF ASPIRIN/CAFFEINE 400-32MG TABLET<br />
ASPIRCAF ASPIRIN/CAFFEINE 400-32MG TABLET<br />
BIOCIN ASPIRIN/CAFFEINE 400-32MG TABLET<br />
FAST ACTING PAIN RELIEF ASPIRIN/CAFFEINE 400-32MG TABLET<br />
MAJORCIN ASPIRIN/CAFFEINE 400-32MG TABLET<br />
NORGESIC ASPIRIN/CAFFEINE/ORPHENADRINE 25-385-30 TABLET<br />
NORGESIC FORTE ASPIRIN/CAFFEINE/ORPHENADRINE 50-770-60 TABLET<br />
ORPHENADRINE COMPOUND ASPIRIN/CAFFEINE/ORPHENADRINE 25-385-30 TABLET<br />
ORPHENADRINE COMPOUND FORTE ASPIRIN/CAFFEINE/ORPHENADRINE 50-770-60 TABLET<br />
ORPHENGESIC ASPIRIN/CAFFEINE/ORPHENADRINE 25-385-30 TABLET<br />
ORPHENGESIC FORTE ASPIRIN/CAFFEINE/ORPHENADRINE 50-770-60 TABLET<br />
ASPIRIN ASPIRIN/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
ASPIRIN BUFFERED ASPIRIN/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
Page 11<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
ASPIRIN TRI-BUFFERED ASPIRIN/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
ASPIR-MOX ASPIRIN/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
BUFFERED ASPIRIN ASPIRIN/CALCIUM CARB/MAGNESIUM 324MG TABLET<br />
BUFFERED ASPIRIN ASPIRIN/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
BUFFERIN ANALGESIC ASPIRIN/CALCIUM CARB/MAGNESIUM 324MG TABLET<br />
BUFPIRIN ASPIRIN/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
TRI-BUFFERED ASPIRIN ASPIRIN/CALCIUM CARB/MAGNESIUM 325MG TABLET<br />
TRI-BUFFERED BUFFERIN ASPIRIN/CALCIUM CARB/MAGNESIUM 324MG TABLET<br />
CARISOPRODOL COMPOUND ASPIRIN/CARISOPRODOL 200-325MG TABLET<br />
SOMA COMPOUND ASPIRIN/CARISOPRODOL 200-325MG TABLET<br />
EFFERVESCENT ASPIRIN/CITRIC ACID/SOD BICARB 324MG TABLET EFF<br />
EFFERVESCENT ANTACID PAIN ASPIRIN/CITRIC ACID/SOD BICARB 324MG TABLET EFF<br />
EFFERVESCENT PAIN RELIEF ASPIRIN/CITRIC ACID/SOD BICARB 324MG TABLET EFF<br />
EFFERVESCENT PAIN RELIEVER ASPIRIN/CITRIC ACID/SOD BICARB 324MG TABLET EFF<br />
SB ANTACID/PAIN ASPIRIN/CITRIC ACID/SOD BICARB 324MG TABLET EFF<br />
V-R EFFERVESCENT PAIN RELIEF ASPIRIN/CITRIC ACID/SOD BICARB 324MG TABLET EFF<br />
ASPIRIN W/CODEINE ASPIRIN/CODEINE PHOS 30-325MG TABLET<br />
ASPIRIN W/CODEINE ASPIRIN/CODEINE PHOS 60-325MG TABLET<br />
ASPIRIN W/CODEINE ASPIRIN/CODEINE PHOSPHATE 15-325MG TABLET<br />
EQUAGESIC ASPIRIN/MEPROBAMATE 325-200MG TABLET<br />
METHOCARBAMOL W/ASPIRIN ASPIRIN/METHOCARBAMOL 400-325MG TABLET<br />
ENDODAN ASPIRIN/OXYCODONE 4.88-325MG TABLET<br />
OXYCODONE W/ASPIRIN ASPIRIN/OXYCODONE 4.88-325MG TABLET<br />
PERCODAN ASPIRIN/OXYCODONE 4.88-325MG TABLET<br />
ATENOLOL ATENOLOL 100MG TABLET<br />
ATENOLOL ATENOLOL 25MG TABLET<br />
ATENOLOL ATENOLOL 50MG TABLET<br />
SENORMIN ATENOLOL 50MG TABLET<br />
TENORMIN ATENOLOL 100MG TABLET<br />
TENORMIN ATENOLOL 25MG TABLET<br />
TENORMIN ATENOLOL 50MG TABLET<br />
ATENOLOL W/CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE 100-25MG TABLET<br />
ATENOLOL W/CHLORTHALIDONE ATENOLOL/CHLORTHALIDONE 50-25MG TABLET<br />
TENORETIC 100 ATENOLOL/CHLORTHALIDONE 100-25MG TABLET<br />
TENORETIC 50 ATENOLOL/CHLORTHALIDONE 50-25MG TABLET<br />
URIN D.S. ATP/BA/HYOS/ME BLUE/MTH/SALICY TABLET<br />
URINARY ANTISEPTIC ATP/BA/HYOS/ME BLUE/MTH/SALICY TABLET<br />
URISED ATP/BA/HYOS/ME BLUE/MTH/SALICY TABLET<br />
URISEPTIC ATP/BA/HYOS/ME BLUE/MTH/SALICY TABLET<br />
USEPT ATP/BA/HYOS/ME BLUE/MTH/SALICY TABLET<br />
ATRACURIUM BESYLATE ATRACURIUM BESYLATE 10MG/ML VIAL<br />
TRACRIUM ATRACURIUM BESYLATE 10MG/ML VIAL<br />
DIPHENOXYLATE W/ATROPINE ATROP SULF/DIPHENOXYLATE HCL 2.5-.025/5 LIQUID<br />
DIPHENOXYLATE W/ATROPINE ATROP SULF/DIPHENOXYLATE HCL 2.5-.025MG TABLET<br />
LOMOTIL ATROP SULF/DIPHENOXYLATE HCL 2.5-.025MG TABLET<br />
LONOX ATROP SULF/DIPHENOXYLATE HCL 2.5-.025MG TABLET<br />
COLYTROL ATROP SULF/HYOSCY/SCOPOL HB 19.4-103.7 ORAL SUSP<br />
COPHENE-B ATROP/CHLORPHENIRAMINE MALEATE VIAL<br />
ATROPINE CARE ATROPINE SULFATE 1% DROPS<br />
ATROPINE SULFATE ATROPINE SULFATE 0.1MG/ML DISP SYRIN<br />
ATROPINE SULFATE ATROPINE SULFATE 0.4MG/ML VIAL<br />
ATROPINE SULFATE ATROPINE SULFATE 1% DROPS<br />
ATROPINE SULFATE ATROPINE SULFATE 1% OINT.(GM)<br />
ATROPINE SULFATE ATROPINE SULFATE 1MG/ML AMPUL<br />
ATROPINE SULFATE ATROPINE SULFATE 1MG/ML VIAL<br />
ISOPTO ATROPINE ATROPINE SULFATE 1% DROPS<br />
AZATHIOPRINE AZATHIOPRINE 50MG TABLET<br />
IMURAN AZATHIOPRINE 50MG TABLET<br />
AZATHIOPRINE SODIUM AZATHIOPRINE SODIUM 100MG VIAL<br />
IMURAN AZATHIOPRINE SODIUM 100MG VIAL<br />
FINEVIN AZELAIC ACID 20% CREAM(GM)<br />
ANEMAGEN B12/FE FUMARATE/STOMC/VIT C CAPSULE<br />
CHROMAGEN B12/FE FUMARATE/STOMC/VIT C CAPSULE<br />
FERRAGEN B12/FE FUMARATE/STOMC/VIT C CAPSULE<br />
FEROCON B12-IF/FA/FE FUMARATE/VIT C 110-0.5MG CAPSULE<br />
FEROTRINSIC B12-IF/FA/FE FUMARATE/VIT C 110-0.5MG CAPSULE<br />
FOLTRIN B12-IF/FA/FE FUMARATE/VIT C 110-0.5MG CAPSULE<br />
TRINSICON B12-IF/FA/FE FUMARATE/VIT C 110-0.5MG CAPSULE<br />
HM TRIPLE ANTIBIOTIC BACITRA/NEOMY SULF/POLYMYXIN B OINT.(GM)<br />
NEOMYCIN/BACITRACIN/POLYMYXIN BACITRA/NEOMY SULF/POLYMYXIN B 3.5MG-400 OINT.(GM)<br />
NEOPORACIN BACITRA/NEOMY SULF/POLYMYXIN B OINT.(GM)<br />
NEOSPORIN BACITRA/NEOMY SULF/POLYMYXIN B OINT.(GM)<br />
NEOSPORIN BACITRA/NEOMY SULF/POLYMYXIN B PACKET<br />
NEOSPORIN BACITRA/NEOMY SULF/POLYMYXIN B 3.5MG-400 OINT.(GM)<br />
TRIPLE ANTIBIOTIC BACITRA/NEOMY SULF/POLYMYXIN B OINT.(GM)<br />
Page 12<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
TRIPLE ANTIBIOTIC BACITRA/NEOMY SULF/POLYMYXIN B PACKET<br />
TRIPLE ANTIBIOTIC BACITRA/NEOMY SULF/POLYMYXIN B 3.5MG-400 OINT.(GM)<br />
AK-SPORE H.C. BACITRAC ZN/HC/NEOMY SULF/POLY 1% OINT.(GM)<br />
CORTISPORIN BACITRAC ZN/HC/NEOMY SULF/POLY 1% OINT.(GM)<br />
CORTOMYCIN BACITRAC ZN/HC/NEOMY SULF/POLY 1% OINT.(GM)<br />
NEOMYCIN/BACITRACIN/POLY/HC BACITRAC ZN/HC/NEOMY SULF/POLY 1% OINT.(GM)<br />
AK-TRACIN BACITRACIN 500 UNIT/G OINT.(GM)<br />
BACI-IM BACITRACIN 50000 UNIT VIAL<br />
BACIIM BACITRACIN 50000 UNIT VIAL<br />
BACITRACIN BACITRACIN 500 UNIT/G OINT.(GM)<br />
BACITRACIN BACITRACIN 5MMU POWDER<br />
BACITRACIN POWDER BACITRACIN 5MMU POWDER<br />
BACITRACIN STERILE BACITRACIN 50000 UNIT VIAL<br />
ZINC BACITRACIN BACITRACIN ZINC 500000 U POWDER<br />
AK-POLY-BAC BACITRACIN/POLYMYXIN B SULFATE OINT.(GM)<br />
BACITRACIN/POLYMYXIN B BACITRACIN/POLYMYXIN B SULFATE OINT.(GM)<br />
POLYCIN-B BACITRACIN/POLYMYXIN B SULFATE OINT.(GM)<br />
POLYSPORIN BACITRACIN/POLYMYXIN B SULFATE OINT.(GM)<br />
ATROFEN BACLOFEN 10MG TABLET<br />
ATROFEN BACLOFEN 20MG TABLET<br />
BACLOFEN BACLOFEN 10MG TABLET<br />
BACLOFEN BACLOFEN 20MG TABLET<br />
SODIUM CHLORIDE BACTERIOSTATIC SODIUM CHLORIDE 0.9% VIAL<br />
AMBERDERM BALSAM PERU/CASTOR OIL AEROSOL<br />
TBC BALSAM PERU/CASTOR OIL/TRYPSIN SPRAY<br />
BAROSPERSE BARIUM SULFATE 95% POWDER<br />
BAROSPERSE-110 BARIUM SULFATE 95% POWDER<br />
ERGOCAFF-PB BELLA/CAFF/ERGOTAMINE/P-BARB SUPP.RECT<br />
COLYTROL BELLADONNA ALKALOIDS TABLET<br />
PAHOMIN BELLADONNA ALKALOIDS 0.3MG/ML TINCTURE<br />
SPACOL BELLADONNA ALKALOIDS 0.0065MG/5 ELIXIR<br />
BELLADONNA & OPIUM BELLADONNA ALKALOIDS/OPIUM 30-16.2MG SUPP.RECT<br />
BELLADONNA & OPIUM BELLADONNA ALKALOIDS/OPIUM 60-16.2MG SUPP.RECT<br />
CAFFEINE/ERGOT/PENT BELLD ALK/CAFF/ERGOT TT/P-BARB SUPP.RECT<br />
FLUROX BENOXINATE HCL/FLUORESCEIN NA 0.4-0.25% DROPS<br />
DUAC BENZ PER/CLINDAMYCIN PHOSPHATE 1-5% GEL<br />
ERYTHROMYCIN-BENZOYL PEROXIDE BENZ PER/ERYTHROMYCIN BASE 3-5% GEL<br />
AMERICAINE BENZOCAINE 20% DROPS<br />
OMEDIA OTIC BENZOCAINE 20% DROPS<br />
OTICAINE BENZOCAINE 20% DROPS<br />
OTOCAIN BENZOCAINE 20% DROPS<br />
BENZONATATE BENZONATATE 100MG CAPSULE<br />
BENZONATATE BENZONATATE 200MG CAPSULE<br />
TESSALON PERLE BENZONATATE 100MG CAPSULE<br />
ACNE 10 BENZOYL PEROXIDE 10% GEL<br />
ACNECLEAR BENZOYL PEROXIDE 10% GEL<br />
BENZAC AC BENZOYL PEROXIDE 10% GEL<br />
BENZAC AC BENZOYL PEROXIDE 10% LIQUID<br />
BENZAC AC BENZOYL PEROXIDE 2.5% GEL<br />
BENZAC AC BENZOYL PEROXIDE 5% GEL<br />
BENZAC AC BENZOYL PEROXIDE 5% LIQUID<br />
BENZAC W 10 BENZOYL PEROXIDE 10% GEL<br />
BENZAC W 2.5 BENZOYL PEROXIDE 2.5% GEL<br />
BENZAC W 5 BENZOYL PEROXIDE 5% GEL<br />
BENZAC W WASH BENZOYL PEROXIDE 10% LIQUID<br />
BENZAC W WASH BENZOYL PEROXIDE 5% LIQUID<br />
BENZAGEL WASH BENZOYL PEROXIDE 10% GEL<br />
BENZAGEL-10 BENZOYL PEROXIDE 10% GEL<br />
BENZAGEL-5 BENZOYL PEROXIDE 5% GEL<br />
BENZOYL PEROXIDE BENZOYL PEROXIDE 10% GEL<br />
BENZOYL PEROXIDE BENZOYL PEROXIDE 10% LIQUID<br />
BENZOYL PEROXIDE BENZOYL PEROXIDE 2.5% GEL<br />
BENZOYL PEROXIDE BENZOYL PEROXIDE 2.5% LIQUID<br />
BENZOYL PEROXIDE BENZOYL PEROXIDE 5% GEL<br />
BENZOYL PEROXIDE BENZOYL PEROXIDE 5% LIQUID<br />
CLEARPLEX V BENZOYL PEROXIDE 5% CREAM(GM)<br />
CLEARPLEX X BENZOYL PEROXIDE 10% CREAM(GM)<br />
DESQUAM-E BENZOYL PEROXIDE 10% GEL<br />
DESQUAM-E BENZOYL PEROXIDE 2.5% GEL<br />
DESQUAM-E BENZOYL PEROXIDE 5% GEL<br />
DESQUAM-X BENZOYL PEROXIDE 10% LIQUID<br />
DESQUAM-X BENZOYL PEROXIDE 5% LIQUID<br />
DESQUAM-X 10 BENZOYL PEROXIDE 10% GEL<br />
DESQUAM-X 5 BENZOYL PEROXIDE 5% GEL<br />
FOSTEX BENZOYL PEROXIDE 10% GEL<br />
Page 13<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
OXY 10 BALANCE BENZOYL PEROXIDE 10% GEL<br />
OXY BALANCE BENZOYL PEROXIDE 5% GEL<br />
PANOXYL 10 BENZOYL PEROXIDE 10% GEL<br />
PANOXYL 5 BENZOYL PEROXIDE 5% GEL<br />
PANOXYL AQ 10 BENZOYL PEROXIDE 10% GEL<br />
PANOXYL AQ 2.5 BENZOYL PEROXIDE 2.5% GEL<br />
PANOXYL AQ 5 BENZOYL PEROXIDE 5% GEL<br />
SEBA-GEL BENZOYL PEROXIDE 10% GEL<br />
TRIAZ BENZOYL PEROXIDE 10% GEL<br />
BENZTROPINE MESYLATE BENZTROPINE MESYLATE 0.5MG TABLET<br />
BENZTROPINE MESYLATE BENZTROPINE MESYLATE 1MG TABLET<br />
BENZTROPINE MESYLATE BENZTROPINE MESYLATE 2MG TABLET<br />
COGENTIN BENZTROPINE MESYLATE 0.5MG TABLET<br />
WATER BENZYL ALCOHOL/WATER VIAL<br />
CLOTRIMAZOLE/BETAMETHASONE BETAMET DIPROP/CLOTRIMAZOLE 1-0.05% CREAM(GM)<br />
BETAMETHASONE DP AUGMENTED BETAMET DIPROP/PROP GLY 0.05% OINT.(GM)<br />
DIPROLENE BETAMET DIPROP/PROP GLY 0.05% OINT.(GM)<br />
ALPHATREX BETAMETHASONE DIPROPIONATE 0.05% CREAM(GM)<br />
ALPHATREX BETAMETHASONE DIPROPIONATE 0.05% LOTION<br />
ALPHATREX BETAMETHASONE DIPROPIONATE 0.05% OINT.(GM)<br />
BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE 0.05% CREAM(GM)<br />
BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE 0.05% LOTION<br />
BETAMETHASONE DIPROPIONATE BETAMETHASONE DIPROPIONATE 0.05% OINT.(GM)<br />
DIPROSONE BETAMETHASONE DIPROPIONATE 0.05% CREAM(GM)<br />
DIPROSONE BETAMETHASONE DIPROPIONATE 0.05% LOTION<br />
DIPROSONE BETAMETHASONE DIPROPIONATE 0.05% OINT.(GM)<br />
MAXIVATE BETAMETHASONE DIPROPIONATE 0.05% CREAM(GM)<br />
MAXIVATE BETAMETHASONE DIPROPIONATE 0.05% LOTION<br />
MAXIVATE BETAMETHASONE DIPROPIONATE 0.05% OINT.(GM)<br />
CELESTONE PHOSPHATE BETAMETHASONE SODIUM PHOSPHATE 3MG/ML VIAL<br />
BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.1% CREAM(GM)<br />
BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.1% LOTION<br />
BETAMETHASONE VALERATE BETAMETHASONE VALERATE 0.1% OINT.(GM)<br />
BETATREX BETAMETHASONE VALERATE 0.1% CREAM(GM)<br />
BETATREX BETAMETHASONE VALERATE 0.1% LOTION<br />
BETATREX BETAMETHASONE VALERATE 0.1% OINT.(GM)<br />
BETA-VAL BETAMETHASONE VALERATE 0.1% CREAM(GM)<br />
BETA-VAL BETAMETHASONE VALERATE 0.1% LOTION<br />
BETAXOLOL HCL BETAXOLOL HCL 0.5% DROPS<br />
BETAXOLOL HCL BETAXOLOL HCL 10MG TABLET<br />
BETAXOLOL HCL BETAXOLOL HCL 20MG TABLET<br />
PEPTO BISMOL BISMUTH SUBSALICYLATE 500<br />
BISOPROLOL FUMARATE BISOPROLOL FUMARATE 10MG TABLET<br />
BISOPROLOL FUMARATE BISOPROLOL FUMARATE 5MG TABLET<br />
BISOPROLOL FUMARATE/HCTZ BISOPROLOL FUMARATE/HCTZ 10-6.25MG TABLET<br />
BISOPROLOL FUMARATE/HCTZ BISOPROLOL FUMARATE/HCTZ 2.5-6.25MG TABLET<br />
BISOPROLOL FUMARATE/HCTZ BISOPROLOL FUMARATE/HCTZ 5-6.25MG TABLET<br />
ZIAC BISOPROLOL FUMARATE/HCTZ 10-6.25MG TABLET<br />
ZIAC BISOPROLOL FUMARATE/HCTZ 2.5-6.25MG TABLET<br />
ZIAC BISOPROLOL FUMARATE/HCTZ 5-6.25MG TABLET<br />
BLENOXANE BLEOMYCIN SULFATE 30 UNIT VIAL<br />
BLEOMYCIN SULFATE BLEOMYCIN SULFATE 15 UNIT VIAL<br />
BLEOMYCIN SULFATE BLEOMYCIN SULFATE 30 UNIT VIAL<br />
ANDEHIST DM BPM/D-METHORPHAN HB/P-EPD HCL 15-60-4/5 SYRUP<br />
ANDEHIST-DM BPM/D-METHORPHAN HB/P-EPD HCL 15-45-4/5 SYRUP<br />
BROMANATE DX BPM/D-METHORPHAN HB/P-EPD HCL 10-30-2/5 SYRUP<br />
BROMATANE DX BPM/D-METHORPHAN HB/P-EPD HCL 10-30-2/5 SYRUP<br />
BROMAXEFED DM RF BPM/D-METHORPHAN HB/P-EPD HCL 15-45-4/5 SYRUP<br />
BROMETANE DX BPM/D-METHORPHAN HB/P-EPD HCL 10-30-2/5 SYRUP<br />
BROMFED-DM BPM/D-METHORPHAN HB/P-EPD HCL 10-30-2/5 SYRUP<br />
BROMOPHED DX BPM/D-METHORPHAN HB/P-EPD HCL 10-30-2/5 SYRUP<br />
CARBODEX DM BPM/D-METHORPHAN HB/P-EPD HCL 15-45-4/5 SYRUP<br />
CARBOFED DM BPM/D-METHORPHAN HB/P-EPD HCL 15-45-4/5 SYRUP<br />
CARDEC DM BPM/D-METHORPHAN HB/P-EPD HCL 15-45-4/5 SYRUP<br />
COLDEC-DM BPM/D-METHORPHAN HB/P-EPD HCL 15-60-4/5 SYRUP<br />
PSE BROM BPM/D-METHORPHAN HB/P-EPD HCL 30-60-4/5 SYRUP<br />
RONDAMINE DM BPM/D-METHORPHAN HB/P-EPD HCL 15-45-4/5 SYRUP<br />
RONDAMINE DM BPM/D-METHORPHAN HB/P-EPD HCL 15-60-4/5 SYRUP<br />
RONDEC-DM BPM/D-METHORPHAN HB/P-EPD HCL 15-45-4/5 SYRUP<br />
SILDEC-DM BPM/D-METHORPHAN HB/P-EPD HCL 15-45-4/5 SYRUP<br />
ANAPLEX HD BPM/HYDROCODONE/P-EPHED HCL 30-1.7-2/5 LIQUID<br />
BRETYLIUM TOSYLATE BRETYLIUM TOSYLATE 50MG/ML VIAL<br />
BROMOCRIPTINE MESYLATE BROMOCRIPTINE MESYLATE 2.5MG TABLET<br />
PARLODEL BROMOCRIPTINE MESYLATE 2.5MG TABLET<br />
ANDEHIST BROMPHENIRAMIN/P-EPHED HCL 45-4MG/5ML SYRUP<br />
Page 14<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
ANDEHIST BROMPHENIRAMIN/P-EPHED HCL 60-4MG/5ML SYRUP<br />
BROMAXEFED RF BROMPHENIRAMIN/P-EPHED HCL 45-4MG/5ML SYRUP<br />
BROMFED BROMPHENIRAMIN/P-EPHED HCL 30-2MG/5ML SYRUP<br />
BROMFED-PD BROMPHENIRAMIN/P-EPHED HCL 60-6MG CAPSULE SA<br />
BROMFENEX-PD BROMPHENIRAMIN/P-EPHED HCL 60-6MG CAPSULE SA<br />
BROMPHENIRAMINE W/PSEUDOEPHED BROMPHENIRAMIN/P-EPHED HCL 60-6MG CAPSULE SA<br />
CARDEC BROMPHENIRAMIN/P-EPHED HCL 45-4MG/5ML SYRUP<br />
DALLERGY-JR BROMPHENIRAMIN/P-EPHED HCL 60-6MG CAPSULE SA<br />
DRIXORAL BROMPHENIRAMIN/P-EPHED HCL 30-2MG/5ML SYRUP<br />
IOFED-PD BROMPHENIRAMIN/P-EPHED HCL 60-6MG CAPSULE SA<br />
LODRANE LD BROMPHENIRAMIN/P-EPHED HCL 60-6MG CAPSULE SA<br />
PSEUBROM-PD BROMPHENIRAMIN/P-EPHED HCL 60-6MG CAPSULE SA<br />
RESPAHIST BROMPHENIRAMIN/P-EPHED HCL 60-6MG CAPSULE SA<br />
RONDEC BROMPHENIRAMIN/P-EPHED HCL 45-4MG/5ML SYRUP<br />
ULTRABROM PD BROMPHENIRAMIN/P-EPHED HCL 60-6MG CAPSULE SA<br />
DECONGESTANT BROMPHENIRAMIN/PPA HCL ELIXIR<br />
DI BROMM BROMPHENIRAMIN/PPA HCL ELIXIR<br />
NASAL DECONGESTANT/ANTIHIST BROMPHENIRAMIN/PPA HCL ELIXIR<br />
CODIMAL-A BROMPHENIRAMINE MALEATE 10MG/ML VIAL<br />
ENDAFED BROMPHENIRAMINE MALEATE 10MG/ML VIAL<br />
ND-STAT BROMPHENIRAMINE MALEATE 10MG/ML VIAL<br />
ALLENT BR-PHENIR MAL/P-EPHED HCL 120-12MG CAPSULE SA<br />
BROMADRINE BR-PHENIR MAL/P-EPHED HCL 120-12MG CAPSULE SA<br />
BROMFED BR-PHENIR MAL/P-EPHED HCL 120-12MG CAPSULE SA<br />
BROMFENEX BR-PHENIR MAL/P-EPHED HCL 120-12MG CAPSULE SA<br />
BROMPHENIRAMINE W/PSEUDOEPHED BR-PHENIR MAL/P-EPHED HCL 120-12MG CAPSULE SA<br />
IOFED BR-PHENIR MAL/P-EPHED HCL 120-12MG CAPSULE SA<br />
PSEUBROM BR-PHENIR MAL/P-EPHED HCL 120-12MG CAPSULE SA<br />
ULTRABROM BR-PHENIR MAL/P-EPHED HCL 120-12MG CAPSULE SA<br />
BIOTAPP BR-PHENIR MAL/PPA HCL ELIXIR<br />
COLD & ALLERGY BR-PHENIR MAL/PPA HCL ELIXIR<br />
DIBROMM BR-PHENIR MAL/PPA HCL ELIXIR<br />
GRAPE FLAVORED ELIXIR BR-PHENIR MAL/PPA HCL ELIXIR<br />
KOMATAPP BR-PHENIR MAL/PPA HCL ELIXIR<br />
BUMETANIDE BUMETANIDE 0.25MG/ML VIAL<br />
BUMETANIDE BUMETANIDE 0.5MG TABLET<br />
BUMETANIDE BUMETANIDE 1MG TABLET<br />
BUMETANIDE BUMETANIDE 2MG TABLET<br />
BUMEX BUMETANIDE 0.5MG TABLET<br />
BUMEX BUMETANIDE 1MG TABLET<br />
BUMEX BUMETANIDE 2MG TABLET<br />
BUPIVACAINE HCL BUPIVACAINE HCL 2.5MG/ML AMPUL<br />
BUPIVACAINE HCL BUPIVACAINE HCL 2.5MG/ML VIAL<br />
BUPIVACAINE HCL BUPIVACAINE HCL 5MG/ML AMPUL<br />
BUPIVACAINE HCL BUPIVACAINE HCL 5MG/ML VIAL<br />
BUPIVACAINE HCL BUPIVACAINE HCL 7.5MG/ML AMPUL<br />
BUPIVACAINE HCL BUPIVACAINE HCL 7.5MG/ML VIAL<br />
MARCAINE BUPIVACAINE HCL 2.5MG/ML AMPUL<br />
MARCAINE BUPIVACAINE HCL 2.5MG/ML VIAL<br />
MARCAINE BUPIVACAINE HCL 5MG/ML VIAL<br />
MARCAINE BUPIVACAINE HCL 7.5MG/ML VIAL<br />
SENSORCAINE BUPIVACAINE HCL 2.5MG/ML AMPUL<br />
SENSORCAINE BUPIVACAINE HCL 2.5MG/ML VIAL<br />
SENSORCAINE BUPIVACAINE HCL 5MG/ML VIAL<br />
MARCAINE SPINAL BUPIVACAINE HCL/DEXTROSE-WATER 0.75% AMPUL<br />
BUPIVACAINE HCL W/EPINEPHRINE BUPIVACAINE HCL/EPINEPHRINE 0.25-.0005 AMPUL<br />
BUPIVACAINE HCL W/EPINEPHRINE BUPIVACAINE HCL/EPINEPHRINE 0.25-.0005 VIAL<br />
BUPIVACAINE HCL W/EPINEPHRINE BUPIVACAINE HCL/EPINEPHRINE 0.5-0.0005 AMPUL<br />
BUPIVACAINE HCL W/EPINEPHRINE BUPIVACAINE HCL/EPINEPHRINE 0.5-0.0005 VIAL<br />
BUPIVACAINE HCL W/EPINEPHRINE BUPIVACAINE HCL/EPINEPHRINE 0.75-.0005 AMPUL<br />
BUPROPION HCL BUPROPION HCL 100MG TABLET<br />
BUPROPION HCL BUPROPION HCL 75MG TABLET<br />
WELLBUTRIN BUPROPION HCL 100MG TABLET<br />
WELLBUTRIN BUPROPION HCL 75MG TABLET<br />
BUSPAR BUSPIRONE HCL 10MG TABLET<br />
BUSPAR BUSPIRONE HCL 15MG TABLET<br />
BUSPAR BUSPIRONE HCL 5MG TABLET<br />
BUSPIRONE HCL BUSPIRONE HCL 10MG TABLET<br />
BUSPIRONE HCL BUSPIRONE HCL 15MG TABLET<br />
BUSPIRONE HCL BUSPIRONE HCL 30MG TABLET<br />
BUSPIRONE HCL BUSPIRONE HCL 5MG TABLET<br />
BUSPIRONE HCL BUSPIRONE HCL 7.5MG TABLET<br />
BUTISOL SODIUM BUTABARBITAL SODIUM 30MG/5ML ELIXIR<br />
BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE 10MG/ML SPRAY<br />
BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE 1MG/ML VIAL<br />
Page 15<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
BUTORPHANOL TARTRATE BUTORPHANOL TARTRATE 2MG/ML VIAL<br />
STADOL BUTORPHANOL TARTRATE 1MG/ML VIAL<br />
STADOL BUTORPHANOL TARTRATE 2MG/ML VIAL<br />
CALCIUM 600+MINERALS CA CARBONATE/MIN/VITAMIN D2 TABLET<br />
DEXATUSS CA/D-METHORPHAN HB/GUAIFEN/POT LIQUID<br />
CARENATE 600 CA/DOSS/FA/IRON,CARB/P-NAT VIT 90-1-600MG COMBO. PKG<br />
CYTRA-3 CA/K CIT/POTASS/SOD/SODIUM CIT 500-550/5 SYRUP<br />
TRICITRATES CA/K CIT/POTASS/SOD/SODIUM CIT 500-550/5 SOLUTION<br />
AKORN BALANCED SALT CAL/MAGNESIUM/POTASSIUM/SODIUM SOLUTION<br />
AMO ENDOSOL CAL/MAGNESIUM/POTASSIUM/SODIUM SOLUTION<br />
BALANCED SALT CAL/MAGNESIUM/POTASSIUM/SODIUM SOLUTION<br />
BSS CAL/MAGNESIUM/POTASSIUM/SODIUM SOLUTION<br />
CALCITRIOL CALCITRIOL 0.25MCG CAPSULE<br />
CALCITRIOL CALCITRIOL 0.5MCG CAPSULE<br />
ANATACID CALCIUM CARBONATE 500MG TAB CHEW<br />
ANTACID CALCIUM CARBONATE 500MG TAB CHEW<br />
ANTACID CALCIUM CARBONATE 750MG TAB CHEW<br />
ANTACID EXTRA STRENGTH CALCIUM CARBONATE 750MG TAB CHEW<br />
CAL-600 CALCIUM CARBONATE 1.5G TABLET<br />
CALCARB 600 CALCIUM CARBONATE 1.5G TABLET<br />
CAL-CARB FORTE CALCIUM CARBONATE 1.25G TABLET<br />
CALCICARB CALCIUM CARBONATE 650MG TABLET<br />
CALCI-CHEW CALCIUM CARBONATE 1.25G TAB CHEW<br />
CALCIUM CALCIUM CARBONATE 1.5G TABLET<br />
CALCIUM CALCIUM CARBONATE 600MG TABLET<br />
CALCIUM 500 CALCIUM CARBONATE 1.25G TABLET<br />
CALCIUM 600 CALCIUM CARBONATE 1.5G TABLET<br />
CALCIUM ANTACID CALCIUM CARBONATE 500MG TAB CHEW<br />
CALCIUM ANTACID EXTRA STRENGTH CALCIUM CARBONATE 750MG TAB CHEW<br />
CALCIUM CARBONATE CALCIUM CARBONATE 1.25G TAB CHEW<br />
CALCIUM CARBONATE CALCIUM CARBONATE 1.25G TABLET<br />
CALCIUM CARBONATE CALCIUM CARBONATE 1.5G TABLET<br />
CALCIUM CARBONATE CALCIUM CARBONATE 500MG TAB CHEW<br />
CALCIUM CARBONATE CALCIUM CARBONATE 600MG TABLET<br />
CALCIUM CARBONATE CALCIUM CARBONATE 650MG TABLET<br />
CALCIUM CARBONATE 600 CALCIUM CARBONATE 1.5G TABLET<br />
CALCIUM OYSTER SHELL CALCIUM CARBONATE 1.25G TABLET<br />
CALCIUM-600 CALCIUM CARBONATE 1.5G TABLET<br />
CALTRATE-600 CALCIUM CARBONATE 1.5G TABLET<br />
CALTREX-600 CALCIUM CARBONATE 1.5G TABLET<br />
CHEWABLE ANTACID CALCIUM CARBONATE 500MG TAB CHEW<br />
DICARBOSIL CALCIUM CARBONATE 500MG TAB CHEW<br />
HM ANTACID CALCIUM CARBONATE 500MG TAB CHEW<br />
HM CALCIUM ANTACID CALCIUM CARBONATE 500MG TAB CHEW<br />
MYLANTA CALCIUM CARBONATE 750MG TAB CHEW<br />
OS-CAL 500 CALCIUM CARBONATE 1.25G TAB CHEW<br />
OS-CAL 500 CALCIUM CARBONATE 1.25G TABLET<br />
OYSCO-500 CALCIUM CARBONATE 1.25G TABLET<br />
OYST-CAL-500 CALCIUM CARBONATE 1.25G TABLET<br />
OYSTER SHELL CALCIUM CARBONATE 1.25G TABLET<br />
OYSTER SHELL CALCIUM CALCIUM CARBONATE 1.25G TABLET<br />
OYSTER TABS CALCIUM CARBONATE 1.25G TABLET<br />
SB ANTACID CALCIUM CARBONATE 500MG TAB CHEW<br />
SB ANTACID CALCIUM CARBONATE 750MG TAB CHEW<br />
SB OYSTER CALCIUM CALCIUM CARBONATE 1.25G TABLET<br />
TITRALAC EXTRA STRENGTH CALCIUM CARBONATE 750MG TAB CHEW<br />
TUMS CALCIUM CARBONATE 500MG TAB CHEW<br />
TUMS CALCIUM CARBONATE 750MG TAB CHEW<br />
TUMS 500 CALCIUM CARBONATE 1.25G TAB CHEW<br />
TUMS CALCIUM FOR LIFE CALCIUM CARBONATE 750MG TAB CHEW<br />
TUMS CALCIUM FOR LIFE PMS CALCIUM CARBONATE 750MG TAB CHEW<br />
UNI-CAL 500 CALCIUM CARBONATE 1.25G TABLET<br />
V-R ANTACID CALCIUM CARBONATE 750MG TAB CHEW<br />
VR CALCIUM CALCIUM CARBONATE 1.25G TABLET<br />
X-STRENGTH ANTACID CALCIUM CARBONATE 750MG TAB CHEW<br />
ANTACID CALCIUM CARBONATE/MAG CARB 311-232MG TABLET<br />
MI-ACID CALCIUM CARBONATE/MAG CARB 311-232MG TABLET<br />
MYLANTA CALCIUM CARBONATE/MAG CARB 311-232MG TABLET<br />
CALCIUM CHLORIDE CALCIUM CHLORIDE 100MG/ML DISP SYRIN<br />
CALCIUM CHLORIDE CALCIUM CHLORIDE 100MG/ML VIAL<br />
CALCITRATE CALCIUM CITRATE 950MG TABLET<br />
CALCIUM CITRATE CALCIUM CITRATE 200MG TABLET<br />
CALCIUM CITRATE CALCIUM CITRATE 950MG TABLET<br />
CITRACAL CALCIUM CITRATE 200MG TABLET<br />
CITRUS CALCIUM CALCIUM CITRATE 200MG TABLET<br />
Page 16<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
CALCIUM CITRATE W/VITAMIN D CALCIUM CITRATE/ERGOCALCIFEROL 1500-200 TABLET<br />
CALCIUM CITRATE + D CALCIUM CITRATE/VITAMIN D3 315MG-200 TABLET<br />
CALCIUM CITRATE W/VITAMIN D CALCIUM CITRATE/VITAMIN D3 315MG-200 TABLET<br />
CALCIUM CITRATE+D CALCIUM CITRATE/VITAMIN D3 315MG-200 TABLET<br />
CITRACAL + D CALCIUM CITRATE/VITAMIN D3 315MG-200 TABLET<br />
CALCIQUID CALCIUM GLUBIONATE 1.8G/5ML SYRUP<br />
CALCIUM GLUCONATE CALCIUM GLUCONATE 100MG/ML AMPUL<br />
CALCIUM GLUCONATE CALCIUM GLUCONATE 100MG/ML VIAL<br />
CALCIUM GLUCONATE CALCIUM GLUCONATE 500MG TABLET<br />
CALCIUM GLUCONATE CALCIUM GLUCONATE 650MG TABLET<br />
CAPOTEN CAPTOPRIL 100MG TABLET<br />
CAPOTEN CAPTOPRIL 12.5MG TABLET<br />
CAPOTEN CAPTOPRIL 25MG TABLET<br />
CAPOTEN CAPTOPRIL 50MG TABLET<br />
CAPTOPRIL CAPTOPRIL 100MG TABLET<br />
CAPTOPRIL CAPTOPRIL 12.5MG TABLET<br />
CAPTOPRIL CAPTOPRIL 25MG TABLET<br />
CAPTOPRIL CAPTOPRIL 50MG TABLET<br />
CAPOZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE 25-15MG TABLET<br />
CAPOZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE 25-25MG TABLET<br />
CAPOZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE 50-15MG TABLET<br />
CAPOZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE 50-25MG TABLET<br />
CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE 25-15MG TABLET<br />
CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE 25-25MG TABLET<br />
CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE 50-15MG TABLET<br />
CAPTOPRIL/HYDROCHLOROTHIAZIDE CAPTOPRIL/HYDROCHLOROTHIAZIDE 50-25MG TABLET<br />
CARBASTAT CARBACHOL 0.01% VIAL<br />
CARBOPTIC CARBACHOL 3% DROPS<br />
MIOSTAT CARBACHOL 0.01% VIAL<br />
CARBAMAZEPINE CARBAMAZEPINE 100MG TAB CHEW<br />
CARBAMAZEPINE CARBAMAZEPINE 100MG/5ML ORAL SUSP<br />
CARBAMAZEPINE CARBAMAZEPINE 200MG TABLET<br />
EPITOL CARBAMAZEPINE 200MG TABLET<br />
TEGRETOL CARBAMAZEPINE 100MG TAB CHEW<br />
TEGRETOL CARBAMAZEPINE 200MG TABLET<br />
ATAMET CARBIDOPA/LEVODOPA 25-100MG TABLET<br />
ATAMET CARBIDOPA/LEVODOPA 25-250MG TABLET<br />
CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA 10-100MG TABLET<br />
CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA 25-100MG TABLET<br />
CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA 25-100MG TABLET SA<br />
CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA 25-250MG TABLET<br />
CARBIDOPA/LEVODOPA CARBIDOPA/LEVODOPA 50-200MG TABLET SA<br />
SINEMET-10/100 CARBIDOPA/LEVODOPA 10-100MG TABLET<br />
SINEMET-25/100 CARBIDOPA/LEVODOPA 25-100MG TABLET<br />
SINEMET-25/250 CARBIDOPA/LEVODOPA 25-250MG TABLET<br />
ANDEHIST CARBINOX MAL/P-EPHED HCL 15-1MG/ML DROPS<br />
ANDEHIST CARBINOX MAL/P-EPHED HCL 15-2MG/ML DROPS<br />
BIODEC CARBINOX MAL/P-EPHED HCL DROPS<br />
CARBINOXAMINE CARBINOX MAL/P-EPHED HCL 25-2MG/ML DROPS<br />
CARBINOXAMINE CARBINOX MAL/P-EPHED HCL 60-4MG/5ML SYRUP<br />
CARBINOXAMINE PSE CARBINOX MAL/P-EPHED HCL 15-2MG/5ML SYRUP<br />
CARDEC CARBINOX MAL/P-EPHED HCL 15-1MG/ML DROPS<br />
CARDEC-S CARBINOX MAL/P-EPHED HCL 60-4MG/5ML SYRUP<br />
COLDEC CARBINOX MAL/P-EPHED HCL 60-4MG TABLET<br />
COLDEC D CARBINOX MAL/P-EPHED HCL 90-8MG TABLET SA<br />
COLDEC TR CARBINOX MAL/P-EPHED HCL 120-8MG TAB.SR 12H<br />
CYDEC CARBINOX MAL/P-EPHED HCL 60-4MG/5ML SYRUP<br />
DURA-RON CARBINOX MAL/P-EPHED HCL 60-4MG/5ML SYRUP<br />
HYDRO-TUSSIN CBX CARBINOX MAL/P-EPHED HCL 15-2MG/5ML SYRUP<br />
PALGIC DS CARBINOX MAL/P-EPHED HCL 15-2MG/5ML SYRUP<br />
P-EPHED HCL/CARBINOX MAL CARBINOX MAL/P-EPHED HCL 15-2MG/5ML SYRUP<br />
RONDAMINE CARBINOX MAL/P-EPHED HCL 120-8MG TAB.SR 12H<br />
RONDAMINE CARBINOX MAL/P-EPHED HCL 60-4MG TABLET<br />
RONDEC CARBINOX MAL/P-EPHED HCL 60-4MG TABLET<br />
RONDEC-TR CARBINOX MAL/P-EPHED HCL 120-8MG TAB.SR 12H<br />
ANDEHIST-DM CARBINOX/DM HB/P-EPHED HCL 4-15-1/ML DROPS<br />
ANDEHIST-DM CARBINOX/DM HB/P-EPHED HCL 4-15-2/ML DROPS<br />
BIODEC-DM CARBINOX/DM HB/P-EPHED HCL DROPS<br />
BIODEC-DM CARBINOX/DM HB/P-EPHED HCL SYRUP<br />
CARBAXEFED DM RF CARBINOX/DM HB/P-EPHED HCL 4-15-1/ML DROPS<br />
CARBINOXAMINE COMPOUND CARBINOX/DM HB/P-EPHED HCL 15-60-4/5 SYRUP<br />
CARBINOXAMINE COMPOUND CARBINOX/DM HB/P-EPHED HCL 4-25-2/ML DROPS<br />
CARBODEX DM CARBINOX/DM HB/P-EPHED HCL 4-15-1/ML DROPS<br />
CARBOFED DM CARBINOX/DM HB/P-EPHED HCL 4-15-1/ML DROPS<br />
CARDEC DM CARBINOX/DM HB/P-EPHED HCL 4-15-1/ML DROPS<br />
Page 17<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
CARDEC-DM CARBINOX/DM HB/P-EPHED HCL 15-60-4/5 SYRUP<br />
CARDEC-DM CARBINOX/DM HB/P-EPHED HCL 4-25-2/ML DROPS<br />
PRODEC-DM CARBINOX/DM HB/P-EPHED HCL 4-25-2/ML DROPS<br />
RONDEC-DM CARBINOX/DM HB/P-EPHED HCL 4-15-1/ML DROPS<br />
SILDEC-DM CARBINOX/DM HB/P-EPHED HCL 4-15-1/ML DROPS<br />
TUSSAFED CARBINOX/DM HB/P-EPHED HCL 15-60-4/5 SYRUP<br />
P-EPD HCL/HCOD BT/CARBINOX CARBINOX/HCOD BT/P-EPHED HCL 30-5-2MG/5 LIQUID<br />
CARBINOXAMINE CARBINOXAMINE MALEATE 2MG/5ML LIQUID<br />
CARBINOXAMINE CARBINOXAMINE MALEATE 4MG/5ML LIQUID<br />
CARBINOXAMINE PD CARBINOXAMINE MALEATE 2MG/5ML LIQUID<br />
HISTEX PD CARBINOXAMINE MALEATE 4MG/5ML LIQUID<br />
MINTEX CT CARBINOXAMINE MALEATE 8MG TAB.SR 12H<br />
PEDIATEX CARBINOXAMINE MALEATE 2MG/5ML LIQUID<br />
PEDIOX CARBINOXAMINE MALEATE 4MG/5ML LIQUID<br />
CAR-B-PEN TA/CHLOR-TAN CAR-B-PEN TA/CHLOR-TAN 60-5MG TABLET<br />
TANA T-12 CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP<br />
TANNATE 12 S CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP<br />
TANNIC-12 CAR-B-PEN TA/CHLOR-TAN 60-5MG TABLET<br />
TANNIC-12 S CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP<br />
TANNIHIST-12 RF CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP<br />
TRIONATE CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP<br />
TRIONATE NF CAR-B-PEN TA/CHLOR-TAN 60-5MG TABLET<br />
TUSSI-12 CAR-B-PEN TA/CHLOR-TAN 60-5MG TABLET<br />
TUSSI-12 S CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP<br />
TUSSIZONE-12 RF CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP<br />
TUSSIZONE-12 RF CAR-B-PEN TA/CHLOR-TAN 60-5MG TABLET<br />
QUAD TANN CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP<br />
QUAD TANN CAR-B-PEN TA/CP/EPHED TAN/PE 60-10-10-5 TABLET<br />
QUAD TANN PEDIATRIC CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP<br />
QUAD-TUSS TANNATE CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP<br />
RENTAMINE CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP<br />
RENTAMINE CAR-B-PEN TA/CP/EPHED TAN/PE 60-10-10-5 TABLET<br />
RYNATUSS CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP<br />
RYNATUSS CAR-B-PEN TA/CP/EPHED TAN/PE 60-10-10-5 TABLET<br />
TETRA TANNATE CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP<br />
RENTAMINE-12 CAR-B-PEN TA/CP/PHENYLEPHRINE 30-5-4/5ML ORAL SUSP<br />
TANNATE-12 CAR-B-PEN TA/CP/PHENYLEPHRINE 30-5-4/5ML ORAL SUSP<br />
TANNIC-12 CAR-B-PEN TA/CP/PHENYLEPHRINE 30-5-4/5ML ORAL SUSP<br />
TANNIHIST-12 CAR-B-PEN TA/CP/PHENYLEPHRINE 30-5-4/5ML ORAL SUSP<br />
ULTRATUSS 12 S CAR-B-PEN TA/CP/PHENYLEPHRINE 30-5-4/5ML ORAL SUSP<br />
XIRATUSS CAR-B-PEN TA/CP/PHENYLEPHRINE 60-10-5MG TABLET<br />
PLEGISOL CARDIOPLEGIC SOLUTION NO.1 K+=16MEQ/L INFUS. BTL<br />
CARISOPRODOL CARISOPRODOL 350MG TABLET<br />
SOMA CARISOPRODOL 350MG TABLET<br />
VANADOM CARISOPRODOL 350MG TABLET<br />
CARTEOLOL HCL CARTEOLOL HCL 1% DROPS<br />
OCUPRESS CARTEOLOL HCL 1% DROPS<br />
CECLOR CEFACLOR 125MG/5ML SUSP RECON<br />
CECLOR CEFACLOR 187MG/5ML SUSP RECON<br />
CECLOR CEFACLOR 250MG CAPSULE<br />
CECLOR CEFACLOR 250MG/5ML SUSP RECON<br />
CECLOR CEFACLOR 375MG/5ML SUSP RECON<br />
CECLOR CEFACLOR 500MG CAPSULE<br />
CEFACLOR CEFACLOR 125MG/5ML SUSP RECON<br />
CEFACLOR CEFACLOR 187MG/5ML SUSP RECON<br />
CEFACLOR CEFACLOR 250MG CAPSULE<br />
CEFACLOR CEFACLOR 250MG/5ML SUSP RECON<br />
CEFACLOR CEFACLOR 375MG/5ML SUSP RECON<br />
CEFACLOR CEFACLOR 500MG CAPSULE<br />
CEFACLOR ER CEFACLOR 375MG TAB.SR 12H<br />
CEFACLOR ER CEFACLOR 500MG TAB.SR 12H<br />
CEFADROXIL CEFADROXIL HYDRATE 500MG CAPSULE<br />
CEFADROXIL MONOHYDRATE CEFADROXIL HYDRATE 1G TABLET<br />
DURICEF CEFADROXIL HYDRATE 1G TABLET<br />
DURICEF CEFADROXIL HYDRATE 500MG CAPSULE<br />
ANCEF CEFAZOLIN SODIUM 10G VIAL<br />
ANCEF CEFAZOLIN SODIUM 1G PIGGYBACK<br />
ANCEF CEFAZOLIN SODIUM 1G VIAL<br />
ANCEF CEFAZOLIN SODIUM 500MG VIAL<br />
CEFAZOLIN CEFAZOLIN SODIUM 10G VIAL<br />
CEFAZOLIN CEFAZOLIN SODIUM 1G VIAL<br />
CEFAZOLIN SODIUM CEFAZOLIN SODIUM 10G VIAL<br />
CEFAZOLIN SODIUM CEFAZOLIN SODIUM 1G PIGGYBACK<br />
CEFAZOLIN SODIUM CEFAZOLIN SODIUM 1G VIAL<br />
CEFAZOLIN SODIUM CEFAZOLIN SODIUM 500MG VIAL<br />
Page 18<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
KEFZOL CEFAZOLIN SODIUM 10G VIAL<br />
KEFZOL CEFAZOLIN SODIUM 1G VIAL<br />
CEFOTAXIME CEFOTAXIME SODIUM 500MG VIAL<br />
CEFOTAXIME SODIUM CEFOTAXIME SODIUM 10G VIAL<br />
CEFOTAXIME SODIUM CEFOTAXIME SODIUM 1G VIAL<br />
CEFOTAXIME SODIUM CEFOTAXIME SODIUM 2G VIAL<br />
CEFOXITIN CEFOXITIN SODIUM 10G VIAL<br />
CEFOXITIN CEFOXITIN SODIUM 1G VIAL<br />
CEFOXITIN CEFOXITIN SODIUM 2G VIAL<br />
CEFUROXIME CEFUROXIME AXETIL 250MG TABLET<br />
CEFUROXIME CEFUROXIME AXETIL 500MG TABLET<br />
CEFUROXIME SODIUM CEFUROXIME SODIUM 1.5G VIAL<br />
CEFUROXIME SODIUM CEFUROXIME SODIUM 7.5G VIAL<br />
CEFUROXIME SODIUM CEFUROXIME SODIUM 750MG VIAL<br />
KEFUROX CEFUROXIME SODIUM 7.5G VIAL<br />
KEFUROX CEFUROXIME SODIUM 750MG VIAL<br />
ZINACEF CEFUROXIME SODIUM 7.5G VIAL<br />
ZINACEF CEFUROXIME SODIUM 750MG VIAL<br />
CEPHALEXIN CEPHALEXIN MONOHYDRATE 125MG/5ML SUSP RECON<br />
CEPHALEXIN CEPHALEXIN MONOHYDRATE 250MG CAPSULE<br />
CEPHALEXIN CEPHALEXIN MONOHYDRATE 250MG TABLET<br />
CEPHALEXIN CEPHALEXIN MONOHYDRATE 250MG/5ML SUSP RECON<br />
CEPHALEXIN CEPHALEXIN MONOHYDRATE 500MG CAPSULE<br />
KEFLEX CEPHALEXIN MONOHYDRATE 250MG CAPSULE<br />
KEFLEX CEPHALEXIN MONOHYDRATE 500MG CAPSULE<br />
CEPHRADINE CEPHRADINE 500MG CAPSULE<br />
VELOSEF CEPHRADINE 250MG CAPSULE<br />
VELOSEF CEPHRADINE 250MG/5ML SUSP RECON<br />
VELOSEF CEPHRADINE 500MG CAPSULE<br />
M.T.E.-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 100-1000 VIAL<br />
M.T.E.-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 500-5000 VIAL<br />
MULTITRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 100-1000 VIAL<br />
MULTITRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 25-1500 VIAL<br />
MULTITRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 500-5000 VIAL<br />
MULTITRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP PEDIATRIC VIAL<br />
NEOTRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 25-1500 VIAL<br />
P.T.E.-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 25-1000 VIAL<br />
PEDTRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 25-500 VIAL<br />
TRACE ELEMENTS-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 30-500 VIAL<br />
M.T.E.-5 CH/CUSO4 P-HYD/MN/SE/ZNSO4 HEP 20-1000 VIAL<br />
M.T.E.-5 CH/CUSO4 P-HYD/MN/SE/ZNSO4 HEP 60-5000 VIAL<br />
MULTITRACE-5 CH/CUSO4 P-HYD/MN/SE/ZNSO4 HEP 20-1000 VIAL<br />
MULTITRACE-5 CH/CUSO4 P-HYD/MN/SE/ZNSO4 HEP 60-5000 VIAL<br />
CHLORAL HYDRATE CHLORAL HYDRATE 500MG/5ML SYRUP<br />
SOMNOTE CHLORAL HYDRATE 500MG CAPSULE<br />
CHLORAMPHENICOL CHLORAMPHENICOL 1% OINT.(GM)<br />
CHLOROPTIC CHLORAMPHENICOL 0.5% DROPS<br />
CHLORAMPHENICOL SOD SUCCINATE CHLORAMPHENICOL NA SUCC 1G VIAL<br />
CHLOROMYCETIN CHLORAMPHENICOL NA SUCC 1G VIAL<br />
CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 10MG CAPSULE<br />
CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 25MG CAPSULE<br />
CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 5MG CAPSULE<br />
LIBRIUM CHLORDIAZEPOXIDE HCL 10MG CAPSULE<br />
LIBRIUM CHLORDIAZEPOXIDE HCL 25MG CAPSULE<br />
LIBRIUM CHLORDIAZEPOXIDE HCL 5MG CAPSULE<br />
POXI CHLORDIAZEPOXIDE HCL 10MG CAPSULE<br />
CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE 1.2MG/ML LIQUID<br />
PERIDEX CHLORHEXIDINE GLUCONATE 1.2MG/ML LIQUID<br />
PERIOGARD CHLORHEXIDINE GLUCONATE 1.2MG/ML LIQUID<br />
PERISOL CHLORHEXIDINE GLUCONATE 1.2MG/ML LIQUID<br />
COUGH FORMULA CHLOR-MAL/DEXTROMETHORPHAN HBR 15-2MG/5ML LIQUID<br />
EXTRA STRENGTH COUGH CHLOR-MAL/DEXTROMETHORPHAN HBR LIQUID<br />
EXTRA STRENGTH COUGH FORMULA CHLOR-MAL/DEXTROMETHORPHAN HBR LIQUID<br />
SCOT-TUSSIN DM CHLOR-MAL/DEXTROMETHORPHAN HBR 15-2MG/5ML LIQUID<br />
AMDRY-C CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H<br />
COLDAMINE CHLOR-MAL/P-EPHED HCL/SCOP 90-8-2.5MG TAB.SR 12H<br />
CPM 8/PSE 90/MSC 2.5 CHLOR-MAL/P-EPHED HCL/SCOP 90-8-2.5MG TAB.SR 12H<br />
HISTA-VENT PSE CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H<br />
MESCOLOR CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H<br />
PANNAZ CHLOR-MAL/P-EPHED HCL/SCOP 90-8-2.5MG TAB.SR 12H<br />
P-EPHED HCL/CHLOR-MAL/SCOP CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB SR SEQ<br />
P-EPHED HCL/CHLOR-MAL/SCOP CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H<br />
RESCON MX CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H<br />
XIRAL CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H<br />
ED A-HIST CHLOR-MAL/PHENYLEPHRINE HCL 20-8MG TABLET SA<br />
Page 19<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
HISTOR-D CHLOR-MAL/PHENYLEPHRINE HCL ELIXIR<br />
MED-HIST CHLOR-MAL/PHENYLEPHRINE HCL 5-2MG/5ML ELIXIR<br />
NOVAHISTINE CHLOR-MAL/PHENYLEPHRINE HCL 5-2MG/5ML ELIXIR<br />
AEROHIST PLUS CHLOR-MAL/PHENYLEPHRINE/SCOP 20-8-2.5MG TAB.SR 12H<br />
AH-CHEW CHLOR-MAL/PHENYLEPHRINE/SCOP 10-2-1.25 TAB CHEW<br />
D.A. CHLOR-MAL/PHENYLEPHRINE/SCOP 10-2-1.25 TAB CHEW<br />
DALLERGY CHLOR-MAL/PHENYLEPHRINE/SCOP 10-2-0.625 SYRUP<br />
DALLERGY CHLOR-MAL/PHENYLEPHRINE/SCOP 20-8-2.5MG TAB.SR 12H<br />
DEHISTINE CHLOR-MAL/PHENYLEPHRINE/SCOP 10-2-1.25 SYRUP<br />
DURADRYL CHLOR-MAL/PHENYLEPHRINE/SCOP 10-2-1.25 SYRUP<br />
DURA-VENT/DA CHLOR-MAL/PHENYLEPHRINE/SCOP 20-8-2.5MG TAB.SR 12H<br />
EXTENDRYL CHLOR-MAL/PHENYLEPHRINE/SCOP 10-2-1.25 TAB CHEW<br />
EXTENDRYL SR CHLOR-MAL/PHENYLEPHRINE/SCOP 20-8-2.5MG CAP.SR 12H<br />
HISTA-VENT DA CHLOR-MAL/PHENYLEPHRINE/SCOP 20-8-2.5MG TAB.SR 12H<br />
NOREL SD CHLOR-MAL/PHENYLEPHRINE/SCOP 10-2-0.625 SYRUP<br />
OMNIHIST L.A. CHLOR-MAL/PHENYLEPHRINE/SCOP 20-8-2.5MG TAB.SR 12H<br />
PCM CHLOR-MAL/PHENYLEPHRINE/SCOP 10-2-1.25 TAB CHEW<br />
PREHIST D CHLOR-MAL/PHENYLEPHRINE/SCOP 20-8-2.5MG TAB.SR 12H<br />
WE ALLERGY CHLOR-MAL/PHENYLEPHRINE/SCOP 10-2-0.625 SYRUP<br />
ALTAMINIC CHLOR-MAL/PPA HCL SYRUP<br />
COLD CAPSULE CHLOR-MAL/PPA HCL 75-8MG CAPSULE SA<br />
DEMAZIN CHLOR-MAL/PPA HCL SYRUP<br />
RESCON CHLOR-MAL/PPA HCL SYRUP<br />
SILAMINIC CHLOR-MAL/PPA HCL SYRUP<br />
THERA-HIST CHLOR-MAL/PPA HCL SYRUP<br />
TRIAC CHLOR-MAL/PPA HCL SYRUP<br />
TRIACTIN SYRUP CHLOR-MAL/PPA HCL SYRUP<br />
TRIACTING CHLOR-MAL/PPA HCL SYRUP<br />
TRIACTING CHLOR-MAL/PPA HCL 6.25-1MG/5 SYRUP<br />
ATROHIST PEDIATRIC CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG CAP.SR 12H<br />
CHLORAFED CHLOR-MAL/PSEUDOEPHEDRINE HCL 30-2 LIQUID<br />
CHLORAFED H.S. TIMECELLES CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG CAP.SR 12H<br />
CHLOR-TRIMETON D CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
COLD & ALLERGY SUPHEDRINE CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
COLFED-A CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
CURALER CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
D-AMINE-SR CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
DECONAMINE CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
DECONAMINE SR CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
DECONGESTANT PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
DE-CONGESTINE TR CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
DECONOMED SR CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
DYNAHIST ER CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG CAP.SR 12H<br />
GENAPHED PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
HAYFEBROL CHLOR-MAL/PSEUDOEPHEDRINE HCL 30-2 LIQUID<br />
HISTADE CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-12MG CAP.SR 12H<br />
HM SUPHEDRINE PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
KRONOFED-A CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
KRONOFED-A-JR CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG CAP.SR 12H<br />
MED-HIST CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
N D CLEAR CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
PSEUDAFEN PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
PSEUDO-CHLOR CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
PSEUDOEHEDRINE PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
PSEUDOEPHEDRINE COLD & ALLERGY CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
PSEUDOEPHEDRINE PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
PSEUDOEPHEDRINE W/CHLORPHENIR CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
PSEUDOEPHEDRINE-60 PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
PSEUDOGEST PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
RESCON JR CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG CAP.SR 12H<br />
RESCON-ED CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
RINADE-BID CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
RYNA CHLOR-MAL/PSEUDOEPHEDRINE HCL 30-2 LIQUID<br />
SUDOGEST PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
SUPHEDRIN PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
SUPHEDRINE PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
TIME-HIST CHLOR-MAL/PSEUDOEPHEDRINE HCL 120-8MG CAP.SR 12H<br />
TRIAMINIC CHLOR-MAL/PSEUDOEPHEDRINE HCL 15-1MG TAB CHEW<br />
UNI-SED PLUS CHLOR-MAL/PSEUDOEPHEDRINE HCL 60-4MG TABLET<br />
PAPAIN-UREA-CHLOROPHYLLIN CHLOROPHYLLIN/PAPAIN/UREA OINT.(GM)<br />
ZIOX CHLOROPHYLLIN/PAPAIN/UREA OINT.(GM)<br />
CHLOROPROCAINE HCL CHLOROPROCAINE HCL 20MG/ML VIAL<br />
CHLOROPROCAINE HCL CHLOROPROCAINE HCL 30MG/ML VIAL<br />
CHLOROQUINE PHOSPHATE CHLOROQUINE PHOSPHATE 500MG TABLET<br />
CHLOROTHIAZIDE CHLOROTHIAZIDE 250MG TABLET<br />
Page 20<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
CHLOROTHIAZIDE CHLOROTHIAZIDE 500MG TABLET<br />
DIURIL CHLOROTHIAZIDE 250MG TABLET<br />
DIURIL CHLOROTHIAZIDE 500MG TABLET<br />
AERO OTIC HC CHLOROXYLENOL/HC/PRAMOXINE HCL 10-10-1/ML DROPS<br />
CORTANE-B CHLOROXYLENOL/HC/PRAMOXINE HCL 10-10-1/ML DROPS<br />
CORTIC CHLOROXYLENOL/HC/PRAMOXINE HCL 10-10-1/ML DROPS<br />
CORTIC-ND CHLOROXYLENOL/HC/PRAMOXINE HCL 10-10-1/ML DROPS<br />
OTOMAR HC CHLOROXYLENOL/HC/PRAMOXINE HCL 10-10-1/ML DROPS<br />
OTOMAR-HC CHLOROXYLENOL/HC/PRAMOXINE HCL 10-10-1/ML DROPS<br />
OTOZONE CHLOROXYLENOL/HC/PRAMOXINE HCL 10-10-1/ML DROPS<br />
TRI-OTIC CHLOROXYLENOL/HC/PRAMOXINE HCL 10-10-1/ML DROPS<br />
ZOTO-HC CHLOROXYLENOL/HC/PRAMOXINE HCL 10-10-1/ML DROPS<br />
NOVAGEST DH CHLORPHENIR/COD/P-EPHED HCL LIQUID<br />
PHENYLHISTINE DH CHLORPHENIR/COD/P-EPHED HCL 30-10-2/5 LIQUID<br />
ATUSS DM CHLORPHENIR/D-METHORPHAN HB/PE 15-10-2/5 SYRUP<br />
ATUSS DR CHLORPHENIR/D-METHORPHAN HB/PE 15-6-2MG/5 SYRUP<br />
D-METHORPHAN HB/PE/CP CHLORPHENIR/D-METHORPHAN HB/PE 15-10-4/5 SOLUTION<br />
D-METHORPHAN HB/PE/CPM LIQ CHLORPHENIR/D-METHORPHAN HB/PE 15-10-2/5 SYRUP<br />
MINTUSS DM CHLORPHENIR/D-METHORPHAN HB/PE 15-10-2/5 SYRUP<br />
P CHLOR DM CHLORPHENIR/D-METHORPHAN HB/PE 15-10-2/5 SYRUP<br />
POLY-TUSSIN DM CHLORPHENIR/D-METHORPHAN HB/PE 15-5-2MG/5 SYRUP<br />
STATUSS DM CHLORPHENIR/D-METHORPHAN HB/PE 15-10-2/5 SYRUP<br />
TRI-VENT DPC CHLORPHENIR/D-METHORPHAN HB/PE 15-6-2MG/5 SYRUP<br />
ALLER-CHLOR CHLORPHENIRAMINE MALEATE 2MG/5ML SYRUP<br />
ALLER-CHLOR CHLORPHENIRAMINE MALEATE 4MG TABLET<br />
ALLERGY CHLORPHENIRAMINE MALEATE 4MG TABLET<br />
ALLERGY RELIEF CHLORPHENIRAMINE MALEATE 4MG TABLET<br />
C P M CHLORPHENIRAMINE MALEATE 4MG TABLET<br />
CHLOR-AL ALLERGY CHLORPHENIRAMINE MALEATE 2MG/5ML SYRUP<br />
CHLORMATE SA CHLORPHENIRAMINE MALEATE 12MG CAPSULE SA<br />
CHLORMATE SA CHLORPHENIRAMINE MALEATE 8MG CAPSULE SA<br />
CHLORPHENIRAMINE MALEATE CHLORPHENIRAMINE MALEATE 12MG CAPSULE SA<br />
CHLORPHENIRAMINE MALEATE CHLORPHENIRAMINE MALEATE 4MG TABLET<br />
CHLORPHENIRAMINE MALEATE CHLORPHENIRAMINE MALEATE 8MG CAPSULE SA<br />
CHLORPHENIRAMINE TR CHLORPHENIRAMINE MALEATE 12MG CAPSULE SA<br />
CHLORPHENIRAMINE TR CHLORPHENIRAMINE MALEATE 8MG CAPSULE SA<br />
CHLOR-TRIMETON CHLORPHENIRAMINE MALEATE 4MG TABLET<br />
CPM CHLORPHENIRAMINE MALEATE 4MG TABLET<br />
HM ALLERGY CHLORPHENIRAMINE MALEATE 4MG TABLET<br />
PROHIST-8 CHLORPHENIRAMINE MALEATE 8MG CAPSULE SA<br />
UNI-CORTROM CHLORPHENIRAMINE MALEATE 4MG TABLET<br />
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 100MG TABLET<br />
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 100MG/ML ORAL CONC.<br />
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 10MG TABLET<br />
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 200MG TABLET<br />
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 25MG TABLET<br />
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 25MG/ML AMPUL<br />
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 30MG/ML ORAL CONC.<br />
CHLORPROMAZINE HCL CHLORPROMAZINE HCL 50MG TABLET<br />
THORAZINE CHLORPROMAZINE HCL 100MG TABLET<br />
THORAZINE CHLORPROMAZINE HCL 200MG TABLET<br />
THORAZINE CHLORPROMAZINE HCL 25MG TABLET<br />
THORAZINE CHLORPROMAZINE HCL 25MG/ML AMPUL<br />
THORAZINE CHLORPROMAZINE HCL 25MG/ML VIAL<br />
THORAZINE CHLORPROMAZINE HCL 50MG TABLET<br />
CHLORPROPAMIDE CHLORPROPAMIDE 100MG TABLET<br />
CHLORPROPAMIDE CHLORPROPAMIDE 250MG TABLET<br />
DIABINESE CHLORPROPAMIDE 100MG TABLET<br />
DIABINESE CHLORPROPAMIDE 250MG TABLET<br />
C-PHED TANNATE CHLOR-TAN/P-EPD TAN 75-4.5/5ML ORAL SUSP<br />
CP-TANNIC CHLOR-TAN/P-EPD TAN 75-4.5/5ML ORAL SUSP<br />
DUOTAN CHLOR-TAN/P-EPD TAN 75-4.5/5ML ORAL SUSP<br />
DURAFED CHLOR-TAN/P-EPD TAN 75-4.5/5ML ORAL SUSP<br />
P-EPD TAN/CHLOR-TAN CHLOR-TAN/P-EPD TAN 75-4.5/5ML ORAL SUSP<br />
TANAFED CHLOR-TAN/P-EPD TAN 75-4.5/5ML ORAL SUSP<br />
NUHIST CHLOR-TAN/PHENYLEPHRINE 5-4.5MG/5 ORAL SUSP<br />
PHENCLOR TANNATE PEDIATRIC CHLOR-TAN/PHENYLEPHRINE 5-4.5MG/5 ORAL SUSP<br />
PHENYL CHLOR-TAN CHLOR-TAN/PHENYLEPHRINE 5-4.5MG/5 ORAL SUSP<br />
PRO-TANNATE CHLOR-TAN/PHENYLEPHRINE 5-4.5MG/5 ORAL SUSP<br />
RHINATATE-NF CHLOR-TAN/PHENYLEPHRINE 5-4.5MG/5 ORAL SUSP<br />
RYNATAN CHLOR-TAN/PHENYLEPHRINE 5-4.5MG/5 ORAL SUSP<br />
CHLORTHALIDONE CHLORTHALIDONE 100MG TABLET<br />
CHLORTHALIDONE CHLORTHALIDONE 25MG TABLET<br />
CHLORTHALIDONE CHLORTHALIDONE 50MG TABLET<br />
CLORPRES CHLORTHALIDONE/CLONIDINE HCL 0.1-15MG TABLET<br />
Page 21<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
CLORPRES CHLORTHALIDONE/CLONIDINE HCL 0.2-15MG TABLET<br />
CLORPRES CHLORTHALIDONE/CLONIDINE HCL 0.3-15MG TABLET<br />
CHLORZOXAZONE CHLORZOXAZONE 250MG TABLET<br />
CHLORZOXAZONE CHLORZOXAZONE 500MG TABLET<br />
EZE D.S. CHLORZOXAZONE 500MG TABLET<br />
PARAFON FORTE DSC CHLORZOXAZONE 500MG TABLET<br />
CHOLINE MAG TRISALICYLATE CHOL SAL/MAGNESIUM SALICYLATE 1000MG TABLET<br />
CHOLINE MAG TRISALICYLATE CHOL SAL/MAGNESIUM SALICYLATE 500MG TABLET<br />
CHOLINE MAG TRISALICYLATE CHOL SAL/MAGNESIUM SALICYLATE 500MG/5ML LIQUID<br />
CHOLINE MAG TRISALICYLATE CHOL SAL/MAGNESIUM SALICYLATE 750MG TABLET<br />
TRICOSAL CHOL SAL/MAGNESIUM SALICYLATE 1000MG TABLET<br />
TRICOSAL CHOL SAL/MAGNESIUM SALICYLATE 500MG TABLET<br />
TRICOSAL CHOL SAL/MAGNESIUM SALICYLATE 750MG TABLET<br />
TRILISATE CHOL SAL/MAGNESIUM SALICYLATE 1000MG TABLET<br />
TRILISATE CHOL SAL/MAGNESIUM SALICYLATE 500MG TABLET<br />
TRILISATE CHOL SAL/MAGNESIUM SALICYLATE 500MG/5ML LIQUID<br />
TRILISATE CHOL SAL/MAGNESIUM SALICYLATE 750MG TABLET<br />
CHOLESTYRAMINE CHOLESTYRAMINE/SUCROSE 4G PACKET<br />
CHOLESTYRAMINE CHOLESTYRAMINE/SUCROSE 4G POWDER<br />
LOCHOLEST CHOLESTYRAMINE/SUCROSE 4G PACKET<br />
QUESTRAN CHOLESTYRAMINE/SUCROSE 4G PACKET<br />
QUESTRAN CHOLESTYRAMINE/SUCROSE 4G POWDER<br />
M.T.E.-6 CHROM/CU/MANG/NAI/SE/ZNSO4 HEP 5-.075-1/1 VIAL<br />
TRACE METALS CHROM/CUPRIC CL/MANG/ZINC CL 0.8-.2-.16 VIAL<br />
CHROMIUM CHROMIC CHLORIDE 4MCG/ML VIAL<br />
CHROMIUM CHLORIDE CHROMIC CHLORIDE 4MCG/ML VIAL<br />
ACID REDUCER CIMETIDINE 200MG TABLET<br />
CIMETIDINE CIMETIDINE 200MG TABLET<br />
CIMETIDINE CIMETIDINE 300MG TABLET<br />
CIMETIDINE CIMETIDINE 400MG TABLET<br />
CIMETIDINE CIMETIDINE 800MG TABLET<br />
HEARTBURN 200 CIMETIDINE 200MG TABLET<br />
HEARTBURN RELIEF CIMETIDINE 200MG TABLET<br />
HM HEARTBURN RELIEF CIMETIDINE 200MG TABLET<br />
SB CIMETIDINE CIMETIDINE 200MG TABLET<br />
TAGAMET CIMETIDINE 300MG TABLET<br />
TAGAMET CIMETIDINE 400MG TABLET<br />
TAGAMET CIMETIDINE 800MG TABLET<br />
TAGAMET HB CIMETIDINE 200MG TABLET<br />
CIMETIDINE CIMETIDINE HCL 150MG/ML VIAL<br />
CIMETIDINE HCL CIMETIDINE HCL 300MG/5ML LIQUID<br />
CISPLATIN CISPLATIN 1MG/ML VIAL<br />
PLATINOL-AQ CISPLATIN 1MG/ML VIAL<br />
K-LYTE/CL CIT AC/POT BICARB/POT CHLORIDE 25MEQ TABLET EFF<br />
POTASSIUM CHLORIDE CIT AC/POT BICARB/POT CHLORIDE 25MEQ TABLET EFF<br />
EFFER-K CIT AC/POTASSIUM BICARBONATE 25MEQ TABLET EFF<br />
K EFFERVESCENT CIT AC/POTASSIUM BICARBONATE 25MEQ TABLET EFF<br />
KLOR-CON/EF CIT AC/POTASSIUM BICARBONATE 25MEQ TABLET EFF<br />
K-LYTE CIT AC/POTASSIUM BICARBONATE 25MEQ TABLET EFF<br />
POTASSIUM CIT AC/POTASSIUM BICARBONATE 25MEQ TABLET EFF<br />
POTASSIUM BICARBONATE CIT AC/POTASSIUM BICARBONATE 25MEQ TABLET EFF<br />
CYTRA-K CITRIC ACID/POTASSIUM CITRATE 1002-3300 PACKET<br />
CYTRA-K CITRIC ACID/POTASSIUM CITRATE 334-1100/5 SOLUTION<br />
POTASSIUM CITRATE/CITRIC ACID CITRIC ACID/POTASSIUM CITRATE 334-1100/5 SOLUTION<br />
BICITRA CITRIC ACID/SODIUM CITRATE 334-500MG SOLUTION<br />
CYTRA-2 CITRIC ACID/SODIUM CITRATE 334-500MG SOLUTION<br />
ORACIT CITRIC ACID/SODIUM CITRATE 640-490MG SOLUTION<br />
SODIUM CITRATE & CITRIC ACID CITRIC ACID/SODIUM CITRATE 334-500MG SOLUTION<br />
CLADRIBINE CLADRIBINE 1MG/ML VIAL<br />
CLEMASTINE FUMARATE CLEMASTINE FUMARATE 0.67MG/5ML SYRUP<br />
CLEMASTINE FUMARATE CLEMASTINE FUMARATE 1.34MG TABLET<br />
CLEMASTINE FUMARATE CLEMASTINE FUMARATE 2.68MG TABLET<br />
DAILYHIST-D CLEMASTINE FUMARATE/PPA HCL 75-1.34MG TABLET SA<br />
CLEOCIN HCL CLINDAMYCIN HCL 150MG CAPSULE<br />
CLINDAMYCIN HCL CLINDAMYCIN HCL 150MG CAPSULE<br />
CLINDAMYCIN HCL CLINDAMYCIN HCL 300MG CAPSULE<br />
CLEOCIN PHOSPHATE CLINDAMYCIN PHOSPHATE 150MG/ML VIAL<br />
CLEOCIN T CLINDAMYCIN PHOSPHATE 1% GEL<br />
CLEOCIN T CLINDAMYCIN PHOSPHATE 1% MED. SWAB<br />
CLEOCIN T CLINDAMYCIN PHOSPHATE 1% SOLUTION<br />
CLINDA-DERM CLINDAMYCIN PHOSPHATE 1% SOLUTION<br />
CLINDAGEL CLINDAMYCIN PHOSPHATE 1% GEL<br />
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE 1% GEL<br />
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE 1% LOTION<br />
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE 1% MED. SWAB<br />
Page 22<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE 1% SOLUTION<br />
CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE 150MG/ML VIAL<br />
CLINDETS CLINDAMYCIN PHOSPHATE 1% MED. SWAB<br />
CLINDAMYCIN INJ IN D5W CLINDAMYCIN PHOSPHATE/D5W 300MG/50ML PIGGYBACK<br />
CLINDAMYCIN INJ IN D5W CLINDAMYCIN PHOSPHATE/D5W 600MG/50ML PIGGYBACK<br />
CLINDAMYCIN INJ IN D5W CLINDAMYCIN PHOSPHATE/D5W 900MG/50ML PIGGYBACK<br />
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.05% CREAM(GM)<br />
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.05% GEL<br />
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.05% OINT.(GM)<br />
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE 0.05% SOLUTION<br />
CLOBEVATE CLOBETASOL PROPIONATE 0.05% GEL<br />
CORMAX CLOBETASOL PROPIONATE 0.05% CREAM(GM)<br />
CORMAX CLOBETASOL PROPIONATE 0.05% OINT.(GM)<br />
CORMAX CLOBETASOL PROPIONATE 0.05% SOLUTION<br />
EMBELINE CLOBETASOL PROPIONATE 0.05% GEL<br />
EMBELINE CLOBETASOL PROPIONATE 0.05% OINT.(GM)<br />
EMBELINE CLOBETASOL PROPIONATE 0.05% SOLUTION<br />
TEMOVATE CLOBETASOL PROPIONATE 0.05% CREAM(GM)<br />
TEMOVATE CLOBETASOL PROPIONATE 0.05% GEL<br />
TEMOVATE CLOBETASOL PROPIONATE 0.05% OINT.(GM)<br />
TEMOVATE CLOBETASOL PROPIONATE 0.05% SOLUTION<br />
CLOBETASOL E CLOBETASOL PROPIONATE/EMOLL 0.05% CREAM(GM)<br />
CLOBETASOL PROPIONATE CLOBETASOL PROPIONATE/EMOLL 0.05% CREAM(GM)<br />
EMBELINE CLOBETASOL PROPIONATE/EMOLL 0.05% CREAM(GM)<br />
EMBELINE E CLOBETASOL PROPIONATE/EMOLL 0.05% CREAM(GM)<br />
TEMOVATE EMOLLIENT CLOBETASOL PROPIONATE/EMOLL 0.05% CREAM(GM)<br />
ANAFRANIL CLOMIPRAMINE HCL 25MG CAPSULE<br />
ANAFRANIL CLOMIPRAMINE HCL 50MG CAPSULE<br />
ANAFRANIL CLOMIPRAMINE HCL 75MG CAPSULE<br />
CLOMIPRAMINE HCL CLOMIPRAMINE HCL 25MG CAPSULE<br />
CLOMIPRAMINE HCL CLOMIPRAMINE HCL 50MG CAPSULE<br />
CLOMIPRAMINE HCL CLOMIPRAMINE HCL 75MG CAPSULE<br />
CEBERCLON CLONAZEPAM 0.5MG TABLET<br />
CEBERCLON CLONAZEPAM 1MG TABLET<br />
CLONAZEPAM CLONAZEPAM 0.5MG TABLET<br />
CLONAZEPAM CLONAZEPAM 1MG TABLET<br />
CLONAZEPAM CLONAZEPAM 2MG TABLET<br />
KLONOPIN CLONAZEPAM 0.5MG TABLET<br />
KLONOPIN CLONAZEPAM 1MG TABLET<br />
KLONOPIN CLONAZEPAM 2MG TABLET<br />
CATAPRES CLONIDINE HCL 0.1MG TABLET<br />
CATAPRES CLONIDINE HCL 0.2MG TABLET<br />
CATAPRES CLONIDINE HCL 0.3MG TABLET<br />
CLONIDINE HCL CLONIDINE HCL 0.1MG TABLET<br />
CLONIDINE HCL CLONIDINE HCL 0.2MG TABLET<br />
CLONIDINE HCL CLONIDINE HCL 0.3MG TABLET<br />
CLORAZEPATE DIPOTASSIUM CLORAZEPATE DIPOTASSIUM 15MG TABLET<br />
CLORAZEPATE DIPOTASSIUM CLORAZEPATE DIPOTASSIUM 3.75MG TABLET<br />
CLORAZEPATE DIPOTASSIUM CLORAZEPATE DIPOTASSIUM 7.5MG TABLET<br />
TRANXENE T-TAB CLORAZEPATE DIPOTASSIUM 15MG TABLET<br />
TRANXENE T-TAB CLORAZEPATE DIPOTASSIUM 3.75MG TABLET<br />
TRANXENE T-TAB CLORAZEPATE DIPOTASSIUM 7.5MG TABLET<br />
ANTI-FUNGAL CLOTRIMAZOLE 1% CREAM(GM)<br />
CLOTRIM ANTIFUNGAL CLOTRIMAZOLE 1% CREAM(GM)<br />
CLOTRIM VAGINAL CLOTRIMAZOLE 1% CREAM/APPL<br />
CLOTRIMAZOLE CLOTRIMAZOLE 1% CREAM(GM)<br />
CLOTRIMAZOLE CLOTRIMAZOLE 1% CREAM/APPL<br />
CLOTRIMAZOLE CLOTRIMAZOLE 1% SOLUTION<br />
CLOTRIMAZOLE CLOTRIMAZOLE 100MG TABLET<br />
CLOTRIMAZOLE 3 DAY CLOTRIMAZOLE 1% CREAM/APPL<br />
CLOTRIMAZOLE AF CLOTRIMAZOLE 1% CREAM(GM)<br />
CLOTRIMAZOLE-7 CLOTRIMAZOLE 100MG TABLET<br />
CRUEX CLOTRIMAZOLE 1% CREAM(GM)<br />
DESENEX CLOTRIMAZOLE 1% CREAM(GM)<br />
FEMCARE CLOTRIMAZOLE 1% CREAM/APPL<br />
FEMCARE CLOTRIMAZOLE 100MG TABLET<br />
FUNGOID CLOTRIMAZOLE 1% CREAM(GM)<br />
FUNGOID CLOTRIMAZOLE 1% SOLUTION<br />
GYNE-LOTRIMIN CLOTRIMAZOLE 1% CREAM/APPL<br />
GYNE-LOTRIMIN CLOTRIMAZOLE 1% CRM/PF APP<br />
GYNE-LOTRIMIN CLOTRIMAZOLE 100MG TABLET<br />
HM CLOTRIMAZOLE AF CLOTRIMAZOLE 1% CREAM(GM)<br />
LOTRIMIN CLOTRIMAZOLE 1% CREAM(GM)<br />
LOTRIMIN CLOTRIMAZOLE 1% SOLUTION<br />
LOTRIMIN AF CLOTRIMAZOLE 1% CREAM(GM)<br />
Page 23<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
SB CLOTRIMAZOLE CLOTRIMAZOLE 1% CREAM(GM)<br />
CLOZAPINE CLOZAPINE 100MG TABLET<br />
CLOZAPINE CLOZAPINE 25MG TABLET<br />
CLOZARIL CLOZAPINE 100MG TABLET<br />
CLOZARIL CLOZAPINE 25MG TABLET<br />
CORTANE-B CL-XYLENOL/HC/PRAMOX HCL/WATER 10-10-1/ML DROPS<br />
ZOTANE HC CL-XYLENOL/HC/PRAMOX HCL/WATER 10-10-1/ML DROPS<br />
IONIL T PLUS COAL TAR 2% SHAMPOO<br />
PC TAR COAL TAR SHAMPOO<br />
TEGRIN PSORIASIS COAL TAR 5% LOTION<br />
TERA-GEL TAR COAL TAR 0.5% SHAMPOO<br />
COCAINE HCL COCAINE HCL 10% SOLUTION<br />
COCAINE HCL COCAINE HCL 4% SOLUTION<br />
ANTITUSSIVE/DECONGESTANT COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
ANTITUSSIVE/DECONGESTANT COD/GUAIFENESIN/P-EPHED HCL 20MG SYRUP<br />
BIOTUSSIN DAC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
CHERATUSSIN DAC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
CODAFED COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
CODAFED COD/GUAIFENESIN/P-EPHED HCL 20MG SYRUP<br />
CO-HISTINE COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
CYCOFED COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
CYCOFED COD/GUAIFENESIN/P-EPHED HCL 20MG SYRUP<br />
DECOHISTINE COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
DEPROIST W/CODEINE COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
DIHISTINE COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
GUA PC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
GUAIFENESIN DAC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
GUAIFENESIN/P-EPHEDRINE/COD COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
GUIATUSS DAC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
GUIATUSS-DAC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
HALOTUSSIN-DAC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
KG-FED COD/GUAIFENESIN/P-EPHED HCL 20MG SYRUP<br />
KG-FED PEDIATRIC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
MYTUSSIN DAC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
NOVAGEST COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
NOVAHISTINE COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
NUCODINE EXP COD/GUAIFENESIN/P-EPHED HCL 20MG SYRUP<br />
NUCODINE PED COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
NUCOFED COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
NUCOFED COD/GUAIFENESIN/P-EPHED HCL 20MG SYRUP<br />
NUCOTUSS COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
NUCOTUSS COD/GUAIFENESIN/P-EPHED HCL 20MG SYRUP<br />
PHENYLHISTINE COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
ROBAFEN-DAC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
ROBITUSSIN-DAC COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
RYNA-CX COD/GUAIFENESIN/P-EPHED HCL 10MG SYRUP<br />
PROMETHAZINE VC W/CODEINE COD/PHENYLEPHRINE HCL/PROMETH 5-10-6.25 SYRUP<br />
CODEINE PHOSPHATE CODEINE PHOS 30MG/ML DISP SYRIN<br />
BRONTEX CODEINE PHOS/GUAIFENESIN 300-10MG TABLET<br />
CHERACOL CODEINE PHOS/GUAIFENESIN 100-10MG/5 SYRUP<br />
CHERATUSSIN AC CODEINE PHOS/GUAIFENESIN 100-10MG/5 SYRUP<br />
GUAIFENESIN W/CODEINE CODEINE PHOS/GUAIFENESIN 100-10MG/5 SYRUP<br />
GUAIFENESIN/CODEINE PHOSPHATE CODEINE PHOS/GUAIFENESIN 300-10MG TABLET<br />
GUIATUSS AC CODEINE PHOS/GUAIFENESIN 100-10MG/5 SYRUP<br />
GUIATUSSIN AC CODEINE PHOS/GUAIFENESIN 100-10MG/5 SYRUP<br />
MYTUSSIN AC CODEINE PHOS/GUAIFENESIN 100-10MG/5 SYRUP<br />
BIOTUSSIN AC CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
BITEX CODEINE PHOSPHATE/GUAIFENESIN 150-5/10ML LIQUID<br />
BRONTEX CODEINE PHOSPHATE/GUAIFENESIN 150-5/10ML LIQUID<br />
BRON-TUSS CODEINE PHOSPHATE/GUAIFENESIN 150-5/10ML LIQUID<br />
DIABETIC TUSSIN C CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
DURAGANIDIN NR CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
GANI-TUSS NR CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
GLYDEINE CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
GUA C CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
GUAIFEN-C CODEINE PHOSPHATE/GUAIFENESIN 150-5/10ML LIQUID<br />
GUAIFENESIN AC CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
GUAIFENESIN W/CODEINE CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
GUAIFENESIN/CODEINE PHOSPHATE CODEINE PHOSPHATE/GUAIFENESIN 300-10MG TABLET<br />
GUAL-CO CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
HALOTUSSIN-AC CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
IOPHEN CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
IOPHEN C-NR CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
IOPHEN-C NR CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
ORGADIN-TUSS CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
Page 24<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
ROBAFEN AC CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
ROMILAR AC CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
TUSSI-ORGANIDIN NR CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
TUSSI-ORGANIDIN-S NR CODEINE PHOSPHATE/GUAIFENESIN SYRUP<br />
CODEINE SULFATE CODEINE SULF 30MG TABLET<br />
CODEINE SULFATE CODEINE SULF 60MG TABLET<br />
CODEINE SULFATE CODEINE SULFATE 30MG TABLET<br />
CODEINE SULFATE CODEINE SULFATE 60MG TABLET<br />
TRIACIN C CODEINE/P-EPHED HCL/TRIPROL 30-10-1.25 SYRUP<br />
PHENERGAN W/CODEINE CODEINE/PROMETHAZINE HCL 10-6.25/5 SYRUP<br />
PROMETHAZINE W/CODEINE CODEINE/PROMETHAZINE HCL 10-6.25/5 SYRUP<br />
PROMETHAZINE-CODEINE CODEINE/PROMETHAZINE HCL 10-6.25/5 SYRUP<br />
KG-FED CODEINE/PSEUDOEPHEDRINE HCL 60-20 SYRUP<br />
NUCOFED CODEINE/PSEUDOEPHEDRINE HCL 60-20 SYRUP<br />
COLCHICINE COLCHICINE 0.6MG TABLET<br />
COL-PROBENECID COLCHICINE/PROBENECID 0.5-500MG TABLET<br />
PROBENECID W/COLCHICINE COLCHICINE/PROBENECID 0.5-500MG TABLET<br />
COLISTIMETHATE SODIUM COLISTIMETHATE SODIUM 150MG VIAL<br />
CORTISONE ACETATE CORTISONE ACETATE 25MG TABLET<br />
C-PHED DM TANNATE CP/D-METHORP TAN/P-EPD TAN 25-75-4.5 ORAL SUSP<br />
TANAFED DM CP/D-METHORP TAN/P-EPD TAN 25-75-4.5 ORAL SUSP<br />
T-TANNA DM CP/D-METHORP TAN/P-EPD TAN 25-75-4.5 ORAL SUSP<br />
KIDCARE CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
PEDIA RELIEF COLD & COUGH CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
PEDIA RELIEF COUGH & COLD CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
PEDIA RELIEF COUGH-COLD CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
PEDIACOLD CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
PEDIATRIC COUGH/COLD CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
PEDIATRIC COUGH/COLD FORMULA CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
TRIACTING COLD & COUGH CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
TRIACTING M-SYM COLD/COUGH CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
TRIAMINIC COLD & COUGH CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
TRIAMINIC COLD/COUGH CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
V-R PEDIA RELIEF COUGH/COLD CP/D-METHORPHAN HB/P-EPHED HCL 5-15-1MG/5 LIQUID<br />
MEDTUSSIN CP/HYDROCOD BIT/P-EPHED HCL SYRUP<br />
ED TUSS HC CP/HYDROCOD BIT/PHENYLEPH HCL 10-2.5-4 SYRUP<br />
TUSS-DS CP/HYDROCOD BIT/PHENYLEPH HCL 5-5-2 SYRUP<br />
COLDCOUGH HC CP/HYDROCODONE/P-EPHED HCL 15-3-2/5 LIQUID<br />
HISTINEX PV CP/HYDROCODONE/P-EPHED HCL 30-2.5-2/5 SYRUP<br />
HYCOFED CP/HYDROCODONE/P-EPHED HCL 30-2.5-2/5 LIQUID<br />
HYDRON PSC CP/HYDROCODONE/P-EPHED HCL 30-5-2MG/5 LIQUID<br />
HYDRO-TUSSIN HC CP/HYDROCODONE/P-EPHED HCL 15-3-2/5 LIQUID<br />
HYPHED CP/HYDROCODONE/P-EPHED HCL 30-2.5-2/5 SYRUP<br />
JAYCOF-HC CP/HYDROCODONE/P-EPHED HCL 15-3-2/5 LIQUID<br />
KG-TUSSIN CP/HYDROCODONE/P-EPHED HCL 30-2.5-2/5 SYRUP<br />
PANCOF HC CP/HYDROCODONE/P-EPHED HCL 15-3-2/5 LIQUID<br />
P-EPHED HCL/HYDROCOD BIT/CP CP/HYDROCODONE/P-EPHED HCL 15-3-2/5 LIQUID<br />
Q-V TUSSIN CP/HYDROCODONE/P-EPHED HCL 30-2.5-2/5 SYRUP<br />
TUSSEND CP/HYDROCODONE/P-EPHED HCL 30-2.5-2/5 SYRUP<br />
ATUSS HD CP/HYDROCODONE/PHENYLEPHRINE 10-2.5-4 SYRUP<br />
ATUSS MS CP/HYDROCODONE/PHENYLEPHRINE 10-5-2MG/5 SYRUP<br />
BALTUSSIN HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
B-TUSS CP/HYDROCODONE/PHENYLEPHRINE 5-5-2MG/5 LIQUID<br />
CHLORPHEN HD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
CYTUSS HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
DURADAL HD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
DURADAL HD PLUS CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
ED-TLC CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
EFASIN HD PLUS CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
EFASIN-HD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
ENDAGEN-HD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
ENPLUS-HD CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
H-C TUSSIVE CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
HIST-HC CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
HISTINEX HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
HIST-PLUS CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
HISTUSSIN HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
HYDROCODONE CP CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
HYDROCODONE HD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
HYDROCODONE/PHENYLEPHRINE/CPM CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
HYPHEN-HD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
IODAL HD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
IOTUSSIN HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
KG-DAL HD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
KG-DAL HD PLUS CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
Page 25<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
MAXI-TUSS HC CP/HYDROCODONE/PHENYLEPHRINE 10-2.5-4 SYRUP<br />
MAXITUSS HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
MED-HIST-HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
TUSS-HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
TUSSIVE HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
TUSS-PD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
UNI TUSS HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP<br />
VANEX HD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP<br />
C-HIST-SR CP/PHENYLEPHRINE/PHENYLTOLOX 20-50-4MG CAP.SR 12H<br />
CHLORTOX LA CP/PHENYLEPHRINE/PHENYLTOLOX 20-50-4MG CAP.SR 12H<br />
ALLERX CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP<br />
PHENATAN-S CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP<br />
RHINATATE CP/PHENYLEPHRINE/PYRIL TAN 25-25-8MG TABLET<br />
RHINATATE CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP<br />
R-TANNAMINE CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP<br />
TANAMINE CP/PHENYLEPHRINE/PYRIL TAN 25-25-8MG TABLET<br />
TRI TANN CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP<br />
TRIOTANN CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP<br />
TRIOTANN-S CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP<br />
TRIPLE TANNATE CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP<br />
TRIPLE TANNATE PEDIATRIC CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP<br />
TRIPLE TANNATE-S CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP<br />
BLANEX-A CP/P-TLOX CI/PHENYLEPHRINE 20-40-4MG TABLET<br />
CHLOREX-A CP/P-TLOX CI/PHENYLEPHRINE 20-40-4MG TABLET<br />
COLDEX-A SR CP/P-TLOX CI/PHENYLEPHRINE 20-40-4MG TABLET<br />
NALEX-A CP/P-TLOX CI/PHENYLEPHRINE 20-40-4MG TABLET<br />
CROLOM CROMOLYN SODIUM 4% DROPS<br />
CROMOLYN SODIUM CROMOLYN SODIUM 20MG/2ML AMPUL-NEB.<br />
CROMOLYN SODIUM CROMOLYN SODIUM 4% DROPS<br />
CROMOLYN SODIUM CROMOLYN SODIUM 40MG/ML SPRAY/PUMP<br />
INTAL CROMOLYN SODIUM 20MG/2ML AMPUL-NEB.<br />
NASAL ALLERGY CONTROL CROMOLYN SODIUM 40MG/ML SPRAY/PUMP<br />
NASAL ALLERGY SYMPTOM CONTROL CROMOLYN SODIUM 40MG/ML SPRAY/PUMP<br />
NASALCROM CROMOLYN SODIUM 40MG/ML SPRAY/PUMP<br />
OPTICROM CROMOLYN SODIUM 4% DROPS<br />
COPPER CHLORIDE CUPRIC CHLORIDE 0.4MG/ML VIAL<br />
CPC-B12 CYANOCOBALAMIN 1000MCG/ML VIAL<br />
CYANOCOBALAMIN CYANOCOBALAMIN 1000MCG/ML VIAL<br />
CYANOJECT-10 CYANOCOBALAMIN 1000MCG/ML VIAL<br />
PAN B-12 VIAL CYANOCOBALAMIN 1000MCG/ML VIAL<br />
RUBESOL-1000 CYANOCOBALAMIN 1000MCG/ML VIAL<br />
VITAMIN B-12 CYANOCOBALAMIN 1000MCG/ML VIAL<br />
VITAMIN B-12 (CYANOCOBALAMIN) CYANOCOBALAMIN 1000MCG/ML VIAL<br />
CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL 10MG TABLET<br />
FLEXERIL CYCLOBENZAPRINE HCL 10MG TABLET<br />
AK-PENTOLATE CYCLOPENTOLATE HCL 1% DROPS<br />
AK-PENTOLATE CYCLOPENTOLATE HCL 2% DROPS<br />
CYCLOGYL CYCLOPENTOLATE HCL 1% DROPS<br />
CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL 1% DROPS<br />
CYLATE CYCLOPENTOLATE HCL 1% DROPS<br />
CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE 25MG TABLET<br />
CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE 50MG TABLET<br />
NEOSAR CYCLOPHOSPHAMIDE 100MG VIAL<br />
NEOSAR CYCLOPHOSPHAMIDE 200MG VIAL<br />
NEOSAR CYCLOPHOSPHAMIDE 2G VIAL<br />
NEOSAR CYCLOPHOSPHAMIDE 500MG VIAL<br />
NEOSAR FOR INJECTION CYCLOPHOSPHAMIDE 1G VIAL<br />
CYCLOSPORINE CYCLOSPORINE 100MG CAPSULE<br />
CYCLOSPORINE CYCLOSPORINE 25MG CAPSULE<br />
CYCLOSPORINE CYCLOSPORINE, MODIFIED 100MG CAPSULE<br />
CYCLOSPORINE CYCLOSPORINE, MODIFIED 100MG/ML SOLUTION<br />
CYCLOSPORINE CYCLOSPORINE, MODIFIED 25MG CAPSULE<br />
GENGRAF CYCLOSPORINE, MODIFIED 100MG CAPSULE<br />
GENGRAF CYCLOSPORINE, MODIFIED 100MG/ML SOLUTION<br />
GENGRAF CYCLOSPORINE, MODIFIED 25MG CAPSULE<br />
NEORAL CYCLOSPORINE, MODIFIED 100MG CAPSULE<br />
NEORAL CYCLOSPORINE, MODIFIED 25MG CAPSULE<br />
CYPROHEPTADINE HCL CYPROHEPTADINE HCL 2MG/5ML SYRUP<br />
CYPROHEPTADINE HCL CYPROHEPTADINE HCL 4MG TABLET<br />
PERIACTIN CYPROHEPTADINE HCL 4MG TABLET<br />
CYSTEINE HYDROCHLORIDE CYSTEINE HCL 50MG/ML VIAL<br />
L-CYSTEINE CYSTEINE HCL 50MG/ML VIAL<br />
CYTARABINE CYTARABINE 100MG VIAL<br />
CYTARABINE CYTARABINE 1G VIAL<br />
CYTARABINE CYTARABINE 20MG/ML VIAL<br />
Page 26<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
CYTARABINE CYTARABINE 2G VIAL<br />
CYTARABINE CYTARABINE 500MG VIAL<br />
DEXTROSE 5%-1/4NS-KCL D5-0.25NACL/POTASSIUM CHLORIDE 10MEQ/L IV SOLN.<br />
DEXTROSE 5%-1/4NS-KCL D5-0.25NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
DEXTROSE 5%-1/4NS-KCL D5-0.25NACL/POTASSIUM CHLORIDE 30MEQ/L IV SOLN.<br />
DEXTROSE 5%-1/4NS-KCL D5-0.25NACL/POTASSIUM CHLORIDE 40MEQ/L IV SOLN.<br />
POTASSIUM CL IN D5W AND NACL D5-0.25NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
DEXTROSE 5%-1/3NS-KCL D5-0.33NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
DEXTROSE 5%-1/3NS-KCL D5-0.33NACL/POTASSIUM CHLORIDE 30MEQ/L IV SOLN.<br />
KCL IN DEXTROSE AND NACL D5-0.33NACL/POTASSIUM CHLORIDE 40MEQ/L IV SOLN.<br />
POTASSIUM CL IN D5W AND NACL D5-0.33NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
DEXTROSE 5%-1/2NS-KCL D5-0.45NACL/POTASSIUM CHLORIDE 10MEQ/L IV SOLN.<br />
DEXTROSE 5%-1/2NS-KCL D5-0.45NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
DEXTROSE 5%-1/2NS-KCL D5-0.45NACL/POTASSIUM CHLORIDE 30MEQ/L IV SOLN.<br />
DEXTROSE 5%-1/2NS-KCL D5-0.45NACL/POTASSIUM CHLORIDE 40MEQ/L IV SOLN.<br />
POTASSIUM CL IN D5W AND NACL D5-0.45NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
KCL IN DEXTROSE & LACT RINGERS D5LR/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
KCL IN DEXTROSE & LACT RINGERS D5LR/POTASSIUM CHLORIDE 40MEQ/L IV SOLN.<br />
DEXTROSE 5%-NS-KCL D5NS/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
POTASSIUM CHLORIDE IN D5W/NACL D5NS/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
POTASSIUM CHLORIDE IN D5W/NACL D5NS/POTASSIUM CHLORIDE 40MEQ/L IV SOLN.<br />
PLASMA-LYTE M IN DEXTROSE D5W/ELECTROLYTE-M SOLUTION 5% IV SOLN.<br />
ISOLYTE R W/DEXTROSE D5W/ELECTROLYTE-R SOLUTION 5% IV SOLN.<br />
PLASMA-LYTE R IN DEXTROSE D5W/ELECTROLYTE-R SOLUTION 5% IV SOLN.<br />
HEPARIN SODIUM IN 5% DEXTROSE D5W/HEPARIN SODIUM,PORCINE 100 U/ML IV SOLN.<br />
HEPARIN SODIUM IN 5% DEXTROSE D5W/HEPARIN SODIUM,PORCINE 40 UNIT/ML IV SOLN.<br />
HEPARIN SODIUM IN 5% DEXTROSE D5W/HEPARIN SODIUM,PORCINE 50 UNIT/ML IV SOLN.<br />
LIDOCAINE HCL IN 5% DEXTROSE D5W/LIDOCAINE HCL 2MG/ML IV SOLN.<br />
LIDOCAINE HCL IN 5% DEXTROSE D5W/LIDOCAINE HCL 4MG/ML IV SOLN.<br />
LIDOCAINE HCL IN 5% DEXTROSE D5W/LIDOCAINE HCL 8MG/ML IV SOLN.<br />
MILRINONE IN 5% DEXTROSE D5W/MILRINONE LACTATE 0.2MG/ML PIGGYBACK<br />
NITROGLYCERIN IN D5W D5W/NITROGLYCERIN 0.1MG/ML INFUS. BTL<br />
NITROGLYCERIN IN D5W D5W/NITROGLYCERIN 0.2MG/ML INFUS. BTL<br />
NITROGLYCERIN IN D5W D5W/NITROGLYCERIN 0.4MG/ML INFUS. BTL<br />
DEXTROSE 5% W/POTASSIUM CL D5W/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
DEXTROSE 5% W/POTASSIUM CL D5W/POTASSIUM CHLORIDE 40MEQ/L IV SOLN.<br />
DEXTROSE 5%-POTASSIUM CHLORIDE D5W/POTASSIUM CHLORIDE 30MEQ/L IV SOLN.<br />
DEXTROSE 5%-POTASSIUM CHLORIDE D5W/POTASSIUM CHLORIDE 40MEQ/L IV SOLN.<br />
DACARBAZINE DACARBAZINE 200MG VIAL<br />
DTIC-DOME IV DACARBAZINE 200MG VIAL<br />
DEXEDRINE D-AMPHETAMINE SULFATE 5MG TABLET<br />
DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 10MG CAPSULE SA<br />
DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 10MG TABLET<br />
DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 15MG CAPSULE SA<br />
DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 5MG CAPSULE SA<br />
DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 5MG TABLET<br />
DEXTROSTAT D-AMPHETAMINE SULFATE 10MG TABLET<br />
DEXTROSTAT D-AMPHETAMINE SULFATE 5MG TABLET<br />
DANAZOL DANAZOL 100MG CAPSULE<br />
DANAZOL DANAZOL 200MG CAPSULE<br />
DANAZOL DANAZOL 50MG CAPSULE<br />
DANOCRINE DANAZOL 200MG CAPSULE<br />
DAUNORUBICIN HCL DAUNORUBICIN HCL 20MG VIAL<br />
DEXAPHEN D-BROMP MAL/P-EPHED SUL 120-6MG TAB.SR 12H<br />
DREXOPHED D-BROMP MAL/P-EPHED SUL 120-6MG TAB.SR 12H<br />
DRIXOMED D-BROMP MAL/P-EPHED SUL 120-6MG TAB.SR 12H<br />
DESIPRAMINE HCL DESIPRAMINE HCL 100MG TABLET<br />
DESIPRAMINE HCL DESIPRAMINE HCL 10MG TABLET<br />
DESIPRAMINE HCL DESIPRAMINE HCL 150MG TABLET<br />
DESIPRAMINE HCL DESIPRAMINE HCL 25MG TABLET<br />
DESIPRAMINE HCL DESIPRAMINE HCL 50MG TABLET<br />
DESIPRAMINE HCL DESIPRAMINE HCL 75MG TABLET<br />
NORPRAMIN DESIPRAMINE HCL 100MG TABLET<br />
NORPRAMIN DESIPRAMINE HCL 10MG TABLET<br />
NORPRAMIN DESIPRAMINE HCL 150MG TABLET<br />
NORPRAMIN DESIPRAMINE HCL 25MG TABLET<br />
NORPRAMIN DESIPRAMINE HCL 50MG TABLET<br />
NORPRAMIN DESIPRAMINE HCL 75MG TABLET<br />
DDAVP DESMOPRESSIN ACETATE 0.1MG/ML SOLUTION<br />
DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 0.1MG/ML SOLUTION<br />
DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 0.1MG/ML SPRAY/PUMP<br />
DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 4MCG/ML AMPUL<br />
DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 4MCG/ML VIAL<br />
APRI DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.03 TABLET<br />
KARIVA DESOG-ET ESTRA/ETHIN ESTRA 21-5 TABLET<br />
Page 27<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
DELONIDE DESONIDE 0.05% CREAM(GM)<br />
DESONIDE DESONIDE 0.05% CREAM(GM)<br />
DESONIDE DESONIDE 0.05% LOTION<br />
DESONIDE DESONIDE 0.05% OINT.(GM)<br />
DESOWEN DESONIDE 0.05% CREAM(GM)<br />
DESOWEN DESONIDE 0.05% OINT.(GM)<br />
TRIDESILON DESONIDE 0.05% CREAM(GM)<br />
TRIDESILON DESONIDE 0.05% OINT.(GM)<br />
DESOXIMETASONE DESOXIMETASONE 0.05% CREAM(GM)<br />
DESOXIMETASONE DESOXIMETASONE 0.05% GEL<br />
DESOXIMETASONE DESOXIMETASONE 0.25% CREAM(GM)<br />
DESOXIMETASONE DESOXIMETASONE 0.25% OINT.(GM)<br />
TOPICORT DESOXIMETASONE 0.25% CREAM(GM)<br />
DEXTROSE IN LACTATED RINGERS DEX 2.5%-HALF STR LACT.RINGERS 2.5%-1/2 IV SOLN.<br />
NEO-DEXAIR DEX NA PH/NEOMYCIN SULFATE 0.35-0.1% DROPS<br />
NEOMYCIN W/DEXAMETHASONE DEX NA PH/NEOMYCIN SULFATE 0.35-0.1% DROPS<br />
AK-TROL DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP<br />
DEXACIDIN DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP<br />
DEXACINE DEXAMETH/NEO/POLYMYX B SULF 0.1% OINT.(GM)<br />
DEXASPORIN DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP<br />
MAXITROL DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP<br />
MAXITROL DEXAMETH/NEO/POLYMYX B SULF 0.1% OINT.(GM)<br />
METHADEX DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP<br />
NEO/POLYMYXIN/DEXAMETHASONE DEXAMETH/NEO/POLYMYX B SULF OINT.(GM)<br />
NEO/POLYMYXIN/DEXAMETHASONE DEXAMETH/NEO/POLYMYX B SULF 0.1% OINT.(GM)<br />
NEOMYCIN/POLYMYXIN/DEXAMETH DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP<br />
POLY-DEX DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP<br />
POLY-DEX DEXAMETH/NEO/POLYMYX B SULF 0.1% OINT.(GM)<br />
DECADRON DEXAMETHASONE 0.5MG TABLET<br />
DECADRON DEXAMETHASONE 0.75MG TAB DS PK<br />
DECADRON DEXAMETHASONE 0.75MG TABLET<br />
DECADRON DEXAMETHASONE 4MG TABLET<br />
DEXAMETHASONE DEXAMETHASONE 0.5MG TABLET<br />
DEXAMETHASONE DEXAMETHASONE 0.5MG/5ML ELIXIR<br />
DEXAMETHASONE DEXAMETHASONE 0.75MG TAB DS PK<br />
DEXAMETHASONE DEXAMETHASONE 0.75MG TABLET<br />
DEXAMETHASONE DEXAMETHASONE 1.5MG TABLET<br />
DEXAMETHASONE DEXAMETHASONE 4MG TABLET<br />
DEXAMETHASONE DEXAMETHASONE 6MG TABLET<br />
DEXPAK DEXAMETHASONE 1.5MG TAB DS PK<br />
DECAJECT-LA DEXAMETHASONE ACETATE 8MG/ML VIAL<br />
DE-SONE LA DEXAMETHASONE ACETATE 8MG/ML VIAL<br />
DEXACEN LA-8 DEXAMETHASONE ACETATE 8MG/ML VIAL<br />
DEXAMETHASONE ACETATE DEXAMETHASONE ACETATE 8MG/ML VIAL<br />
SOLUREX LA DEXAMETHASONE ACETATE 8MG/ML VIAL<br />
CPC-CORT-D DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL<br />
DECADRON DEXAMETHASONE SOD PHOSPHATE 0.05% OINT.(GM)<br />
DECADRON DEXAMETHASONE SOD PHOSPHATE 0.1% DROPS<br />
DECADRON PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL<br />
DECAJECT-10 DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL<br />
DEXAMETHASONE SODIUM PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 0.05% OINT.(GM)<br />
DEXAMETHASONE SODIUM PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 0.1% DROPS<br />
DEXAMETHASONE SODIUM PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 10MG/ML VIAL<br />
DEXAMETHASONE SODIUM PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL<br />
DEXASOL DEXAMETHASONE SOD PHOSPHATE 0.1% DROPS<br />
DEXONE DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL<br />
SOLUREX DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL<br />
DEXCHLOR DEXCHLORPHENIRAMINE MALEATE 4MG TABLET SA<br />
DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE 2MG/5ML SYRUP<br />
DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE 4MG TABLET SA<br />
DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE 6MG TABLET SA<br />
POLARAMINE DEXCHLORPHENIRAMINE MALEATE 2MG/5ML SYRUP<br />
POLARAMINE DEXCHLORPHENIRAMINE MALEATE 4MG TABLET SA<br />
POLARAMINE REPETAB DEXCHLORPHENIRAMINE MALEATE 6MG TABLET SA<br />
DEXPANTHENOL DEXPANTHENOL 250MG/ML VIAL<br />
DEXTRAN 40 IN DEXTROSE 5% DEXTRAN 40/DEXTROSE 5%-WATER 10% IV SOLN.<br />
GENTRAN 40 IN DEXTROSE 5% DEXTRAN 40/DEXTROSE 5%-WATER 10% IV SOLN.<br />
LMD 10% W/5% DEXTROSE DEXTRAN 40/DEXTROSE 5%-WATER 10% IV SOLN.<br />
DEXTRAN 40 IN NORMAL SALINE DEXTRAN 40/NACL 0.9% 10-0.9% IV SOLN.<br />
GENTRAN 40 IN NORMAL SALINE DEXTRAN 40/NACL 0.9% 10-0.9% IV SOLN.<br />
LMD 10% W/0.9% SODIUM CHLORIDE DEXTRAN 40/NACL 0.9% 10-0.9% IV SOLN.<br />
DEXTRAN 75 IN NORMAL SALINE DEXTRAN 75/NACL 0.9% 6-0.9% IV SOLN.<br />
GENTRAN 75 IN NORMAL SALINE DEXTRAN 75/NACL 0.9% 6-0.9% IV SOLN.<br />
BENYLIN DEXTROMETHORPHAN HBR 15MG/5ML SYRUP<br />
BENYLIN DEXTROMETHORPHAN HBR 7.5MG/5ML SYRUP<br />
Page 28<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
DIABE-TUSS DM DEXTROMETHORPHAN HBR 15MG/5ML SYRUP<br />
HOLD DEXTROMETHORPHAN HBR 5MG LOZENGE<br />
HONEY TUSSIN COUGH DEXTROMETHORPHAN HBR 10MG/5ML SYRUP<br />
PERTUSSIN ES DEXTROMETHORPHAN HBR 15MG/5ML SYRUP<br />
ROBAFEN DEXTROMETHORPHAN HBR 10MG/5ML SYRUP<br />
ROBAFEN PEDIATRIC DEXTROMETHORPHAN HBR 7.5MG/5ML SYRUP<br />
ROBITUSSIN DEXTROMETHORPHAN HBR 15MG/5ML SYRUP<br />
ROBITUSSIN PEDIATRIC DEXTROMETHORPHAN HBR 7.5MG/5ML SYRUP<br />
SILPHEN DM DEXTROMETHORPHAN HBR 10MG/5ML SYRUP<br />
TUSSIN MAXIMUM STRENGTH DEXTROMETHORPHAN HBR 15MG/5ML SYRUP<br />
TUSSIN PEDIATRIC DEXTROMETHORPHAN HBR 7.5MG/5ML SYRUP<br />
DEXTROSE 10%-1/4NS DEXTROSE 10%-0.25% SALINE 10-0.2% IV SOLN.<br />
DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 10%-NORMAL SALINE 10%-0.9% IV SOLN.<br />
DEXTROSE IN WATER DEXTROSE 10%-WATER 10% AMPUL<br />
DEXTROSE IN WATER DEXTROSE 10%-WATER 10% IV SOLN.<br />
DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 2.5%-0.45% SALINE 2.5%-0.45% IV SOLN.<br />
DEXTROSE IN WATER DEXTROSE 20%-WATER 20% IV SOLN.<br />
DEXTROSE IN WATER DEXTROSE 25%-WATER 25% DISP SYRIN<br />
DEXTROSE IN WATER DEXTROSE 30%-WATER 30% IV SOLN.<br />
DEXTROSE IN WATER DEXTROSE 40%-WATER 40% IV SOLN.<br />
DEXTROSE IN RINGERS INJECTION DEXTROSE 5% IN RINGERS 5% IV SOLN.<br />
DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 5%-0.25% SALINE 5-0.25% IV SOLN.<br />
DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 5%-0.33% SALINE 5%-0.33% IV SOLN.<br />
DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 5%-0.45% SALINE 5%-0.45% IV SOLN.<br />
DEXTROSE IN LACTATED RINGERS DEXTROSE 5%-LACTATED RINGERS 5% IV SOLN.<br />
DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 5%-NORMAL SALINE 5%-0.9% IV SOLN.<br />
DEXTROSE IN WATER DEXTROSE 5%-WATER 5% IV SOLN.<br />
DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 0.8MG/ML INFUS. BTL<br />
DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 0.8MG/ML PLAST. BAG<br />
DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 1.6MG/ML INFUS. BTL<br />
DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 1.6MG/ML PLAST. BAG<br />
DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 3.2MG/ML INFUS. BTL<br />
DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 3.2MG/ML PLAST. BAG<br />
DOPAMINE HCL IN D5W DEXTROSE 5%-WATER/DOPAMINE HCL 0.8MG/ML INFUS. BTL<br />
DOPAMINE IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 0.8MG/ML INFUS. BTL<br />
DOPAMINE IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 1.6MG/ML INFUS. BTL<br />
DOPAMINE IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 3.2MG/ML INFUS. BTL<br />
THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 200MG/0.1L IV SOLN.<br />
THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 200MG/50ML IV SOLN.<br />
THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 400MG/.25L IV SOLN.<br />
THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 400MG/0.1L IV SOLN.<br />
THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 400MG/0.5L IV SOLN.<br />
THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 800MG/.25L IV SOLN.<br />
THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 800MG/0.5L IV SOLN.<br />
THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 800MG/L IV SOLN.<br />
DEXTROSE IN WATER DEXTROSE 50%-WATER 50% DISP SYRIN<br />
DEXTROSE IN WATER DEXTROSE 50%-WATER 50% IV SOLN.<br />
DEXTROSE IN WATER DEXTROSE 50%-WATER 50% VIAL<br />
DEXTROSE IN WATER DEXTROSE 70%-WATER 70% IV SOLN.<br />
INPERSOL-LM W/1.5% DEXTROSE DIALYSIS SOLUTIONS 346MOSM/L IP SOLN.<br />
DIAZEPAM DIAZEPAM 10MG TABLET<br />
DIAZEPAM DIAZEPAM 2MG TABLET<br />
DIAZEPAM DIAZEPAM 5MG TABLET<br />
DIAZEPAM DIAZEPAM 5MG/ML AMPUL<br />
DIAZEPAM DIAZEPAM 5MG/ML DISP SYRIN<br />
DIAZEPAM DIAZEPAM 5MG/ML VIAL<br />
DIBUCAINE DIBUCAINE 1% OINT.(GM)<br />
CATAFLAM DICLOFENAC POTASSIUM 50MG TABLET<br />
DICLOFENAC POTASSIUM DICLOFENAC POTASSIUM 50MG TABLET<br />
DICLOFENAC SODIUM DICLOFENAC SODIUM 100MG TAB.SR 24H<br />
DICLOFENAC SODIUM DICLOFENAC SODIUM 25MG TABLET DR<br />
DICLOFENAC SODIUM DICLOFENAC SODIUM 50MG TABLET DR<br />
DICLOFENAC SODIUM DICLOFENAC SODIUM 75MG TABLET DR<br />
VOLTAREN DICLOFENAC SODIUM 25MG TABLET DR<br />
VOLTAREN DICLOFENAC SODIUM 50MG TABLET DR<br />
VOLTAREN DICLOFENAC SODIUM 75MG TABLET DR<br />
VOLTAREN-XR DICLOFENAC SODIUM 100MG TAB.SR 24H<br />
DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 250MG CAPSULE<br />
DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 500MG CAPSULE<br />
ANTISPAS DICYCLOMINE HCL 10MG/ML VIAL<br />
BENTYL DICYCLOMINE HCL 10MG CAPSULE<br />
BENTYL DICYCLOMINE HCL 20MG TABLET<br />
DICYCLOMINE HCL DICYCLOMINE HCL 10MG CAPSULE<br />
DICYCLOMINE HCL DICYCLOMINE HCL 20MG TABLET<br />
DIFLORASONE DIACETATE DIFLORASONE DIACETATE 0.05% CREAM(GM)<br />
Page 29<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
DIFLORASONE DIACETATE DIFLORASONE DIACETATE 0.05% OINT.(GM)<br />
MAXIFLOR DIFLORASONE DIACETATE 0.05% CREAM(GM)<br />
MAXIFLOR DIFLORASONE DIACETATE 0.05% OINT.(GM)<br />
PSORCON DIFLORASONE DIACETATE 0.05% CREAM(GM)<br />
PSORCON DIFLORASONE DIACETATE 0.05% OINT.(GM)<br />
DIFLUNISAL DIFLUNISAL 250MG TABLET<br />
DIFLUNISAL DIFLUNISAL 500MG TABLET<br />
DOLOBID DIFLUNISAL 250MG TABLET<br />
DOLOBID DIFLUNISAL 500MG TABLET<br />
DIGITEK DIGOXIN 125MCG TABLET<br />
DIGITEK DIGOXIN 250MCG TABLET<br />
DIGOXIN DIGOXIN 125MCG TABLET<br />
DIGOXIN DIGOXIN 250MCG TABLET<br />
DIGOXIN DIGOXIN 250MCG/ML AMPUL<br />
DIGOXIN DIGOXIN 250MCG/ML DISP SYRIN<br />
DIGOXIN DIGOXIN 500MCG TABLET<br />
DIGOXIN DIGOXIN 50MCG/ML ELIXIR<br />
LANOXIN DIGOXIN 0.25MG TABLET<br />
LANOXIN DIGOXIN 125MCG TABLET<br />
LANOXIN DIGOXIN 250MCG TABLET<br />
LANOXIN PEDIATRIC DIGOXIN 100MCG/ML AMPUL<br />
CARDIZEM DILTIAZEM HCL 120MG TABLET<br />
CARDIZEM DILTIAZEM HCL 30MG TABLET<br />
CARDIZEM DILTIAZEM HCL 5MG/ML VIAL<br />
CARDIZEM DILTIAZEM HCL 60MG TABLET<br />
CARDIZEM DILTIAZEM HCL 90MG TABLET<br />
CARDIZEM CD DILTIAZEM HCL 120MG CAP.SR 24H<br />
CARDIZEM CD DILTIAZEM HCL 180MG CAP.SR 24H<br />
CARDIZEM CD DILTIAZEM HCL 240MG CAP.SR 24H<br />
CARDIZEM CD DILTIAZEM HCL 300MG CAP.SR 24H<br />
CARTIA XT DILTIAZEM HCL 120MG CAP.SR 24H<br />
CARTIA XT DILTIAZEM HCL 180MG CAP.SR 24H<br />
CARTIA XT DILTIAZEM HCL 240MG CAP.SR 24H<br />
CARTIA XT DILTIAZEM HCL 300MG CAP.SR 24H<br />
DILACOR XR DILTIAZEM HCL 120MG CAPSULE CR<br />
DILACOR XR DILTIAZEM HCL 180MG CAPSULE CR<br />
DILACOR XR DILTIAZEM HCL 240MG CAPSULE CR<br />
DILTIA XT DILTIAZEM HCL 120MG CAPSULE CR<br />
DILTIA XT DILTIAZEM HCL 180MG CAPSULE CR<br />
DILTIA XT DILTIAZEM HCL 240MG CAPSULE CR<br />
DILTIAZEM ER DILTIAZEM HCL 120MG CAPSULE CR<br />
DILTIAZEM ER DILTIAZEM HCL 180MG CAPSULE CR<br />
DILTIAZEM ER DILTIAZEM HCL 240MG CAPSULE CR<br />
DILTIAZEM HCL DILTIAZEM HCL 120MG CAP.SR 12H<br />
DILTIAZEM HCL DILTIAZEM HCL 120MG CAP.SR 24H<br />
DILTIAZEM HCL DILTIAZEM HCL 120MG CAPSULE CR<br />
DILTIAZEM HCL DILTIAZEM HCL 120MG TABLET<br />
DILTIAZEM HCL DILTIAZEM HCL 180MG CAP.SR 24H<br />
DILTIAZEM HCL DILTIAZEM HCL 180MG CAPSULE CR<br />
DILTIAZEM HCL DILTIAZEM HCL 240MG CAP.SR 24H<br />
DILTIAZEM HCL DILTIAZEM HCL 240MG CAPSULE CR<br />
DILTIAZEM HCL DILTIAZEM HCL 300MG CAP.SR 24H<br />
DILTIAZEM HCL DILTIAZEM HCL 30MG TABLET<br />
DILTIAZEM HCL DILTIAZEM HCL 5MG/ML DISP SYRIN<br />
DILTIAZEM HCL DILTIAZEM HCL 5MG/ML VIAL<br />
DILTIAZEM HCL DILTIAZEM HCL 60MG CAP.SR 12H<br />
DILTIAZEM HCL DILTIAZEM HCL 60MG TABLET<br />
DILTIAZEM HCL DILTIAZEM HCL 90MG CAP.SR 12H<br />
DILTIAZEM HCL DILTIAZEM HCL 90MG TABLET<br />
DILTIAZEM XR DILTIAZEM HCL 180MG CAP.SR 24H<br />
DILTIAZEM XR DILTIAZEM HCL 240MG CAP.SR 24H<br />
DILTIAZEM XR DILTIAZEM HCL 240MG CAPSULE CR<br />
DIMENHYDRINATE DIMENHYDRINATE 50MG TABLET<br />
DYMENATE DIMENHYDRINATE 50MG/ML VIAL<br />
NUQUIN HP DIOXYBENZONE/HYDROQUINONE/PDO 3-5-4% CREAM(GM)<br />
ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
ALLERGY DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
ALLERGY ELIXIR DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
ALLERGY MEDICATION DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
ALLERGY MEDICINE DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
ALLERGY MEDICINE DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
ALLERGY MEDICINE COMPLETE DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
ALTARYL DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
ANTIHIST DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
ANTIHISTAMINE DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
Page 30<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
ANTITUSSIVE COUGH SYRUP DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP<br />
BANOPHEN DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
BANOPHEN DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
BANOPHEN ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
BENADRILINA DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
BENADRYL DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
BENADRYL DIPHENHYDRAMINE HCL 50MG/ML VIAL<br />
BENADRYL ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
BENADRYL ALLERGY DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
BENADRYL STERI-DOSE DIPHENHYDRAMINE HCL 50MG/ML DISP SYRIN<br />
BENAHIST-10 DIPHENHYDRAMINE HCL 10MG/ML VIAL<br />
BENAHIST-50 DIPHENHYDRAMINE HCL 50MG/ML VIAL<br />
BYDRAMINE DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP<br />
CHILDREN'S ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
CHILDREN'S ALLERGY MEDICINE DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
CHILDREN'S COLD & ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
COMPLETE ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
COMPLETE ALLERGY DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
COMPLETE ALLERGY MEDICINE DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
DIPHEDRYL DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
DIPHEDRYL DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
DIPHEDRYL ALLERGY DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
DIPHEN DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP<br />
DIPHEN AF DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
DIPHENHIST DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
DIPHENHIST DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP<br />
DIPHENHIST DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
DIPHENHIST DIPHENHYDRAMINE HCL 50MG CAPSULE<br />
DIPHENHYDRAMINE DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
DIPHENHYDRAMINE DIPHENHYDRAMINE HCL 50MG CAPSULE<br />
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP<br />
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50MG CAPSULE<br />
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50MG/ML DISP SYRIN<br />
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50MG/ML VIAL<br />
DIPHENHYDRAMINE MIN-I-JET DIPHENHYDRAMINE HCL 50MG/ML DISP SYRIN<br />
DYTUSS DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP<br />
GENAHIST DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
GENAHIST DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
HM ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
HM DIPHEDRYL DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
HYDRAMINE DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
HYDRAMINE DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
HYDRAMINE DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP<br />
KOMADRYL DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
KOSHER CARE ALLERGY RELIEF DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
MEDIPHEDRYL DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
PROHIST DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
Q-DRYL DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
Q-DRYL DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
QUENALIN DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP<br />
SCOT-TUSSIN DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
SILADRYL DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
SILADRYL DAS DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
SILPHEN DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP<br />
TOTAL ALLERGY MEDICINE DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
TOTAL ALLERGY MEDICINE DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
VALU-DRYL DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR<br />
VALU-DRYL DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID<br />
VALU-DRYL DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
V-R VALU-DRYL DIPHENHYDRAMINE HCL 25MG CAPSULE<br />
DIPIVEFRIN HCL DIPIVEFRIN HCL 0.1% DROPS<br />
PROPINE DIPIVEFRIN HCL 0.1% DROPS<br />
DIPYRIDAMOLE DIPYRIDAMOLE 25MG TABLET<br />
DIPYRIDAMOLE DIPYRIDAMOLE 50MG TABLET<br />
DIPYRIDAMOLE DIPYRIDAMOLE 5MG/ML AMPUL<br />
DIPYRIDAMOLE DIPYRIDAMOLE 5MG/ML VIAL<br />
DIPYRIDAMOLE DIPYRIDAMOLE 75MG TABLET<br />
PERSANTINE DIPYRIDAMOLE 25MG TABLET<br />
PERSANTINE DIPYRIDAMOLE 50MG TABLET<br />
PERSANTINE DIPYRIDAMOLE 75MG TABLET<br />
DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE 100MG CAPSULE<br />
DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE 150MG CAPSULE<br />
Page 31<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE 150MG CAPSULE SA<br />
NORPACE DISOPYRAMIDE PHOSPHATE 100MG CAPSULE<br />
NORPACE DISOPYRAMIDE PHOSPHATE 150MG CAPSULE<br />
BENYLIN DM HB/GUAIFEN/P-EPHEDRINE 100-5-15/5 SYRUP<br />
DECONGESTANT COUGH FORMULA-D DM HB/GUAIFEN/P-EPHEDRINE 67-10 LIQUID<br />
DECONGESTANT D DM HB/GUAIFEN/P-EPHEDRINE 67-10 LIQUID<br />
FORMULA D DM HB/GUAIFEN/P-EPHEDRINE 67-10 LIQUID<br />
GFN 1200/DM 60/PSE 120 DM HB/GUAIFEN/P-EPHEDRINE 60-120MG TAB.SR 12H<br />
GFN600/PSE60/DM30 DM HB/GUAIFEN/P-EPHEDRINE 600-30-60 TAB.SR 12H<br />
GUAI/DM HB/P-EPHED DM HB/GUAIFEN/P-EPHEDRINE 60-120MG TAB.SR 12H<br />
GUAIFEN/DM HB/P-EPHEDRINE DM HB/GUAIFEN/P-EPHEDRINE 600-30-45 TAB.SR 12H<br />
GUAIFENEX-RX DM DM HB/GUAIFEN/P-EPHEDRINE 600-30-60 TAB SR SEQ<br />
MED-RX DM DM HB/GUAIFEN/P-EPHEDRINE 600-30-60 TAB SR SEQ<br />
MINTAB DM HB/GUAIFEN/P-EPHEDRINE 60-120MG TAB.SR 12H<br />
NOVAGEST DEX DM HB/GUAIFEN/P-EPHEDRINE 100-10-30 LIQUID<br />
PROTUSS DM DM HB/GUAIFEN/P-EPHEDRINE 600-30-60 TAB.SR 12H<br />
PSEUDOEPHEDRINE/GUAIFENESIN/DM DM HB/GUAIFEN/P-EPHEDRINE 800-30-45 TAB.SR 12H<br />
PSEUDOVENT DM DM HB/GUAIFEN/P-EPHEDRINE 600-30-45 TAB.SR 12H<br />
P-TUSS DM DM HB/GUAIFEN/P-EPHEDRINE 600-30-60 TAB.SR 12H<br />
ROLATUSS DM HB/GUAIFEN/P-EPHEDRINE 100-10-30 LIQUID<br />
RU-TUSS DM DM HB/GUAIFEN/P-EPHEDRINE 100-15-45 LIQUID<br />
SEUDAFAIRE DM HB/GUAIFEN/P-EPHEDRINE 100-5-15/5 SYRUP<br />
TUSSAFED-LA DM HB/GUAIFEN/P-EPHEDRINE 600-30-60 TAB.SR 12H<br />
ALATUSS D-METHORPHAN HB/GUAIFEN/PE 100-10-5 SYRUP<br />
GOLDLINE COUGH D-METHORPHAN HB/GUAIFEN/PE 100-10-5 SYRUP<br />
TUSSAPHEN D-METHORPHAN HB/GUAIFEN/PE 100-10-5 SYRUP<br />
TUSSAPHEN DM D-METHORPHAN HB/GUAIFEN/PE 100-10-5 SYRUP<br />
TUSSAPHEN-DM D-METHORPHAN HB/GUAIFEN/PE 100-10-5 SYRUP<br />
TUSSEDYN D-METHORPHAN HB/GUAIFEN/PE 100-10-5 SYRUP<br />
TUSSEX D-METHORPHAN HB/GUAIFEN/PE 100-10-5 SYRUP<br />
TUSSEX COUGH D-METHORPHAN HB/GUAIFEN/PE 100-10-5 SYRUP<br />
ALTARUSSIN CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
ANATUSS D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
BIOTUSS CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
COUGH CONTROL CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
DEX-CON CHILDREN'S D-METHORPHAN HB/GUAIFEN/PPA 100MG/5ML SYRUP<br />
EXPECTORANT CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
GUAIATUSSIN CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
GUAIFENESIN CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
GUIATUSS CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
HALOTUSSIN-CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
KOMATUSSIN-CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
MYTUSSIN CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
NALDECOLD DX D-METHORPHAN HB/GUAIFEN/PPA 100MG/5ML SYRUP<br />
NALDECON-DX D-METHORPHAN HB/GUAIFEN/PPA 100MG/5ML SYRUP<br />
NALDELATE DX D-METHORPHAN HB/GUAIFEN/PPA 100MG/5ML SYRUP<br />
NALPHEN DX D-METHORPHAN HB/GUAIFEN/PPA 100MG/5ML SYRUP<br />
NALSPAN DX D-METHORPHAN HB/GUAIFEN/PPA 100MG/5ML SYRUP<br />
NOLAMINE DEX D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
PEDIACON DX D-METHORPHAN HB/GUAIFEN/PPA 100MG/5ML SYRUP<br />
Q-TUSSIN CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
RECOFEN DX D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
ROBAFEN-CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
ROBITUSSIN-CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
SILTUSSIN-CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
TRI-DEC D-METHORPHAN HB/GUAIFEN/PPA 100MG/5ML SYRUP<br />
TUSSIN CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
TUSSIN COUGH FORMULA D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
TUSSIN-CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
UNI-TUSSIN CF D-METHORPHAN HB/GUAIFEN/PPA SYRUP<br />
ALTARUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
AMERITUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
AMIBID DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
AQUABID-DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
AQUATAB DM D-METHORPHAN HB/GUAIFENESIN 1200-60MG TAB.SR 12H<br />
BIOTUSS-DM D-METHORPHAN HB/GUAIFENESIN 100-15/5ML SYRUP<br />
CHERACOL D D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
COUGH CONTROL DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
COUGH-EX D-METHORPHAN HB/GUAIFENESIN 200-15MG TABLET<br />
DIABETIC FORMULA D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
DIABETIC TUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
DIABETIC TUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
DIABETIC TUSSIN MAX-STRENGTH D-METHORPHAN HB/GUAIFENESIN 200-10/5ML LIQUID<br />
DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
DOUBLE-TUSSIN DM D-METHORPHAN HB/GUAIFENESIN 200-30/5ML LIQUID<br />
Page 32<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
DRITUSS DM D-METHORPHAN HB/GUAIFENESIN 200-20/5ML ELIXIR<br />
DURAGANIDIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
DURATUSS DM D-METHORPHAN HB/GUAIFENESIN 200-20/5ML ELIXIR<br />
ENTAB-DM D-METHORPHAN HB/GUAIFENESIN 1200-60MG TAB.SR 12H<br />
EXPECTORANT DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
EXPECTORANT DM CLEAR D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
FENESIN DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
GANI-TUSS-DM NR D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
GENATUSS DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
GFN 1000/DM 60 D-METHORPHAN HB/GUAIFENESIN 1000-60MG TAB.SR 12H<br />
GFN 1200/DM 60 D-METHORPHAN HB/GUAIFENESIN 1200-60MG TAB.SR 12H<br />
GUAIASORB D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
GUAIATUSSIN-DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
GUAIBID DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
GUAIFENESIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
GUAIFENESIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
GUAIFENESIN DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
GUAIFENESIN DM NR D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
GUAIFENESIN W/DEXTROMETHORPHAN D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
GUAIFENESIN W/DEXTROMETHORPHAN D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
GUAIFENESIN W/DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
GUAIFENESIN/D-METHORPHAN D-METHORPHAN HB/GUAIFENESIN 1200-60MG TAB.SR 12H<br />
GUAIFENESIN-DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
GUAIFENEX DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
GUAL-DEX D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
GUIADRINE DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
GUIATUSS CLEAR D-METHORPHAN HB/GUAIFENESIN 100-15/5ML LIQUID<br />
GUIATUSS CLEAR DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
GUIATUSS DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
HALOTUSSIN-DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
HT-TUSS DM D-METHORPHAN HB/GUAIFENESIN 200-20/5ML ELIXIR<br />
HUMIBID DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
HYDRO-TUSSIN DM D-METHORPHAN HB/GUAIFENESIN 200-20/5ML ELIXIR<br />
IOBID DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
IOPHEN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
IOPHEN DM-NR D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
IOPHEN-DM NR D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
KITA LA TOS D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
KOMATUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
KOSHER CARE DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
MAXI-TUSS DM D-METHORPHAN HB/GUAIFENESIN 200-20/5ML LIQUID<br />
MINTAB D-METHORPHAN HB/GUAIFENESIN 1200-60MG TAB.SR 12H<br />
MONAFED DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
MUCO-FEN DM D-METHORPHAN HB/GUAIFENESIN 1000-60MG TAB.SR 12H<br />
MYTUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-15/5ML SYRUP<br />
NALSPAN SENIOR DX D-METHORPHAN HB/GUAIFENESIN 200-10/5ML LIQUID<br />
ORGADIN-TUSS DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
PULEXN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
PULMOVITAL D-METHORPHAN HB/GUAIFENESIN 100-15/5ML LIQUID<br />
Q-BID-DM D-METHORPHAN HB/GUAIFENESIN 600-30MG TAB.SR 12H<br />
Q-TUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
Q-TUSSIN-DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
RI-TUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
ROBAFEN-DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
ROBAFEN-DM CLEAR D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
ROBITUSSIN-DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
RU-TUSS 800 DM D-METHORPHAN HB/GUAIFENESIN 800-60MG TAB.SR 12H<br />
SCOT-TUSSIN DM2 D-METHORPHAN HB/GUAIFENESIN 100-15/5ML SYRUP<br />
SILTUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
SILTUSSIN DM DAS COUGH FORMULA D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
SU-TUSS DM D-METHORPHAN HB/GUAIFENESIN 200-20/5ML ELIXIR<br />
TOLU-SED DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
TUSSI-BID D-METHORPHAN HB/GUAIFENESIN 1200-60MG TAB.SR 12H<br />
TUSSID DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
TUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
TUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
TUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-15/5ML SYRUP<br />
TUSSIN DM CLEAR D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
TUSSIN-DM CLEAR D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
TUSSI-ORGANIDIN DM NR D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
TUSSI-ORGANIDIN DM-S NR D-METHORPHAN HB/GUAIFENESIN 100-10/5ML LIQUID<br />
UNI-TUSSIN DM D-METHORPHAN HB/GUAIFENESIN 100-15/5ML SYRUP<br />
VICKS PEDIATRIC 44E D-METHORPHAN HB/GUAIFENESIN 100-10/5ML SYRUP<br />
CODAL-DM D-METHORPHAN HB/PE/PYRIL 10-5-8.33 SYRUP<br />
PHENERGAN W/DEXTROMETHORPHAN D-METHORPHAN HB/PROMETH HCL SYRUP<br />
Page 33<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
PROMETHAZINE DM D-METHORPHAN HB/PROMETH HCL 15-6.25/5 SYRUP<br />
PROMETHAZINE W/DM D-METHORPHAN HB/PROMETH HCL 15-6.25/5 SYRUP<br />
DOBUTAMINE HCL DOBUTAMINE HCL 12.5MG/ML VIAL<br />
DOBUTREX DOBUTAMINE HCL 12.5MG/ML VIAL<br />
DOBUTAMINE HCL IN DEXTROSE DOBUTAMINE HCL/D5W 1000MCG/ML IV SOLN.<br />
DOBUTAMINE HCL IN DEXTROSE DOBUTAMINE HCL/D5W 2000MCG/ML IV SOLN.<br />
DOBUTAMINE HCL IN DEXTROSE DOBUTAMINE HCL/D5W 4000MCG/ML IV SOLN.<br />
DOBUTAMINE HCL IN DEXTROSE DOBUTAMINE HCL/D5W 500MCG/ML IV SOLN.<br />
FERROUS FUMARATE W/DOCUSATE DOCUSATE NA/FERROUS FUMARATE 150-100MG CAPSULE SA<br />
DOPAMINE HCL DOPAMINE HCL 40MG/ML AMPUL<br />
DOPAMINE HCL DOPAMINE HCL 40MG/ML DISP SYRIN<br />
DOPAMINE HCL DOPAMINE HCL 40MG/ML VIAL<br />
DOPAMINE HCL DOPAMINE HCL 80MG/ML AMPUL<br />
DOPAMINE HCL DOPAMINE HCL 80MG/ML VIAL<br />
DOPAMINE HCL ADDITIVE SYRINGE DOPAMINE HCL 40MG/ML DISP SYRIN<br />
DOPAMINE HCL FLIPTOP DOPAMINE HCL 80MG/ML VIAL<br />
AMINATE W/90MG IRON DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA<br />
MATERNAL 90 DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA<br />
MYNATE 90 PLUS DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA<br />
NATALFIRST DOSS/FA/FE FUM/PRENATAL VIT 29-1MG TABLET<br />
PRENATAL 19 DOSS/FA/FE FUM/PRENATAL VIT 29-1MG TABLET<br />
PRENATAL MR 90 FE DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA<br />
VINATE 90 DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA<br />
VINATE-90 DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA<br />
ANEMAGEN OB DOSS/FA/FE FUM/PV W-O VIT A 28-1MG CAPSULE<br />
ADVANCED NATALCARE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
INATAL ADVANCE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
INATAL GT DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
INATAL ULTRA DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
MYNATAL DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
MYNATAL ADVANCE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
NATALCARE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
PRENATAL AD DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
PRENATAL OPTIMA ADVANCE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
PRENATE ADVANCE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
PRENATE GT DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
ULTRA DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
ULTRA NATALCARE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
ULTRA-NATAL DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
VINATE ADVANCED DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
VINATE GT DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
VINATE ULTRA DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET<br />
CARDURA DOXAZOSIN MESYLATE 1MG TABLET<br />
CARDURA DOXAZOSIN MESYLATE 2MG TABLET<br />
CARDURA DOXAZOSIN MESYLATE 4MG TABLET<br />
CARDURA DOXAZOSIN MESYLATE 8MG TABLET<br />
DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 1MG TABLET<br />
DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 2MG TABLET<br />
DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 4MG TABLET<br />
DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 8MG TABLET<br />
ADAPIN DOXEPIN HCL 100MG CAPSULE<br />
ADAPIN DOXEPIN HCL 10MG CAPSULE<br />
ADAPIN DOXEPIN HCL 150MG CAPSULE<br />
ADAPIN DOXEPIN HCL 25MG CAPSULE<br />
ADAPIN DOXEPIN HCL 50MG CAPSULE<br />
ADAPIN DOXEPIN HCL 75MG CAPSULE<br />
DOXEPIN HCL DOXEPIN HCL 100MG CAPSULE<br />
DOXEPIN HCL DOXEPIN HCL 10MG CAPSULE<br />
DOXEPIN HCL DOXEPIN HCL 10MG/ML ORAL CONC.<br />
DOXEPIN HCL DOXEPIN HCL 150MG CAPSULE<br />
DOXEPIN HCL DOXEPIN HCL 25MG CAPSULE<br />
DOXEPIN HCL DOXEPIN HCL 50MG CAPSULE<br />
DOXEPIN HCL DOXEPIN HCL 75MG CAPSULE<br />
SINEQUAN DOXEPIN HCL 100MG CAPSULE<br />
SINEQUAN DOXEPIN HCL 10MG CAPSULE<br />
SINEQUAN DOXEPIN HCL 10MG/ML ORAL CONC.<br />
SINEQUAN DOXEPIN HCL 150MG CAPSULE<br />
SINEQUAN DOXEPIN HCL 25MG CAPSULE<br />
SINEQUAN DOXEPIN HCL 50MG CAPSULE<br />
SINEQUAN DOXEPIN HCL 75MG CAPSULE<br />
ADRIAMYCIN RDF DOXORUBICIN HCL 50MG VIAL<br />
ADRIAMYCIN-PFS DOXORUBICIN HCL 2MG/ML VIAL<br />
DOXORUBICIN HCL DOXORUBICIN HCL 10MG VIAL<br />
DOXORUBICIN HCL DOXORUBICIN HCL 20MG VIAL<br />
DOXORUBICIN HCL DOXORUBICIN HCL 2MG/ML VIAL<br />
Page 34<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
DOXORUBICIN HCL DOXORUBICIN HCL 50MG VIAL<br />
RUBEX DOXORUBICIN HCL 50MG VIAL<br />
DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 100MG CAPSULE<br />
DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 100MG TABLET<br />
DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 100MG VIAL<br />
DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 50MG CAPSULE<br />
ED DOXY-CAPS DOXYCYCLINE HYCLATE 100MG CAPSULE<br />
VIBRAMYCIN DOXYCYCLINE HYCLATE 100MG CAPSULE<br />
VIBRAMYCIN DOXYCYCLINE HYCLATE 50MG CAPSULE<br />
VIBRA-TABS DOXYCYCLINE HYCLATE 100MG TABLET<br />
DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE 100MG CAPSULE<br />
DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE 50MG CAPSULE<br />
MONODOX DOXYCYCLINE MONOHYDRATE 100MG CAPSULE<br />
MONODOX DOXYCYCLINE MONOHYDRATE 50MG CAPSULE<br />
BANOPHEN PLUS DP-HYDRAM HCL/P-EPHED HCL CAPSULE<br />
DROPERIDOL DROPERIDOL 2.5MG/ML AMPUL<br />
DROPERIDOL DROPERIDOL 2.5MG/ML VIAL<br />
DILOR DYPHYLLINE 200MG TABLET<br />
DILOR DYPHYLLINE 400MG TABLET<br />
DYLIX DYPHYLLINE 100MG/15ML ELIXIR<br />
LUFYLLIN DYPHYLLINE 200MG TABLET<br />
NEOTHYLLINE DYPHYLLINE 200MG TABLET<br />
COPD DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
D-G DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID<br />
DG 200 DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
DIFIL-G DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
DIFIL-G FORTE DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID<br />
DILEX-G DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID<br />
DILEX-G DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
DILOR-G DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID<br />
DILOR-G DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
DYFILIN GG DYPHYLLINE/GUAIFENESIN 100-100/15 ELIXIR<br />
DYFLEX-G DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
DY-G LIQUID DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID<br />
DYLINE-GG DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID<br />
DYLINE-GG DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
DYPHYL-G DYPHYLLINE/GUAIFENESIN 50-100/5ML SYRUP<br />
DYPHYLLIN GG DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
DYPHYLLINE GG DYPHYLLINE/GUAIFENESIN 100-100/15 ELIXIR<br />
DYPHYLLINE GG DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
DYPHYLLINE-GG DYPHYLLINE/GUAIFENESIN 100-100/15 ELIXIR<br />
DYPHYLLINE-GG DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
LUFYLLIN-GG DYPHYLLINE/GUAIFENESIN 100-100/15 ELIXIR<br />
LUFYLLIN-GG DYPHYLLINE/GUAIFENESIN 200-200MG TABLET<br />
ECONAZOLE NITRATE ECONAZOLE NITRATE 1% CREAM(GM)<br />
EDROPHONIUM CHLORIDE EDROPHONIUM CHLORIDE 10MG/ML VIAL<br />
ENLON EDROPHONIUM CHLORIDE 10MG/ML VIAL<br />
REVERSOL EDROPHONIUM CHLORIDE 10MG/ML VIAL<br />
TENSILON EDROPHONIUM CHLORIDE 10MG/ML VIAL<br />
MULTILYTE-20 ELECTROLYTE SOLUTION VIAL<br />
MULTILYTE-40 ELECTROLYTE SOLUTION VIAL<br />
NUTRILYTE ELECTROLYTE SOLUTION,INJ VIAL<br />
NUTRILYTE II ELECTROLYTE SOLUTION,INJ VIAL<br />
ELECTROLYTE SOLUTION ELECTROLYTE,ORAL SOLUTION<br />
ENFALYTE ELECTROLYTE,ORAL SOLUTION<br />
NATURALYTE ELECTROLYTE,ORAL SOLUTION<br />
ORALYTE ELECTROLYTE,ORAL SOLUTION<br />
PEDIALYTE ELECTROLYTE,ORAL SOLUTION<br />
PEDIA-POP ELECTROLYTE,ORAL SOLUTION<br />
PEDIATRIC ELECTROLYTE ELECTROLYTE,ORAL SOLUTION<br />
PEDIATRIC SOLUTION ELECTROLYTE,ORAL SOLUTION<br />
REHYDRALYTE ELECTROLYTE,ORAL SOLUTION<br />
REVITAL ELECTROLYTE,ORAL SOLUTION<br />
PLASMA-LYTE R ELECTROLYTE-R SOLUTION IV SOLN.<br />
DIAB EMOLLIENT GEL<br />
RADIACARE EMOLLIENT GEL<br />
FLUOCINONIDE EMOLLIENT/FLUOCINONIDE 0.05% CREAM(GM)<br />
FLUOCINONIDE-E EMOLLIENT/FLUOCINONIDE 0.05% CREAM(GM)<br />
LIDEX-E EMOLLIENT/FLUOCINONIDE 0.05% CREAM(GM)<br />
ENALAPRIL MALEATE ENALAPRIL MALEATE 10MG TABLET<br />
ENALAPRIL MALEATE ENALAPRIL MALEATE 2.5MG TABLET<br />
ENALAPRIL MALEATE ENALAPRIL MALEATE 20MG TABLET<br />
ENALAPRIL MALEATE ENALAPRIL MALEATE 5MG TABLET<br />
VASOTEC ENALAPRIL MALEATE 10MG TABLET<br />
VASOTEC ENALAPRIL MALEATE 2.5MG TABLET<br />
Page 35<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
VASOTEC ENALAPRIL MALEATE 20MG TABLET<br />
VASOTEC ENALAPRIL MALEATE 5MG TABLET<br />
ENALAPRIL MALEATE/HCTZ ENALAPRIL MALEATE/HCTZ 10-25MG TABLET<br />
ENALAPRIL MALEATE/HCTZ ENALAPRIL MALEATE/HCTZ 5-12.5MG TABLET<br />
VASERETIC ENALAPRIL MALEATE/HCTZ 10-25MG TABLET<br />
VASERETIC ENALAPRIL MALEATE/HCTZ 5-12.5MG TABLET<br />
ENALAPRILAT ENALAPRILAT DIHYDRATE 1.25MG/ML VIAL<br />
VASOTEC I.V. ENALAPRILAT DIHYDRATE 1.25MG/ML VIAL<br />
ETHRANE ENFLURANE GAS<br />
EPHEDRINE SULFATE EPHEDRINE SULFATE 50MG/ML AMPUL<br />
ADRENALIN CHLORIDE EPINEPHRINE 1MG/ML AMPUL<br />
ADRENALIN CHLORIDE EPINEPHRINE 1MG/ML VIAL<br />
EPINEPHRINE EPINEPHRINE 0.1MG/ML DISP SYRIN<br />
EPINEPHRINE EPINEPHRINE 1MG/ML AMPUL<br />
EPINEPHRINE EPINEPHRINE 1MG/ML VIAL<br />
LIDOCAINE HCL W/EPINEPHRINE EPINEPHRINE/LIDOCAINE HCL 0.5-0.0005 VIAL<br />
LIDOCAINE HCL W/EPINEPHRINE EPINEPHRINE/LIDOCAINE HCL 1.5-0.0005 AMPUL<br />
LIDOCAINE HCL W/EPINEPHRINE EPINEPHRINE/LIDOCAINE HCL 1.5-0.0005 VIAL<br />
LIDOCAINE HCL W/EPINEPHRINE EPINEPHRINE/LIDOCAINE HCL 1-0.0005% AMPUL<br />
LIDOCAINE HCL W/EPINEPHRINE EPINEPHRINE/LIDOCAINE HCL 1-0.001% VIAL<br />
LIDOCAINE HCL W/EPINEPHRINE EPINEPHRINE/LIDOCAINE HCL 2-0.0005% VIAL<br />
LIDOCAINE HCL W/EPINEPHRINE EPINEPHRINE/LIDOCAINE HCL 2-0.001% VIAL<br />
CALCIFEROL ERGOCALCIFEROL 8000 U/ML DROPS<br />
DRISDOL ERGOCALCIFEROL 50000 UNIT CAPSULE<br />
DRISDOL ERGOCALCIFEROL 8000 U/ML DROPS<br />
VITAMIN D ERGOCALCIFEROL 50000 UNIT CAPSULE<br />
VITAMIN D ERGOCALCIFEROL 8000 U/ML DROPS<br />
ERGOLOID MESYLATES ERGOLOID MESYLATES 1MG TAB SUBL<br />
ERGOLOID MESYLATES ERGOLOID MESYLATES 1MG TABLET<br />
ERYTHROMYCIN W/SULFISOXAZOLE ERY E-SUCC/SULFISOXAZOLE 200-600/5 SUSP RECON<br />
PEDIAZOLE ERY E-SUCC/SULFISOXAZOLE 200-600/5 SUSP RECON<br />
ERYC ERYTHROMYCIN BASE 250MG CAPSULE DR<br />
ERY-TAB ERYTHROMYCIN BASE 333MG TABLET DR<br />
ERYTHROMYCIN ERYTHROMYCIN BASE 5MG/G OINT.(GM)<br />
ERYTHROMYCIN BASE ERYTHROMYCIN BASE 250MG CAPSULE DR<br />
ROMYCIN ERYTHROMYCIN BASE 5MG/G OINT.(GM)<br />
A/T/S ERYTHROMYCIN BASE/ETHANOL 2% GEL<br />
A/T/S ERYTHROMYCIN BASE/ETHANOL 2% SOLUTION<br />
EMGEL ERYTHROMYCIN BASE/ETHANOL 2% GEL<br />
ERY ERYTHROMYCIN BASE/ETHANOL 2% MED. SWAB<br />
ERYCETTE ERYTHROMYCIN BASE/ETHANOL 2% MED. SWAB<br />
ERYDERM ERYTHROMYCIN BASE/ETHANOL 2% SOLUTION<br />
ERYGEL ERYTHROMYCIN BASE/ETHANOL 2% GEL<br />
ERYMAX ERYTHROMYCIN BASE/ETHANOL 2% SOLUTION<br />
ERYTHRA-DERM ERYTHROMYCIN BASE/ETHANOL 2% SOLUTION<br />
ERYTHROMYCIN ERYTHROMYCIN BASE/ETHANOL 2% SOLUTION<br />
ERYTHROMYCIN BASE ERYTHROMYCIN BASE/ETHANOL 2% GEL<br />
THERAMYCIN Z ERYTHROMYCIN BASE/ETHANOL 2% SOLUTION<br />
T-STAT ERYTHROMYCIN BASE/ETHANOL 2% MED. SWAB<br />
T-STAT ERYTHROMYCIN BASE/ETHANOL 2% SOLUTION<br />
ERYTHROMYCIN ESTOLATE ERYTHROMYCIN ESTOLATE 125MG/5ML ORAL SUSP<br />
E.E.S. 200 ERYTHROMYCIN ETHYLSUCCINATE 200MG/5ML ORAL SUSP<br />
E.E.S. 200 ERYTHROMYCIN ETHYLSUCCINATE 200MG/5ML SUSP RECON<br />
E.E.S. 400 ERYTHROMYCIN ETHYLSUCCINATE 400MG TABLET<br />
E.E.S. 400 ERYTHROMYCIN ETHYLSUCCINATE 400MG/5ML ORAL SUSP<br />
ERYPED 200 ERYTHROMYCIN ETHYLSUCCINATE 200MG/5ML SUSP RECON<br />
ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE 200MG/5ML ORAL SUSP<br />
ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE 200MG/5ML SUSP RECON<br />
ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE 400MG TABLET<br />
ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ETHYLSUCCINATE 400MG/5ML ORAL SUSP<br />
ERYTHROCIN STEARATE ERYTHROMYCIN STEARATE 250MG TABLET<br />
ERYTHROCIN STEARATE ERYTHROMYCIN STEARATE 500MG TABLET<br />
ERYTHROMYCIN STEARATE ERYTHROMYCIN STEARATE 250MG TABLET<br />
ERYTHROMYCIN STEARATE ERYTHROMYCIN STEARATE 500MG TABLET<br />
MY-E FILM ERYTHROMYCIN STEARATE 250MG TABLET<br />
DEPO-TESTADIOL ESTRAD CYP/TESTOST CYP 50-2 VIAL<br />
DUO-CYP ESTRAD CYP/TESTOST CYP 50-2 VIAL<br />
ESTRADIOL/TESTOSTERONE ESTRAD VAL/TESTOST ENAN 90-4 VIAL<br />
ALORA ESTRADIOL .075MG/24H PATCH TDBW<br />
ALORA ESTRADIOL 0.05MG/24H PATCH TDBW<br />
ALORA ESTRADIOL 0.1MG/24HR PATCH TDBW<br />
ESCLIM ESTRADIOL .0375MG/24 PATCH TDBW<br />
ESCLIM ESTRADIOL .075MG/24H PATCH TDBW<br />
ESCLIM ESTRADIOL 0.05MG/24H PATCH TDBW<br />
ESCLIM ESTRADIOL 0.1MG/24HR PATCH TDBW<br />
Page 36<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
ESTRACE ESTRADIOL 0.5MG TABLET<br />
ESTRACE ESTRADIOL 1MG TABLET<br />
ESTRACE ESTRADIOL 2MG TABLET<br />
ESTRADERM ESTRADIOL 0.05MG/24H PATCH TDBW<br />
ESTRADERM ESTRADIOL 0.1MG/24HR PATCH TDBW<br />
ESTRADIOL ESTRADIOL 0.5MG TABLET<br />
ESTRADIOL ESTRADIOL 1MG TABLET<br />
ESTRADIOL ESTRADIOL 2MG TABLET<br />
ESTRADIOL TRANSDERMAL PATCH ESTRADIOL 0.05MG/24H PATCH TDWK<br />
ESTRADIOL TRANSDERMAL PATCH ESTRADIOL 0.1MG/24HR PATCH TDWK<br />
GYNODIOL ESTRADIOL 0.5MG TABLET<br />
GYNODIOL ESTRADIOL 1MG TABLET<br />
GYNODIOL ESTRADIOL 2MG TABLET<br />
VIVELLE ESTRADIOL .0375MG/24 PATCH TDBW<br />
VIVELLE ESTRADIOL .075MG/24H PATCH TDBW<br />
VIVELLE ESTRADIOL 0.05MG/24H PATCH TDBW<br />
VIVELLE ESTRADIOL 0.1MG/24HR PATCH TDBW<br />
VIVELLE-DOT ESTRADIOL .0375MG/24 PATCH TDBW<br />
VIVELLE-DOT ESTRADIOL .075MG/24H PATCH TDBW<br />
VIVELLE-DOT ESTRADIOL 0.05MG/24H PATCH TDBW<br />
VIVELLE-DOT ESTRADIOL 0.1MG/24HR PATCH TDBW<br />
DEPO-ESTRADIOL ESTRADIOL CYPIONATE 5MG/ML VIAL<br />
DELESTROGEN ESTRADIOL VALERATE 20MG/ML VIAL<br />
DELESTROGEN ESTRADIOL VALERATE 40MG/ML VIAL<br />
DIOVAL-40 ESTRADIOL VALERATE 40MG/ML VIAL<br />
DIOVAL-XX ESTRADIOL VALERATE 20MG/ML VIAL<br />
VALERGEN-20 ESTRADIOL VALERATE 20MG/ML VIAL<br />
SYNTEST D.S. ESTROGEN,ESTER/ME-TESTOSTERONE 2.5-1.25MG TABLET<br />
SYNTEST H.S. ESTROGEN,ESTER/ME-TESTOSTERONE 1.25-0.625 TABLET<br />
MENEST ESTROGENS,ESTERIFIED 0.3MG TABLET<br />
MENEST ESTROGENS,ESTERIFIED 0.625MG TABLET<br />
MENEST ESTROGENS,ESTERIFIED 2.5MG TABLET<br />
ESTRONE ESTRONE 5MG/ML VIAL<br />
KESTRONE-5 ESTRONE 5MG/ML VIAL<br />
ESTROPIPATE ESTROPIPATE 0.75MG TABLET<br />
ESTROPIPATE ESTROPIPATE 1.5MG TABLET<br />
ESTROPIPATE ESTROPIPATE 3MG TABLET<br />
OGEN ESTROPIPATE 0.75MG TABLET<br />
OGEN ESTROPIPATE 1.5MG TABLET<br />
OGEN ESTROPIPATE 3MG TABLET<br />
ORTHO-EST ESTROPIPATE 0.75MG TABLET<br />
ORTHO-EST ESTROPIPATE 1.5MG TABLET<br />
ETHAMBUTOL HCL ETHAMBUTOL HCL 100MG TABLET<br />
ETHAMBUTOL HCL ETHAMBUTOL HCL 400MG TABLET<br />
ETHAMBUTOL HYDROCHLORIDE ETHAMBUTOL HCL 400MG TABLET<br />
MYAMBUTOL ETHAMBUTOL HCL 400MG TABLET<br />
ETHAVERINE HCL ETHAVERINE HCL 100MG TABLET<br />
ETHAVEX-100 ETHAVERINE HCL 100MG TABLET<br />
ETHOSUXIMIDE ETHOSUXIMIDE 250MG CAPSULE<br />
ETHOSUXIMIDE ETHOSUXIMIDE 250MG/5ML SYRUP<br />
ALCOHOL,DEHYDRATED ETHYL ALCOHOL 98% AMPUL<br />
ETHANOL ETHYL ALCOHOL 98% AMPUL<br />
ZOVIA 1/35E ETHYNODIOL D-ETHINYL ESTRADIOL 1-0.035MG TABLET<br />
ZOVIA 1/50E ETHYNODIOL D-ETHINYL ESTRADIOL 1-0.05MG TABLET<br />
ETODOLAC ETODOLAC 200MG CAPSULE<br />
ETODOLAC ETODOLAC 300MG CAPSULE<br />
ETODOLAC ETODOLAC 400MG TAB.SR 24H<br />
ETODOLAC ETODOLAC 400MG TABLET<br />
ETODOLAC ETODOLAC 500MG TAB.SR 24H<br />
ETODOLAC ETODOLAC 500MG TABLET<br />
ETODOLAC ETODOLAC 600MG TAB.SR 24H<br />
LODINE ETODOLAC 200MG CAPSULE<br />
LODINE ETODOLAC 300MG CAPSULE<br />
LODINE ETODOLAC 400MG TABLET<br />
LODINE ETODOLAC 500MG TABLET<br />
LODINE XL ETODOLAC 400MG TAB.SR 24H<br />
AMIDATE ETOMIDATE 2MG/ML VIAL<br />
ETOMIDATE ETOMIDATE 2MG/ML VIAL<br />
ETOPOSIDE ETOPOSIDE 20MG/ML VIAL<br />
ETOPOSIDE ETOPOSIDE 50MG CAPSULE<br />
TOPOSAR ETOPOSIDE 20MG/ML VIAL<br />
VEPESID ETOPOSIDE 20MG/ML VIAL<br />
VINATAL FORTE FA/FE CARB-FESO4/PRENATAL VIT 60-1MG TABLET<br />
NATAFORT FA/FE CARB-FESO4/PV W-O CAL 60-1MG TABLET<br />
NATALCARE CFE FA/FE CARB-FESO4/PV W-O CAL 60-1MG TABLET<br />
Page 37<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
LACTOCAL-F FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET<br />
MARNATAL F FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET<br />
MATERNAL VITAMIN & MINERAL FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET<br />
MISSION PRENATAL RX FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET<br />
MYNATAL FC FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET<br />
MYNATAL PLUS FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET<br />
MYNATAL PN FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET<br />
MYNATAL PN FORTE FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET<br />
MYNATAL RX FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET<br />
MYNATAL-Z FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET<br />
NATAFOLIC-PN FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET<br />
NATALCARE PLUS FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET<br />
NATALCARE RX FA/FE FUMARATE/PRENATAL VIT 27-0.5MG TABLET<br />
NATALCARE THREE FA/FE FUMARATE/PRENATAL VIT 28-1MG TABLET<br />
NATAREX FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET<br />
NATATAB FA FA/FE FUMARATE/PRENATAL VIT 29-1MG TABLET<br />
O-CAL FA FA/FE FUMARATE/PRENATAL VIT 66-1MG TABLET<br />
PRENATABS FA FA/FE FUMARATE/PRENATAL VIT 29-1MG TABLET<br />
PRENATAL FA/FE FUMARATE/PRENATAL VIT 27-0.8MG TABLET<br />
PRENATAL 1 PLUS 1 FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET<br />
PRENATAL 1+1 FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET<br />
PRENATAL 19 FA/FE FUMARATE/PRENATAL VIT 29-1MG TAB CHEW<br />
PRENATAL FORMULA 3 FA/FE FUMARATE/PRENATAL VIT 28-1MG TABLET<br />
PRENATAL LOW IRON FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET<br />
PRENATAL PLUS FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET<br />
PRENATAL PLUS FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET<br />
PRENATAL PLUS NF FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET<br />
PRENATAL RX FA/FE FUMARATE/PRENATAL VIT 27-0.5MG TABLET<br />
PRENATAL RX FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET<br />
PRENATAL S FA/FE FUMARATE/PRENATAL VIT 27-0.8MG TABLET<br />
PRENATAL VITAMIN FORMULA FA/FE FUMARATE/PRENATAL VIT 27-0.8MG TABLET<br />
PRENATAL W/FOLIC ACID FA/FE FUMARATE/PRENATAL VIT 27-0.8MG TABLET<br />
PRENATAL Z FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET<br />
PRENAVITE FA/FE FUMARATE/PRENATAL VIT 27-0.8MG TABLET<br />
PRENAVITE FA/FE FUMARATE/PRENATAL VIT 28-0.8MG TABLET<br />
STUARTNATAL PLUS 3 FA/FE FUMARATE/PRENATAL VIT 28-1MG TABLET<br />
TERNAMAR FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET<br />
TRICARE FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET<br />
TRINATE FA/FE FUMARATE/PRENATAL VIT 28-1MG TABLET<br />
VINATAL FA/FE FUMARATE/PRENATAL VIT 27-0.5MG TABLET<br />
VITAFOL-OB FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET<br />
VITAFOL-PN FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET<br />
VITELLE NESTABS FA/FE FUMARATE/PRENATAL VIT 29-0.8MG TABLET<br />
MATERNA FA/FE FUMARATE/PRENATAL VIT/SE 27-1MG TABLET<br />
MATERNITY FA/FE FUMARATE/PRENATAL VIT/SE 27-1MG TABLET<br />
PRENATAL MTR FA/FE FUMARATE/PRENATAL VIT/SE 27-1MG TABLET<br />
VINATE-M FA/FE FUMARATE/PRENATAL VIT/SE 27-1MG TABLET<br />
NATACAPS FA/FE FUMARATE/PV W-O VIT A 106-1MG CAPSULE<br />
PRENATAL-H FA/FE FUMARATE/PV W-O VIT A 106-1MG CAPSULE<br />
ANEMAGEN FA FA/FE FUMARATE/VIT B12/VIT C 200-250MG CAPSULE<br />
CHROMAGEN FA FA/FE FUMARATE/VIT B12/VIT C 200-250MG CAPSULE<br />
CHROMAGEN FORTE FA/FE FUMARATE/VIT B12/VIT C 460-60MG CAPSULE<br />
FEOGEN FA FA/FE FUMARATE/VIT B12/VIT C 200-250MG CAPSULE<br />
FEOGEN FORTE FA/FE FUMARATE/VIT B12/VIT C 460-60MG CAPSULE<br />
FERROGELS FORTE FA/FE FUMARATE/VIT B12/VIT C 460-60MG CAPSULE<br />
HEMATOGEN FA FA/FE FUMARATE/VIT B12/VIT C 200-250MG CAPSULE<br />
NATALCARE PIC FA/FE P-SAC CMPLX/PRENATAL VIT 60-1MG TABLET<br />
NATALCARE PIC FORTE FA/FE P-SAC CMPLX/PRENATAL VIT 60-1MG TABLET<br />
FERREX 150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE<br />
FERREX-150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE<br />
FE-TINIC 150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE<br />
IFEREX 150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE<br />
MYFERON-150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE<br />
NIFEREX-150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE<br />
POLY-IRON 150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE<br />
PRENATAL PC 40 FA/FECBN-FEFM/PV W-O VIT A 40-1MG TABLET<br />
M-VIT FA/FERROUS FUMARATE/PV W-O CAL 27-1MG TABLET<br />
NUTRINATE FA/FERROUS FUMARATE/PV W-O CAL 29-1MG TAB CHEW<br />
IBERET-FOLIC 500 FA/FERROUS SULFATE/VIT BCOMP&C 105-0.8MG TABLET SA<br />
MULTI FERROUS FOLIC 500 FA/FERROUS SULFATE/VIT BCOMP&C 105-0.8MG TABLET SA<br />
MULTI-RET FOLIC 500 FA/FERROUS SULFATE/VIT BCOMP&C 105-0.8MG TABLET SA<br />
FOLITAB 500 FA/FERROUS SULFATE/VIT C 105-500-.8 TABLET SA<br />
NATATAB FA/IRON,CARBONYL/PRENATAL VIT 29-1MG TABLET<br />
NATATAB CFE FA/IRON,CARBONYL/PRENATAL VIT 50-1MG TABLET<br />
PRENATABS CBF FA/IRON,CARBONYL/PRENATAL VIT 50-1MG TABLET<br />
Page 38<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
PRENATABS RX FA/IRON,CARBONYL/PRENATAL VIT 29-1MG TABLET<br />
HEMATINIC PLUS FA/IRON/MIN/VITAMIN B COMP W-C 106-1MG TABLET<br />
MEGATON FA/IRON/MIN/VITAMIN B COMPLEX 1MG ELIXIR<br />
KONYNE 80 FACTOR IX COMPLEX HUMAN 1000(+/-)U VIAL<br />
KONYNE 80 FACTOR IX COMPLEX HUMAN 500 (+/-)U VIAL<br />
PROFILNINE SD FACTOR IX COMPLEX HUMAN 500 (+/-)U VIAL<br />
ACID REDUCER FAMOTIDINE 10MG TABLET<br />
FAMOTIDINE FAMOTIDINE 10MG TABLET<br />
FAMOTIDINE FAMOTIDINE 10MG/ML VIAL<br />
FAMOTIDINE FAMOTIDINE 20MG TABLET<br />
FAMOTIDINE FAMOTIDINE 40MG TABLET<br />
HEARTBURN RELIEF FAMOTIDINE 10MG TABLET<br />
HM ACID REDUCER FAMOTIDINE 10MG TABLET<br />
PEPCID FAMOTIDINE 10MG/ML VIAL<br />
PEPCID FAMOTIDINE 20MG TABLET<br />
PEPCID FAMOTIDINE 40MG TABLET<br />
PEPCID AC FAMOTIDINE 10MG TABLET<br />
V-R ACID REDUCER FAMOTIDINE 10MG TABLET<br />
FAMOTIDINE FAMOTIDINE/NACL 0.9% 20MG/50ML PIGGYBACK<br />
INTRALIPID FAT EMULSIONS 10% IV SOLN.<br />
INTRALIPID FAT EMULSIONS 20% IV SOLN.<br />
INTRALIPID FAT EMULSIONS 30% IV SOLN.<br />
LIPOSYN II FAT EMULSIONS 10% IV SOLN.<br />
LIPOSYN II FAT EMULSIONS 20% IV SOLN.<br />
LIPOSYN III FAT EMULSIONS 10% IV SOLN.<br />
LIPOSYN III FAT EMULSIONS 20% IV SOLN.<br />
LIPOSYN III FAT EMULSIONS 30% IV SOLN.<br />
NUTRILIPID FAT EMULSIONS 10% IV SOLN.<br />
TRAVAMULSION FAT EMULSIONS 10% IV SOLN.<br />
TRAVAMULSION FAT EMULSIONS 20% IV SOLN.<br />
MICROGESTIN FE FE FUMARATE/NORETH A-ET ESTRA 1.5-0.03MG TABLET<br />
MICROGESTIN FE FE FUMARATE/NORETH A-ET ESTRA 1-0.02MG TABLET<br />
LICOPLEX DS FE/LIVER/VIT B COMP/VIT B12 VIAL<br />
FENOFIBRATE FENOFIBRATE,MICRONIZED 200MG CAPSULE<br />
FENOFIBRATE FENOFIBRATE,MICRONIZED 67MG CAPSULE<br />
FENOPROFEN CALCIUM FENOPROFEN CALCIUM 600MG TABLET<br />
FENTANYL CITRATE FENTANYL CITRATE 0.05MG/ML AMPUL<br />
FENTANYL CITRATE FENTANYL CITRATE 0.05MG/ML VIAL<br />
SUBLIMAZE FENTANYL CITRATE 0.05MG/ML AMPUL<br />
FERRETTS FERROUS FUMARATE 324MG TABLET<br />
FERROUS FUMARATE FERROUS FUMARATE 90MG TABLET<br />
FERROUS FUMARATE 324 FERROUS FUMARATE 324MG TABLET<br />
HEMOCYTE FERROUS FUMARATE 324MG TABLET<br />
IRCON FERROUS FUMARATE 200MG TABLET<br />
ED CYTE F FERROUS FUMARATE/FOLIC ACID 106-1MG TABLET<br />
HEMATINIC W/FOLIC ACID FERROUS FUMARATE/FOLIC ACID 106-1MG TABLET<br />
HEMOCYTE-F FERROUS FUMARATE/FOLIC ACID 106-1MG TABLET<br />
FERATE FERROUS GLUCONATE 325MG TABLET<br />
FERGON FERROUS GLUCONATE 240MG TABLET<br />
FERRONATE FERROUS GLUCONATE 325MG TABLET<br />
FERROUS GLUCONATE FERROUS GLUCONATE 240MG TABLET<br />
FERROUS GLUCONATE FERROUS GLUCONATE 325MG TABLET<br />
FEOSOL FERROUS SULFATE 200MG TABLET<br />
FEOSOL FERROUS SULFATE 220MG/5ML ELIXIR<br />
FERATAB FERROUS SULFATE 300MG TABLET<br />
FER-GEN-SOL FERROUS SULFATE 75MG/0.6ML DROPS<br />
FER-IN-SOL FERROUS SULFATE 75MG/0.6ML DROPS<br />
FER-IRON FERROUS SULFATE 75MG/0.6ML DROPS<br />
FEROSUL FERROUS SULFATE 325(65)MG TABLET<br />
FERRO-BOB FERROUS SULFATE 325(65)MG TABLET<br />
FERROUS SULFATE FERROUS SULFATE 134MG TABLET<br />
FERROUS SULFATE FERROUS SULFATE 160MG TABLET SA<br />
FERROUS SULFATE FERROUS SULFATE 220MG/5ML ELIXIR<br />
FERROUS SULFATE FERROUS SULFATE 250MG CAPSULE SA<br />
FERROUS SULFATE FERROUS SULFATE 300MG/5ML LIQUID<br />
FERROUS SULFATE FERROUS SULFATE 325(65)MG TABLET<br />
FERROUS SULFATE FERROUS SULFATE 325(65)MG TABLET DR<br />
FERROUS SULFATE FERROUS SULFATE 325MG TABLET<br />
FERROUS SULFATE FERROUS SULFATE 75MG/0.6ML DROPS<br />
FERROUSUL FERROUS SULFATE 325(65)MG TABLET<br />
HM IRON FERROUS SULFATE 325(65)MG TABLET<br />
IROMAR FERROUS SULFATE 325(65)MG TABLET<br />
IRON FERROUS SULFATE 325(65)MG TABLET<br />
IRON FERROUS SULFATE 325MG TABLET<br />
RIDOSOL FERROUS SULFATE 325(65)MG TABLET<br />
Page 39<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
SLOW FE FERROUS SULFATE 160MG TABLET SA<br />
SLOW RELEASE IRON FERROUS SULFATE 160MG TABLET SA<br />
VIT SLOW RELEASE IRON FERROUS SULFATE 160MG TABLET SA<br />
VITEDYN-SLO FERROUS SULFATE 250MG CAPSULE SA<br />
YIERO-GOTA FERROUS SULFATE 75MG/0.6ML DROPS<br />
YIERONIA FERROUS SULFATE 220MG/5ML ELIXIR<br />
ISOSOURCE 1.5 CAL FIBER/LACTOSE-FREE FOOD LIQUID<br />
PEDIASURE WITH FIBER FIBER/LACTOSE-FREE FOOD LIQUID<br />
RESOURCE W/FIBER FIBER/LACTOSE-FREE FOOD LIQUID<br />
NUTREN 1.0 W/FIBER FIBER/NUTRITIONAL SUPPLEMENT LIQUID<br />
NUTREN JUNIOR W/FIBER FIBER/NUTRITIONAL SUPPLEMENT LIQUID<br />
REPLETE W/FIBER FIBER/NUTRITIONAL SUPPLEMENT LIQUID<br />
FLECAINIDE ACETATE FLECAINIDE ACETATE 100MG TABLET<br />
FLECAINIDE ACETATE FLECAINIDE ACETATE 150MG TABLET<br />
FLECAINIDE ACETATE FLECAINIDE ACETATE 50MG TABLET<br />
TAMBOCOR FLECAINIDE ACETATE 100MG TABLET<br />
TAMBOCOR FLECAINIDE ACETATE 150MG TABLET<br />
TAMBOCOR FLECAINIDE ACETATE 50MG TABLET<br />
FLOXURIDINE FLOXURIDINE 500MG VIAL<br />
FLUDROCORTISONE ACETATE FLUDROCORTISONE ACETATE 0.1MG TABLET<br />
FLUNISOLIDE FLUNISOLIDE 0.025% SPRAY<br />
FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.01% CREAM(GM)<br />
FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.01% SOLUTION<br />
FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.025% CREAM(GM)<br />
FLUOCINOLONE ACETONIDE FLUOCINOLONE ACETONIDE 0.025% OINT.(GM)<br />
SYNALAR FLUOCINOLONE ACETONIDE 0.01% SOLUTION<br />
SYNALAR FLUOCINOLONE ACETONIDE 0.025% CREAM(GM)<br />
SYNALAR FLUOCINOLONE ACETONIDE 0.025% OINT.(GM)<br />
DERMACIN FLUOCINONIDE 0.05% CREAM(GM)<br />
FLUOCINONIDE FLUOCINONIDE 0.05% CREAM(GM)<br />
FLUOCINONIDE FLUOCINONIDE 0.05% GEL<br />
FLUOCINONIDE FLUOCINONIDE 0.05% OINT.(GM)<br />
FLUOCINONIDE FLUOCINONIDE 0.05% SOLUTION<br />
LIDEX FLUOCINONIDE 0.05% CREAM(GM)<br />
LIDEX FLUOCINONIDE 0.05% GEL<br />
LIDEX FLUOCINONIDE 0.05% OINT.(GM)<br />
LIDEX FLUOCINONIDE 0.05% SOLUTION<br />
FLUORACAINE FLUORESCEIN NA/PROPARAC HCL 0.5-0.25% DROPS<br />
AK-FLUOR FLUORESCEIN SODIUM 10% AMPUL<br />
AK-FLUOR FLUORESCEIN SODIUM 25% AMPUL<br />
ANGISCEIN FLUORESCEIN SODIUM 10% AMPUL<br />
FLUORESCEIN LITE FLUORESCEIN SODIUM 10% VIAL<br />
FLUORESCEIN LITE FLUORESCEIN SODIUM 25% VIAL<br />
FLUORESCEIN SODIUM FLUORESCEIN SODIUM 2% DROPS<br />
FLUORESCITE FLUORESCEIN SODIUM 10% AMPUL<br />
FLUORESCITE FLUORESCEIN SODIUM 25% AMPUL<br />
FLUORETS FLUORESCEIN SODIUM 1MG STRIP<br />
FLUOR-I-STRIP AT FLUORESCEIN SODIUM 1MG STRIP<br />
TRI-VI-FLOR W/IRON FLUORIDE ION/IRON/VIT A,C&D 0.25MG/ML DROPS<br />
TRI-VIT W/FLUORIDE & IRON FLUORIDE ION/IRON/VIT A,C&D 0.25MG/ML DROPS<br />
TRI-VITAMIN W/IRON & FLUORIDE FLUORIDE ION/IRON/VIT A,C&D 0.25MG/ML DROPS<br />
VI-DAYLIN/F ADC PLUS IRON FLUORIDE ION/IRON/VIT A,C&D 0.25MG/ML DROPS<br />
FLORVITE FLUORIDE ION/MULTIVITAMINS 1MG TAB CHEW<br />
MULTI VIT W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.25MG TAB CHEW<br />
MULTI VITA-BETS W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.25MG TAB CHEW<br />
MULTI-VIT W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.25MG/ML DROPS<br />
MULTI-VIT W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.5MG/ML DROPS<br />
MULTI-VITA BETS W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.5MG TAB CHEW<br />
MULTI-VITA BETS W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 1MG TAB CHEW<br />
MULTI-VITA W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.25MG/ML DROPS<br />
MULTI-VITA W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.5MG/ML DROPS<br />
MULTI-VITAM FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.25MG/ML DROPS<br />
MULTIVITAMINS W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.25MG/ML DROPS<br />
MULTIVITAMINS W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.5MG TAB CHEW<br />
MULTIVITAMINS W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.5MG/ML DROPS<br />
MULTIVITAMINS W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 1MG TAB CHEW<br />
MULTIVITE W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 1MG TAB CHEW<br />
POLYTAB FLUORIDE ION/MULTIVITAMINS 0.5MG TAB CHEW<br />
POLY-VI-FLOR FLUORIDE ION/MULTIVITAMINS 0.25MG TAB CHEW<br />
POLY-VI-FLOR FLUORIDE ION/MULTIVITAMINS 0.25MG/ML DROPS<br />
POLY-VI-FLOR FLUORIDE ION/MULTIVITAMINS 0.5MG TAB CHEW<br />
POLY-VI-FLOR FLUORIDE ION/MULTIVITAMINS 0.5MG/ML DROPS<br />
POLY-VI-FLOR FLUORIDE ION/MULTIVITAMINS 1MG TAB CHEW<br />
POLY-VITAMIN W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.25MG/ML DROPS<br />
POLY-VITAMIN W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.5MG/ML DROPS<br />
Page 40<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
POLY-VITAMINS W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.25MG/ML DROPS<br />
POLYVITAMINS W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.25MG/ML DROPS<br />
POLYVITAMINS W/FLUORIDE FLUORIDE ION/MULTIVITAMINS 0.5MG/ML DROPS<br />
VI-DAYLIN/F FLUORIDE ION/MULTIVITAMINS 0.25MG/ML DROPS<br />
MULTI-VIT W/FLUORIDE & IRON FLUORIDE ION/MULTIVITS W-FE 0.5MG/ML DROPS<br />
MULTI-VIT/IRON & FLUORIDE FLUORIDE ION/MULTIVITS W-FE 0.25MG/ML DROPS<br />
MULTI-VIT/IRON & FLUORIDE FLUORIDE ION/MULTIVITS W-FE 0.5MG/ML DROPS<br />
MULTIVITA BETS W/FLUORIDE/IRON FLUORIDE ION/MULTIVITS W-FE 0.5MG TAB CHEW<br />
MULTI-VITA BETS/FLUORIDE/IRON FLUORIDE ION/MULTIVITS W-FE 1MG TAB CHEW<br />
MULTIVITAMIN W/FLUORIDE & IRON FLUORIDE ION/MULTIVITS W-FE 0.25MG/ML DROPS<br />
MULTIVITAMIN W/FLUORIDE & IRON FLUORIDE ION/MULTIVITS W-FE 0.5MG TAB CHEW<br />
MULTIVITAMIN W/FLUORIDE & IRON FLUORIDE ION/MULTIVITS W-FE 0.5MG/ML DROPS<br />
MULTIVITAMINS/FLUORIDE/IRON FLUORIDE ION/MULTIVITS W-FE 1MG TAB CHEW<br />
POLY-VI-FLOR W/IRON FLUORIDE ION/MULTIVITS W-FE 0.25MG/ML DROPS<br />
POLY-VI-FLOR W/IRON FLUORIDE ION/MULTIVITS W-FE 0.5MG TAB CHEW<br />
POLY-VITAMIN W/IRON & FLUORIDE FLUORIDE ION/MULTIVITS W-FE 0.25MG/ML DROPS<br />
POLY-VITAMIN W/IRON & FLUORIDE FLUORIDE ION/MULTIVITS W-FE 0.5MG/ML DROPS<br />
VI-DAYLIN/F + IRON FLUORIDE ION/MULTIVITS W-FE 0.25MG/ML DROPS<br />
ADC W/FLUORIDE FLUORIDE ION/VIT A,C&D 0.25MG/ML DROPS<br />
ADC W/FLUORIDE FLUORIDE ION/VIT A,C&D 0.5MG/ML DROPS<br />
ADC W/FLUORIDE FLUORIDE ION/VIT A,C&D 1MG TAB CHEW<br />
SOLUVITE-F FLUORIDE ION/VIT A,C&D 0.25MG/ML DROPS<br />
TRI-A-VITE W/FLUORIDE FLUORIDE ION/VIT A,C&D 1MG TAB CHEW<br />
TRI-VI-FLOR FLUORIDE ION/VIT A,C&D 0.25MG/ML DROPS<br />
TRI-VIT/FL FLUORIDE ION/VIT A,C&D 0.25MG/ML DROPS<br />
TRI-VIT/FL FLUORIDE ION/VIT A,C&D 0.5MG/ML DROPS<br />
TRI-VIT/FLUORIDE FLUORIDE ION/VIT A,C&D 1MG TAB CHEW<br />
TRI-VITA BETS W/FLUORIDE FLUORIDE ION/VIT A,C&D 1MG TAB CHEW<br />
TRI-VITAM W/FLUORIDE FLUORIDE ION/VIT A,C&D 0.25MG/ML DROPS<br />
TRI-VITAM W/FLUORIDE FLUORIDE ION/VIT A,C&D 0.5MG/ML DROPS<br />
TRI-VITAMIN W/FLUORIDE FLUORIDE ION/VIT A,C&D 0.25MG/ML DROPS<br />
TRI-VITAMIN W/FLUORIDE FLUORIDE ION/VIT A,C&D 0.5MG/ML DROPS<br />
TRI-VITAMINS W/FLUORIDE FLUORIDE ION/VIT A,C&D 0.25MG/ML DROPS<br />
TRI-VITAMINS W/FLUORIDE FLUORIDE ION/VIT A,C&D 0.5MG/ML DROPS<br />
TRI-VITE W/FLUORIDE FLUORIDE ION/VIT A,C&D 0.25MG/ML DROPS<br />
TRI-VITE W/FLUORIDE FLUORIDE ION/VIT A,C&D 0.5MG/ML DROPS<br />
VI-DAYLIN F ADC FLUORIDE ION/VIT A,C&D 0.25MG/ML DROPS<br />
FLUOROMETHOLONE FLUOROMETHOLONE 0.1% DROPS SUSP<br />
FLUOR-OP FLUOROMETHOLONE 0.1% DROPS SUSP<br />
FML FLUOROMETHOLONE 0.1% DROPS SUSP<br />
EFLONE FLUOROMETHOLONE ACETATE 0.1% DROPS SUSP<br />
ADRUCIL FLUOROURACIL 50MG/ML VIAL<br />
FLUOROURACIL FLUOROURACIL 50MG/ML VIAL<br />
FLUOXETINE HCL FLUOXETINE HCL 10MG CAPSULE<br />
FLUOXETINE HCL FLUOXETINE HCL 10MG TABLET<br />
FLUOXETINE HCL FLUOXETINE HCL 20MG CAPSULE<br />
FLUOXETINE HCL FLUOXETINE HCL 20MG TABLET<br />
FLUOXETINE HCL FLUOXETINE HCL 20MG/5ML SOLUTION<br />
FLUOXETINE HCL FLUOXETINE HCL 40MG CAPSULE<br />
PROZAC FLUOXETINE HCL 10MG CAPSULE<br />
PROZAC FLUOXETINE HCL 10MG TABLET<br />
PROZAC FLUOXETINE HCL 20MG CAPSULE<br />
PROZAC FLUOXETINE HCL 20MG/5ML SOLUTION<br />
PROZAC FLUOXETINE HCL 40MG CAPSULE<br />
SARAFEM FLUOXETINE HCL 10MG CAPSULE<br />
SARAFEM FLUOXETINE HCL 20MG CAPSULE<br />
FLUOXYMESTERONE FLUOXYMESTERONE 10MG TABLET<br />
HALOTESTIN FLUOXYMESTERONE 10MG TABLET<br />
FLUPHENAZINE DECANOATE FLUPHENAZINE DECANOATE 25MG/ML VIAL<br />
PROLIXIN DECANOATE FLUPHENAZINE DECANOATE 25MG/ML VIAL<br />
FLUPHENAZINE HCL FLUPHENAZINE HCL 10MG TABLET<br />
FLUPHENAZINE HCL FLUPHENAZINE HCL 1MG TABLET<br />
FLUPHENAZINE HCL FLUPHENAZINE HCL 2.5MG TABLET<br />
FLUPHENAZINE HCL FLUPHENAZINE HCL 2.5MG/5ML ELIXIR<br />
FLUPHENAZINE HCL FLUPHENAZINE HCL 2.5MG/ML VIAL<br />
FLUPHENAZINE HCL FLUPHENAZINE HCL 5MG TABLET<br />
FLUPHENAZINE HCL FLUPHENAZINE HCL 5MG/ML ORAL CONC.<br />
PERMITIL FLUPHENAZINE HCL 10MG TABLET<br />
PERMITIL FLUPHENAZINE HCL 2.5MG TABLET<br />
PERMITIL FLUPHENAZINE HCL 5MG TABLET<br />
PROLIXIN FLUPHENAZINE HCL 10MG TABLET<br />
PROLIXIN FLUPHENAZINE HCL 1MG TABLET<br />
PROLIXIN FLUPHENAZINE HCL 2.5MG TABLET<br />
PROLIXIN FLUPHENAZINE HCL 2.5MG/5ML ELIXIR<br />
PROLIXIN FLUPHENAZINE HCL 5MG TABLET<br />
Page 41<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
PROLIXIN FLUPHENAZINE HCL 5MG/ML ORAL CONC.<br />
DALMANE FLURAZEPAM HCL 15MG CAPSULE<br />
DALMANE FLURAZEPAM HCL 30MG CAPSULE<br />
FLURAZEPAM HCL FLURAZEPAM HCL 15MG CAPSULE<br />
FLURAZEPAM HCL FLURAZEPAM HCL 30MG CAPSULE<br />
ANSAID FLURBIPROFEN 100MG TABLET<br />
ANSAID FLURBIPROFEN 50MG TABLET<br />
FLURBIPROFEN FLURBIPROFEN 100MG TABLET<br />
FLURBIPROFEN FLURBIPROFEN 50MG TABLET<br />
FLURBIPROFEN SODIUM FLURBIPROFEN SODIUM 0.03% DROPS<br />
OCUFEN FLURBIPROFEN SODIUM 0.03% DROPS<br />
EULEXIN FLUTAMIDE 125MG CAPSULE<br />
FLUTAMIDE FLUTAMIDE 125MG CAPSULE<br />
FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 100MG TABLET<br />
FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 25MG TABLET<br />
FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 50MG TABLET<br />
LUVOX FLUVOXAMINE MALEATE 100MG TABLET<br />
LUVOX FLUVOXAMINE MALEATE 25MG TABLET<br />
LUVOX FLUVOXAMINE MALEATE 50MG TABLET<br />
FOLIC ACID FOLIC ACID 1MG TABLET<br />
FOLIC ACID FOLIC ACID 5MG/ML VIAL<br />
GLUTOFAC-ZX FOLIC ACID/MULTIVITS-MIN TABLET<br />
NUTRIFAC ZX FOLIC ACID/MULTIVITS-MIN TABLET<br />
NUTRIFAC ZX FOLIC ACID/MULTIVITS-MIN 1MG TABLET<br />
THERAPEUTIC VITAMIN W/MINERALS FOLIC ACID/MU-VITS-MIN TH CAPSULE<br />
V-C FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE<br />
VI-C FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE<br />
VICA-FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE<br />
VIC-FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE<br />
VICON FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE<br />
VITACON FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE<br />
VITA S FORTE FOLIC ACID/MV,FE,OTHER MIN 0.8MG TABLET<br />
NIAFOL FOLIC ACID/NIACINAMIDE/ZINC 0.5-750-25 TABLET<br />
NEPHPLEX RX FOLIC ACID/VIT BCOMP&C/ZINC 1MG TABLET<br />
B-PLEX FOLIC ACID/VITAMIN B COMP W-C 0.5MG TABLET<br />
DIALYVITE FOLIC ACID/VITAMIN B COMP W-C 1MG TABLET<br />
DIATX FOLIC ACID/VITAMIN B COMP W-C 5MG TABLET<br />
FORMULA-B FOLIC ACID/VITAMIN B COMP W-C 0.5MG TABLET<br />
NEPHRONEX FOLIC ACID/VITAMIN B COMP W-C 1MG TABLET<br />
NEPHRO-VITE RX FOLIC ACID/VITAMIN B COMP W-C 1MG TABLET<br />
RENAL CAPS FOLIC ACID/VITAMIN B COMP W-C 1MG CAPSULE<br />
RENAPHRO FOLIC ACID/VITAMIN B COMP W-C 1MG CAPSULE<br />
RENA-VITE RX FOLIC ACID/VITAMIN B COMP W-C 1MG TABLET<br />
LAZERFORMALYDE FORMALDEHYDE 10% SOLUTION<br />
FUROSEMIDE FUROSEMIDE 10MG/ML AMPUL<br />
FUROSEMIDE FUROSEMIDE 10MG/ML DISP SYRIN<br />
FUROSEMIDE FUROSEMIDE 10MG/ML SOLUTION<br />
FUROSEMIDE FUROSEMIDE 10MG/ML VIAL<br />
FUROSEMIDE FUROSEMIDE 20MG TABLET<br />
FUROSEMIDE FUROSEMIDE 40MG TABLET<br />
FUROSEMIDE FUROSEMIDE 80MG TABLET<br />
LASIX FUROSEMIDE 20MG TABLET<br />
LASIX FUROSEMIDE 40MG TABLET<br />
LASIX FUROSEMIDE 80MG TABLET<br />
GEMFIBROZIL GEMFIBROZIL 600MG TABLET<br />
LOPID GEMFIBROZIL 600MG TABLET<br />
GENTAMICIN SULFATE IN NS GENTAM SULF/SODIUM CHLORIDE 100MG/0.1L PIGGYBACK<br />
GENTAMICIN SULFATE IN NS GENTAM SULF/SODIUM CHLORIDE 60MG/100ML PIGGYBACK<br />
GENTAMICIN SULFATE IN NS GENTAM SULF/SODIUM CHLORIDE 60MG/50ML PIGGYBACK<br />
GENTAMICIN SULFATE IN NS GENTAM SULF/SODIUM CHLORIDE 80MG/100ML PIGGYBACK<br />
GENTAMICIN SULFATE IN NS GENTAM SULF/SODIUM CHLORIDE 80MG/50ML PIGGYBACK<br />
ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 100MG/0.1L PIGGYBACK<br />
ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 100MG/50ML PIGGYBACK<br />
ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 60MG/100ML PIGGYBACK<br />
ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 60MG/50ML PIGGYBACK<br />
ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 80MG/100ML PIGGYBACK<br />
ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 80MG/50ML PIGGYBACK<br />
GARAMYCIN GENTAMICIN SULFATE 0.1% CREAM(GM)<br />
GARAMYCIN GENTAMICIN SULFATE 0.3% DROPS<br />
GARAMYCIN GENTAMICIN SULFATE 0.3% OINT.(GM)<br />
GARAMYCIN GENTAMICIN SULFATE 40MG/ML VIAL<br />
GENOPTIC GENTAMICIN SULFATE 0.3% DROPS<br />
GENTACIDIN GENTAMICIN SULFATE 0.3% DROPS<br />
GENTAFAIR GENTAMICIN SULFATE 0.3% DROPS<br />
GENTAK GENTAMICIN SULFATE 0.3% DROPS<br />
Page 42<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
GENTAK GENTAMICIN SULFATE 0.3% OINT.(GM)<br />
GENTAMICIN SULFATE GENTAMICIN SULFATE 0.1% CREAM(GM)<br />
GENTAMICIN SULFATE GENTAMICIN SULFATE 0.1% OINT.(GM)<br />
GENTAMICIN SULFATE GENTAMICIN SULFATE 0.3% DROPS<br />
GENTAMICIN SULFATE GENTAMICIN SULFATE 10MG/ML VIAL<br />
GENTAMICIN SULFATE GENTAMICIN SULFATE 40MG/ML VIAL<br />
GENTASOL GENTAMICIN SULFATE 0.3% DROPS<br />
G-MYTICIN GENTAMICIN SULFATE 0.1% CREAM(GM)<br />
GLIPIZIDE GLIPIZIDE 10MG TABLET<br />
GLIPIZIDE GLIPIZIDE 5MG TABLET<br />
GLUCOTROL GLIPIZIDE 10MG TABLET<br />
GLUCOTROL GLIPIZIDE 5MG TABLET<br />
GLUCAGEN GLUCAGON,HUMAN RECOMBINANT 1MG VIAL<br />
HEMORRHOIDAL GLY/PE/PET,WH/SHARK LIVER CREAM(GM)<br />
HEM-PREP GLY/PE/PET,WH/SHARK LIVER CREAM(GM)<br />
PREPARATION H GLY/PE/PET,WH/SHARK LIVER CREAM(GM)<br />
V-R HEMORRHOIDAL GLY/PE/PET,WH/SHARK LIVER CREAM(GM)<br />
DIABETA GLYBURIDE 1.25MG TABLET<br />
DIABETA GLYBURIDE 2.5MG TABLET<br />
DIABETA GLYBURIDE 5MG TABLET<br />
GLYBURIDE GLYBURIDE 1.25MG TABLET<br />
GLYBURIDE GLYBURIDE 2.5MG TABLET<br />
GLYBURIDE GLYBURIDE 5MG TABLET<br />
MICRONASE GLYBURIDE 1.25MG TABLET<br />
MICRONASE GLYBURIDE 2.5MG TABLET<br />
MICRONASE GLYBURIDE 5MG TABLET<br />
GLYBURIDE MICRONIZED GLYBURIDE,MICRONIZED 1.5MG TABLET<br />
GLYBURIDE MICRONIZED GLYBURIDE,MICRONIZED 3MG TABLET<br />
GLYBURIDE MICRONIZED GLYBURIDE,MICRONIZED 6MG TABLET<br />
GLYCRON GLYBURIDE,MICRONIZED 1.5MG TABLET<br />
GLYCRON GLYBURIDE,MICRONIZED 3MG TABLET<br />
GLYCRON GLYBURIDE,MICRONIZED 6MG TABLET<br />
GLYNASE GLYBURIDE,MICRONIZED 1.5MG TABLET<br />
GLYNASE GLYBURIDE,MICRONIZED 3MG TABLET<br />
GLYNASE GLYBURIDE,MICRONIZED 6MG TABLET<br />
AMINOACETIC ACID GLYCINE 1.5% IRRIG SOLN<br />
GLYCINE GLYCINE 1.5% IRRIG SOLN<br />
GLYCOPYRROLATE GLYCOPYRROLATE 0.2MG/ML VIAL<br />
ROBINUL GLYCOPYRROLATE 0.2MG/ML VIAL<br />
CHOREX-10 GONADOTROPIN,CHORIONIC,HUMAN 10000 UNIT VIAL<br />
CHORIONIC GONADOTROPIN GONADOTROPIN,CHORIONIC,HUMAN 10000 UNIT VIAL<br />
CHORIONIC GONADOTROPIN GONADOTROPIN,CHORIONIC,HUMAN 10MU VIAL<br />
NOVAREL GONADOTROPIN,CHORIONIC,HUMAN 10000 UNIT VIAL<br />
PREGNYL GONADOTROPIN,CHORIONIC,HUMAN 10000 UNIT VIAL<br />
PROFASI GONADOTROPIN,CHORIONIC,HUMAN 10000 UNIT VIAL<br />
PROFASI GONADOTROPIN,CHORIONIC,HUMAN 5000 UNIT VIAL<br />
NEOCIDIN GRAMICID D/NEOMY SULF/POLY DROPS<br />
NEOCIN-PG GRAMICID D/NEOMY SULF/POLY DROPS<br />
NEOMYCIN/POLYMYXIN/GRAMICIDIN GRAMICID D/NEOMY SULF/POLY DROPS<br />
NEOPTIC GRAMICID D/NEOMY SULF/POLY DROPS<br />
NEOSPORIN GRAMICID D/NEOMY SULF/POLY DROPS<br />
FULVICIN P/G GRISEOFULVIN ULTRAMICROSIZE 125MG TABLET<br />
FULVICIN P/G GRISEOFULVIN ULTRAMICROSIZE 165MG TABLET<br />
FULVICIN P/G GRISEOFULVIN ULTRAMICROSIZE 250MG TABLET<br />
FULVICIN P/G GRISEOFULVIN ULTRAMICROSIZE 330MG TABLET<br />
GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN ULTRAMICROSIZE 125MG TABLET<br />
GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN ULTRAMICROSIZE 250MG TABLET<br />
GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN ULTRAMICROSIZE 330MG TABLET<br />
FULVICIN U/F GRISEOFULVIN,MICROSIZE 500MG TABLET<br />
ALLFEN-M GUAIFENESIN 600MG TABLET SA<br />
ALTARUSSIN GUAIFENESIN 100MG/5ML SYRUP<br />
AMIBID LA GUAIFENESIN 600MG TABLET SA<br />
AQUAMIST GUAIFENESIN 600MG TABLET SA<br />
BENADRILINA GUAIFENESIN 100MG/5ML SYRUP<br />
COUGH CONTROL GUAIFENESIN 100MG/5ML SYRUP<br />
DIABETIC FORMULA GUAIFENESIN 100MG/5ML SYRUP<br />
DIABETIC TUSSIN EX GUAIFENESIN 100MG/5ML LIQUID<br />
DIABETIC TUSSIN EX GUAIFENESIN 100MG/5ML SYRUP<br />
DURATUSS G GUAIFENESIN 1200MG TAB.SR 12H<br />
EXPECTORANT GUAIFENESIN 100MG/5ML SYRUP<br />
FENESIN GUAIFENESIN 600MG TABLET SA<br />
GANIDIN NR GUAIFENESIN 100MG/5ML LIQUID<br />
GEE-GEE GUAIFENESIN 200MG TABLET<br />
GG 200 NR GUAIFENESIN 200MG TABLET<br />
GLYTUSS GUAIFENESIN 200MG TABLET<br />
Page 43<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
GUAIATUSSIN GUAIFENESIN 100MG/5ML SYRUP<br />
GUAIBID LA GUAIFENESIN 600MG TABLET SA<br />
GUAIFENESIN GUAIFENESIN 100MG/5ML LIQUID<br />
GUAIFENESIN GUAIFENESIN 100MG/5ML SYRUP<br />
GUAIFENESIN GUAIFENESIN 1200MG TAB.SR 12H<br />
GUAIFENESIN GUAIFENESIN 200MG TABLET<br />
GUAIFENESIN GUAIFENESIN 600MG TABLET SA<br />
GUAIFENESIN ER GUAIFENESIN 600MG TABLET SA<br />
GUAIFENESIN LA GUAIFENESIN 1200MG TAB.SR 12H<br />
GUAIFENESIN LA GUAIFENESIN 600MG TABLET SA<br />
GUAIFENESIN NR GUAIFENESIN 100MG/5ML LIQUID<br />
GUAIFENESIN-SR GUAIFENESIN 1200MG TAB.SR 12H<br />
GUAIFENESIN-SR GUAIFENESIN 600MG TABLET SA<br />
GUAIFENEX LA GUAIFENESIN 600MG TABLET SA<br />
GUA-SR GUAIFENESIN 600MG TABLET SA<br />
GUIADRINE G-1200 GUAIFENESIN 1200MG TAB.SR 12H<br />
GUIATUSS GUAIFENESIN 100MG/5ML SYRUP<br />
HM TUSSIN GUAIFENESIN 100MG/5ML SYRUP<br />
HM TUSSIN COUGH GUAIFENESIN 100MG/5ML SYRUP<br />
HUMIBID L.A. GUAIFENESIN 600MG TABLET SA<br />
IODROL NR GUAIFENESIN 200MG TABLET<br />
IOPHEN NR GUAIFENESIN 100MG/5ML LIQUID<br />
IOPHEN-NR GUAIFENESIN 100MG/5ML LIQUID<br />
KOMATUSSIN GUAIFENESIN 100MG/5ML SYRUP<br />
LIQUIBID GUAIFENESIN 600MG TABLET SA<br />
LIQUIBID 1200 GUAIFENESIN 1200MG TAB.SR 12H<br />
MONAFED GUAIFENESIN 600MG TABLET SA<br />
MUCO-FEN 1200 GUAIFENESIN 1200MG TAB.SR 12H<br />
NALDECON SENIOR EX GUAIFENESIN 200MG/5ML LIQUID<br />
ORGADIN GUAIFENESIN 100MG/5ML LIQUID<br />
ORGAN-I NR GUAIFENESIN 200MG TABLET<br />
ORGANIDIN NR GUAIFENESIN 100MG/5ML LIQUID<br />
ORGANIDIN NR GUAIFENESIN 200MG TABLET<br />
PEDIATRIC COUGH/COLD GUAIFENESIN 100MG/5ML SYRUP<br />
PHANASIN GUAIFENESIN 100MG/5ML SYRUP<br />
PHARMASIN GUAIFENESIN 100MG/5ML SYRUP<br />
Q-BID LA GUAIFENESIN 600MG TABLET SA<br />
Q-TUSSIN GUAIFENESIN 100MG/5ML SYRUP<br />
REFENESEN GUAIFENESIN 200MG TABLET<br />
RESPA-GF GUAIFENESIN 600MG TABLET SA<br />
RI-TUSSIN GUAIFENESIN 100MG/5ML SYRUP<br />
ROBAFEN GUAIFENESIN 100MG/5ML SYRUP<br />
ROBITUSSIN GUAIFENESIN 100MG/5ML SYRUP<br />
SCOT-TUSSIN GUAIFENESIN 100MG/5ML LIQUID<br />
SILTUSSIN DAS GUAIFENESIN 100MG/5ML LIQUID<br />
SILTUSSIN SA GUAIFENESIN 100MG/5ML SYRUP<br />
TUSSIN GUAIFENESIN 100MG/5ML SYRUP<br />
TUSSIN COUGH GUAIFENESIN 100MG/5ML SYRUP<br />
TUSSIN EXPECTORANT GUAIFENESIN 100MG/5ML SYRUP<br />
TUSSIN HONEY GUAIFENESIN 100MG/5ML SYRUP<br />
UNI-TUSSIN GUAIFENESIN 100MG/5ML SYRUP<br />
COLDCOUGH XP GUAIFENESIN/HCOD/P-EPHED HCL 100-15-3/5 LIQUID<br />
DECONAMINE CX GUAIFENESIN/HCOD/P-EPHED HCL 200-60-5 EXPECT.<br />
DECONAMINE CX GUAIFENESIN/HCOD/P-EPHED HCL 300-30-5 TABLET<br />
DETUSSIN GUAIFENESIN/HCOD/P-EPHED HCL 200-60-5 EXPECT.<br />
DRITUSS HD GUAIFENESIN/HCOD/P-EPHED HCL 100-30-2.5 ELIXIR<br />
DURATUSS HD GUAIFENESIN/HCOD/P-EPHED HCL 100-30-2.5 ELIXIR<br />
ENTUSS-D GUAIFENESIN/HCOD/P-EPHED HCL 100-30-2.5 SOLUTION<br />
ENTUSS-D GUAIFENESIN/HCOD/P-EPHED HCL 300-30-5 TABLET<br />
GUAIFENESIN/P-EPHED HCL/HCOD GUAIFENESIN/HCOD/P-EPHED HCL 100-15-3/5 LIQUID<br />
HYDRO-TUSSIN HD GUAIFENESIN/HCOD/P-EPHED HCL 100-30-2.5 SOLUTION<br />
HYDRO-TUSSIN XP GUAIFENESIN/HCOD/P-EPHED HCL 100-15-3/5 LIQUID<br />
JAYCOF-XP GUAIFENESIN/HCOD/P-EPHED HCL 100-15-3/5 LIQUID<br />
KG-TUSS HD GUAIFENESIN/HCOD/P-EPHED HCL 100-30-2.5 SOLUTION<br />
MED-HIST GUAIFENESIN/HCOD/P-EPHED HCL 200-60-5 EXPECT.<br />
MEDTUSS HD GUAIFENESIN/HCOD/P-EPHED HCL 100-30-2.5 ELIXIR<br />
NALEX GUAIFENESIN/HCOD/P-EPHED HCL 200-60-5 EXPECT.<br />
PANCOF XP GUAIFENESIN/HCOD/P-EPHED HCL 100-15-3/5 LIQUID<br />
POLY-TUSSIN XP GUAIFENESIN/HCOD/P-EPHED HCL 200-60-5 EXPECT.<br />
SU-TUSS HD GUAIFENESIN/HCOD/P-EPHED HCL 100-30-2.5 ELIXIR<br />
TUSSADUR-HD GUAIFENESIN/HCOD/P-EPHED HCL 100-30-2.5 SOLUTION<br />
TUSS-AX GUAIFENESIN/HCOD/P-EPHED HCL 200-60-5 EXPECT.<br />
TUSSEND GUAIFENESIN/HCOD/P-EPHED HCL 100-30-2.5 SOLUTION<br />
VANACON GUAIFENESIN/HCOD/P-EPHED HCL 200-60-5 EXPECT.<br />
CLEARTUSS DH GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
Page 44<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
CODICLEAR DH GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
CODOTUSS GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
CO-TUSSIN GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
COTUSS-V GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
FENTUSS GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
G-TUSS GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
HYCOSIN GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
HYCOTUSS GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
HYDROCODONE GF GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
HYDROCODONE W/GUAIFENESIN GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
HYDRO-TUSS GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
HYDROTUSS GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
KWELCOF GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
M-CLEAR GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
MEDCODIN GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
PNEUMOTUSSIN HC GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
VICOCLEAR DH GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
VICODIN TUSS GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
VI-Q-TUSS GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
VITUSSIN GUAIFENESIN/HYDROCOD BIT 100-5/5ML SYRUP<br />
ABLETEX PSE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
AMI-TEX PSE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
BOCA-TEX PSE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
G-PHED-PD GUAIFENESIN/P-EPHED HCL 300-60MG CAPSULE SA<br />
GUAIFEN PSE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
GUAIFENESIN 600/PSE 120 GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
GUAIFENESIN W/PSEUDOEPHEDRINE GUAIFENESIN/P-EPHED HCL 300-60MG CAPSULE SA<br />
GUAIFENESIN W/PSEUDOEPHEDRINE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
GUAIFENESIN-P-PD GUAIFENESIN/P-EPHED HCL 300-60MG CAPSULE SA<br />
GUAIFENEX PSE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
GUAIFEN-PSE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
GUAIMAX-D GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
GUAIPAX PSE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
GUAI-VENT/PSE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
IOTEX PSE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
MIRAPHEN PSE GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
NALEX JR GUAIFENESIN/P-EPHED HCL 300-60MG CAPSULE SA<br />
PSE 120 GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
PSEUDOEPHEDRINE W/GUAIFENESIN GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
PSEUDO-G/PSI GUAIFENESIN/P-EPHED HCL 600-120MG TAB.SR 12H<br />
PSEUDOVENT PED GUAIFENESIN/P-EPHED HCL 300-60MG CAPSULE SA<br />
SINUFED TIMECELLES GUAIFENESIN/P-EPHED HCL 300-60MG CAPSULE SA<br />
MEDEX-LA GUAIFENESIN/PPA HCL 400-75MG TABLET SA<br />
BRONCOMAR GG GUAIFENESIN/THEOPHYLLINE 90-150 ELIXIR<br />
THEOLATE GUAIFENESIN/THEOPHYLLINE 90-150 ELIXIR<br />
THEOMAR GG GUAIFENESIN/THEOPHYLLINE 90-150 LIQUID<br />
GUANABENZ ACETATE GUANABENZ ACETATE 4MG TABLET<br />
GUANABENZ ACETATE GUANABENZ ACETATE 8MG TABLET<br />
GUANFACINE HCL GUANFACINE HCL 1MG TABLET<br />
GUANFACINE HCL GUANFACINE HCL 2MG TABLET<br />
TENEX GUANFACINE HCL 1MG TABLET<br />
TENEX GUANFACINE HCL 2MG TABLET<br />
HALOPERIDOL HALOPERIDOL 0.5MG TABLET<br />
HALOPERIDOL HALOPERIDOL 10MG TABLET<br />
HALOPERIDOL HALOPERIDOL 1MG TABLET<br />
HALOPERIDOL HALOPERIDOL 20MG TABLET<br />
HALOPERIDOL HALOPERIDOL 2MG TABLET<br />
HALOPERIDOL HALOPERIDOL 5MG TABLET<br />
HALDOL DECANOATE 100 HALOPERIDOL DECANOATE 100MG/ML VIAL<br />
HALDOL DECANOATE 50 HALOPERIDOL DECANOATE 50MG/ML VIAL<br />
HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 100MG/ML VIAL<br />
HALOPERIDOL DECANOATE HALOPERIDOL DECANOATE 50MG/ML VIAL<br />
HALDOL HALOPERIDOL LACTATE 5MG/ML VIAL<br />
HALOPERIDOL LACTATE HALOPERIDOL LACTATE 2MG/ML ORAL CONC.<br />
HALOPERIDOL LACTATE HALOPERIDOL LACTATE 5MG/ML VIAL<br />
ANTIBIOTIC EAR SOLUTION HC/NEOMY SULF/POLYMYX B SULF 1% SOLUTION<br />
ANTIBIOTIC EAR SUSPENSION HC/NEOMY SULF/POLYMYX B SULF 3.5-10M-1 DROPS SUSP<br />
CORTISPORIN HC/NEOMY SULF/POLYMYX B SULF DROPS SUSP<br />
CORTISPORIN HC/NEOMY SULF/POLYMYX B SULF 1% SOLUTION<br />
CORTISPORIN HC/NEOMY SULF/POLYMYX B SULF 3.5-10M-1 DROPS SUSP<br />
CORTOMYCIN HC/NEOMY SULF/POLYMYX B SULF 1% SOLUTION<br />
CORTOMYCIN HC/NEOMY SULF/POLYMYX B SULF 3.5-10M-1 DROPS SUSP<br />
NEOMYCIN/POLYMYXIN/HC HC/NEOMY SULF/POLYMYX B SULF 1% SOLUTION<br />
NEOMYCIN/POLYMYXIN/HC HC/NEOMY SULF/POLYMYX B SULF 3.5-10M-1 DROPS SUSP<br />
OTIMAR HC/NEOMY SULF/POLYMYX B SULF 1% SOLUTION<br />
Page 45<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
OTIMAR HC/NEOMY SULF/POLYMYX B SULF 3.5-10M-1 DROPS SUSP<br />
HYDRALAZINE W/HCTZ HCTZ/HYDRALAZINE HCL 50-50MG CAPSULE<br />
HYDRA-ZIDE HCTZ/HYDRALAZINE HCL 100-50MG CAPSULE<br />
HYDRA-ZIDE HCTZ/HYDRALAZINE HCL 25-25MG CAPSULE<br />
HYDRA-ZIDE HCTZ/HYDRALAZINE HCL 50-50MG CAPSULE<br />
CAM-AP-ES HCTZ/HYDRALAZINE HCL/RESERPINE 25-0.1-15 TABLET<br />
SERPAZIDE HCTZ/HYDRALAZINE HCL/RESERPINE 25-0.1-15 TABLET<br />
UNI-SERP HCTZ/HYDRALAZINE HCL/RESERPINE 25-0.1-15 TABLET<br />
INDERIDE-40/25 HCTZ/PROPRANOLOL HCL 40-25MG TABLET<br />
INDERIDE-80/25 HCTZ/PROPRANOLOL HCL 80-25MG TABLET<br />
PROPRANOLOL HCL W/HCTZ HCTZ/PROPRANOLOL HCL 25-80MG TABLET<br />
PROPRANOLOL HCL W/HCTZ HCTZ/PROPRANOLOL HCL 40-25MG TABLET<br />
PROPRANOLOL HCL W/HCTZ HCTZ/PROPRANOLOL HCL 80-25MG TABLET<br />
ALDACTAZIDE HCTZ/SPIRONOLACTONE 25-25MG TABLET<br />
SPIRONOLACTONE W/HCTZ HCTZ/SPIRONOLACTONE 25-25MG TABLET<br />
SPIRONOLACTONE/HCTZ HCTZ/SPIRONOLACTONE 25-25MG TABLET<br />
DYAZIDE HCTZ/TRIAMTERENE 37.5-25MG CAPSULE<br />
MAXZIDE HCTZ/TRIAMTERENE 75-50MG TABLET<br />
MAXZIDE-25MG HCTZ/TRIAMTERENE 37.5-25MG TABLET<br />
TRIAMTERENE W/HCTZ HCTZ/TRIAMTERENE 37.5-25MG CAPSULE<br />
TRIAMTERENE W/HCTZ HCTZ/TRIAMTERENE 37.5-25MG TABLET<br />
TRIAMTERENE W/HCTZ HCTZ/TRIAMTERENE 50-25MG CAPSULE<br />
TRIAMTERENE W/HCTZ HCTZ/TRIAMTERENE 50-75MG TABLET<br />
TRIAMTERENE W/HCTZ HCTZ/TRIAMTERENE 75-50MG TABLET<br />
TRIAMTERENE-HCTZ HCTZ/TRIAMTERENE 75-50MG TABLET<br />
HEPARIN FLUSH HEP NA,PORCINE/NACL 0.9% 10 UNIT/ML KIT<br />
HEPARIN FLUSH HEP NA,PORCINE/NACL 0.9% 100 U/ML KIT<br />
HEPARIN SODIUM IN 0.9% NACL HEP NA,PORCINE/NACL 0.9% 2 UNIT/ML IV SOLN.<br />
HEP-PAK HEP NA,PORCINE/NACL 0.9% 10 UNIT/ML KIT<br />
HEP-PAK HEP NA,PORCINE/NACL 0.9% 100 U/ML KIT<br />
HEP-PAK CVC HEP NA,PORCINE/NACL 0.9% 100 U/ML KIT<br />
HEP-PAK LKFL HEP NA,PORCINE/NACL 0.9% 100 U/ML KIT<br />
HEPARIN LOCK HEPARIN SODIUM (PORCINE) 10U/ML VIAL<br />
HEPARIN SODIUM HEPARIN SODIUM,BEEF 1000 U/ML VIAL<br />
HEPARIN SODIUM HEPARIN SODIUM,BEEF 10000 U/ML VIAL<br />
HEPARIN IV FLUSH HEPARIN SODIUM,PORCINE 10 UNIT/ML DISP SYRIN<br />
HEPARIN IV FLUSH HEPARIN SODIUM,PORCINE 100 U/ML DISP SYRIN<br />
HEPARIN LOCK HEPARIN SODIUM,PORCINE 10 UNIT/ML VIAL<br />
HEPARIN LOCK HEPARIN SODIUM,PORCINE 100 U/ML VIAL<br />
HEPARIN LOCK FLUSH HEPARIN SODIUM,PORCINE 10 UNIT/ML DISP SYRIN<br />
HEPARIN LOCK FLUSH HEPARIN SODIUM,PORCINE 10 UNIT/ML VIAL<br />
HEPARIN LOCK FLUSH HEPARIN SODIUM,PORCINE 100 U/ML DISP SYRIN<br />
HEPARIN LOCK FLUSH HEPARIN SODIUM,PORCINE 100 U/ML VIAL<br />
HEPARIN SODIUM HEPARIN SODIUM,PORCINE 1000 U/ML VIAL<br />
HEPARIN SODIUM HEPARIN SODIUM,PORCINE 10000 U/ML DISP SYRIN<br />
HEPARIN SODIUM HEPARIN SODIUM,PORCINE 10000 U/ML VIAL<br />
HEPARIN SODIUM HEPARIN SODIUM,PORCINE 20000 U/ML VIAL<br />
HEPARIN SODIUM HEPARIN SODIUM,PORCINE 2500 U/ML DISP SYRIN<br />
HEPARIN SODIUM HEPARIN SODIUM,PORCINE 5000 U/ML DISP SYRIN<br />
HEPARIN SODIUM HEPARIN SODIUM,PORCINE 5000 U/ML VIAL<br />
HEPARIN SODIUM HEPARIN SODIUM,PORCINE 7500 U/ML DISP SYRIN<br />
HEP-LOCK HEPARIN SODIUM,PORCINE 10 UNIT/ML VIAL<br />
HEP-LOCK HEPARIN SODIUM,PORCINE 100 U/ML VIAL<br />
HEP-LOCK U/P HEPARIN SODIUM,PORCINE 10 UNIT/ML VIAL<br />
HEP-LOCK U/P HEPARIN SODIUM,PORCINE 100 U/ML VIAL<br />
VASCEZE (VAFD) HEPARIN SODIUM,PORCINE 100U/ML DISP SYRIN<br />
VASCEZE (VAFD) HEPARIN SODIUM,PORCINE 10U/ML DISP SYRIN<br />
BAYHEP B HEPATITIS B IMMUNE GLOBULIN DISP SYRIN<br />
BAYHEP B HEPATITIS B IMMUNE GLOBULIN VIAL<br />
HESPAN HETASTARCH/NACL 0.9% 6-0.9% PLAST. BAG<br />
HETASTARCH W/SODIUM CHLORIDE HETASTARCH/NACL 0.9% 6-0.9% PLAST. BAG<br />
HOMATROPAIRE HOMATROPINE HBR 5% DROPS<br />
HOMATROPINE HYDROBROMIDE HOMATROPINE HBR 5% DROPS<br />
HYCODAN HOMATROPINE/HYDROCODONE BIT 5-1-.5MG/5 SYRUP<br />
HYDROCODONE HOMATROPINE/HYDROCODONE BIT 5-1-.5MG/5 SYRUP<br />
HYDROCODONE BT/HOMATROPINE MBR HOMATROPINE/HYDROCODONE BIT 5-1.5MG TABLET<br />
HYDROCODONE COMPOUND HOMATROPINE/HYDROCODONE BIT 5-1-.5MG/5 SYRUP<br />
HYDROMET HOMATROPINE/HYDROCODONE BIT 5-1-.5MG/5 SYRUP<br />
HYDROPANE HOMATROPINE/HYDROCODONE BIT 5-1-.5MG/5 SYRUP<br />
TUSSIGON HOMATROPINE/HYDROCODONE BIT 5-1.5MG TABLET<br />
BIOLON HYALURONATE SODIUM 10MG/ML DISP SYRIN<br />
VITRAX HYALURONATE SODIUM 10MG/ML DISP SYRIN<br />
HYDRALAZINE HCL HYDRALAZINE HCL 100MG TABLET<br />
HYDRALAZINE HCL HYDRALAZINE HCL 10MG TABLET<br />
HYDRALAZINE HCL HYDRALAZINE HCL 20MG/ML VIAL<br />
Page 46<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
HYDRALAZINE HCL HYDRALAZINE HCL 25MG TABLET<br />
HYDRALAZINE HCL HYDRALAZINE HCL 50MG TABLET<br />
CAROZIDE HYDROCHLOROTHIAZIDE 50MG TABLET<br />
EZIDE HYDROCHLOROTHIAZIDE 50MG TABLET<br />
HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 100MG TABLET<br />
HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5MG CAPSULE<br />
HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 25MG TABLET<br />
HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 50MG TABLET<br />
HYDRODIURIL HYDROCHLOROTHIAZIDE 25MG TABLET<br />
MICROZIDE HYDROCHLOROTHIAZIDE 12.5MG CAPSULE<br />
ORETIC HYDROCHLOROTHIAZIDE 25MG TABLET<br />
ORETIC HYDROCHLOROTHIAZIDE 50MG TABLET<br />
LISINOPRIL-HCTZ HYDROCHLOROTHIAZIDE/LISINOPRIL 10-12.5MG TABLET<br />
LISINOPRIL-HCTZ HYDROCHLOROTHIAZIDE/LISINOPRIL 20-12.5MG TABLET<br />
LISINOPRIL-HCTZ HYDROCHLOROTHIAZIDE/LISINOPRIL 20-25MG TABLET<br />
PRINZIDE HYDROCHLOROTHIAZIDE/LISINOPRIL 10-12.5MG TABLET<br />
PRINZIDE HYDROCHLOROTHIAZIDE/LISINOPRIL 20-12.5MG TABLET<br />
PRINZIDE HYDROCHLOROTHIAZIDE/LISINOPRIL 20-25MG TABLET<br />
ZESTORETIC HYDROCHLOROTHIAZIDE/LISINOPRIL 10-12.5MG TABLET<br />
ZESTORETIC HYDROCHLOROTHIAZIDE/LISINOPRIL 20-12.5MG TABLET<br />
ZESTORETIC HYDROCHLOROTHIAZIDE/LISINOPRIL 20-25MG TABLET<br />
ALDORIL-15 HYDROCHLOROTHIAZIDE/METHYLDOPA 250-15MG TABLET<br />
ALDORIL-25 HYDROCHLOROTHIAZIDE/METHYLDOPA 250-25MG TABLET<br />
ALDORIL-D30 HYDROCHLOROTHIAZIDE/METHYLDOPA 500-30MG TABLET<br />
ALDORIL-D50 HYDROCHLOROTHIAZIDE/METHYLDOPA 500-50MG TABLET<br />
METHYLDOPA/HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE/METHYLDOPA 250-15MG TABLET<br />
METHYLDOPA/HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE/METHYLDOPA 250-25MG TABLET<br />
HYDROCHLOROTHIAZIDE/RESERPINE HYDROCHLOROTHIAZIDE/RESERPINE 0.125-25MG TABLET<br />
HYDROCHLOROTHIAZIDE/RESERPINE HYDROCHLOROTHIAZIDE/RESERPINE 0.125-50MG TABLET<br />
HYDRO-RESERP HYDROCHLOROTHIAZIDE/RESERPINE 0.125-50MG TABLET<br />
DETUSSIN HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SOLUTION<br />
H-C TUSSIVE-D HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SOLUTION<br />
HC TUSSIVE-D HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SOLUTION<br />
HISTUSSIN D HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SOLUTION<br />
IOTUSSIN D HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SOLUTION<br />
TUSS-S HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SYRUP<br />
ENTUSS HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SOLUTION<br />
HYDONE HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SOLUTION<br />
HYDRO PRO HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SYRUP<br />
HYDRON EX HYDROCODONE BIT/POT GUAIACO 120-2.5/5 SYRUP<br />
HYDRON KGS HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SYRUP<br />
JAYCOF HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SOLUTION<br />
POT GUAIACO/HYDROCODONE BIT HYDROCODONE BIT/POT GUAIACO 300-4.5/5 SYRUP<br />
PRO-COF HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SYRUP<br />
PROLEX DH HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SOLUTION<br />
PROTUSS HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SYRUP<br />
CODAL-DH HYDROCODONE/PHENYLEPHRINE/PYR 5-1.66MG/5 SYRUP<br />
CODIMAL DH HYDROCODONE/PHENYLEPHRINE/PYR 5-1.66MG/5 SYRUP<br />
CODITUSS DH HYDROCODONE/PHENYLEPHRINE/PYR 5-1.66MG/5 SYRUP<br />
HYCOMAL DH HYDROCODONE/PHENYLEPHRINE/PYR 5-1.66MG/5 SYRUP<br />
HYDROPHENE DH HYDROCODONE/PHENYLEPHRINE/PYR 5-1.66MG/5 SYRUP<br />
ANUSOL-HC HYDROCORTISONE 2.5% CREAM(GM)<br />
AQUANIL HC HYDROCORTISONE 1% LOTION<br />
BETA HC HYDROCORTISONE 1% LOTION<br />
CETACORT HYDROCORTISONE 1% LOTION<br />
COLOCORT HYDROCORTISONE 100MG/60ML ENEMA<br />
CORTAID HYDROCORTISONE 1% CREAM(GM)<br />
CORTEF HYDROCORTISONE 20MG TABLET<br />
DERMOLATE ANTI-ITCH HYDROCORTISONE 0.5% CREAM(GM)<br />
DR. SMITH'S ANTI-ITCH HYDROCORTISONE 0.25% LOTION<br />
HYCORT HYDROCORTISONE 1% CREAM(GM)<br />
HYCORT HYDROCORTISONE 1% OINT.(GM)<br />
HYDRO LOTION HYDROCORTISONE 1% LOTION<br />
HYDROCORTISONE HYDROCORTISONE 0.5% CREAM(GM)<br />
HYDROCORTISONE HYDROCORTISONE 0.5% LOTION<br />
HYDROCORTISONE HYDROCORTISONE 0.5% OINT.(GM)<br />
HYDROCORTISONE HYDROCORTISONE 1% CREAM(GM)<br />
HYDROCORTISONE HYDROCORTISONE 1% LOTION<br />
HYDROCORTISONE HYDROCORTISONE 1% OINT.(GM)<br />
HYDROCORTISONE HYDROCORTISONE 100MG/60ML ENEMA<br />
HYDROCORTISONE HYDROCORTISONE 2.5% CREAM(GM)<br />
HYDROCORTISONE HYDROCORTISONE 2.5% LOTION<br />
HYDROCORTISONE HYDROCORTISONE 2.5% OINT.(GM)<br />
HYDROCORTISONE HYDROCORTISONE 20MG TABLET<br />
HYDROCORTONE HYDROCORTISONE 10MG TABLET<br />
Page 47<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
HYTONE HYDROCORTISONE 1% CREAM(GM)<br />
HYTONE HYDROCORTISONE 1% LOTION<br />
HYTONE HYDROCORTISONE 2.5% CREAM(GM)<br />
HYTONE HYDROCORTISONE 2.5% LOTION<br />
HYTONE HYDROCORTISONE 2.5% OINT.(GM)<br />
INSTACORT-10 HYDROCORTISONE 1% GEL<br />
LACTICARE-HC HYDROCORTISONE 1% LOTION<br />
LACTICARE-HC HYDROCORTISONE 2.5% LOTION<br />
NUPERCAINAL HC HYDROCORTISONE 1% CREAM(GM)<br />
NUTRACORT HYDROCORTISONE 1% LOTION<br />
NUTRACORT HYDROCORTISONE 2.5% LOTION<br />
PREPARATION H HYDROCORTISONE 1% CREAM(GM)<br />
PROCTOCREAM-HC HYDROCORTISONE 2.5% CREAM(GM)<br />
PROCTO-KIT HYDROCORTISONE 1% CREAM(GM)<br />
PROCTOSOL-HC HYDROCORTISONE 2.5% CREAM(GM)<br />
PROCTOZONE-HC HYDROCORTISONE 2.5% CREAM(GM)<br />
RECORT PLUS HYDROCORTISONE 1% CREAM(GM)<br />
RECORT PLUS HYDROCORTISONE 1% LOTION<br />
REDERM HYDROCORTISONE 1% LOTION<br />
SARNOL-HC HYDROCORTISONE 1% LOTION<br />
SB HYDROCORTISONE HYDROCORTISONE 1% CREAM(GM)<br />
SCALP HYDROCORTISONE 1% SOLUTION<br />
SCALP CORT HYDROCORTISONE 1% LOTION<br />
SCALP-AID HYDROCORTISONE 1% LOTION<br />
CORTAID HYDROCORTISONE ACETATE 1% OINT.(GM)<br />
HEMRIL HYDROCORTISONE ACETATE 30MG SUPP.RECT<br />
HM HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE 1% CREAM(GM)<br />
HM HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE 1% OINT.(GM)<br />
HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE 0.5% CREAM(GM)<br />
HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE 1% CREAM(GM)<br />
HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE 1% OINT.(GM)<br />
HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE 25MG/ML VIAL<br />
PROCTOSERT HC HYDROCORTISONE ACETATE 30MG SUPP.RECT<br />
A-HYDROCORT HYDROCORTISONE SOD SUCCINATE 1000MG/8ML VIAL<br />
A-HYDROCORT HYDROCORTISONE SOD SUCCINATE 100MG/2ML VIAL<br />
A-HYDROCORT HYDROCORTISONE SOD SUCCINATE 250MG/2ML VIAL<br />
A-HYDROCORT HYDROCORTISONE SOD SUCCINATE 500MG/4ML VIAL<br />
HYDROCORTISONE SOD SUCCINATE HYDROCORTISONE SOD SUCCINATE 1000MG VIAL<br />
HYDROCORTISONE SOD SUCCINATE HYDROCORTISONE SOD SUCCINATE 100MG VIAL<br />
HYDROCORTISONE SOD SUCCINATE HYDROCORTISONE SOD SUCCINATE 250MG VIAL<br />
HYDROCORTISONE SOD SUCCINATE HYDROCORTISONE SOD SUCCINATE 500MG VIAL<br />
SOLU-CORTEF HYDROCORTISONE SOD SUCCINATE 1000MG/8ML VIAL<br />
SOLU-CORTEF HYDROCORTISONE SOD SUCCINATE 250MG/2ML VIAL<br />
SOLU-CORTEF HYDROCORTISONE SOD SUCCINATE 500MG/4ML VIAL<br />
HYDROCORTISONE VALERATE HYDROCORTISONE VALERATE 0.2% CREAM(GM)<br />
HYDROCORTISONE VALERATE HYDROCORTISONE VALERATE 0.2% OINT.(GM)<br />
WESTCORT HYDROCORTISONE VALERATE 0.2% CREAM(GM)<br />
DILAUDID HYDROMORPHONE HCL 2MG TABLET<br />
DILAUDID HYDROMORPHONE HCL 2MG/ML VIAL<br />
DILAUDID HYDROMORPHONE HCL 4MG TABLET<br />
DILAUDID STRIP PACKS HYDROMORPHONE HCL 2MG TABLET<br />
HYDROMORPHONE HCL HYDROMORPHONE HCL 10MG/ML AMPUL<br />
HYDROMORPHONE HCL HYDROMORPHONE HCL 1MG/ML DISP SYRIN<br />
HYDROMORPHONE HCL HYDROMORPHONE HCL 1MG/ML LIQUID<br />
HYDROMORPHONE HCL HYDROMORPHONE HCL 2MG TABLET<br />
HYDROMORPHONE HCL HYDROMORPHONE HCL 2MG/ML DISP SYRIN<br />
HYDROMORPHONE HCL HYDROMORPHONE HCL 2MG/ML VIAL<br />
HYDROMORPHONE HCL HYDROMORPHONE HCL 3MG SUPP.RECT<br />
HYDROMORPHONE HCL HYDROMORPHONE HCL 4MG TABLET<br />
HYDROMORPHONE HCL HYDROMORPHONE HCL 4MG/ML DISP SYRIN<br />
HYDROMORPHONE HCL HYDROMORPHONE HCL 8MG TABLET<br />
HYDROMORPHONE HYDROCHLORIDE HYDROMORPHONE HCL 2MG/ML VIAL<br />
LUSTRA HYDROQUINONE 4% CREAM(GM)<br />
HYDROXOCOBALAMIN HYDROXOCOBALAMIN 1000MCG/ML VIAL<br />
HYDROXYCHLOROQUINE SULFATE HYDROXYCHLOROQUINE SULFATE 200MG TABLET<br />
PLAQUENIL HYDROXYCHLOROQUINE SULFATE 200MG TABLET<br />
HYPROGEST 250 HYDROXYPROGESTERONE CAPROATE 250MG/ML VIAL<br />
HYDREA HYDROXYUREA 500MG CAPSULE<br />
HYDROXYUREA HYDROXYUREA 500MG CAPSULE<br />
ANX HYDROXYZINE HCL 25MG TABLET<br />
ATARAX HYDROXYZINE HCL 10MG TABLET<br />
ATARAX HYDROXYZINE HCL 10MG/5ML SYRUP<br />
ATARAX HYDROXYZINE HCL 25MG TABLET<br />
ATARAX HYDROXYZINE HCL 50MG TABLET<br />
HYDROXYZINE HCL HYDROXYZINE HCL 10MG TABLET<br />
Page 48<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
HYDROXYZINE HCL HYDROXYZINE HCL 10MG/5ML SYRUP<br />
HYDROXYZINE HCL HYDROXYZINE HCL 25MG TABLET<br />
HYDROXYZINE HCL HYDROXYZINE HCL 25MG/ML VIAL<br />
HYDROXYZINE HCL HYDROXYZINE HCL 50MG TABLET<br />
HYDROXYZINE HCL HYDROXYZINE HCL 50MG/ML VIAL<br />
HYZINE HYDROXYZINE HCL 50MG/ML VIAL<br />
VISTARIL HYDROXYZINE HCL 50MG/ML VIAL<br />
VISTAZINE HYDROXYZINE HCL 50MG/ML VIAL<br />
HYDROXYZINE PAMOATE HYDROXYZINE PAMOATE 100MG CAPSULE<br />
HYDROXYZINE PAMOATE HYDROXYZINE PAMOATE 25MG CAPSULE<br />
HYDROXYZINE PAMOATE HYDROXYZINE PAMOATE 50MG CAPSULE<br />
VISTARIL HYDROXYZINE PAMOATE 100MG CAPSULE<br />
VISTARIL HYDROXYZINE PAMOATE 25MG CAPSULE<br />
VISTARIL HYDROXYZINE PAMOATE 50MG CAPSULE<br />
URIMAR-T HYOS/METH BLUE/METH/SALICY/SOD TABLET<br />
UROGESIC-BLUE HYOS/METH BLUE/METH/SALICY/SOD TABLET<br />
CYSTOSPAZ HYOSCYAMINE 0.15MG TABLET<br />
HYOSCYAMINE HYOSCYAMINE 0.15MG TABLET<br />
HYOSPAZ HYOSCYAMINE 0.15MG TABLET<br />
ANASPAZ HYOSCYAMINE SULFATE 0.125MG TABLET<br />
A-SPAS-S/L HYOSCYAMINE SULFATE 0.125MG TAB SUBL<br />
CYSTOSPAZ-M HYOSCYAMINE SULFATE 0.375MG CAP.SR 12H<br />
GASTROSED HYOSCYAMINE SULFATE 0.125MG TABLET<br />
GASTROSED HYOSCYAMINE SULFATE 0.125MG/ML DROPS<br />
HYCO HYOSCYAMINE SULFATE 0.125MG/ML DROPS<br />
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE 0.125MG TAB DIS LN<br />
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE 0.125MG TAB SUBL<br />
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE 0.125MG TABLET<br />
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE 0.125MG/ML DROPS<br />
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE 0.375MG CAP.SR 12H<br />
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE 0.375MG TAB.SR 12H<br />
HYOSCYAMINE SULFATE HYOSCYAMINE SULFATE 125MCG/5ML ELIXIR<br />
HYOSYNE HYOSCYAMINE SULFATE 0.125MG/ML DROPS<br />
HYOSYNE HYOSCYAMINE SULFATE 125MCG/5ML ELIXIR<br />
LEVBID HYOSCYAMINE SULFATE 0.375MG TAB.SR 12H<br />
LEVSIN HYOSCYAMINE SULFATE 0.125MG TABLET<br />
LEVSIN HYOSCYAMINE SULFATE 0.125MG/ML DROPS<br />
LEVSIN HYOSCYAMINE SULFATE 125MCG/5ML ELIXIR<br />
LEVSIN/SL HYOSCYAMINE SULFATE 0.125MG TAB SUBL<br />
LEVSINEX HYOSCYAMINE SULFATE 0.375MG CAP.SR 12H<br />
MEDISPAZ HYOSCYAMINE SULFATE 0.125MG TABLET<br />
NEOSOL HYOSCYAMINE SULFATE 0.125MG TAB DIS LN<br />
NULEV HYOSCYAMINE SULFATE 0.125MG TAB DIS LN<br />
SPACOL I.D. HYOSCYAMINE SULFATE 0.125MG/ML DROPS<br />
SPACOL T/S HYOSCYAMINE SULFATE 0.375MG TAB.SR 12H<br />
SPASDEL HYOSCYAMINE SULFATE 0.125MG TABLET<br />
SPASDEL HYOSCYAMINE SULFATE 0.125MG/ML DROPS<br />
SPASDEL HYOSCYAMINE SULFATE 125MCG/5ML ELIXIR<br />
SYMAX-SL HYOSCYAMINE SULFATE 0.125MG TAB SUBL<br />
SYMAX-SR HYOSCYAMINE SULFATE 0.375MG TAB.SR 12H<br />
ADVANCED PAIN RELIEF IBUPROFEN 200MG TABLET<br />
ADVIL IBUPROFEN 200MG TABLET<br />
CHILD IBUPROFEN IBUPROFEN 100MG/5ML ORAL SUSP<br />
CHILDREN'S ADVIL IBUPROFEN 100MG/5ML ORAL SUSP<br />
CHILDREN'S IBUPROFEN IBUPROFEN 100MG/5ML ORAL SUSP<br />
CHILDREN'S MOTRIN IBUPROFEN 100MG/5ML ORAL SUSP<br />
GENPRIL IBUPROFEN 200MG TABLET<br />
IBU-200 IBUPROFEN 200MG TABLET<br />
IBUPAIN-200 IBUPROFEN 200MG TABLET<br />
IBU-PROFEN IBUPROFEN 200MG TABLET<br />
IBUPROFEN IBUPROFEN 100MG/5ML ORAL SUSP<br />
IBUPROFEN IBUPROFEN 200MG TABLET<br />
IBUPROFEN IBUPROFEN 400MG TABLET<br />
IBUPROFEN IBUPROFEN 600MG TABLET<br />
IBUPROFEN IBUPROFEN 800MG TABLET<br />
IBUPROFEN IB IBUPROFEN 200MG TABLET<br />
IBUPROFEN M IBUPROFEN 200MG TABLET<br />
IBUPROFEN PMR IBUPROFEN 200MG TABLET<br />
IBUPROHM IBUPROFEN 400MG TABLET<br />
MENADOL IBUPROFEN 200MG TABLET<br />
MOTRIN IBUPROFEN 100MG/5ML ORAL SUSP<br />
MOTRIN IBUPROFEN 400MG TABLET<br />
MOTRIN IBUPROFEN 600MG TABLET<br />
MOTRIN IBUPROFEN 800MG TABLET<br />
MOTRIN IB IBUPROFEN 200MG TABLET<br />
Page 49<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
MOTRIN MIGRAINE IBUPROFEN 200MG TABLET<br />
NUPRIN IBUPROFEN 200MG TABLET<br />
PROVIL IBUPROFEN 200MG TABLET<br />
Q-PROFEN IBUPROFEN 200MG TABLET<br />
SUPERIOR PAIN MEDICINE IBUPROFEN 200MG TABLET<br />
TAB-PROFEN IBUPROFEN 200MG TABLET<br />
V-R IBUPROFEN IBUPROFEN 100MG/5ML ORAL SUSP<br />
V-R IBUPROFEN IBUPROFEN 200MG TABLET<br />
YAPROFEN IBUPROFEN 200MG TABLET<br />
IDARUBICIN HCL IDARUBICIN HCL 1MG/ML VIAL<br />
IFOSFAMIDE IFOSFAMIDE 1G VIAL<br />
IFOSFAMIDE/MESNA IFOSFAMIDE/MESNA 1-1G KIT<br />
IFOSFAMIDE/MESNA IFOSFAMIDE/MESNA 3-1G KIT<br />
IMIPRAMINE HCL IMIPRAMINE HCL 10MG TABLET<br />
IMIPRAMINE HCL IMIPRAMINE HCL 25MG TABLET<br />
IMIPRAMINE HCL IMIPRAMINE HCL 50MG TABLET<br />
TOFRANIL IMIPRAMINE HCL 10MG TABLET<br />
TOFRANIL IMIPRAMINE HCL 25MG TABLET<br />
TOFRANIL IMIPRAMINE HCL 50MG TABLET<br />
GAMIMUNE N IMMU GLOBULIN,GAMMA (IGG) 10% VIAL<br />
GAMMAGARD S/D IMMU GLOBULIN,GAMMA (IGG) 2.5G VIAL<br />
GAMMAGARD S/D IMMU GLOBULIN,GAMMA (IGG) 5G VIAL<br />
GAMMAR-P I.V. IMMU GLOBULIN,GAMMA (IGG) 10G VIAL<br />
GAMMAR-P I.V. IMMU GLOBULIN,GAMMA (IGG) 1G VIAL<br />
GAMMAR-P I.V. IMMU GLOBULIN,GAMMA (IGG) 2.5G VIAL<br />
GAMMAR-P I.V. IMMU GLOBULIN,GAMMA (IGG) 5G VIAL<br />
IMMUNE GLOBULIN IMMU GLOBULIN,GAMMA (IGG) VIAL<br />
IVEEGAM EN IMMU GLOBULIN,GAMMA (IGG) 5G VIAL<br />
POLYGAM S/D IMMU GLOBULIN,GAMMA (IGG) 10G VIAL<br />
POLYGAM S/D IMMU GLOBULIN,GAMMA (IGG) 2.5G VIAL<br />
POLYGAM S/D IMMU GLOBULIN,GAMMA (IGG) 5G VIAL<br />
SANDOGLOBULIN IMMU GLOBULIN,GAMMA (IGG) 6G VIAL<br />
INAMRINONE INAMRINONE LACTATE 5MG/ML AMPUL<br />
INDAPAMIDE INDAPAMIDE 1.25MG TABLET<br />
INDAPAMIDE INDAPAMIDE 2.5MG TABLET<br />
LOZOL INDAPAMIDE 1.25MG TABLET<br />
LOZOL INDAPAMIDE 2.5MG TABLET<br />
INDIGO CARMINE INDIGOTINDISULFONATE SODIUM 0.8% AMPUL<br />
INDOCIN INDOMETHACIN 25MG CAPSULE<br />
INDOCIN INDOMETHACIN 50MG CAPSULE<br />
INDOMETHACIN INDOMETHACIN 25MG CAPSULE<br />
INDOMETHACIN INDOMETHACIN 25MG/5ML ORAL SUSP<br />
INDOMETHACIN INDOMETHACIN 50MG CAPSULE<br />
INDOMETHACIN INDOMETHACIN 75MG CAPSULE SA<br />
NEOSURE INFANT FORMULA W-IRON POWDER<br />
FLUZONE INFLUENZA VIRUS TRI-SPLIT DISP SYRIN<br />
FLUZONE INFLUENZA VIRUS TRI-SPLIT VIAL<br />
IOPAMIDOL IOPAMIDOL 41% INFUS. BTL<br />
IOPAMIDOL IOPAMIDOL 51% INFUS. BTL<br />
IOPAMIDOL IOPAMIDOL 51% VIAL<br />
IOPAMIDOL IOPAMIDOL 61% INFUS. BTL<br />
IOPAMIDOL IOPAMIDOL 61% VIAL<br />
IOPAMIDOL IOPAMIDOL 76% INFUS. BTL<br />
IOPAMIDOL IOPAMIDOL 76% VIAL<br />
GLOFIL IOTHALAMATE SODIUM 0.1% VIAL<br />
ATROVENT IPRATROPIUM BROMIDE 0.2MG/ML SOLUTION<br />
IPRATROPIUM BROMIDE IPRATROPIUM BROMIDE 0.2MG/ML SOLUTION<br />
FEROSUL IRON 50MG TABLET<br />
FERREX-150 IRON POLYSACCHARIDES COMPLEX 150MG CAPSULE<br />
MYFERON 150 IRON POLYSACCHARIDES COMPLEX 150MG CAPSULE<br />
NIFEREX-150 IRON POLYSACCHARIDES COMPLEX 150MG CAPSULE<br />
NU-IRON 150 IRON POLYSACCHARIDES COMPLEX 150MG CAPSULE<br />
POLY-IRON IRON POLYSACCHARIDES COMPLEX 150MG CAPSULE<br />
POLYSACCHARIDE IRON IRON POLYSACCHARIDES COMPLEX 150MG CAPSULE<br />
POLYSACCHARIDE-IRON IRON POLYSACCHARIDES COMPLEX 150MG CAPSULE<br />
FEOSOL IRON,CARBONYL 45MG TABLET<br />
STRESS FORMULA 600 W/IRON IRON/MULTIVITS,STRESS FORMULA TABLET<br />
STRESS FORMULA W/IRON IRON/MULTIVITS,STRESS FORMULA TABLET<br />
STRESS FORMULA+IRON IRON/MULTIVITS,STRESS FORMULA TABLET<br />
STRESS W/IRON IRON/MULTIVITS,STRESS FORMULA TABLET<br />
STRESSTABS W/IRON IRON/MULTIVITS,STRESS FORMULA TABLET<br />
THERAGRAN STRESS IRON/MULTIVITS,STRESS FORMULA TABLET<br />
VI-STRESS PLUS IRON IRON/MULTIVITS,STRESS FORMULA TABLET<br />
GERITON IRON/VITAMIN B COMPLEX LIQUID<br />
SENETONIC IRON/VITAMIN B COMPLEX LIQUID<br />
Page 50<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
STRESS B PLUS IRON IRON/VITAMIN B COMPLEX TABLET<br />
BETA-2 ISOETHARINE HCL 10MG/ML SOLUTION<br />
ISOETHARINE HCL ISOETHARINE HCL 10MG/ML SOLUTION<br />
FORANE ISOFLURANE LIQUID<br />
ISOFLURANE ISOFLURANE LIQUID<br />
ISONIAZID ISONIAZID 100MG TABLET<br />
ISONIAZID ISONIAZID 300MG TABLET<br />
ISONIAZID ISONIAZID 50MG/5ML SYRUP<br />
ISOPROTERENOL HCL INJECTION ISOPROTERENOL HCL 0.2MG/ML AMPUL<br />
ISORDIL ISOSORBIDE DINITRATE 10MG TABLET<br />
ISORDIL ISOSORBIDE DINITRATE 2.5MG TAB SUBL<br />
ISORDIL ISOSORBIDE DINITRATE 20MG TABLET<br />
ISORDIL ISOSORBIDE DINITRATE 30MG TABLET<br />
ISORDIL ISOSORBIDE DINITRATE 5MG TAB SUBL<br />
ISORDIL ISOSORBIDE DINITRATE 5MG TABLET<br />
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 10MG TABLET<br />
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 2.5MG TAB SUBL<br />
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 20MG TABLET<br />
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 30MG TABLET<br />
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 40MG TABLET<br />
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 40MG TABLET SA<br />
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 5MG TAB SUBL<br />
ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 5MG TABLET<br />
SORBITRATE ISOSORBIDE DINITRATE 10MG TABLET<br />
SORBITRATE ISOSORBIDE DINITRATE 20MG TABLET<br />
IMDUR ISOSORBIDE MONONITRATE 120MG TAB.SR 24H<br />
IMDUR ISOSORBIDE MONONITRATE 30MG TAB.SR 24H<br />
IMDUR ISOSORBIDE MONONITRATE 60MG TAB.SR 24H<br />
ISMO ISOSORBIDE MONONITRATE 20MG TABLET<br />
ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 10MG TABLET<br />
ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 120MG TAB.SR 24H<br />
ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 20MG TABLET<br />
ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 30MG TAB.SR 24H<br />
ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE 60MG TAB.SR 24H<br />
MONOKET ISOSORBIDE MONONITRATE 10MG TABLET<br />
MONOKET ISOSORBIDE MONONITRATE 20MG TABLET<br />
AMNESTEEM ISOTRETINOIN 10MG CAPSULE<br />
AMNESTEEM ISOTRETINOIN 20MG CAPSULE<br />
AMNESTEEM ISOTRETINOIN 40MG CAPSULE<br />
KANAMYCIN SULFATE KANAMYCIN SULFATE 1G/3ML VIAL<br />
KANTREX KANAMYCIN SULFATE 1G/3ML VIAL<br />
KETALAR KETAMINE HCL 50MG/ML VIAL<br />
KETAMINE HCL KETAMINE HCL 100MG/ML VIAL<br />
KETAMINE HCL KETAMINE HCL 10MG/ML VIAL<br />
KETAMINE HCL KETAMINE HCL 50MG/ML VIAL<br />
KETOCONAZOLE KETOCONAZOLE 2% CREAM(GM)<br />
KETOCONAZOLE KETOCONAZOLE 200MG TABLET<br />
NIZORAL KETOCONAZOLE 200MG TABLET<br />
KETOPROFEN KETOPROFEN 100MG CAP24H PEL<br />
KETOPROFEN KETOPROFEN 150MG CAP24H PEL<br />
KETOPROFEN KETOPROFEN 200MG CAP24H PEL<br />
KETOPROFEN KETOPROFEN 25MG CAPSULE<br />
KETOPROFEN KETOPROFEN 50MG CAPSULE<br />
KETOPROFEN KETOPROFEN 75MG CAPSULE<br />
ORUVAIL KETOPROFEN 200MG CAP24H PEL<br />
KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 10MG TABLET<br />
KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 15MG/ML CARTRIDGE<br />
KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 15MG/ML VIAL<br />
KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 30MG/ML CARTRIDGE<br />
KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 30MG/ML VIAL<br />
KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE 60MG/2ML VIAL<br />
TORADOL KETOROLAC TROMETHAMINE 10MG TABLET<br />
TORADOL KETOROLAC TROMETHAMINE 15MG/ML VIAL<br />
TORADOL KETOROLAC TROMETHAMINE 30MG/ML VIAL<br />
TORADOL KETOROLAC TROMETHAMINE 60MG/2ML VIAL<br />
LABETALOL HCL LABETALOL HCL 100MG TABLET<br />
LABETALOL HCL LABETALOL HCL 200MG TABLET<br />
LABETALOL HCL LABETALOL HCL 300MG TABLET<br />
LABETALOL HCL LABETALOL HCL 5MG/ML DISP SYRIN<br />
LABETALOL HCL LABETALOL HCL 5MG/ML VIAL<br />
NORMODYNE LABETALOL HCL 100MG TABLET<br />
NORMODYNE LABETALOL HCL 200MG TABLET<br />
NORMODYNE LABETALOL HCL 300MG TABLET<br />
NORMODYNE LABETALOL HCL 5MG/ML VIAL<br />
TRANDATE LABETALOL HCL 100MG TABLET<br />
Page 51<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
TRANDATE LABETALOL HCL 200MG TABLET<br />
TRANDATE LABETALOL HCL 300MG TABLET<br />
TRANDATE LABETALOL HCL 5MG/ML VIAL<br />
DAIRY-RELIEF LACTASE 3000 UNIT TABLET<br />
CEBOCAP #1 LACTOSE CAPSULE<br />
CEBOCAP #2 LACTOSE CAPSULE<br />
CEBOCAP #3 LACTOSE CAPSULE<br />
BOOST LACTOSE-FREE FOOD LIQUID<br />
BOOST HIGH PROTEIN LACTOSE-FREE FOOD LIQUID<br />
BOOST PLUS LACTOSE-FREE FOOD LIQUID<br />
COMPLEAT MODIFIED FORMULA LACTOSE-FREE FOOD LIQUID<br />
GO HEALTHY LACTOSE-FREE FOOD LIQUID<br />
HIGH CALORIE PLUS LACTOSE-FREE FOOD LIQUID<br />
HI-NUTRITIONAL SUPPLEMENT LACTOSE-FREE FOOD LIQUID<br />
HI-NUTRITIONAL SUPPLEMENT PLUS LACTOSE-FREE FOOD LIQUID<br />
IMPACT LACTOSE-FREE FOOD LIQUID<br />
IMPACT 1.5 LACTOSE-FREE FOOD LIQUID<br />
INTROLITE LACTOSE-FREE FOOD LIQUID<br />
ISOCAL LACTOSE-FREE FOOD LIQUID<br />
ISOCAL HN LACTOSE-FREE FOOD LIQUID<br />
ISOSOURCE LACTOSE-FREE FOOD LIQUID<br />
ISOSOURCE HN LACTOSE-FREE FOOD LIQUID<br />
JEVITY LACTOSE-FREE FOOD LIQUID<br />
NU/TASTE LACTOSE-FREE FOOD LIQUID<br />
NUTRITION LACTOSE-FREE FOOD LIQUID<br />
NUTRITION ADVANCE FORMULA LACTOSE-FREE FOOD LIQUID<br />
NUTRITION PLUS LACTOSE-FREE FOOD LIQUID<br />
NUTRITIONAL LIQUID LACTOSE-FREE FOOD LIQUID<br />
NUTRITIONAL SUPPLEMENT LACTOSE-FREE FOOD LIQUID<br />
NUTRITIONAL SUPPLEMENT PLUS LACTOSE-FREE FOOD LIQUID<br />
OSMOLITE LACTOSE-FREE FOOD LIQUID<br />
OSMOLITE HN LACTOSE-FREE FOOD LIQUID<br />
PRO/VIDE LACTOSE-FREE FOOD LIQUID<br />
RESOURCE LACTOSE-FREE FOOD LIQUID<br />
RESOURCE PLUS LACTOSE-FREE FOOD LIQUID<br />
SANDOSOURCE PEPTIDE LACTOSE-FREE FOOD LIQUID<br />
SB COMPLETE NUTRITION LACTOSE-FREE FOOD LIQUID<br />
ULTRACAL LACTOSE-FREE FOOD LIQUID<br />
CALULOSE LACTULOSE 10G/15ML SYRUP<br />
CATULAC LACTULOSE 10G/15ML SYRUP<br />
CONSTULOSE LACTULOSE 10G/15ML SYRUP<br />
ENULOSE LACTULOSE 10G/15ML SYRUP<br />
GENERLAC LACTULOSE 10G/15ML SYRUP<br />
LACTULOSE LACTULOSE 10G/15ML SYRUP<br />
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 100MG VIAL<br />
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 10MG/ML VIAL<br />
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 200MG VIAL<br />
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 25MG TABLET<br />
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 350MG VIAL<br />
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 500MG VIAL<br />
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 50MG VIAL<br />
LEUCOVORIN CALCIUM LEUCOVORIN CALCIUM 5MG TABLET<br />
LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML KIT<br />
LEUPROLIDE ACETATE LEUPROLIDE ACETATE 1MG/0.2ML VIAL<br />
LUPRON LEUPROLIDE ACETATE 1MG/0.2ML KIT<br />
LUPRON LEUPROLIDE ACETATE 1MG/0.2ML VIAL<br />
BETAGAN LEVOBUNOLOL HCL 0.25% DROPS<br />
BETAGAN LEVOBUNOLOL HCL 0.5% DROPS<br />
LEVOBUNOLOL HCL LEVOBUNOLOL HCL 0.25% DROPS<br />
LEVOBUNOLOL HCL LEVOBUNOLOL HCL 0.5% DROPS<br />
CARNITOR LEVOCARNITINE 200MG/ML VIAL<br />
LEVOCARNITINE LEVOCARNITINE 200MG/ML VIAL<br />
AVIANE LEVONORGESTREL-ETH ESTRA 0.1-0.02 TABLET<br />
ENPRESSE LEVONORGESTREL-ETH ESTRA 6-5-10 TABLET<br />
LESSINA LEVONORGESTREL-ETH ESTRA 0.1-0.02 TABLET<br />
LEVORA-28 LEVONORGESTREL-ETH ESTRA 0.15-0.03 TABLET<br />
PORTIA LEVONORGESTREL-ETH ESTRA 0.15-0.03 TABLET<br />
TRI-LEVLEN 21 LEVONORGESTREL-ETH ESTRA 6-5-10 TABLET<br />
TRI-LEVLEN 28 LEVONORGESTREL-ETH ESTRA 6-5-10 TABLET<br />
TRIPHASIL-21 LEVONORGESTREL-ETH ESTRA 6-5-10 TABLET<br />
TRIPHASIL-28 LEVONORGESTREL-ETH ESTRA 6-5-10 TABLET<br />
TRIVORA-28 LEVONORGESTREL-ETH ESTRA 6-5-10 TABLET<br />
LEVORPHANOL TARTRATE LEVORPHANOL TARTRATE 2MG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 100MCG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 112MCG TABLET<br />
Page 52<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
LEVOTHROID LEVOTHYROXINE SODIUM 125MCG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 137MCG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 150MCG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 175MCG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 200MCG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 200MCG VIAL<br />
LEVOTHROID LEVOTHYROXINE SODIUM 25MCG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 300MCG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 50MCG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 75MCG TABLET<br />
LEVOTHROID LEVOTHYROXINE SODIUM 88MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 100MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 112MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 125MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 137MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 150MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 175MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 200MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 200MCG VIAL<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 25MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 300MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 500MCG VIAL<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 50MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 75MCG TABLET<br />
LEVOTHYROXINE SODIUM LEVOTHYROXINE SODIUM 88MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 100MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 112MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 125MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 137MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 150MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 175MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 200MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 25MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 300MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 50MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 75MCG TABLET<br />
LEVOXYL LEVOTHYROXINE SODIUM 88MCG TABLET<br />
L-THYROXINE LEVOTHYROXINE SODIUM 125MCG TABLET<br />
L-THYROXINE LEVOTHYROXINE SODIUM 25MCG TABLET<br />
L-THYROXINE LEVOTHYROXINE SODIUM 50MCG TABLET<br />
L-THYROXINE LEVOTHYROXINE SODIUM 75MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 100MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 112MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 125MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 137MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 150MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 175MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 200MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 200MCG VIAL<br />
SYNTHROID LEVOTHYROXINE SODIUM 25MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 300MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 500MCG VIAL<br />
SYNTHROID LEVOTHYROXINE SODIUM 50MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 75MCG TABLET<br />
SYNTHROID LEVOTHYROXINE SODIUM 88MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 100MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 112MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 125MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 150MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 175MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 200MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 25MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 300MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 50MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 75MCG TABLET<br />
UNITHROID LEVOTHYROXINE SODIUM 88MCG TABLET<br />
LIDOCAINE HCL LIDOCAINE HCL 10MG/ML AMPUL<br />
LIDOCAINE HCL LIDOCAINE HCL 10MG/ML DISP SYRIN<br />
LIDOCAINE HCL LIDOCAINE HCL 10MG/ML VIAL<br />
LIDOCAINE HCL LIDOCAINE HCL 15MG/ML AMPUL<br />
LIDOCAINE HCL LIDOCAINE HCL 2% JEL<br />
LIDOCAINE HCL LIDOCAINE HCL 20MG/ML AMPUL<br />
LIDOCAINE HCL LIDOCAINE HCL 20MG/ML DISP SYRIN<br />
LIDOCAINE HCL LIDOCAINE HCL 20MG/ML VIAL<br />
LIDOCAINE HCL LIDOCAINE HCL 40MG/ML AMPUL<br />
Page 53<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
LIDOCAINE HCL LIDOCAINE HCL 40MG/ML SOLUTION<br />
LIDOCAINE HCL LIDOCAINE HCL 5% OINT.(GM)<br />
LIDOCAINE HCL LIDOCAINE HCL 5MG/ML VIAL<br />
LIDOCAINE HCL VISCOUS LIDOCAINE HCL 20MG/ML SOLUTION<br />
LIDOJECT-2 LIDOCAINE HCL 20MG/ML VIAL<br />
LIDOMAR VISCOUS LIDOCAINE HCL 20MG/ML SOLUTION<br />
NERVOCAINE LIDOCAINE HCL 20MG/ML VIAL<br />
UAD CAINE LIDOCAINE HCL 10MG/ML VIAL<br />
XYLOCAINE LIDOCAINE HCL 10MG/ML VIAL<br />
XYLOCAINE LIDOCAINE HCL 2% JEL<br />
XYLOCAINE LIDOCAINE HCL 20MG/ML VIAL<br />
XYLOCAINE LIDOCAINE HCL 40MG/ML SOLUTION<br />
XYLOCAINE LIDOCAINE HCL 5% OINT.(GM)<br />
XYLOCAINE VISCOUS LIDOCAINE HCL 20MG/ML SOLUTION<br />
XYLOCAINE-MPF LIDOCAINE HCL 10MG/ML VIAL<br />
XYLOCAINE-MPF LIDOCAINE HCL 20MG/ML VIAL<br />
LINCOCIN LINCOMYCIN HCL 300MG/ML VIAL<br />
LINCOJECT LINCOMYCIN HCL 300MG/ML VIAL<br />
LINDANE LINDANE 1% LOTION<br />
LINDANE LINDANE 1% SHAMPOO<br />
LISINOPRIL LISINOPRIL 10MG TABLET<br />
LISINOPRIL LISINOPRIL 2.5MG TABLET<br />
LISINOPRIL LISINOPRIL 20MG TABLET<br />
LISINOPRIL LISINOPRIL 30MG TABLET<br />
LISINOPRIL LISINOPRIL 40MG TABLET<br />
LISINOPRIL LISINOPRIL 5MG TABLET<br />
PRINIVIL LISINOPRIL 10MG TABLET<br />
PRINIVIL LISINOPRIL 2.5MG TABLET<br />
PRINIVIL LISINOPRIL 20MG TABLET<br />
PRINIVIL LISINOPRIL 40MG TABLET<br />
PRINIVIL LISINOPRIL 5MG TABLET<br />
ZESTRIL LISINOPRIL 10MG TABLET<br />
ZESTRIL LISINOPRIL 2.5MG TABLET<br />
ZESTRIL LISINOPRIL 20MG TABLET<br />
ZESTRIL LISINOPRIL 30MG TABLET<br />
ZESTRIL LISINOPRIL 40MG TABLET<br />
ZESTRIL LISINOPRIL 5MG TABLET<br />
ESKALITH LITHIUM CARBONATE 300MG CAPSULE<br />
LITHIUM CARBONATE LITHIUM CARBONATE 300MG CAPSULE<br />
LITHIUM CITRATE LITHIUM CITRATE 8MEQ/5ML SYRUP<br />
ANTI-DIARRHEAL LOPERAMIDE HCL 1MG/5ML LIQUID<br />
ANTI-DIARRHEAL LOPERAMIDE HCL 2MG TABLET<br />
ANTIDIARRHEAL LOPERAMIDE HCL 2MG TABLET<br />
HM ANTI-DIARRHEAL LOPERAMIDE HCL 1MG/5ML LIQUID<br />
HM ANTI-DIARRHEAL LOPERAMIDE HCL 2MG TABLET<br />
IMODIUM A-D LOPERAMIDE HCL 1MG/5ML LIQUID<br />
IMODIUM A-D LOPERAMIDE HCL 2MG TABLET<br />
IMOGEN LOPERAMIDE HCL 1MG/5ML LIQUID<br />
IMPERIM LOPERAMIDE HCL 2MG TABLET<br />
KAO-PAVERIN LOPERAMIDE HCL 2MG TABLET<br />
LOPERAMIDE HCL LOPERAMIDE HCL 1MG/5ML LIQUID<br />
LOPERAMIDE HCL LOPERAMIDE HCL 2MG CAPSULE<br />
LOPERAMIDE HCL LOPERAMIDE HCL 2MG TABLET<br />
ATIVAN LORAZEPAM 0.5MG TABLET<br />
ATIVAN LORAZEPAM 1MG TABLET<br />
ATIVAN LORAZEPAM 2MG TABLET<br />
ATIVAN LORAZEPAM 2MG/ML DISP SYRIN<br />
ATIVAN LORAZEPAM 2MG/ML VIAL<br />
ATIVAN LORAZEPAM 4MG/ML DISP SYRIN<br />
ATIVAN LORAZEPAM 4MG/ML VIAL<br />
LORAZEPAM LORAZEPAM 0.5MG TABLET<br />
LORAZEPAM LORAZEPAM 1MG TABLET<br />
LORAZEPAM LORAZEPAM 2MG TABLET<br />
LORAZEPAM LORAZEPAM 2MG/ML DISP SYRIN<br />
LORAZEPAM LORAZEPAM 2MG/ML VIAL<br />
LORAZEPAM LORAZEPAM 4MG/ML DISP SYRIN<br />
LORAZEPAM LORAZEPAM 4MG/ML VIAL<br />
LOVASTATIN LOVASTATIN 10MG TABLET<br />
LOVASTATIN LOVASTATIN 20MG TABLET<br />
LOVASTATIN LOVASTATIN 40MG TABLET<br />
MEVACOR LOVASTATIN 10MG TABLET<br />
MEVACOR LOVASTATIN 20MG TABLET<br />
MEVACOR LOVASTATIN 40MG TABLET<br />
LOXAPINE LOXAPINE SUCCINATE 10MG CAPSULE<br />
LOXAPINE LOXAPINE SUCCINATE 25MG CAPSULE<br />
Page 54<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
LOXAPINE LOXAPINE SUCCINATE 50MG CAPSULE<br />
LOXAPINE LOXAPINE SUCCINATE 5MG CAPSULE<br />
LOXAPINE SUCCINATE LOXAPINE SUCCINATE 10MG CAPSULE<br />
LOXAPINE SUCCINATE LOXAPINE SUCCINATE 25MG CAPSULE<br />
LOXAPINE SUCCINATE LOXAPINE SUCCINATE 50MG CAPSULE<br />
LOXAPINE SUCCINATE LOXAPINE SUCCINATE 5MG CAPSULE<br />
LOXITANE LOXAPINE SUCCINATE 10MG CAPSULE<br />
LOXITANE LOXAPINE SUCCINATE 25MG CAPSULE<br />
LOXITANE LOXAPINE SUCCINATE 50MG CAPSULE<br />
LOXITANE LOXAPINE SUCCINATE 5MG CAPSULE<br />
MAGNESIUM CHLORIDE MAGNESIUM CHLORIDE 200MG/ML VIAL<br />
MAGNESIUM SULFATE MAGNESIUM SULFATE 4MEQ/ML AMPUL<br />
MAGNESIUM SULFATE MAGNESIUM SULFATE 4MEQ/ML DISP SYRIN<br />
MAGNESIUM SULFATE MAGNESIUM SULFATE 4MEQ/ML VIAL<br />
MANGANESE MANGANESE CHLORIDE 0.1MG/ML VIAL<br />
MANGANESE CHLORIDE MANGANESE CHLORIDE 0.1MG/ML VIAL<br />
MANNITOL MANNITOL 10% IV SOLN.<br />
MANNITOL MANNITOL 15% IV SOLN.<br />
MANNITOL MANNITOL 20% IV SOLN.<br />
MANNITOL MANNITOL 25% VIAL<br />
MANNITOL MANNITOL 5% IV SOLN.<br />
OSMITROL MANNITOL 15% IV SOLN.<br />
OSMITROL MANNITOL 20% IV SOLN.<br />
MAPROTILINE HCL MAPROTILINE HCL 25MG TABLET<br />
MAPROTILINE HCL MAPROTILINE HCL 50MG TABLET<br />
MAPROTILINE HCL MAPROTILINE HCL 75MG TABLET<br />
MEBENDAZOLE MEBENDAZOLE 100MG TAB CHEW<br />
MECLIZINE HCL MECLIZINE HCL 12.5MG TABLET<br />
MECLIZINE HCL MECLIZINE HCL 25MG TABLET<br />
RU-VERT-M MECLIZINE HCL 25MG TABLET<br />
MECLOFENAMATE SODIUM MECLOFENAMATE SODIUM 100MG CAPSULE<br />
MECLOFENAMATE SODIUM MECLOFENAMATE SODIUM 50MG CAPSULE<br />
MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACET 10MG TABLET<br />
MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACET 2.5MG TABLET<br />
MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACET 5MG TABLET<br />
PROVERA MEDROXYPROGESTERONE ACET 10MG TABLET<br />
PROVERA MEDROXYPROGESTERONE ACET 2.5MG TABLET<br />
PROVERA MEDROXYPROGESTERONE ACET 5MG TABLET<br />
MEFLOQUINE HCL MEFLOQUINE HCL 250MG TABLET<br />
MEGACE MEGESTROL ACETATE 20MG TABLET<br />
MEGACE MEGESTROL ACETATE 40MG TABLET<br />
MEGESTROL ACETATE MEGESTROL ACETATE 20MG TABLET<br />
MEGESTROL ACETATE MEGESTROL ACETATE 40MG TABLET<br />
MEGESTROL ACETATE MEGESTROL ACETATE 40MG/ML ORAL SUSP<br />
WATER ME-PARABEN/PROPYLPARABEN/WATER VIAL<br />
DEMEROL MEPERIDINE HCL 100MG TABLET<br />
DEMEROL MEPERIDINE HCL 100MG/ML DISP SYRIN<br />
DEMEROL MEPERIDINE HCL 100MG/ML VIAL<br />
DEMEROL MEPERIDINE HCL 50MG TABLET<br />
DEMEROL MEPERIDINE HCL 50MG/ML VIAL<br />
MEPERIDINE HCL MEPERIDINE HCL 100MG TABLET<br />
MEPERIDINE HCL MEPERIDINE HCL 100MG/ML AMPUL<br />
MEPERIDINE HCL MEPERIDINE HCL 100MG/ML VIAL<br />
MEPERIDINE HCL MEPERIDINE HCL 10MG/ML DISP SYRIN<br />
MEPERIDINE HCL MEPERIDINE HCL 50MG TABLET<br />
MEPERIDINE HCL MEPERIDINE HCL 50MG/5ML SYRUP<br />
MEPERIDINE HCL MEPERIDINE HCL 50MG/ML AMPUL<br />
MEPERIDINE HCL MEPERIDINE HCL 50MG/ML VIAL<br />
MEPERIDINE HCL MEPERIDINE HCL 75MG/ML VIAL<br />
MEPERITAB MEPERIDINE HCL 100MG TABLET<br />
MEPERITAB MEPERIDINE HCL 50MG TABLET<br />
MEPERIDINE W/PROMETHAZINE MEPERIDINE HCL/PROMETH HCL 50-25MG CAPSULE<br />
CARBOCAINE MEPIVACAINE HCL 10MG/ML VIAL<br />
CARBOCAINE MEPIVACAINE HCL 15MG/ML VIAL<br />
POLOCAINE MEPIVACAINE HCL 10MG/ML VIAL<br />
POLOCAINE MEPIVACAINE HCL 15MG/ML VIAL<br />
POLOCAINE MEPIVACAINE HCL 20MG/ML VIAL<br />
MEPROBAMATE MEPROBAMATE 200MG TABLET<br />
MEPROBAMATE MEPROBAMATE 400MG TABLET<br />
MILTOWN MEPROBAMATE 200MG TABLET<br />
MILTOWN MEPROBAMATE 400MG TABLET<br />
MESNA MESNA 100MG/ML VIAL<br />
ARM-A-MED (METAPROTERENOL) METAPROTERENOL SULFATE 6MG/ML SOLUTION<br />
METAPROTERENOL SULFATE METAPROTERENOL SULFATE 10MG TABLET<br />
METAPROTERENOL SULFATE METAPROTERENOL SULFATE 10MG/5ML SYRUP<br />
Page 55<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
METAPROTERENOL SULFATE METAPROTERENOL SULFATE 20MG TABLET<br />
METAPROTERENOL SULFATE METAPROTERENOL SULFATE 4MG/ML SOLUTION<br />
METAPROTERENOL SULFATE METAPROTERENOL SULFATE 50MG/ML SOLUTION<br />
METAPROTERENOL SULFATE METAPROTERENOL SULFATE 6MG/ML SOLUTION<br />
GLUCOPHAGE METFORMIN HCL 1000MG TABLET<br />
GLUCOPHAGE METFORMIN HCL 500MG TABLET<br />
GLUCOPHAGE METFORMIN HCL 850MG TABLET<br />
METFORMIN HCL METFORMIN HCL 1000MG TABLET<br />
METFORMIN HCL METFORMIN HCL 500MG TABLET<br />
METFORMIN HCL METFORMIN HCL 850MG TABLET<br />
DOLOPHINE HCL METHADONE HCL 5MG TABLET<br />
METHADONE METHADONE HCL 10MG/ML ORAL CONC.<br />
METHADONE HCL METHADONE HCL 10MG TABLET<br />
METHADONE HCL METHADONE HCL 10MG/ML ORAL CONC.<br />
METHADONE HCL METHADONE HCL 40MG TAB DISPER<br />
METHADONE HCL METHADONE HCL 5MG TABLET<br />
METHADONE INTENSOL METHADONE HCL 10MG/ML ORAL CONC.<br />
METHADOSE METHADONE HCL 10MG TABLET<br />
METHADOSE METHADONE HCL 10MG/ML ORAL CONC.<br />
METHADOSE METHADONE HCL 40MG TAB DISPER<br />
METHADOSE METHADONE HCL 5MG TABLET<br />
METHAZOLAMIDE METHAZOLAMIDE 25MG TABLET<br />
METHAZOLAMIDE METHAZOLAMIDE 50MG TABLET<br />
HIPREX METHENAMINE HIPPURATE 1G TABLET<br />
UREX METHENAMINE HIPPURATE 1G TABLET<br />
MANDELAMINE METHENAMINE MANDELATE 1G TABLET<br />
MANDELAMINE HAFGRAMS METHENAMINE MANDELATE 500MG TABLET<br />
METHENAMINE MANDELATE METHENAMINE MANDELATE 1G TABLET<br />
METHENAMINE MANDELATE METHENAMINE MANDELATE 500MG TABLET<br />
METHIMAZOLE METHIMAZOLE 10MG TABLET<br />
METHIMAZOLE METHIMAZOLE 5MG TABLET<br />
METHOCARBAMOL METHOCARBAMOL 500MG TABLET<br />
METHOCARBAMOL METHOCARBAMOL 750MG TABLET<br />
ROBAXIN METHOCARBAMOL 500MG TABLET<br />
ROBAXIN-750 METHOCARBAMOL 750MG TABLET<br />
ROBOMOL 500 METHOCARBAMOL 500MG TABLET<br />
METHOTREXATE METHOTREXATE SODIUM 1G VIAL<br />
METHOTREXATE METHOTREXATE SODIUM 2.5MG TAB DS PK<br />
METHOTREXATE METHOTREXATE SODIUM 2.5MG TABLET<br />
METHOTREXATE METHOTREXATE SODIUM 25MG/ML VIAL<br />
METHOTREXATE LPF METHOTREXATE SODIUM 25MG/ML VIAL<br />
METHOTREXATE SODIUM METHOTREXATE SODIUM 25MG/ML VIAL<br />
METHOTREXATE SODIUM PARENTERAL METHOTREXATE SODIUM 25MG/ML VIAL<br />
RHEUMATREX METHOTREXATE SODIUM 2.5MG TAB DS PK<br />
AQUATENSEN METHYCLOTHIAZIDE 5MG TABLET<br />
ENDURON METHYCLOTHIAZIDE 5MG TABLET<br />
METHYCLOTHIAZIDE METHYCLOTHIAZIDE 5MG TABLET<br />
ALDOMET METHYLDOPA 125MG TABLET<br />
METHYLDOPA METHYLDOPA 250MG TABLET<br />
METHYLDOPA METHYLDOPA 500MG TABLET<br />
METHYLDOPATE HCL METHYLDOPATE HCL 250MG/5ML VIAL<br />
METHYLENE BLUE METHYLENE BLUE 1% AMPUL<br />
METHYLENE BLUE METHYLENE BLUE 1% VIAL<br />
METADATE ER METHYLPHENIDATE HCL 10MG TABLET SA<br />
METADATE ER METHYLPHENIDATE HCL 20MG TABLET SA<br />
METHYLIN METHYLPHENIDATE HCL 10MG TABLET<br />
METHYLIN METHYLPHENIDATE HCL 20MG TABLET<br />
METHYLIN METHYLPHENIDATE HCL 5MG TABLET<br />
METHYLIN ER METHYLPHENIDATE HCL 20MG TABLET SA<br />
METHYLPHENIDATE METHYLPHENIDATE HCL 20MG TABLET SA<br />
METHYLPHENIDATE ER METHYLPHENIDATE HCL 20MG TABLET SA<br />
METHYLPHENIDATE HCL METHYLPHENIDATE HCL 10MG TABLET<br />
METHYLPHENIDATE HCL METHYLPHENIDATE HCL 20MG TABLET<br />
METHYLPHENIDATE HCL METHYLPHENIDATE HCL 20MG TABLET SA<br />
METHYLPHENIDATE HCL METHYLPHENIDATE HCL 5MG TABLET<br />
RITALIN METHYLPHENIDATE HCL 10MG TABLET<br />
RITALIN METHYLPHENIDATE HCL 20MG TABLET<br />
RITALIN METHYLPHENIDATE HCL 5MG TABLET<br />
RITALIN-SR METHYLPHENIDATE HCL 20MG TABLET SA<br />
MEDROL METHYLPREDNISOLONE 4MG TAB DS PK<br />
MEDROL METHYLPREDNISOLONE 4MG TABLET<br />
MEPROLONE UNIPAK METHYLPREDNISOLONE 4MG TAB DS PK<br />
METHYLPREDNISOLONE METHYLPREDNISOLONE 4MG TAB DS PK<br />
METHYLPREDNISOLONE METHYLPREDNISOLONE 4MG TABLET<br />
METHYLPREDNISOLONE METHYLPREDNISOLONE 8MG TABLET<br />
Page 56<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
DEPO-MEDROL METHYLPREDNISOLONE ACETATE 40MG/ML VIAL<br />
DEPO-MEDROL METHYLPREDNISOLONE ACETATE 80MG/ML VIAL<br />
MEDRALONE 40 METHYLPREDNISOLONE ACETATE 40MG/ML VIAL<br />
A-METHAPRED METHYLPREDNISOLONE SOD SUCC 1000MG/8ML VIAL<br />
A-METHAPRED METHYLPREDNISOLONE SOD SUCC 125MG/2ML VIAL<br />
A-METHAPRED METHYLPREDNISOLONE SOD SUCC 40MG/ML VIAL<br />
A-METHAPRED METHYLPREDNISOLONE SOD SUCC 500MG/4ML VIAL<br />
METHYLPREDNISOLONE SOD SUCC METHYLPREDNISOLONE SOD SUCC 1000MG VIAL<br />
SOLU-MEDROL METHYLPREDNISOLONE SOD SUCC 125MG/2ML VIAL<br />
SOLU-MEDROL METHYLPREDNISOLONE SOD SUCC 500MG VIAL<br />
SOLU-MEDROL METHYLPREDNISOLONE SOD SUCC 500MG/4ML VIAL<br />
METIPRANOLOL METIPRANOLOL 0.3% DROPS<br />
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 10MG TABLET<br />
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 5MG TABLET<br />
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 5MG/5ML SOLUTION<br />
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 5MG/ML AMPUL<br />
METOCLOPRAMIDE HCL METOCLOPRAMIDE HCL 5MG/ML VIAL<br />
REGLAN METOCLOPRAMIDE HCL 10MG TABLET<br />
REGLAN METOCLOPRAMIDE HCL 5MG TABLET<br />
REGLAN METOCLOPRAMIDE HCL 5MG/ML VIAL<br />
LOPRESSOR METOPROLOL TARTRATE 100MG TABLET<br />
LOPRESSOR METOPROLOL TARTRATE 50MG TABLET<br />
METOPROLOL TARTRATE METOPROLOL TARTRATE 100MG TABLET<br />
METOPROLOL TARTRATE METOPROLOL TARTRATE 1MG/ML AMPUL<br />
METOPROLOL TARTRATE METOPROLOL TARTRATE 50MG TABLET<br />
FLAGYL METRONIDAZOLE 250MG TABLET<br />
FLAGYL METRONIDAZOLE 500MG TABLET<br />
METRONIDAZOLE METRONIDAZOLE 250MG TABLET<br />
METRONIDAZOLE METRONIDAZOLE 500MG TABLET<br />
FLAGYL I.V. RTU METRONIDAZOLE/SODIUM CHLORIDE 500MG/0.1L PIGGYBACK<br />
METRONIDAZOLE METRONIDAZOLE/SODIUM CHLORIDE 500MG/0.1L PIGGYBACK<br />
MEXILETINE HCL MEXILETINE HCL 150MG CAPSULE<br />
MEXILETINE HCL MEXILETINE HCL 200MG CAPSULE<br />
MEXILETINE HCL MEXILETINE HCL 250MG CAPSULE<br />
MEXITIL MEXILETINE HCL 150MG CAPSULE<br />
MEXITIL MEXILETINE HCL 200MG CAPSULE<br />
MEXITIL MEXILETINE HCL 250MG CAPSULE<br />
MAG-PHEN MG SALICYLATE/PHENYLTOLX CIT 600-25MG TABLET<br />
MAGSAL MG SALICYLATE/PHENYLTOLX CIT 600-25MG TABLET<br />
TETRA-MAG MG SALICYLATE/PHENYLTOLX CIT 600-25MG TABLET<br />
ANTIFUNGAL CREAM MICONAZOLE NITRATE 2% CREAM(GM)<br />
BAZA ANTIFUNGAL MICONAZOLE NITRATE 2% CREAM(GM)<br />
CARRINGTON ANTIFUNGAL MICONAZOLE NITRATE 2% CREAM(GM)<br />
GYNE-STAT-7 MICONAZOLE NITRATE 2% CREAM/APPL<br />
HM MICONAZOLE 7 MICONAZOLE NITRATE 2% CREAM/APPL<br />
MICADERM MICONAZOLE NITRATE 2% CREAM(GM)<br />
MICATIN MICONAZOLE NITRATE 2% CREAM(GM)<br />
MICONAZOLE 3 MICONAZOLE NITRATE 200MG SUPP.VAG<br />
MICONAZOLE 7 MICONAZOLE NITRATE 100MG SUPP.VAG<br />
MICONAZOLE 7 MICONAZOLE NITRATE 2% CREAM/APPL<br />
MICONAZOLE NITRATE MICONAZOLE NITRATE 100MG SUPP.VAG<br />
MICONAZOLE NITRATE MICONAZOLE NITRATE 2% CREAM(GM)<br />
MICONAZOLE NITRATE MICONAZOLE NITRATE 2% CREAM/APPL<br />
MICONAZOLE-7 MICONAZOLE NITRATE 2% CREAM/APPL<br />
MICRO-GUARD MICONAZOLE NITRATE 2% CREAM(GM)<br />
MITRAZOL MICONAZOLE NITRATE 2% CREAM(GM)<br />
MONISTAT 7 MICONAZOLE NITRATE 100MG SUPP.VAG<br />
MONISTAT 7 MICONAZOLE NITRATE 2% CREAM/APPL<br />
MONISTAT-DERM MICONAZOLE NITRATE 2% CREAM(GM)<br />
PODACTIN MICONAZOLE NITRATE 2% CREAM(GM)<br />
TRIPLE CARE ANTIFUNGAL MICONAZOLE NITRATE 2% CREAM(GM)<br />
YEAST-X MICONAZOLE NITRATE 2% CREAM/APPL<br />
INSTAT MCH MICROFIBRILLAR COLLAGEN 1G EACH<br />
COMPLEAT PEDIATRIC MILK BASED FORMULA LIQUID<br />
MILRINONE LACTATE MILRINONE LACTATE 1MG/ML VIAL<br />
PRIMACOR MILRINONE LACTATE 1MG/ML VIAL<br />
DYNACIN MINOCYCLINE HCL 100MG CAPSULE<br />
DYNACIN MINOCYCLINE HCL 50MG CAPSULE<br />
DYNACIN MINOCYCLINE HCL 75MG CAPSULE<br />
MINOCIN MINOCYCLINE HCL 100MG CAPSULE<br />
MINOCIN MINOCYCLINE HCL 50MG CAPSULE<br />
MINOCYCLINE HCL MINOCYCLINE HCL 100MG CAPSULE<br />
MINOCYCLINE HCL MINOCYCLINE HCL 50MG CAPSULE<br />
MINOCYCLINE HCL MINOCYCLINE HCL 75MG CAPSULE<br />
LONITEN MINOXIDIL 10MG TABLET<br />
Page 57<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
LONITEN MINOXIDIL 2.5MG TABLET<br />
MINODIXIL MINOXIDIL 10MG TABLET<br />
MINOXIDIL MINOXIDIL 10MG TABLET<br />
MINOXIDIL MINOXIDIL 2.5MG TABLET<br />
MIRTAZAPINE MIRTAZAPINE 15MG TABLET<br />
MIRTAZAPINE MIRTAZAPINE 30MG TABLET<br />
MISOPROSTOL MISOPROSTOL 100MCG TABLET<br />
MISOPROSTOL MISOPROSTOL 200MCG TABLET<br />
MITOMYCIN MITOMYCIN 20MG VIAL<br />
MITOMYCIN MITOMYCIN 40MG VIAL<br />
MITOMYCIN MITOMYCIN 5MG VIAL<br />
FORMULATION R MO/PET,WH/PHENYLEPHRINE/SHK LV OINT.(GM)<br />
HEMORRHOIDAL MO/PET,WH/PHENYLEPHRINE/SHK LV OINT.(GM)<br />
HEMORRHOIDAL OINTMENT MO/PET,WH/PHENYLEPHRINE/SHK LV OINT.(GM)<br />
PREPARATION H MO/PET,WH/PHENYLEPHRINE/SHK LV OINT.(GM)<br />
PROMPT RELIEF MO/PET,WH/PHENYLEPHRINE/SHK LV OINT.(GM)<br />
RECTACAINE MO/PET,WH/PHENYLEPHRINE/SHK LV OINT.(GM)<br />
SB HEMORRHOID MO/PET,WH/PHENYLEPHRINE/SHK LV OINT.(GM)<br />
CANDIN MOLD EXTRACTS ALLERGEN<br />
DERMATOPHYTIN O MOLD EXTRACTS ALLERGEN<br />
AMMONIUM MOLYBDATE MOLYBDENUM 25MCG/ML VIAL<br />
MOMETASONE FUROATE MOMETASONE FUROATE 0.1% OINT.(GM)<br />
ASTRAMORPH-PF MORPHINE SULFATE 1MG/ML VIAL<br />
DURAMORPH MORPHINE SULFATE 0.5MG/ML AMPUL<br />
DURAMORPH MORPHINE SULFATE 1MG/ML AMPUL<br />
MORPHINE SULFATE MORPHINE SULFATE 0.5MG/ML AMPUL<br />
MORPHINE SULFATE MORPHINE SULFATE 0.5MG/ML VIAL<br />
MORPHINE SULFATE MORPHINE SULFATE 100MG TABLET SA<br />
MORPHINE SULFATE MORPHINE SULFATE 10MG SUPP.RECT<br />
MORPHINE SULFATE MORPHINE SULFATE 10MG/5ML SOLUTION<br />
MORPHINE SULFATE MORPHINE SULFATE 10MG/ML AMPUL<br />
MORPHINE SULFATE MORPHINE SULFATE 10MG/ML DISP SYRIN<br />
MORPHINE SULFATE MORPHINE SULFATE 10MG/ML VIAL<br />
MORPHINE SULFATE MORPHINE SULFATE 15MG TABLET<br />
MORPHINE SULFATE MORPHINE SULFATE 15MG TABLET SA<br />
MORPHINE SULFATE MORPHINE SULFATE 15MG/ML DISP SYRIN<br />
MORPHINE SULFATE MORPHINE SULFATE 15MG/ML VIAL<br />
MORPHINE SULFATE MORPHINE SULFATE 1MG/ML AMPUL<br />
MORPHINE SULFATE MORPHINE SULFATE 1MG/ML DISP SYRIN<br />
MORPHINE SULFATE MORPHINE SULFATE 1MG/ML VIAL<br />
MORPHINE SULFATE MORPHINE SULFATE 200MG TABLET SA<br />
MORPHINE SULFATE MORPHINE SULFATE 20MG SUPP.RECT<br />
MORPHINE SULFATE MORPHINE SULFATE 20MG/5ML SOLUTION<br />
MORPHINE SULFATE MORPHINE SULFATE 20MG/ML SOLUTION<br />
MORPHINE SULFATE MORPHINE SULFATE 25MG/ML DISP SYRIN<br />
MORPHINE SULFATE MORPHINE SULFATE 25MG/ML VIAL<br />
MORPHINE SULFATE MORPHINE SULFATE 2MG/ML DISP SYRIN<br />
MORPHINE SULFATE MORPHINE SULFATE 2MG/ML VIAL<br />
MORPHINE SULFATE MORPHINE SULFATE 30MG SUPP.RECT<br />
MORPHINE SULFATE MORPHINE SULFATE 30MG TABLET<br />
MORPHINE SULFATE MORPHINE SULFATE 30MG TABLET SA<br />
MORPHINE SULFATE MORPHINE SULFATE 4MG/ML DISP SYRIN<br />
MORPHINE SULFATE MORPHINE SULFATE 50MG/ML DISP SYRIN<br />
MORPHINE SULFATE MORPHINE SULFATE 50MG/ML VIAL<br />
MORPHINE SULFATE MORPHINE SULFATE 5MG SUPP.RECT<br />
MORPHINE SULFATE MORPHINE SULFATE 5MG/ML VIAL<br />
MORPHINE SULFATE MORPHINE SULFATE 60MG TABLET SA<br />
MORPHINE SULFATE MORPHINE SULFATE 8MG/ML AMPUL<br />
MORPHINE SULFATE MORPHINE SULFATE 8MG/ML DISP SYRIN<br />
MORPHINE SULFATE INJECTION MORPHINE SULFATE 15MG/ML VIAL<br />
MORPHINE SULFATE INJECTION MORPHINE SULFATE 5MG/ML VIAL<br />
MORPHINE SULFATE IR MORPHINE SULFATE 15MG TABLET<br />
MORPHINE SULFATE IR MORPHINE SULFATE 30MG TABLET<br />
MS CONTIN MORPHINE SULFATE 100MG TABLET SA<br />
MS CONTIN MORPHINE SULFATE 15MG TABLET SA<br />
MS CONTIN MORPHINE SULFATE 30MG TABLET SA<br />
MS CONTIN MORPHINE SULFATE 60MG TABLET SA<br />
MSIR MORPHINE SULFATE 10MG/5ML SOLUTION<br />
MSIR MORPHINE SULFATE 15MG TABLET<br />
MSIR MORPHINE SULFATE 20MG/5ML SOLUTION<br />
MSIR MORPHINE SULFATE 20MG/ML SOLUTION<br />
MSIR MORPHINE SULFATE 30MG TABLET<br />
ORAMORPH SR MORPHINE SULFATE 100MG TABLET SA<br />
ORAMORPH SR MORPHINE SULFATE 15MG TABLET SA<br />
ORAMORPH SR MORPHINE SULFATE 30MG TABLET SA<br />
Page 58<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
ORAMORPH SR MORPHINE SULFATE 60MG TABLET SA<br />
RMS-SUPPOSITORY MORPHINE SULFATE 10MG SUPP.RECT<br />
RMS-SUPPOSITORY MORPHINE SULFATE 20MG SUPP.RECT<br />
RMS-SUPPOSITORY MORPHINE SULFATE 30MG SUPP.RECT<br />
RMS-SUPPOSITORY MORPHINE SULFATE 5MG SUPP.RECT<br />
ROXANOL MORPHINE SULFATE 20MG/ML SOLUTION<br />
ROXANOL 100 MORPHINE SULFATE 20MG/ML SOLUTION<br />
ROXANOL-T MORPHINE SULFATE 20MG/ML SOLUTION<br />
CAROMEGA MULTIVITAMINS TABLET<br />
INFUVITE ADULT MULTIVITAMINS VIAL<br />
M.V.I. PEDIATRIC MULTIVITAMINS VIAL<br />
M.V.I.-12 MULTIVITAMINS VIAL<br />
MULTI-12 MULTIVITAMINS VIAL<br />
MULTIVITAMIN 12 MULTIVITAMINS VIAL<br />
STROVITE MULTIVITAMINS TABLET<br />
ELDERCAPS MULTIVITAMINS W-MINERALS CAPSULE<br />
ZODEAC-100 MULTIVITAMINS W-MINERALS TABLET<br />
LIVER,IRON & VITAMINS MULTIVITS W-FE,LIVER VIAL<br />
CENTAMIN MULTIVITS W-FE,OTHER MIN LIQUID<br />
GERAVINE MULTIVITS W-FE,OTHER MIN LIQUID<br />
STROVITE PLUS MULTIVITS W-FE,OTHER MIN TABLET<br />
CENTRUM MULTIVITS W-IRON,HEMATINIC 27-0.4MG TABLET<br />
CEFOL MULTIVITS,STRESS FORMULA TABLET<br />
B-COMPLEX PLUS VITAMIN MULTIVITS,THERAP W-FE,HEMATIN TABLET<br />
B-COMPLEX VITAMIN PLUS MULTIVITS,THERAP W-FE,HEMATIN 27-0.8MG TABLET<br />
B-PLEX PLUS MULTIVITS,THERAP W-FE,HEMATIN 27-0.8MG TABLET<br />
FORMULA B PLUS MULTIVITS,THERAP W-FE,HEMATIN 27-0.8MG TABLET<br />
THERAGRAN HEMATINIC MULTIVITS,THERAP W-FE,HEMATIN 66.7-.33MG TABLET<br />
THERAPEUTIC HEMATINIC MULTIVITS,THERAP W-FE,HEMATIN TABLET<br />
THEROBEC PLUS MULTIVITS,THERAP W-FE,HEMATIN 27-0.8MG TABLET<br />
VITALIZE PLUS MULTIVITS,THERAP W-FE,HEMATIN 27-0.8MG TABLET<br />
VITAPLEX PLUS MULTIVITS,THERAP W-FE,HEMATIN 27-0.8MG TABLET<br />
VITAROCA PLUS MULTIVITS,THERAP W-FE,HEMATIN 27-0.8MG TABLET<br />
SULFACETAMIDE W/PREDNISOLONE NA SULFACETM/PREDNIS SP 10-0.25% DROPS<br />
VASOCIDIN NA SULFACETM/PREDNIS SP 10-0.25% DROPS<br />
NABUMETONE NABUMETONE 500MG TABLET<br />
NABUMETONE NABUMETONE 750MG TABLET<br />
RELAFEN NABUMETONE 500MG TABLET<br />
RELAFEN NABUMETONE 750MG TABLET<br />
POTASSIUM CHL/NORMAL SALINE NACL 0.9%/POTASSIUM CHLORIDE 20MEQ/L IV SOLN.<br />
POTASSIUM CHL/NORMAL SALINE NACL 0.9%/POTASSIUM CHLORIDE 40MEQ/L IV SOLN.<br />
CORGARD NADOLOL 120MG TABLET<br />
CORGARD NADOLOL 160MG TABLET<br />
CORGARD NADOLOL 20MG TABLET<br />
CORGARD NADOLOL 40MG TABLET<br />
CORGARD NADOLOL 80MG TABLET<br />
NADOLOL NADOLOL 120MG TABLET<br />
NADOLOL NADOLOL 160MG TABLET<br />
NADOLOL NADOLOL 20MG TABLET<br />
NADOLOL NADOLOL 40MG TABLET<br />
NADOLOL NADOLOL 80MG TABLET<br />
NAFCILLIN SODIUM NAFCILLIN SODIUM 1G VIAL<br />
NAFCILLIN SODIUM NAFCILLIN SODIUM 2G VIAL<br />
NALLPEN NAFCILLIN SODIUM 10G VIAL<br />
NALLPEN NAFCILLIN SODIUM 2G PIGGYBACK<br />
NALLPEN NAFCILLIN SODIUM 2G VIAL<br />
NALLPEN NAFCILLIN SODIUM 500MG VIAL<br />
NALBUPHINE HCL NALBUPHINE HCL 10MG/ML AMPUL<br />
NALBUPHINE HCL NALBUPHINE HCL 10MG/ML VIAL<br />
NALBUPHINE HCL NALBUPHINE HCL 20MG/ML AMPUL<br />
NALBUPHINE HCL NALBUPHINE HCL 20MG/ML VIAL<br />
NUBAIN NALBUPHINE HCL 20MG/ML AMPUL<br />
NALOXONE HCL NALOXONE HCL 0.02MG/ML AMPUL<br />
NALOXONE HCL NALOXONE HCL 0.4MG/ML AMPUL<br />
NALOXONE HCL NALOXONE HCL 0.4MG/ML DISP SYRIN<br />
NALOXONE HCL NALOXONE HCL 0.4MG/ML VIAL<br />
NARCAN NALOXONE HCL 0.02MG/ML AMPUL<br />
NARCAN NALOXONE HCL 0.4MG/ML AMPUL<br />
NARCAN MULTIPLE DOSE NALOXONE HCL 0.4MG/ML VIAL<br />
PENTAZOCINE AND NALOXONE HCL NALOXONE HCL/PENTAZOCINE HCL 50-0.5MG TABLET<br />
PENTAZOCINE/NALOXONE NALOXONE HCL/PENTAZOCINE HCL 50-0.5MG TABLET<br />
TALWIN NX NALOXONE HCL/PENTAZOCINE HCL 50-0.5MG TABLET<br />
DEPADE NALTREXONE HCL 50MG TABLET<br />
NALTREXONE HYDROCHLORIDE NALTREXONE HCL 50MG TABLET<br />
REVIA NALTREXONE HCL 50MG TABLET<br />
Page 59<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
DECA-DURABOLIN NANDROLONE DECANOATE 100MG/ML VIAL<br />
NANDROLONE DECANOATE NANDROLONE DECANOATE 100MG/ML VIAL<br />
NANDROLONE DECANOATE NANDROLONE DECANOATE 200MG/ML VIAL<br />
NANDROLONE DECANOATE NANDROLONE DECANOATE 50MG/ML VIAL<br />
AK-CON NAPHAZOLINE HCL 0.1% DROPS<br />
ALBALON NAPHAZOLINE HCL 0.1% DROPS<br />
ALLERSOL NAPHAZOLINE HCL 0.1% DROPS<br />
NAPHAZOLE NAPHAZOLINE HCL 0.1% DROPS<br />
NAPHAZOLINE HCL NAPHAZOLINE HCL 0.1% DROPS<br />
EC-NAPROSYN NAPROXEN 375MG TABLET DR<br />
EC-NAPROSYN NAPROXEN 500MG TABLET DR<br />
NAPROSYN NAPROXEN 250MG TABLET<br />
NAPROSYN NAPROXEN 375MG TABLET<br />
NAPROSYN NAPROXEN 500MG TABLET<br />
NAPROXEN NAPROXEN 125MG/5ML ORAL SUSP<br />
NAPROXEN NAPROXEN 250MG TABLET<br />
NAPROXEN NAPROXEN 375MG TABLET<br />
NAPROXEN NAPROXEN 375MG TABLET DR<br />
NAPROXEN NAPROXEN 500MG TABLET<br />
NAPROXEN NAPROXEN 500MG TABLET DR<br />
ANAPROX NAPROXEN SODIUM 275MG TABLET<br />
ANAPROX DS NAPROXEN SODIUM 550MG TABLET<br />
NAPROXEN SODIUM NAPROXEN SODIUM 220MG TABLET<br />
NAPROXEN SODIUM NAPROXEN SODIUM 275MG TABLET<br />
NAPROXEN SODIUM NAPROXEN SODIUM 550MG TABLET<br />
NAPROXEN SODIUM NAPROXEN SODIUM 550MG TABLET SA<br />
V-R NAPROXEN SODIUM NAPROXEN SODIUM 220MG TABLET<br />
ANTIBIOTIC NEOMY SULF/POLYMYXIN B SULFATE CREAM(GM)<br />
NEOMYCIN SULFATE NEOMYCIN SULFATE 500MG TABLET<br />
NEOSTIGMINE METHYLSULFATE NEOSTIGMINE METHYLSULFATE 1:1000 VIAL<br />
NEOSTIGMINE METHYLSULFATE NEOSTIGMINE METHYLSULFATE 1:2000 VIAL<br />
PROSTIGMIN NEOSTIGMINE METHYLSULFATE 1:1000 VIAL<br />
PROSTIGMIN NEOSTIGMINE METHYLSULFATE 1:2000 VIAL<br />
NIACIN NIACIN 125MG CAPSULE SA<br />
NIACIN NIACIN 250MG CAPSULE SA<br />
NIACIN TD NIACIN 250MG CAPSULE SA<br />
NIACOR NIACIN 500MG TABLET<br />
CARDENE NICARDIPINE HCL 20MG CAPSULE<br />
CARDENE NICARDIPINE HCL 30MG CAPSULE<br />
NICARDIPINE HCL NICARDIPINE HCL 20MG CAPSULE<br />
NICARDIPINE HCL NICARDIPINE HCL 30MG CAPSULE<br />
NIFEDICAL XL NIFEDIPINE 30MG TAB SA OSM<br />
NIFEDICAL XL NIFEDIPINE 60MG TAB SA OSM<br />
NIFEDIPINE NIFEDIPINE 10MG CAPSULE<br />
NIFEDIPINE NIFEDIPINE 20MG CAPSULE<br />
NIFEDIPINE NIFEDIPINE 30MG TABLET SA<br />
NIFEDIPINE NIFEDIPINE 60MG TABLET SA<br />
NIFEDIPINE NIFEDIPINE 90MG TABLET SA<br />
NIFEDIPINE ER NIFEDIPINE 30MG TAB SA OSM<br />
NIFEDIPINE ER NIFEDIPINE 60MG TAB SA OSM<br />
NIFEDIPINE ER NIFEDIPINE 90MG TAB SA OSM<br />
PROCARDIA NIFEDIPINE 10MG CAPSULE<br />
PROCARDIA NIFEDIPINE 20MG CAPSULE<br />
PROCARDIA XL NIFEDIPINE 30MG TAB SA OSM<br />
PROCARDIA XL NIFEDIPINE 60MG TAB SA OSM<br />
MACRODANTIN NITROFURANTOIN MACROCRYSTAL 100MG CAPSULE<br />
MACRODANTIN NITROFURANTOIN MACROCRYSTAL 50MG CAPSULE<br />
NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MACROCRYSTAL 100MG CAPSULE<br />
NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MACROCRYSTAL 50MG CAPSULE<br />
FURACIN NITROFURAZONE 0.2% OINT.(GM)<br />
NITROFURAZONE NITROFURAZONE 0.2% OINT.(GM)<br />
NITROFURAZONE NITROFURAZONE 0.2% SOLUTION<br />
MINITRAN NITROGLYCERIN 0.1MG/HR PATCH TD24<br />
MINITRAN NITROGLYCERIN 0.2MG/HR PATCH TD24<br />
MINITRAN NITROGLYCERIN 0.4MG/HR PATCH TD24<br />
MINITRAN NITROGLYCERIN 0.6MG/HR PATCH TD24<br />
NITREK NITROGLYCERIN 0.2MG/HR PATCH TD24<br />
NITREK NITROGLYCERIN 0.4MG/HR PATCH TD24<br />
NITREK NITROGLYCERIN 0.6MG/HR PATCH TD24<br />
NITRO-BID NITROGLYCERIN 2% OINT.(GM)<br />
NITRO-DUR NITROGLYCERIN 0.1MG/HR PATCH TD24<br />
NITRO-DUR NITROGLYCERIN 0.2MG/HR PATCH TD24<br />
NITRO-DUR NITROGLYCERIN 0.4MG/HR PATCH TD24<br />
NITRO-DUR NITROGLYCERIN 0.6MG/HR PATCH TD24<br />
NITROGLYCERIN NITROGLYCERIN 0.1MG/HR PATCH TD24<br />
Page 60<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
NITROGLYCERIN NITROGLYCERIN 0.2MG/HR PATCH TD24<br />
NITROGLYCERIN NITROGLYCERIN 0.3MG TAB SUBL<br />
NITROGLYCERIN NITROGLYCERIN 0.4MG TAB SUBL<br />
NITROGLYCERIN NITROGLYCERIN 0.4MG/HR PATCH TD24<br />
NITROGLYCERIN NITROGLYCERIN 0.6MG TAB SUBL<br />
NITROGLYCERIN NITROGLYCERIN 0.6MG/HR PATCH TD24<br />
NITROGLYCERIN NITROGLYCERIN 2.5MG CAPSULE SA<br />
NITROGLYCERIN NITROGLYCERIN 5MG/ML VIAL<br />
NITROGLYCERIN NITROGLYCERIN 6.5MG CAPSULE SA<br />
NITROGLYCERIN NITROGLYCERIN 9MG CAPSULE SA<br />
NITROGLYCERIN TRANSDERMAL NITROGLYCERIN 0.1MG/HR PATCH TD24<br />
NITROGLYCERIN TRANSDERMAL NITROGLYCERIN 0.2MG/HR PATCH TD24<br />
NITROGLYCERIN TRANSDERMAL NITROGLYCERIN 0.4MG/HR PATCH TD24<br />
NITROGLYCERIN TRANSDERMAL NITROGLYCERIN 0.6MG/HR PATCH TD24<br />
NITROGLYN NITROGLYCERIN 2.5MG CAPSULE SA<br />
NITROGLYN NITROGLYCERIN 6.5MG CAPSULE SA<br />
NITROGLYN NITROGLYCERIN 9MG CAPSULE SA<br />
NITROL NITROGLYCERIN 2% OINT.(GM)<br />
NITROQUICK NITROGLYCERIN 0.3MG TAB SUBL<br />
NITROQUICK NITROGLYCERIN 0.4MG TAB SUBL<br />
NITROQUICK NITROGLYCERIN 0.6MG TAB SUBL<br />
NITROSTAT NITROGLYCERIN 0.3MG TAB SUBL<br />
NITROSTAT NITROGLYCERIN 0.4MG TAB SUBL<br />
NITROSTAT NITROGLYCERIN 0.6MG TAB SUBL<br />
NITROTAB NITROGLYCERIN 0.3MG TAB SUBL<br />
NITROTAB NITROGLYCERIN 0.4MG TAB SUBL<br />
NITROTAB NITROGLYCERIN 0.6MG TAB SUBL<br />
NITRO-TIME NITROGLYCERIN 2.5MG CAPSULE SA<br />
NITRO-TIME NITROGLYCERIN 6.5MG CAPSULE SA<br />
NITRO-TIME NITROGLYCERIN 9MG CAPSULE SA<br />
TRIDIL NITROGLYCERIN 5MG/ML VIAL<br />
NITROPRUSSIDE SODIUM NITROPRUSSIDE SODIUM 25MG/ML VIAL<br />
AXID NIZATIDINE 150MG CAPSULE<br />
AXID NIZATIDINE 300MG CAPSULE<br />
NIZATIDINE NIZATIDINE 150MG CAPSULE<br />
NIZATIDINE NIZATIDINE 300MG CAPSULE<br />
LEVOPHED BITARTATE NOREPINEPHRINE BITARTRATE 1MG/ML AMPUL<br />
CAMILA NORETHINDRONE 0.35MG TABLET<br />
ERRIN NORETHINDRONE 0.35MG TABLET<br />
NORA-BE NORETHINDRONE 0.35MG TABLET<br />
NOR-Q-D NORETHINDRONE 0.35MG TABLET<br />
NORETHINDRONE ACETATE NORETHINDRONE ACETATE 5MG TABLET<br />
BREVICON NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET<br />
MODICON NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET<br />
NECON NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET<br />
NECON NORETHINDRONE-ETHINYL ESTRAD 1-0.035MG TABLET<br />
NECON NORETHINDRONE-ETHINYL ESTRAD 10-11 TABLET<br />
NECON NORETHINDRONE-ETHINYL ESTRAD 7 DAYS X 3 TABLET<br />
NORINYL 1+35 NORETHINDRONE-ETHINYL ESTRAD 1-0.035MG TABLET<br />
NORTREL NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET<br />
NORTREL NORETHINDRONE-ETHINYL ESTRAD 1-0.035MG TABLET<br />
NORTREL NORETHINDRONE-ETHINYL ESTRAD 7 DAYS X 3 TABLET<br />
ORTHO-NOVUM NORETHINDRONE-ETHINYL ESTRAD 1-0.035MG TABLET<br />
NECON NORETHINDRONE-MESTRANOL 1-0.05MG TABLET<br />
NORINYL 1+50 NORETHINDRONE-MESTRANOL 1-0.05MG TABLET<br />
ORTHO-NOVUM NORETHINDRONE-MESTRANOL 1-0.05MG TABLET<br />
MONONESSA NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 TABLET<br />
SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 TABLET<br />
CRYSELLE NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET<br />
LO/OVRAL-21 NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET<br />
LO/OVRAL-28 NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET<br />
LOW-OGESTREL NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET<br />
OGESTREL NORGESTREL-ETHINYL ESTRADIOL 0.5-0.05MG TABLET<br />
AVENTYL HCL NORTRIPTYLINE HCL 10MG CAPSULE<br />
AVENTYL HCL NORTRIPTYLINE HCL 10MG/5ML SOLUTION<br />
AVENTYL HCL NORTRIPTYLINE HCL 25MG CAPSULE<br />
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10MG CAPSULE<br />
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10MG/5ML SOLUTION<br />
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 25MG CAPSULE<br />
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 50MG CAPSULE<br />
NORTRIPTYLINE HCL NORTRIPTYLINE HCL 75MG CAPSULE<br />
PAMELOR NORTRIPTYLINE HCL 10MG CAPSULE<br />
PAMELOR NORTRIPTYLINE HCL 10MG/5ML SOLUTION<br />
PAMELOR NORTRIPTYLINE HCL 25MG CAPSULE<br />
PAMELOR NORTRIPTYLINE HCL 50MG CAPSULE<br />
Page 61<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
PAMELOR NORTRIPTYLINE HCL 75MG CAPSULE<br />
NUTRIHEP NUT.TX. METABOLIC DISORDER,REG LIQUID<br />
PHENYLADE NUT.TX. METABOLIC DISORDER,REG PACKET<br />
PHENYLADE NUT.TX. METABOLIC DISORDER,REG POWDER<br />
PHENYLADE MTE NUT.TX. METABOLIC DISORDER,REG POWDER<br />
PKU AID NUT.TX. METABOLIC DISORDER,REG POWDER<br />
PERATIVE NUT.TX. METABOLIC DISORDER,SOY LIQUID<br />
CRUCIAL NUT.TX.COMP. IMMUNE SYSTM,SOY LIQUID<br />
DIABETISOURCE NUT.TX.GLUC.INTOLER,LAC-FR,REG LIQUID<br />
RESOURCE DIABETIC NUT.TX.GLUC.INTOLER,LAC-FR,REG LIQUID<br />
GLUCERNA NUT.TX.GLUC.INTOLER,LAC-FR,SOY LIQUID<br />
GLYTROL NUT.TX.GLUC.INTOLER,LAC-FR,SOY LIQUID<br />
GLUCERNA NUT.TX.GLUCOSE INTOLERANCE,SOY BAR<br />
NUTRIRENAL NUT.TX.IMP.RENAL FXN,LAC-FREE LIQUID<br />
RE/NEPH HP/HC NUT.TX.IMP.RENAL FXN,LAC-FREE LIQUID<br />
RENALCAL NUT.TX.IMP.RENAL FXN,LAC-FREE LIQUID<br />
VIVONEX RTF NUT.TX.IMPAIRED DIGEST FXN,SOY LIQUID<br />
MAGNACAL RENAL NUT.TX.IMPAIRED RENAL FXN,SOY LIQUID<br />
SUPLENA NUT.TX.IMPAIRED RENAL FXN,SOY LIQUID<br />
RESPALOR NUT.TX.PULM.DISORD.SOY,LAC-FR LIQUID<br />
ACERFLEX NUTRITIONAL SUPPLEMENT POWDER<br />
ATTAIN NUTRITIONAL SUPPLEMENT LIQUID<br />
BOOST NUTRITIONAL SUPPLEMENT BAR<br />
COMPLY NUTRITIONAL SUPPLEMENT LIQUID<br />
ENTRITION NUTRITIONAL SUPPLEMENT LIQUID<br />
ENTRITION HN NUTRITIONAL SUPPLEMENT LIQUID<br />
EO28 EXTRA NUTRITIONAL SUPPLEMENT POWDER<br />
GLUCO-PRO NUTRITIONAL SUPPLEMENT LIQUID<br />
GLUTASORB NUTRITIONAL SUPPLEMENT LIQUID<br />
ISOCAL HN PLUS NUTRITIONAL SUPPLEMENT LIQUID<br />
K.D.S. ATTAIN NUTRITIONAL SUPPLEMENT LIQUID<br />
K.D.S. COMPLY NUTRITIONAL SUPPLEMENT LIQUID<br />
K.D.S. PRE-ATTAIN NUTRITIONAL SUPPLEMENT LIQUID<br />
K.D.S. PROTAIN XL NUTRITIONAL SUPPLEMENT LIQUID<br />
LACTA/CARE NUTRITIONAL SUPPLEMENT LIQUID<br />
MAINTAIN NUTRITIONAL SUPPLEMENT LIQUID<br />
MAXAMAID XP NUTRITIONAL SUPPLEMENT BAR<br />
METAFORM NUTRITIONAL SUPPLEMENT PACKET<br />
METHIONAID NUTRITIONAL SUPPLEMENT POWDER<br />
MSUD AID NUTRITIONAL SUPPLEMENT POWDER<br />
MSUD MAXAMAID NUTRITIONAL SUPPLEMENT POWDER<br />
MSUD MAXAMUM NUTRITIONAL SUPPLEMENT POWDER<br />
NOVASOURCE 2.0 NUTRITIONAL SUPPLEMENT LIQUID<br />
NOVASOURCE PULMONARY NUTRITIONAL SUPPLEMENT LIQUID<br />
NOVASOURCE RENAL NUTRITIONAL SUPPLEMENT LIQUID<br />
NUTREN 1.0 NUTRITIONAL SUPPLEMENT LIQUID<br />
NUTREN 1.5 NUTRITIONAL SUPPLEMENT LIQUID<br />
NUTREN 2.0 NUTRITIONAL SUPPLEMENT LIQUID<br />
NUTREN JUNIOR NUTRITIONAL SUPPLEMENT LIQUID<br />
OPTIMENTAL NUTRITIONAL SUPPLEMENT LIQUID<br />
PEPTAMEN NUTRITIONAL SUPPLEMENT LIQUID<br />
PEPTAMEN 1.5 NUTRITIONAL SUPPLEMENT LIQUID<br />
PEPTAMEN JUNIOR NUTRITIONAL SUPPLEMENT LIQUID<br />
PEPTAMEN VHP NUTRITIONAL SUPPLEMENT LIQUID<br />
PERIFLEX NUTRITIONAL SUPPLEMENT POWDER<br />
PHLEXY-10 NUTRITIONAL SUPPLEMENT BAR<br />
PHLEXY-10 NUTRITIONAL SUPPLEMENT PACKET<br />
PHLEXY-VITS NUTRITIONAL SUPPLEMENT PACKET<br />
PRE-ATTAIN NUTRITIONAL SUPPLEMENT LIQUID<br />
PRO-PEPTIDE NUTRITIONAL SUPPLEMENT LIQUID<br />
PRO-PEPTIDE FOR KIDS NUTRITIONAL SUPPLEMENT LIQUID<br />
PRO-PEPTIDE VHN NUTRITIONAL SUPPLEMENT LIQUID<br />
PROTAIN XL NUTRITIONAL SUPPLEMENT LIQUID<br />
REABILAN NUTRITIONAL SUPPLEMENT LIQUID<br />
REABILANHN NUTRITIONAL SUPPLEMENT LIQUID<br />
REPLETE NUTRITIONAL SUPPLEMENT LIQUID<br />
RESOURCE NUTRITIONAL SUPPLEMENT LIQUID<br />
RESOURCE JUST FOR KIDS NUTRITIONAL SUPPLEMENT LIQUID<br />
SUBDUE NUTRITIONAL SUPPLEMENT LIQUID<br />
SUBDUE PLUS NUTRITIONAL SUPPLEMENT LIQUID<br />
SUPER ENERGY NUTRITIONAL SUPPLEMENT POWDER<br />
VANILLA LOW LACTOSE NUTRITIONAL SUPPLEMENT POWDER<br />
VITALIZE NUTRITIONAL SUPPLEMENT BAR<br />
VITALIZE NUTRITIONAL SUPPLEMENT LIQUID<br />
XLEU MAXAMAID NUTRITIONAL SUPPLEMENT POWDER<br />
Page 62<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
XLEU MAXAMUM NUTRITIONAL SUPPLEMENT POWDER<br />
XLYS, TRY MAXAMAID NUTRITIONAL SUPPLEMENT POWDER<br />
XLYS, TRY MAXAMUM NUTRITIONAL SUPPLEMENT POWDER<br />
XMET MAXAMAID NUTRITIONAL SUPPLEMENT POWDER<br />
XMET MAXAMUM NUTRITIONAL SUPPLEMENT POWDER<br />
XMTVI MAXAMAID NUTRITIONAL SUPPLEMENT POWDER<br />
XMTVI MAXAMUM NUTRITIONAL SUPPLEMENT POWDER<br />
XP MAXAMAID NUTRITIONAL SUPPLEMENT POWDER<br />
XP MAXAMUM NUTRITIONAL SUPPLEMENT POWDER<br />
XPHEN, TYR MAXAMAID NUTRITIONAL SUPPLEMENT POWDER<br />
XPTM MAXAMAID NUTRITIONAL SUPPLEMENT POWDER<br />
MYCOSTATIN NYSTATIN 100000 U/G CREAM(GM)<br />
MYCOSTATIN NYSTATIN 100K U/ML ORAL SUSP<br />
MYCOSTATIN NYSTATIN 500000 U TABLET<br />
NYSTATIN NYSTATIN 100000 U TABLET<br />
NYSTATIN NYSTATIN 100000 U/G CREAM(GM)<br />
NYSTATIN NYSTATIN 100000 U/G OINT.(GM)<br />
NYSTATIN NYSTATIN 100K U/ML ORAL SUSP<br />
NYSTATIN NYSTATIN 150MMU POWDER<br />
NYSTATIN NYSTATIN 2B UNIT POWDER<br />
NYSTATIN NYSTATIN 500000 U TABLET<br />
NYSTEX NYSTATIN 100000 U/G CREAM(GM)<br />
NYSTEX NYSTATIN 100000 U/G OINT.(GM)<br />
NYSTEX NYSTATIN 100K U/ML ORAL SUSP<br />
NYSTOP NYSTATIN 100000 U/G POWDER<br />
PEDI-DRI NYSTATIN 100000 U/G POWDER<br />
MYCOGEN II NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM)<br />
MYCOLOG II NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM)<br />
MYCOLOG II NYSTATIN/TRIAMCIN 100000-0.1 OINT.(GM)<br />
MYCONEL NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM)<br />
MYCO-TRIACET II NYSTATIN/TRIAMCIN OINT.(GM)<br />
MYTREX NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM)<br />
MYTREX NYSTATIN/TRIAMCIN 100000-0.1 OINT.(GM)<br />
N.T.A. NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM)<br />
N.T.A. NYSTATIN/TRIAMCIN 100000-0.1 OINT.(GM)<br />
NYSTATIN W/TRIAMCINOLONE NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM)<br />
NYSTATIN W/TRIAMCINOLONE NYSTATIN/TRIAMCIN 100000-0.1 OINT.(GM)<br />
OMEPRAZOLE OMEPRAZOLE 20MG CAPSULE DR<br />
FLEXOJECT ORPHENADRINE CITRATE 30MG/ML VIAL<br />
FLEXON ORPHENADRINE CITRATE 30MG/ML VIAL<br />
NORFLEX ORPHENADRINE CITRATE 100MG TABLET SA<br />
ORPHENADRINE CITRATE ORPHENADRINE CITRATE 100MG TABLET SA<br />
BACTOCILL OXACILLIN SODIUM 10G VIAL<br />
BACTOCILL OXACILLIN SODIUM 1G VIAL<br />
BACTOCILL OXACILLIN SODIUM 250MG CAPSULE<br />
BACTOCILL OXACILLIN SODIUM 2G PIGGYBACK<br />
BACTOCILL OXACILLIN SODIUM 2G VIAL<br />
BACTOCILL OXACILLIN SODIUM 500MG CAPSULE<br />
BACTOCILL OXACILLIN SODIUM 500MG VIAL<br />
OXACILLIN SODIUM OXACILLIN SODIUM 250MG/5ML SUSP RECON<br />
OXACILLIN SODIUM OXACILLIN SODIUM 2G VIAL<br />
DAYPRO OXAPROZIN 600MG TABLET<br />
OXAPROZIN OXAPROZIN 600MG TABLET<br />
OXAZEPAM OXAZEPAM 10MG CAPSULE<br />
OXAZEPAM OXAZEPAM 15MG CAPSULE<br />
OXAZEPAM OXAZEPAM 30MG CAPSULE<br />
SERAX OXAZEPAM 10MG CAPSULE<br />
SERAX OXAZEPAM 15MG CAPSULE<br />
SERAX OXAZEPAM 30MG CAPSULE<br />
DITROPAN OXYBUTYNIN CHLORIDE 5MG TABLET<br />
DITROPAN OXYBUTYNIN CHLORIDE 5MG/5ML SYRUP<br />
OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 5MG TABLET<br />
OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 5MG/5ML SYRUP<br />
OXYCODONE HCL OXYCODONE HCL 20MG/ML ORAL CONC.<br />
OXYCODONE HCL OXYCODONE HCL 5MG CAPSULE<br />
OXYCODONE HCL OXYCODONE HCL 5MG TABLET<br />
OXYCODONE HCL OXYCODONE HCL 5MG/5ML SOLUTION<br />
OXYDOSE OXYCODONE HCL 20MG/ML ORAL CONC.<br />
OXYFAST OXYCODONE HCL 20MG/ML ORAL CONC.<br />
OXYIR OXYCODONE HCL 5MG CAPSULE<br />
PERCOLONE OXYCODONE HCL 5MG TABLET<br />
ROXICODONE OXYCODONE HCL 5MG TABLET<br />
ROXICODONE OXYCODONE HCL 5MG/5ML SOLUTION<br />
ROXICODONE INTENSOL OXYCODONE HCL 20MG/ML ORAL CONC.<br />
TERAK OXY-TCN HCL/POLYMYX B SULF OINT.(GM)<br />
Page 63<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
TERRAMYCIN W/POLYMYXIN OXY-TCN HCL/POLYMYX B SULF OINT.(GM)<br />
OXYTOCIN OXYTOCIN 10 UNIT/ML AMPUL<br />
OXYTOCIN OXYTOCIN 10 UNIT/ML VIAL<br />
PITOCIN OXYTOCIN 10 UNIT/ML AMPUL<br />
PITOCIN OXYTOCIN 10 UNIT/ML VIAL<br />
ONXOL PACLITAXEL,SEMI-SYNTHETIC 6MG/ML VIAL<br />
PACLITAXEL PACLITAXEL,SEMI-SYNTHETIC 6MG/ML VIAL<br />
TAXOL PACLITAXEL,SEMI-SYNTHETIC 6MG/ML VIAL<br />
PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM 3MG/ML VIAL<br />
PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM 9MG/ML VIAL<br />
PANCURONIUM BROMIDE PANCURONIUM BROMIDE 1MG/ML VIAL<br />
PANCURONIUM BROMIDE PANCURONIUM BROMIDE 2MG/ML AMPUL<br />
PANCURONIUM BROMIDE PANCURONIUM BROMIDE 2MG/ML VIAL<br />
ETHEZYME PAPAIN/UREA 1.1MMU/G OINT.(GM)<br />
ETHEZYME 830 PAPAIN/UREA 0.83MMU/G OINT.(GM)<br />
KOVIA PAPAIN/UREA 0.83MMU/G OINT.(GM)<br />
KOVIA OINTMENT PAPAIN/UREA 0.83MMU/G OINT.(GM)<br />
PAPAVERINE HCL PAPAVERINE HCL 150MG CAPSULE SA<br />
PAPAVERINE HCL PAPAVERINE HCL 30MG/ML VIAL<br />
PARA-TIME PAPAVERINE HCL 150MG CAPSULE SA<br />
PAREGORIC PAREGORIC 2MG/5ML LIQUID<br />
PAROMOMYCIN SULFATE PAROMOMYCIN SULFATE 250MG CAPSULE<br />
CYLERT PEMOLINE 18.75MG TABLET<br />
CYLERT PEMOLINE 37.5MG TAB CHEW<br />
CYLERT PEMOLINE 37.5MG TABLET<br />
CYLERT PEMOLINE 75MG TABLET<br />
PEMOLINE PEMOLINE 18.75MG TABLET<br />
PEMOLINE PEMOLINE 37.5MG TAB CHEW<br />
PEMOLINE PEMOLINE 37.5MG TABLET<br />
PEMOLINE PEMOLINE 75MG TABLET<br />
PERMAPEN ISOJECT PENICILLIN G BENZATHINE 1.2MMU/2ML DISP SYRIN<br />
PENICILLIN G POTASSIUM PENICILLIN G POTASSIUM 1MMU VIAL<br />
PENICILLIN G POTASSIUM PENICILLIN G POTASSIUM 20MMU VIAL<br />
PENICILLIN G POTASSIUM PENICILLIN G POTASSIUM 5MMU VIAL<br />
PFIZERPEN PENICILLIN G POTASSIUM 20MMU VIAL<br />
PFIZERPEN PENICILLIN G POTASSIUM 5MMU VIAL<br />
PENICILLIN G SODIUM PENICILLIN G SODIUM 5MMU VIAL<br />
LEDERCILLIN VK PENICILLIN V POTASSIUM 250MG TABLET<br />
PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 125MG/5ML SUSP RECON<br />
PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250MG TABLET<br />
PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250MG/5ML SUSP RECON<br />
PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 500MG TABLET<br />
VEETIDS 125 PENICILLIN V POTASSIUM 125MG/5ML SUSP RECON<br />
VEETIDS 250 PENICILLIN V POTASSIUM 250MG TABLET<br />
VEETIDS 250 PENICILLIN V POTASSIUM 250MG/5ML SUSP RECON<br />
VEETIDS 500 PENICILLIN V POTASSIUM 500MG TABLET<br />
PENTOPAK PENTOXIFYLLINE 400MG TABLET SA<br />
PENTOXIFYLLINE PENTOXIFYLLINE 400MG TABLET SA<br />
PENTOXIL PENTOXIFYLLINE 400MG TABLET SA<br />
TRENTAL PENTOXIFYLLINE 400MG TABLET SA<br />
ALLERX-D P-EPHED HCL/SCOP ME-NITRATE 120-2.5MG TAB.SR 12H<br />
HISTACLEAR D P-EPHED HCL/SCOP ME-NITRATE 120-2.5MG TAB.SR 12H<br />
P-EPHED HCL/SCOP ME-NITRATE P-EPHED HCL/SCOP ME-NITRATE 120-2.5MG TAB.SR 12H<br />
PSE 120/MSC 2.5 P-EPHED HCL/SCOP ME-NITRATE 120-2.5MG TAB.SR 12H<br />
ACTANOL P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
ACTIVE P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP<br />
ALLERFRIM P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP<br />
ALLERFRIM P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
ALTAFED P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP<br />
ANTIHISTAMINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
ANTIHISTAMINE/DECONGESTANT P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
APHEDRID P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP<br />
APHEDRID P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
APRODINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
BIOFED-PE P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP<br />
DECONGESTANT P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
DECONGESTANT/ANTIHISTAMINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
GENAC P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
HISTAFED P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP<br />
HISTAFED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
HISTA-TABS P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
HM ANTIHIST/DECONGESTANT P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
LONG ACTING DECONGESTANT P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
NASAL DECONGEST/ANTIHISTAMINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
NASAL DECONGESTANT ANTIHIST P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
Page 64<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
RIDIFED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
RITIFED P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP<br />
SB ANTIHISTAMINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
SILAFED P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP<br />
TRI-AFED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
TRI-FED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
TRIPHED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
TRIPROLIDINE W/PSEUDOEPHEDRINE P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP<br />
TRIPROLIDINE W/PSEUDOEPHEDRINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
TRI-PSEUDATED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
TRI-SOFED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
TRISUDEX P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
TRI-SUDO P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
UNI-FED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
V-R NASAL DECONGEST/ANTIHIST P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET<br />
PERGOLIDE MESYLATE PERGOLIDE MESYLATE 0.05MG TABLET<br />
PERGOLIDE MESYLATE PERGOLIDE MESYLATE 0.25MG TABLET<br />
PERGOLIDE MESYLATE PERGOLIDE MESYLATE 1MG TABLET<br />
ACTICIN PERMETHRIN 5% CREAM(GM)<br />
LICE CREAM RINSE PERMETHRIN 1% LIQUID<br />
LICE CREME RINSE PERMETHRIN 1% LIQUID<br />
LICE KILLING PERMETHRIN 1% LIQUID<br />
NIX PERMETHRIN 1% LIQUID<br />
PERMETHRIN PERMETHRIN 1% LIQUID<br />
SB LICE TREATMENT PERMETHRIN 1% LIQUID<br />
V-R PERMETHRIN LICE PERMETHRIN 1% LIQUID<br />
PERPHENAZINE PERPHENAZINE 16MG TABLET<br />
PERPHENAZINE PERPHENAZINE 16MG/5ML ORAL CONC.<br />
PERPHENAZINE PERPHENAZINE 2MG TABLET<br />
PERPHENAZINE PERPHENAZINE 4MG TABLET<br />
PERPHENAZINE PERPHENAZINE 8MG TABLET<br />
TRILAFON PERPHENAZINE 16MG TABLET<br />
TRILAFON PERPHENAZINE 2MG TABLET<br />
TRILAFON PERPHENAZINE 4MG TABLET<br />
TRILAFON PERPHENAZINE 8MG TABLET<br />
PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL 100MG TABLET<br />
PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL 200MG TABLET<br />
PYRIDIUM PHENAZOPYRIDINE HCL 100MG TABLET<br />
PYRIDIUM PHENAZOPYRIDINE HCL 200MG TABLET<br />
URODOL PHENAZOPYRIDINE HCL 200MG TABLET<br />
PHENOBARBITAL PHENOBARBITAL 100MG TABLET<br />
PHENOBARBITAL PHENOBARBITAL 15MG TABLET<br />
PHENOBARBITAL PHENOBARBITAL 16.2MG TABLET<br />
PHENOBARBITAL PHENOBARBITAL 20MG/5ML ELIXIR<br />
PHENOBARBITAL PHENOBARBITAL 30MG TABLET<br />
PHENOBARBITAL PHENOBARBITAL 32.4MG TABLET<br />
PHENOBARBITAL PHENOBARBITAL 60MG TABLET<br />
PHENOBARBITAL PHENOBARBITAL 64.8MG TABLET<br />
PHENOBARBITAL PHENOBARBITAL 97.2MG TABLET<br />
LUMINAL SODIUM PHENOBARBITAL SODIUM 130MG/ML DISP SYRIN<br />
LUMINAL SODIUM PHENOBARBITAL SODIUM 60MG/ML DISP SYRIN<br />
AK-DILATE PHENYLEPHRINE HCL 10% DROPS<br />
AK-DILATE PHENYLEPHRINE HCL 2.5% DROPS<br />
ALTAFRIN PHENYLEPHRINE HCL 10% DROPS<br />
ALTAFRIN PHENYLEPHRINE HCL 2.5% DROPS<br />
MYDFRIN PHENYLEPHRINE HCL 2.5% DROPS<br />
NEOFRIN PHENYLEPHRINE HCL 10% DROPS<br />
NEOFRIN PHENYLEPHRINE HCL 2.5% DROPS<br />
NEO-SYNEPHRINE PHENYLEPHRINE HCL 10% DROPS<br />
NEO-SYNEPHRINE PHENYLEPHRINE HCL 2.5% DROPS<br />
PHENOPTIC PHENYLEPHRINE HCL 2.5% DROPS<br />
PHENYLEPHRINE HCL PHENYLEPHRINE HCL 10MG/ML VIAL<br />
PHENYLEPHRINE HCL PHENYLEPHRINE HCL 2.5% DROPS<br />
PROMETHAZINE VC PHENYLEPHRINE HCL/PROMETH HCL SYRUP<br />
PROMETHAZINE VC PHENYLEPHRINE HCL/PROMETH HCL 5-6.25MG/5 SYRUP<br />
DUONATE-12 PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP<br />
K-TAN 4 PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP<br />
PYRILAFEN TANNATE-12 PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP<br />
RHINATATE-12 PEDIATRIC PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP<br />
R-TANNA 12 PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP<br />
R-TANNIC-S PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP<br />
RYNA-12 S PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP<br />
EMPRO PHENYLPROPANOLAMINE HCL 75MG CAPSULE SA<br />
PHENYTOIN PHENYTOIN 125MG/5ML ORAL SUSP<br />
PHENYTOIN SODIUM PHENYTOIN SODIUM 100MG CAPSULE<br />
Page 65<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
PHENYTOIN SODIUM PHENYTOIN SODIUM 50MG/ML AMPUL<br />
PHENYTOIN SODIUM PHENYTOIN SODIUM 50MG/ML DISP SYRIN<br />
PHENYTOIN SODIUM INJECTION PHENYTOIN SODIUM 50MG/ML VIAL<br />
DILANTIN PHENYTOIN SODIUM EXTENDED 100MG CAPSULE<br />
PHENYTOIN SODIUM PHENYTOIN SODIUM EXTENDED 100MG CAPSULE<br />
PHENYTOIN SODIUM, EXTENDED PHENYTOIN SODIUM EXTENDED 100MG CAPSULE<br />
PHENYTOIN SODIUM,EXTENDED PHENYTOIN SODIUM EXTENDED 100MG CAPSULE<br />
K-PHOS NEUTRAL PHOSPHORUS 250MG TABLET<br />
PHOSPHA 250 NEUTRAL PHOSPHORUS 250MG TABLET<br />
PHYSIOLYTE PHYSIOLOGICAL IRRIGATION SOLN IRRIG SOLN<br />
PHYSOSTIGMINE SALICYLATE PHYSOSTIGMINE SALICYLATE 1MG/ML AMPUL<br />
VITAMIN K PHYTONADIONE 10MG/ML AMPUL<br />
VITAMIN K PHYTONADIONE 2MG/ML AMPUL<br />
ISOPTO CARPINE PILOCARPINE HCL 1% DROPS<br />
ISOPTO CARPINE PILOCARPINE HCL 2% DROPS<br />
ISOPTO CARPINE PILOCARPINE HCL 4% DROPS<br />
ISOPTO CARPINE PILOCARPINE HCL 6% DROPS<br />
PILOCAR PILOCARPINE HCL 0.5% DROPS<br />
PILOCAR PILOCARPINE HCL 1% DROPS<br />
PILOCAR PILOCARPINE HCL 2% DROPS<br />
PILOCAR PILOCARPINE HCL 4% DROPS<br />
PILOCAR PILOCARPINE HCL 6% DROPS<br />
PILOCARPINE HCL PILOCARPINE HCL 0.5% DROPS<br />
PILOCARPINE HCL PILOCARPINE HCL 1% DROPS<br />
PILOCARPINE HCL PILOCARPINE HCL 2% DROPS<br />
PILOCARPINE HCL PILOCARPINE HCL 3% DROPS<br />
PILOCARPINE HCL PILOCARPINE HCL 4% DROPS<br />
PILOCARPINE HCL PILOCARPINE HCL 6% DROPS<br />
PILOPTIC-1 PILOCARPINE HCL 1% DROPS<br />
PILOPTIC-2 PILOCARPINE HCL 2% DROPS<br />
PILOPTIC-3 PILOCARPINE HCL 3% DROPS<br />
PILOPTIC-4 PILOCARPINE HCL 4% DROPS<br />
PILOPTIC-6 PILOCARPINE HCL 6% DROPS<br />
PINDOLOL PINDOLOL 10MG TABLET<br />
PINDOLOL PINDOLOL 5MG TABLET<br />
LICE PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO<br />
LICE CREME RINSE PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% LIQUID<br />
LICE KILLING PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO<br />
LICE TREAMENT PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO<br />
LICE TREATMENT PIPERONYL BUTOXIDE/PYRETHRINS LIQUID<br />
LICE TREATMENT PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO<br />
LICE-AID PIPERONYL BUTOXIDE/PYRETHRINS LIQUID<br />
LICE-X PIPERONYL BUTOXIDE/PYRETHRINS LIQUID<br />
LICIDE PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO<br />
PIOJINA II PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% LIQUID<br />
PYRETHRIN PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% LIQUID<br />
PYRETHRIN LICE TREATMENT PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% LIQUID<br />
PYRINYL PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO<br />
PYRINYL PLUS PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% LIQUID<br />
FELDENE PIROXICAM 10MG CAPSULE<br />
FELDENE PIROXICAM 20MG CAPSULE<br />
PIROXICAM PIROXICAM 10MG CAPSULE<br />
PIROXICAM PIROXICAM 20MG CAPSULE<br />
PLASMA PROTEIN FRACTION PLASMA PROTEIN FRACTION 5% IV SOLN.<br />
PLASMANATE PLASMA PROTEIN FRACTION 5% VIAL<br />
PLASMA-PLEX PLASMA PROTEIN FRACTION 5% IV SOLN.<br />
PNEUMOVAX 23 PNEUMOCOCCAL 23-VAL P-SAC VAC 25MCG/.5ML DISP SYRIN<br />
PNEUMOVAX 23 PNEUMOCOCCAL 23-VAL P-SAC VAC 25MCG/.5ML VIAL<br />
PODOFILOX PODOFILOX 0.5% SOLUTION<br />
POLYMYXIN B SULFATE POLYMYXIN B SULFATE 100MMU EACH<br />
POLYMYXIN B SUL/TRIMETHOPRIM POLYMYXIN B SULFATE/TMP 10K U-0.1% DROPS<br />
POLYTRIM POLYMYXIN B SULFATE/TMP 10K U-0.1% DROPS<br />
POLYSORBATE 80 POLYSORBATES 80 SOLUTION<br />
POTASSIUM ACETATE POTASSIUM ACETATE 2MEQ/ML VIAL<br />
POTASSIUM ACETATE POTASSIUM ACETATE 4MEQ/ML VIAL<br />
AMINOBENZOATE POTASSIUM POTASSIUM AMINOBENZOATE 500MG CAPSULE<br />
ED K+10 POTASSIUM CHLORIDE 10MEQ TABLET SA<br />
K CL-20 POTASSIUM CHLORIDE 20MEQ/15ML LIQUID<br />
K CL-40 POTASSIUM CHLORIDE 40MEQ/15ML LIQUID<br />
K+ POTASSIUM POTASSIUM CHLORIDE 20MEQ PACKET<br />
KAOCHLOR POTASSIUM CHLORIDE 20MEQ/15ML LIQUID<br />
KAON-CL POTASSIUM CHLORIDE 40MEQ/15ML LIQUID<br />
KAON-CL 10 POTASSIUM CHLORIDE 10MEQ TABLET SA<br />
KAY CIEL POTASSIUM CHLORIDE 20MEQ PACKET<br />
KAY CIEL POTASSIUM CHLORIDE 20MEQ/15ML LIQUID<br />
Page 66<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
K-DUR POTASSIUM CHLORIDE 10MEQ TAB PRT SR<br />
K-DUR POTASSIUM CHLORIDE 20MEQ TAB PRT SR<br />
K-LOR POTASSIUM CHLORIDE 20MEQ PACKET<br />
KLOR-CON POTASSIUM CHLORIDE 20MEQ PACKET<br />
KLOR-CON 10 POTASSIUM CHLORIDE 10MEQ TABLET SA<br />
KLOR-CON 8 POTASSIUM CHLORIDE 8MEQ TABLET SA<br />
KLOR-CON M10 POTASSIUM CHLORIDE 10MEQ TAB PRT SR<br />
KLOR-CON M20 POTASSIUM CHLORIDE 20MEQ TAB PRT SR<br />
KLORVESS POTASSIUM CHLORIDE 20MEQ/15ML LIQUID<br />
KLOTRIX POTASSIUM CHLORIDE 10MEQ TABLET SA<br />
K-SOL POTASSIUM CHLORIDE 20MEQ PACKET<br />
K-TAB POTASSIUM CHLORIDE 10MEQ TABLET SA<br />
K-VESCENT POTASSIUM CHLORIDE 20MEQ PACKET<br />
MICRO-K 10 POTASSIUM CHLORIDE 10MEQ CAPSULE SA<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10MEQ CAPSULE SA<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10MEQ TAB PRT SR<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10MEQ TABLET SA<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10MEQ/0.1L PIGGYBACK<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10MEQ/50ML PIGGYBACK<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ PACKET<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ TAB PRT SR<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/0.1L PIGGYBACK<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/15ML LIQUID<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/50ML PIGGYBACK<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 2MEQ/ML DISP SYRIN<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 2MEQ/ML IV SOLN.<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 2MEQ/ML VIAL<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 30MEQ/0.1L PIGGYBACK<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 40MEQ/0.1L PIGGYBACK<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 40MEQ/15ML LIQUID<br />
POTASSIUM CHLORIDE POTASSIUM CHLORIDE 8MEQ TABLET SA<br />
KAON POTASSIUM GLUCONATE 20MEQ/15ML ELIXIR<br />
POTASSIUM GLUCONATE POTASSIUM GLUCONATE 20MEQ/15ML ELIXIR<br />
POTASSIUM PHOSPHATE POTASSIUM PHOS,M-BASIC-D-BASIC 3MMOL/ML VIAL<br />
MINIPRESS PRAZOSIN HCL 1MG CAPSULE<br />
MINIPRESS PRAZOSIN HCL 2MG CAPSULE<br />
MINIPRESS PRAZOSIN HCL 5MG CAPSULE<br />
PRAZOSIN HCL PRAZOSIN HCL 1MG CAPSULE<br />
PRAZOSIN HCL PRAZOSIN HCL 2MG CAPSULE<br />
PRAZOSIN HCL PRAZOSIN HCL 5MG CAPSULE<br />
PREDNISOLONE PREDNISOLONE 15MG/5ML SYRUP<br />
PREDNISOLONE PREDNISOLONE 5MG TABLET<br />
PREDNISOLONE PREDNISOLONE 5MG/5ML SYRUP<br />
PRELONE PREDNISOLONE 15MG/5ML SYRUP<br />
ECONOPRED PLUS PREDNISOLONE ACETATE 1% DROPS SUSP<br />
KEY-PRED PREDNISOLONE ACETATE 50MG/ML VIAL<br />
KEY-PRED 25 PREDNISOLONE ACETATE 25MG/ML VIAL<br />
PRED FORTE PREDNISOLONE ACETATE 1% DROPS SUSP<br />
PREDICORT-50 PREDNISOLONE ACETATE 50MG/ML VIAL<br />
PREDNISOLONE ACETATE PREDNISOLONE ACETATE 1% DROPS SUSP<br />
PREDNISOLONE ACETATE PREDNISOLONE ACETATE 50MG/ML VIAL<br />
UAD PRED PREDNISOLONE ACETATE 50MG/ML VIAL<br />
AK-PRED PREDNISOLONE SOD PHOSPHATE 1% DROPS<br />
INFLAMASE FORTE PREDNISOLONE SOD PHOSPHATE 1% DROPS<br />
INFLAMASE MILD PREDNISOLONE SOD PHOSPHATE 0.125% DROPS<br />
PEDIAPRED PREDNISOLONE SOD PHOSPHATE 5MG/5ML SOLUTION<br />
PREDNISOL PREDNISOLONE SOD PHOSPHATE 1% DROPS<br />
PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE 15MG/5ML SOLUTION<br />
PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE 5MG/5ML SOLUTION<br />
PREDNISOLONE SODIUM PHOSPHATE PREDNISOLONE SOD PHOSPHATE 1% DROPS<br />
PREDNISOLONE SODIUM PHOSPHATE PREDNISOLONE SOD PHOSPHATE 5MG/5ML SOLUTION<br />
DELTASONE PREDNISONE 10MG TABLET<br />
DELTASONE PREDNISONE 2.5MG TABLET<br />
DELTASONE PREDNISONE 20MG TABLET<br />
DELTASONE PREDNISONE 50MG TABLET<br />
DELTASONE PREDNISONE 5MG TABLET<br />
PREDNISONE PREDNISONE 10MG TAB DS PK<br />
PREDNISONE PREDNISONE 10MG TABLET<br />
PREDNISONE PREDNISONE 1MG TABLET<br />
PREDNISONE PREDNISONE 20MG TABLET<br />
PREDNISONE PREDNISONE 50MG TABLET<br />
PREDNISONE PREDNISONE 5MG TAB DS PK<br />
PREDNISONE PREDNISONE 5MG TABLET<br />
STERAPRED PREDNISONE 5MG TAB DS PK<br />
STERAPRED DS PREDNISONE 10MG TAB DS PK<br />
Page 67<br />
MAC list as of February 03.xls
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
PRE-NATAL PRENATAL VITS W-CA,FE,FA(
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
DARVON PROPOXYPHENE HCL 65MG CAPSULE<br />
PROPOXYPHENE HCL PROPOXYPHENE HCL 65MG CAPSULE<br />
INDERAL PROPRANOLOL HCL 10MG TABLET<br />
INDERAL PROPRANOLOL HCL 20MG TABLET<br />
INDERAL PROPRANOLOL HCL 40MG TABLET<br />
INDERAL PROPRANOLOL HCL 60MG TABLET<br />
INDERAL PROPRANOLOL HCL 80MG TABLET<br />
INDERAL LA PROPRANOLOL HCL 120MG CAPSULE SA<br />
INDERAL LA PROPRANOLOL HCL 160MG CAPSULE SA<br />
INDERAL LA PROPRANOLOL HCL 60MG CAPSULE SA<br />
INDERAL LA PROPRANOLOL HCL 80MG CAPSULE SA<br />
PROPRANOLOL HCL PROPRANOLOL HCL 10MG TABLET<br />
PROPRANOLOL HCL PROPRANOLOL HCL 1MG/ML VIAL<br />
PROPRANOLOL HCL PROPRANOLOL HCL 20MG TABLET<br />
PROPRANOLOL HCL PROPRANOLOL HCL 40MG TABLET<br />
PROPRANOLOL HCL PROPRANOLOL HCL 60MG TABLET<br />
PROPRANOLOL HCL PROPRANOLOL HCL 80MG TABLET<br />
PROPRANOLOL HCL PROPRANOLOL HCL 90MG TABLET<br />
PROPYLTHIOURACIL PROPYLTHIOURACIL 50MG TABLET<br />
PROTAMINE SULFATE PROTAMINE SULFATE 10MG/ML VIAL<br />
RESOURCE INSTANT PROTEIN PROTEIN SUPPLEMENT POWDER<br />
VIVACTIL PROTRIPTYLINE HCL 10MG TABLET<br />
BIOFED PSEUDOEPHEDRINE HCL 30MG/5ML SYRUP<br />
CONGESTACLEAR PSEUDOEPHEDRINE HCL 30MG TABLET<br />
DECOFED PSEUDOEPHEDRINE HCL 30MG/5ML SYRUP<br />
DECONGESTANT PSEUDOEPHEDRINE HCL 30MG TABLET<br />
DECONGESTANT TABLET PSEUDOEPHEDRINE HCL 30MG TABLET<br />
GENAPHED PSEUDOEPHEDRINE HCL 30MG TABLET<br />
HM SUPHEDRINE PSEUDOEPHEDRINE HCL 30MG TABLET<br />
MYFEDRINE PSEUDOEPHEDRINE HCL 30MG/5ML SYRUP<br />
NASAL & SINUS DECONGESTANT PSEUDOEPHEDRINE HCL 30MG TABLET<br />
NASAL DECONGESTANT PSEUDOEPHEDRINE HCL 30MG TABLET<br />
PSEUDAFEN PSEUDOEPHEDRINE HCL 30MG TABLET<br />
PSEUDAFEN PSEUDOEPHEDRINE HCL 60MG TABLET<br />
PSEUDOEPHEDRINE PSEUDOEPHEDRINE HCL 60MG TABLET<br />
PSEUDOEPHEDRINE HCL PSEUDOEPHEDRINE HCL 30MG TABLET<br />
PSEUDOEPHEDRINE HCL PSEUDOEPHEDRINE HCL 30MG/5ML SYRUP<br />
PSEUDOEPHEDRINE HCL PSEUDOEPHEDRINE HCL 60MG TABLET<br />
PSEUDOGEST PSEUDOEPHEDRINE HCL 30MG/5ML SYRUP<br />
PSEUDOTABS PSEUDOEPHEDRINE HCL 30MG TABLET<br />
Q-FED PSEUDOEPHEDRINE HCL 30MG TABLET<br />
RIDAFED PSEUDOEPHEDRINE HCL 30MG TABLET<br />
SILFEDRINE PSEUDOEPHEDRINE HCL 30MG/5ML SYRUP<br />
SIMPLY STUFFY PSEUDOEPHEDRINE HCL 30MG TABLET<br />
SUDAFED PSEUDOEPHEDRINE HCL 30MG TABLET<br />
SUDOGEST PSEUDOEPHEDRINE HCL 30MG TABLET<br />
SUDOGEST PSEUDOEPHEDRINE HCL 60MG TABLET<br />
SUDOGEST CHILDREN'S PSEUDOEPHEDRINE HCL 30MG/5ML SYRUP<br />
SUDOPHED PSEUDOEPHEDRINE HCL 30MG TABLET<br />
SUPHEDRIN PSEUDOEPHEDRINE HCL 30MG TABLET<br />
SUPHEDRIN PSEUDOEPHEDRINE HCL 30MG/5ML SYRUP<br />
SUPHEDRINE PSEUDOEPHEDRINE HCL 30MG TABLET<br />
UNIFED PSEUDOEPHEDRINE HCL 30MG/5ML SYRUP<br />
V-R SUPHEDRINE PSEUDOEPHEDRINE HCL 30MG TABLET<br />
PINWORM TREATMENT PYRANTEL PAMOATE 144MG/ML ORAL SUSP<br />
PIN-X PYRANTEL PAMOATE 144MG/ML ORAL SUSP<br />
REESE PINWORM PYRANTEL PAMOATE 144MG/ML ORAL SUSP<br />
PYRAZINAMIDE PYRAZINAMIDE 500MG TABLET<br />
PYRIDOSTIGMINE BROMIDE PYRIDOSTIGMINE BROMIDE 60MG TABLET<br />
REGONOL PYRIDOSTIGMINE BROMIDE 5MG/ML AMPUL<br />
PYRIDOXINE HCL PYRIDOXINE HCL 100MG/ML VIAL<br />
VITAMIN B-6 PYRIDOXINE HCL 100MG/ML VIAL<br />
QUINAGLUTE QUINIDINE GLUCONATE 324MG TABLET SA<br />
QUINIDINE GLUCONATE QUINIDINE GLUCONATE 324MG TABLET SA<br />
QUINIDEX QUINIDINE SULFATE 300MG TABLET SA<br />
QUINIDINE SULFATE QUINIDINE SULFATE 200MG TABLET<br />
QUINIDINE SULFATE QUINIDINE SULFATE 300MG TABLET<br />
QUINIDINE SULFATE QUINIDINE SULFATE 300MG TABLET SA<br />
QUININE SULFATE QUININE SULFATE 200MG CAPSULE<br />
QUININE SULFATE QUININE SULFATE 260MG TABLET<br />
QUININE SULFATE QUININE SULFATE 324MG CAPSULE<br />
QUININE SULFATE QUININE SULFATE 325MG CAPSULE<br />
ACID REDUCER RANITIDINE HCL 75MG TABLET<br />
HCA RANITIDINE RANITIDINE HCL 75MG TABLET<br />
HM ACID REDUCER RANITIDINE HCL 75MG TABLET<br />
Page 69<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
RANITIDINE RANITIDINE HCL 75MG TABLET<br />
RANITIDINE HCL RANITIDINE HCL 150MG CAPSULE<br />
RANITIDINE HCL RANITIDINE HCL 150MG TABLET<br />
RANITIDINE HCL RANITIDINE HCL 300MG CAPSULE<br />
RANITIDINE HCL RANITIDINE HCL 300MG TABLET<br />
RANITIDINE HCL RANITIDINE HCL 75MG TABLET<br />
V-R ACID REDUCER RANITIDINE HCL 75MG TABLET<br />
ZANTAC RANITIDINE HCL 150MG TABLET<br />
ZANTAC RANITIDINE HCL 300MG TABLET<br />
ZANTAC 75 RANITIDINE HCL 75MG TABLET<br />
RESERPINE RESERPINE 0.1MG TABLET<br />
RESERPINE RESERPINE 0.25MG TABLET<br />
BAYRHO-D RHO(D) IMMUNE GLOBULIN 50MCG DISP SYRIN<br />
RIFADIN RIFAMPIN 300MG CAPSULE<br />
RIFAMPIN RIFAMPIN 150MG CAPSULE<br />
RIFAMPIN RIFAMPIN 300MG CAPSULE<br />
RIFAMPIN RIFAMPIN 600MG VIAL<br />
RIMACTANE RIFAMPIN 300MG CAPSULE<br />
FLUMADINE RIMANTADINE HCL 100MG TABLET<br />
RIMANTADINE HCL RIMANTADINE HCL 100MG TABLET<br />
RINGERS RINGERS SOLUTION IRRIG SOLN<br />
RINGERS RINGERS SOLUTION IV SOLN.<br />
RINGER'S INJECTION RINGERS SOLUTION IV SOLN.<br />
RINGERS IRRIGATION RINGERS SOLUTION IRRIG SOLN<br />
TIS-U-SOL RINGERS SOLUTION IRRIG SOLN<br />
LACTATED RINGERS RINGERS SOLUTION,LACTATED IRRIG SOLN<br />
LACTATED RINGERS RINGERS SOLUTION,LACTATED IV SOLN.<br />
RINGER'S LACTATED RINGERS SOLUTION,LACTATED IRRIG SOLN<br />
AMIGESIC SALSALATE 500MG TABLET<br />
AMIGESIC SALSALATE 750MG TABLET<br />
ARGESIC-SA SALSALATE 500MG TABLET<br />
MONO-GESIC SALSALATE 750MG TABLET<br />
SALFLEX SALSALATE 500MG TABLET<br />
SALFLEX SALSALATE 750MG TABLET<br />
SALSALATE SALSALATE 500MG TABLET<br />
SALSALATE SALSALATE 750MG TABLET<br />
V.V.S. S-BENZ/SULFACET/SULFATHIAZ/URE CREAM(GM)<br />
ELDEPRYL SELEGILINE HCL 5MG CAPSULE<br />
SELEGILINE HCL SELEGILINE HCL 5MG CAPSULE<br />
SELEGILINE HCL SELEGILINE HCL 5MG TABLET<br />
SELENIUM SELENIUM 40MCG/ML VIAL<br />
EXSEL SELENIUM SULFIDE 2.5% SHAMPOO<br />
SELENIUM SULFIDE SELENIUM SULFIDE 2.5% SHAMPOO<br />
SEL-PEN SELENIUM SULFIDE 2.5% SHAMPOO<br />
SELSUN RX SELENIUM SULFIDE 2.5% SHAMPOO<br />
HEMORRHOIDAL SHARK LIVER OIL/SRF CREAM/APPL<br />
MAJOR-PREP HEMORRHOIDAL SHARK LIVER OIL/SRF CREAM/APPL<br />
SILVADENE SILVER SULFADIAZINE 1% CREAM(GM)<br />
SILVER SULFADIAZINE SILVER SULFADIAZINE 1% CREAM(GM)<br />
SSD SILVER SULFADIAZINE 1% CREAM(GM)<br />
SSD AF SILVER SULFADIAZINE 1% CREAM(GM)<br />
THERMAZENE SILVER SULFADIAZINE 1% CREAM(GM)<br />
SODIUM ACETATE SODIUM ACETATE 2MEQ/ML VIAL<br />
SODIUM ACETATE SODIUM ACETATE 4MEQ/ML VIAL<br />
SODIUM ACETATE SINGLE-DOSE SODIUM ACETATE 2MEQ/ML VIAL<br />
SODIUM BICARBONATE SODIUM BICARBONATE 0.5MEQ/ML DISP SYRIN<br />
SODIUM BICARBONATE SODIUM BICARBONATE 0.6MEQ/ML IV SOLN.<br />
SODIUM BICARBONATE SODIUM BICARBONATE 0.9MEQ/ML DISP SYRIN<br />
SODIUM BICARBONATE SODIUM BICARBONATE 0.9MEQ/ML VIAL<br />
SODIUM BICARBONATE SODIUM BICARBONATE 1MEQ/ML DISP SYRIN<br />
SODIUM BICARBONATE SODIUM BICARBONATE 1MEQ/ML VIAL<br />
SODIUM CHLORIDE SODIUM CHLORIDE 2.5MEQ/ML VIAL<br />
SODIUM CHLORIDE SODIUM CHLORIDE 4MEQ/ML VIAL<br />
SODIUM CHLORIDE RAPID ADD SODIUM CHLORIDE 4MEQ/ML VIAL<br />
SODIUM CHLORIDE SODIUM CHLORIDE 0.45% 0.45% IV SOLN.<br />
NORMAL SALINE SODIUM CHLORIDE 0.9% 0.9% DISP SYRIN<br />
NORMAL SALINE FLUSH SODIUM CHLORIDE 0.9% 0.9% DISP SYRIN<br />
SALINE FLUSH SODIUM CHLORIDE 0.9% 0.9% DISP SYRIN<br />
SODIUM CHLORIDE SODIUM CHLORIDE 0.9% 0.9% DISP SYRIN<br />
SODIUM CHLORIDE SODIUM CHLORIDE 0.9% 0.9% IV SOLN.<br />
SODIUM CHLORIDE SODIUM CHLORIDE 0.9% 0.9% VIAL<br />
SYREX SODIUM CHLORIDE 0.9% 0.9% DISP SYRIN<br />
VASCEZE (VAFD) SODIUM CHLORIDE 0.9% 0.9% DISP SYRIN<br />
SODIUM CHLORIDE SODIUM CHLORIDE 3% 3% IV SOLN.<br />
SODIUM CHLORIDE SODIUM CHLORIDE 5% 5% IV SOLN.<br />
Page 70<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
SODIUM CHLORIDE SODIUM CL 0.45PC IRRIG. SOLN 0.45% IRRIG SOLN<br />
SODIUM CHLORIDE SODIUM CL FOR INHALATION 0.9% VIAL-NEB.<br />
SODIUM CHLORIDE SODIUM CL IRRIG SOLN 0.9% IRRIG SOLN<br />
APF SODIUM FLUORIDE 1.1% GEL<br />
CONTROL RX SODIUM FLUORIDE 1.1% CREAM(GM)<br />
ETHEDENT SODIUM FLUORIDE 0.25MG TAB CHEW<br />
ETHEDENT SODIUM FLUORIDE 0.5MG TAB CHEW<br />
ETHEDENT SODIUM FLUORIDE 1MG TAB CHEW<br />
FLUOR-A-DAY SODIUM FLUORIDE 0.25MG TAB CHEW<br />
FLUOR-A-DAY SODIUM FLUORIDE 0.5MG TAB CHEW<br />
FLUOR-A-DAY SODIUM FLUORIDE 1MG TAB CHEW<br />
FLUORIDE SODIUM FLUORIDE 1MG TAB CHEW<br />
FLUORIDE LOZ SODIUM FLUORIDE 1MG LOZENGE<br />
FLUORITAB SODIUM FLUORIDE 0.25MG TAB CHEW<br />
FLUORITAB SODIUM FLUORIDE 0.5MG TAB CHEW<br />
FLUORITAB SODIUM FLUORIDE 1MG TAB CHEW<br />
FLUORITAB SODIUM FLUORIDE 5MG/ML DROPS<br />
FLURA-DROPS SODIUM FLUORIDE 2.2MG/ML DROPS<br />
FLURA-DROPS SODIUM FLUORIDE 5MG/ML DROPS<br />
FLURA-TAB SODIUM FLUORIDE 1MG TABLET<br />
LURIDE SODIUM FLUORIDE 0.25MG TAB CHEW<br />
LURIDE SODIUM FLUORIDE 0.5MG TAB CHEW<br />
LURIDE SODIUM FLUORIDE 0.5MG/ML DROPS<br />
LURIDE SODIUM FLUORIDE 1MG TAB CHEW<br />
LURIDE-SF SODIUM FLUORIDE 1MG TAB CHEW<br />
PEDIAFLOR SODIUM FLUORIDE 0.5MG/ML DROPS<br />
PHARMAFLUR SODIUM FLUORIDE 0.5MG TAB CHEW<br />
PHARMAFLUR SODIUM FLUORIDE 1MG TAB CHEW<br />
PREVIDENT 5000 PLUS SODIUM FLUORIDE 1.1% CREAM(GM)<br />
SF SODIUM FLUORIDE 1.1% GEL<br />
SF 5000 PLUS SODIUM FLUORIDE 1.1% CREAM(GM)<br />
SODIUM FLUORIDE SODIUM FLUORIDE 0.2% SOLUTION<br />
SODIUM FLUORIDE SODIUM FLUORIDE 0.25MG TAB CHEW<br />
SODIUM FLUORIDE SODIUM FLUORIDE 0.5MG TAB CHEW<br />
SODIUM FLUORIDE SODIUM FLUORIDE 0.5MG/ML DROPS<br />
SODIUM FLUORIDE SODIUM FLUORIDE 1MG TAB CHEW<br />
SODIUM FLUORIDE SODIUM FLUORIDE 2.2MG/ML DROPS<br />
SODIUM LACTATE SODIUM LACTATE 167MEQ/L IV SOLN.<br />
SODIUM LACTATE SODIUM LACTATE 5MEQ/ML VIAL<br />
MORRHUATE SODIUM SODIUM MORRHUATE 50MG/ML VIAL<br />
SODIUM PHOSPHATE SODIUM PHOS,M-BASIC-D-BASIC 3MMOL/ML VIAL<br />
KIONEX SODIUM POLYSTYRENE SULFONATE POWDER<br />
SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE POWDER<br />
SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE 15G/60ML ORAL SUSP<br />
SODIUM POLYSTYRENE SULFONATE SODIUM POLYSTYRENE SULFONATE 30G/120ML ENEMA<br />
SPS SODIUM POLYSTYRENE SULFONATE 15G/60ML ORAL SUSP<br />
SPS SODIUM POLYSTYRENE SULFONATE 30G/120ML ENEMA<br />
CPC-THIOSAL SODIUM THIOSALICYLATE 50MG/ML VIAL<br />
SODIUM THIOSULFATE SODIUM THIOSULFATE 10% VIAL<br />
SODIUM THIOSULFATE SODIUM THIOSULFATE 25% VIAL<br />
TEV-TROPIN SOMATROPIN 5MG VIAL<br />
SORBITOL SORBITOL SOLUTION 70% SOLUTION<br />
BETAPACE SOTALOL HCL 120MG TABLET<br />
BETAPACE SOTALOL HCL 160MG TABLET<br />
BETAPACE SOTALOL HCL 240MG TABLET<br />
BETAPACE SOTALOL HCL 80MG TABLET<br />
BETAPACE AF SOTALOL HCL 120MG TABLET<br />
BETAPACE AF SOTALOL HCL 160MG TABLET<br />
BETAPACE AF SOTALOL HCL 80MG TABLET<br />
SORINE SOTALOL HCL 120MG TABLET<br />
SORINE SOTALOL HCL 160MG TABLET<br />
SORINE SOTALOL HCL 240MG TABLET<br />
SORINE SOTALOL HCL 80MG TABLET<br />
SOTALOL SOTALOL HCL 120MG TABLET<br />
SOTALOL SOTALOL HCL 160MG TABLET<br />
SOTALOL SOTALOL HCL 240MG TABLET<br />
SOTALOL SOTALOL HCL 80MG TABLET<br />
SOTALOL HCL SOTALOL HCL 120MG TABLET<br />
SOTALOL HCL SOTALOL HCL 160MG TABLET<br />
SOTALOL HCL SOTALOL HCL 240MG TABLET<br />
SOTALOL HCL SOTALOL HCL 80MG TABLET<br />
ALDACTONE SPIRONOLACTONE 100MG TABLET<br />
ALDACTONE SPIRONOLACTONE 25MG TABLET<br />
ALDACTONE SPIRONOLACTONE 50MG TABLET<br />
SPIRONOLACTONE SPIRONOLACTONE 100MG TABLET<br />
Page 71<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
SPIRONOLACTONE SPIRONOLACTONE 25MG TABLET<br />
SPIRONOLACTONE SPIRONOLACTONE 50MG TABLET<br />
OMNII GEL STANNOUS FLUORIDE 0.4% GEL<br />
OMNII MED STANNOUS FLUORIDE 0.4% GEL<br />
PERIO MED STANNOUS FLUORIDE 0.63% SOLUTION<br />
STANNOUS FLUORIDE STANNOUS FLUORIDE 0.63% SOLUTION<br />
ANECTINE SUCCINYLCHOLINE CHLORIDE 20MG/ML VIAL<br />
QUELICIN ABBOJECT SUCCINYLCHOLINE CHLORIDE 20MG/ML VIAL<br />
QUELICIN FLIPTOP SUCCINYLCHOLINE CHLORIDE 20MG/ML VIAL<br />
SUCCINYLCHOLINE CHLORIDE SUCCINYLCHOLINE CHLORIDE 20MG/ML VIAL<br />
CARAFATE SUCRALFATE 1G TABLET<br />
SUCRALFATE SUCRALFATE 1G TABLET<br />
SUFENTA SUFENTANIL CITRATE 50MCG/ML AMPUL<br />
SUFENTANIL CITRATE SUFENTANIL CITRATE 50MCG/ML AMPUL<br />
GYNE SULF SULFABENZ/SULFACET/SULFATHIAZ CREAM/APPL<br />
TRIPLE SULFA VAGINAL SULFABENZ/SULFACET/SULFATHIAZ CREAM/APPL<br />
TRYSUL SULFABENZ/SULFACET/SULFATHIAZ CREAM/APPL<br />
AK-SULF SULFACETAMIDE SODIUM 10% OINT.(GM)<br />
BLEPH-10 SULFACETAMIDE SODIUM 10% DROPS<br />
BLEPH-10 SULFACETAMIDE SODIUM 10% OINT.(GM)<br />
OCUSULF-10 SULFACETAMIDE SODIUM 10% DROPS<br />
SULF-10 SULFACETAMIDE SODIUM 10% DROPS<br />
SULFAC SULFACETAMIDE SODIUM 10% DROPS<br />
SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM 10% DROPS<br />
SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM 10% OINT.(GM)<br />
SULFAMIDE SULFACETAMIDE SODIUM 10% DROPS<br />
NICOSYN SULFACETAMIDE SODIUM/SULFUR 10-5%(W/V) LOTION<br />
SOD.SULFACETAMIDE/SULFUR TF SULFACETAMIDE SODIUM/SULFUR 10-5%(W/V) LOTION<br />
SODIUM SULFACETAMIDE/SULFUR SULFACETAMIDE SODIUM/SULFUR 10-5% LOTION<br />
SODIUM SULFACETAMIDE/SULFUR SULFACETAMIDE SODIUM/SULFUR 10-5%(W/V) LOTION<br />
SODIUM SULFACETAMIDE/SULFUR SULFACETAMIDE SODIUM/SULFUR 10-5%(W/W) LOTION<br />
SULFACET-R SULFACETAMIDE SODIUM/SULFUR 10-5%(W/V) LOTION<br />
CARMOL SULFACETAMIDE SODIUM/UREA 10% LOTION<br />
SULFADIAZINE SULFADIAZINE 500MG TABLET<br />
BACTRIM SULFAMETHOXAZOLE/TRIMETHOPRIM 400-80MG TABLET<br />
BACTRIM DS SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160MG TABLET<br />
BETHAPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ORAL SUSP<br />
BETHAPRIM DS SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160MG TABLET<br />
BETHAPRIM SS SULFAMETHOXAZOLE/TRIMETHOPRIM 400-80MG TABLET<br />
SEPTRA SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ORAL SUSP<br />
SEPTRA SULFAMETHOXAZOLE/TRIMETHOPRIM 400-80MG TABLET<br />
SEPTRA DS SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160MG TABLET<br />
SEPTRA I.V. SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML VIAL<br />
SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ORAL SUSP<br />
SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM 400-80MG TABLET<br />
SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM 800-160MG TABLET<br />
SULFAMETHOXAZOLE/TRIMETHOPRIM SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML VIAL<br />
SULFATRIM SULFAMETHOXAZOLE/TRIMETHOPRIM 200-40MG/5 ORAL SUSP<br />
AZULFIDINE SULFASALAZINE 500MG TABLET<br />
AZULFIDINE SULFASALAZINE 500MG TABLET DR<br />
SULFASALAZINE SULFASALAZINE 500MG TABLET<br />
SULFASALAZINE SULFASALAZINE 500MG TABLET DR<br />
SULFAZINE SULFASALAZINE 500MG TABLET<br />
SULFAZINE EC SULFASALAZINE 500MG TABLET DR<br />
SULFINPYRAZONE SULFINPYRAZONE 100MG TABLET<br />
SULFISOXAZOLE SULFISOXAZOLE 500MG TABLET<br />
SULFUR SULFUR POWDER<br />
CLINORIL SULINDAC 150MG TABLET<br />
CLINORIL SULINDAC 200MG TABLET<br />
SULINDAC SULINDAC 150MG TABLET<br />
SULINDAC SULINDAC 200MG TABLET<br />
RESTORIL TEMAZEPAM 15MG CAPSULE<br />
RESTORIL TEMAZEPAM 30MG CAPSULE<br />
TEMAZEPAM TEMAZEPAM 15MG CAPSULE<br />
TEMAZEPAM TEMAZEPAM 30MG CAPSULE<br />
HYTRIN TERAZOSIN HCL 10MG CAPSULE<br />
HYTRIN TERAZOSIN HCL 1MG CAPSULE<br />
HYTRIN TERAZOSIN HCL 2MG CAPSULE<br />
HYTRIN TERAZOSIN HCL 5MG CAPSULE<br />
TERAZOSIN TERAZOSIN HCL 1MG CAPSULE<br />
TERAZOSIN TERAZOSIN HCL 2MG CAPSULE<br />
TERAZOSIN TERAZOSIN HCL 5MG CAPSULE<br />
TERAZOSIN HCL TERAZOSIN HCL 10MG CAPSULE<br />
TERAZOSIN HCL TERAZOSIN HCL 1MG CAPSULE<br />
TERAZOSIN HCL TERAZOSIN HCL 2MG CAPSULE<br />
Page 72<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
TERAZOSIN HCL TERAZOSIN HCL 5MG CAPSULE<br />
TERBUTALINE SULFATE TERBUTALINE SULFATE 2.5MG TABLET<br />
TERBUTALINE SULFATE TERBUTALINE SULFATE 5MG TABLET<br />
TESTODERM TTS TESTOSTERONE 5MG/24HR PATCH TD24<br />
TESTOSTERONE TESTOSTERONE 100MG/ML VIAL<br />
DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 100MG/ML VIAL<br />
DEPO-TESTOSTERONE TESTOSTERONE CYPIONATE 200MG/ML VIAL<br />
DELATESTRYL TESTOSTERONE ENANTHATE 200MG/ML VIAL<br />
TESTOSTERONE PROPIONATE TESTOSTERONE PROPIONATE 100MG/ML VIAL<br />
TETANUS TOXOID TETANUS TOXOID,ADSORBED 5LFU/0.5ML DISP SYRIN<br />
TETANUS TOXOID ADSORBED TETANUS TOXOID,ADSORBED 5LFU/0.5ML VIAL<br />
TETANUS TOXOID (FLUID) TETANUS TOXOID,FLUID 5 LF UNIT VIAL<br />
TETANUS DIPHTHERIA TETANUS,DIPHTHERIA TOXOID 5-1.5LFU DISP SYRIN<br />
TETANUS DIPHTHERIA TOXOIDS TETANUS,DIPHTHERIA TOXOID 5-1.5LFU VIAL<br />
TETANUS/DIPHTHERIA TOXOIDS TETANUS,DIPHTHERIA TOXOID 5-2LFU DISP SYRIN<br />
TETANUS/DIPHTHERIA TOXOIDS TETANUS,DIPHTHERIA TOXOID 5-2LFU VIAL<br />
DIPHTHERIA/TETANUS TOXOID TETANUS,DIPHTHERIA TOXOID PED 5-6.6LFU VIAL<br />
DIPHTHERIA/TETANUS TOXOIDS TETANUS,DIPHTHERIA TOXOID PED 5-10LFU VIAL<br />
AK-T-CAINE PF TETRACAINE HCL 0.5% DROPS<br />
ALTACAINE TETRACAINE HCL 0.5% DROPS<br />
OPTICAINE TETRACAINE HCL 0.5% DROPS<br />
PONTOCAINE TETRACAINE HCL 0.5% DROPS<br />
TETCAINE TETRACAINE HCL 0.5% DROPS<br />
TETRACAINE HCL TETRACAINE HCL 0.5% DROPS<br />
ACHROMYCIN V TETRACYCLINE HCL 250MG CAPSULE<br />
EMTET-500 TETRACYCLINE HCL 500MG CAPSULE<br />
TETRACYCLINE HCL TETRACYCLINE HCL 250MG CAPSULE<br />
TETRACYCLINE HCL TETRACYCLINE HCL 500MG CAPSULE<br />
AEROLATE SR THEOPHYLLINE ANHYDROUS 260MG CAP.SR 12H<br />
ELIXOPHYLLIN THEOPHYLLINE ANHYDROUS 80MG/15ML ELIXIR<br />
QUIBRON-T/SR THEOPHYLLINE ANHYDROUS 300MG TAB.SR 12H<br />
THEOCHRON THEOPHYLLINE ANHYDROUS 100MG TAB.SR 12H<br />
THEOCHRON THEOPHYLLINE ANHYDROUS 200MG TAB.SR 12H<br />
THEOCHRON THEOPHYLLINE ANHYDROUS 300MG TAB.SR 12H<br />
THEOPHYLLINE THEOPHYLLINE ANHYDROUS 80MG/15ML ELIXIR<br />
THEOPHYLLINE THEOPHYLLINE ANHYDROUS 80MG/15ML SOLUTION<br />
THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 100MG TAB.SR 12H<br />
THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 125MG CAP.SR 12H<br />
THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 200MG CAP.SR 12H<br />
THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 200MG TAB.SR 12H<br />
THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 300MG CAP.SR 12H<br />
THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 300MG TAB.SR 12H<br />
THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS 450MG TAB.SR 12H<br />
THEOVENT THEOPHYLLINE ANHYDROUS 125MG CAP.SR 12H<br />
T-PHYL THEOPHYLLINE ANHYDROUS 200MG TAB.SR 12H<br />
THIAMINE HCL THIAMINE HCL 100MG/ML VIAL<br />
THIAMINE HCL INJECTION THIAMINE HCL 100MG/ML VIAL<br />
PENTOTHAL THIOPENTAL SODIUM 1G KIT<br />
PENTOTHAL THIOPENTAL SODIUM 1G VIAL<br />
PENTOTHAL THIOPENTAL SODIUM 5G KIT<br />
THIOPENTAL SODIUM THIOPENTAL SODIUM 2.5G KIT<br />
THIOPENTAL SODIUM THIOPENTAL SODIUM 500MG KIT<br />
THIOPENTAL SODIUM THIOPENTAL SODIUM 5G KIT<br />
MELLARIL THIORIDAZINE HCL 100MG TABLET<br />
MELLARIL THIORIDAZINE HCL 15MG TABLET<br />
MELLARIL THIORIDAZINE HCL 200MG TABLET<br />
MELLARIL THIORIDAZINE HCL 25MG TABLET<br />
MELLARIL THIORIDAZINE HCL 30MG/ML ORAL CONC.<br />
THIORIDAZINE HCL THIORIDAZINE HCL 100MG TABLET<br />
THIORIDAZINE HCL THIORIDAZINE HCL 100MG/ML ORAL CONC.<br />
THIORIDAZINE HCL THIORIDAZINE HCL 10MG TABLET<br />
THIORIDAZINE HCL THIORIDAZINE HCL 150MG TABLET<br />
THIORIDAZINE HCL THIORIDAZINE HCL 15MG TABLET<br />
THIORIDAZINE HCL THIORIDAZINE HCL 200MG TABLET<br />
THIORIDAZINE HCL THIORIDAZINE HCL 25MG TABLET<br />
THIORIDAZINE HCL THIORIDAZINE HCL 30MG/ML ORAL CONC.<br />
THIORIDAZINE HCL THIORIDAZINE HCL 50MG TABLET<br />
THIOTEPA THIOTEPA 15MG VIAL<br />
NAVANE THIOTHIXENE 10MG CAPSULE<br />
NAVANE THIOTHIXENE 1MG CAPSULE<br />
NAVANE THIOTHIXENE 2MG CAPSULE<br />
NAVANE THIOTHIXENE 5MG CAPSULE<br />
THIOTHIXENE THIOTHIXENE 10MG CAPSULE<br />
THIOTHIXENE THIOTHIXENE 1MG CAPSULE<br />
THIOTHIXENE THIOTHIXENE 2MG CAPSULE<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
THIOTHIXENE THIOTHIXENE 5MG CAPSULE<br />
THIOTHIXENE HCL THIOTHIXENE HCL 5MG/ML ORAL CONC.<br />
THROMBOGEN THROMBIN 1000 UNIT VIAL<br />
THROMBOGEN THROMBIN 10000 UNIT KIT<br />
THROMBOGEN THROMBIN 10000 UNIT VIAL<br />
THROMBOGEN THROMBIN 20000 UNIT KIT<br />
THROMBOGEN THROMBIN 20000 UNIT VIAL<br />
THROMBOGEN THROMBIN 5000 UNIT VIAL<br />
ARMOUR THYROID THYROID 120MG TABLET<br />
ARMOUR THYROID THYROID 180MG TABLET<br />
ARMOUR THYROID THYROID 30MG TABLET<br />
ARMOUR THYROID THYROID 60MG TABLET<br />
NATURE-THROID THYROID 120MG TABLET<br />
NATURE-THROID THYROID 180MG TABLET<br />
NATURE-THROID THYROID 30MG TABLET<br />
NATURE-THROID THYROID 60MG TABLET<br />
THYROID THYROID 120MG TABLET<br />
THYROID THYROID 180MG TABLET<br />
THYROID THYROID 30MG TABLET<br />
THYROID THYROID 60MG TABLET<br />
THYROID THYROID 65MG TABLET<br />
WESTHROID THYROID 120MG TABLET<br />
WESTHROID THYROID 180MG TABLET<br />
WESTHROID THYROID 30MG TABLET<br />
WESTHROID THYROID 60MG TABLET<br />
TICLID TICLOPIDINE HCL 250MG TABLET<br />
TICLOPIDINE HCL TICLOPIDINE HCL 250MG TABLET<br />
BLOCADREN TIMOLOL MALEATE 10MG TABLET<br />
BLOCADREN TIMOLOL MALEATE 20MG TABLET<br />
BLOCADREN TIMOLOL MALEATE 5MG TABLET<br />
TIMOLOL MALEATE TIMOLOL MALEATE 0.25% DROPS<br />
TIMOLOL MALEATE TIMOLOL MALEATE 0.25% SOL-GEL<br />
TIMOLOL MALEATE TIMOLOL MALEATE 0.5% DROPS<br />
TIMOLOL MALEATE TIMOLOL MALEATE 0.5% SOL-GEL<br />
TIMOLOL MALEATE TIMOLOL MALEATE 10MG TABLET<br />
TIMOLOL MALEATE TIMOLOL MALEATE 20MG TABLET<br />
TIMOLOL MALEATE TIMOLOL MALEATE 5MG TABLET<br />
TIMOPTIC TIMOLOL MALEATE 0.25% DROPS<br />
TIMOPTIC TIMOLOL MALEATE 0.5% DROPS<br />
TIZANIDINE HCL TIZANIDINE HCL 2MG TABLET<br />
TIZANIDINE HCL TIZANIDINE HCL 4MG TABLET<br />
ZANAFLEX TIZANIDINE HCL 2MG TABLET<br />
ZANAFLEX TIZANIDINE HCL 4MG TABLET<br />
AKTOB TOBRAMYCIN SULFATE 0.3% DROPS<br />
NEBCIN TOBRAMYCIN SULFATE 40MG/ML VIAL<br />
TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE 0.3% DROPS<br />
TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE 1.2G VIAL<br />
TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE 10MG/ML VIAL<br />
TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE 40MG/ML DISP SYRIN<br />
TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE 40MG/ML VIAL<br />
TOBRASOL TOBRAMYCIN SULFATE 0.3% DROPS<br />
TOBREX TOBRAMYCIN SULFATE 0.3% DROPS<br />
TOLAZAMIDE TOLAZAMIDE 100MG TABLET<br />
TOLAZAMIDE TOLAZAMIDE 250MG TABLET<br />
TOLAZAMIDE TOLAZAMIDE 500MG TABLET<br />
TOLINASE TOLAZAMIDE 100MG TABLET<br />
TOLINASE TOLAZAMIDE 250MG TABLET<br />
TOLBUTAMIDE TOLBUTAMIDE 500MG TABLET<br />
TOLECTIN 600 TOLMETIN SODIUM 600MG TABLET<br />
TOLECTIN DS TOLMETIN SODIUM 400MG CAPSULE<br />
TOLMETIN SODIUM TOLMETIN SODIUM 200MG TABLET<br />
TOLMETIN SODIUM TOLMETIN SODIUM 400MG CAPSULE<br />
TOLMETIN SODIUM TOLMETIN SODIUM 600MG TABLET<br />
TOLNAFTATE TOLNAFTATE 1% CREAM(GM)<br />
TORSEMIDE TORSEMIDE 100MG TABLET<br />
TORSEMIDE TORSEMIDE 10MG TABLET<br />
TORSEMIDE TORSEMIDE 20MG TABLET<br />
TORSEMIDE TORSEMIDE 5MG TABLET<br />
TRAMADOL HCL TRAMADOL HCL 50MG TABLET<br />
ULTRAM TRAMADOL HCL 50MG TABLET<br />
DESYREL TRAZODONE HCL 100MG TABLET<br />
DESYREL TRAZODONE HCL 150MG TABLET<br />
DESYREL TRAZODONE HCL 50MG TABLET<br />
TRAZODONE TRAZODONE HCL 100MG TABLET<br />
TRAZODONE HCL TRAZODONE HCL 100MG TABLET<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
TRAZODONE HCL TRAZODONE HCL 150MG TABLET<br />
TRAZODONE HCL TRAZODONE HCL 300MG TABLET<br />
TRAZODONE HCL TRAZODONE HCL 50MG TABLET<br />
ALTINAC TRETINOIN 0.025% CREAM(GM)<br />
ALTINAC TRETINOIN 0.05% CREAM(GM)<br />
ALTINAC TRETINOIN 0.1% CREAM(GM)<br />
AVITA TRETINOIN 0.025% CREAM(GM)<br />
AVITA TRETINOIN 0.025% GEL<br />
RETIN-A TRETINOIN 0.025% CREAM(GM)<br />
RETIN-A TRETINOIN 0.05% LIQUID<br />
TRETINOIN TRETINOIN 0.01% GEL<br />
TRETINOIN TRETINOIN 0.025% CREAM(GM)<br />
TRETINOIN TRETINOIN 0.025% GEL<br />
TRETINOIN TRETINOIN 0.05% CREAM(GM)<br />
TRETINOIN TRETINOIN 0.1% CREAM(GM)<br />
ARISTOCORT TRIAMCINOLONE 4MG TABLET<br />
ARISTOCORT TRIAMCINOLONE ACETONIDE 0.1% CREAM(GM)<br />
ARISTOCORT HP TRIAMCINOLONE ACETONIDE 0.5% OINT.(GM)<br />
CENOCORT A-40 TRIAMCINOLONE ACETONIDE 40MG/ML VIAL<br />
CINALOG TRIAMCINOLONE ACETONIDE 0.5% CREAM(GM)<br />
KENAJECT-40 TRIAMCINOLONE ACETONIDE 40MG/ML VIAL<br />
KENALOG TRIAMCINOLONE ACETONIDE 0.1% CREAM(GM)<br />
KENALOG TRIAMCINOLONE ACETONIDE 0.1% LOTION<br />
KENALOG TRIAMCINOLONE ACETONIDE 0.1% OINT.(GM)<br />
KENALOG TRIAMCINOLONE ACETONIDE 0.5% CREAM(GM)<br />
KENALOG IN ORABASE TRIAMCINOLONE ACETONIDE 0.1% PASTE<br />
KENALOG-40 TRIAMCINOLONE ACETONIDE 40MG/ML VIAL<br />
ORALONE TRIAMCINOLONE ACETONIDE 0.1% PASTE<br />
TRIAM-A TRIAMCINOLONE ACETONIDE 40MG/ML VIAL<br />
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.025% CREAM(GM)<br />
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.025% LOTION<br />
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.025% OINT.(GM)<br />
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% CREAM(GM)<br />
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% LOTION<br />
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% OINT.(GM)<br />
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% PASTE<br />
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.5% CREAM(GM)<br />
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.5% OINT.(GM)<br />
TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 40MG/ML VIAL<br />
ARISTOCORT FORTE TRIAMCINOLONE DIACETATE 40MG/ML VIAL<br />
CENOCORT FORTE SUSPENSION TRIAMCINOLONE DIACETATE 40MG/ML VIAL<br />
TRIAM FORTE TRIAMCINOLONE DIACETATE 40MG/ML VIAL<br />
TRIAMCINOLONE DIACETATE TRIAMCINOLONE DIACETATE 40MG/ML VIAL<br />
U-TRI-LONE TRIAMCINOLONE DIACETATE 40MG/ML VIAL<br />
HALCION TRIAZOLAM 0.125MG TABLET<br />
HALCION TRIAZOLAM 0.25MG TABLET<br />
TRIAZOLAM TRIAZOLAM 0.125MG TABLET<br />
TRIAZOLAM TRIAZOLAM 0.25MG TABLET<br />
NAQUA TRICHLORMETHIAZIDE 4MG TABLET<br />
TRICHLORMETHIAZIDE TRICHLORMETHIAZIDE 4MG TABLET<br />
STELAZINE TRIFLUOPERAZINE HCL 2MG TABLET<br />
STELAZINE TRIFLUOPERAZINE HCL 5MG TABLET<br />
TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL 10MG TABLET<br />
TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL 1MG TABLET<br />
TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL 2MG TABLET<br />
TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL 5MG TABLET<br />
TRIFLURIDINE TRIFLURIDINE 1% DROPS<br />
TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 2MG TABLET<br />
TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 2MG/5ML ELIXIR<br />
TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 5MG TABLET<br />
TIGAN TRIMETHOBENZAMIDE HCL 100MG SUPP.RECT<br />
TRIMETHOBENZAMIDE HCL TRIMETHOBENZAMIDE HCL 100MG/ML DISP SYRIN<br />
PROLOPRIM TRIMETHOPRIM 100MG TABLET<br />
PROLOPRIM TRIMETHOPRIM 200MG TABLET<br />
TRIMETHOPRIM TRIMETHOPRIM 100MG TABLET<br />
MYDRAL TROPICAMIDE 0.5% DROPS<br />
MYDRAL TROPICAMIDE 1% DROPS<br />
MYDRIACYL TROPICAMIDE 0.5% DROPS<br />
MYDRIACYL TROPICAMIDE 1% DROPS<br />
TROPICAMIDE TROPICAMIDE 0.5% DROPS<br />
TROPICAMIDE TROPICAMIDE 1% DROPS<br />
TUBERSOL TUBERCULIN,PURIF.PROT.DERIV. 5T U/0.1ML VIAL<br />
TUBOCURARINE CHLORIDE TUBOCURARINE CHLORIDE 3MG/ML VIAL<br />
IRRIGATING SOLUTION G UROLOGIC SOLUTION-G IRRIG SOLN<br />
UROLOGIC G IRRIGATION W/HANGER UROLOGIC SOLUTION-G IRRIG SOLN<br />
Page 75<br />
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Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
UROLOGIC SOLUTION G UROLOGIC SOLUTION-G IRRIG SOLN<br />
ACTIGALL URSODIOL 300MG CAPSULE<br />
URSODIOL URSODIOL 300MG CAPSULE<br />
DEPAKENE VALPROATE SODIUM 250MG/5ML SYRUP<br />
VALPROATE SODIUM VALPROATE SODIUM 100MG/ML VIAL<br />
VALPROIC ACID VALPROATE SODIUM 250MG/5ML SYRUP<br />
DEPAKENE VALPROIC ACID 250MG CAPSULE<br />
VALPROIC ACID VALPROIC ACID 250MG CAPSULE<br />
VANCOCIN HCL VANCOMYCIN HCL 10G VIAL<br />
VANCOCIN HCL VANCOMYCIN HCL 1G VIAL<br />
VANCOCIN HCL VANCOMYCIN HCL 500MG VIAL<br />
VANCOLED VANCOMYCIN HCL 1G VIAL<br />
VANCOLED VANCOMYCIN HCL 500MG VIAL<br />
VANCOMYCIN HCL VANCOMYCIN HCL 1G VIAL<br />
VANCOMYCIN HCL VANCOMYCIN HCL 500MG VIAL<br />
VANCOMYCIN HCL VANCOMYCIN HCL 5G VIAL<br />
PITRESSIN VASOPRESSIN 20 UNIT/ML VIAL<br />
VASOPRESSIN VASOPRESSIN 20 UNIT/ML VIAL<br />
NORCURON VECURONIUM BROMIDE 10MG VIAL<br />
VECURONIUM BROMIDE VECURONIUM BROMIDE 10MG VIAL<br />
VECURONIUM BROMIDE VECURONIUM BROMIDE 20MG VIAL<br />
CALAN VERAPAMIL HCL 120MG TABLET<br />
CALAN VERAPAMIL HCL 40MG TABLET<br />
CALAN VERAPAMIL HCL 80MG TABLET<br />
CALAN SR VERAPAMIL HCL 120MG TABLET SA<br />
CALAN SR VERAPAMIL HCL 180MG TABLET SA<br />
CALAN SR VERAPAMIL HCL 240MG TABLET SA<br />
ISOPTIN VERAPAMIL HCL 2.5MG/ML VIAL<br />
ISOPTIN S.R. VERAPAMIL HCL 120MG TABLET SA<br />
ISOPTIN S.R. VERAPAMIL HCL 180MG TABLET SA<br />
ISOPTIN S.R. VERAPAMIL HCL 240MG TABLET SA<br />
VERAPAMIL HCL VERAPAMIL HCL 120MG CAP24H PEL<br />
VERAPAMIL HCL VERAPAMIL HCL 120MG TABLET<br />
VERAPAMIL HCL VERAPAMIL HCL 120MG TABLET SA<br />
VERAPAMIL HCL VERAPAMIL HCL 180MG CAP24H PEL<br />
VERAPAMIL HCL VERAPAMIL HCL 180MG TABLET SA<br />
VERAPAMIL HCL VERAPAMIL HCL 2.5MG/ML AMPUL<br />
VERAPAMIL HCL VERAPAMIL HCL 2.5MG/ML DISP SYRIN<br />
VERAPAMIL HCL VERAPAMIL HCL 2.5MG/ML VIAL<br />
VERAPAMIL HCL VERAPAMIL HCL 240MG CAP24H PEL<br />
VERAPAMIL HCL VERAPAMIL HCL 240MG TABLET SA<br />
VERAPAMIL HCL VERAPAMIL HCL 360MG CAP24H PEL<br />
VERAPAMIL HCL VERAPAMIL HCL 40MG TABLET<br />
VERAPAMIL HCL VERAPAMIL HCL 80MG TABLET<br />
VERELAN VERAPAMIL HCL 120MG CAP24H PEL<br />
VERELAN VERAPAMIL HCL 180MG CAP24H PEL<br />
VERELAN VERAPAMIL HCL 240MG CAP24H PEL<br />
VINBLASTINE SULFATE VINBLASTINE SULFATE 10MG VIAL<br />
VINCRISTINE SULFATE VINCRISTINE SULFATE 1MG/ML VIAL<br />
VINORELBINE TARTRATE VINORELBINE TARTRATE 10MG/ML VIAL<br />
NATAFOLIC VIT B-COMP W-FE,CA,FA
Drug Brand Name<br />
<strong>Alabama</strong> <strong>Medicaid</strong> <strong>Maximum</strong> <strong>Allowable</strong> <strong>Cost</strong> <strong>List</strong><br />
GCN - Generic Drug Description<br />
Drug Strength/Dosage<br />
Description<br />
Dose Form<br />
Description<br />
WARFARIN SODIUM WARFARIN SODIUM 1MG TABLET<br />
WARFARIN SODIUM WARFARIN SODIUM 2.5MG TABLET<br />
WARFARIN SODIUM WARFARIN SODIUM 2MG TABLET<br />
WARFARIN SODIUM WARFARIN SODIUM 3MG TABLET<br />
WARFARIN SODIUM WARFARIN SODIUM 4MG TABLET<br />
WARFARIN SODIUM WARFARIN SODIUM 5MG TABLET<br />
WARFARIN SODIUM WARFARIN SODIUM 6MG TABLET<br />
WARFARIN SODIUM WARFARIN SODIUM 7.5MG TABLET<br />
WATER WATER FOR INHALATION VIAL-NEB.<br />
WATER FOR INHALATION WATER FOR INHALATION VIAL-NEB.<br />
WATER WATER FOR INJ.,BACTERIOSTATIC VIAL<br />
WATER WATER FOR INJECTION,STERILE IV SOLN.<br />
WATER WATER FOR INJECTION,STERILE VIAL<br />
WATER WATER FOR IRRIGATION,STERILE IRRIG SOLN<br />
APHRODYNE YOHIMBINE HCL 5.4MG TABLET<br />
DAYTO-HIMBIN YOHIMBINE HCL 5.4MG TABLET<br />
MEDEREK YOHIMBINE HCL 5.4MG TABLET<br />
TESTOMAR YOHIMBINE HCL 5.4MG TABLET<br />
YOHIMBINE HCL YOHIMBINE HCL 5.4MG TABLET<br />
YOHIMBINE HCL YOHIMBINE HCL 5MG TABLET<br />
ZINC CHLORIDE ZINC CHLORIDE 1MG/ML VIAL<br />
MAR-ZINC ZINC SULFATE 220MG TABLET<br />
ZINC SULFATE ZINC SULFATE 220MG CAPSULE<br />
ZINCATE ZINC SULFATE 220MG CAPSULE<br />
3479<br />
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