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 />
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
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