Alabama Medicaid Maximum Allowable Cost List

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Drug Brand Name Alabama Medicaid Maximum Allowable Cost List GCN - Generic Drug Description Drug Strength/Dosage Description Dose Form Description CARDEC-DM CARBINOX/DM HB/P-EPHED HCL 15-60-4/5 SYRUP CARDEC-DM CARBINOX/DM HB/P-EPHED HCL 4-25-2/ML DROPS PRODEC-DM CARBINOX/DM HB/P-EPHED HCL 4-25-2/ML DROPS RONDEC-DM CARBINOX/DM HB/P-EPHED HCL 4-15-1/ML DROPS SILDEC-DM CARBINOX/DM HB/P-EPHED HCL 4-15-1/ML DROPS TUSSAFED CARBINOX/DM HB/P-EPHED HCL 15-60-4/5 SYRUP P-EPD HCL/HCOD BT/CARBINOX CARBINOX/HCOD BT/P-EPHED HCL 30-5-2MG/5 LIQUID CARBINOXAMINE CARBINOXAMINE MALEATE 2MG/5ML LIQUID CARBINOXAMINE CARBINOXAMINE MALEATE 4MG/5ML LIQUID CARBINOXAMINE PD CARBINOXAMINE MALEATE 2MG/5ML LIQUID HISTEX PD CARBINOXAMINE MALEATE 4MG/5ML LIQUID MINTEX CT CARBINOXAMINE MALEATE 8MG TAB.SR 12H PEDIATEX CARBINOXAMINE MALEATE 2MG/5ML LIQUID PEDIOX CARBINOXAMINE MALEATE 4MG/5ML LIQUID CAR-B-PEN TA/CHLOR-TAN CAR-B-PEN TA/CHLOR-TAN 60-5MG TABLET TANA T-12 CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP TANNATE 12 S CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP TANNIC-12 CAR-B-PEN TA/CHLOR-TAN 60-5MG TABLET TANNIC-12 S CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP TANNIHIST-12 RF CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP TRIONATE CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP TRIONATE NF CAR-B-PEN TA/CHLOR-TAN 60-5MG TABLET TUSSI-12 CAR-B-PEN TA/CHLOR-TAN 60-5MG TABLET TUSSI-12 S CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP TUSSIZONE-12 RF CAR-B-PEN TA/CHLOR-TAN 30-4MG/5ML ORAL SUSP TUSSIZONE-12 RF CAR-B-PEN TA/CHLOR-TAN 60-5MG TABLET QUAD TANN CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP QUAD TANN CAR-B-PEN TA/CP/EPHED TAN/PE 60-10-10-5 TABLET QUAD TANN PEDIATRIC CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP QUAD-TUSS TANNATE CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP RENTAMINE CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP RENTAMINE CAR-B-PEN TA/CP/EPHED TAN/PE 60-10-10-5 TABLET RYNATUSS CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP RYNATUSS CAR-B-PEN TA/CP/EPHED TAN/PE 60-10-10-5 TABLET TETRA TANNATE CAR-B-PEN TA/CP/EPHED TAN/PE 30-5-5-4/5 ORAL SUSP RENTAMINE-12 CAR-B-PEN TA/CP/PHENYLEPHRINE 30-5-4/5ML ORAL SUSP TANNATE-12 CAR-B-PEN TA/CP/PHENYLEPHRINE 30-5-4/5ML ORAL SUSP TANNIC-12 CAR-B-PEN TA/CP/PHENYLEPHRINE 30-5-4/5ML ORAL SUSP TANNIHIST-12 CAR-B-PEN TA/CP/PHENYLEPHRINE 30-5-4/5ML ORAL SUSP ULTRATUSS 12 S CAR-B-PEN TA/CP/PHENYLEPHRINE 30-5-4/5ML ORAL SUSP XIRATUSS CAR-B-PEN TA/CP/PHENYLEPHRINE 60-10-5MG TABLET PLEGISOL CARDIOPLEGIC SOLUTION NO.1 K+=16MEQ/L INFUS. BTL CARISOPRODOL CARISOPRODOL 350MG TABLET SOMA CARISOPRODOL 350MG TABLET VANADOM CARISOPRODOL 350MG TABLET CARTEOLOL HCL CARTEOLOL HCL 1% DROPS OCUPRESS CARTEOLOL HCL 1% DROPS CECLOR CEFACLOR 125MG/5ML SUSP RECON CECLOR CEFACLOR 187MG/5ML SUSP RECON CECLOR CEFACLOR 250MG CAPSULE CECLOR CEFACLOR 250MG/5ML SUSP RECON CECLOR CEFACLOR 375MG/5ML SUSP RECON CECLOR CEFACLOR 500MG CAPSULE CEFACLOR CEFACLOR 125MG/5ML SUSP RECON CEFACLOR CEFACLOR 187MG/5ML SUSP RECON CEFACLOR CEFACLOR 250MG CAPSULE CEFACLOR CEFACLOR 250MG/5ML SUSP RECON CEFACLOR CEFACLOR 375MG/5ML SUSP RECON CEFACLOR CEFACLOR 500MG CAPSULE CEFACLOR ER CEFACLOR 375MG TAB.SR 12H CEFACLOR ER CEFACLOR 500MG TAB.SR 12H CEFADROXIL CEFADROXIL HYDRATE 500MG CAPSULE CEFADROXIL MONOHYDRATE CEFADROXIL HYDRATE 1G TABLET DURICEF CEFADROXIL HYDRATE 1G TABLET DURICEF CEFADROXIL HYDRATE 500MG CAPSULE ANCEF CEFAZOLIN SODIUM 10G VIAL ANCEF CEFAZOLIN SODIUM 1G PIGGYBACK ANCEF CEFAZOLIN SODIUM 1G VIAL ANCEF CEFAZOLIN SODIUM 500MG VIAL CEFAZOLIN CEFAZOLIN SODIUM 10G VIAL CEFAZOLIN CEFAZOLIN SODIUM 1G VIAL CEFAZOLIN SODIUM CEFAZOLIN SODIUM 10G VIAL CEFAZOLIN SODIUM CEFAZOLIN SODIUM 1G PIGGYBACK CEFAZOLIN SODIUM CEFAZOLIN SODIUM 1G VIAL CEFAZOLIN SODIUM CEFAZOLIN SODIUM 500MG VIAL Page 18 MAC list as of February 03.xls
Drug Brand Name Alabama Medicaid Maximum Allowable Cost List GCN - Generic Drug Description Drug Strength/Dosage Description Dose Form Description KEFZOL CEFAZOLIN SODIUM 10G VIAL KEFZOL CEFAZOLIN SODIUM 1G VIAL CEFOTAXIME CEFOTAXIME SODIUM 500MG VIAL CEFOTAXIME SODIUM CEFOTAXIME SODIUM 10G VIAL CEFOTAXIME SODIUM CEFOTAXIME SODIUM 1G VIAL CEFOTAXIME SODIUM CEFOTAXIME SODIUM 2G VIAL CEFOXITIN CEFOXITIN SODIUM 10G VIAL CEFOXITIN CEFOXITIN SODIUM 1G VIAL CEFOXITIN CEFOXITIN SODIUM 2G VIAL CEFUROXIME CEFUROXIME AXETIL 250MG TABLET CEFUROXIME CEFUROXIME AXETIL 500MG TABLET CEFUROXIME SODIUM CEFUROXIME SODIUM 1.5G VIAL CEFUROXIME SODIUM CEFUROXIME SODIUM 7.5G VIAL CEFUROXIME SODIUM CEFUROXIME SODIUM 750MG VIAL KEFUROX CEFUROXIME SODIUM 7.5G VIAL KEFUROX CEFUROXIME SODIUM 750MG VIAL ZINACEF CEFUROXIME SODIUM 7.5G VIAL ZINACEF CEFUROXIME SODIUM 750MG VIAL CEPHALEXIN CEPHALEXIN MONOHYDRATE 125MG/5ML SUSP RECON CEPHALEXIN CEPHALEXIN MONOHYDRATE 250MG CAPSULE CEPHALEXIN CEPHALEXIN MONOHYDRATE 250MG TABLET CEPHALEXIN CEPHALEXIN MONOHYDRATE 250MG/5ML SUSP RECON CEPHALEXIN CEPHALEXIN MONOHYDRATE 500MG CAPSULE KEFLEX CEPHALEXIN MONOHYDRATE 250MG CAPSULE KEFLEX CEPHALEXIN MONOHYDRATE 500MG CAPSULE CEPHRADINE CEPHRADINE 500MG CAPSULE VELOSEF CEPHRADINE 250MG CAPSULE VELOSEF CEPHRADINE 250MG/5ML SUSP RECON VELOSEF CEPHRADINE 500MG CAPSULE M.T.E.-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 100-1000 VIAL M.T.E.-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 500-5000 VIAL MULTITRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 100-1000 VIAL MULTITRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 25-1500 VIAL MULTITRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 500-5000 VIAL MULTITRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP PEDIATRIC VIAL NEOTRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 25-1500 VIAL P.T.E.-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 25-1000 VIAL PEDTRACE-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 25-500 VIAL TRACE ELEMENTS-4 CH/CUSO4 P-HYD/MANG/ZNSO4 HEP 30-500 VIAL M.T.E.-5 CH/CUSO4 P-HYD/MN/SE/ZNSO4 HEP 20-1000 VIAL M.T.E.-5 CH/CUSO4 P-HYD/MN/SE/ZNSO4 HEP 60-5000 VIAL MULTITRACE-5 CH/CUSO4 P-HYD/MN/SE/ZNSO4 HEP 20-1000 VIAL MULTITRACE-5 CH/CUSO4 P-HYD/MN/SE/ZNSO4 HEP 60-5000 VIAL CHLORAL HYDRATE CHLORAL HYDRATE 500MG/5ML SYRUP SOMNOTE CHLORAL HYDRATE 500MG CAPSULE CHLORAMPHENICOL CHLORAMPHENICOL 1% OINT.(GM) CHLOROPTIC CHLORAMPHENICOL 0.5% DROPS CHLORAMPHENICOL SOD SUCCINATE CHLORAMPHENICOL NA SUCC 1G VIAL CHLOROMYCETIN CHLORAMPHENICOL NA SUCC 1G VIAL CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 10MG CAPSULE CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 25MG CAPSULE CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL 5MG CAPSULE LIBRIUM CHLORDIAZEPOXIDE HCL 10MG CAPSULE LIBRIUM CHLORDIAZEPOXIDE HCL 25MG CAPSULE LIBRIUM CHLORDIAZEPOXIDE HCL 5MG CAPSULE POXI CHLORDIAZEPOXIDE HCL 10MG CAPSULE CHLORHEXIDINE GLUCONATE CHLORHEXIDINE GLUCONATE 1.2MG/ML LIQUID PERIDEX CHLORHEXIDINE GLUCONATE 1.2MG/ML LIQUID PERIOGARD CHLORHEXIDINE GLUCONATE 1.2MG/ML LIQUID PERISOL CHLORHEXIDINE GLUCONATE 1.2MG/ML LIQUID COUGH FORMULA CHLOR-MAL/DEXTROMETHORPHAN HBR 15-2MG/5ML LIQUID EXTRA STRENGTH COUGH CHLOR-MAL/DEXTROMETHORPHAN HBR LIQUID EXTRA STRENGTH COUGH FORMULA CHLOR-MAL/DEXTROMETHORPHAN HBR LIQUID SCOT-TUSSIN DM CHLOR-MAL/DEXTROMETHORPHAN HBR 15-2MG/5ML LIQUID AMDRY-C CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H COLDAMINE CHLOR-MAL/P-EPHED HCL/SCOP 90-8-2.5MG TAB.SR 12H CPM 8/PSE 90/MSC 2.5 CHLOR-MAL/P-EPHED HCL/SCOP 90-8-2.5MG TAB.SR 12H HISTA-VENT PSE CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H MESCOLOR CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H PANNAZ CHLOR-MAL/P-EPHED HCL/SCOP 90-8-2.5MG TAB.SR 12H P-EPHED HCL/CHLOR-MAL/SCOP CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB SR SEQ P-EPHED HCL/CHLOR-MAL/SCOP CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H RESCON MX CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H XIRAL CHLOR-MAL/P-EPHED HCL/SCOP 120-8-2.5 TAB.SR 12H ED A-HIST CHLOR-MAL/PHENYLEPHRINE HCL 20-8MG TABLET SA Page 19 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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