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 MAXI-TUSS HC CP/HYDROCODONE/PHENYLEPHRINE 10-2.5-4 SYRUP MAXITUSS HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP MED-HIST-HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP TUSS-HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP TUSSIVE HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP TUSS-PD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP UNI TUSS HC CP/HYDROCODONE/PHENYLEPHRINE 5-2.5-2 SYRUP VANEX HD CP/HYDROCODONE/PHENYLEPHRINE 5-1.67-2 SYRUP C-HIST-SR CP/PHENYLEPHRINE/PHENYLTOLOX 20-50-4MG CAP.SR 12H CHLORTOX LA CP/PHENYLEPHRINE/PHENYLTOLOX 20-50-4MG CAP.SR 12H ALLERX CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP PHENATAN-S CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP RHINATATE CP/PHENYLEPHRINE/PYRIL TAN 25-25-8MG TABLET RHINATATE CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP R-TANNAMINE CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP TANAMINE CP/PHENYLEPHRINE/PYRIL TAN 25-25-8MG TABLET TRI TANN CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP TRIOTANN CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP TRIOTANN-S CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP TRIPLE TANNATE CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP TRIPLE TANNATE PEDIATRIC CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP TRIPLE TANNATE-S CP/PHENYLEPHRINE/PYRIL TAN 5-12.5-2/5 ORAL SUSP BLANEX-A CP/P-TLOX CI/PHENYLEPHRINE 20-40-4MG TABLET CHLOREX-A CP/P-TLOX CI/PHENYLEPHRINE 20-40-4MG TABLET COLDEX-A SR CP/P-TLOX CI/PHENYLEPHRINE 20-40-4MG TABLET NALEX-A CP/P-TLOX CI/PHENYLEPHRINE 20-40-4MG TABLET CROLOM CROMOLYN SODIUM 4% DROPS CROMOLYN SODIUM CROMOLYN SODIUM 20MG/2ML AMPUL-NEB. CROMOLYN SODIUM CROMOLYN SODIUM 4% DROPS CROMOLYN SODIUM CROMOLYN SODIUM 40MG/ML SPRAY/PUMP INTAL CROMOLYN SODIUM 20MG/2ML AMPUL-NEB. NASAL ALLERGY CONTROL CROMOLYN SODIUM 40MG/ML SPRAY/PUMP NASAL ALLERGY SYMPTOM CONTROL CROMOLYN SODIUM 40MG/ML SPRAY/PUMP NASALCROM CROMOLYN SODIUM 40MG/ML SPRAY/PUMP OPTICROM CROMOLYN SODIUM 4% DROPS COPPER CHLORIDE CUPRIC CHLORIDE 0.4MG/ML VIAL CPC-B12 CYANOCOBALAMIN 1000MCG/ML VIAL CYANOCOBALAMIN CYANOCOBALAMIN 1000MCG/ML VIAL CYANOJECT-10 CYANOCOBALAMIN 1000MCG/ML VIAL PAN B-12 VIAL CYANOCOBALAMIN 1000MCG/ML VIAL RUBESOL-1000 CYANOCOBALAMIN 1000MCG/ML VIAL VITAMIN B-12 CYANOCOBALAMIN 1000MCG/ML VIAL VITAMIN B-12 (CYANOCOBALAMIN) CYANOCOBALAMIN 1000MCG/ML VIAL CYCLOBENZAPRINE HCL CYCLOBENZAPRINE HCL 10MG TABLET FLEXERIL CYCLOBENZAPRINE HCL 10MG TABLET AK-PENTOLATE CYCLOPENTOLATE HCL 1% DROPS AK-PENTOLATE CYCLOPENTOLATE HCL 2% DROPS CYCLOGYL CYCLOPENTOLATE HCL 1% DROPS CYCLOPENTOLATE HCL CYCLOPENTOLATE HCL 1% DROPS CYLATE CYCLOPENTOLATE HCL 1% DROPS CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE 25MG TABLET CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE 50MG TABLET NEOSAR CYCLOPHOSPHAMIDE 100MG VIAL NEOSAR CYCLOPHOSPHAMIDE 200MG VIAL NEOSAR CYCLOPHOSPHAMIDE 2G VIAL NEOSAR CYCLOPHOSPHAMIDE 500MG VIAL NEOSAR FOR INJECTION CYCLOPHOSPHAMIDE 1G VIAL CYCLOSPORINE CYCLOSPORINE 100MG CAPSULE CYCLOSPORINE CYCLOSPORINE 25MG CAPSULE CYCLOSPORINE CYCLOSPORINE, MODIFIED 100MG CAPSULE CYCLOSPORINE CYCLOSPORINE, MODIFIED 100MG/ML SOLUTION CYCLOSPORINE CYCLOSPORINE, MODIFIED 25MG CAPSULE GENGRAF CYCLOSPORINE, MODIFIED 100MG CAPSULE GENGRAF CYCLOSPORINE, MODIFIED 100MG/ML SOLUTION GENGRAF CYCLOSPORINE, MODIFIED 25MG CAPSULE NEORAL CYCLOSPORINE, MODIFIED 100MG CAPSULE NEORAL CYCLOSPORINE, MODIFIED 25MG CAPSULE CYPROHEPTADINE HCL CYPROHEPTADINE HCL 2MG/5ML SYRUP CYPROHEPTADINE HCL CYPROHEPTADINE HCL 4MG TABLET PERIACTIN CYPROHEPTADINE HCL 4MG TABLET CYSTEINE HYDROCHLORIDE CYSTEINE HCL 50MG/ML VIAL L-CYSTEINE CYSTEINE HCL 50MG/ML VIAL CYTARABINE CYTARABINE 100MG VIAL CYTARABINE CYTARABINE 1G VIAL CYTARABINE CYTARABINE 20MG/ML VIAL Page 26 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 CYTARABINE CYTARABINE 2G VIAL CYTARABINE CYTARABINE 500MG VIAL DEXTROSE 5%-1/4NS-KCL D5-0.25NACL/POTASSIUM CHLORIDE 10MEQ/L IV SOLN. DEXTROSE 5%-1/4NS-KCL D5-0.25NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN. DEXTROSE 5%-1/4NS-KCL D5-0.25NACL/POTASSIUM CHLORIDE 30MEQ/L IV SOLN. DEXTROSE 5%-1/4NS-KCL D5-0.25NACL/POTASSIUM CHLORIDE 40MEQ/L IV SOLN. POTASSIUM CL IN D5W AND NACL D5-0.25NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN. DEXTROSE 5%-1/3NS-KCL D5-0.33NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN. DEXTROSE 5%-1/3NS-KCL D5-0.33NACL/POTASSIUM CHLORIDE 30MEQ/L IV SOLN. KCL IN DEXTROSE AND NACL D5-0.33NACL/POTASSIUM CHLORIDE 40MEQ/L IV SOLN. POTASSIUM CL IN D5W AND NACL D5-0.33NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN. DEXTROSE 5%-1/2NS-KCL D5-0.45NACL/POTASSIUM CHLORIDE 10MEQ/L IV SOLN. DEXTROSE 5%-1/2NS-KCL D5-0.45NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN. DEXTROSE 5%-1/2NS-KCL D5-0.45NACL/POTASSIUM CHLORIDE 30MEQ/L IV SOLN. DEXTROSE 5%-1/2NS-KCL D5-0.45NACL/POTASSIUM CHLORIDE 40MEQ/L IV SOLN. POTASSIUM CL IN D5W AND NACL D5-0.45NACL/POTASSIUM CHLORIDE 20MEQ/L IV SOLN. KCL IN DEXTROSE & LACT RINGERS D5LR/POTASSIUM CHLORIDE 20MEQ/L IV SOLN. KCL IN DEXTROSE & LACT RINGERS D5LR/POTASSIUM CHLORIDE 40MEQ/L IV SOLN. DEXTROSE 5%-NS-KCL D5NS/POTASSIUM CHLORIDE 20MEQ/L IV SOLN. POTASSIUM CHLORIDE IN D5W/NACL D5NS/POTASSIUM CHLORIDE 20MEQ/L IV SOLN. POTASSIUM CHLORIDE IN D5W/NACL D5NS/POTASSIUM CHLORIDE 40MEQ/L IV SOLN. PLASMA-LYTE M IN DEXTROSE D5W/ELECTROLYTE-M SOLUTION 5% IV SOLN. ISOLYTE R W/DEXTROSE D5W/ELECTROLYTE-R SOLUTION 5% IV SOLN. PLASMA-LYTE R IN DEXTROSE D5W/ELECTROLYTE-R SOLUTION 5% IV SOLN. HEPARIN SODIUM IN 5% DEXTROSE D5W/HEPARIN SODIUM,PORCINE 100 U/ML IV SOLN. HEPARIN SODIUM IN 5% DEXTROSE D5W/HEPARIN SODIUM,PORCINE 40 UNIT/ML IV SOLN. HEPARIN SODIUM IN 5% DEXTROSE D5W/HEPARIN SODIUM,PORCINE 50 UNIT/ML IV SOLN. LIDOCAINE HCL IN 5% DEXTROSE D5W/LIDOCAINE HCL 2MG/ML IV SOLN. LIDOCAINE HCL IN 5% DEXTROSE D5W/LIDOCAINE HCL 4MG/ML IV SOLN. LIDOCAINE HCL IN 5% DEXTROSE D5W/LIDOCAINE HCL 8MG/ML IV SOLN. MILRINONE IN 5% DEXTROSE D5W/MILRINONE LACTATE 0.2MG/ML PIGGYBACK NITROGLYCERIN IN D5W D5W/NITROGLYCERIN 0.1MG/ML INFUS. BTL NITROGLYCERIN IN D5W D5W/NITROGLYCERIN 0.2MG/ML INFUS. BTL NITROGLYCERIN IN D5W D5W/NITROGLYCERIN 0.4MG/ML INFUS. BTL DEXTROSE 5% W/POTASSIUM CL D5W/POTASSIUM CHLORIDE 20MEQ/L IV SOLN. DEXTROSE 5% W/POTASSIUM CL D5W/POTASSIUM CHLORIDE 40MEQ/L IV SOLN. DEXTROSE 5%-POTASSIUM CHLORIDE D5W/POTASSIUM CHLORIDE 30MEQ/L IV SOLN. DEXTROSE 5%-POTASSIUM CHLORIDE D5W/POTASSIUM CHLORIDE 40MEQ/L IV SOLN. DACARBAZINE DACARBAZINE 200MG VIAL DTIC-DOME IV DACARBAZINE 200MG VIAL DEXEDRINE D-AMPHETAMINE SULFATE 5MG TABLET DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 10MG CAPSULE SA DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 10MG TABLET DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 15MG CAPSULE SA DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 5MG CAPSULE SA DEXTROAMPHETAMINE SULFATE D-AMPHETAMINE SULFATE 5MG TABLET DEXTROSTAT D-AMPHETAMINE SULFATE 10MG TABLET DEXTROSTAT D-AMPHETAMINE SULFATE 5MG TABLET DANAZOL DANAZOL 100MG CAPSULE DANAZOL DANAZOL 200MG CAPSULE DANAZOL DANAZOL 50MG CAPSULE DANOCRINE DANAZOL 200MG CAPSULE DAUNORUBICIN HCL DAUNORUBICIN HCL 20MG VIAL DEXAPHEN D-BROMP MAL/P-EPHED SUL 120-6MG TAB.SR 12H DREXOPHED D-BROMP MAL/P-EPHED SUL 120-6MG TAB.SR 12H DRIXOMED D-BROMP MAL/P-EPHED SUL 120-6MG TAB.SR 12H DESIPRAMINE HCL DESIPRAMINE HCL 100MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 10MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 150MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 25MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 50MG TABLET DESIPRAMINE HCL DESIPRAMINE HCL 75MG TABLET NORPRAMIN DESIPRAMINE HCL 100MG TABLET NORPRAMIN DESIPRAMINE HCL 10MG TABLET NORPRAMIN DESIPRAMINE HCL 150MG TABLET NORPRAMIN DESIPRAMINE HCL 25MG TABLET NORPRAMIN DESIPRAMINE HCL 50MG TABLET NORPRAMIN DESIPRAMINE HCL 75MG TABLET DDAVP DESMOPRESSIN ACETATE 0.1MG/ML SOLUTION DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 0.1MG/ML SOLUTION DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 0.1MG/ML SPRAY/PUMP DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 4MCG/ML AMPUL DESMOPRESSIN ACETATE DESMOPRESSIN ACETATE 4MCG/ML VIAL APRI DESOGESTREL-ETHINYL ESTRADIOL 0.15-0.03 TABLET KARIVA DESOG-ET ESTRA/ETHIN ESTRA 21-5 TABLET Page 27 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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