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 DELONIDE DESONIDE 0.05% CREAM(GM) DESONIDE DESONIDE 0.05% CREAM(GM) DESONIDE DESONIDE 0.05% LOTION DESONIDE DESONIDE 0.05% OINT.(GM) DESOWEN DESONIDE 0.05% CREAM(GM) DESOWEN DESONIDE 0.05% OINT.(GM) TRIDESILON DESONIDE 0.05% CREAM(GM) TRIDESILON DESONIDE 0.05% OINT.(GM) DESOXIMETASONE DESOXIMETASONE 0.05% CREAM(GM) DESOXIMETASONE DESOXIMETASONE 0.05% GEL DESOXIMETASONE DESOXIMETASONE 0.25% CREAM(GM) DESOXIMETASONE DESOXIMETASONE 0.25% OINT.(GM) TOPICORT DESOXIMETASONE 0.25% CREAM(GM) DEXTROSE IN LACTATED RINGERS DEX 2.5%-HALF STR LACT.RINGERS 2.5%-1/2 IV SOLN. NEO-DEXAIR DEX NA PH/NEOMYCIN SULFATE 0.35-0.1% DROPS NEOMYCIN W/DEXAMETHASONE DEX NA PH/NEOMYCIN SULFATE 0.35-0.1% DROPS AK-TROL DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP DEXACIDIN DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP DEXACINE DEXAMETH/NEO/POLYMYX B SULF 0.1% OINT.(GM) DEXASPORIN DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP MAXITROL DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP MAXITROL DEXAMETH/NEO/POLYMYX B SULF 0.1% OINT.(GM) METHADEX DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP NEO/POLYMYXIN/DEXAMETHASONE DEXAMETH/NEO/POLYMYX B SULF OINT.(GM) NEO/POLYMYXIN/DEXAMETHASONE DEXAMETH/NEO/POLYMYX B SULF 0.1% OINT.(GM) NEOMYCIN/POLYMYXIN/DEXAMETH DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP POLY-DEX DEXAMETH/NEO/POLYMYX B SULF 0.1% DROPS SUSP POLY-DEX DEXAMETH/NEO/POLYMYX B SULF 0.1% OINT.(GM) DECADRON DEXAMETHASONE 0.5MG TABLET DECADRON DEXAMETHASONE 0.75MG TAB DS PK DECADRON DEXAMETHASONE 0.75MG TABLET DECADRON DEXAMETHASONE 4MG TABLET DEXAMETHASONE DEXAMETHASONE 0.5MG TABLET DEXAMETHASONE DEXAMETHASONE 0.5MG/5ML ELIXIR DEXAMETHASONE DEXAMETHASONE 0.75MG TAB DS PK DEXAMETHASONE DEXAMETHASONE 0.75MG TABLET DEXAMETHASONE DEXAMETHASONE 1.5MG TABLET DEXAMETHASONE DEXAMETHASONE 4MG TABLET DEXAMETHASONE DEXAMETHASONE 6MG TABLET DEXPAK DEXAMETHASONE 1.5MG TAB DS PK DECAJECT-LA DEXAMETHASONE ACETATE 8MG/ML VIAL DE-SONE LA DEXAMETHASONE ACETATE 8MG/ML VIAL DEXACEN LA-8 DEXAMETHASONE ACETATE 8MG/ML VIAL DEXAMETHASONE ACETATE DEXAMETHASONE ACETATE 8MG/ML VIAL SOLUREX LA DEXAMETHASONE ACETATE 8MG/ML VIAL CPC-CORT-D DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL DECADRON DEXAMETHASONE SOD PHOSPHATE 0.05% OINT.(GM) DECADRON DEXAMETHASONE SOD PHOSPHATE 0.1% DROPS DECADRON PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL DECAJECT-10 DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL DEXAMETHASONE SODIUM PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 0.05% OINT.(GM) DEXAMETHASONE SODIUM PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 0.1% DROPS DEXAMETHASONE SODIUM PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 10MG/ML VIAL DEXAMETHASONE SODIUM PHOSPHATE DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL DEXASOL DEXAMETHASONE SOD PHOSPHATE 0.1% DROPS DEXONE DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL SOLUREX DEXAMETHASONE SOD PHOSPHATE 4MG/ML VIAL DEXCHLOR DEXCHLORPHENIRAMINE MALEATE 4MG TABLET SA DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE 2MG/5ML SYRUP DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE 4MG TABLET SA DEXCHLORPHENIRAMINE MALEATE DEXCHLORPHENIRAMINE MALEATE 6MG TABLET SA POLARAMINE DEXCHLORPHENIRAMINE MALEATE 2MG/5ML SYRUP POLARAMINE DEXCHLORPHENIRAMINE MALEATE 4MG TABLET SA POLARAMINE REPETAB DEXCHLORPHENIRAMINE MALEATE 6MG TABLET SA DEXPANTHENOL DEXPANTHENOL 250MG/ML VIAL DEXTRAN 40 IN DEXTROSE 5% DEXTRAN 40/DEXTROSE 5%-WATER 10% IV SOLN. GENTRAN 40 IN DEXTROSE 5% DEXTRAN 40/DEXTROSE 5%-WATER 10% IV SOLN. LMD 10% W/5% DEXTROSE DEXTRAN 40/DEXTROSE 5%-WATER 10% IV SOLN. DEXTRAN 40 IN NORMAL SALINE DEXTRAN 40/NACL 0.9% 10-0.9% IV SOLN. GENTRAN 40 IN NORMAL SALINE DEXTRAN 40/NACL 0.9% 10-0.9% IV SOLN. LMD 10% W/0.9% SODIUM CHLORIDE DEXTRAN 40/NACL 0.9% 10-0.9% IV SOLN. DEXTRAN 75 IN NORMAL SALINE DEXTRAN 75/NACL 0.9% 6-0.9% IV SOLN. GENTRAN 75 IN NORMAL SALINE DEXTRAN 75/NACL 0.9% 6-0.9% IV SOLN. BENYLIN DEXTROMETHORPHAN HBR 15MG/5ML SYRUP BENYLIN DEXTROMETHORPHAN HBR 7.5MG/5ML SYRUP Page 28 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 DIABE-TUSS DM DEXTROMETHORPHAN HBR 15MG/5ML SYRUP HOLD DEXTROMETHORPHAN HBR 5MG LOZENGE HONEY TUSSIN COUGH DEXTROMETHORPHAN HBR 10MG/5ML SYRUP PERTUSSIN ES DEXTROMETHORPHAN HBR 15MG/5ML SYRUP ROBAFEN DEXTROMETHORPHAN HBR 10MG/5ML SYRUP ROBAFEN PEDIATRIC DEXTROMETHORPHAN HBR 7.5MG/5ML SYRUP ROBITUSSIN DEXTROMETHORPHAN HBR 15MG/5ML SYRUP ROBITUSSIN PEDIATRIC DEXTROMETHORPHAN HBR 7.5MG/5ML SYRUP SILPHEN DM DEXTROMETHORPHAN HBR 10MG/5ML SYRUP TUSSIN MAXIMUM STRENGTH DEXTROMETHORPHAN HBR 15MG/5ML SYRUP TUSSIN PEDIATRIC DEXTROMETHORPHAN HBR 7.5MG/5ML SYRUP DEXTROSE 10%-1/4NS DEXTROSE 10%-0.25% SALINE 10-0.2% IV SOLN. DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 10%-NORMAL SALINE 10%-0.9% IV SOLN. DEXTROSE IN WATER DEXTROSE 10%-WATER 10% AMPUL DEXTROSE IN WATER DEXTROSE 10%-WATER 10% IV SOLN. DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 2.5%-0.45% SALINE 2.5%-0.45% IV SOLN. DEXTROSE IN WATER DEXTROSE 20%-WATER 20% IV SOLN. DEXTROSE IN WATER DEXTROSE 25%-WATER 25% DISP SYRIN DEXTROSE IN WATER DEXTROSE 30%-WATER 30% IV SOLN. DEXTROSE IN WATER DEXTROSE 40%-WATER 40% IV SOLN. DEXTROSE IN RINGERS INJECTION DEXTROSE 5% IN RINGERS 5% IV SOLN. DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 5%-0.25% SALINE 5-0.25% IV SOLN. DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 5%-0.33% SALINE 5%-0.33% IV SOLN. DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 5%-0.45% SALINE 5%-0.45% IV SOLN. DEXTROSE IN LACTATED RINGERS DEXTROSE 5%-LACTATED RINGERS 5% IV SOLN. DEXTROSE WITH SODIUM CHLORIDE DEXTROSE 5%-NORMAL SALINE 5%-0.9% IV SOLN. DEXTROSE IN WATER DEXTROSE 5%-WATER 5% IV SOLN. DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 0.8MG/ML INFUS. BTL DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 0.8MG/ML PLAST. BAG DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 1.6MG/ML INFUS. BTL DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 1.6MG/ML PLAST. BAG DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 3.2MG/ML INFUS. BTL DOPAMINE HCL IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 3.2MG/ML PLAST. BAG DOPAMINE HCL IN D5W DEXTROSE 5%-WATER/DOPAMINE HCL 0.8MG/ML INFUS. BTL DOPAMINE IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 0.8MG/ML INFUS. BTL DOPAMINE IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 1.6MG/ML INFUS. BTL DOPAMINE IN 5% DEXTROSE DEXTROSE 5%-WATER/DOPAMINE HCL 3.2MG/ML INFUS. BTL THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 200MG/0.1L IV SOLN. THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 200MG/50ML IV SOLN. THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 400MG/.25L IV SOLN. THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 400MG/0.1L IV SOLN. THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 400MG/0.5L IV SOLN. THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 800MG/.25L IV SOLN. THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 800MG/0.5L IV SOLN. THEOPHYLLINE IN 5% DEXTROSE DEXTROSE 5%-WATER/THEOPHYLLINE 800MG/L IV SOLN. DEXTROSE IN WATER DEXTROSE 50%-WATER 50% DISP SYRIN DEXTROSE IN WATER DEXTROSE 50%-WATER 50% IV SOLN. DEXTROSE IN WATER DEXTROSE 50%-WATER 50% VIAL DEXTROSE IN WATER DEXTROSE 70%-WATER 70% IV SOLN. INPERSOL-LM W/1.5% DEXTROSE DIALYSIS SOLUTIONS 346MOSM/L IP SOLN. DIAZEPAM DIAZEPAM 10MG TABLET DIAZEPAM DIAZEPAM 2MG TABLET DIAZEPAM DIAZEPAM 5MG TABLET DIAZEPAM DIAZEPAM 5MG/ML AMPUL DIAZEPAM DIAZEPAM 5MG/ML DISP SYRIN DIAZEPAM DIAZEPAM 5MG/ML VIAL DIBUCAINE DIBUCAINE 1% OINT.(GM) CATAFLAM DICLOFENAC POTASSIUM 50MG TABLET DICLOFENAC POTASSIUM DICLOFENAC POTASSIUM 50MG TABLET DICLOFENAC SODIUM DICLOFENAC SODIUM 100MG TAB.SR 24H DICLOFENAC SODIUM DICLOFENAC SODIUM 25MG TABLET DR DICLOFENAC SODIUM DICLOFENAC SODIUM 50MG TABLET DR DICLOFENAC SODIUM DICLOFENAC SODIUM 75MG TABLET DR VOLTAREN DICLOFENAC SODIUM 25MG TABLET DR VOLTAREN DICLOFENAC SODIUM 50MG TABLET DR VOLTAREN DICLOFENAC SODIUM 75MG TABLET DR VOLTAREN-XR DICLOFENAC SODIUM 100MG TAB.SR 24H DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 250MG CAPSULE DICLOXACILLIN SODIUM DICLOXACILLIN SODIUM 500MG CAPSULE ANTISPAS DICYCLOMINE HCL 10MG/ML VIAL BENTYL DICYCLOMINE HCL 10MG CAPSULE BENTYL DICYCLOMINE HCL 20MG TABLET DICYCLOMINE HCL DICYCLOMINE HCL 10MG CAPSULE DICYCLOMINE HCL DICYCLOMINE HCL 20MG TABLET DIFLORASONE DIACETATE DIFLORASONE DIACETATE 0.05% CREAM(GM) Page 29 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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