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 />
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 />
MAC list as of February 03.xls