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 DIFLORASONE DIACETATE DIFLORASONE DIACETATE 0.05% OINT.(GM) MAXIFLOR DIFLORASONE DIACETATE 0.05% CREAM(GM) MAXIFLOR DIFLORASONE DIACETATE 0.05% OINT.(GM) PSORCON DIFLORASONE DIACETATE 0.05% CREAM(GM) PSORCON DIFLORASONE DIACETATE 0.05% OINT.(GM) DIFLUNISAL DIFLUNISAL 250MG TABLET DIFLUNISAL DIFLUNISAL 500MG TABLET DOLOBID DIFLUNISAL 250MG TABLET DOLOBID DIFLUNISAL 500MG TABLET DIGITEK DIGOXIN 125MCG TABLET DIGITEK DIGOXIN 250MCG TABLET DIGOXIN DIGOXIN 125MCG TABLET DIGOXIN DIGOXIN 250MCG TABLET DIGOXIN DIGOXIN 250MCG/ML AMPUL DIGOXIN DIGOXIN 250MCG/ML DISP SYRIN DIGOXIN DIGOXIN 500MCG TABLET DIGOXIN DIGOXIN 50MCG/ML ELIXIR LANOXIN DIGOXIN 0.25MG TABLET LANOXIN DIGOXIN 125MCG TABLET LANOXIN DIGOXIN 250MCG TABLET LANOXIN PEDIATRIC DIGOXIN 100MCG/ML AMPUL CARDIZEM DILTIAZEM HCL 120MG TABLET CARDIZEM DILTIAZEM HCL 30MG TABLET CARDIZEM DILTIAZEM HCL 5MG/ML VIAL CARDIZEM DILTIAZEM HCL 60MG TABLET CARDIZEM DILTIAZEM HCL 90MG TABLET CARDIZEM CD DILTIAZEM HCL 120MG CAP.SR 24H CARDIZEM CD DILTIAZEM HCL 180MG CAP.SR 24H CARDIZEM CD DILTIAZEM HCL 240MG CAP.SR 24H CARDIZEM CD DILTIAZEM HCL 300MG CAP.SR 24H CARTIA XT DILTIAZEM HCL 120MG CAP.SR 24H CARTIA XT DILTIAZEM HCL 180MG CAP.SR 24H CARTIA XT DILTIAZEM HCL 240MG CAP.SR 24H CARTIA XT DILTIAZEM HCL 300MG CAP.SR 24H DILACOR XR DILTIAZEM HCL 120MG CAPSULE CR DILACOR XR DILTIAZEM HCL 180MG CAPSULE CR DILACOR XR DILTIAZEM HCL 240MG CAPSULE CR DILTIA XT DILTIAZEM HCL 120MG CAPSULE CR DILTIA XT DILTIAZEM HCL 180MG CAPSULE CR DILTIA XT DILTIAZEM HCL 240MG CAPSULE CR DILTIAZEM ER DILTIAZEM HCL 120MG CAPSULE CR DILTIAZEM ER DILTIAZEM HCL 180MG CAPSULE CR DILTIAZEM ER DILTIAZEM HCL 240MG CAPSULE CR DILTIAZEM HCL DILTIAZEM HCL 120MG CAP.SR 12H DILTIAZEM HCL DILTIAZEM HCL 120MG CAP.SR 24H DILTIAZEM HCL DILTIAZEM HCL 120MG CAPSULE CR DILTIAZEM HCL DILTIAZEM HCL 120MG TABLET DILTIAZEM HCL DILTIAZEM HCL 180MG CAP.SR 24H DILTIAZEM HCL DILTIAZEM HCL 180MG CAPSULE CR DILTIAZEM HCL DILTIAZEM HCL 240MG CAP.SR 24H DILTIAZEM HCL DILTIAZEM HCL 240MG CAPSULE CR DILTIAZEM HCL DILTIAZEM HCL 300MG CAP.SR 24H DILTIAZEM HCL DILTIAZEM HCL 30MG TABLET DILTIAZEM HCL DILTIAZEM HCL 5MG/ML DISP SYRIN DILTIAZEM HCL DILTIAZEM HCL 5MG/ML VIAL DILTIAZEM HCL DILTIAZEM HCL 60MG CAP.SR 12H DILTIAZEM HCL DILTIAZEM HCL 60MG TABLET DILTIAZEM HCL DILTIAZEM HCL 90MG CAP.SR 12H DILTIAZEM HCL DILTIAZEM HCL 90MG TABLET DILTIAZEM XR DILTIAZEM HCL 180MG CAP.SR 24H DILTIAZEM XR DILTIAZEM HCL 240MG CAP.SR 24H DILTIAZEM XR DILTIAZEM HCL 240MG CAPSULE CR DIMENHYDRINATE DIMENHYDRINATE 50MG TABLET DYMENATE DIMENHYDRINATE 50MG/ML VIAL NUQUIN HP DIOXYBENZONE/HYDROQUINONE/PDO 3-5-4% CREAM(GM) ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR ALLERGY DIPHENHYDRAMINE HCL 25MG CAPSULE ALLERGY ELIXIR DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR ALLERGY MEDICATION DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID ALLERGY MEDICINE DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR ALLERGY MEDICINE DIPHENHYDRAMINE HCL 25MG CAPSULE ALLERGY MEDICINE COMPLETE DIPHENHYDRAMINE HCL 25MG CAPSULE ALTARYL DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID ANTIHIST DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR ANTIHISTAMINE DIPHENHYDRAMINE HCL 25MG CAPSULE Page 30 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 ANTITUSSIVE COUGH SYRUP DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP BANOPHEN DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR BANOPHEN DIPHENHYDRAMINE HCL 25MG CAPSULE BANOPHEN ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID BENADRILINA DIPHENHYDRAMINE HCL 25MG CAPSULE BENADRYL DIPHENHYDRAMINE HCL 25MG CAPSULE BENADRYL DIPHENHYDRAMINE HCL 50MG/ML VIAL BENADRYL ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID BENADRYL ALLERGY DIPHENHYDRAMINE HCL 25MG CAPSULE BENADRYL STERI-DOSE DIPHENHYDRAMINE HCL 50MG/ML DISP SYRIN BENAHIST-10 DIPHENHYDRAMINE HCL 10MG/ML VIAL BENAHIST-50 DIPHENHYDRAMINE HCL 50MG/ML VIAL BYDRAMINE DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP CHILDREN'S ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR CHILDREN'S ALLERGY MEDICINE DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR CHILDREN'S COLD & ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR COMPLETE ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID COMPLETE ALLERGY DIPHENHYDRAMINE HCL 25MG CAPSULE COMPLETE ALLERGY MEDICINE DIPHENHYDRAMINE HCL 25MG CAPSULE DIPHEDRYL DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR DIPHEDRYL DIPHENHYDRAMINE HCL 25MG CAPSULE DIPHEDRYL ALLERGY DIPHENHYDRAMINE HCL 25MG CAPSULE DIPHEN DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP DIPHEN AF DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID DIPHENHIST DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID DIPHENHIST DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP DIPHENHIST DIPHENHYDRAMINE HCL 25MG CAPSULE DIPHENHIST DIPHENHYDRAMINE HCL 50MG CAPSULE DIPHENHYDRAMINE DIPHENHYDRAMINE HCL 25MG CAPSULE DIPHENHYDRAMINE DIPHENHYDRAMINE HCL 50MG CAPSULE DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 25MG CAPSULE DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50MG CAPSULE DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50MG/ML DISP SYRIN DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL 50MG/ML VIAL DIPHENHYDRAMINE MIN-I-JET DIPHENHYDRAMINE HCL 50MG/ML DISP SYRIN DYTUSS DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP GENAHIST DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID GENAHIST DIPHENHYDRAMINE HCL 25MG CAPSULE HM ALLERGY DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR HM DIPHEDRYL DIPHENHYDRAMINE HCL 25MG CAPSULE HYDRAMINE DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR HYDRAMINE DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID HYDRAMINE DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP KOMADRYL DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR KOSHER CARE ALLERGY RELIEF DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID MEDIPHEDRYL DIPHENHYDRAMINE HCL 25MG CAPSULE PROHIST DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR Q-DRYL DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID Q-DRYL DIPHENHYDRAMINE HCL 25MG CAPSULE QUENALIN DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP SCOT-TUSSIN DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID SILADRYL DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID SILADRYL DAS DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID SILPHEN DIPHENHYDRAMINE HCL 12.5MG/5ML SYRUP TOTAL ALLERGY MEDICINE DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID TOTAL ALLERGY MEDICINE DIPHENHYDRAMINE HCL 25MG CAPSULE VALU-DRYL DIPHENHYDRAMINE HCL 12.5MG/5ML ELIXIR VALU-DRYL DIPHENHYDRAMINE HCL 12.5MG/5ML LIQUID VALU-DRYL DIPHENHYDRAMINE HCL 25MG CAPSULE V-R VALU-DRYL DIPHENHYDRAMINE HCL 25MG CAPSULE DIPIVEFRIN HCL DIPIVEFRIN HCL 0.1% DROPS PROPINE DIPIVEFRIN HCL 0.1% DROPS DIPYRIDAMOLE DIPYRIDAMOLE 25MG TABLET DIPYRIDAMOLE DIPYRIDAMOLE 50MG TABLET DIPYRIDAMOLE DIPYRIDAMOLE 5MG/ML AMPUL DIPYRIDAMOLE DIPYRIDAMOLE 5MG/ML VIAL DIPYRIDAMOLE DIPYRIDAMOLE 75MG TABLET PERSANTINE DIPYRIDAMOLE 25MG TABLET PERSANTINE DIPYRIDAMOLE 50MG TABLET PERSANTINE DIPYRIDAMOLE 75MG TABLET DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE 100MG CAPSULE DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE PHOSPHATE 150MG CAPSULE Page 31 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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