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 PROMETHAZINE DM D-METHORPHAN HB/PROMETH HCL 15-6.25/5 SYRUP PROMETHAZINE W/DM D-METHORPHAN HB/PROMETH HCL 15-6.25/5 SYRUP DOBUTAMINE HCL DOBUTAMINE HCL 12.5MG/ML VIAL DOBUTREX DOBUTAMINE HCL 12.5MG/ML VIAL DOBUTAMINE HCL IN DEXTROSE DOBUTAMINE HCL/D5W 1000MCG/ML IV SOLN. DOBUTAMINE HCL IN DEXTROSE DOBUTAMINE HCL/D5W 2000MCG/ML IV SOLN. DOBUTAMINE HCL IN DEXTROSE DOBUTAMINE HCL/D5W 4000MCG/ML IV SOLN. DOBUTAMINE HCL IN DEXTROSE DOBUTAMINE HCL/D5W 500MCG/ML IV SOLN. FERROUS FUMARATE W/DOCUSATE DOCUSATE NA/FERROUS FUMARATE 150-100MG CAPSULE SA DOPAMINE HCL DOPAMINE HCL 40MG/ML AMPUL DOPAMINE HCL DOPAMINE HCL 40MG/ML DISP SYRIN DOPAMINE HCL DOPAMINE HCL 40MG/ML VIAL DOPAMINE HCL DOPAMINE HCL 80MG/ML AMPUL DOPAMINE HCL DOPAMINE HCL 80MG/ML VIAL DOPAMINE HCL ADDITIVE SYRINGE DOPAMINE HCL 40MG/ML DISP SYRIN DOPAMINE HCL FLIPTOP DOPAMINE HCL 80MG/ML VIAL AMINATE W/90MG IRON DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA MATERNAL 90 DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA MYNATE 90 PLUS DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA NATALFIRST DOSS/FA/FE FUM/PRENATAL VIT 29-1MG TABLET PRENATAL 19 DOSS/FA/FE FUM/PRENATAL VIT 29-1MG TABLET PRENATAL MR 90 FE DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA VINATE 90 DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA VINATE-90 DOSS/FA/FE FUM/PRENATAL VIT 90-1MG TABLET SA ANEMAGEN OB DOSS/FA/FE FUM/PV W-O VIT A 28-1MG CAPSULE ADVANCED NATALCARE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET INATAL ADVANCE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET INATAL GT DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET INATAL ULTRA DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET MYNATAL DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET MYNATAL ADVANCE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET NATALCARE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET PRENATAL AD DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET PRENATAL OPTIMA ADVANCE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET PRENATE ADVANCE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET PRENATE GT DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET ULTRA DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET ULTRA NATALCARE DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET ULTRA-NATAL DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET VINATE ADVANCED DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET VINATE GT DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET VINATE ULTRA DOSS/FA/IRON,CARB/PRENATAL VIT 90-1MG TABLET CARDURA DOXAZOSIN MESYLATE 1MG TABLET CARDURA DOXAZOSIN MESYLATE 2MG TABLET CARDURA DOXAZOSIN MESYLATE 4MG TABLET CARDURA DOXAZOSIN MESYLATE 8MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 1MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 2MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 4MG TABLET DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE 8MG TABLET ADAPIN DOXEPIN HCL 100MG CAPSULE ADAPIN DOXEPIN HCL 10MG CAPSULE ADAPIN DOXEPIN HCL 150MG CAPSULE ADAPIN DOXEPIN HCL 25MG CAPSULE ADAPIN DOXEPIN HCL 50MG CAPSULE ADAPIN DOXEPIN HCL 75MG CAPSULE DOXEPIN HCL DOXEPIN HCL 100MG CAPSULE DOXEPIN HCL DOXEPIN HCL 10MG CAPSULE DOXEPIN HCL DOXEPIN HCL 10MG/ML ORAL CONC. DOXEPIN HCL DOXEPIN HCL 150MG CAPSULE DOXEPIN HCL DOXEPIN HCL 25MG CAPSULE DOXEPIN HCL DOXEPIN HCL 50MG CAPSULE DOXEPIN HCL DOXEPIN HCL 75MG CAPSULE SINEQUAN DOXEPIN HCL 100MG CAPSULE SINEQUAN DOXEPIN HCL 10MG CAPSULE SINEQUAN DOXEPIN HCL 10MG/ML ORAL CONC. SINEQUAN DOXEPIN HCL 150MG CAPSULE SINEQUAN DOXEPIN HCL 25MG CAPSULE SINEQUAN DOXEPIN HCL 50MG CAPSULE SINEQUAN DOXEPIN HCL 75MG CAPSULE ADRIAMYCIN RDF DOXORUBICIN HCL 50MG VIAL ADRIAMYCIN-PFS DOXORUBICIN HCL 2MG/ML VIAL DOXORUBICIN HCL DOXORUBICIN HCL 10MG VIAL DOXORUBICIN HCL DOXORUBICIN HCL 20MG VIAL DOXORUBICIN HCL DOXORUBICIN HCL 2MG/ML VIAL Page 34 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 DOXORUBICIN HCL DOXORUBICIN HCL 50MG VIAL RUBEX DOXORUBICIN HCL 50MG VIAL DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 100MG CAPSULE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 100MG TABLET DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 100MG VIAL DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE 50MG CAPSULE ED DOXY-CAPS DOXYCYCLINE HYCLATE 100MG CAPSULE VIBRAMYCIN DOXYCYCLINE HYCLATE 100MG CAPSULE VIBRAMYCIN DOXYCYCLINE HYCLATE 50MG CAPSULE VIBRA-TABS DOXYCYCLINE HYCLATE 100MG TABLET DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE 100MG CAPSULE DOXYCYCLINE MONOHYDRATE DOXYCYCLINE MONOHYDRATE 50MG CAPSULE MONODOX DOXYCYCLINE MONOHYDRATE 100MG CAPSULE MONODOX DOXYCYCLINE MONOHYDRATE 50MG CAPSULE BANOPHEN PLUS DP-HYDRAM HCL/P-EPHED HCL CAPSULE DROPERIDOL DROPERIDOL 2.5MG/ML AMPUL DROPERIDOL DROPERIDOL 2.5MG/ML VIAL DILOR DYPHYLLINE 200MG TABLET DILOR DYPHYLLINE 400MG TABLET DYLIX DYPHYLLINE 100MG/15ML ELIXIR LUFYLLIN DYPHYLLINE 200MG TABLET NEOTHYLLINE DYPHYLLINE 200MG TABLET COPD DYPHYLLINE/GUAIFENESIN 200-200MG TABLET D-G DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID DG 200 DYPHYLLINE/GUAIFENESIN 200-200MG TABLET DIFIL-G DYPHYLLINE/GUAIFENESIN 200-200MG TABLET DIFIL-G FORTE DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID DILEX-G DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID DILEX-G DYPHYLLINE/GUAIFENESIN 200-200MG TABLET DILOR-G DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID DILOR-G DYPHYLLINE/GUAIFENESIN 200-200MG TABLET DYFILIN GG DYPHYLLINE/GUAIFENESIN 100-100/15 ELIXIR DYFLEX-G DYPHYLLINE/GUAIFENESIN 200-200MG TABLET DY-G LIQUID DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID DYLINE-GG DYPHYLLINE/GUAIFENESIN 100-100/5 LIQUID DYLINE-GG DYPHYLLINE/GUAIFENESIN 200-200MG TABLET DYPHYL-G DYPHYLLINE/GUAIFENESIN 50-100/5ML SYRUP DYPHYLLIN GG DYPHYLLINE/GUAIFENESIN 200-200MG TABLET DYPHYLLINE GG DYPHYLLINE/GUAIFENESIN 100-100/15 ELIXIR DYPHYLLINE GG DYPHYLLINE/GUAIFENESIN 200-200MG TABLET DYPHYLLINE-GG DYPHYLLINE/GUAIFENESIN 100-100/15 ELIXIR DYPHYLLINE-GG DYPHYLLINE/GUAIFENESIN 200-200MG TABLET LUFYLLIN-GG DYPHYLLINE/GUAIFENESIN 100-100/15 ELIXIR LUFYLLIN-GG DYPHYLLINE/GUAIFENESIN 200-200MG TABLET ECONAZOLE NITRATE ECONAZOLE NITRATE 1% CREAM(GM) EDROPHONIUM CHLORIDE EDROPHONIUM CHLORIDE 10MG/ML VIAL ENLON EDROPHONIUM CHLORIDE 10MG/ML VIAL REVERSOL EDROPHONIUM CHLORIDE 10MG/ML VIAL TENSILON EDROPHONIUM CHLORIDE 10MG/ML VIAL MULTILYTE-20 ELECTROLYTE SOLUTION VIAL MULTILYTE-40 ELECTROLYTE SOLUTION VIAL NUTRILYTE ELECTROLYTE SOLUTION,INJ VIAL NUTRILYTE II ELECTROLYTE SOLUTION,INJ VIAL ELECTROLYTE SOLUTION ELECTROLYTE,ORAL SOLUTION ENFALYTE ELECTROLYTE,ORAL SOLUTION NATURALYTE ELECTROLYTE,ORAL SOLUTION ORALYTE ELECTROLYTE,ORAL SOLUTION PEDIALYTE ELECTROLYTE,ORAL SOLUTION PEDIA-POP ELECTROLYTE,ORAL SOLUTION PEDIATRIC ELECTROLYTE ELECTROLYTE,ORAL SOLUTION PEDIATRIC SOLUTION ELECTROLYTE,ORAL SOLUTION REHYDRALYTE ELECTROLYTE,ORAL SOLUTION REVITAL ELECTROLYTE,ORAL SOLUTION PLASMA-LYTE R ELECTROLYTE-R SOLUTION IV SOLN. DIAB EMOLLIENT GEL RADIACARE EMOLLIENT GEL FLUOCINONIDE EMOLLIENT/FLUOCINONIDE 0.05% CREAM(GM) FLUOCINONIDE-E EMOLLIENT/FLUOCINONIDE 0.05% CREAM(GM) LIDEX-E EMOLLIENT/FLUOCINONIDE 0.05% CREAM(GM) ENALAPRIL MALEATE ENALAPRIL MALEATE 10MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 2.5MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 20MG TABLET ENALAPRIL MALEATE ENALAPRIL MALEATE 5MG TABLET VASOTEC ENALAPRIL MALEATE 10MG TABLET VASOTEC ENALAPRIL MALEATE 2.5MG TABLET Page 35 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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