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 LACTOCAL-F FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET MARNATAL F FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET MATERNAL VITAMIN & MINERAL FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET MISSION PRENATAL RX FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET MYNATAL FC FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET MYNATAL PLUS FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET MYNATAL PN FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET MYNATAL PN FORTE FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET MYNATAL RX FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET MYNATAL-Z FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET NATAFOLIC-PN FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET NATALCARE PLUS FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET NATALCARE RX FA/FE FUMARATE/PRENATAL VIT 27-0.5MG TABLET NATALCARE THREE FA/FE FUMARATE/PRENATAL VIT 28-1MG TABLET NATAREX FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET NATATAB FA FA/FE FUMARATE/PRENATAL VIT 29-1MG TABLET O-CAL FA FA/FE FUMARATE/PRENATAL VIT 66-1MG TABLET PRENATABS FA FA/FE FUMARATE/PRENATAL VIT 29-1MG TABLET PRENATAL FA/FE FUMARATE/PRENATAL VIT 27-0.8MG TABLET PRENATAL 1 PLUS 1 FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET PRENATAL 1+1 FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET PRENATAL 19 FA/FE FUMARATE/PRENATAL VIT 29-1MG TAB CHEW PRENATAL FORMULA 3 FA/FE FUMARATE/PRENATAL VIT 28-1MG TABLET PRENATAL LOW IRON FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET PRENATAL PLUS FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET PRENATAL PLUS FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET PRENATAL PLUS NF FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET PRENATAL RX FA/FE FUMARATE/PRENATAL VIT 27-0.5MG TABLET PRENATAL RX FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET PRENATAL S FA/FE FUMARATE/PRENATAL VIT 27-0.8MG TABLET PRENATAL VITAMIN FORMULA FA/FE FUMARATE/PRENATAL VIT 27-0.8MG TABLET PRENATAL W/FOLIC ACID FA/FE FUMARATE/PRENATAL VIT 27-0.8MG TABLET PRENATAL Z FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET PRENAVITE FA/FE FUMARATE/PRENATAL VIT 27-0.8MG TABLET PRENAVITE FA/FE FUMARATE/PRENATAL VIT 28-0.8MG TABLET STUARTNATAL PLUS 3 FA/FE FUMARATE/PRENATAL VIT 28-1MG TABLET TERNAMAR FA/FE FUMARATE/PRENATAL VIT 60-1MG TABLET TRICARE FA/FE FUMARATE/PRENATAL VIT 27-1MG TABLET TRINATE FA/FE FUMARATE/PRENATAL VIT 28-1MG TABLET VINATAL FA/FE FUMARATE/PRENATAL VIT 27-0.5MG TABLET VITAFOL-OB FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET VITAFOL-PN FA/FE FUMARATE/PRENATAL VIT 65-1MG TABLET VITELLE NESTABS FA/FE FUMARATE/PRENATAL VIT 29-0.8MG TABLET MATERNA FA/FE FUMARATE/PRENATAL VIT/SE 27-1MG TABLET MATERNITY FA/FE FUMARATE/PRENATAL VIT/SE 27-1MG TABLET PRENATAL MTR FA/FE FUMARATE/PRENATAL VIT/SE 27-1MG TABLET VINATE-M FA/FE FUMARATE/PRENATAL VIT/SE 27-1MG TABLET NATACAPS FA/FE FUMARATE/PV W-O VIT A 106-1MG CAPSULE PRENATAL-H FA/FE FUMARATE/PV W-O VIT A 106-1MG CAPSULE ANEMAGEN FA FA/FE FUMARATE/VIT B12/VIT C 200-250MG CAPSULE CHROMAGEN FA FA/FE FUMARATE/VIT B12/VIT C 200-250MG CAPSULE CHROMAGEN FORTE FA/FE FUMARATE/VIT B12/VIT C 460-60MG CAPSULE FEOGEN FA FA/FE FUMARATE/VIT B12/VIT C 200-250MG CAPSULE FEOGEN FORTE FA/FE FUMARATE/VIT B12/VIT C 460-60MG CAPSULE FERROGELS FORTE FA/FE FUMARATE/VIT B12/VIT C 460-60MG CAPSULE HEMATOGEN FA FA/FE FUMARATE/VIT B12/VIT C 200-250MG CAPSULE NATALCARE PIC FA/FE P-SAC CMPLX/PRENATAL VIT 60-1MG TABLET NATALCARE PIC FORTE FA/FE P-SAC CMPLX/PRENATAL VIT 60-1MG TABLET FERREX 150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE FERREX-150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE FE-TINIC 150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE IFEREX 150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE MYFERON-150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE NIFEREX-150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE POLY-IRON 150 FORTE FA/FE P-SAC CMPLX/VIT B12 150-.025-1 CAPSULE PRENATAL PC 40 FA/FECBN-FEFM/PV W-O VIT A 40-1MG TABLET M-VIT FA/FERROUS FUMARATE/PV W-O CAL 27-1MG TABLET NUTRINATE FA/FERROUS FUMARATE/PV W-O CAL 29-1MG TAB CHEW IBERET-FOLIC 500 FA/FERROUS SULFATE/VIT BCOMP&C 105-0.8MG TABLET SA MULTI FERROUS FOLIC 500 FA/FERROUS SULFATE/VIT BCOMP&C 105-0.8MG TABLET SA MULTI-RET FOLIC 500 FA/FERROUS SULFATE/VIT BCOMP&C 105-0.8MG TABLET SA FOLITAB 500 FA/FERROUS SULFATE/VIT C 105-500-.8 TABLET SA NATATAB FA/IRON,CARBONYL/PRENATAL VIT 29-1MG TABLET NATATAB CFE FA/IRON,CARBONYL/PRENATAL VIT 50-1MG TABLET PRENATABS CBF FA/IRON,CARBONYL/PRENATAL VIT 50-1MG TABLET Page 38 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 PRENATABS RX FA/IRON,CARBONYL/PRENATAL VIT 29-1MG TABLET HEMATINIC PLUS FA/IRON/MIN/VITAMIN B COMP W-C 106-1MG TABLET MEGATON FA/IRON/MIN/VITAMIN B COMPLEX 1MG ELIXIR KONYNE 80 FACTOR IX COMPLEX HUMAN 1000(+/-)U VIAL KONYNE 80 FACTOR IX COMPLEX HUMAN 500 (+/-)U VIAL PROFILNINE SD FACTOR IX COMPLEX HUMAN 500 (+/-)U VIAL ACID REDUCER FAMOTIDINE 10MG TABLET FAMOTIDINE FAMOTIDINE 10MG TABLET FAMOTIDINE FAMOTIDINE 10MG/ML VIAL FAMOTIDINE FAMOTIDINE 20MG TABLET FAMOTIDINE FAMOTIDINE 40MG TABLET HEARTBURN RELIEF FAMOTIDINE 10MG TABLET HM ACID REDUCER FAMOTIDINE 10MG TABLET PEPCID FAMOTIDINE 10MG/ML VIAL PEPCID FAMOTIDINE 20MG TABLET PEPCID FAMOTIDINE 40MG TABLET PEPCID AC FAMOTIDINE 10MG TABLET V-R ACID REDUCER FAMOTIDINE 10MG TABLET FAMOTIDINE FAMOTIDINE/NACL 0.9% 20MG/50ML PIGGYBACK INTRALIPID FAT EMULSIONS 10% IV SOLN. INTRALIPID FAT EMULSIONS 20% IV SOLN. INTRALIPID FAT EMULSIONS 30% IV SOLN. LIPOSYN II FAT EMULSIONS 10% IV SOLN. LIPOSYN II FAT EMULSIONS 20% IV SOLN. LIPOSYN III FAT EMULSIONS 10% IV SOLN. LIPOSYN III FAT EMULSIONS 20% IV SOLN. LIPOSYN III FAT EMULSIONS 30% IV SOLN. NUTRILIPID FAT EMULSIONS 10% IV SOLN. TRAVAMULSION FAT EMULSIONS 10% IV SOLN. TRAVAMULSION FAT EMULSIONS 20% IV SOLN. MICROGESTIN FE FE FUMARATE/NORETH A-ET ESTRA 1.5-0.03MG TABLET MICROGESTIN FE FE FUMARATE/NORETH A-ET ESTRA 1-0.02MG TABLET LICOPLEX DS FE/LIVER/VIT B COMP/VIT B12 VIAL FENOFIBRATE FENOFIBRATE,MICRONIZED 200MG CAPSULE FENOFIBRATE FENOFIBRATE,MICRONIZED 67MG CAPSULE FENOPROFEN CALCIUM FENOPROFEN CALCIUM 600MG TABLET FENTANYL CITRATE FENTANYL CITRATE 0.05MG/ML AMPUL FENTANYL CITRATE FENTANYL CITRATE 0.05MG/ML VIAL SUBLIMAZE FENTANYL CITRATE 0.05MG/ML AMPUL FERRETTS FERROUS FUMARATE 324MG TABLET FERROUS FUMARATE FERROUS FUMARATE 90MG TABLET FERROUS FUMARATE 324 FERROUS FUMARATE 324MG TABLET HEMOCYTE FERROUS FUMARATE 324MG TABLET IRCON FERROUS FUMARATE 200MG TABLET ED CYTE F FERROUS FUMARATE/FOLIC ACID 106-1MG TABLET HEMATINIC W/FOLIC ACID FERROUS FUMARATE/FOLIC ACID 106-1MG TABLET HEMOCYTE-F FERROUS FUMARATE/FOLIC ACID 106-1MG TABLET FERATE FERROUS GLUCONATE 325MG TABLET FERGON FERROUS GLUCONATE 240MG TABLET FERRONATE FERROUS GLUCONATE 325MG TABLET FERROUS GLUCONATE FERROUS GLUCONATE 240MG TABLET FERROUS GLUCONATE FERROUS GLUCONATE 325MG TABLET FEOSOL FERROUS SULFATE 200MG TABLET FEOSOL FERROUS SULFATE 220MG/5ML ELIXIR FERATAB FERROUS SULFATE 300MG TABLET FER-GEN-SOL FERROUS SULFATE 75MG/0.6ML DROPS FER-IN-SOL FERROUS SULFATE 75MG/0.6ML DROPS FER-IRON FERROUS SULFATE 75MG/0.6ML DROPS FEROSUL FERROUS SULFATE 325(65)MG TABLET FERRO-BOB FERROUS SULFATE 325(65)MG TABLET FERROUS SULFATE FERROUS SULFATE 134MG TABLET FERROUS SULFATE FERROUS SULFATE 160MG TABLET SA FERROUS SULFATE FERROUS SULFATE 220MG/5ML ELIXIR FERROUS SULFATE FERROUS SULFATE 250MG CAPSULE SA FERROUS SULFATE FERROUS SULFATE 300MG/5ML LIQUID FERROUS SULFATE FERROUS SULFATE 325(65)MG TABLET FERROUS SULFATE FERROUS SULFATE 325(65)MG TABLET DR FERROUS SULFATE FERROUS SULFATE 325MG TABLET FERROUS SULFATE FERROUS SULFATE 75MG/0.6ML DROPS FERROUSUL FERROUS SULFATE 325(65)MG TABLET HM IRON FERROUS SULFATE 325(65)MG TABLET IROMAR FERROUS SULFATE 325(65)MG TABLET IRON FERROUS SULFATE 325(65)MG TABLET IRON FERROUS SULFATE 325MG TABLET RIDOSOL FERROUS SULFATE 325(65)MG TABLET Page 39 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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