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 PROLIXIN FLUPHENAZINE HCL 5MG/ML ORAL CONC. DALMANE FLURAZEPAM HCL 15MG CAPSULE DALMANE FLURAZEPAM HCL 30MG CAPSULE FLURAZEPAM HCL FLURAZEPAM HCL 15MG CAPSULE FLURAZEPAM HCL FLURAZEPAM HCL 30MG CAPSULE ANSAID FLURBIPROFEN 100MG TABLET ANSAID FLURBIPROFEN 50MG TABLET FLURBIPROFEN FLURBIPROFEN 100MG TABLET FLURBIPROFEN FLURBIPROFEN 50MG TABLET FLURBIPROFEN SODIUM FLURBIPROFEN SODIUM 0.03% DROPS OCUFEN FLURBIPROFEN SODIUM 0.03% DROPS EULEXIN FLUTAMIDE 125MG CAPSULE FLUTAMIDE FLUTAMIDE 125MG CAPSULE FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 100MG TABLET FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 25MG TABLET FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE 50MG TABLET LUVOX FLUVOXAMINE MALEATE 100MG TABLET LUVOX FLUVOXAMINE MALEATE 25MG TABLET LUVOX FLUVOXAMINE MALEATE 50MG TABLET FOLIC ACID FOLIC ACID 1MG TABLET FOLIC ACID FOLIC ACID 5MG/ML VIAL GLUTOFAC-ZX FOLIC ACID/MULTIVITS-MIN TABLET NUTRIFAC ZX FOLIC ACID/MULTIVITS-MIN TABLET NUTRIFAC ZX FOLIC ACID/MULTIVITS-MIN 1MG TABLET THERAPEUTIC VITAMIN W/MINERALS FOLIC ACID/MU-VITS-MIN TH CAPSULE V-C FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE VI-C FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE VICA-FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE VIC-FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE VICON FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE VITACON FORTE FOLIC ACID/MU-VITS-MIN TH CAPSULE VITA S FORTE FOLIC ACID/MV,FE,OTHER MIN 0.8MG TABLET NIAFOL FOLIC ACID/NIACINAMIDE/ZINC 0.5-750-25 TABLET NEPHPLEX RX FOLIC ACID/VIT BCOMP&C/ZINC 1MG TABLET B-PLEX FOLIC ACID/VITAMIN B COMP W-C 0.5MG TABLET DIALYVITE FOLIC ACID/VITAMIN B COMP W-C 1MG TABLET DIATX FOLIC ACID/VITAMIN B COMP W-C 5MG TABLET FORMULA-B FOLIC ACID/VITAMIN B COMP W-C 0.5MG TABLET NEPHRONEX FOLIC ACID/VITAMIN B COMP W-C 1MG TABLET NEPHRO-VITE RX FOLIC ACID/VITAMIN B COMP W-C 1MG TABLET RENAL CAPS FOLIC ACID/VITAMIN B COMP W-C 1MG CAPSULE RENAPHRO FOLIC ACID/VITAMIN B COMP W-C 1MG CAPSULE RENA-VITE RX FOLIC ACID/VITAMIN B COMP W-C 1MG TABLET LAZERFORMALYDE FORMALDEHYDE 10% SOLUTION FUROSEMIDE FUROSEMIDE 10MG/ML AMPUL FUROSEMIDE FUROSEMIDE 10MG/ML DISP SYRIN FUROSEMIDE FUROSEMIDE 10MG/ML SOLUTION FUROSEMIDE FUROSEMIDE 10MG/ML VIAL FUROSEMIDE FUROSEMIDE 20MG TABLET FUROSEMIDE FUROSEMIDE 40MG TABLET FUROSEMIDE FUROSEMIDE 80MG TABLET LASIX FUROSEMIDE 20MG TABLET LASIX FUROSEMIDE 40MG TABLET LASIX FUROSEMIDE 80MG TABLET GEMFIBROZIL GEMFIBROZIL 600MG TABLET LOPID GEMFIBROZIL 600MG TABLET GENTAMICIN SULFATE IN NS GENTAM SULF/SODIUM CHLORIDE 100MG/0.1L PIGGYBACK GENTAMICIN SULFATE IN NS GENTAM SULF/SODIUM CHLORIDE 60MG/100ML PIGGYBACK GENTAMICIN SULFATE IN NS GENTAM SULF/SODIUM CHLORIDE 60MG/50ML PIGGYBACK GENTAMICIN SULFATE IN NS GENTAM SULF/SODIUM CHLORIDE 80MG/100ML PIGGYBACK GENTAMICIN SULFATE IN NS GENTAM SULF/SODIUM CHLORIDE 80MG/50ML PIGGYBACK ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 100MG/0.1L PIGGYBACK ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 100MG/50ML PIGGYBACK ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 60MG/100ML PIGGYBACK ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 60MG/50ML PIGGYBACK ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 80MG/100ML PIGGYBACK ISOTONIC GENTAMICIN SULFATE GENTAM SULF/SODIUM CHLORIDE 80MG/50ML PIGGYBACK GARAMYCIN GENTAMICIN SULFATE 0.1% CREAM(GM) GARAMYCIN GENTAMICIN SULFATE 0.3% DROPS GARAMYCIN GENTAMICIN SULFATE 0.3% OINT.(GM) GARAMYCIN GENTAMICIN SULFATE 40MG/ML VIAL GENOPTIC GENTAMICIN SULFATE 0.3% DROPS GENTACIDIN GENTAMICIN SULFATE 0.3% DROPS GENTAFAIR GENTAMICIN SULFATE 0.3% DROPS GENTAK GENTAMICIN SULFATE 0.3% DROPS Page 42 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 GENTAK GENTAMICIN SULFATE 0.3% OINT.(GM) GENTAMICIN SULFATE GENTAMICIN SULFATE 0.1% CREAM(GM) GENTAMICIN SULFATE GENTAMICIN SULFATE 0.1% OINT.(GM) GENTAMICIN SULFATE GENTAMICIN SULFATE 0.3% DROPS GENTAMICIN SULFATE GENTAMICIN SULFATE 10MG/ML VIAL GENTAMICIN SULFATE GENTAMICIN SULFATE 40MG/ML VIAL GENTASOL GENTAMICIN SULFATE 0.3% DROPS G-MYTICIN GENTAMICIN SULFATE 0.1% CREAM(GM) GLIPIZIDE GLIPIZIDE 10MG TABLET GLIPIZIDE GLIPIZIDE 5MG TABLET GLUCOTROL GLIPIZIDE 10MG TABLET GLUCOTROL GLIPIZIDE 5MG TABLET GLUCAGEN GLUCAGON,HUMAN RECOMBINANT 1MG VIAL HEMORRHOIDAL GLY/PE/PET,WH/SHARK LIVER CREAM(GM) HEM-PREP GLY/PE/PET,WH/SHARK LIVER CREAM(GM) PREPARATION H GLY/PE/PET,WH/SHARK LIVER CREAM(GM) V-R HEMORRHOIDAL GLY/PE/PET,WH/SHARK LIVER CREAM(GM) DIABETA GLYBURIDE 1.25MG TABLET DIABETA GLYBURIDE 2.5MG TABLET DIABETA GLYBURIDE 5MG TABLET GLYBURIDE GLYBURIDE 1.25MG TABLET GLYBURIDE GLYBURIDE 2.5MG TABLET GLYBURIDE GLYBURIDE 5MG TABLET MICRONASE GLYBURIDE 1.25MG TABLET MICRONASE GLYBURIDE 2.5MG TABLET MICRONASE GLYBURIDE 5MG TABLET GLYBURIDE MICRONIZED GLYBURIDE,MICRONIZED 1.5MG TABLET GLYBURIDE MICRONIZED GLYBURIDE,MICRONIZED 3MG TABLET GLYBURIDE MICRONIZED GLYBURIDE,MICRONIZED 6MG TABLET GLYCRON GLYBURIDE,MICRONIZED 1.5MG TABLET GLYCRON GLYBURIDE,MICRONIZED 3MG TABLET GLYCRON GLYBURIDE,MICRONIZED 6MG TABLET GLYNASE GLYBURIDE,MICRONIZED 1.5MG TABLET GLYNASE GLYBURIDE,MICRONIZED 3MG TABLET GLYNASE GLYBURIDE,MICRONIZED 6MG TABLET AMINOACETIC ACID GLYCINE 1.5% IRRIG SOLN GLYCINE GLYCINE 1.5% IRRIG SOLN GLYCOPYRROLATE GLYCOPYRROLATE 0.2MG/ML VIAL ROBINUL GLYCOPYRROLATE 0.2MG/ML VIAL CHOREX-10 GONADOTROPIN,CHORIONIC,HUMAN 10000 UNIT VIAL CHORIONIC GONADOTROPIN GONADOTROPIN,CHORIONIC,HUMAN 10000 UNIT VIAL CHORIONIC GONADOTROPIN GONADOTROPIN,CHORIONIC,HUMAN 10MU VIAL NOVAREL GONADOTROPIN,CHORIONIC,HUMAN 10000 UNIT VIAL PREGNYL GONADOTROPIN,CHORIONIC,HUMAN 10000 UNIT VIAL PROFASI GONADOTROPIN,CHORIONIC,HUMAN 10000 UNIT VIAL PROFASI GONADOTROPIN,CHORIONIC,HUMAN 5000 UNIT VIAL NEOCIDIN GRAMICID D/NEOMY SULF/POLY DROPS NEOCIN-PG GRAMICID D/NEOMY SULF/POLY DROPS NEOMYCIN/POLYMYXIN/GRAMICIDIN GRAMICID D/NEOMY SULF/POLY DROPS NEOPTIC GRAMICID D/NEOMY SULF/POLY DROPS NEOSPORIN GRAMICID D/NEOMY SULF/POLY DROPS FULVICIN P/G GRISEOFULVIN ULTRAMICROSIZE 125MG TABLET FULVICIN P/G GRISEOFULVIN ULTRAMICROSIZE 165MG TABLET FULVICIN P/G GRISEOFULVIN ULTRAMICROSIZE 250MG TABLET FULVICIN P/G GRISEOFULVIN ULTRAMICROSIZE 330MG TABLET GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN ULTRAMICROSIZE 125MG TABLET GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN ULTRAMICROSIZE 250MG TABLET GRISEOFULVIN ULTRAMICROSIZE GRISEOFULVIN ULTRAMICROSIZE 330MG TABLET FULVICIN U/F GRISEOFULVIN,MICROSIZE 500MG TABLET ALLFEN-M GUAIFENESIN 600MG TABLET SA ALTARUSSIN GUAIFENESIN 100MG/5ML SYRUP AMIBID LA GUAIFENESIN 600MG TABLET SA AQUAMIST GUAIFENESIN 600MG TABLET SA BENADRILINA GUAIFENESIN 100MG/5ML SYRUP COUGH CONTROL GUAIFENESIN 100MG/5ML SYRUP DIABETIC FORMULA GUAIFENESIN 100MG/5ML SYRUP DIABETIC TUSSIN EX GUAIFENESIN 100MG/5ML LIQUID DIABETIC TUSSIN EX GUAIFENESIN 100MG/5ML SYRUP DURATUSS G GUAIFENESIN 1200MG TAB.SR 12H EXPECTORANT GUAIFENESIN 100MG/5ML SYRUP FENESIN GUAIFENESIN 600MG TABLET SA GANIDIN NR GUAIFENESIN 100MG/5ML LIQUID GEE-GEE GUAIFENESIN 200MG TABLET GG 200 NR GUAIFENESIN 200MG TABLET GLYTUSS GUAIFENESIN 200MG TABLET Page 43 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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