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 OTIMAR HC/NEOMY SULF/POLYMYX B SULF 3.5-10M-1 DROPS SUSP HYDRALAZINE W/HCTZ HCTZ/HYDRALAZINE HCL 50-50MG CAPSULE HYDRA-ZIDE HCTZ/HYDRALAZINE HCL 100-50MG CAPSULE HYDRA-ZIDE HCTZ/HYDRALAZINE HCL 25-25MG CAPSULE HYDRA-ZIDE HCTZ/HYDRALAZINE HCL 50-50MG CAPSULE CAM-AP-ES HCTZ/HYDRALAZINE HCL/RESERPINE 25-0.1-15 TABLET SERPAZIDE HCTZ/HYDRALAZINE HCL/RESERPINE 25-0.1-15 TABLET UNI-SERP HCTZ/HYDRALAZINE HCL/RESERPINE 25-0.1-15 TABLET INDERIDE-40/25 HCTZ/PROPRANOLOL HCL 40-25MG TABLET INDERIDE-80/25 HCTZ/PROPRANOLOL HCL 80-25MG TABLET PROPRANOLOL HCL W/HCTZ HCTZ/PROPRANOLOL HCL 25-80MG TABLET PROPRANOLOL HCL W/HCTZ HCTZ/PROPRANOLOL HCL 40-25MG TABLET PROPRANOLOL HCL W/HCTZ HCTZ/PROPRANOLOL HCL 80-25MG TABLET ALDACTAZIDE HCTZ/SPIRONOLACTONE 25-25MG TABLET SPIRONOLACTONE W/HCTZ HCTZ/SPIRONOLACTONE 25-25MG TABLET SPIRONOLACTONE/HCTZ HCTZ/SPIRONOLACTONE 25-25MG TABLET DYAZIDE HCTZ/TRIAMTERENE 37.5-25MG CAPSULE MAXZIDE HCTZ/TRIAMTERENE 75-50MG TABLET MAXZIDE-25MG HCTZ/TRIAMTERENE 37.5-25MG TABLET TRIAMTERENE W/HCTZ HCTZ/TRIAMTERENE 37.5-25MG CAPSULE TRIAMTERENE W/HCTZ HCTZ/TRIAMTERENE 37.5-25MG TABLET TRIAMTERENE W/HCTZ HCTZ/TRIAMTERENE 50-25MG CAPSULE TRIAMTERENE W/HCTZ HCTZ/TRIAMTERENE 50-75MG TABLET TRIAMTERENE W/HCTZ HCTZ/TRIAMTERENE 75-50MG TABLET TRIAMTERENE-HCTZ HCTZ/TRIAMTERENE 75-50MG TABLET HEPARIN FLUSH HEP NA,PORCINE/NACL 0.9% 10 UNIT/ML KIT HEPARIN FLUSH HEP NA,PORCINE/NACL 0.9% 100 U/ML KIT HEPARIN SODIUM IN 0.9% NACL HEP NA,PORCINE/NACL 0.9% 2 UNIT/ML IV SOLN. HEP-PAK HEP NA,PORCINE/NACL 0.9% 10 UNIT/ML KIT HEP-PAK HEP NA,PORCINE/NACL 0.9% 100 U/ML KIT HEP-PAK CVC HEP NA,PORCINE/NACL 0.9% 100 U/ML KIT HEP-PAK LKFL HEP NA,PORCINE/NACL 0.9% 100 U/ML KIT HEPARIN LOCK HEPARIN SODIUM (PORCINE) 10U/ML VIAL HEPARIN SODIUM HEPARIN SODIUM,BEEF 1000 U/ML VIAL HEPARIN SODIUM HEPARIN SODIUM,BEEF 10000 U/ML VIAL HEPARIN IV FLUSH HEPARIN SODIUM,PORCINE 10 UNIT/ML DISP SYRIN HEPARIN IV FLUSH HEPARIN SODIUM,PORCINE 100 U/ML DISP SYRIN HEPARIN LOCK HEPARIN SODIUM,PORCINE 10 UNIT/ML VIAL HEPARIN LOCK HEPARIN SODIUM,PORCINE 100 U/ML VIAL HEPARIN LOCK FLUSH HEPARIN SODIUM,PORCINE 10 UNIT/ML DISP SYRIN HEPARIN LOCK FLUSH HEPARIN SODIUM,PORCINE 10 UNIT/ML VIAL HEPARIN LOCK FLUSH HEPARIN SODIUM,PORCINE 100 U/ML DISP SYRIN HEPARIN LOCK FLUSH HEPARIN SODIUM,PORCINE 100 U/ML VIAL HEPARIN SODIUM HEPARIN SODIUM,PORCINE 1000 U/ML VIAL HEPARIN SODIUM HEPARIN SODIUM,PORCINE 10000 U/ML DISP SYRIN HEPARIN SODIUM HEPARIN SODIUM,PORCINE 10000 U/ML VIAL HEPARIN SODIUM HEPARIN SODIUM,PORCINE 20000 U/ML VIAL HEPARIN SODIUM HEPARIN SODIUM,PORCINE 2500 U/ML DISP SYRIN HEPARIN SODIUM HEPARIN SODIUM,PORCINE 5000 U/ML DISP SYRIN HEPARIN SODIUM HEPARIN SODIUM,PORCINE 5000 U/ML VIAL HEPARIN SODIUM HEPARIN SODIUM,PORCINE 7500 U/ML DISP SYRIN HEP-LOCK HEPARIN SODIUM,PORCINE 10 UNIT/ML VIAL HEP-LOCK HEPARIN SODIUM,PORCINE 100 U/ML VIAL HEP-LOCK U/P HEPARIN SODIUM,PORCINE 10 UNIT/ML VIAL HEP-LOCK U/P HEPARIN SODIUM,PORCINE 100 U/ML VIAL VASCEZE (VAFD) HEPARIN SODIUM,PORCINE 100U/ML DISP SYRIN VASCEZE (VAFD) HEPARIN SODIUM,PORCINE 10U/ML DISP SYRIN BAYHEP B HEPATITIS B IMMUNE GLOBULIN DISP SYRIN BAYHEP B HEPATITIS B IMMUNE GLOBULIN VIAL HESPAN HETASTARCH/NACL 0.9% 6-0.9% PLAST. BAG HETASTARCH W/SODIUM CHLORIDE HETASTARCH/NACL 0.9% 6-0.9% PLAST. BAG HOMATROPAIRE HOMATROPINE HBR 5% DROPS HOMATROPINE HYDROBROMIDE HOMATROPINE HBR 5% DROPS HYCODAN HOMATROPINE/HYDROCODONE BIT 5-1-.5MG/5 SYRUP HYDROCODONE HOMATROPINE/HYDROCODONE BIT 5-1-.5MG/5 SYRUP HYDROCODONE BT/HOMATROPINE MBR HOMATROPINE/HYDROCODONE BIT 5-1.5MG TABLET HYDROCODONE COMPOUND HOMATROPINE/HYDROCODONE BIT 5-1-.5MG/5 SYRUP HYDROMET HOMATROPINE/HYDROCODONE BIT 5-1-.5MG/5 SYRUP HYDROPANE HOMATROPINE/HYDROCODONE BIT 5-1-.5MG/5 SYRUP TUSSIGON HOMATROPINE/HYDROCODONE BIT 5-1.5MG TABLET BIOLON HYALURONATE SODIUM 10MG/ML DISP SYRIN VITRAX HYALURONATE SODIUM 10MG/ML DISP SYRIN HYDRALAZINE HCL HYDRALAZINE HCL 100MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 10MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 20MG/ML VIAL Page 46 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 HYDRALAZINE HCL HYDRALAZINE HCL 25MG TABLET HYDRALAZINE HCL HYDRALAZINE HCL 50MG TABLET CAROZIDE HYDROCHLOROTHIAZIDE 50MG TABLET EZIDE HYDROCHLOROTHIAZIDE 50MG TABLET HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 100MG TABLET HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 12.5MG CAPSULE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 25MG TABLET HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE 50MG TABLET HYDRODIURIL HYDROCHLOROTHIAZIDE 25MG TABLET MICROZIDE HYDROCHLOROTHIAZIDE 12.5MG CAPSULE ORETIC HYDROCHLOROTHIAZIDE 25MG TABLET ORETIC HYDROCHLOROTHIAZIDE 50MG TABLET LISINOPRIL-HCTZ HYDROCHLOROTHIAZIDE/LISINOPRIL 10-12.5MG TABLET LISINOPRIL-HCTZ HYDROCHLOROTHIAZIDE/LISINOPRIL 20-12.5MG TABLET LISINOPRIL-HCTZ HYDROCHLOROTHIAZIDE/LISINOPRIL 20-25MG TABLET PRINZIDE HYDROCHLOROTHIAZIDE/LISINOPRIL 10-12.5MG TABLET PRINZIDE HYDROCHLOROTHIAZIDE/LISINOPRIL 20-12.5MG TABLET PRINZIDE HYDROCHLOROTHIAZIDE/LISINOPRIL 20-25MG TABLET ZESTORETIC HYDROCHLOROTHIAZIDE/LISINOPRIL 10-12.5MG TABLET ZESTORETIC HYDROCHLOROTHIAZIDE/LISINOPRIL 20-12.5MG TABLET ZESTORETIC HYDROCHLOROTHIAZIDE/LISINOPRIL 20-25MG TABLET ALDORIL-15 HYDROCHLOROTHIAZIDE/METHYLDOPA 250-15MG TABLET ALDORIL-25 HYDROCHLOROTHIAZIDE/METHYLDOPA 250-25MG TABLET ALDORIL-D30 HYDROCHLOROTHIAZIDE/METHYLDOPA 500-30MG TABLET ALDORIL-D50 HYDROCHLOROTHIAZIDE/METHYLDOPA 500-50MG TABLET METHYLDOPA/HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE/METHYLDOPA 250-15MG TABLET METHYLDOPA/HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE/METHYLDOPA 250-25MG TABLET HYDROCHLOROTHIAZIDE/RESERPINE HYDROCHLOROTHIAZIDE/RESERPINE 0.125-25MG TABLET HYDROCHLOROTHIAZIDE/RESERPINE HYDROCHLOROTHIAZIDE/RESERPINE 0.125-50MG TABLET HYDRO-RESERP HYDROCHLOROTHIAZIDE/RESERPINE 0.125-50MG TABLET DETUSSIN HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SOLUTION H-C TUSSIVE-D HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SOLUTION HC TUSSIVE-D HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SOLUTION HISTUSSIN D HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SOLUTION IOTUSSIN D HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SOLUTION TUSS-S HYDROCODONE BIT/P-EPHED HCL 60-5MG/5ML SYRUP ENTUSS HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SOLUTION HYDONE HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SOLUTION HYDRO PRO HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SYRUP HYDRON EX HYDROCODONE BIT/POT GUAIACO 120-2.5/5 SYRUP HYDRON KGS HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SYRUP JAYCOF HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SOLUTION POT GUAIACO/HYDROCODONE BIT HYDROCODONE BIT/POT GUAIACO 300-4.5/5 SYRUP PRO-COF HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SYRUP PROLEX DH HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SOLUTION PROTUSS HYDROCODONE BIT/POT GUAIACO 300-5MG/5 SYRUP CODAL-DH HYDROCODONE/PHENYLEPHRINE/PYR 5-1.66MG/5 SYRUP CODIMAL DH HYDROCODONE/PHENYLEPHRINE/PYR 5-1.66MG/5 SYRUP CODITUSS DH HYDROCODONE/PHENYLEPHRINE/PYR 5-1.66MG/5 SYRUP HYCOMAL DH HYDROCODONE/PHENYLEPHRINE/PYR 5-1.66MG/5 SYRUP HYDROPHENE DH HYDROCODONE/PHENYLEPHRINE/PYR 5-1.66MG/5 SYRUP ANUSOL-HC HYDROCORTISONE 2.5% CREAM(GM) AQUANIL HC HYDROCORTISONE 1% LOTION BETA HC HYDROCORTISONE 1% LOTION CETACORT HYDROCORTISONE 1% LOTION COLOCORT HYDROCORTISONE 100MG/60ML ENEMA CORTAID HYDROCORTISONE 1% CREAM(GM) CORTEF HYDROCORTISONE 20MG TABLET DERMOLATE ANTI-ITCH HYDROCORTISONE 0.5% CREAM(GM) DR. SMITH'S ANTI-ITCH HYDROCORTISONE 0.25% LOTION HYCORT HYDROCORTISONE 1% CREAM(GM) HYCORT HYDROCORTISONE 1% OINT.(GM) HYDRO LOTION HYDROCORTISONE 1% LOTION HYDROCORTISONE HYDROCORTISONE 0.5% CREAM(GM) HYDROCORTISONE HYDROCORTISONE 0.5% LOTION HYDROCORTISONE HYDROCORTISONE 0.5% OINT.(GM) HYDROCORTISONE HYDROCORTISONE 1% CREAM(GM) HYDROCORTISONE HYDROCORTISONE 1% LOTION HYDROCORTISONE HYDROCORTISONE 1% OINT.(GM) HYDROCORTISONE HYDROCORTISONE 100MG/60ML ENEMA HYDROCORTISONE HYDROCORTISONE 2.5% CREAM(GM) HYDROCORTISONE HYDROCORTISONE 2.5% LOTION HYDROCORTISONE HYDROCORTISONE 2.5% OINT.(GM) HYDROCORTISONE HYDROCORTISONE 20MG TABLET HYDROCORTONE HYDROCORTISONE 10MG TABLET Page 47 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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