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 LIDOCAINE HCL LIDOCAINE HCL 40MG/ML SOLUTION LIDOCAINE HCL LIDOCAINE HCL 5% OINT.(GM) LIDOCAINE HCL LIDOCAINE HCL 5MG/ML VIAL LIDOCAINE HCL VISCOUS LIDOCAINE HCL 20MG/ML SOLUTION LIDOJECT-2 LIDOCAINE HCL 20MG/ML VIAL LIDOMAR VISCOUS LIDOCAINE HCL 20MG/ML SOLUTION NERVOCAINE LIDOCAINE HCL 20MG/ML VIAL UAD CAINE LIDOCAINE HCL 10MG/ML VIAL XYLOCAINE LIDOCAINE HCL 10MG/ML VIAL XYLOCAINE LIDOCAINE HCL 2% JEL XYLOCAINE LIDOCAINE HCL 20MG/ML VIAL XYLOCAINE LIDOCAINE HCL 40MG/ML SOLUTION XYLOCAINE LIDOCAINE HCL 5% OINT.(GM) XYLOCAINE VISCOUS LIDOCAINE HCL 20MG/ML SOLUTION XYLOCAINE-MPF LIDOCAINE HCL 10MG/ML VIAL XYLOCAINE-MPF LIDOCAINE HCL 20MG/ML VIAL LINCOCIN LINCOMYCIN HCL 300MG/ML VIAL LINCOJECT LINCOMYCIN HCL 300MG/ML VIAL LINDANE LINDANE 1% LOTION LINDANE LINDANE 1% SHAMPOO LISINOPRIL LISINOPRIL 10MG TABLET LISINOPRIL LISINOPRIL 2.5MG TABLET LISINOPRIL LISINOPRIL 20MG TABLET LISINOPRIL LISINOPRIL 30MG TABLET LISINOPRIL LISINOPRIL 40MG TABLET LISINOPRIL LISINOPRIL 5MG TABLET PRINIVIL LISINOPRIL 10MG TABLET PRINIVIL LISINOPRIL 2.5MG TABLET PRINIVIL LISINOPRIL 20MG TABLET PRINIVIL LISINOPRIL 40MG TABLET PRINIVIL LISINOPRIL 5MG TABLET ZESTRIL LISINOPRIL 10MG TABLET ZESTRIL LISINOPRIL 2.5MG TABLET ZESTRIL LISINOPRIL 20MG TABLET ZESTRIL LISINOPRIL 30MG TABLET ZESTRIL LISINOPRIL 40MG TABLET ZESTRIL LISINOPRIL 5MG TABLET ESKALITH LITHIUM CARBONATE 300MG CAPSULE LITHIUM CARBONATE LITHIUM CARBONATE 300MG CAPSULE LITHIUM CITRATE LITHIUM CITRATE 8MEQ/5ML SYRUP ANTI-DIARRHEAL LOPERAMIDE HCL 1MG/5ML LIQUID ANTI-DIARRHEAL LOPERAMIDE HCL 2MG TABLET ANTIDIARRHEAL LOPERAMIDE HCL 2MG TABLET HM ANTI-DIARRHEAL LOPERAMIDE HCL 1MG/5ML LIQUID HM ANTI-DIARRHEAL LOPERAMIDE HCL 2MG TABLET IMODIUM A-D LOPERAMIDE HCL 1MG/5ML LIQUID IMODIUM A-D LOPERAMIDE HCL 2MG TABLET IMOGEN LOPERAMIDE HCL 1MG/5ML LIQUID IMPERIM LOPERAMIDE HCL 2MG TABLET KAO-PAVERIN LOPERAMIDE HCL 2MG TABLET LOPERAMIDE HCL LOPERAMIDE HCL 1MG/5ML LIQUID LOPERAMIDE HCL LOPERAMIDE HCL 2MG CAPSULE LOPERAMIDE HCL LOPERAMIDE HCL 2MG TABLET ATIVAN LORAZEPAM 0.5MG TABLET ATIVAN LORAZEPAM 1MG TABLET ATIVAN LORAZEPAM 2MG TABLET ATIVAN LORAZEPAM 2MG/ML DISP SYRIN ATIVAN LORAZEPAM 2MG/ML VIAL ATIVAN LORAZEPAM 4MG/ML DISP SYRIN ATIVAN LORAZEPAM 4MG/ML VIAL LORAZEPAM LORAZEPAM 0.5MG TABLET LORAZEPAM LORAZEPAM 1MG TABLET LORAZEPAM LORAZEPAM 2MG TABLET LORAZEPAM LORAZEPAM 2MG/ML DISP SYRIN LORAZEPAM LORAZEPAM 2MG/ML VIAL LORAZEPAM LORAZEPAM 4MG/ML DISP SYRIN LORAZEPAM LORAZEPAM 4MG/ML VIAL LOVASTATIN LOVASTATIN 10MG TABLET LOVASTATIN LOVASTATIN 20MG TABLET LOVASTATIN LOVASTATIN 40MG TABLET MEVACOR LOVASTATIN 10MG TABLET MEVACOR LOVASTATIN 20MG TABLET MEVACOR LOVASTATIN 40MG TABLET LOXAPINE LOXAPINE SUCCINATE 10MG CAPSULE LOXAPINE LOXAPINE SUCCINATE 25MG CAPSULE Page 54 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 LOXAPINE LOXAPINE SUCCINATE 50MG CAPSULE LOXAPINE LOXAPINE SUCCINATE 5MG CAPSULE LOXAPINE SUCCINATE LOXAPINE SUCCINATE 10MG CAPSULE LOXAPINE SUCCINATE LOXAPINE SUCCINATE 25MG CAPSULE LOXAPINE SUCCINATE LOXAPINE SUCCINATE 50MG CAPSULE LOXAPINE SUCCINATE LOXAPINE SUCCINATE 5MG CAPSULE LOXITANE LOXAPINE SUCCINATE 10MG CAPSULE LOXITANE LOXAPINE SUCCINATE 25MG CAPSULE LOXITANE LOXAPINE SUCCINATE 50MG CAPSULE LOXITANE LOXAPINE SUCCINATE 5MG CAPSULE MAGNESIUM CHLORIDE MAGNESIUM CHLORIDE 200MG/ML VIAL MAGNESIUM SULFATE MAGNESIUM SULFATE 4MEQ/ML AMPUL MAGNESIUM SULFATE MAGNESIUM SULFATE 4MEQ/ML DISP SYRIN MAGNESIUM SULFATE MAGNESIUM SULFATE 4MEQ/ML VIAL MANGANESE MANGANESE CHLORIDE 0.1MG/ML VIAL MANGANESE CHLORIDE MANGANESE CHLORIDE 0.1MG/ML VIAL MANNITOL MANNITOL 10% IV SOLN. MANNITOL MANNITOL 15% IV SOLN. MANNITOL MANNITOL 20% IV SOLN. MANNITOL MANNITOL 25% VIAL MANNITOL MANNITOL 5% IV SOLN. OSMITROL MANNITOL 15% IV SOLN. OSMITROL MANNITOL 20% IV SOLN. MAPROTILINE HCL MAPROTILINE HCL 25MG TABLET MAPROTILINE HCL MAPROTILINE HCL 50MG TABLET MAPROTILINE HCL MAPROTILINE HCL 75MG TABLET MEBENDAZOLE MEBENDAZOLE 100MG TAB CHEW MECLIZINE HCL MECLIZINE HCL 12.5MG TABLET MECLIZINE HCL MECLIZINE HCL 25MG TABLET RU-VERT-M MECLIZINE HCL 25MG TABLET MECLOFENAMATE SODIUM MECLOFENAMATE SODIUM 100MG CAPSULE MECLOFENAMATE SODIUM MECLOFENAMATE SODIUM 50MG CAPSULE MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACET 10MG TABLET MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACET 2.5MG TABLET MEDROXYPROGESTERONE ACETATE MEDROXYPROGESTERONE ACET 5MG TABLET PROVERA MEDROXYPROGESTERONE ACET 10MG TABLET PROVERA MEDROXYPROGESTERONE ACET 2.5MG TABLET PROVERA MEDROXYPROGESTERONE ACET 5MG TABLET MEFLOQUINE HCL MEFLOQUINE HCL 250MG TABLET MEGACE MEGESTROL ACETATE 20MG TABLET MEGACE MEGESTROL ACETATE 40MG TABLET MEGESTROL ACETATE MEGESTROL ACETATE 20MG TABLET MEGESTROL ACETATE MEGESTROL ACETATE 40MG TABLET MEGESTROL ACETATE MEGESTROL ACETATE 40MG/ML ORAL SUSP WATER ME-PARABEN/PROPYLPARABEN/WATER VIAL DEMEROL MEPERIDINE HCL 100MG TABLET DEMEROL MEPERIDINE HCL 100MG/ML DISP SYRIN DEMEROL MEPERIDINE HCL 100MG/ML VIAL DEMEROL MEPERIDINE HCL 50MG TABLET DEMEROL MEPERIDINE HCL 50MG/ML VIAL MEPERIDINE HCL MEPERIDINE HCL 100MG TABLET MEPERIDINE HCL MEPERIDINE HCL 100MG/ML AMPUL MEPERIDINE HCL MEPERIDINE HCL 100MG/ML VIAL MEPERIDINE HCL MEPERIDINE HCL 10MG/ML DISP SYRIN MEPERIDINE HCL MEPERIDINE HCL 50MG TABLET MEPERIDINE HCL MEPERIDINE HCL 50MG/5ML SYRUP MEPERIDINE HCL MEPERIDINE HCL 50MG/ML AMPUL MEPERIDINE HCL MEPERIDINE HCL 50MG/ML VIAL MEPERIDINE HCL MEPERIDINE HCL 75MG/ML VIAL MEPERITAB MEPERIDINE HCL 100MG TABLET MEPERITAB MEPERIDINE HCL 50MG TABLET MEPERIDINE W/PROMETHAZINE MEPERIDINE HCL/PROMETH HCL 50-25MG CAPSULE CARBOCAINE MEPIVACAINE HCL 10MG/ML VIAL CARBOCAINE MEPIVACAINE HCL 15MG/ML VIAL POLOCAINE MEPIVACAINE HCL 10MG/ML VIAL POLOCAINE MEPIVACAINE HCL 15MG/ML VIAL POLOCAINE MEPIVACAINE HCL 20MG/ML VIAL MEPROBAMATE MEPROBAMATE 200MG TABLET MEPROBAMATE MEPROBAMATE 400MG TABLET MILTOWN MEPROBAMATE 200MG TABLET MILTOWN MEPROBAMATE 400MG TABLET MESNA MESNA 100MG/ML VIAL ARM-A-MED (METAPROTERENOL) METAPROTERENOL SULFATE 6MG/ML SOLUTION METAPROTERENOL SULFATE METAPROTERENOL SULFATE 10MG TABLET METAPROTERENOL SULFATE METAPROTERENOL SULFATE 10MG/5ML SYRUP Page 55 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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