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 DECA-DURABOLIN NANDROLONE DECANOATE 100MG/ML VIAL NANDROLONE DECANOATE NANDROLONE DECANOATE 100MG/ML VIAL NANDROLONE DECANOATE NANDROLONE DECANOATE 200MG/ML VIAL NANDROLONE DECANOATE NANDROLONE DECANOATE 50MG/ML VIAL AK-CON NAPHAZOLINE HCL 0.1% DROPS ALBALON NAPHAZOLINE HCL 0.1% DROPS ALLERSOL NAPHAZOLINE HCL 0.1% DROPS NAPHAZOLE NAPHAZOLINE HCL 0.1% DROPS NAPHAZOLINE HCL NAPHAZOLINE HCL 0.1% DROPS EC-NAPROSYN NAPROXEN 375MG TABLET DR EC-NAPROSYN NAPROXEN 500MG TABLET DR NAPROSYN NAPROXEN 250MG TABLET NAPROSYN NAPROXEN 375MG TABLET NAPROSYN NAPROXEN 500MG TABLET NAPROXEN NAPROXEN 125MG/5ML ORAL SUSP NAPROXEN NAPROXEN 250MG TABLET NAPROXEN NAPROXEN 375MG TABLET NAPROXEN NAPROXEN 375MG TABLET DR NAPROXEN NAPROXEN 500MG TABLET NAPROXEN NAPROXEN 500MG TABLET DR ANAPROX NAPROXEN SODIUM 275MG TABLET ANAPROX DS NAPROXEN SODIUM 550MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 220MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 275MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 550MG TABLET NAPROXEN SODIUM NAPROXEN SODIUM 550MG TABLET SA V-R NAPROXEN SODIUM NAPROXEN SODIUM 220MG TABLET ANTIBIOTIC NEOMY SULF/POLYMYXIN B SULFATE CREAM(GM) NEOMYCIN SULFATE NEOMYCIN SULFATE 500MG TABLET NEOSTIGMINE METHYLSULFATE NEOSTIGMINE METHYLSULFATE 1:1000 VIAL NEOSTIGMINE METHYLSULFATE NEOSTIGMINE METHYLSULFATE 1:2000 VIAL PROSTIGMIN NEOSTIGMINE METHYLSULFATE 1:1000 VIAL PROSTIGMIN NEOSTIGMINE METHYLSULFATE 1:2000 VIAL NIACIN NIACIN 125MG CAPSULE SA NIACIN NIACIN 250MG CAPSULE SA NIACIN TD NIACIN 250MG CAPSULE SA NIACOR NIACIN 500MG TABLET CARDENE NICARDIPINE HCL 20MG CAPSULE CARDENE NICARDIPINE HCL 30MG CAPSULE NICARDIPINE HCL NICARDIPINE HCL 20MG CAPSULE NICARDIPINE HCL NICARDIPINE HCL 30MG CAPSULE NIFEDICAL XL NIFEDIPINE 30MG TAB SA OSM NIFEDICAL XL NIFEDIPINE 60MG TAB SA OSM NIFEDIPINE NIFEDIPINE 10MG CAPSULE NIFEDIPINE NIFEDIPINE 20MG CAPSULE NIFEDIPINE NIFEDIPINE 30MG TABLET SA NIFEDIPINE NIFEDIPINE 60MG TABLET SA NIFEDIPINE NIFEDIPINE 90MG TABLET SA NIFEDIPINE ER NIFEDIPINE 30MG TAB SA OSM NIFEDIPINE ER NIFEDIPINE 60MG TAB SA OSM NIFEDIPINE ER NIFEDIPINE 90MG TAB SA OSM PROCARDIA NIFEDIPINE 10MG CAPSULE PROCARDIA NIFEDIPINE 20MG CAPSULE PROCARDIA XL NIFEDIPINE 30MG TAB SA OSM PROCARDIA XL NIFEDIPINE 60MG TAB SA OSM MACRODANTIN NITROFURANTOIN MACROCRYSTAL 100MG CAPSULE MACRODANTIN NITROFURANTOIN MACROCRYSTAL 50MG CAPSULE NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MACROCRYSTAL 100MG CAPSULE NITROFURANTOIN MACROCRYSTAL NITROFURANTOIN MACROCRYSTAL 50MG CAPSULE FURACIN NITROFURAZONE 0.2% OINT.(GM) NITROFURAZONE NITROFURAZONE 0.2% OINT.(GM) NITROFURAZONE NITROFURAZONE 0.2% SOLUTION MINITRAN NITROGLYCERIN 0.1MG/HR PATCH TD24 MINITRAN NITROGLYCERIN 0.2MG/HR PATCH TD24 MINITRAN NITROGLYCERIN 0.4MG/HR PATCH TD24 MINITRAN NITROGLYCERIN 0.6MG/HR PATCH TD24 NITREK NITROGLYCERIN 0.2MG/HR PATCH TD24 NITREK NITROGLYCERIN 0.4MG/HR PATCH TD24 NITREK NITROGLYCERIN 0.6MG/HR PATCH TD24 NITRO-BID NITROGLYCERIN 2% OINT.(GM) NITRO-DUR NITROGLYCERIN 0.1MG/HR PATCH TD24 NITRO-DUR NITROGLYCERIN 0.2MG/HR PATCH TD24 NITRO-DUR NITROGLYCERIN 0.4MG/HR PATCH TD24 NITRO-DUR NITROGLYCERIN 0.6MG/HR PATCH TD24 NITROGLYCERIN NITROGLYCERIN 0.1MG/HR PATCH TD24 Page 60 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 NITROGLYCERIN NITROGLYCERIN 0.2MG/HR PATCH TD24 NITROGLYCERIN NITROGLYCERIN 0.3MG TAB SUBL NITROGLYCERIN NITROGLYCERIN 0.4MG TAB SUBL NITROGLYCERIN NITROGLYCERIN 0.4MG/HR PATCH TD24 NITROGLYCERIN NITROGLYCERIN 0.6MG TAB SUBL NITROGLYCERIN NITROGLYCERIN 0.6MG/HR PATCH TD24 NITROGLYCERIN NITROGLYCERIN 2.5MG CAPSULE SA NITROGLYCERIN NITROGLYCERIN 5MG/ML VIAL NITROGLYCERIN NITROGLYCERIN 6.5MG CAPSULE SA NITROGLYCERIN NITROGLYCERIN 9MG CAPSULE SA NITROGLYCERIN TRANSDERMAL NITROGLYCERIN 0.1MG/HR PATCH TD24 NITROGLYCERIN TRANSDERMAL NITROGLYCERIN 0.2MG/HR PATCH TD24 NITROGLYCERIN TRANSDERMAL NITROGLYCERIN 0.4MG/HR PATCH TD24 NITROGLYCERIN TRANSDERMAL NITROGLYCERIN 0.6MG/HR PATCH TD24 NITROGLYN NITROGLYCERIN 2.5MG CAPSULE SA NITROGLYN NITROGLYCERIN 6.5MG CAPSULE SA NITROGLYN NITROGLYCERIN 9MG CAPSULE SA NITROL NITROGLYCERIN 2% OINT.(GM) NITROQUICK NITROGLYCERIN 0.3MG TAB SUBL NITROQUICK NITROGLYCERIN 0.4MG TAB SUBL NITROQUICK NITROGLYCERIN 0.6MG TAB SUBL NITROSTAT NITROGLYCERIN 0.3MG TAB SUBL NITROSTAT NITROGLYCERIN 0.4MG TAB SUBL NITROSTAT NITROGLYCERIN 0.6MG TAB SUBL NITROTAB NITROGLYCERIN 0.3MG TAB SUBL NITROTAB NITROGLYCERIN 0.4MG TAB SUBL NITROTAB NITROGLYCERIN 0.6MG TAB SUBL NITRO-TIME NITROGLYCERIN 2.5MG CAPSULE SA NITRO-TIME NITROGLYCERIN 6.5MG CAPSULE SA NITRO-TIME NITROGLYCERIN 9MG CAPSULE SA TRIDIL NITROGLYCERIN 5MG/ML VIAL NITROPRUSSIDE SODIUM NITROPRUSSIDE SODIUM 25MG/ML VIAL AXID NIZATIDINE 150MG CAPSULE AXID NIZATIDINE 300MG CAPSULE NIZATIDINE NIZATIDINE 150MG CAPSULE NIZATIDINE NIZATIDINE 300MG CAPSULE LEVOPHED BITARTATE NOREPINEPHRINE BITARTRATE 1MG/ML AMPUL CAMILA NORETHINDRONE 0.35MG TABLET ERRIN NORETHINDRONE 0.35MG TABLET NORA-BE NORETHINDRONE 0.35MG TABLET NOR-Q-D NORETHINDRONE 0.35MG TABLET NORETHINDRONE ACETATE NORETHINDRONE ACETATE 5MG TABLET BREVICON NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET MODICON NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET NECON NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET NECON NORETHINDRONE-ETHINYL ESTRAD 1-0.035MG TABLET NECON NORETHINDRONE-ETHINYL ESTRAD 10-11 TABLET NECON NORETHINDRONE-ETHINYL ESTRAD 7 DAYS X 3 TABLET NORINYL 1+35 NORETHINDRONE-ETHINYL ESTRAD 1-0.035MG TABLET NORTREL NORETHINDRONE-ETHINYL ESTRAD 0.5-0.035 TABLET NORTREL NORETHINDRONE-ETHINYL ESTRAD 1-0.035MG TABLET NORTREL NORETHINDRONE-ETHINYL ESTRAD 7 DAYS X 3 TABLET ORTHO-NOVUM NORETHINDRONE-ETHINYL ESTRAD 1-0.035MG TABLET NECON NORETHINDRONE-MESTRANOL 1-0.05MG TABLET NORINYL 1+50 NORETHINDRONE-MESTRANOL 1-0.05MG TABLET ORTHO-NOVUM NORETHINDRONE-MESTRANOL 1-0.05MG TABLET MONONESSA NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 TABLET SPRINTEC NORGESTIMATE-ETHINYL ESTRADIOL 0.25-0.035 TABLET CRYSELLE NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET LO/OVRAL-21 NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET LO/OVRAL-28 NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET LOW-OGESTREL NORGESTREL-ETHINYL ESTRADIOL 0.3-0.03MG TABLET OGESTREL NORGESTREL-ETHINYL ESTRADIOL 0.5-0.05MG TABLET AVENTYL HCL NORTRIPTYLINE HCL 10MG CAPSULE AVENTYL HCL NORTRIPTYLINE HCL 10MG/5ML SOLUTION AVENTYL HCL NORTRIPTYLINE HCL 25MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 10MG/5ML SOLUTION NORTRIPTYLINE HCL NORTRIPTYLINE HCL 25MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 50MG CAPSULE NORTRIPTYLINE HCL NORTRIPTYLINE HCL 75MG CAPSULE PAMELOR NORTRIPTYLINE HCL 10MG CAPSULE PAMELOR NORTRIPTYLINE HCL 10MG/5ML SOLUTION PAMELOR NORTRIPTYLINE HCL 25MG CAPSULE PAMELOR NORTRIPTYLINE HCL 50MG CAPSULE Page 61 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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