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 PAMELOR NORTRIPTYLINE HCL 75MG CAPSULE NUTRIHEP NUT.TX. METABOLIC DISORDER,REG LIQUID PHENYLADE NUT.TX. METABOLIC DISORDER,REG PACKET PHENYLADE NUT.TX. METABOLIC DISORDER,REG POWDER PHENYLADE MTE NUT.TX. METABOLIC DISORDER,REG POWDER PKU AID NUT.TX. METABOLIC DISORDER,REG POWDER PERATIVE NUT.TX. METABOLIC DISORDER,SOY LIQUID CRUCIAL NUT.TX.COMP. IMMUNE SYSTM,SOY LIQUID DIABETISOURCE NUT.TX.GLUC.INTOLER,LAC-FR,REG LIQUID RESOURCE DIABETIC NUT.TX.GLUC.INTOLER,LAC-FR,REG LIQUID GLUCERNA NUT.TX.GLUC.INTOLER,LAC-FR,SOY LIQUID GLYTROL NUT.TX.GLUC.INTOLER,LAC-FR,SOY LIQUID GLUCERNA NUT.TX.GLUCOSE INTOLERANCE,SOY BAR NUTRIRENAL NUT.TX.IMP.RENAL FXN,LAC-FREE LIQUID RE/NEPH HP/HC NUT.TX.IMP.RENAL FXN,LAC-FREE LIQUID RENALCAL NUT.TX.IMP.RENAL FXN,LAC-FREE LIQUID VIVONEX RTF NUT.TX.IMPAIRED DIGEST FXN,SOY LIQUID MAGNACAL RENAL NUT.TX.IMPAIRED RENAL FXN,SOY LIQUID SUPLENA NUT.TX.IMPAIRED RENAL FXN,SOY LIQUID RESPALOR NUT.TX.PULM.DISORD.SOY,LAC-FR LIQUID ACERFLEX NUTRITIONAL SUPPLEMENT POWDER ATTAIN NUTRITIONAL SUPPLEMENT LIQUID BOOST NUTRITIONAL SUPPLEMENT BAR COMPLY NUTRITIONAL SUPPLEMENT LIQUID ENTRITION NUTRITIONAL SUPPLEMENT LIQUID ENTRITION HN NUTRITIONAL SUPPLEMENT LIQUID EO28 EXTRA NUTRITIONAL SUPPLEMENT POWDER GLUCO-PRO NUTRITIONAL SUPPLEMENT LIQUID GLUTASORB NUTRITIONAL SUPPLEMENT LIQUID ISOCAL HN PLUS NUTRITIONAL SUPPLEMENT LIQUID K.D.S. ATTAIN NUTRITIONAL SUPPLEMENT LIQUID K.D.S. COMPLY NUTRITIONAL SUPPLEMENT LIQUID K.D.S. PRE-ATTAIN NUTRITIONAL SUPPLEMENT LIQUID K.D.S. PROTAIN XL NUTRITIONAL SUPPLEMENT LIQUID LACTA/CARE NUTRITIONAL SUPPLEMENT LIQUID MAINTAIN NUTRITIONAL SUPPLEMENT LIQUID MAXAMAID XP NUTRITIONAL SUPPLEMENT BAR METAFORM NUTRITIONAL SUPPLEMENT PACKET METHIONAID NUTRITIONAL SUPPLEMENT POWDER MSUD AID NUTRITIONAL SUPPLEMENT POWDER MSUD MAXAMAID NUTRITIONAL SUPPLEMENT POWDER MSUD MAXAMUM NUTRITIONAL SUPPLEMENT POWDER NOVASOURCE 2.0 NUTRITIONAL SUPPLEMENT LIQUID NOVASOURCE PULMONARY NUTRITIONAL SUPPLEMENT LIQUID NOVASOURCE RENAL NUTRITIONAL SUPPLEMENT LIQUID NUTREN 1.0 NUTRITIONAL SUPPLEMENT LIQUID NUTREN 1.5 NUTRITIONAL SUPPLEMENT LIQUID NUTREN 2.0 NUTRITIONAL SUPPLEMENT LIQUID NUTREN JUNIOR NUTRITIONAL SUPPLEMENT LIQUID OPTIMENTAL NUTRITIONAL SUPPLEMENT LIQUID PEPTAMEN NUTRITIONAL SUPPLEMENT LIQUID PEPTAMEN 1.5 NUTRITIONAL SUPPLEMENT LIQUID PEPTAMEN JUNIOR NUTRITIONAL SUPPLEMENT LIQUID PEPTAMEN VHP NUTRITIONAL SUPPLEMENT LIQUID PERIFLEX NUTRITIONAL SUPPLEMENT POWDER PHLEXY-10 NUTRITIONAL SUPPLEMENT BAR PHLEXY-10 NUTRITIONAL SUPPLEMENT PACKET PHLEXY-VITS NUTRITIONAL SUPPLEMENT PACKET PRE-ATTAIN NUTRITIONAL SUPPLEMENT LIQUID PRO-PEPTIDE NUTRITIONAL SUPPLEMENT LIQUID PRO-PEPTIDE FOR KIDS NUTRITIONAL SUPPLEMENT LIQUID PRO-PEPTIDE VHN NUTRITIONAL SUPPLEMENT LIQUID PROTAIN XL NUTRITIONAL SUPPLEMENT LIQUID REABILAN NUTRITIONAL SUPPLEMENT LIQUID REABILANHN NUTRITIONAL SUPPLEMENT LIQUID REPLETE NUTRITIONAL SUPPLEMENT LIQUID RESOURCE NUTRITIONAL SUPPLEMENT LIQUID RESOURCE JUST FOR KIDS NUTRITIONAL SUPPLEMENT LIQUID SUBDUE NUTRITIONAL SUPPLEMENT LIQUID SUBDUE PLUS NUTRITIONAL SUPPLEMENT LIQUID SUPER ENERGY NUTRITIONAL SUPPLEMENT POWDER VANILLA LOW LACTOSE NUTRITIONAL SUPPLEMENT POWDER VITALIZE NUTRITIONAL SUPPLEMENT BAR VITALIZE NUTRITIONAL SUPPLEMENT LIQUID XLEU MAXAMAID NUTRITIONAL SUPPLEMENT POWDER Page 62 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 XLEU MAXAMUM NUTRITIONAL SUPPLEMENT POWDER XLYS, TRY MAXAMAID NUTRITIONAL SUPPLEMENT POWDER XLYS, TRY MAXAMUM NUTRITIONAL SUPPLEMENT POWDER XMET MAXAMAID NUTRITIONAL SUPPLEMENT POWDER XMET MAXAMUM NUTRITIONAL SUPPLEMENT POWDER XMTVI MAXAMAID NUTRITIONAL SUPPLEMENT POWDER XMTVI MAXAMUM NUTRITIONAL SUPPLEMENT POWDER XP MAXAMAID NUTRITIONAL SUPPLEMENT POWDER XP MAXAMUM NUTRITIONAL SUPPLEMENT POWDER XPHEN, TYR MAXAMAID NUTRITIONAL SUPPLEMENT POWDER XPTM MAXAMAID NUTRITIONAL SUPPLEMENT POWDER MYCOSTATIN NYSTATIN 100000 U/G CREAM(GM) MYCOSTATIN NYSTATIN 100K U/ML ORAL SUSP MYCOSTATIN NYSTATIN 500000 U TABLET NYSTATIN NYSTATIN 100000 U TABLET NYSTATIN NYSTATIN 100000 U/G CREAM(GM) NYSTATIN NYSTATIN 100000 U/G OINT.(GM) NYSTATIN NYSTATIN 100K U/ML ORAL SUSP NYSTATIN NYSTATIN 150MMU POWDER NYSTATIN NYSTATIN 2B UNIT POWDER NYSTATIN NYSTATIN 500000 U TABLET NYSTEX NYSTATIN 100000 U/G CREAM(GM) NYSTEX NYSTATIN 100000 U/G OINT.(GM) NYSTEX NYSTATIN 100K U/ML ORAL SUSP NYSTOP NYSTATIN 100000 U/G POWDER PEDI-DRI NYSTATIN 100000 U/G POWDER MYCOGEN II NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM) MYCOLOG II NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM) MYCOLOG II NYSTATIN/TRIAMCIN 100000-0.1 OINT.(GM) MYCONEL NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM) MYCO-TRIACET II NYSTATIN/TRIAMCIN OINT.(GM) MYTREX NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM) MYTREX NYSTATIN/TRIAMCIN 100000-0.1 OINT.(GM) N.T.A. NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM) N.T.A. NYSTATIN/TRIAMCIN 100000-0.1 OINT.(GM) NYSTATIN W/TRIAMCINOLONE NYSTATIN/TRIAMCIN 100000-0.1 CREAM(GM) NYSTATIN W/TRIAMCINOLONE NYSTATIN/TRIAMCIN 100000-0.1 OINT.(GM) OMEPRAZOLE OMEPRAZOLE 20MG CAPSULE DR FLEXOJECT ORPHENADRINE CITRATE 30MG/ML VIAL FLEXON ORPHENADRINE CITRATE 30MG/ML VIAL NORFLEX ORPHENADRINE CITRATE 100MG TABLET SA ORPHENADRINE CITRATE ORPHENADRINE CITRATE 100MG TABLET SA BACTOCILL OXACILLIN SODIUM 10G VIAL BACTOCILL OXACILLIN SODIUM 1G VIAL BACTOCILL OXACILLIN SODIUM 250MG CAPSULE BACTOCILL OXACILLIN SODIUM 2G PIGGYBACK BACTOCILL OXACILLIN SODIUM 2G VIAL BACTOCILL OXACILLIN SODIUM 500MG CAPSULE BACTOCILL OXACILLIN SODIUM 500MG VIAL OXACILLIN SODIUM OXACILLIN SODIUM 250MG/5ML SUSP RECON OXACILLIN SODIUM OXACILLIN SODIUM 2G VIAL DAYPRO OXAPROZIN 600MG TABLET OXAPROZIN OXAPROZIN 600MG TABLET OXAZEPAM OXAZEPAM 10MG CAPSULE OXAZEPAM OXAZEPAM 15MG CAPSULE OXAZEPAM OXAZEPAM 30MG CAPSULE SERAX OXAZEPAM 10MG CAPSULE SERAX OXAZEPAM 15MG CAPSULE SERAX OXAZEPAM 30MG CAPSULE DITROPAN OXYBUTYNIN CHLORIDE 5MG TABLET DITROPAN OXYBUTYNIN CHLORIDE 5MG/5ML SYRUP OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 5MG TABLET OXYBUTYNIN CHLORIDE OXYBUTYNIN CHLORIDE 5MG/5ML SYRUP OXYCODONE HCL OXYCODONE HCL 20MG/ML ORAL CONC. OXYCODONE HCL OXYCODONE HCL 5MG CAPSULE OXYCODONE HCL OXYCODONE HCL 5MG TABLET OXYCODONE HCL OXYCODONE HCL 5MG/5ML SOLUTION OXYDOSE OXYCODONE HCL 20MG/ML ORAL CONC. OXYFAST OXYCODONE HCL 20MG/ML ORAL CONC. OXYIR OXYCODONE HCL 5MG CAPSULE PERCOLONE OXYCODONE HCL 5MG TABLET ROXICODONE OXYCODONE HCL 5MG TABLET ROXICODONE OXYCODONE HCL 5MG/5ML SOLUTION ROXICODONE INTENSOL OXYCODONE HCL 20MG/ML ORAL CONC. TERAK OXY-TCN HCL/POLYMYX B SULF OINT.(GM) Page 63 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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