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 TERRAMYCIN W/POLYMYXIN OXY-TCN HCL/POLYMYX B SULF OINT.(GM) OXYTOCIN OXYTOCIN 10 UNIT/ML AMPUL OXYTOCIN OXYTOCIN 10 UNIT/ML VIAL PITOCIN OXYTOCIN 10 UNIT/ML AMPUL PITOCIN OXYTOCIN 10 UNIT/ML VIAL ONXOL PACLITAXEL,SEMI-SYNTHETIC 6MG/ML VIAL PACLITAXEL PACLITAXEL,SEMI-SYNTHETIC 6MG/ML VIAL TAXOL PACLITAXEL,SEMI-SYNTHETIC 6MG/ML VIAL PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM 3MG/ML VIAL PAMIDRONATE DISODIUM PAMIDRONATE DISODIUM 9MG/ML VIAL PANCURONIUM BROMIDE PANCURONIUM BROMIDE 1MG/ML VIAL PANCURONIUM BROMIDE PANCURONIUM BROMIDE 2MG/ML AMPUL PANCURONIUM BROMIDE PANCURONIUM BROMIDE 2MG/ML VIAL ETHEZYME PAPAIN/UREA 1.1MMU/G OINT.(GM) ETHEZYME 830 PAPAIN/UREA 0.83MMU/G OINT.(GM) KOVIA PAPAIN/UREA 0.83MMU/G OINT.(GM) KOVIA OINTMENT PAPAIN/UREA 0.83MMU/G OINT.(GM) PAPAVERINE HCL PAPAVERINE HCL 150MG CAPSULE SA PAPAVERINE HCL PAPAVERINE HCL 30MG/ML VIAL PARA-TIME PAPAVERINE HCL 150MG CAPSULE SA PAREGORIC PAREGORIC 2MG/5ML LIQUID PAROMOMYCIN SULFATE PAROMOMYCIN SULFATE 250MG CAPSULE CYLERT PEMOLINE 18.75MG TABLET CYLERT PEMOLINE 37.5MG TAB CHEW CYLERT PEMOLINE 37.5MG TABLET CYLERT PEMOLINE 75MG TABLET PEMOLINE PEMOLINE 18.75MG TABLET PEMOLINE PEMOLINE 37.5MG TAB CHEW PEMOLINE PEMOLINE 37.5MG TABLET PEMOLINE PEMOLINE 75MG TABLET PERMAPEN ISOJECT PENICILLIN G BENZATHINE 1.2MMU/2ML DISP SYRIN PENICILLIN G POTASSIUM PENICILLIN G POTASSIUM 1MMU VIAL PENICILLIN G POTASSIUM PENICILLIN G POTASSIUM 20MMU VIAL PENICILLIN G POTASSIUM PENICILLIN G POTASSIUM 5MMU VIAL PFIZERPEN PENICILLIN G POTASSIUM 20MMU VIAL PFIZERPEN PENICILLIN G POTASSIUM 5MMU VIAL PENICILLIN G SODIUM PENICILLIN G SODIUM 5MMU VIAL LEDERCILLIN VK PENICILLIN V POTASSIUM 250MG TABLET PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 125MG/5ML SUSP RECON PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250MG TABLET PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 250MG/5ML SUSP RECON PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM 500MG TABLET VEETIDS 125 PENICILLIN V POTASSIUM 125MG/5ML SUSP RECON VEETIDS 250 PENICILLIN V POTASSIUM 250MG TABLET VEETIDS 250 PENICILLIN V POTASSIUM 250MG/5ML SUSP RECON VEETIDS 500 PENICILLIN V POTASSIUM 500MG TABLET PENTOPAK PENTOXIFYLLINE 400MG TABLET SA PENTOXIFYLLINE PENTOXIFYLLINE 400MG TABLET SA PENTOXIL PENTOXIFYLLINE 400MG TABLET SA TRENTAL PENTOXIFYLLINE 400MG TABLET SA ALLERX-D P-EPHED HCL/SCOP ME-NITRATE 120-2.5MG TAB.SR 12H HISTACLEAR D P-EPHED HCL/SCOP ME-NITRATE 120-2.5MG TAB.SR 12H P-EPHED HCL/SCOP ME-NITRATE P-EPHED HCL/SCOP ME-NITRATE 120-2.5MG TAB.SR 12H PSE 120/MSC 2.5 P-EPHED HCL/SCOP ME-NITRATE 120-2.5MG TAB.SR 12H ACTANOL P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET ACTIVE P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP ALLERFRIM P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP ALLERFRIM P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET ALTAFED P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP ANTIHISTAMINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET ANTIHISTAMINE/DECONGESTANT P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET APHEDRID P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP APHEDRID P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET APRODINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET BIOFED-PE P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP DECONGESTANT P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET DECONGESTANT/ANTIHISTAMINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET GENAC P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET HISTAFED P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP HISTAFED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET HISTA-TABS P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET HM ANTIHIST/DECONGESTANT P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET LONG ACTING DECONGESTANT P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET NASAL DECONGEST/ANTIHISTAMINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET NASAL DECONGESTANT ANTIHIST P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET Page 64 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 RIDIFED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET RITIFED P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP SB ANTIHISTAMINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET SILAFED P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP TRI-AFED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET TRI-FED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET TRIPHED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET TRIPROLIDINE W/PSEUDOEPHEDRINE P-EPHED HCL/TRIPROLIDINE HCL 30-1.25/5 SYRUP TRIPROLIDINE W/PSEUDOEPHEDRINE P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET TRI-PSEUDATED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET TRI-SOFED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET TRISUDEX P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET TRI-SUDO P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET UNI-FED P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET V-R NASAL DECONGEST/ANTIHIST P-EPHED HCL/TRIPROLIDINE HCL 60-2.5MG TABLET PERGOLIDE MESYLATE PERGOLIDE MESYLATE 0.05MG TABLET PERGOLIDE MESYLATE PERGOLIDE MESYLATE 0.25MG TABLET PERGOLIDE MESYLATE PERGOLIDE MESYLATE 1MG TABLET ACTICIN PERMETHRIN 5% CREAM(GM) LICE CREAM RINSE PERMETHRIN 1% LIQUID LICE CREME RINSE PERMETHRIN 1% LIQUID LICE KILLING PERMETHRIN 1% LIQUID NIX PERMETHRIN 1% LIQUID PERMETHRIN PERMETHRIN 1% LIQUID SB LICE TREATMENT PERMETHRIN 1% LIQUID V-R PERMETHRIN LICE PERMETHRIN 1% LIQUID PERPHENAZINE PERPHENAZINE 16MG TABLET PERPHENAZINE PERPHENAZINE 16MG/5ML ORAL CONC. PERPHENAZINE PERPHENAZINE 2MG TABLET PERPHENAZINE PERPHENAZINE 4MG TABLET PERPHENAZINE PERPHENAZINE 8MG TABLET TRILAFON PERPHENAZINE 16MG TABLET TRILAFON PERPHENAZINE 2MG TABLET TRILAFON PERPHENAZINE 4MG TABLET TRILAFON PERPHENAZINE 8MG TABLET PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL 100MG TABLET PHENAZOPYRIDINE HCL PHENAZOPYRIDINE HCL 200MG TABLET PYRIDIUM PHENAZOPYRIDINE HCL 100MG TABLET PYRIDIUM PHENAZOPYRIDINE HCL 200MG TABLET URODOL PHENAZOPYRIDINE HCL 200MG TABLET PHENOBARBITAL PHENOBARBITAL 100MG TABLET PHENOBARBITAL PHENOBARBITAL 15MG TABLET PHENOBARBITAL PHENOBARBITAL 16.2MG TABLET PHENOBARBITAL PHENOBARBITAL 20MG/5ML ELIXIR PHENOBARBITAL PHENOBARBITAL 30MG TABLET PHENOBARBITAL PHENOBARBITAL 32.4MG TABLET PHENOBARBITAL PHENOBARBITAL 60MG TABLET PHENOBARBITAL PHENOBARBITAL 64.8MG TABLET PHENOBARBITAL PHENOBARBITAL 97.2MG TABLET LUMINAL SODIUM PHENOBARBITAL SODIUM 130MG/ML DISP SYRIN LUMINAL SODIUM PHENOBARBITAL SODIUM 60MG/ML DISP SYRIN AK-DILATE PHENYLEPHRINE HCL 10% DROPS AK-DILATE PHENYLEPHRINE HCL 2.5% DROPS ALTAFRIN PHENYLEPHRINE HCL 10% DROPS ALTAFRIN PHENYLEPHRINE HCL 2.5% DROPS MYDFRIN PHENYLEPHRINE HCL 2.5% DROPS NEOFRIN PHENYLEPHRINE HCL 10% DROPS NEOFRIN PHENYLEPHRINE HCL 2.5% DROPS NEO-SYNEPHRINE PHENYLEPHRINE HCL 10% DROPS NEO-SYNEPHRINE PHENYLEPHRINE HCL 2.5% DROPS PHENOPTIC PHENYLEPHRINE HCL 2.5% DROPS PHENYLEPHRINE HCL PHENYLEPHRINE HCL 10MG/ML VIAL PHENYLEPHRINE HCL PHENYLEPHRINE HCL 2.5% DROPS PROMETHAZINE VC PHENYLEPHRINE HCL/PROMETH HCL SYRUP PROMETHAZINE VC PHENYLEPHRINE HCL/PROMETH HCL 5-6.25MG/5 SYRUP DUONATE-12 PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP K-TAN 4 PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP PYRILAFEN TANNATE-12 PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP RHINATATE-12 PEDIATRIC PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP R-TANNA 12 PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP R-TANNIC-S PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP RYNA-12 S PHENYLEPHRINE/PYRIL TAN 5-30MG/5ML ORAL SUSP EMPRO PHENYLPROPANOLAMINE HCL 75MG CAPSULE SA PHENYTOIN PHENYTOIN 125MG/5ML ORAL SUSP PHENYTOIN SODIUM PHENYTOIN SODIUM 100MG CAPSULE Page 65 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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