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 PHENYTOIN SODIUM PHENYTOIN SODIUM 50MG/ML AMPUL PHENYTOIN SODIUM PHENYTOIN SODIUM 50MG/ML DISP SYRIN PHENYTOIN SODIUM INJECTION PHENYTOIN SODIUM 50MG/ML VIAL DILANTIN PHENYTOIN SODIUM EXTENDED 100MG CAPSULE PHENYTOIN SODIUM PHENYTOIN SODIUM EXTENDED 100MG CAPSULE PHENYTOIN SODIUM, EXTENDED PHENYTOIN SODIUM EXTENDED 100MG CAPSULE PHENYTOIN SODIUM,EXTENDED PHENYTOIN SODIUM EXTENDED 100MG CAPSULE K-PHOS NEUTRAL PHOSPHORUS 250MG TABLET PHOSPHA 250 NEUTRAL PHOSPHORUS 250MG TABLET PHYSIOLYTE PHYSIOLOGICAL IRRIGATION SOLN IRRIG SOLN PHYSOSTIGMINE SALICYLATE PHYSOSTIGMINE SALICYLATE 1MG/ML AMPUL VITAMIN K PHYTONADIONE 10MG/ML AMPUL VITAMIN K PHYTONADIONE 2MG/ML AMPUL ISOPTO CARPINE PILOCARPINE HCL 1% DROPS ISOPTO CARPINE PILOCARPINE HCL 2% DROPS ISOPTO CARPINE PILOCARPINE HCL 4% DROPS ISOPTO CARPINE PILOCARPINE HCL 6% DROPS PILOCAR PILOCARPINE HCL 0.5% DROPS PILOCAR PILOCARPINE HCL 1% DROPS PILOCAR PILOCARPINE HCL 2% DROPS PILOCAR PILOCARPINE HCL 4% DROPS PILOCAR PILOCARPINE HCL 6% DROPS PILOCARPINE HCL PILOCARPINE HCL 0.5% DROPS PILOCARPINE HCL PILOCARPINE HCL 1% DROPS PILOCARPINE HCL PILOCARPINE HCL 2% DROPS PILOCARPINE HCL PILOCARPINE HCL 3% DROPS PILOCARPINE HCL PILOCARPINE HCL 4% DROPS PILOCARPINE HCL PILOCARPINE HCL 6% DROPS PILOPTIC-1 PILOCARPINE HCL 1% DROPS PILOPTIC-2 PILOCARPINE HCL 2% DROPS PILOPTIC-3 PILOCARPINE HCL 3% DROPS PILOPTIC-4 PILOCARPINE HCL 4% DROPS PILOPTIC-6 PILOCARPINE HCL 6% DROPS PINDOLOL PINDOLOL 10MG TABLET PINDOLOL PINDOLOL 5MG TABLET LICE PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO LICE CREME RINSE PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% LIQUID LICE KILLING PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO LICE TREAMENT PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO LICE TREATMENT PIPERONYL BUTOXIDE/PYRETHRINS LIQUID LICE TREATMENT PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO LICE-AID PIPERONYL BUTOXIDE/PYRETHRINS LIQUID LICE-X PIPERONYL BUTOXIDE/PYRETHRINS LIQUID LICIDE PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO PIOJINA II PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% LIQUID PYRETHRIN PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% LIQUID PYRETHRIN LICE TREATMENT PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% LIQUID PYRINYL PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% SHAMPOO PYRINYL PLUS PIPERONYL BUTOXIDE/PYRETHRINS 4-0.33% LIQUID FELDENE PIROXICAM 10MG CAPSULE FELDENE PIROXICAM 20MG CAPSULE PIROXICAM PIROXICAM 10MG CAPSULE PIROXICAM PIROXICAM 20MG CAPSULE PLASMA PROTEIN FRACTION PLASMA PROTEIN FRACTION 5% IV SOLN. PLASMANATE PLASMA PROTEIN FRACTION 5% VIAL PLASMA-PLEX PLASMA PROTEIN FRACTION 5% IV SOLN. PNEUMOVAX 23 PNEUMOCOCCAL 23-VAL P-SAC VAC 25MCG/.5ML DISP SYRIN PNEUMOVAX 23 PNEUMOCOCCAL 23-VAL P-SAC VAC 25MCG/.5ML VIAL PODOFILOX PODOFILOX 0.5% SOLUTION POLYMYXIN B SULFATE POLYMYXIN B SULFATE 100MMU EACH POLYMYXIN B SUL/TRIMETHOPRIM POLYMYXIN B SULFATE/TMP 10K U-0.1% DROPS POLYTRIM POLYMYXIN B SULFATE/TMP 10K U-0.1% DROPS POLYSORBATE 80 POLYSORBATES 80 SOLUTION POTASSIUM ACETATE POTASSIUM ACETATE 2MEQ/ML VIAL POTASSIUM ACETATE POTASSIUM ACETATE 4MEQ/ML VIAL AMINOBENZOATE POTASSIUM POTASSIUM AMINOBENZOATE 500MG CAPSULE ED K+10 POTASSIUM CHLORIDE 10MEQ TABLET SA K CL-20 POTASSIUM CHLORIDE 20MEQ/15ML LIQUID K CL-40 POTASSIUM CHLORIDE 40MEQ/15ML LIQUID K+ POTASSIUM POTASSIUM CHLORIDE 20MEQ PACKET KAOCHLOR POTASSIUM CHLORIDE 20MEQ/15ML LIQUID KAON-CL POTASSIUM CHLORIDE 40MEQ/15ML LIQUID KAON-CL 10 POTASSIUM CHLORIDE 10MEQ TABLET SA KAY CIEL POTASSIUM CHLORIDE 20MEQ PACKET KAY CIEL POTASSIUM CHLORIDE 20MEQ/15ML LIQUID Page 66 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 K-DUR POTASSIUM CHLORIDE 10MEQ TAB PRT SR K-DUR POTASSIUM CHLORIDE 20MEQ TAB PRT SR K-LOR POTASSIUM CHLORIDE 20MEQ PACKET KLOR-CON POTASSIUM CHLORIDE 20MEQ PACKET KLOR-CON 10 POTASSIUM CHLORIDE 10MEQ TABLET SA KLOR-CON 8 POTASSIUM CHLORIDE 8MEQ TABLET SA KLOR-CON M10 POTASSIUM CHLORIDE 10MEQ TAB PRT SR KLOR-CON M20 POTASSIUM CHLORIDE 20MEQ TAB PRT SR KLORVESS POTASSIUM CHLORIDE 20MEQ/15ML LIQUID KLOTRIX POTASSIUM CHLORIDE 10MEQ TABLET SA K-SOL POTASSIUM CHLORIDE 20MEQ PACKET K-TAB POTASSIUM CHLORIDE 10MEQ TABLET SA K-VESCENT POTASSIUM CHLORIDE 20MEQ PACKET MICRO-K 10 POTASSIUM CHLORIDE 10MEQ CAPSULE SA POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10MEQ CAPSULE SA POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10MEQ TAB PRT SR POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10MEQ TABLET SA POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10MEQ/0.1L PIGGYBACK POTASSIUM CHLORIDE POTASSIUM CHLORIDE 10MEQ/50ML PIGGYBACK POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ PACKET POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ TAB PRT SR POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/0.1L PIGGYBACK POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/15ML LIQUID POTASSIUM CHLORIDE POTASSIUM CHLORIDE 20MEQ/50ML PIGGYBACK POTASSIUM CHLORIDE POTASSIUM CHLORIDE 2MEQ/ML DISP SYRIN POTASSIUM CHLORIDE POTASSIUM CHLORIDE 2MEQ/ML IV SOLN. POTASSIUM CHLORIDE POTASSIUM CHLORIDE 2MEQ/ML VIAL POTASSIUM CHLORIDE POTASSIUM CHLORIDE 30MEQ/0.1L PIGGYBACK POTASSIUM CHLORIDE POTASSIUM CHLORIDE 40MEQ/0.1L PIGGYBACK POTASSIUM CHLORIDE POTASSIUM CHLORIDE 40MEQ/15ML LIQUID POTASSIUM CHLORIDE POTASSIUM CHLORIDE 8MEQ TABLET SA KAON POTASSIUM GLUCONATE 20MEQ/15ML ELIXIR POTASSIUM GLUCONATE POTASSIUM GLUCONATE 20MEQ/15ML ELIXIR POTASSIUM PHOSPHATE POTASSIUM PHOS,M-BASIC-D-BASIC 3MMOL/ML VIAL MINIPRESS PRAZOSIN HCL 1MG CAPSULE MINIPRESS PRAZOSIN HCL 2MG CAPSULE MINIPRESS PRAZOSIN HCL 5MG CAPSULE PRAZOSIN HCL PRAZOSIN HCL 1MG CAPSULE PRAZOSIN HCL PRAZOSIN HCL 2MG CAPSULE PRAZOSIN HCL PRAZOSIN HCL 5MG CAPSULE PREDNISOLONE PREDNISOLONE 15MG/5ML SYRUP PREDNISOLONE PREDNISOLONE 5MG TABLET PREDNISOLONE PREDNISOLONE 5MG/5ML SYRUP PRELONE PREDNISOLONE 15MG/5ML SYRUP ECONOPRED PLUS PREDNISOLONE ACETATE 1% DROPS SUSP KEY-PRED PREDNISOLONE ACETATE 50MG/ML VIAL KEY-PRED 25 PREDNISOLONE ACETATE 25MG/ML VIAL PRED FORTE PREDNISOLONE ACETATE 1% DROPS SUSP PREDICORT-50 PREDNISOLONE ACETATE 50MG/ML VIAL PREDNISOLONE ACETATE PREDNISOLONE ACETATE 1% DROPS SUSP PREDNISOLONE ACETATE PREDNISOLONE ACETATE 50MG/ML VIAL UAD PRED PREDNISOLONE ACETATE 50MG/ML VIAL AK-PRED PREDNISOLONE SOD PHOSPHATE 1% DROPS INFLAMASE FORTE PREDNISOLONE SOD PHOSPHATE 1% DROPS INFLAMASE MILD PREDNISOLONE SOD PHOSPHATE 0.125% DROPS PEDIAPRED PREDNISOLONE SOD PHOSPHATE 5MG/5ML SOLUTION PREDNISOL PREDNISOLONE SOD PHOSPHATE 1% DROPS PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE 15MG/5ML SOLUTION PREDNISOLONE SOD PHOSPHATE PREDNISOLONE SOD PHOSPHATE 5MG/5ML SOLUTION PREDNISOLONE SODIUM PHOSPHATE PREDNISOLONE SOD PHOSPHATE 1% DROPS PREDNISOLONE SODIUM PHOSPHATE PREDNISOLONE SOD PHOSPHATE 5MG/5ML SOLUTION DELTASONE PREDNISONE 10MG TABLET DELTASONE PREDNISONE 2.5MG TABLET DELTASONE PREDNISONE 20MG TABLET DELTASONE PREDNISONE 50MG TABLET DELTASONE PREDNISONE 5MG TABLET PREDNISONE PREDNISONE 10MG TAB DS PK PREDNISONE PREDNISONE 10MG TABLET PREDNISONE PREDNISONE 1MG TABLET PREDNISONE PREDNISONE 20MG TABLET PREDNISONE PREDNISONE 50MG TABLET PREDNISONE PREDNISONE 5MG TAB DS PK PREDNISONE PREDNISONE 5MG TABLET STERAPRED PREDNISONE 5MG TAB DS PK STERAPRED DS PREDNISONE 10MG TAB DS PK Page 67 MAC list as of February 03.xls
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