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 ACYCLOVIR SODIUM ACYCLOVIR SODIUM 1G/40ML VIAL ACYCLOVIR SODIUM ACYCLOVIR SODIUM 500MG VIAL ACYCLOVIR SODIUM ACYCLOVIR SODIUM 500MG/20ML VIAL ACYCLOVIR SODIUM ACYCLOVIR SODIUM 50MG/ML VIAL ZOVIRAX ACYCLOVIR SODIUM 1000MG VIAL ZOVIRAX ACYCLOVIR SODIUM 500MG VIAL BUFFERED ASPIRIN AL AMINOACET/ASPIRIN/MAG CARB 325MG TABLET UNI-BUFF AL AMINOACET/ASPIRIN/MAG CARB 325MG TABLET ARTHRITIS PAIN FORMULA AL HYDROX/ASPIRIN/MAG HYDROX 325MG TABLET MAGNAPRIN AL HYDROX/ASPIRIN/MAG HYDROX 325MG TABLET ALAMAG PLUS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP ALMACONE AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP ALMACONE-2 AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP ANTACID AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP ANTACID AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP ANTACID ANTI-GAS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP ANTACID ANTI-GAS AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP ANTACID ANTI-GAS DOUBLE STR AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP ANTACID DOUBLE STRENGTH AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP ANTACID M AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP ANTACID M AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP ANTACID PLUS AL HYDROX/MAG HYDROX/SIMETH 200-200-25 TAB CHEW ANTACID W/SIMETHICONE AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP ANTACID W/SIMETHICONE AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP ANTACID/ANTI-GAS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP ANTACID/ANTIGAS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP ANTACID-ANTIGAS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP GELUSIL AL HYDROX/MAG HYDROX/SIMETH 200-200-25 TAB CHEW GERI-LANTA AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP HM ANTACID/ANTIGAS AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP MAALOX MS AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP MAALOX QUICK DISSOLVE AL HYDROX/MAG HYDROX/SIMETH 200-200-25 TAB CHEW MASANTI AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP MASANTI AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP MASANTI II AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP MI ACID AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP MI-ACID II AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP MILANTEX AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP MINTOX PLUS AL HYDROX/MAG HYDROX/SIMETH 200-200-25 TAB CHEW MYLANTA AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP MYLANTA DOUBLE-STRENGTH AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP MYLANTEX DOUBLE-STRENGTH AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP RI-GEL AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP RI-GEL II AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP UNI-LAN AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP UNI-LAN II AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP URBAN AL HYDROX/MAG HYDROX/SIMETH 200-200-20 ORAL SUSP URBAN D.S. AL HYDROX/MAG HYDROX/SIMETH 400-400-40 ORAL SUSP ALAMAG AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP ANTACID AL HYDROX/MAGNESIUM HYDROXIDE 200-225 ORAL SUSP ANTACID AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP HM ANTACID AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP LIQUID ANTACID AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP MAALOX AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP MAGNESIUM HYDR/ALUMINUM HYDR AL HYDROX/MAGNESIUM HYDROXIDE 200-225 ORAL SUSP MALDROXAL AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP MINTOX AL HYDROX/MAGNESIUM HYDROXIDE 200-200 TAB CHEW MINTOX AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP RI-MOX AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP RULOX AL HYDROX/MAGNESIUM HYDROXIDE 200-225/5 ORAL SUSP RULOX NO.1 AL HYDROX/MAGNESIUM HYDROXIDE 200-200 TAB CHEW ALBUMARC ALBUMIN HUMAN 25% IV SOLN. ALBUMARC ALBUMIN HUMAN 5% IV SOLN. ALBUMIN ALBUMIN HUMAN 25% IV SOLN. ALBUMIN ALBUMIN HUMAN 25% VIAL ALBUMIN ALBUMIN HUMAN 5% IV SOLN. ALBUMINAR-25 ALBUMIN HUMAN 25% IV SOLN. ALBUMINAR-25 ALBUMIN HUMAN 25% VIAL ALBUMINAR-5 ALBUMIN HUMAN 5% IV SOLN. ALBURX ALBUMIN HUMAN 25% VIAL ALBURX ALBUMIN HUMAN 5% VIAL ALBUTEIN ALBUMIN HUMAN 25% IV SOLN. ALBUTEIN ALBUMIN HUMAN 25% VIAL ALBUTEIN ALBUMIN HUMAN 5% IV SOLN. BUMINATE ALBUMIN HUMAN 25% VIAL Page 6 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 BUMINATE ALBUMIN HUMAN 5% IV SOLN. BUMINATE W/ADMINISTRATION SET ALBUMIN HUMAN 25% IV SOLN. PLASBUMIN-25 ALBUMIN HUMAN 25% VIAL PLASBUMIN-5 ALBUMIN HUMAN 5% IV SOLN. PLASBUMIN-5 ALBUMIN HUMAN 5% VIAL ALBUMIN-SALINE ALBUMIN HUMAN/SODIUM CHLORIDE 0.03% VIAL ALBUTEROL ALBUTEROL 90MCG AER REFILL ALBUTEROL ALBUTEROL 90MCG AEROSOL PROVENTIL ALBUTEROL 90MCG AER REFILL PROVENTIL ALBUTEROL 90MCG AEROSOL VENTOLIN ALBUTEROL 90MCG AER REFILL VENTOLIN ALBUTEROL 90MCG AEROSOL AIRET ALBUTEROL SULFATE 0.83MG/ML SOLUTION ALBUTEROL SULFATE ALBUTEROL SULFATE 0.83MG/ML SOLUTION ALBUTEROL SULFATE ALBUTEROL SULFATE 2MG TABLET ALBUTEROL SULFATE ALBUTEROL SULFATE 2MG/5ML SYRUP ALBUTEROL SULFATE ALBUTEROL SULFATE 4MG TABLET ALBUTEROL SULFATE ALBUTEROL SULFATE 5MG/ML SOLUTION PROVENTIL ALBUTEROL SULFATE 0.83MG/ML SOLUTION PROVENTIL ALBUTEROL SULFATE 2MG TABLET PROVENTIL ALBUTEROL SULFATE 4MG TABLET PROVENTIL ALBUTEROL SULFATE 5MG/ML SOLUTION VOSPIRE ER ALBUTEROL SULFATE 4MG TAB.SR 12H VOSPIRE ER ALBUTEROL SULFATE 8MG TAB.SR 12H ALFENTANIL HYDROCHLORIDE ALFENTANIL HCL 500MCG/ML AMPUL ASCRIPTIN ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET ASCRIPTIN A/D ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET ASPIRIN W/ANTACID ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET ASPIRIN W/ANTACID A/D ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET ASPIR-MOX IB ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET ASPRIDROX ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET ASPRIMOX ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET ASPRIMOX ID ALH/ASA/CALCIUM CARB/MAGNESIUM 325MG TABLET ASPRIMOX ID ALH/ASA/CALCIUM CARB/MAGNESIUM 500MG TABLET BUFFERIN ALH/ASA/CALCIUM CARB/MAGNESIUM 500MG TABLET ALLOPURINOL ALLOPURINOL 100MG TABLET ALLOPURINOL ALLOPURINOL 300MG TABLET ZYLOPRIM ALLOPURINOL 100MG TABLET ZYLOPRIM ALLOPURINOL 300MG TABLET CORTAID W/ALOE ALO VER/HYDROCORTISONE ACETATE 0.5% CREAM(GM) HYDROCORTISONE W/ALOE ALO VER/HYDROCORTISONE ACETATE 0.5% CREAM(GM) HYDROCORTISONE W/ALOE ALO VER/HYDROCORTISONE ACETATE 0.5% OINT.(GM) HYDROCORTISONE ALOE VERA/HYDROCORTISONE 0.5% CREAM(GM) HYDROCORTISONE PLUS ALOE VERA/HYDROCORTISONE 1% CREAM(GM) HYDROCORTISONE W/ALOE ALOE VERA/HYDROCORTISONE 0.5% CREAM(GM) HYDROCORTISONE W/ALOE ALOE VERA/HYDROCORTISONE 0.5% OINT.(GM) HYDROCORTISONE W/ALOE ALOE VERA/HYDROCORTISONE 1% CREAM(GM) HYDROCORTISONE W/ALOE ALOE VERA/HYDROCORTISONE 1% OINT.(GM) ALPROSTADIL ALPROSTADIL 500MCG/ML AMPUL ALPROSTADIL ALPROSTADIL 500MCG/ML VIAL EDEX ALPROSTADIL 10MCG VIAL EDEX ALPROSTADIL 20MCG VIAL EDEX ALPROSTADIL 40MCG VIAL ALUMINUM HYDROXIDE ALUMINUM HYDROXIDE 320MG/5ML ORAL SUSP M.T.E.-7 AM MB/CH/CU/MN/NAI/SE/ZSO4 HP VIAL AMANTADINE AMANTADINE HCL 100MG CAPSULE AMANTADINE HCL AMANTADINE HCL 100MG CAPSULE AMANTADINE HCL AMANTADINE HCL 50MG/5ML SYRUP SYMMETREL AMANTADINE HCL 50MG/5ML SYRUP AMCINONIDE AMCINONIDE 0.1% CREAM(GM) AMIKACIN SULFATE AMIKACIN SULFATE 250MG/ML VIAL AMIKACIN SULFATE AMIKACIN SULFATE 50MG/ML VIAL AMIKIN AMIKACIN SULFATE 250MG/ML DISP SYRIN AMIKIN AMIKACIN SULFATE 250MG/ML VIAL AMIKIN AMIKACIN SULFATE 50MG/ML VIAL AMIKIN PEDIATRIC AMIKACIN SULFATE 50MG/ML VIAL AMILORIDE HCL AMILORIDE HCL 5MG TABLET MIDAMOR AMILORIDE HCL 5MG TABLET AMILORIDE HCL W/HCTZ AMILORIDE HCL/HCTZ 5-50MG TABLET MODURETIC AMILORIDE HCL/HCTZ 5-50MG TABLET AMINO ACID CERVICAL AMINO AC/SODIUM PROPIONATE/URE CREAM/APPL CERVICAL AMINO ACID AMINO AC/SODIUM PROPIONATE/URE CREAM/APPL ELECARE AMINO ACIDS POWDER PHLEXY-10 AMINO ACIDS CAPSULE AMINOSYN AMINO ACIDS 10% 10% IV SOLN. Page 7 MAC list as of February 03.xls
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