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 THIOTHIXENE THIOTHIXENE 5MG CAPSULE THIOTHIXENE HCL THIOTHIXENE HCL 5MG/ML ORAL CONC. THROMBOGEN THROMBIN 1000 UNIT VIAL THROMBOGEN THROMBIN 10000 UNIT KIT THROMBOGEN THROMBIN 10000 UNIT VIAL THROMBOGEN THROMBIN 20000 UNIT KIT THROMBOGEN THROMBIN 20000 UNIT VIAL THROMBOGEN THROMBIN 5000 UNIT VIAL ARMOUR THYROID THYROID 120MG TABLET ARMOUR THYROID THYROID 180MG TABLET ARMOUR THYROID THYROID 30MG TABLET ARMOUR THYROID THYROID 60MG TABLET NATURE-THROID THYROID 120MG TABLET NATURE-THROID THYROID 180MG TABLET NATURE-THROID THYROID 30MG TABLET NATURE-THROID THYROID 60MG TABLET THYROID THYROID 120MG TABLET THYROID THYROID 180MG TABLET THYROID THYROID 30MG TABLET THYROID THYROID 60MG TABLET THYROID THYROID 65MG TABLET WESTHROID THYROID 120MG TABLET WESTHROID THYROID 180MG TABLET WESTHROID THYROID 30MG TABLET WESTHROID THYROID 60MG TABLET TICLID TICLOPIDINE HCL 250MG TABLET TICLOPIDINE HCL TICLOPIDINE HCL 250MG TABLET BLOCADREN TIMOLOL MALEATE 10MG TABLET BLOCADREN TIMOLOL MALEATE 20MG TABLET BLOCADREN TIMOLOL MALEATE 5MG TABLET TIMOLOL MALEATE TIMOLOL MALEATE 0.25% DROPS TIMOLOL MALEATE TIMOLOL MALEATE 0.25% SOL-GEL TIMOLOL MALEATE TIMOLOL MALEATE 0.5% DROPS TIMOLOL MALEATE TIMOLOL MALEATE 0.5% SOL-GEL TIMOLOL MALEATE TIMOLOL MALEATE 10MG TABLET TIMOLOL MALEATE TIMOLOL MALEATE 20MG TABLET TIMOLOL MALEATE TIMOLOL MALEATE 5MG TABLET TIMOPTIC TIMOLOL MALEATE 0.25% DROPS TIMOPTIC TIMOLOL MALEATE 0.5% DROPS TIZANIDINE HCL TIZANIDINE HCL 2MG TABLET TIZANIDINE HCL TIZANIDINE HCL 4MG TABLET ZANAFLEX TIZANIDINE HCL 2MG TABLET ZANAFLEX TIZANIDINE HCL 4MG TABLET AKTOB TOBRAMYCIN SULFATE 0.3% DROPS NEBCIN TOBRAMYCIN SULFATE 40MG/ML VIAL TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE 0.3% DROPS TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE 1.2G VIAL TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE 10MG/ML VIAL TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE 40MG/ML DISP SYRIN TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE 40MG/ML VIAL TOBRASOL TOBRAMYCIN SULFATE 0.3% DROPS TOBREX TOBRAMYCIN SULFATE 0.3% DROPS TOLAZAMIDE TOLAZAMIDE 100MG TABLET TOLAZAMIDE TOLAZAMIDE 250MG TABLET TOLAZAMIDE TOLAZAMIDE 500MG TABLET TOLINASE TOLAZAMIDE 100MG TABLET TOLINASE TOLAZAMIDE 250MG TABLET TOLBUTAMIDE TOLBUTAMIDE 500MG TABLET TOLECTIN 600 TOLMETIN SODIUM 600MG TABLET TOLECTIN DS TOLMETIN SODIUM 400MG CAPSULE TOLMETIN SODIUM TOLMETIN SODIUM 200MG TABLET TOLMETIN SODIUM TOLMETIN SODIUM 400MG CAPSULE TOLMETIN SODIUM TOLMETIN SODIUM 600MG TABLET TOLNAFTATE TOLNAFTATE 1% CREAM(GM) TORSEMIDE TORSEMIDE 100MG TABLET TORSEMIDE TORSEMIDE 10MG TABLET TORSEMIDE TORSEMIDE 20MG TABLET TORSEMIDE TORSEMIDE 5MG TABLET TRAMADOL HCL TRAMADOL HCL 50MG TABLET ULTRAM TRAMADOL HCL 50MG TABLET DESYREL TRAZODONE HCL 100MG TABLET DESYREL TRAZODONE HCL 150MG TABLET DESYREL TRAZODONE HCL 50MG TABLET TRAZODONE TRAZODONE HCL 100MG TABLET TRAZODONE HCL TRAZODONE HCL 100MG TABLET Page 74 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 TRAZODONE HCL TRAZODONE HCL 150MG TABLET TRAZODONE HCL TRAZODONE HCL 300MG TABLET TRAZODONE HCL TRAZODONE HCL 50MG TABLET ALTINAC TRETINOIN 0.025% CREAM(GM) ALTINAC TRETINOIN 0.05% CREAM(GM) ALTINAC TRETINOIN 0.1% CREAM(GM) AVITA TRETINOIN 0.025% CREAM(GM) AVITA TRETINOIN 0.025% GEL RETIN-A TRETINOIN 0.025% CREAM(GM) RETIN-A TRETINOIN 0.05% LIQUID TRETINOIN TRETINOIN 0.01% GEL TRETINOIN TRETINOIN 0.025% CREAM(GM) TRETINOIN TRETINOIN 0.025% GEL TRETINOIN TRETINOIN 0.05% CREAM(GM) TRETINOIN TRETINOIN 0.1% CREAM(GM) ARISTOCORT TRIAMCINOLONE 4MG TABLET ARISTOCORT TRIAMCINOLONE ACETONIDE 0.1% CREAM(GM) ARISTOCORT HP TRIAMCINOLONE ACETONIDE 0.5% OINT.(GM) CENOCORT A-40 TRIAMCINOLONE ACETONIDE 40MG/ML VIAL CINALOG TRIAMCINOLONE ACETONIDE 0.5% CREAM(GM) KENAJECT-40 TRIAMCINOLONE ACETONIDE 40MG/ML VIAL KENALOG TRIAMCINOLONE ACETONIDE 0.1% CREAM(GM) KENALOG TRIAMCINOLONE ACETONIDE 0.1% LOTION KENALOG TRIAMCINOLONE ACETONIDE 0.1% OINT.(GM) KENALOG TRIAMCINOLONE ACETONIDE 0.5% CREAM(GM) KENALOG IN ORABASE TRIAMCINOLONE ACETONIDE 0.1% PASTE KENALOG-40 TRIAMCINOLONE ACETONIDE 40MG/ML VIAL ORALONE TRIAMCINOLONE ACETONIDE 0.1% PASTE TRIAM-A TRIAMCINOLONE ACETONIDE 40MG/ML VIAL TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.025% CREAM(GM) TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.025% LOTION TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.025% OINT.(GM) TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% CREAM(GM) TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% LOTION TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% OINT.(GM) TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.1% PASTE TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.5% CREAM(GM) TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 0.5% OINT.(GM) TRIAMCINOLONE ACETONIDE TRIAMCINOLONE ACETONIDE 40MG/ML VIAL ARISTOCORT FORTE TRIAMCINOLONE DIACETATE 40MG/ML VIAL CENOCORT FORTE SUSPENSION TRIAMCINOLONE DIACETATE 40MG/ML VIAL TRIAM FORTE TRIAMCINOLONE DIACETATE 40MG/ML VIAL TRIAMCINOLONE DIACETATE TRIAMCINOLONE DIACETATE 40MG/ML VIAL U-TRI-LONE TRIAMCINOLONE DIACETATE 40MG/ML VIAL HALCION TRIAZOLAM 0.125MG TABLET HALCION TRIAZOLAM 0.25MG TABLET TRIAZOLAM TRIAZOLAM 0.125MG TABLET TRIAZOLAM TRIAZOLAM 0.25MG TABLET NAQUA TRICHLORMETHIAZIDE 4MG TABLET TRICHLORMETHIAZIDE TRICHLORMETHIAZIDE 4MG TABLET STELAZINE TRIFLUOPERAZINE HCL 2MG TABLET STELAZINE TRIFLUOPERAZINE HCL 5MG TABLET TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL 10MG TABLET TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL 1MG TABLET TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL 2MG TABLET TRIFLUOPERAZINE HCL TRIFLUOPERAZINE HCL 5MG TABLET TRIFLURIDINE TRIFLURIDINE 1% DROPS TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 2MG TABLET TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 2MG/5ML ELIXIR TRIHEXYPHENIDYL HCL TRIHEXYPHENIDYL HCL 5MG TABLET TIGAN TRIMETHOBENZAMIDE HCL 100MG SUPP.RECT TRIMETHOBENZAMIDE HCL TRIMETHOBENZAMIDE HCL 100MG/ML DISP SYRIN PROLOPRIM TRIMETHOPRIM 100MG TABLET PROLOPRIM TRIMETHOPRIM 200MG TABLET TRIMETHOPRIM TRIMETHOPRIM 100MG TABLET MYDRAL TROPICAMIDE 0.5% DROPS MYDRAL TROPICAMIDE 1% DROPS MYDRIACYL TROPICAMIDE 0.5% DROPS MYDRIACYL TROPICAMIDE 1% DROPS TROPICAMIDE TROPICAMIDE 0.5% DROPS TROPICAMIDE TROPICAMIDE 1% DROPS TUBERSOL TUBERCULIN,PURIF.PROT.DERIV. 5T U/0.1ML VIAL TUBOCURARINE CHLORIDE TUBOCURARINE CHLORIDE 3MG/ML VIAL IRRIGATING SOLUTION G UROLOGIC SOLUTION-G IRRIG SOLN UROLOGIC G IRRIGATION W/HANGER UROLOGIC SOLUTION-G IRRIG SOLN Page 75 MAC list as of February 03.xls
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Alabama Medicaid Maximum Allowable Cost List

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