Screening, Assesssment and Support Services (SASS) Program Approved Pharmaceutical Classes for Non-Medicaid Covered Children/Adolescents THERAPEUTIC CLASS CODE DESCRIPTION LABEL NAME HYPOTENSIVES, SYMPATHOLYTIC CLONIDINE (CATAPRES) GUANFACINE (TENEX) CENTRAL NERVOUS SYSTEM STIMULANTS DOXAPRAM (DORPRAM) SEDATIVE-HYPNOTICS, NON-BARBITURATE CHLORAL HYDRATE DORAL ESTAZOLAM (PROSOM) FLURAZEPAM (DALMANE) LORAZEPAM (ATIVAN) LUNESTA MIDAZOLAM (VERSED) TEMAZEPAM (RESTORIL) TRIAZOLAM (HALCION) ZALEPLON (SONATA) ZOLPIDEM (AMBIEN) ANTI-PSYCHOTICS, PHENOTHIAZINES CHLORPROMAZINE (THORAZINE) FLUPHENAZINE DEC (PROLIXIN DEC) FLUPHENAZINE (PROLIXIN) PERPHENAZINE (TRILAFON) THIORIDAZINE (MELLARIL) TRIFLUOPERAZINE (STELAZINE) BIPOLAR DISORDER DRUGS EQUETRO LITHIUM CARBONATE (ESKALITH, LITHOBID) LITHIUM CITRATE SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) CITALOPRAM (CELEXA) ESCITALOPRAM (LEXAPRO) FLUOXETINE (PROZAC) FLUOXETINE WEEKLY (PROZAC WEEKLY) FLUVOXAMINE (LUVOX) PAROXETINE (PAXIL) PEXEVA SERTALINE (ZOLOFT) Page 1 of 4 Revised 04/17/2012 Screening, Assesssment and Support Services (SASS) Program Approved Pharmaceutical Classes for Non-Medicaid Covered Children/Adolescents THERAPEUTIC CLASS CODE DESCRIPTION LABEL NAME TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB AMITRIPTYLINE (ELAVIL) AMOXAPINE (ASENDIN) CLOMIPRAMINE (ANAFRANIL) DESIPRAMINE (NORPRAMIN) DOXEPIN (ADAPIN, SINEQUAN) IMIPRAMINE (TOFRANIL, TOFRANIL PM) MAPROTILINE (LUDIOMIL) NORTRIPTYLINE (PAMELOR, AVENTYL) PROTRIPTYLINE (VIVACTIL) TRIMIPRAMINE (SURMONTIL) TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY DEXMETHYLPHENIDATE (FOCALIN) FOCALIN XR METHYLPHENIDATE (CONCERTA,DAYTRANA, METADATE, METHYLIN, RITALIN) TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINE COMBINATNS AMITRIPTYLINE-PERPHENAZINE (TRIAVIL) TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS AMITRIPTYLINE-CHLORDIAZEPOXIDE (LIMBITROL) ANTICONVULSANTS BANZEL CARBAMAZEPINE (TEGRETOL) CELONTIN CLONAZEPAM (KLONOPIN) DIAZEPAM RECTAL (DIASTAT) DIVALPROEX (DEPAKOTE) ETHOSUXIMIDE (ZARONTIN) FELBAMATE (FELBATOL) FOSPHENYTOIN (CEREBYX) GABAPENTIN (NEURONTIN) GABITRIL LAMOTRIGINE (LAMICTAL) LEVETIRACETAM (KEPPRA) LYRICA MEBARAL ONFI OXCARBAZEPINE (TRILEPTAL) PEGANONE PHENYTOIN (DILANTIN) PRIMIDONE (MYSOLINE) SABRIL TOPIRAMATE (TOPAMAX) Page 2 of 4 Revised 04/17/2012 Screening, Assesssment and Support Services (SASS) Program Approved Pharmaceutical Classes for Non-Medicaid Covered Children/Adolescents THERAPEUTIC CLASS CODE DESCRIPTION LABEL NAME VALPROIC ACID (DEPAKENE, STAVZOR) VIMPAT ZONISAMIDE (ZONEGRAN) ANTIPARKINSONISM DRUGS, ANTICHOLINERGIC BENZTROPINE (COGENTIN) TRIHEXYPHENIDYL (ARTANE) ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS MIRTAZAPINE (REMERON) SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) CYMBALTA PRISTIQ VENLAFAXINE (EFFEXOR, EFFEXOR XR) NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION (WELLBUTRIN, WELLBUTRIN XR) SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NEFAZODONE (SERZONE) TRAZODONE (DESYREL) MAOIS - NON-SELECTIVE & IRREVERSIBLE MARPLAN PHENELZINE (NARDIL) TRANYLCYPROMINE (PARNATE) ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS, BUTYROPHENONES DROPERIDOL (INAPSINE) HALOPERIDOL DEC (HALDOL DEC) HALOPERIDOL LAC (HALDOL) HALOPERIDOL (HALDOL) ANTIPSYCHOTICS, DOPAMINE ANTAGONISTS, THIOXANTHENES THIOTHIXENE (NAVANE) ANTIPSYCH,DOPAMINE ANTAG.,DIPHENYLBUTYLPIPERIDINES ORAP ANTIPSYCHOTICS, DOPAMINE ANTAGONST,DIHYDROINDOLONES MOBAN ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG CLOZAPINE (CLOZARIL,FAZACLO) FANAPT INVEGA ER INVEGA SUSTENNA LATUDA OLANZAPINE (ZYPREXA, ZYPREXA RELPREV) QUETIAPINE (SEROQUEL) RISPERDAL CONSTA RISPERIDONE (RISPERDAL ) Page 3 of 4 Revised 04/17/2012 Screening, Assesssment and Support Services (SASS) Program Approved Pharmaceutical Classes for Non-Medicaid Covered Children/Adolescents THERAPEUTIC CLASS CODE DESCRIPTION LABEL NAME SAPHRIS ZIPRASIDONE (GEODON) ANTIPSYCHOTICS, DOPAMINE & SEROTONIN ANTAGONISTS LOXAPINE (LOXITANE) ANTIPSYCHOTICS, ATYP,D2 PARTIAL AGONIST/5HT MIXED ABILIFY TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE STRATTERA SSRI &ANTIPSYCH,ATYP,DOPAMINE&SEROTONIN ANTAG COMB SYMBYAX ADRENERGICS, AROMATIC, NON-CATECHOLAMINE AMPHETAMINE SALTS (ADDERALL, ADDERALL XR) D-AMPHETAMINE (DEXEDRINE) METHAMPHETAMINE (DESOXYN) VYVANSE BETA-ADRENERGIC BLOCKING AGENTS ACEBUTOLOL (SECTRAL) ATENOLOL (TENORMIN) BETAXOLOL (KERLONE) BISOPROLOL (ZEBETA) BYSTOLIC ESMOLOL (BREVIBLOC) LEVATOL METOPROLOL (LOPRESSOR, TOPROL XL) NADOLOL (CORGARD) PINDOLOL (VISKEN) PROPRANOLOL (INDERAL, INNOPRAN) SOTALOL (BETAPACE) TIMOLOL (BLOCADREN) Page 4 of 4 Revised 04/17/2012.