Access Plans High Risk Prescription List

Home , Fingolimod, Lenalidomide, Pomalidomide

This document is to help you as a broker find the most appropriate plan for your clients. It lists high-cost prescriptions whose use could potentially trigger a higher rate for Access plan members. While Access plans are guaranteed issue and all applicants are offered coverage, your clients who have a condition on this list may likely find an Affordable Care Act (ACA) plan to better suit their needs. BRAND NAME GENERIC NAME INDICATION Adempas Riociguat Pulmonary arterial hypertension (PAH) Afinitor Everolimus Oncology - breast cancer, neuroendocrine tumors of gastrointestinal, lung or pancreatic origin, advanced renal cell carcinoma, astrocytoma Alecensa Alectinib Oncology - small cell lung cancer Alunbrig Brigatinib Oncology - small cell lung cancer Ampyra Dalfampridine ER Multiple sclerosis tablets Aralast NP Alpha-1-Proteinase Alpha-1 antitrypsin deficiency Inhibitor Atripla Efavirenz/ Human immunodeficiency virus (HIV) Emtricitabine/ Tenofovir Aubagio Teriflunomide Multiple sclerosis Austedo Deutetrabenazine Huntington's disease Avonex Interferon Beta-1a Multiple sclerosis Avonex Pen Interferon Beta-1a Multiple sclerosis Benlysta Belimumab Systemic lupus erthematosus (SLE) Betaseron Interferon beta - 1b Multiple sclerosis Bosulif Bosutinib oncology - chronic myelogenous leukemia (CML) Braftovi Encorafenib oncology - melanoma Buphenyl Sodium Urea cycle disorders Phenylbutyrate Cabometyx Cabozantinib Oncology - thyroid, kidney and liver cancer Calquence Acalabrutinib Oncology - lymphoma Capecitabine Generic Xeloda Oncology - breast, colon and rectal Cancer Cayston Aztreonam Cystic fibrosis Cerdelga Eliglustat Gaucher disease Cimzia Prefilled Certolizumab Pegol Ankylosing spondylitis, Crohn's, psoriatic arthritis, (injection) rheumatoid arthritis Cimzia Starter Kit Certolizumab Pegol Ankylosing spondylitis, Crohn's, psoriatic arthritis, (injection) rheumatoid arthritis Cometriq Cabozantinib Oncology - thyroid, kidney and liver cancer Complera Emtricitabine/ Human immunodeficiency virus (HIV) Rilpivirine/ Tenofovir Disoproxil Fumarate tablets Copaxone Glatiramer Multiple sclerosis Cosentyx Secuklinumab Ankylosing spondylitis, psoriatic arthritis (injection) Cotellic Cobimetinib Oncology - melanoma Dupixent Dupilumab Asthma, eczema Enbrel Etanercept Psoriatic arthritis, rheumatoid arthritis

Enbrel Sureclick Etanercept Rheumatoid arthritis Epclusa Sofosbuvir and Hepatitis C Velpatasir Erivedge Vismodegib Oncology - metastatic basal cell carcinoma (BCC) Erleada Apalutamide Oncology - prostate cancer Esbriet Pirfenidone Idiopathic pulmonary fibrosis (IPF) Extavia Interferon Beta - 1b Multiple sclerosis Fasenra Benralizumab Asthma Firazyr Icatibant - Hereditary andioedema (HAE) subcutaneous (SC) injection FORTEO Teriparatide Bone fractures Gammagard S/D Less IgA Immune Globulin Immune system disorders Genotropin Somatropin Growth hormone Gilenya Fingolimod Multiple sclerosis Hydrochloride - oral Gilotrif Afatinib Oncology - metastatic non-small cell lung cancer Glatiramer Glatiramer Multiple sclerosis Glatopa Glatopa Multiple sclerosis Gleevec Imatinib Oncology - leukemias, myelodysplastic syndromes Haegarda Human C1- Esterase Hereditary andioedema (HAE) inhibitor Harvoni Sofosbuvir/Ledipasvir Hepatitis C Humate-P Antihemophilic Factor Hemophilia A Humatrope Somatropin Growth hormone Humira Adalimumab Ankylosing spondylitis, Crohn's, psoriatic arthritis, ulcerative colitis Humira Pen Adalimumab Ankylosing spondylitis, Crohn's, psoriatic arthritis, ulcerative colitis Humira Pen Adalimumab Ankylosing spondylitis, Crohn's, psoriatic arthritis, ulcerative colitis Ibrance Palbociclib Oncology - metastatic breast cancer Iclusig Ponatinib Oncology - chronic myelogenous leukemia (CML), acute lymphoblastic leukemia (ALL) Ilaris Monoclonal Autoinflammatory syndromes, Crohn's disease, antibodies rheumatoid arthritis Imatinib mesylate Imatinib mesylate Oncology - leukemias, myelodysplastic syndromes Ingrezza Valbenazine Tardive dyskinesia Invega Trinza Paliperidone Schizophrenia (given as injection every 3 months) Jadenu Deferasirox Transfusional iron overload, non transfusion-dependent thalassemia Jakafi Ruxolitinib Myelofibrosis, polycythemia vera Jynarque Tolvaptan Treat low sodium levels in blood Keveyis Dichlorphenamide Periodic paralysis (muscle weakness) Kevzara Sarilumab Rheumatoid arthritis Kineret Anakinra Rheumatoid arthritis

Kisqali Ribociclib Oncology - breast cancer Kuvan Sapropterin Phenylketonuria (PKU) Lenvima Lenvatinib Oncology - endometrial, kidney, liver, thyroid cancer Lenvima Lenvatinib Oncology - thyroid, kidney cancer Letairis Ambrisentan Pulmonary arterial hypertension (PAH) Lonsurf Trifluridine Oncology - colon, rectal and stomach cancer Lupron Depot Leuprolide Oncology - prostate cancer, endometriosis, fibroids Lynparza Olaparib Oncology - ovarian cancer Mavyret Glecaprevir, Hepatitis C Pibrentasvir Mekinist Trametinib Oncology - melanoma, leukemia, breast, lung and renal cancers Mektovi Binimetinib Oncology - melanoma Nerlynx Neratinib Oncology - breast cancer Neulasta Pegfilgrastim Prevention of chemotherapy-induced neutropenia NexAVAR Sorafenib Oncology - liver, kidney and thyroid cancer Ninlaro Ixazomib Oncology - multiple myeloma Norditropin FlexPro Somatropin Growth hormone Nucala Mepolizumab Asthma Nutropin AQ NuSpin 20 Somatropin Growth hormone Ocaliva Obeticholic Acid Primary biliary cholangitis, cirrhosis Odomzo Sonidegib Oncology - basal cell carcinoma Ominitrope Somatropin Growth hormone Opsumit Macitentan Pulmonary arterial hypertension (PAH) Orencia Abatacept Psoriatic arthritis, rheumatoid arthritis, ulcerative colitis Orencia ClickJect Abatacept Psoriatic arthritis, rheumatoid arthritis Orkambi Lumacaftor or Cystic fibrosis Ivacaftor Otezla Apremilast placque psoriasis, psoriatic arthritis Palynziq Pegvaliase PKU - phenylketonuria Phenoxybenzamine HCl Phenoxybenzamine Pheochromocytoma Pomalyst Pomalidomide Oncology - multiple myeloma Pulmozyme Dornase Alfa Cystic fibrosis Rebif Interferon Beta-1a Multiple sclerosis Rebif Rebidose Interferon Beta - 1a Multiple sclerosis Remicade Infliximab Ankylosing spondylitis, arthritis, Crohn's, plaque psoriasis, ulcerative colitis Renflexis Infliximab Ankylosing spondylitis, arthritis, Crohn's, plaque psoriasis, ulcerative colitis Revatio Sildenafil Pulmonary arterial hypertension (PAH) Revlimid Lenalidomide Oncology - multiple myeloma, mantle cell lymphoma, myelodysplatic syndomes Reyataz Atazanavir Human immunodeficiency virus (HIV) Rubraca Rucaparib Oncology - ovarian cancer Saizen Click.Easy Somatropin Growth hormone Saizenprep Somatropin Growth hormone SandIMMUNE Cyclosporine Prevent rejection of transplanted organ/tissue

Siliq Brodalumab Psoriasis Simponi Golimumab Ankylosing spondylitis, psoriatic arthritis, rhematoid arthritis, ulcerative colitis Somatuline Depot Lanreotide Acromegaly, carcinoid syndrome, neuroendocrine tumors Somavert Pegvisomant Acromegaly Sovaldi Sofosbuvir Hepatitis C Sprycel Dasatinib Oncology - chronic myeloid leukemia (CML), acute lymphoblastic leukemia (ALL) Stelara Ustekinumab Plaque psoriasis and psoriatic arthritis, Crohn's disease Strensiq Asfotase Alfa Hypophosphatasia (HPP) Sucraid Sacrosidase Congenital sucrase-isomalase deficiency (CSID) Sutent Sunitinib Oncology - digestive GIST tumors, kidney cancer, neuroendocrine tumors Symdeko Tezacaftor/Ivacaftor Cystic fibrosis SymlinPen 120 Pramlintide Diabetes (Type 1 and Type 2) Tadalafil (PAH) Tadalafil Pulmonary arterial hypertension (PAH) Tafinlar Dabrafenib Oncology - melanoma, Tagrisso Osimertinib Oncology - non-small cell lung cancer Taltz Ixekizumab Ankylosing spondylitis, psoriasis, psoriatic arthritis Tarceva Erlotinib Oncology - non-small cell lung cancer, pancreatic cancer Tecfidera Dimethyl Fumarate Multiple sclerosis Temozolomide Temozolomide Oncology - brain cancer Tetrabenazine Tetrabenazine Huntington's disease Thalomid Thalidomide Multiple myeloma Tracleer Bosentan Pulmonary hypertension Tremfya Guselkumab Plaque psoriasis Tykerb Lapatinib Oncology - breast cancer Tysabri Natalizumab Multiple sclerosis Tyvaso Starter Treprostinil Pulmonary arterial hypertension (PAH) Uptravi Selexipag Pulmonary arterial hypertension (PAH) Vemlidy Tenofovir Hepatitis B Alafenamide Venclexta Venetoclax Oncology - chronic lymphocytic leukemia, small lymphoctic lymphoma, acute myelogenous leukemia Verzenio Abemaciclib Oncology - breast cancer Vigabatrin Vigabatrin Epilepsy Vosevi Sofosbuvir, Hepatitis C Velpatasvir, Voxilaprvir Votrient Pazopanib Oncology - renal cancer, soft tissue sarcoma Xalkori Crizotnib Oncology - non-small cell lung cancer Xeljanz Tofacitinib Psoriatic arthritis, rheumatoid arthritis, ulcerative colitis Xeljanz XR Tofacitinib Psoriatic arthritis, rheumatoid arthritis Xenazine Tetrabenazine Huntington's disease Xiaflex Collagenase Dupuytren's contracture Xolair Omalizumab Asthma, allergic, chronic hives

Xtandi Enzalutamide Oncology - prostate cancer, metastatic Xyrem Sodium Oxybate Narcolepsy Zegerid Omeprazole/ Erosive esophagitis, duodenal ulcers, gastric, GERD Sodium Bicarbonate Zejula Niraparib Oncology - ovarian cancer, fallopian tube cancer, peritoneal cancer Zelboraf Vemurafenib Oncology - melanoma Zepatier Elbasvir, Grazoprevir Hepatitis C Zileuton ER Zileuton Asthma