United Mine Workers of America Health and Retirement Funds 2021 UPDATED 01/01/2021 INTRODUCTION .............................................................................................................................................................................. 5 NONDISCRIMINATION STATEMENT ............................................................................................................................................. 5 PREFACE ......................................................................................................................................................................................... 8 PHARMACY AND THERAPEUTICS (P&T) COMMITTEE .............................................................................................................. 8 PRODUCT SELECTION CRITERIA ................................................................................................................................................. 8 DRUG LIST PRODUCT DESCRIPTIONS ........................................................................................................................................ 8 GENERIC SUBSTITUTION .............................................................................................................................................................. 9 PREFERRED PRODUCT PROGRAM ............................................................................................................................................. 9 ADVANCED CONTROL SPECIALTY FORMULARY .................................................................................................................... 11 SPECIFIC LIMITATIONS AND EXCLUSIONS .............................................................................................................................. 11 PRESCRIPTION QUANTITY LIMITS ............................................................................................................................................. 13 SPECIALTY PHARMACY .............................................................................................................................................................. 14 NOTICE .......................................................................................................................................................................................... 14 LEGEND ......................................................................................................................................................................................... 14 FUNDS' WEBSITE ......................................................................................................................................................................... 14 ANALGESICS ................................................................................................................................................................................ 16 ANALGESICS, OTHER ......................................................................................................................................................... 16 NSAIDs .................................................................................................................................................................................. 16 NSAIDs, COMBINATIONS .................................................................................................................................................... 16 NSAIDs, TOPICAL ................................................................................................................................................................ 16 COX-2 INHIBITORS .............................................................................................................................................................. 16 GOUT .................................................................................................................................................................................... 16 OPIOID ANALGESICS .......................................................................................................................................................... 16 NON-OPIOID ANALGESICS ................................................................................................................................................. 17 VISCOSUPPLEMENTS......................................................................................................................................................... 17 ANTI-INFECTIVES ......................................................................................................................................................................... 17 ANTIBACTERIALS ................................................................................................................................................................ 18 ANTIFUNGALS ..................................................................................................................................................................... 19 ANTIMALARIALS .................................................................................................................................................................. 19 ANTIRETROVIRAL AGENTS................................................................................................................................................ 19 ANTITUBERCULAR AGENTS .............................................................................................................................................. 20 ANTIVIRALS ......................................................................................................................................................................... 20 MISCELLANEOUS ................................................................................................................................................................ 21 ANTINEOPLASTIC AGENTS ........................................................................................................................................................ 21 ALKYLATING AGENTS ........................................................................................................................................................ 21 ANTIMETABOLITES ............................................................................................................................................................. 21 HORMONAL ANTINEOPLASTIC AGENTS .......................................................................................................................... 22 KINASE INHIBITORS ............................................................................................................................................................ 22 MULTIPLE MYELOMA .......................................................................................................................................................... 23 MISCELLANEOUS ................................................................................................................................................................ 23 CARDIOVASCULAR ...................................................................................................................................................................... 23 ACE INHIBITORS ................................................................................................................................................................. 23 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS .................................................................................. 24 ACE INHIBITOR/DIURETIC COMBINATIONS ..................................................................................................................... 24 ADRENOLYTICS, CENTRAL ................................................................................................................................................ 24 ALDOSTERONE RECEPTOR ANTAGONISTS .................................................................................................................... 24 ALPHA BLOCKERS .............................................................................................................................................................. 24 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS .................................................................... 24 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ................................... 25 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ................. 25 ANTIARRHYTHMICS ............................................................................................................................................................ 25 ANTILIPEMICS ..................................................................................................................................................................... 25 BETA-BLOCKERS ................................................................................................................................................................ 26 BETA-BLOCKER/DIURETIC COMBINATIONS .................................................................................................................... 26 CALCIUM CHANNEL BLOCKERS........................................................................................................................................ 27 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS