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In a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without being subject to the plan’s deductible. For drugs on the preventive drug list, you pay only the generic, brand formulary, or brand non-formulary coinsurance percentage described in your plan summary. This list is periodically reviewed and updated to ensure that the drugs listed meet the criteria for inclusion. Because this list is subject to change, please log in to www.express-scripts.com/boeing to check the status of the medications you take. Medications must be covered by your plan to be eligible for the preventive medication program. Preventive medications list PDL4833D

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Page 1: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

In a high-deductible health plan like Boeing’s Advantage + health plan,federal rules permit certain preventive drugs to be paid without beingsubject to the plan’s deductible. For drugs on the preventive drug list, you pay only the generic, brandformulary, or brand non-formulary coinsurance percentage described inyour plan summary.This list is periodically reviewed and updated to ensure that the drugslisted meet the criteria for inclusion. Because this list is subject tochange, please log in to www.express-scripts.com/boeing to check thestatus of the medications you take.Medications must be covered by your plan to be eligible for the preventive medication program.

Preventive medications list

PDL4833D

Page 2: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

Aacarboseacebutolol hclacetazolamideADVAIR DISKUSADVAIR HFAafeditab CRAGGRENOXalbuterolalbuterol sulfatealendronate sodiumamantadineamiloride hclamiloride hcl-hctzaminophyllineamlodipine atorvastatinamlodipine besylateamlodipine besylate-benazeprilAMTURNIDEanagrelideanastrozoleARCAPTA NEOHALERand metersASMANEXATELVIAatenololatenolol-chlorthalidoneatorvastatinatovaquone/proguanil hclATROVENT HFAAUVI-QAZOR

Bbenazepril hclbenazepril hcl-hctz

BENICARBENICAR HCTbetaxolol hclbisoprolol fumaratebisoprolol-hydrochlorothiazideBREO ELLIPTABRILINTAbudesonidebumetanidebuproban SRbupropion SRBYDUREONBYETTABYSTOLIC

Ccandesartan cilexetilcandesartan- hydrochlorothiazidecalcitonin, salmoncaptoprilcaptopril-hydrochlorothiazide CARTIA XT carvedilolCHANTIXchloroquine chlorothiazidechlorpropamidechlorthalidonecholestyraminecholestyramine light cilostazol clonidineclopidogrelcholestyraminecholestyramine lightcilostazol

The following section lists generic and brand formulary drugs.

Some brand drugs may change to non-formulary status during the year.

Page 3: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

C (continued)clonidineclopidogrelCOARTEMcolestipol hclCOMBIVENTCOREG CRCRESTORcromolyn sodium

DDALIRESPDARAPRIMDEMSERDIBENZYLINEdifil-Gdilex-GDILT-CDDILTIA XTdiltiazem CDdiltiazem ERdiltiazem hcldiltiazem SRDILT-XRDILTZAC ERdipyridamoledoxazosinDULERAdyflex-Gdylix

EEFFIENTELIQUISenalapril maleateenalapril maleate-hctzenoxaparin sodium

epinephrine pen injectionEPIPENEPIPEN JR.eplerenoneepoprostenol sodiumetidronateEXFORGEEXFORGE HCTexemestane

FFASLODEXFAST TAKE TEST STRIPSfelodipine ERfenofibratefenofibrate micronizedfenofibric acidFLUMISTflu vaccinesfluvastatinfolic acidfondaparinux sodiumFORADILFORTICALFORTEOfosinopril sodiumfosinopril-hydrochlorothiazidefurosemide

Ggemfibrozilglimepirideglipizideglipizide ERglipizide XLglipizide-metforminglucose tabletsGLUCAGON EMERGENCY KIT

The following section lists generic and brand formulary drugs.

Some brand drugs may change to non-formulary status during the year.

Page 4: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

G (continued)glucose tabletsGLUCAGON EMERGENCY KITglyburideglyburide micronizedglyburide-metformin hclguanabenz acetateguanfacine hcl

Hheparin sodiumHUMALOGHUMALOG MIX 50/50HUMALOG MIX 75/25HUMULINHUMULIN 70/30HUMULIN Rhydralazinehydrochloroquine sultatehydrochlorothiazide

Iibandronate sodiumimmune globulinsindapamideipratropium bromideipratropium-albuterolirbesartanirbesartan-hctzisradipine

JjantovenJANUMETJANUMET XRJANUVIAJENTADUETO

JUXTAPID

KKOMBIGLYZE XR

Llabetalol hclLANTUS SoloSTAR cartridgeLANTUS vialletrozolelevalbuterol hclLEVEMIRLIPOFENLIPTRUZETlisinoprillisinopril-hydrochlorothiazidelosartanlosartan-hctzlovastatinLOVAZA

Mmatzim LAmefloquine hclmetaproterenolmetformin hclmetformin hcl ERmetazolamidemethyclothiazidemethyldopamethyldopa-hydrochlorothiazidemetoprolol succinatemetoprolol tartratemetoprolol SRmetoprolol-hydrochlorothiazideminoxidilmoexipril hclmoexipril-hydrochlorothiazide

The following section lists generic and brand formulary drugs.

Some brand drugs may change to non-formulary status during the year.

Page 5: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

M (continued)montelukast sodium

Nnadololnadolol-bendroflumethiazidenateglinidenicardipine hclnifediac ccnifedical XLnifedipine CRnifedipine ERnifedipine SRnimodipinenislodipine

OONE TOUCH strips and metersONGLYZA

Ppamidronatepapaverinepediatric multi-vit w/fluoridepediatric multi-vit w/fluoride& ironPERFOROMISTperindopril erbuminepindololpioglitazone hclpioglitazone hcl-glimeprimidepioglitazone hcl-metformin hclPNEUMOVAX 23PRADAXAPRANDIMETpravastatin sodiumprazosin

prenatal vitamin (generic)prevalitePRIMAQUINEPROAIR HFAPROGLYCEMpropranolol hclpropranolol SRpropranolol hcl w/hctzPULMICORT FLEXHALER

Qquinapril hclquinapril-hydrochlorothiazidequinine sulfateQVAR

Rraloxiphene hclramaprilRELENZArepaglinidereserpinerimantadine hclrisedronate sodiumRIOMET

SSEREVENTSIMCORsimvastatinsodium fluoridesorinesotalolsotalol AFspironolactoneSPIRIVA

The following section lists generic and brand formulary drugs.

Some brand drugs may change to non-formulary status during the year.

Page 6: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

S (continued)spironolactone-hctzSURESTEP TEST STRIPSSYMBICORTSYMLINSYMLINPENSYNAGIS

TTAMIFLUtamoxifen citratetaztia xtTEKAMLOTEKTURNATEKTURNA HCTterazosinterbutaline sulfatetheochronticlopidine HCltimolol maleatetheophyllinetolazamidetolbutamidetorsemideTRADJENTA trandolapriltrandolapril-verapamiltriamterene-hctzTRIBENZORTRILIPIXTUDORZA

Vvalsartanvalsartan-hctzVALTURNA

VASCEPAVELETRIVENTOLIN HFAverapamil ERverapamil hclVYTORIN

Wwarfarin sodiumWELCHOL

XXARELTOXGEVA

ZzafirlukastZETIAzolendronic acidZOSTAVAX

The following section lists generic and brand formulary drugs.

Some brand drugs may change to non-formulary status during the year.

Page 7: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

AACCOLATEACCU-CHEK strips and metersACCUNEBACCUPRILACCURETICACEONACTONELACTOPLUS METACTOPLUS MET XRACTOSADALAT CCADRENACLICKADVICORAEROBIDAEROBID-MAGRYLINALDACTAZIDEALDACTONEALTACEALTOPREVALVESCOAMARYLANTARAAPIDRAAPIDRA SOLOSTARARALEN PHOSPHATEAREDIAARIMIDEXARIXTRAAROMASINASCENTIA strips and metersATACANDATACAND HCTAVALIDEAVANDAMET

AVANDARYLAVANDIAAVAPRO

BBETAPACEBETAPACE AFBIDILBINOSTROBONIVABREEZE 2 strips and metersBRONCOMAR-1BROVANAbudesonide

CCADUETCALANCALAN SRCARDENECARDENE SRCARDIZEMCARDIZEM CDCARDIZEM LACARDURACARDURA XLCATAPRESCATAPRES TTSCLORPRESCOLESTIDCONTOUR STRIPS AND METERSCOREGCORGARDCORZIDECOVERA-HSCOZAARCYCLOSET

The following section lists non-formulary brand drugs.

Some brand drugs may change to non-formulary status during the year.

Page 8: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

DDEMADEXDIABETADIAMOXDIDRONELDILACOR XRDIOVANDIOVAN HCTDIURILDUETACTDUONEBDYNACIRC CRDYAZIDEDYRENIUM

EEDARBIEDARBYCLOREDECRINENDURONEVISTA

FFARESTONFEMARAFENOGLIDEFIBRICORFLOLANFLOVENT DISKUSFLOVENT HFAFLUMADINEFORTAMETFOSAMAXFOSAMAX PLUS DFRAGMINFREE STYLE TEST STRIPS

GGANITEGASTROCROMGLUCAGENGLUCOPHAGEGLUCOPHAGE XRGLUCOTROLGLUCOTROL XLGLUCOVANCEGLUMETZAGLYNASEGLYSET

HHYTRINHYZAAR

IINDERALINDERAL LAINDERIDEINNOPRAN XLINOHEPINSPRAINTALINTROLIPRIVASKISOPTIN SR

JJUVISYNC

KKAZANOKERLONE

The following section lists non-formulary brand drugs.

Some brand drugs may change to non-formulary status during the year.

Page 9: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

LLASIXLESCOLLESCOL XLLEVATOLLIPITORLIVALOLOFIBRALOPIDLOPRESSORLOPRESSOR HCTLOTENSINLOTENSIN HCTLOTRELLOVENOXLUFYLLINLUFYLLIN GG

MMALARONEMAVIKMAXAIR AUTOHALERMAXZIDEMETAGLIPMEVACORMIACALCIN nasal sprayMICARDISMICARDIS HCTMICRONASEMICROZIDEMIDAMORMINIPRESMONOPRILMONOPRIL HCT

NNEPTAZANENESINANEXICLON XRNIASPANNICOTROL NSNIMOTOPNORVASCNOVOLINNOVOLOGNOVOLOG MIX 70/30NYMALIZE

OOSENI

PPERSANTINEPLAVIXPLAQUINILPLENDILPLETALPRANDINPRAVACHOLPRECOSEPRECISION QID strips andmetersPRECISION PCX stripsPRECISION XTRA stripsPRECOSEPRESTIGE SMART strips andmetersPRINIVILPRINZIDEPROCARDIAPROCARDIA XL

The following section lists non-formulary brand drugs.

Some brand drugs may change to non-formulary status during the year.

Page 10: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

PROGLYCEMPROLIAPROVENTIL HFAPULMICORT

QQUESTRANQUESTRAN LIGHTquinaretic

RRECLASTRELIONREMODULIN

SSECTRALSKELIDSINGULAIRSOLTAMOXSTARLIXSULAR

TTARKATENEXTENORETIC 100-25TENORETIC 50-25TENORMIN tabletTEVETENTEVETEN HCTTHALITONETHEO-24TIAZACTOPROL XLTRANDATETRIGLIDETRUETRACK strips and meters

TWYNSTA

UUNIPHYLUNIRETICUNIVASC

VVASERETICVASOTECVENTOLIN HFAVERELANVERELAN PMVERELAN SRVICTOZAVOSPIRE ER

XXOLAIRXOPENEXXOPENEX HFA

ZZAROXOLYNZEBETAZESTORETICZESTRILZIACZOCORZOMETAZYBANZYFLOZYFLO CR

The following section lists non-formulary brand drugs.

Some brand drugs may change to non-formulary status during the year.

Page 11: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without
Page 12: Preventive medications list - Express Scripts a high-deductible health plan like Boeing’s Advantage + health plan, federal rules permit certain preventive drugs to be paid without

*0000000PDL4833D**0000000PDL4833D*

Express Scripts manages your prescription benefit for The Boeing Company.

All rights in the product names of all third-party products appearing here, whether or not appearing with the trademark symbol, belong exclusively to their respective owners.

PDL4833D 9.14


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