Effective 11/4/2019 Guide to low-cost prescriptions Low ...

Effective 11/4/2019

Guide to low-cost prescriptions

Low-cost

drugs available

starting at:

4 10

$

$

30 day

90 day

prescriptions

Check pharmacy counter for details. ?*

Diabetes

$4

$10

30 Day Qty 90 Day Qty

GLIMEPIRIDE 1MG, 2MG, 4MG

30

90

GLIPIZIDE 5MG, 10MG

60

180

METFORMIN 500MG, 850MG, 1000MG

60

180

METFORMIN ER 500MG TAB

120

360

METFORMIN ER 750MG TAB

60

180

GLIPIZIDE ER 2.5MG, 5MG, 10MG

GLYBURIDE/METFORMIN

2.5/500MG, 5/500MG

PIOGLITAZONE 15MG, 30MG, 45MG

$9

$24

30

90

$9

$24

$15

$38

$4

$10

60

30

90

30

180

90

270

90

30 Day Qty 90 Day Qty

30

90

60

180

Heart

Cholesterol

FENOFIBRATE 145MG

GEMFIBROZIL 600MG

SIMVASTATIN 10MG, 20MG, 40MG

30 Day Qty 90 Day Qty

30

90

60

180

30

90

Cholesterol

ATORVASTATIN 10MG, 20MG, 40MG

30 Day Qty 90 Day Qty

30

90

Heart Health & Blood Pressure

ATENOLOL 25MG, 50MG, 100MG

BENAZEPRIL 20MG, 40MG

CARVEDILOL 3.125MG, 6.25MG,

12.5MG, 25MG

CLONIDINE 0.1MG, 0.2MG, 0.3MG

FUROSEMIDE 20MG, 40MG, 80MG

HYDRALAZINE 10MG, 25MG, 50MG

HYDROCHLOROTHIAZIDE 12.5MG,

25MG, 50MG TAB

30 Day Qty 90 Day Qty

30

90

30

90

60

180

HYDROCHLOROTHIAZIDE 12.5MG CAP

INDAPAMIDE 1.25MG, 2.5MG

ISOSORBIDE MONONITRATE ER

30MG, 60MG

LISINOPRIL 2.5MG, 5MG, 10MG,

20MG, 30MG

LISINOPRIL/HCTZ 20/25MG

LOSARTAN/HCT 50/12.5MG TAB

METOPROLOL TART 25MG, 50MG, 100MG

RAMIPRIL 2.5MG, 5MG, 10MG

TRIAMTERENE/HCTZ

37.5/25MG, 75/50MG TAB

WARFARIN 1MG, 2MG, 2.5MG, 3MG,

4MG, 5MG, 6MG, 7.5MG, 10MG

30

30

30

90

90

90

30

90

30

30

60

30

30

90

90

180

90

90

30

90

$9

$24

$15

$38

Heart Health & Blood Pressure

30 Day Qty 90 Day Qty

AMIODARONE 200MG

30

90

AMLODIPINE 2.5MG, 5MG, 10MG

30

90

BISOPROLOL 5MG

30

90

CILOSTAZOL 50MG, 100MG

60

180

DIGOXIN 0.125MG, 0.25MG

30

90

DILTIAZEM ER 120MG CAP (24 HOUR)

30

90

DILTIAZEM 30MG, 60MG, 120MG

60

180

DOXAZOSIN 1MG, 2MG, 4MG, 8MG

30

90

ENALAPRIL 2.5MG, 10MG, 20MG

30

90

IRBESARTAN 150MG, 300MG

30

90

LOSARTAN 25MG, 50MG, 100MG

30

90

METOPROLOL ER 25MG, ER 50MG

30

90

MINOXIDIL 10MG TAB

30

90

TORSEMIDE 20MG, 100MG

30

90

TRIAMTERENE/HCTZ 37.5/25MG CAP

30

90

VALSARTAN/HCTZ 160/12.5MG, 160/25MG 30

90

VERAPAMIL ER 120MG, 180MG, 240MG TAB 30

90

Heart Health & Blood Pressure

CLOPIDOGREL 75MG

30 Day Qty 90 Day Qty

30

90

Continued

*Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some covered generic drugs at commonly prescribed dosages. Higher dosages cost more. Prices for some drugs

covered by the Prescription Program may be higher or vary in some states including, but not necessarily limited to, CA and MN. For important information regarding Walmart¡¯s Patient accessibility

program, including the availability of language interpretive services, please see the last page.

? Prepackaged drugs are covered only in unit sizes specified on Drug List (back page). Other restrictions may apply. See Program Details or your Walmart Pharmacist for details.

Program pricing may be limited to select manufacturers of a covered drug and is available as long as supplies from such manufacturers are in stock at the dispensing pharmacy.

?2019 Walmart Apollo, LLC | Page 1 of 3

Art Revised 11/01/2019 10:40AM

Effective 11/4/2019

Mental Health

AMITRIPTYLINE 10MG, 25MG,

50MG, 75MG

BUSPIRONE 5MG, 10MG

CITALOPRAM 10MG, 20MG, 40MG

FLUOXETINE 10MG TAB

FLUOXETINE 20MG, 40MG CAP

LITHIUM CARB 300MG CAP

NORTRIPTYLINE 10MG, 25MG, 50MG

PAROXETINE 20MG, 30MG

RISPERIDONE 0.25MG, 0.5MG,

1MG, 2MG, 3MG, 4MG

TRAZODONE 50MG, 100MG, 150MG

TRIHEXYPHENIDYL 2MG TAB

AMANTADINE 100MG

BUPROPION 75MG, 100MG

BUPROPION ER/SR 100MG,

150MG, 200MG TAB

BUPROPION XL 150MG TAB

CARB/LEVO 10/100MG, 25/100MG

DIVALPROEX DR 250MG TAB

DONEPEZIL 5MG, 10MG

ESCITALOPRAM 5MG, 10MG, 20MG

LAMOTRIGINE 100MG, 200MG

LAMOTRIGINE 25MG, 150MG

LEVETIRACETAM 500MG

LITHIUM CARB ER 300MG, 450MG TAB

MIRTAZAPINE 15MG, 30MG, 45MG

OLANZAPINE 2.5MG, 5MG, 7.5MG,

10MG, 15MG, 20MG

OXCARBAZEPINE 300MG

PAROXETINE 40MG

PRAMIPEXOLE 0.125MG, 0.25MG,

0.5MG, 1MG, 1.5MG

PRIMIDONE 250MG TAB

PRIMIDONE 50MG TAB

QUETIAPINE 25MG, 50MG, 100MG,

200MG, 300MG

ROPINIROLE 0.25MG, 0.5MG, 1MG,

2MG, 3MG, 4MG

$4

$10

60

30

30

30

60

30

30

30

180

90

90

90

180

90

90

90

30

60

90

180

$9

$24

30 Day Qty 90 Day Qty

30

90

30 Day Qty 90 Day Qty

60

180

60

180

60

180

SERTRALINE 25MG, 100MG

TOPIRAMATE 25MG, 50MG, 100MG, 200MG

TRIHEXYPHENIDYL 5MG TAB

VENLAFAXINE 37.5MG TAB

VENLAFAXINE 75MG, 100MG TAB

VENLAFAXINE ER 37.5MG,

75MG, 150MG CAP

ZONISAMIDE 50MG CAP

DULOXETINE 20MG, 30MG, 60MG

30

60

60

60

60

30

90

180

180

180

180

90

60

180

$15

$38

30 Day Qty 90 Day Qty

30

90

Other Therapeutic Category

$4

$10

$15

$38

$4

$10

$4

$10

$9

$24

$9

$24

Digestion

METOCLOPRAMIDE 5MG, 10MG

30 Day Qty 90 Day Qty

90

270

Digestion

OMEPRAZOLE 20MG CAP

OMEPRAZOLE DR 40MG

30 Day Qty 90 Day Qty

30

90

30

90

Thyroid

LEVOTHYROXINE 25MCG, 50MCG,

75MCG, 88MCG 100MCG, 112MCG,

125MCG, 137MCG, 150MCG,

175MCG, 200MCG

30 Day Qty 90 Day Qty

30

90

Vitamin & Nutrition

FOLIC ACID 1MG

30 Day Qty 90 Day Qty

30

90

30

90

60

30

30

30

60

60

60

30

30

90

270

180

90

90

90

180

180

180

90

90

60

30

30

180

90

90

Vitamin & Nutrition

FOLBEE TAB

30 Day Qty 90 Day Qty

30

90

60

30

30

180

90

90

Family Planning

NORETHINDRONE TAB 0.35 MG

SPRINTEC 28 TAB 28 DAY

TRI-SPRINTEC TAB

30 Day Qty 90 Day Qty

28

84

28

84

28

84

30

90

*Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some covered generic drugs at commonly prescribed dosages. Higher dosages cost more. Prices for some drugs

covered by the Prescription Program may be higher or vary in some states including, but not necessarily limited to, CA and MN. For important information regarding Walmart¡¯s Patient accessibility

program, including the availability of language interpretive services, please see the last page.

? Prepackaged drugs are covered only in unit sizes specified on Drug List (back page). Other restrictions may apply. See Program Details or your Walmart Pharmacist for details.

Program pricing may be limited to select manufacturers of a covered drug and is available as long as supplies from such manufacturers are in stock at the dispensing pharmacy.

?2019 Walmart Apollo, LLC | Page 2 of 3

Art Revised 11/01/2019 10:40AM

Effective 11/4/2019

Walmart¡¯s Prescription Program Details

1. Walmart¡¯s Prescription

Program (theProgram

¡°Program¡±) is available

at all Walmart

Walmart¡¯s

Prescription

Details

and Neighborhood Market pharmacies in the United States (¡°Walmart Retail

1.

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pharmacies. Delivery under the Program through Walmart Mail Service is limited

covered

by the $10 Retail

Program are

covered

by the $10

Mail Service

notfor

all an

to

U.S. addresses

by First-Class

Mail;

expedited

delivery

is alsoProgram;

available

drugs covered

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by the

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additional

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health

plansare

docovered

not cover

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or 90day

of the

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and refills.

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90-day supplies.drugs,

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for quantities

greater than a 90-day supply of drugs covered by the

Walmart¡¯s Prescription

Program

(theDakota,

¡°Program¡±)

is available

at all Walmart

and 3. The

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except

in North

as set

forth below

in Sections

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Market

pharmacies

in the

United States

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available

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as

set forth

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2. The Program applies only to certain generic drugs at commonly prescribed

2. dosages.

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applies

only to certain

genericYou

drugs

at commonly

prescribed

dosages.

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Higher

dosages

cost more.

may

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$24

is the price of a 90-day supply of certain Family Planning and Men¡¯s health and

Section 6.

other covered generic drugs at commonly prescribed dosages (the ¡°$24 Retail

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to prepackaged

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a 90-day

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see Section

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otherthrough

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all drugs

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Accessibility

& Non-Discrimination

Accessibility

& Non-Discrimination

Walmart

is

committed

to making

its healthcare

Walmart is committed

to making

its healthcare

services

accessible

to allto

seeking

to usetothem

and and

services

accessible

all seeking

use them

provides

auxiliary

aidsservices,

and services,

including

language

provides

auxiliary

aids and

including

language

assistance

services,

to patients

no cost.

Walmart

assistance

services,

to patients

at noat

cost.

Walmart

will discriminate

not discriminate

onbasis

the basis

of race,

will not

on the

of race,

color,color,

national

origin,

sex, age,

or disability

andnot

will not

national

origin,

sex, age,

or disability

and will

retaliate

against

anyone

who raises

a complaint

retaliate

against

anyone

who raises

a complaint

of of

discrimination.

discrimination.

$10 Mail Servicedrugs

Program

the $24under

Mail Service

Program only

are prorated

basedsizes

on the

$10

5. Prepackaged

areand

covered

the Program

in the unit

specified

andthe

$24Retail

Program

price,

respectively.

Pricesdrugs

for quantities

less thanbased

a 90-day

are not

on

Drug

List.

Prepackaged

are dispensed

onsupply

the quantities

prorated under

$10inMail

Service

Program

or the $24

Mail Service

prescribed

andeither

unit the

sizes

stock

at the

dispensing

pharmacy.

UnitProgram.

sizes not

Prorated pricing

not available

the not

Program

for prepackaged

For pricing

specified

on theis Retail

Drugunder

List are

covered

under the drugs.

Program.

Multipolicies

relating to

prepackaged

Section

6. based on the price per unit size

unit

purchases

are

charged atdrugs,

a persee

unit

price,

otherwise

specified.

Prepackaged

drugs

dispensed

inon

unit

6. dispensed,

Prepackagedunless

drugs are

covered under

the Program

only in the

unit sizes

specified

thesizes

not

specified

Drug

be priced

higher,

even if equivalent

Retail

Drug Liston

andthe

MailRetail

Service

DrugList

List.may

Prepackaged

drugs

are dispensed

based on the

quantities

of the drug

in specified

unit sizes.

Prorated

quantities prescribed

andare

unitavailable

sizes in stock

at the dispensing

pharmacy.

Unit pricing

sizes not is not

available

under the Program for prepackaged drugs.

specified on the Retail Drug List or Mail Service Drug List are not covered under the

Program.

Multi-unit

purchases

are charged

a per unitmay

price,be

based

on the

price per

unit as

6. Prices

of certain

drugs

covered

by theatProgram

higher

in some

states,

size dispensed,

unless otherwise

noted

on the Retail

Drug List.specified. Prepackaged drugs dispensed in unit sizes not

specified on the Retail Drug List and Mail Service Drug List may be priced higher, even if

7. Program pricing may be limited to select manufacturers of a covered drug and is

equivalent quantities of the drug are available in specified unit sizes. Prorated pricing is not

available as long as supplies from such manufacturers are in stock at the dispensing

available under the Program for prepackaged drugs.

pharmacy.

7.

Prices of certain drugs covered by the Program may be higher in some states, as noted on

8. You may pay less or more than the Program price, depending on the terms of your

the Retail Drug List and Mail Service Drug List.

health plan. Prescriber permission may be required to change a 30-day prescription

8. to

Program

pricing

may be limited

to select

manufacturers

a covered drug and is available

as

a 90-day

prescription.

Certain

plans,

including of

government-funded

programs,

long not

as supplies

such manufacturers

are in stock at the dispensing pharmacy.

may

coverfrom

a 90-day

supply.

9.

Youpurchases

may pay lessmade

or more

the Program

depending

on the terms of

yourinitially

health be

9. For

atthan

Walmart

Retail price,

Pharmacies,

prescriptions

must

plan. in

Prescriber

be required

to change

a 30-day

prescription

a 90-day

filled

person,permission

and refillsmay

must

be picked

up in store.

There

are no to

substitutions.

prescription.made

Certain

plans, including

government-funded

may not

cover a Retail

Purchases

through

Walmart

Mail Service mayprograms,

be ordered

at Walmart

90-day supply.by phone or through .

Pharmacies,

10.

For purchases

made

at Walmart

Retail Pharmacies,

must initially

be filled

in

10. These

Program

Details

are subject

to changeprescriptions

without advance

notice.

Changes

to

person,

and refillsDetails

must bemay

picked

in store.

are no substitutions. Purchases made

these

Program

beupmade

onlyThere

in writing.

through Walmart Mail Service may be ordered at Walmart Retail Pharmacies, by phone or

through .

11. These Program Details are subject to change without advance notice. Changes to these

Program Details may be made only in writing.

English Translation: Interpreter Services are available at no cost.

Please visit your local Walmart for assistance.

Complaints or Grievances

Complaints or Grievances

To raise

a complaint

or initiate

a grievance

regarding

To raise

a complaint

or initiate

a grievance

regarding

healthcare accessibility or discrimination, please

healthcare accessibility or discrimination, please

contact your local Walmart pharmacy, vision center or

contact your local Walmart pharmacy, vision center or

care clinic. You also have the right to raise concerns

care or

clinic.

You also

have the

right to raise

concerns or

to initiate

a formal

accessibility

or discrimination

to initiate

grievance by contacting either (1) the office of

a formal

accessibility

or discrimination

grievance

by

Walmart¡¯s

Vice President,

US Ethics

& Compliance

contacting

either (1) the

of Walmart¡¯s Viceor (2) the

(1-800-WM-Ethic

oroffice

ethics@)

President,

& Compliance

(1-800-WM-Ethic

OfficeUS

of Ethics

Civil Rights,

U.S. Dept.

Health & Human

or ethics@)

or (2) or

theOCRComplaint@).

Office of Civil

Services (1-800-368-1019

Rights, U.S. Dept. Health & Human Services (1-800368-1019 or OCRComplaint@).

Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some covered generic drugs at commonly prescribed dosages. Higher dosages cost more. Prices for some drugs

covered by the Prescription Program may be higher in some states, including but not necessarily limited to, CA, HI, MN, MT, PA, TN, WI, and WY. Prices may also vary in some states. For important

information regarding Walmart¡¯s Patient accessibility program, including the availability of language interpretive services, please see the last page.

Prepackaged drugs are covered only in unit sizes specified on Drug List (back page)other restrictions may apply.

See Program Details or your Walmart Pharmacist for details.

?2019 Walmart Apollo, LLC | Page 3 of 3

Revised 11/01/2019

10:40AM

?2017Art

Wal-Mart

Stores, Inc.

| Page 5 of 5

?

Effective 11/4/2019

Revised 12/15/2017

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