Effective 6/22/2020 Guide to low-cost prescriptions Low-cost drugs ...
Effective 6/22/2020
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
$9
GLIPIZIDE ER 2.5MG, 5MG, 10MG
GLYBURIDE/METFORMIN
2.5/500MG, 5/500MG
$15
PIOGLITAZONE 15MG, 30MG, 45MG
$24
30 Day Qty 90 Day Qty
30
90
60
180
HYDROCHLOROTHIAZIDE 12.5MG,
25MG, 50MG TAB
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
$38
30 Day Qty 90 Day Qty
30
90
Heart
$9
$24
$15
$38
$4
$10
60
30
90
180
90
270
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
30 Day Qty 90 Day Qty
30
90
30
90
60
180
30
90
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.
?2020 Walmart Apollo, LLC | Page 1 of 3
Art Revised 06/18/2020 02:15PM
Effective 6/22/2020
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
$4
$10
60
30
30
30
60
30
30
30
180
90
90
90
180
90
90
90
30
60
90
180
30 Day Qty 90 Day Qty
30
90
$9
$24
30 Day Qty 90 Day Qty
AMANTADINE 100MG
60
180
CARB/LEVO 10/100MG, 25/100MG
90
270
DIVALPROEX DR 250MG TAB
60
180
DONEPEZIL 5MG, 10MG
30
90
LAMOTRIGINE 100MG, 200MG
30
90
LAMOTRIGINE 25MG, 150MG
60
180
LEVETIRACETAM 500MG
60
180
LITHIUM CARB ER 300MG, 450MG TAB
60
180
MIRTAZAPINE 15MG, 30MG, 45MG
30
90
OLANZAPINE 2.5MG, 5MG, 7.5MG,
30
90
10MG, 15MG, 20MG
OXCARBAZEPINE 300MG
60
180
PAROXETINE 40MG
30
90
PRAMIPEXOLE 0.125MG, 0.25MG,
30
90
0.5MG, 1MG, 1.5MG
PRIMIDONE 250MG TAB
60
180
PRIMIDONE 50MG TAB
30
90
QUETIAPINE 25MG, 50MG, 100MG,
30
90
200MG, 300MG
ROPINIROLE 0.25MG, 0.5MG, 1MG,
30
90
2MG, 3MG, 4MG
SERTRALINE 25MG, 100MG
30
90
TOPIRAMATE 25MG, 50MG, 100MG, 200MG 60
180
TRIHEXYPHENIDYL 5MG TAB
60
180
ZONISAMIDE 50MG CAP
60
180
$15
BUPROPION 75MG, 100MG
BUPROPION ER/SR 100MG,
150MG, 200MG TAB
BUPROPION XL 150MG TAB
$38
30 Day Qty 90 Day Qty
60
180
60
180
30
90
DULOXETINE 20MG, 30MG, 60MG
ESCITALOPRAM 5MG, 10MG, 20MG
VENLAFAXINE 37.5MG TAB
VENLAFAXINE 75MG, 100MG TAB
VENLAFAXINE ER 37.5MG,
75MG, 150MG CAP
30
30
60
60
30
90
90
180
180
90
Other Therapeutic Category
$4
$10
$9
$24
$15
$38
$15
$38
$4
$10
$4
$10
$9
$24
$9
$24
Digestion
METOCLOPRAMIDE 5MG, 10MG
30 Day Qty 90 Day Qty
90
270
Digestion
MECLIZINE 12.5MG, 25MG TAB
30 Day Qty 90 Day Qty
30
90
Digestion
OMEPRAZOLE 20MG CAP
OMEPRAZOLE DR 40MG
PROMETHAZINE 12.5MG, 25MG
30 Day Qty 90 Day Qty
30
90
30
90
30
90
Pain Managment
METHOCARBAMOL 750MG
LIDOCAINE 2% VISC SOL
30 Day Qty 90 Day Qty
30
90
100 ML
300 ML
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
Vitamin & Nutrition
FOLBEE TAB
30 Day Qty 90 Day Qty
30
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
Respiratory Health
ALBUTEROL HFA
30 Day Qty
1 INHALER
$24
Preferred version of Proventil HFA only
*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.
?2020 Walmart Apollo, LLC | Page 2 of 3
Art Revised 06/18/2020 02:15PM
Effective 6/22/2020
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
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to
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2. dosages.
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genericYou
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at commonly
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Higher
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cost more.
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$24
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Section 6.
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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
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the $24under
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are prorated
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andeither
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a persee
unit
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be priced
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Retail
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andthe
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List.may
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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.
Walmart
Apollo,
| Page53of
of53
?2017?2020
Wal-Mart
Stores,
Inc.LLC
| Page
Art Revised 06/18/2020 02:15PM
Revised 12/15/2017
Effective 6/22/2020
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