Effective 11/4/2019 Guide to low-cost prescriptions Low ...
[Pages:3]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
HYDROCHLOROTHIAZIDE 12.5MG CAP 30
90
INDAPAMIDE 1.25MG, 2.5MG
30
90
ISOSORBIDE MONONITRATE ER
30
90
$4
$10
30 Day Qty 90 Day Qty
30MG, 60MG LISINOPRIL 2.5MG, 5MG, 10MG,
30
90
GLIMEPIRIDE 1MG, 2MG, 4MG
30
90
20MG, 30MG
GLIPIZIDE 5MG, 10MG
60
180
LISINOPRIL/HCTZ 20/25MG
30
90
METFORMIN 500MG, 850MG, 1000MG 60
180
LOSARTAN/HCT 50/12.5MG TAB
30
90
METFORMIN ER 500MG TAB
120
360
METOPROLOL TART 25MG, 50MG, 100MG 60
180
METFORMIN ER 750MG TAB
60
180
RAMIPRIL 2.5MG, 5MG, 10MG
30
90
TRIAMTERENE/HCTZ
30
90
$9
$24
37.5/25MG, 75/50MG TAB
30 Day Qty 90 Day Qty WARFARIN 1MG, 2MG, 2.5MG, 3MG,
30
90
GLIPIZIDE ER 2.5MG, 5MG, 10MG
30
90
4MG, 5MG, 6MG, 7.5MG, 10MG
GLYBURIDE/METFORMIN
60
180
2.5/500MG, 5/500MG
$9
$24
PIOGLITAZONE 15MG, 30MG, 45MG
30
90
Heart Health & Blood Pressure
30 Day Qty 90 Day Qty
AMIODARONE 200MG
30
90
Heart
AMLODIPINE 2.5MG, 5MG, 10MG BISOPROLOL 5MG
30
90
30
90
Cholesterol
$9
$24
30 Day Qty 90 Day Qty
CILOSTAZOL 50MG, 100MG DIGOXIN 0.125MG, 0.25MG
60
180
30
90
FENOFIBRATE 145MG
30
90
DILTIAZEM ER 120MG CAP (24 HOUR) 30
90
GEMFIBROZIL 600MG
60
180
DILTIAZEM 30MG, 60MG, 120MG
60
180
SIMVASTATIN 10MG, 20MG, 40MG
30
90
DOXAZOSIN 1MG, 2MG, 4MG, 8MG
30
90
ENALAPRIL 2.5MG, 10MG, 20MG
30
90
Cholesterol
$15
$38
30 Day Qty 90 Day Qty
IRBESARTAN 150MG, 300MG LOSARTAN 25MG, 50MG, 100MG
30
90
30
90
ATORVASTATIN 10MG, 20MG, 40MG
30
90
METOPROLOL ER 25MG, ER 50MG
30
90
MINOXIDIL 10MG TAB
30
90
$4
$10
TORSEMIDE 20MG, 100MG
30
90
Heart Health & Blood Pressure
30 Day Qty 90 Day Qty TRIAMTERENE/HCTZ 37.5/25MG CAP
30
90
ATENOLOL 25MG, 50MG, 100MG
30
90
VALSARTAN/HCTZ 160/12.5MG, 160/25MG 30
90
BENAZEPRIL 20MG, 40MG
30
90
VERAPAMIL ER 120MG, 180MG, 240MG TAB 30
90
CARVEDILOL 3.125MG, 6.25MG,
60
180
12.5MG, 25MG CLONIDINE 0.1MG, 0.2MG, 0.3MG
60
180
Heart Health & Blood Pressure
$15
$38
30 Day Qty 90 Day Qty
FUROSEMIDE 20MG, 40MG, 80MG
30
90
CLOPIDOGREL 75MG
30
90
HYDRALAZINE 10MG, 25MG, 50MG
90
270
HYDROCHLOROTHIAZIDE 12.5MG,
30
90
25MG, 50MG TAB
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
$4
$10
30 Day Qty 90 Day Qty
30
90
60
180
30
90
30
90
30
90
60
180
30
90
30
90
30
90
30
90
60
180
$9
$24
30 Day Qty 90 Day Qty
AMANTADINE 100MG
60
180
BUPROPION 75MG, 100MG
60
180
BUPROPION ER/SR 100MG,
60
180
150MG, 200MG TAB
BUPROPION XL 150MG TAB
30
90
CARB/LEVO 10/100MG, 25/100MG
90
270
DIVALPROEX DR 250MG TAB
60
180
DONEPEZIL 5MG, 10MG
30
90
ESCITALOPRAM 5MG, 10MG, 20MG
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
VENLAFAXINE 37.5MG TAB
60
180
VENLAFAXINE 75MG, 100MG TAB
60
180
VENLAFAXINE ER 37.5MG,
30
90
75MG, 150MG CAP
ZONISAMIDE 50MG CAP
60
180
DULOXETINE 20MG, 30MG, 60MG
$15
$38
30 Day Qty 90 Day Qty
30
90
Other Therapeutic Category
Digestion METOCLOPRAMIDE 5MG, 10MG
$4
$10
30 Day Qty 90 Day Qty
90
270
Digestion OMEPRAZOLE 20MG CAP OMEPRAZOLE DR 40MG
$15
$38
30 Day Qty 90 Day Qty
30
90
30
90
Thyroid LEVOTHYROXINE 25MCG, 50MCG, 75MCG, 88MCG 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG
$4
$10
30 Day Qty 90 Day Qty
30
90
Vitamin & Nutrition FOLIC ACID 1MG
$4
$10
30 Day Qty 90 Day Qty
30
90
Vitamin & Nutrition FOLBEE TAB
$9
$24
30 Day Qty 90 Day Qty
30
90
Family Planning NORETHINDRONE TAB 0.35 MG SPRINTEC 28 TAB 28 DAY TRI-SPRINTEC TAB
$9
$24
30 Day Qty 90 Day Qty
28
84
28
84
28
84
*Prescription Program includes up to a 30-day supply for $4 and a 90-day supply for $10 of some covered generic drugs at commonly prescribed dosages. Higher dosages cost more. Prices for some drugs covered by the Prescription Program may be higher or vary in some states including, but not necessarily limited to, CA and MN. For important information regarding Walmart's Patient accessibility program, including the availability of language interpretive services, please see the last page.
Prepackaged drugs are covered only in unit sizes specified on Drug List (back page). Other restrictions may apply. See Program Details or your Walmart Pharmacist for details.
Program pricing may be limited to select manufacturers of a covered drug and is available as long as supplies from such manufacturers are in stock at the dispensing pharmacy.
?2019 Walmart Apollo, LLC | Page 2 of 3 Art Revised 11/01/2019 10:40AM
Effective 11/4/2019
Walmart's Prescription Program Details
W1. aWlamlmaartr'stP'sresPcrripetisoncPrriopgrtaimo(ntheP"rProoggrrama"m) is aDvaeilatbaleialtsall Walmart and Neighborhood Market pharmacies in the United States ("Walmart Retail 1. PWhaalmrmarat'csiPerse"s)c,reipxtcioenpPtriongrNamor(tthheD"aPkroogtraa,mas")siseatvfaoilratbhlebaetlaollwWianlmSaerct tainodns 3. The
PNreoigghrbaomrhiosoadlsMoaarkveatilpahbalremtahcrioesuignhthWe UalnmiteadrtSMtataeisl S("eWravlimcear(t"RWetaaliml PahratrmMaaciileSs"e),rvice"), aesxcseepttfionrNthorbtheDloawkoitna,Saescsettiofnor4th. below in Sections 3 and 4. The Program is also available
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4. PUrnodgerathme"P)r.oNgoratmalaltdWrualgmsarctoRveetraeildPhbayrmthaceie$s9, $R9eisttahiel Ppriocegrfoarmupartoeac3o0v-edraeydsubpypltyhoef $24 Pcerortgairnawmo.mPernic'sehsefaoltrhqanudanothiteier csobvetrewdegeenneari3c0d-rudgasyastucpomplmy oannldy pare9s0cr-idbeadydsouspapgleys of d(trhueg"s$9coRveetariel Pdrobgyrabmo"t)h. $t2h4eis$t9heRpertiaceil fPoroag9r0a-mdayansudpp$l2y4ofRcerttaaiilnPwroomgreanm's haeraelthparondrated boathseerdcoovnertehdeg$e9nePrircodgrruagms atpcroicmem, bounltywpriellsncroibteedxdcoeseagde$s2(t4h.eP"r$i2c4eRseftoarilqPuroagnrtaimti"e)s. gNroetaatlel drrtuhgasncoave9r0ed-dbayythseup$9pRlyeotafildPruoggrsamcoavrerceodvebreydtbhyet$he24$2R4eRteatialilPPrrooggraamm. aPreices pforroqruaatnetditibeas sbeedtwoenentha e30$-2d4ayPsurpopglyraamndpar9ic0e-d. aPyrsourpaptleydofpdrriucginsgcoivsenreodtbayvbaoiltahbtlheeu$n9der tPhreogPrarmogarnadm$2f4oRr eptraeilpParocgkraagmeadredprurogrsa.teFdobrapsreidcoinngthpeo$li9cPiersogrrealmatpinrigcet,obuptrwepillancoktaged derxucegesd($s2u4c.hPariscetsufboersq,uvainatlistieosrgbroeattteler sth),asneae9S0e-dcatyiosunp5pl.y of drugs covered by the $24
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5. aUnnddecretrhteaPinroogtrhamertchorovuegrheWd adlmruagrtsMataicl Soemrvmiceo,n$l1y0pisrtehsecprribiceedfodromsaaigl deesli(v"e$ry24ofMa ail S9e0r-vdaicyesuPprpolygoraf mce"r)ta. iNn ogetnaelrlidcrduruggsscaotvceormemdobnylytphrees$c1r0ibeRdedtoasilaPgerso(g"r$a10mMaariel Sceorvviceered bPyrotghream$"1)0. $M24aiilsStheervpirciceePforor mgraailmde;lnivoertyaollfdcerurtgaisncwoovmeeren'ds hbeyaltthhean$d2c4erRtaeitnaoilthPerrogram acroevecroedvedrreugdsbayt ctohmem$2o4nlyMpareilscSreibrevdicdeoPsargoegsr(a$2m4.MWaaillmSearvritceMPariol gSrearmv"i)c.eNcootvaellrdsrubgosth initial fills and refills. Delivery of covered drugs is available only through Walmart
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6. dPisreppeancskeagde, dundrleugsss aortehceorvweriseed uspndeecriftiheedP. rPorgerapmacoknalygeindthderuungist sdiziseps espnesceifdieidnounntihtesizes nqaRqsvoupueaateatinclansaiitptflbiiiDteteliieedcresuisoufgpinnoerLedtfdihssettceohrraRnientbehdetdthedaMreiualPanDgRirldorSeauugetrgnrearviLatiliaimcssDvetizaoerfDiousrlraMgirunbgpaLlseirtLilsoeiSsitcnptek.marsvPacpaitrckeyeteahpcbgDeaifeecrdiukedipasgdpgrdLieeurcinsdunetsgdidiatnsrrguh.segiipzngsheohaastrer.ecmrPo,darveicosevpyrr.eeeadnnUtseuneidfnidtdepsbeiqzrareuistcseihivdnneaogolteninsthtneot
6. PPrriocgersamof. cMeurltai-iunnidtrpuugrcshcaosevsearreedchbayrgtehdeaPtraopgerraumnitmpraicyeb, beahseigdhoenrthinesporimceepsetrautneits, as nsoizteeddisopenntsheed,RunelteassiloDthreurgwLisiests.pecified. Prepackaged drugs dispensed in unit sizes not
7. PasevrpqaoeuigcliavirfabailelemedntoapnqsruitlcoahnienntgRgiteiaemtssaaioslyfuDtpbrhupeegldileLirmisustgiftaraenorddemMtaovsaauisillceaShbleelremcviitncaemnspuDaefrncauiucfgifteLaudicsruttenumrirstaesyarirzbseeeosi.pfnrPaisrcotecordoacvthkeeigdarhepterdrti,chdeienvrgeudnigissifnpaonetdnsiisng pahvaairlambalecuyn. der the Program for prepackaged drugs.
78.. YhtPoehruaeicltRemhseatopayflilacpDenarr.ytuPaglireneLsdisssrctuoragrinbsdmecMorovpareieelreSrtdmehrbavisynicsteithoheDnerPumPrgoragLoyrigsabtmr.eammreapyqrbuiecirehe,idgdhteeopr cienhnsadonimngegesoatan3tet0sh-,edasatneyorptmeredssoocnfriypotuiorn 8. tPoroag9r0am-dparyicpinrgemscaryipbetiolimn.itCedetrotasienlepcltamnsa,niunfcaclutudrienrgs ogfoavceorvnemreedndtr-ufguannddeids apvraoilagbrlaemass,
mloanygnasostucpopvlieesrfaro9m0s-udcahymsuanpupflayc.turers are in stock at the dispensing pharmacy.
99.. FYoorupmuarycphaaysleesssmoradmeoraettWhaanltmhearPtroRgertaamilpPrhicaer,mdeapceinedsi,npgroenstchreiptteiromnssomf yuosutrihneitailathlly be fpillaend. iPnrepsecrisboenr ,paenrmdisrseiofinllms mayubsetrbeqeupiriecdketodcuhpanignesato30re-d. aTyhperreescarripetinoon tsouabs9t0it-duatyions. Ppurrecschraipsteiosnm. Caderetatihnrpolaungs,hinWcluadlmingargtoMvearnilmSeenrtv-ifcuendmedayprboegroamrdse, mready naottWcoavlmeraart Retail P9h0a-rdmayascuipepsl,yb. y phone or through .
1100..TFhoerspeurPcrhoagsersammaDdeeattaWilsalamrearstuRbetjeaicl tPhtoarmchaacinegs,eprweistchrioputitonasdmvaunstcienitniaolltyicbee.fCillehdaninges to tpheersseonP, raondgrraemfillsDmeutsatilbsempiacykebdeupminadsteoroen. lyThinerwe rairteinngo.substitutions. Purchases made
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.
AcceAsscicbeilsistyib&ilitNyo&n-NDoisnc-rDimisicnraitmioination WalmWaartlmisacrot mis mcoitmtemditotemd atokinmgaiktisnhgeiatslthcearltehcare servisceersvaiccecsesascicbelesstioblaelltsoeaelklisnegetkoinugsetothuesemtahnedm and provpidreosvaiduexsiliaaurxyilaiaidrsyaaniddssaenrvdicsesr,vinccelsu,dinincgluldainnggulaagneguage assisatasnsicsetasnecrevisceersv, itcoeps,atoiepnatstiaetnntsoactonsot. cWoasltm. Waratlmart will nwoitlldniosctrdimiscinraimteinoantethoenbtahseisboafsrisacoef,rcaocleo,rc, olor, nationnaatlioonriaglion,risgeixn,, asgeex,, aogred,isoarbdiliistyabainlidtywainlldnowtill not retalriaettealaiagtaeinasgtaainnsytoanneywohnoe rwahisoesraaisceosmapcloaimntpolafint of discrdimiscinraimtioinna. tion.
ComCpolaminptslaoinrtGs roier vGarniceevsances luceoYiatniramoctayirilccuaooepce.tcauloeYsaaalrsmcosilaniolcbuWoptfeihcolalosaiaatalrsrlsiyvmmlnioibeWntoaaihiltrortliaahttirdalayvmepciitesnocehraciiteratrrgahitsridhamemsgpittisrebihranctiieiacogaralivryithtmrgma,iytaornviiaiotnnscieosce,raeviyoptrdac,rianlonieoevsinscgnacicsees,aecrieopirencmrdnlrteoeineingncnarsgacesaooreetndrirrtoinennsrgor to ingitriaietveance by contacting either (1) the office of a forWmaallmacacrte'sssVibiiclietyPorersdidisecnritm, UinSatEiothnicgsri&evCanocmepbliyance cont(a1c-t8i0ng0-eWithMe-rE(t1h) itcheoroefftihciecso@f Wwaallmmaarrtt'.scoVmic)eor (2) the PresiOdeffnitc,eUoSfECtihviiclsR&igChtosm, Up.lSia.nDcep(t1-. 8H0e0a-ltWhM&-HEtuhmican or etSheicrsv@icewsa(lm1-8ar0t0.c-o3m6)8o-1r0(129)othreOOCfRfiCceomofpClaivnitl@). Rights, U.S. Dept. Health & Human Services (1-800368-1019 or OCRComplaint@).
English Translation: Interpreter Services are available at no cost. Please visit your local Walmart for assistance.
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 P?ro2g0ra1m9 WDaeltmaialsrot rAypooulrloW, LaLlmCa|rPt aPghear3moafc3ist for details.
?2017AWrt Rale-vMisaerdt 1S1/t0o1r/e20s,19In1c0. :|4P0aAgMe 5 of 5
Revised 12/15/20E17ffective 11/4/2019
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