©2020 Walmart Apollo, LLC | Page 1 of 3

*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 drugscovered 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.

Art Revised 01/20/2020 08:10PMEffective 2/3/2020

Effective 2/3/2020

$1090 Day Qty

GLIMEPIRIDE 1MG, 2MG, 4MG 90GLIPIZIDE 5MG, 10MG 180

METFORMIN 500MG, 850MG, 1000MG 180METFORMIN ER 500MG TAB 360

$2490 Day Qty

GLIPIZIDE ER 2.5MG 90

180 GLYBURIDE/METFORMIN 2.5/500MG, 5/500MG

$3890 Day Qty

PIOGLITAZONE 45MG 90

$24Cholesterol 90 Day Qty

FENOFIBRATE 145MG 90SIMVASTATIN 10MG, 20MG, 40MG 90

ATORVASTATIN 10MG, 20MG, 40MG 90

$10Heart Health & Blood Pressure 90 Day QtyATENOLOL 25MG, 50MG, 100MG 90BENAZEPRIL 20MG, 40MG 90

180 CARVEDILOL 3.125MG, 6.25MG, 12.5MG, 25MGCLONIDINE 0.1MG, 0.3MG 180FUROSEMIDE 20MG, 40MG, 80MG 90HYDRALAZINE 10MG, 25MG, 50MG 270

90 HYDROCHLOROTHIAZIDE 12.5MG, 25MG, 50MG TAB

HYDROCHLOROTHIAZIDE 12.5MG CAP 90INDAPAMIDE 1.25MG 90

90 ISOSORBIDE MONONITRATE ER 30MG, 60MG

90 LISINOPRIL 2.5MG, 5MG, 10MG, 20MG, 30MGLISINOPRIL/HCTZ 20/25MG 90LOSARTAN/HCT 50/12.5MG TAB 90METOPROLOL TART 25MG, 50MG, 100MG 180RAMIPRIL 2.5MG, 5MG, 10MG 90

90 TRIAMTERENE/HCTZ 37.5/25MG, 75/50MG TAB90 WARFARIN 1MG, 2MG, 2.5MG, 3MG,5MG, 6MG,

7.5MG, 10MG

$24Heart Health & Blood Pressure 90 Day QtyAMIODARONE 200MG 90AMLODIPINE 2.5MG, 5MG, 10MG 90BISOPROLOL 5MG 90CILOSTAZOL 50MG, 100MG 180DIGOXIN 0.125MG 90DILTIAZEM ER 120MG CAP (24 HOUR) 90DILTIAZEM 30MG, 60MG, 120MG 180DOXAZOSIN 1MG, 2MG, 4MG, 8MG 90ENALAPRIL 2.5MG, 10MG, 20MG 90LOSARTAN 25MG, 50MG, 100MG 90METOPROLOL ER 25MG, ER 50MG 90MINOXIDIL 10MG TAB 90TORSEMIDE 20MG, 100MG 90TRIAMTERENE/HCTZ 37.5/25MG CAP 90VALSARTAN/HCTZ 160/12.5MG, 160/25MG 90VERAPAMIL ER 120MG, 180MG, 240MG TAB 90

Continued

Heart

Diabetes

prescriptionsCall 1-800-2REFILL for details. †*

$1090 day

Guide to low-cost prescriptionsMail-order drugs available delivered to you starting at:

PIOGLITAZONE 15MG, 30 MG 90

METFORMIN ER 750MG TAB 180

*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 drugscovered 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.

Art Revised 01/20/2020 08:10PMEffective 2/3/2020©2020 Walmart Apollo, LLC | Page 2 of 3

$1090 Day Qty

90 AMITRIPTYLINE 10MG, 25MG, 50MG, 75MGBUSPIRONE 5MG, 10MG 180CITALOPRAM 10MG, 20MG, 40MG 90FLUOXETINE 10MG TAB 90FLUOXETINE 20MG, 40MG CAP 90LITHIUM CARB 300MG CAP 180NORTRIPTYLINE 10MG, 25MG, 50MG 90PAROXETINE 20MG, 30MG 90

90 RISPERIDONE 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG

TRAZODONE 50MG, 100MG, 150MG 90TRIHEXYPHENIDYL 2MG TAB 180

$2490 Day Qty

AMANTADINE 100MG 180CARB/LEVO 10/100MG, 25/100MG 270DIVALPROEX DR 250MG TAB 180DONEPEZIL 5MG, 10MG 90LAMOTRIGINE 100MG, 200MG 90LAMOTRIGINE 25MG, 150MG 180LEVETIRACETAM 500MG 180LITHIUM CARB ER 300MG, 450MG TAB 180MIRTAZAPINE 15MG, 30MG, 45MG 90OLANZAPINE 2.5MG, 5MG, 7.5MG, 10MG, 15MG, 20MG 90 OXCARBAZEPINE 300MG 180PAROXETINE 40MG 90PRAMIPEXOLE 0.125MG, 0.25MG, 0.5MG, 1MG, 1.5MG 90 PRIMIDONE 250MG TAB 180PRIMIDONE 50MG TAB 90QUETIAPINE 25MG, 50MG, 100MG, 200MG, 300MG 90 ROPINIROLE 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG 90 SERTRALINE 25MG, 100MG 90

180TOPIRAMATE 25MG, 50MG, 100MG, 200MG TRIHEXYPHENIDYL 5MG TAB 180ZONISAMIDE 50MG CAP 180

$3890 Day Qty

180 BUPROPION ER/SR 100MG, 150MG, 200MG TABBUPROPION XL 150MG TAB 90DULOXETINE 20MG, 30MG, 60MG 90ESCITALOPRAM 5MG, 10MG, 20MG 90VENLAFAXINE 37.5MG TAB 180VENLAFAXINE 75MG, 100MG TAB 180

$10Digestion 90 Day QtyMETOCLOPRAMIDE 5MG, 10MG 270

$38Digestion 90 Day QtyOMEPRAZOLE 20MG CAP 90OMEPRAZOLE DR 40MG 90

$10Thyroid 90 Day Qty

90 LEVOTHYROXINE 25MCG, 50MCG, 75MCG, 88MCG 100MCG, 112MCG, 125MCG, 137MCG, 150MCG, 175MCG, 200MCG

$10Vitamin & Nutrition 90 Day QtyFOLIC ACID 1MG 90

$24Vitamin & Nutrition 90 Day QtyFOLBEE TAB 90

$24Family Planning 90 Day QtyNORETHINDRONE TAB 0.35 MG 84SPRINTEC 28 TAB 28 DAY 84TRI-SPRINTEC TAB 84

Mental Health Other Therapeutic Categories

dosages. H e. Pstates. 

drugs. 

drugs. 

plan. 

Walmart’s Prescription Program Details

English Translation:Accessibility & Non-Discrimination

Complaints or Grievances

Walmart’s Prescription Program Details

Accessibility & Non-Discrimination

Complaints or Grievances