Sam s Plus Members enjoy more Pharmacy savings 5 prescription drugs available for FREE Generic medications: Donepezil, Pioglitazone, Escitalopram, Finasteride and Vitamin D2 50,000 IU are $ 0 for a 30-day supply. (Restrictions apply. See Pharmacy ) Big savings on generic prescriptions Over 200 available for $ 4 per 30-day supply Over 400 available for $ 10 per 30-day supply Exclusive savings on name-brand drugs Save 10-30% on select name-brand prescriptions every day Stop by and see your friendly Sam s Club Pharmacist today for details Don t miss a dose because of high prescription prices! Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) price listed. See SamsClub.com/EVDL for the list of EVDL and free drugs. Covered prescriptions could change. part of a compound or to purchases submitted to any health benefit program, pharmacy benefit program, insurer, CA, GA, HI, MA, MD, ME, MN, OK, PA, PR, SC, WI. EVDL price not available in Puerto Rico. Discount savings are restrictions apply. Terms subject to change without notice. See SamsClub.com or your local Sam s Club Pharmacy Sam s Club is committed to making its healthcare services accessible to all seeking to use them and provides auxiliary aids and services, including language assistance services, to patients at no cost. Sam s Club will not discriminate on the basis of race, color, national origin, sex, age, or disability and will not retaliate against anyone who raises a complaint of discrimination. To raise a complaint or initiate a grievance regarding healthcare accessibility or discrimination, please contact your local Sam s Club pharmacy or optical center. You also have the right to raise concerns or to initiate a formal accessibility or discrimination grievance by contacting either (1) the office of Walmart s Vice President, US Ethics & Compliance (1-800-WM-Ethic or ethics@walmart.com) or (2) the Office of Civil Rights, U.S Dept. Health & Human Services (1-800-368-1019 or OCRComplaint@hhs.gov). See last page for information on the availability of language interpreter services at no cost.
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs FREE for Sam s Plus Members Class Contour NEXT Blood Glucose Monitoring System Contour NEXT EZ Blood Glucose Monitoring System 1 ct. Diabetes 1 ct. Diabetes Contour NEXT One Meter 1 ct. Diabetes Donepezil HCL 5 MG TAB 30 Donepezil HCL 10 MG TAB 30 Escitalopram 5 MG TAB 30 Escitalopram 10 MG TAB 30 Escitalopram 20 MG TAB 30 Alzheimer's Disease Alzheimer's Disease Mental Health Mental Health Mental Health Finasteride 5 MG Tab 30 Men s Health Pioglitazone 15 MG TAB 30 Diabetes Pioglitazone 30 MG TAB 30 Diabetes Pioglitazone 45 MG TAB 30 Diabetes True Metrix Blood Glucose Monitoring System 1 ct. Diabetes Vitamin D2 (ergocalciferol) 50,000 IU CAP 4 Women's Health Acarbose 100 MG TAB 90 $ Acarbose 25 MG TAB 90 $ Acarbose 50 MG TAB 90 $ Acebutolol 200 MG CAP Acebutolol 400 MG CAP Acyclovir 200 MG CAP Acyclovir 400 MG TAB Acyclovir 800 MG TAB Albuterol 2 MG/5 ML SYRUP 473 ML $ Albuterol 2.5 MG/3ML NEBULIZER 75 $ Alendronate 10 MG TAB Alendronate 35 MG TAB 4 $ Alendronate 5 MG TAB Alendronate 70 MG TAB 4 $ Alfuzosin 10 MG TAB Allopurinol 100 MG TAB Allopurinol 300 MG TAB Alphagan P 0.1% DROPS 5 ML $ 127.52 Alphagan P 0.1% DROPS 10 ML $ 251.53 Alphagan P 0.1% DROPS 15 ML $ 375.60 Amiloride 5 MG TAB Amiodarone 200 MG TAB Amitriptyline 10 MG TAB Amitriptyline 25 MG TAB Amlodipine besylate 10 MG TAB Amlodipine besylate 2.5 MG TAB Amlodipine besylate 5 MG TAB Amlodipine besylate-benazepril 10 MG/20 MG CAP Amlodipine besylate-benazepril 10 MG/40 MG CAP Amlodipine besylate-benazepril 2.5 MG/10 MG CAP Amlodipine besylate-benazepril 5 MG/10 MG CAP Amlodipine besylate-benazepril 5 MG/20 MG CAP Amlodipine besylate-benazepril 5 MG/40 MG CAP Amoxicillin 125 MG/5 ML 80 ML $ Amoxicillin 125 MG/5 ML 100 ML $ Amoxicillin 125 MG/5 ML 150 ML $ Amoxicillin 200 MG/5 ML 50 ML $ Amoxicillin 200 MG/5 ML 75 ML $ Amoxicillin 200 MG/5 ML 100 ML $ Amoxicillin 250 MG CAP Amoxicillin 250 MG/5 ML 80 ML $ Amoxicillin 250 MG/5 ML 100 ML $ Amoxicillin 250 MG/5 ML 150 ML $ Amoxicillin 400 MG/5 ML 50 ML $ Amoxicillin 400 MG/5 ML 75 ML $ Amoxicillin 400 MG/5 ML 100 ML $ Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-1
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Amoxicillin 500 MG CAP Amoxicillin 500 MG TAB Amoxicillin 875 MG TAB 20 $ Amoxicillin-potassium clav 200 MG/5 ML Amoxicillin-potassium clav 200 MG/5 ML Amoxicillin-potassium clav 400 MG/5 ML Amoxicillin-potassium clav 400 MG/5 ML Amoxicillin-potassium clav 400 MG/5 ML 75 ML $ 100 ML $ 50 ML $ 75 ML $ 100 ML $ Amoxicillin-potassium clav 500 MG TAB Amoxicillin-potassium clav 600 MG/5 ML Amoxicillin-potassium clav 600 MG/5 ML Amoxicillin-potassium clav 600 MG/5 ML 75 ML $ 125 ML $ 200 ML $ Amoxicillin-potassium clav 875 MG TAB 20 $ Ampicillin 250 MG CAP Ampicillin 500 MG CAP Anastrozole 1 MG TAB Atenolol 100 MG TAB Atenolol 25 MG TAB Atenolol 50 MG TAB Atorvastatin 10 MG TAB Atorvastatin 20 MG TAB Atorvastatin 40 MG TAB Atorvastatin 80 MG TAB Azathioprine 50 MG TAB Azelastine 0.05% OPHTH SOL 6 ML $ Azithromycin 200 MG/5 ML 15 ML $ Azithromycin 200 MG/5 ML 23 ML $ Azithromycin 200 MG/5 ML 30 ML $ Azithromycin 250 MG TAB 6 PK $ Azithromycin 500 MG TAB 3 PK $ Bacitracin-polymyxin B 500-10,000/G OPHTH OINTMENT 4 G $ Baclofen 10 MG TAB BD Insulin Syringe 3 /10 ml/cc 31G x 6MM WHOLE UNIT BD Insulin Syringe 3 /10 ml/cc 31G x 6MM HALF UNIT 100 $ 17.50 100 $ 17.50 BD Insulin Syringe ½ ml/cc 31G x 6MM 100 $ 17.50 BD Insulin Syringe 1 ml/cc 31G x 6MM 100 $ 17.50 BD Ultra-Fine Nano Pen Needles 32G x 4MM 100 $ 27.50 Benazepril 10 MG TAB Benazepril 20 MG TAB Benazepril 40 MG TAB Benazepril 5 MG TAB Benztropine 0.5 MG TAB Benztropine 1 MG TAB Benztropine 2 MG TAB Betamethasone valerate 0.1% CREAM 15 G $ Beyaz 28 TAB 28 $ 72.05 Bicalutamide 50 MG TAB Bisoprolol 10 MG TAB Bisoprolol 5 MG TAB Bisoprolol fumarate-hctz 10 MG/6.25 MG TAB Bisoprolol fumarate-hctz 2.5 MG/6.25 MG TAB Bisoprolol fumarate-hctz 5 MG/6.25 MG TAB Breeze 2 Disc Test Strip 50 $ 18.50 Breeze 2 Disc Test Strip 100 $ 33.50 Brilinta 60 MG TAB 60 $ 299.83 Brilinta 90 MG TAB 60 $ 299.83 Brimonidine 0.2% OPHTH SOL 5 ML $ Brimonidine 0.2% OPHTH SOL 10 ML $ Brimonidine 0.2% OPHTH SOL 15 ML $ Bupropion 100 MG ER TAB (12 Hour) 60 $ Bupropion 100 MG TAB Bupropion 150 MG ER TAB (12 Hour) 60 $ Bupropion 200 MG ER TAB (12 Hour) Bupropion 75 MG TAB Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-2
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Buspirone 10 MG TAB Buspirone 15 MG TAB Buspirone 5 MG TAB Calcitriol 0.25 MCG CAP Carbidopa-levodopa 10 MG/100 MG TAB 90 $ Carbidopa-levodopa 25 MG/100 MG ER TAB Carbidopa-levodopa 25 MG/100 MG TAB 90 $ Carbidopa-levodopa 25 MG/250 MG TAB 60 $ Carbidopa-levodopa 50 MG/200 MG ER TAB 60 $ Carbinoxamine 4 MG TAB Carteolol HCL 1% OPHTH SOL 5 ML $ Carteolol HCL 1% OPHTH SOL 10 ML $ Carvedilol 3.125 MG TAB 60 $ Carvedilol 6.25 MG TAB 60 $ Carvedilol 12.5 MG TAB 60 $ Carvedilol 25 MG TAB 60 $ Cefadroxil monohydrate 500 MG CAP Cefuroxime 250 MG TAB 20 $ Cephalexin 250 MG CAP 28 $ Cephalexin 500 MG CAP Chlorhexidine gluconate 0.12% SOL 473 ML $ Chlorthalidone-atenolol 100 MG/25 MG TAB Chlorthalidone-atenolol 50 MG/25 MG TAB Chlorzoxazone 500 MG TAB Ciclopirox 0.77% CREAM 30 G $ Cilostazol 100 MG TAB 60 $ Cilostazol 50 MG TAB 60 $ Cimetidine 300 MG TAB Cimetidine 400 MG TAB Ciprofloxacin 250 MG TAB 14 $ Ciprofloxacin 500 MG TAB 20 $ Ciprofloxacin 750 MG TAB Ciprofloxacin HCL 0.3% OPHTH SOL 3 ML $ Ciprofloxacin HCL 0.3% OPHTH SOL 5 ML $ Ciprofloxacin HCL 0.3% OPHTH SOL 10 ML $ Citalopram 10 MG TAB Citalopram 20 MG TAB Citalopram 40 MG TAB CitraNatal 90 DHA 60 $ 82.69 CitraNatal Assure 60 $ 79.94 CitraNatal B-Calm 90 $ 69.46 CitraNatal DHA 60 $ 76.44 CitraNatal Harmony 80.19 CitraNatal RX 90 $ 162.06 Clarithromycin 250 MG TAB Clarithromycin 500 MG TAB 20 $ Climara 0.025 Patch 4 $ 63.50 Climara 0.0375 Patch 4 $ 63.50 Climara 0.05 Patch 4 $ 63.50 Climara 0.06 Patch 4 $ 63.50 Climara 0.075 Patch 4 $ 63.50 Climara 0.1 Patch 4 $ 63.50 Clindamycin 150 MG CAP Clindamycin 300 MG CAP Clomiphene citrate 50 MG TAB 6 $ Clonidine 0.1 MG TAB Clonidine 0.2 MG TAB Clonidine 0.3 MG TAB 60 $ Clopidogrel 75 MG TAB Clotrimazole 1% CREAM 30 G $ Clotrimazole 1% CREAM 45 G $ Clotrimazole 1% CREAM 15 G $ Clotrimazole-betamethasone 1%/0.05% CREAM 15 G $ Combigan EYE DROPS 5 ML $ 137.32 Combigan EYE DROPS 10 ML $ 271.17 Contour NEXT Blood Glucose Monitoring System Contour NEXT EZ Blood Glucose Monitoring System 1 ct. Free 1 ct. Free Contour NEXT Test Strips 50 ct. $ 18.50 Contour NEXT Test Strips 100 ct. $ 33.50 Contour NEXT One Meter 1 ct. Free Contour Test Strips 50 ct. $ 18.50 Contour Test Strips 100 ct. $ 33.50 Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-3
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Cromolyn Sodium 4% OPHTH SOL 10 ML $ Generic equivalent for Cyclessa TAB 28 $ Cyclobenzaprine 10 MG TAB Cyclobenzaprine 5 MG TAB Cyclopentolate HCL 1% OPHTH SOL 2 ML $ Cyclopentolate HCL 1% OPHTH SOL 15 ML $ Generic equivalent for Demulen 1/35 TAB 28 $ Desloratadine 5 MG TAB Desmopressin acetate 0.1 MG TAB Dexamethasone.5 MG/5 ML ELX 237 ML $ Dexamethasone 0.5 MG TAB Dexamethasone 0.75 MG TAB Dexamethasone 1.5 MG TAB 10 $ Dexamethasone 4 MG TAB Dexcom G4 Platinum (Adult) Receiver with Share Black Dexcom G4 Platinum (Adult) Receiver with Share Blue Dexcom G4 Platinum (Adult) Receiver with Share Pink Dexcom G4 Platinum (Pediatric) Receiver with Share Black Dexcom G4 Platinum (Pediatric) Receiver with Share Blue Dexcom G4 Platinum (Pediatric) Receiver with Share Pink 1 ct. $ 1 ct. $ 1 ct. $ 1 ct. $ 1 ct. $ 1 ct. $ Dexcom G4 Platinum Transmitter 1 ct. $ Dexcom G5 Receiver Kit-Black 1 ct. $ Dexcom G5 Receiver Kit-Blue 1 ct. $ Dexcom G5 Receiver Kit-Pink 1 ct. $ Dexcom G5 Mobile/ G4 Platinum Sensors 4 pk. $ 375.69 Dexcom G5 Transmitter 1 ct. $ 322.44 Diclofenac potassium 50 MG TAB Diclofenac sodium 100 MG ER TAB Diclofenac sodium 25 MG ER TAB Diclofenac sodium 75 MG ER TAB Dicyclomine 10 MG CAP Diltiazem 120 MG TAB Diltiazem 30 MG TAB Diltiazem 60 MG TAB Diltiazem 90 MG TAB Diltiazem HCL 120 MG CAP Diltiazem HCL 180 MG CAP Diltiazem HCL 240 MG CAP Diltiazem HCL 300 MG CAP Divalproex sodium 125 MG DR TAB Divalproex sodium 250 MG DR TAB Divalproex sodium 500 MG DR TAB Donepezil HCL 10 MG TAB 30 Free Donepezil HCL 5 MG TAB 30 Free Dorzolamide 2% OPHTH SOL 10 ML $ Dorzolamide-timolol 22.3 MG/6.8 MG/1 ML OPHTH SOL 10 ML $ Doxazosin 1 MG TAB Doxazosin 2 MG TAB Doxazosin 4 MG TAB Doxazosin 8 MG TAB Doxepin HCL 10 MG CAP Doxycycline hyclate 20 MG TAB Doxycycline monohydrate 100 MG CAP Doxycycline monohydrate 100 MG TAB Doxycycline monohydrate 50 MG CAP Doxycycline monohydrate 50 MG TAB Enalapril 10 MG TAB Enalapril 2.5 MG TAB Enalapril 20 MG TAB Enalapril 5 MG TAB Enalapril maleate-hctz 10 MG/25 MG TAB Enalapril maleate-hctz 5 MG/12.5 MG TAB Erythromycin 5 MG/1 G OPHTH OINTMENT 4 G $ Escitalopram 10 MG TAB 30 Free Escitalopram 20 MG TAB 30 Free Escitalopram 5 MG TAB 30 Free Estradiol 0.5 MG TAB Estradiol 1 MG TAB Estradiol 2 MG TAB Famciclovir 125 MG TAB Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-4
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Famciclovir 250 MG TAB Famotidine 20 MG TAB Famotidine 40 MG TAB Felodipine 10 MG ER TAB Felodipine 2.5 MG ER TAB Felodipine 5 MG ER TAB Fenofibrate 48 MG TAB Fenofibrate 54 MG TAB Ferralet 90 90 $ 133.76 Ferrous sulfate 325 MG TAB Fexofenadine 180 MG TAB Finasteride 1 MG TAB Finasteride 5 MG TAB 30 Free Fluconazole 10 MG/1 ML 35 ML $ Fluconazole 150 MG TAB 1 $ Fluoxetine 10 MG CAP Fluoxetine 20 MG CAP Fluoxetine 20 MG/5 ML SOL 120 ML $ Fluoxetine 40 MG CAP Fluticasone 0.05% CREAM 30 G $ Fluticasone 0.05% CREAM 15 G $ Fluticasone 0.05% OINTMENT 15 G $ Fluticasone 50 MCG NASAL SPRAY 16 $ Fluvoxamine maleate 100 MG TAB Fluvoxamine maleate 25 MG TAB Fluvoxamine maleate 50 MG TAB Folic acid 1 MG TAB Fosinopril 10 MG TAB Fosinopril 20 MG TAB Fosinopril 40 MG TAB Fosinopril sod-hctz 10 MG/12.5 MG TAB Fosinopril sod-hctz 20 MG/12.5 MG TAB Furosemide 10 MG/1 ML SOL 60 ML $ Furosemide 20 MG TAB Furosemide 40 MG TAB Furosemide 80 MG TAB Gemfibrozil 600 MG TAB Gentamicin 0.3% OPHTH OINTMENT 4 G $ Gentamicin 0.3% OPHTH SOL 5 ML $ Glimepiride 1 MG TAB Glimepiride 2 MG TAB Glimepiride 4 MG TAB Glipizide 10 MG TAB 60 $ Glipizide 2.5 MG ER TAB Glipizide 5 MG TAB Glipizide-metformin 2.5 MG/500 MG TAB Glipizide-metformin 5 MG/500 MG TAB Glyburide 1.25 MG TAB Glyburide 2.5 MG TAB Glyburide 3 MG TAB Glyburide 5 MG TAB Glyburide 6 MG TAB Glyburide-metformin 1.25 MG/250 MG TAB Glyburide-metformin 2.5 MG/500 MG TAB Glyburide-metformin 5 MG/500 MG TAB Glycopyrrolate 1 MG TAB 60 $ Glycopyrrolate 2 MG TAB 60 $ Griseofulvin microsize 125 MG/5 ML 120 ML $ Guanfacine 1 MG TAB Guanfacine 2 MG TAB Hydralazine 10 MG TAB Hydralazine 100 MG TAB 60 $ Hydralazine 25 MG TAB Hydralazine 50 MG TAB 120 $ Hydrochlorothiazide 12.5 MG CAP Hydrochlorothiazide 12.5 MG TAB Hydrochlorothiazide 25 MG TAB Hydrochlorothiazide 50 MG TAB Hydrocortisone 10 MG TAB Hydrocortisone 2.5% CREAM 30 G $ Hydrocortisone 2.5% OINTMENT 30 G $ Hydrocortisone 20 MG TAB Hydrocortisone 5 MG TAB Hydrocortisone acetate 2.5% CREAM 30 G $ Hydroxyurea 500 MG CAP Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-5
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Hydroxyzine 10 MG TAB Hydroxyzine 10 MG/5 ML SOL 120 ML $ Hydroxyzine Pamoate 25 MG CAP Hydroxyzine 25 MG TAB Hydroxyzine Pamoate 50 MG CAP Hydroxyzine 50 MG TAB Hyoscyamine sulfate 0.125 MG ODT Hyoscyamine sulfate 0.125 MG TAB Hyoscyamine sulfate 0.375 MG TAB Ibandronate 150 MG 1 $ Ibuprofen 400 MG TAB Ibuprofen 600 MG TAB Ibuprofen 800 MG TAB Imipramine HCL 10 MG TAB Imipramine HCL 25 MG TAB Imipramine HCL 50 MG TAB Indapamide 1.25 MG TAB Indapamide 2.5 MG TAB Indomethacin 25 MG CAP Indomethacin 50 MG CAP Indomethacin 75 MG ER Ipratropium 21 MCG NASAL SPRAY Ipratropium 0.02% NEBULIZER SOL 75 ML $ Irbesartan 150 MG TAB Irbesartan 300 MG TAB Irbesartan 75 MG TAB Irbesartan-HCTZ 150 MG/12.5 MG TAB Irbesartan-HCTZ 300 MG/12.5 MG TAB Isoniazid 300 MG TAB Isosorbide mononitrate 10 MG TAB Isosorbide mononitrate 20 MG TAB Isosorbide mononitrate 30 MG ER TAB Isosorbide mononitrate 60 MG ER TAB Jardiance 10 MG 352.21 Jardiance 25 MG 352.21 Jentadueto 2.5-500 MG 60 $ 274.01 Jentadueto 2.5-850 MG 60 $ 274.01 Jentadueto 2.5-1000 MG 60 $ 274.01 Ketoconazole 2% SHAMPOO 120 ML $ Ketoconazole 200 MG TAB Ketorolac tromethamine 0.5% OPHTH SOL 3 ML $ Ketorolac tromethamine 0.5% OPHTH SOL 5 ML $ Ketotifen Fumarate 0.025% OPHTH SOL 5 ML $ Kristalose 10 GM PACKET 157.50 Kristalose 20 GM PACKET 163.08 Labetalol 100 MG TAB Labetalol 200 MG TAB Labetalol 300 MG TAB Lactic acid 12% CREAM 140 G $ Lactulose 10 G/15 ML SOL 237 ML $ Lamotrigine 100 MG TAB Lamotrigine 150 MG TAB Lamotrigine 200 MG TAB Lamotrigine 25 MG CHEW Lamotrigine 25 MG TAB Lansoprazole 15 MG ER CAP Lansoprazole 30 MG ER CAP Latanoprost 0.005% OPHTH SOL 2.5 ML $ Latisse 0.03% Eye Drops 2.5 ML $ 95.05 Latisse 0.03% Eye Drops 5 ML $ 144.40 Letrozole 2.5 MG TAB Levemir 100 UNITS/ML VIAL 10 ML $ 221.39 Levemir FlexTouch Pen 100 UNITS/ML VIAL 15 ML $ 330.34 Levetiracetam 100 MG/1ML SOL 120 ML $ Levetiracetam 250 MG TAB 120 $ Levetiracetam 500 MG TAB 60 $ Levetiracetam 750 MG TAB 60 $ Levetiracetam 500 MG ER TAB 60 $ Levobunolol 0.5% OPHTH SOL 5 ML $ Levobunolol 0.5% OPHTH SOL 10 ML $ Levocetirizine 5 MG TAB Levofloxacin 250 MG TAB 10 $ Levofloxacin 500 MG TAB 10 $ Levofloxacin 750 MG TAB 10 $ Generic equivalent for Levora TAB 28 $ Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-6
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Levothyroxine 100 MCG TAB Levothyroxine 112 MCG TAB Levothyroxine 125 MG TAB Levothyroxine 137 MCG TAB Levothyroxine 150 MCG TAB Levothyroxine 175 MCG TAB Levothyroxine 200 MCG TAB Levothyroxine 25 MCG TAB Levothyroxine 300 MCG TAB Levothyroxine 50 MCG TAB Levothyroxine 75 MCG TAB Levothyroxine 88 MCG TAB Lidocaine 2% SOL 100 ML $ Lidocaine HCL 2% GEL 30 G $ Liothyronine 25 MCG TAB Liothyronine 5 MCG TAB Lisinopril-HCTZ 10 MG/12.5 MG TAB Lisinopril-HCTZ 20 MG/12.5 MG TAB Lisinopril-HCTZ 20 MG/25 MG TAB Lisinopril 10 MG TAB Lisinopril 2.5 MG TAB Lisinopril 20 MG TAB Lisinopril 30 MG TAB Lisinopril 40 MG TAB Lisinopril 5 MG TAB Lithium carbonate 300 MG CAP 90 $ Lithium carbonate 300 MG ER TAB 90 $ Lithium carbonate 600 MG CAP 90 $ Generic equivalent for Lo/ovral TAB 28 $ Generic equivalent for Loestrin 1/20-21 TAB 21 $ Generic equivalent for Loestrin FE 1/20 TAB 28 $ Generic equivalent for Loestrin 1.5/30-21 21 $ Loperamide 2 MG CAP Loratadine 10 MG TAB Loratadine 5 MG/5 ML SYRUP 120 ML $ Losartan-HCTZ 100 MG/12.5 MG TAB Losartan-HCTZ 100 MG/25 MG TAB Losartan-HCTZ 50 MG/12.5 MG TAB Losartan 100 MG TAB Losartan 25 MG TAB Losartan 50 MG TAB Lovastatin 10 MG TAB Lovastatin 20 MG TAB Lovastatin 40 MG TAB Lumigan 0.01% EYE DROPS 2.5 ML $ 152.99 Lumigan 0.01% EYE DROPS 5 ML $ 302.36 Lumigan 0.01% EYE DROPS 7.5 ML $ 451.77 Magnesium chloride 64 MG TAB 60 $ Magnesium oxide 400 MG TAB Meclizine 12.5 MG TAB Meclizine 25 MG CHEW Meclizine 25 MG TAB Medroxyprogesterone acetate 10 MG TAB 10 $ Medroxyprogesterone acetate 2.5 MG TAB Medroxyprogesterone acetate 5 MG TAB Megestrol acetate 40 MG TAB Meloxicam 15 MG TAB Meloxicam 7.5 MG TAB Metformin HCL 1000 MG TAB 60 $ Metformin HCL 500 MG ER TAB 60 $ Metformin HCL 500 MG TAB 60 $ Metformin HCL 750 MG ER TAB Metformin HCL 850 MG TAB 60 $ Methimazole 10 MG TAB 90 $ Methimazole 5 MG TAB 90 $ Methyldopa 250 MG TAB 60 $ Methyldopa 500 MG TAB 60 $ Methylprednisolone 4 MG TAB Metoclopramide 10 MG TAB 60 $ Metoclopramide 5 MG TAB Metoclopramide 5 MG/5 ML SOL 473 ML $ Metoprolol succinate 100 MG ER TAB Metoprolol succinate 200 MG ER TAB Metoprolol succinate 25 MG ER TAB Metoprolol succinate 50 MG ER TAB Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-7
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Metoprolol tartrate 100 MG TAB 60 $ Metoprolol tartrate 25 MG TAB 60 $ Metoprolol tartrate 50 MG TAB 60 $ Metronidazole 250 MG TAB Metronidazole 500 MG TAB Miconazole 2% CREAM 30 G $ Midodrine 10 MG TAB Midodrine 2.5 MG TAB Midodrine 5 MG TAB Minocycline 100 MG CAP Minoxidil 10 MG TAB Minoxidil 2.5 MG TAB Generic equivalent for Mircette 28 DAY TAB 28 $ Mirtazapine 15 MG TAB Mirtazapine 30 MG TAB Mirtazapine 45 MG TAB Mometasone 0.1% CREAM 15 G $ Mometasone 0.1% CREAM 45 G $ Mometasone 0.1% OINTMENT 15 G $ Mometasone 0.1% OINTMENT 45 G $ Mometasone 0.1% SOL 30 ML $ Mometasone 0.1% SOL 60 ML $ Montelukast 10 MG TAB Montelukast 4 MG CHEW Montelukast 5 MG CHEW Mupirocin 2% OINTMENT 22 G $ Mycophenolate 500 MG TAB Myorisan 10 MG CAP 96.90 Myorisan 20 MG CAP 114.90 Myorisan 40 MG CAP 135.00 Naproxen 250 MG TAB Naproxen 375 MG TAB Naproxen 500 MG TAB Naproxen EC 375 MG TAB Naproxen EC 500 MG ER TAB Neo/polymyxin/dexamethasone 0.1% OPHTH OINTMENT Neo/polymyxin/dexamethasone 0.1% OPHTH Neomycin/bactiracin/polymyxi 5MG- 400UNT-10000UNT OPHTH OINTMENT 4 G $ 5 ML $ 3.5 G $ Nifedipine 30 MG ER TAB Nifedipine 60 MG ER TAB Nifedipine 90 MG ER TAB Nifedipine Osmotic 30 MG ER TAB Nifedipine Osmotic 60 MG ER TAB Nitroglycerin 0.2 MG/24HR PATCH Nitroglycerin 0.4 MG/24HR PATCH Nitroglycerin 2.5 MG CAP Nizatidine 150 MG CAP Nortriptyline 10 MG CAP Nortriptyline 25 MG CAP Nortriptyline 50 MG CAP Nortriptyline 75 MG CAP Novolin 70/30 Relion Insulin VIAL 10 ML $ 22.89 Novolin-N Relion Insulin VIAL 10 ML $ 22.89 Novolin-R Relion Insulin VIAL 10 ML $ 22.89 NovoLog 100 UNIT/ML CARTRIDGE 15 ML $ 418.12 NovoLog 100 UNIT/ML VIAL 10 ML $ 226.72 NovoLog FLEXPEN SYRINGE 15 ML $ 434.60 NovoLog Mix 70-30 FLEXPEN SYRINGE 15 ML $ 434.60 NovoLog Mix 70-30 VIAL 10 ML $ 235.02 Nystatin 100,000 IU CREAM 15 G $ Nystatin 100,000 IU CREAM 30 G $ Nystatin 100,000 IU OINTMENT 15 G $ Nystatin 100,000 IU OINTMENT 30 G $ Nystatin 100,000 IU POW 15 G $ Ofloxacin 0.3% OPHTH SOL 5 ML $ Ofloxacin 0.3% OPHTH SOL 10 ML $ Olanzapine 10 MG TAB Olanzapine 15 MG TAB Olanzapine 2.5 MG TAB Olanzapine 20 MG TAB Olanzapine 5 MG TAB Olanzapine 7.5 MG TAB Omeclamox-Pak Combo PACK 80 $ 474.28 Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-8
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Omeprazole 10 MG CAP Omeprazole 20 MG CAP Omeprazole 40 MG ER CAP Ondansetron 4 MG ODT Ondansetron 4 MG TAB Ondansetron 4 MG/5 ML SOL 50 ML $ Ondansetron 8 MG ODT Ondansetron 8 MG TAB Generic equivalent for Ortho micronor dpk TAB 28 $ Generic equivalent for Ortho tri-cyclen TAB 28 $ Generic equivalent for Ortho-cept TAB 28 $ Generic equivalent for Ortho-cyclen 0.25/35 TAB Generic equivalent for Ortho-novum 7/7/7 TAB 28 $ 28 $ Generic equivalent for Ortho-novum TAB 28 $ Osphena 60 mg 61.01 Generic equivalent for Ovcon-35 TAB 28 $ Oxcarbazepine 150 MG TAB 60 $ Oxcarbazepine 300 MG TAB 60 $ Oxybutynin 5 MG TAB Oxybutynin 5 MG/5 ML SYRUP 473 ML $ Pantoprazole 20 MG TAB Pantoprazole 40 MG TAB Paroxetine 10 MG TAB Paroxetine 20 MG TAB Paroxetine 30 MG TAB Paroxetine 40 MG TAB Peg-3350 electrolyte 240 G SOL 4 L $ Peg-3350 electrolyte 420 G SOL 4 L $ Penicillin V potassium 250 MG TAB Penicillin V potassium 250 MG/5 ML SOL 100 ML $ Penicillin V potassium 250 MG/5 ML SOL 200 ML $ Penicillin V potassium 500 MG TAB Pentoxifylline 400 MG ER TAB Perindopril 4 MG TAB Perindopril 8 MG TAB Phenytoin 100 MG ER CAP Phenytoin 50 MG CHEW Pilocarpine 5 MG TAB Pioglitazone 15 MG TAB 30 Free Pioglitazone 30 MG TAB 30 Free Pioglitazone 45 MG TAB 30 Free Polyethylene glycol 3350 ORAL POW 255 G $ Polymyxin B-trimethoprim 10000 UNIT/0.1% OPHTH SOL 10 ML $ Potassium bicarbonate 25 MEQ TAB Potassium chloride 10 MEQ CAP Potassium chloride 10 MEQ TAB Pramipexole.75 MG TAB 90 $ Pramipexole 0.125 MG TAB 90 $ Pramipexole 0.25 MG TAB 90 $ Pramipexole 0.5 MG TAB 90 $ Pramipexole 1 MG TAB 90 $ Pramipexole 1.5 MG TAB 90 $ Pravastatin 10 MG TAB Pravastatin 20 MG TAB Pravastatin 40 MG TAB Pravastatin 80 MG TAB Prazosin 1 MG CAP Prednisolone 15 MG/5 ML SYRUP 240 ML $ Prednisone 1 MG TAB 10 $ Prednisone 10 MG TAB Prednisone 2.5 MG TAB Prednisone 20 MG TAB Prednisone 5 MG TAB Primidone 250 MG TAB 90 $ Primidone 50 MG TAB Probenecid 500 MG TAB Prochlorperazine maleate 10 MG TAB Prochlorperazine maleate 5 MG TAB Promethazine 12.5 MG TAB Promethazine 25 MG TAB Promethazine 50 MG TAB Promethazine 6.25 MG/5 ML SYRUP 473 ML $ Propafenone 150 MG TAB 90 $ Propranolol 10 MG TAB Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-9
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Propranolol 20 MG TAB Propranolol 40 MG TAB Propranolol 60 MG TAB Propranolol 80 MG TAB Pulmicort 90 MCG FLEXHALER 1 ct. $ 158.72 Pulmicort 180 MCG FLEXHALER 1 ct. $ 211.35 Quetiapine 100 MG TAB Quetiapine 200 MG TAB Quetiapine 25 MG TAB Quetiapine 300 MG TAB Quetiapine 400 MG TAB Quetiapine 50 MG TAB Quinapril-HCTZ 10 MG/12.5 MG TAB Quinapril-HCTZ 20 MG/12.5 MG TAB Quinapril-HCTZ 20 MG/25 MG TAB Quinapril 10 MG TAB Quinapril 20 MG TAB Quinapril 40 MG TAB Quinapril 5 MG TAB Rabeprazole 20 MG TAB Ramipril 1.25 MG CAP Ramipril 10 MG CAP Ramipril 2.5 MG CAP Ramipril 5 MG CAP Ranitidine 150 MG TAB 60 $ Ranitidine 300 MG TAB Ranitidine 75 MG/5 ML SYRUP 473 ML $ Rasuvo 7.5 MG/0.15 ML 4 $ Rasuvo 10 MG/0.2 ML 4 $ Rasuvo 12.5 MG/0.25 ML 4 $ Rasuvo 15 MG/0.3 ML 4 $ Rasuvo 17.5 MG/0.35 ML 4 $ Rasuvo 20 MG/0.4 ML 4 $ Rasuvo 22.5 MG/0.45 ML 4 $ Rasuvo 25 MG/0.5 ML 4 $ Rasuvo 27.5 MG/0.55 ML 4 $ Rasuvo 30 MG/0.6 ML 4 $ Restasis 0.05% EYE EMULSION 30 udv $ 229.09 Restasis 0.05% EYE EMULSION 60 udv $ 454.69 Risperidone 0.25 MG TAB 60 $ Risperidone 0.5 MG ODT Risperidone 0.5 MG TAB 60 $ Risperidone 1 MG TAB 60 $ Risperidone 1 MG/1 ML SOL 30 ML $ Risperidone 2 MG TAB 60 $ Risperidone 3 MG TAB 60 $ Risperidone 4 MG TAB 60 $ Ropinirole 0.25 MG TAB 90 $ Ropinirole 0.5 MG TAB 90 $ Ropinirole 1 MG TAB 90 $ Ropinirole 2 MG ER TAB Ropinirole 2 MG TAB 90 $ Ropinirole 3 MG TAB 90 $ Ropinirole 4 MG ER TAB Ropinirole 4 MG TAB 90 $ Ropinirole 5 MG TAB 90 $ Saxenda 6 MG/ML Injection 15 ML $ 1100.04 Selenium sulfide 3% LOTION 120 G $ Sertraline 100 MG TAB Sertraline 25 MG TAB Sertraline 50 MG TAB Sildenafil 20 MG TAB Silver sulfadiazine 1% CREAM 25 G $ Silver sulfadiazine 1% CREAM 50 G $ Simvastatin 10 MG TAB Simvastatin 20 MG TAB Simvastatin 40 MG TAB Simvastatin 5 MG TAB Simvastatin 80 MG TAB Sodium bicarbonate 650 MG TAB Sodium chloride 5% OPHTH OINTMENT 4 G $ Sodium chloride 5% OPHTH SOL 15 ML $ Sodium fluoride 0.2% SOL 473 ML $ Sodium fluoride 0.5 MG/1ML DROP 50 ML $ Sodium fluoride 1.1 MG CHEW 120 $ Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-10
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Sodium fluoride 1% CREAM 51 G $ Sodium fluoride 1% GEL 56 G $ Sodium fluoride 2.2 MG CHEW 120 $ Sotalol HCL 120 MG TAB 60 $ Sotalol HCL 160 MG TAB 60 $ Sotalol HCL 80 MG TAB Spiriva Respimat 1 ct. $ 338.56 Spironolactone 100 MG TAB Spironolactone 25 MG TAB Spironolactone 50 MG TAB Stiolto Respimat 1 ct. $ 313.75 Sucralfate 1 G TAB Sulfacetamide sodium 1% OPHTH SOL 15 ML $ Sulfacetamide-prednisolone 10%/0.25% OPHTH SOL Sulfamethoxazole-trimethoprim 400 MG/800 MG TAB Sulfamethoxazole-trimethoprim 800 MG/160 MG TAB 5 ML $ 20 $ Sulfasalazine 500 MG ER TAB Sulfasalazine 500 MG TAB Sulindac 150 MG TAB Sulindac 200 MG TAB Sumatriptan succinate 100 MG TAB 9 $ Sumatriptan succinate 25 MG TAB 9 $ Sumatriptan succinate 50 MG TAB 9 $ Symbicort 80-4.5 MCG INHALER 1 ct. $ 283.08 Symbicort 160-4.5 MCG INHALER 1 ct. $ 323.07 Synjardy 5-500 MG TAB 60 $ 352.21 Synjardy 5-1000 MG TAB 60 $ 352.21 Synjardy 12.5-500 MG TAB 60 $ 352.21 Synjardy 12.5-1000 MG TAB 60 $ 352.21 Tamsulosin 0.4 MG CAP Telmisartan 20 MG TAB Telmisartan 40 MG TAB Telmisartan 80 MG TAB Terazosin 1 MG CAP Terazosin 10 MG CAP Terazosin 2 MG CAP Terazosin 5 MG CAP Terbinafine 250 MG TAB Theophylline 100 MG TAB Timolol maleate 0.25% OPHTH SOL 5 ML $ Timolol maleate 0.25% OPHTH SOL 10 ML $ Timolol maleate 0.25% OPHTH SOL 15 ML $ Timolol maleate 0.5% OPHTH SOL 5 ML $ Timolol maleate 0.5% OPHTH SOL 10 ML $ Timolol maleate 0.5% OPHTH SOL 15 ML $ Tobramycin 0.3% OPHTH SOL 5 ML $ Tolterodine 1 MG TAB Tolterodine 2 MG TAB Topiramate 100 MG TAB 60 $ Topiramate 200 MG TAB 60 $ Topiramate 25 MG TAB 60 $ Topiramate 50 MG TAB 60 $ Torsemide 10 MG TAB Torsemide 100 MG TAB Torsemide 20 MG TAB Torsemide 5 MG TAB Tradjenta 5 MG 274.01 Trandolapril 1 MG TAB Trandolapril 2 MG TAB Trandolapril 4 MG TAB Trazodone 100 MG TAB Trazodone 150 MG TAB Trazodone 50 MG TAB Tresiba FlexTouch 100 UNIT INJECTION 15 $ 389.65 Tresiba FlexTouch 200 UNIT INJECTION 9 $ 466.88 Generic equivalent for Tri-norinyl TAB 28 $ Triamcinolone 0.025% CREAM 15 G $ Triamcinolone 0.025% CREAM 80 G $ Triamcinolone 0.025% OINTMENT 15 G $ Triamcinolone 0.025% OINTMENT 80 G $ Triamcinolone 0.1% CREAM 15 G $ Triamcinolone 0.1% CREAM 80 G $ Triamcinolone 0.1% OINTMENT 15 G $ Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-11
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs Triamcinolone 0.1% OINTMENT 80 G $ Triamcinolone 0.5% CREAM 15 G $ Triamterene-HCTZ 37.5 MG/25 MG CAP Triamterene-HCTZ 37.5 MG/25 MG TAB Triamterene-HCTZ 75 MG/50 MG TAB Tricare prenatal multivitamin TAB Trihexyphenidyl 2 MG TAB 60 $ Trihexyphenidyl 5 MG TAB Trimethoprim 100 MG TAB Generic equivalent for Triphasil TAB 28 $ Triphrocaps w/ folic acid 1 MG CAP Tropicamide 1% OPHTH SOL 15 ML $ True Metrix Blood Glucose Monitoring System 1 ct. Free True Metrix Test Strips 50 $ 20.56 True Metrix Test Strips 100 $ 37.05 Valacyclovir 500 MG TAB Valproate sodium 250 MG CAP Valproate sodium 250 MG/5 ML SYRUP 473 ML $ Valsartan-HCTZ 160 MG/12.5 MG TAB Valsartan-HCTZ 160 MG/25 MG TAB Valsartan-HCTZ 320 MG/12.5 MG TAB Valsartan-HCTZ 320 MG/25 MG TAB Valsartan-HCTZ 80 MG/12.5 MG TAB Valsartan 160 MG TAB Valsartan 320 MG TAB Valsartan 40 MG TAB Valsartan 80 MG TAB Vaniqa 13.9% Cream 45 G $ 136.16 Venlafaxine 100 MG TAB Venlafaxine 150 MG ER CAP Venlafaxine 25 MG TAB Venlafaxine 37.5 MG ER CAP Venlafaxine 37.5 MG TAB Venlafaxine 50 MG TAB Venlafaxine 75 MG ER CAP Venlafaxine 75 MG TAB Verapamil 120 MG ER TAB Verapamil 120 MG TAB Verapamil 180 MG ER TAB Verapamil 240 MG ER TAB Verapamil 80 MG TAB Victoza 2-pak 18 MG/3 ML PEN 6 ML $ 514.39 Victoza 3-pak 18 MG/3 ML PEN 9 ML $ 769.84 Vitamin D2 (ergocalciferol) 50,000 IU CAP 4 Free Warfarin 1 MG TAB Warfarin 10 MG TAB Warfarin 2 MG TAB Warfarin 2.5 MG TAB Warfarin 3 MG TAB Warfarin 4 MG TAB Warfarin 5 MG TAB Warfarin 6 MG TAB Warfarin 7.5 MG TAB Xultophy 100/3.6 Injection 15 ML $ 889.96 Yasmin 28 $ 30.00 Yaz 28 $ 30.00 Zonisamide 100 MG CAP Zonisamide 25 MG CAP Zonisamide 50 MG CAP Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free) V2-12
List for Plus Members over 200 prescriptions available at $ 4 and over 400 prescriptions available at $ 10. s valid as of November 3, 2017 Bold items indicate name-brand drugs 1. Sam s Club List (the Program ) prices are available only at Sam s Club Retail Pharmacy locations and only to Sam s Plus Members and Sam s Plus Members for business. 2. The Program applies only to certain generic drugs at commonly prescribed dosages. Higher dosages cost more. You may obtain a list of generic drugs and dosages covered under the Program at Sam s Club Retail Pharmacies (the List ) at SamsClub.com/EVDL. The List may change and also may vary by state. Not all formulations of a drug (for example, enteric-coated, extended- or timed-release formulations) are covered under the Program. Program pricing is not available when a covered drug is dispensed as part of a compound. 3. Under the Program, the price listed on the List is the price for up to a 30-day supply of certain covered generic drugs at commonly prescribed dosages as listed on the List. If the prescribed quantity exceeds the stated 30-day supply amount listed on the List, any amount above the stated 30-day supply would price at a prorated per-unit price. For $ 0 medications, any quantity up to and including the stated 30-day supply would price at $ 0, while any amount above the stated 30-day supply would price at a prorated per-unit price. 4. Prepackaged drugs are covered under the Program only in the unit sizes specified on the List. Prepackaged drugs are dispensed based on the quantities prescribed and unit sizes in stock at the dispensing Pharmacy. Unit sizes not specified on the Retail List are not covered under the Program. Multi-unit purchases are charged at a per-unit price based on the price per unit size dispensed unless otherwise specified. Prepackaged drugs dispensed in unit sizes not specified on the List may be priced higher, even if equivalent quantities of the drug are available in specified unit sizes. Prorated pricing is not available under the Program for prepackaged drugs. 5. s of certain drugs covered by the Program may be higher in some states, as noted on the List. 6. 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. 7. Program pricing does not apply to purchases submitted to any health benefit program, pharmacy benefit program, insurer or government health care program. Discount is nontransferable, may not be combined with other offers and is available in-club only. Valid prescription required. 8. An active Sam s Plus Membership or Sam s Plus Membership for business is required for program eligibility. Such membership must be confirmed before discounts are applied. There are no substitutions. 9. These Program details are subject to change without advance notice. Changes to these Program details may be made only in writing. 10. Interpreter Services are available at no cost. Please visit your local Sam s Club for assistance. Only quantity, formulation, and strength stated on List ( EVDL ) covered at the EVDL (or free)