$4 Walmart Voucher Instructions



Many EAC patients experience financial hardship severe enough to be impacted even by buying several of their prescriptions from the Walmart $4 fomulary.  Please use this guide to help them receive these prescriptions for free.


NOTE:  You must be using CHOICES Form Version X2 or above in order to use the Walmart Vouchers.  If you use an incorrect version, the resultant accounting error means the vouchers may be cancelled.

  1. When completing your patient’s prescriptions, confer with the pharmacy staff.  If they recommend the $4 Walmart formulary for one or more of them, offer your patient the option of having them paid for by EAC.
  2. If the patient accepts, complete the normal prescription, but also completely fill out a $4 Walmart voucher.  Use these vouchers for items on the $4 list only.
  3. Collect the bottom copies of each voucher you use, and put them all in the EAC locker in MDL 2 the next day.
  4. Provide the patient with the top copy of the prescription attached to the top copy of the voucher.
  5. Enter the prescription information into the CHOICES form, select $4 for the price, select “NO” under “Self-Pay?”, and select “YES” under “Walmart Voucher?” Enter the Walmart Voucher Number where indicated.
  6. If you select one or more refills, you complete this line for each refill (all same voucher number).

Say John E. Access is being prescribed amoxicillin, 30 tablets, with 3 refills. The CHOICES form entry should look like this:


Patient number drug name dosage (mg) qty + refills price self-pay? walmart voucher? voucher #
3 Amoxicillin 500 mg 30 tab – Refill 1 $4 No Yes A000130
3 Amoxicillin 500 mg 30 tab – Refill 2 $4 No Yes A000130
3 Amoxicillin 500 mg 30 tab – Refill 3 $4 No Yes A000130

You are done! Thank you!