CVSI CARFMARK MAIL SERVICE 000001449432292012

CAREMARJC "^ INVOICE/RECEIPT

Balance Due Upon Receipt

$0.00
 033000448

HARRY E. BRYANT
587 PICKERINGTON HILLS DRIVE
PICKERINGTON, OH 43147

Please return the top portion of this form with your payment.
See. reverse side_ for oavment or refund options^ .

CAREMrtf CAREMARjC Name / Retain the bottom portion of this form for your records.
Summary for Order: 000001449432292 Date: 12/09/2008 Days
Benefit Co-Pay Supply Drug Name / NDC
Rx# Quantity Provider Paid Amount
JULIA BRYANT Rx# 931712336 FloventHfa INK 110MCG/A
3 PKG 90 NDC 00 17307 1920 $267.32 $0. 00*
HARRY E. BRYANT Rx# Bisoprl/hctz TAB 5/6.25MG
930712987 90 EA 90 NDC 003780503 10 $7.29 $20. 00*
HARRY E. BRYANT Rx# 9307 Lipitor TAB 10MG
13004 90 EA 90 NDC 00071015523 $132.78 $51.00*
JULIA BRYANT Rx# 93 1712297 4 PKG Albuter 3ml NEB 0.083% $59.04 $0.00*
90 Your physician authorized a change in this drug NDC 49502069761
therapy. Information regarding this prescription is
enclosed.
JULIA BRYANT Rx# 929230620 Proventil INK HFA 200
1 PKG 25 NDC 000851 13201 $28.18 $0.00*
JULIA BRYANT Rx# 93 1712327 Spiriva CAP HANDIHLR
1 PKG 90 NDC 00597007547 $362.63 $0.00*

* FSA/HRA eligible health care expenses. Retain Invoice/Receipt for your records.
Shipping Charge Total $0.00
for this Order $857.24 $71.00
Previous Account Balance $51.00
Payment Received with this Order by DISCOVER CARD $122.00
Balance Due Upon Receipt $0.00
A Balance Due may not reflect payments recently mailed separate from this order.
Thank you for your participation. Please remember that you can order refills online at www.caremark.com
If you have any questions, you can contact Caremark Customer Care at 1-800-378-8851 Page