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Caremarjc: Julia Bryant 587 Pickerington Hills Drive PICKERINGTON, OH 43147-1368
Caremarjc: Julia Bryant 587 Pickerington Hills Drive PICKERINGTON, OH 43147-1368
033000448
JULIA BRYANT
587 PICKERINGTON HILLS DRIVE
PICKERINGTON, OH 43147-1368
Please return the top portion of this form with your payment.
See reverse side for payment or refund options.
CVS Retain the bottom portion of this form for your records.
C A R E M A R JC C A R E M A R JC
Summary for Order: 000001642332276
Date: 12/12/2008
Name / Rx#
Quantity
JULIA BRYANT
Rx# 932702947
90 EA
Days Benefit Co-Pay
Supply______Drug Name / NDC___________Provider Paid______Amount
Sertraline TAB 50MG
90 NDC 00339647511 $19.22 $0. 00*
* FSA/HRA eligible health care expenses. Retain Invoice/Receipt for your records.
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