CVS!

MAIL SERVICE 000001294992794006

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 payment or refund options.
CVS
Retain the bottom portion of this form for your records.
CAREMARJ< Summary for Order: 000001294992794 Date: 02/16/2009 Days
Benefit Co-Pay Supply Drug Name / NDC
Name / Rx# Quantity Provider Paid Amount
HARRY E. BRYANT 90 EA Lipitor TAB 10MG90 NDC 0007 101 5523 $54.00*
Rx# 9307 13004 $157.94
HARRY E. BRYANT Antara CAP 130MG90 NDC 677070 13030
Rx# 932746932 90 EA $108. 00*
$196.97
HARRY E. BRYANT Bisoprl/hctz TAB 5/6.25MG-SO ND(5 00378050310
Rx# 930712987 90 EA $0.00 $16.09*

* FSA/HRA eligible health care expenses. Retain Invoice/Receipt for your records.

Shipping Charge Total $0 .

for this Order $354.91 00
$178.09
Previous Account Balance
Payment Received with this Order by DISCOVER CARD $0.00
Balance Due Upon Receipt $178.09
A Balance Due may not reflect payments recently mailed separate from this order. $0.00

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