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000001846043424005
CVS I MAIL SERVICE
CAREMARjO 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.

Retain the bottom portion of this form for your records.

CVS Summary for Order: 000001846043424 Date: 04/14/2009 Days
C A R E M A R iJC Benefit Co-Pay Quantity Supply Drug Name / NDC
Name / Rx# Provider Paid Amount
HARRY E. BRYANT Antara CAP 130MG Rx# 932746932 $108.00*
90 EA 90 NDC 67707013030 $196.97
JULIA BRYANT Flovent Hfa INH 1 1 OMCG/A Rx# 931712336
3 PKG 90 NDC 00173071920 $233.25 $54.00*

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

Shipping Charge $0.00

Total for this Order $430.22 $162.00
Previous Account Balance $0.00
Payment Received with this Order by DISCOVER CARD $162.00
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 the web address on your id card.
If you have any questions, you can contact Customer Care at 1-800-378-8851 Page 1