CVS MAIL SERVICE 000001486343822004

CAREMARJCI INVOICE/RECEIPT
Balance Due Upon Receipt
$0.00

033000448

JULIABRYANT
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.

CV Summary for Order: 000001486343822
S Date: 04/17/2009
Days Benefit Co-Pay
Name / Rx# Quantity Supply_______Drug Name / NDC____________Provider Paid_______Amount
Clindamycin CAP 300MG
JULIA BRYANT ciinaamycin CAI* ;
Rx# 934862529 16 EA 90 NDC 63304069301 $0 .00 $15.01*

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

Shipping Charge Total $0.00

for this Order $0.00 $15.01
Previous Account Balance $0.00
Payment Received with this Order by DISCOVER CARD - $15.01
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