000001224153407004

CVS MAIL SERVICE

CAREMARJC INVOICE/RECEIPT
Balance Due Upon Receipt
$0.00

033000448

JULIA 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.
C A R E M A R jC Summary for Order: 000001224153407
Date: 04/27/2009
Name / Rx# Days Benefit Co-Pay
JULIA BRYANT Quantity_____Supply______Drug Name / NDC___________Provider Paid______Amount
Rx# 933931042 Synthroid. TAB 0.IMG
90 EA 90 NDC 00339635111 $0.00 $12.52*

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

Shipping Charge $0.00

Total for this Order $0.00 $12.52
Previous Account Balance $0.00
Payment Received with this Order by DISCOVER CARD $12.52
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