000001667561593007

•CMAIL SERVICE
Balance Due Upon Receipt
AREM A R JC $51.00
INVOICE/RECEIPT
033000448

JULIA BRYANT
587 PICKERINGTON HILLS DRIVE
PICKERINGTON, OH 43147-1368

Please return the top portion of this form with vour payment,
See reverse side for payment or refund options.

Retain the bottom portion of this form for your records.

' Summary for Order: 000001667561593
Date: 10/03/2008
Days Benefit Co-Pay
Name / Rx# Quantity Supply_______Drug Name / NDC____________Provider Paid Amount
JULIA BRYANT Albuter3ml NEB 0.083%
Rx# 93 1712297 NDC 00172640549 $59.04
4 PKG 90 $0 .
Your physician authorized a change in this drug therapy. 00
Information regarding this prescription is enclosed.
JULIA BRYANT Spiriva CAP HANDIHLR
Rx# 93 17 12327 PKG 90 NDC 00597007547 $362.63
JULIA BRYANT Fioveni HfaT'lNH 110MCG/A $0.00
Rx# 931 712336 NDC 00173071920 $267.32
3 PKG 90 $0.00

Shipping Charge Total $0 . 00

for this Order $688.99 $0.00
Previous Account Balance Payment $51.00
Received with this Order Balance $0.00
Due Upon Receipt $51.00
A Balance Due may not reflect payments recently mailed separate from this order.

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If you have any questions, you can contact Caremark Customer Care at 1-800-378-8851 Page