000001519532218003

CV C A R E M A RMAIL
J C SERVICE
S INVOICE/RECEIPT
Balance Due Upon Receipt
C A R E M A R JC
$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.

C A R E M A R JC Summary for Order: 000001519532218
Date: 12/12/2008
CVS Days Benefit Co-Pay
CAREMARjC Supply_______Drug Name / NDC____________Provider Paid_______Amount
Antara CAP 130MG
N am e / R x# Q u a n t ity 90 NDC 67707013030 $197.50 $101.00*
HARRY E. BRYANT
Rx# 932746932 90 EA

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

Shipping Charge Total $0.00

for this Order $197.50 $101.00
Previous Account Balance $0.00
Payment Received with this Order by DISCOVER CARD $101.00
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