000001725423797004

CV
S MAIL SERVICE
INVOICE/RECEIPT
Balance Due Upon Receipt
C A R E M A R JC $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.
• -Retain -the bottom -portmn-of-thisform for your records-.--------------------------------------------------
Summary for Order: 000001725423797
CVS Date: 03/18/2009
C A R E M A R j< Days Benefit Co-Pay
Name / Rx# Quantity Supply______Drug Name / NDC___________Provider Paid______Amount
JULIA BRYANT Spiriva CAP HANDIHLR
$54.00*
Rx# 931712327 NDC 00597007547 $336.06
1PKG 90

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

Shipping Charge Total $0.00

for this Order $336.06 $54.00
Previous Account Balance $0.00
Payment Received with this Order by DISCOVER CARD $54.00
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