Cvs Mail Service Caremarjc Invoice/receipt

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 C A R E M A R jC

Name / Rx# JULIA BRYANT Rx# 933931042

Retain the bottom portion of this form for your records.

Summary for Order: 000001224153407 Date: 04/27/2009 Days Benefit Co-Pay Quantity_____Supply______Drug Name / NDC___________Provider Paid______Amount 90 EA

90

Synthroid. TAB 0.IMG NDC 00339635111

$0.00

$12.52*

$0.00

$0.00 $12.52

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

Shipping Charge Total for this Order Previous Account Balance Payment Received with this Order by DISCOVER CARD Balance Due Upon Receipt

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

$0.00 $12.52 $0.00

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