Cvs! Mail Service Invoice/receipt

CVS! MAIL SERVICE INVOICE/RECEIPT

000001294992794006

Balance Due Upon Receipt $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.

CVS

Retain the bottom portion of this form for your records.

CAREMARJ< Name / Rx# HARRY E. BRYANT Rx# 9307 13004 HARRY E. BRYANT Rx# 932746932 HARRY E. BRYANT Rx# 930712987

Quantity 90 EA 90 EA 90 EA

Summary for Order: 000001294992794 Date: 02/16/2009 Days Benefit Co-Pay Supply Drug Name / NDC Provider Paid Amount Lipitor TAB 10MG90 $157.94 Antara CAP 130MG90 $196.97 Bisoprl/hctz TAB 5/6.25MG-SO $0.00

NDC 0007 101 5523 NDC 677070 13030 ND(5 00378050310

$54.00* $108. 00* $16.09*

* 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.

$354.91

$0 . 00 $178.09 $0.00 $178.09 $0.00

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 at1-800-378-8851

Page