CVSI MAIL SERVICE 000001792153949004

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.
PtfQ letam me torn portion of form Jor your records.
Dot mis. Summary for Order: 000001792153949
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Date: 04/27/2009
Days Benefit Co-Pay
Name / Rx# Quantity Supply Drug Name / NDC Provider Paid Amount
JULIA BRYANT Potassium Cl CAP 10MEQ ER
Rx# 934022052 NDC 62037056001 $34 .49
90 EA 90 $17.00*
:
FSA/HRA eligible health care expenses. Retain Invoice/Receipt for your records.

Shipping Charge Total $0.00

for this Order $34.49 $17.00
Previous Account Balance $0.00
Payment Received with this Order by DISCOVER CARD $17.00
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