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Final Agenda Packet
s r.r� CITY OF RENTON FIREMEN'S PENSION BOARD Regular Meeting 7th Floor-Mayor's Conference Room Thursday, November 19, 2009 2:00 P.M. 1. CALL TO ORDER 2. APPROVAL OF MINUTES OF OCTOBER 15, 2009 3. CORRESPONDENCE Memo- Bruce Phillips Term Expiration 4. MONTHLY STATEMENT TO OCTOBER 31, 2009 5. MONTHLY BILLS AND PENSION PAYMENTS 6. UNFINISHED BUSINESS 7. NEW BUSINESS Set Date &Time for 2010 Board Meetings 8. ADJOURNMENT MINUTES w FIREMEN'S PENSION BOARD CITY OF RENTON October 15, 2009 Denis Law, Mayor Don Persson, Council Finance Committee Chair Bonnie Walton, City Clerk Ray Barilleaux, Fire Department Representative Bruce Phillips, Fire Department Representative Chuck Christensen, Fire Department Alternate The regular meeting of the Firemen's Pension Board was called to order by Mayor Denis Law at 2:04 p.m. in the Mayor's Conference room, 7th floor of Renton City Hall. In attendance were Board members Denis Law, Don Persson, Ray Barilleaux, and Bonnie Walton, as well as Finance Department representative Jill Masunaga. MINUTES APPROVAL MOVED BY PERSSON, SECONDED BY BARILLEAUX,THE PENSION BOARD APPROVE THE MINUTES OF THE SEPTEMBER 17, 2009, MEETING. CARRIED. MONTHLY STATEMENT The financial report as of September 30, 2009, was reviewed. Total cash/investment balance was $4,222,353.74. MONTHLY BILLS AND PENSION PAYMENTS MOVED BY BARILLAUX, SECONDED BY PERSSON,TO APPROVE THE PENSION/MEDICAL PAYMENTS FOR OCTOBER 2009, IN THE TOTAL AMOUNT OF $36,323.65 TO BE PAID FROM THE FIREMEN'S PENSION FUND. CARRIED. ADJOURNMENT MOVED BY PERSSON, SECONDED BY BARILLEAUX,THE MEETING OF THE FIREMEN'S PENSION BOARD BE ADJOURNED. CARRIED. Time: 2:08 p.m. 4#1(42-fl:4. CcJa- - Bonnie Walton Firemen's Pension Board Secretary `— ,_��� o ADMINISTRATIVE,JUDICIAL, AND 1 {' LEGAL SERVICES DEPARTMENT �'� Office of the City Clerk N<Nt.19 MEMORANDUM DATE: November 16, 2009 TO: I. David Daniels, Fire Chief FROM: !l" Bonnie Walton, City Clerk and Firemen's Pension Board member/Secretary,x6502 SUBJECT: Firemen's Pension Board Term Expiration The two-year term of office for Bruce Phillips as a member of the Firemen's Pension Board expires on December 31, 2009. An election among the firefighters must be held so that the position may be filled accordingly. Retired members are eligible both to elect and be elected to serve on the board. Following the election, please report the name of the firefighter elected to serve on the board for a two-year term from January 1, 2010 to December 31, 2011. Thank you for your assistance. I can be reached at x6502 if you need additional information. cc: Mark Peterson, Deputy Fire Chief Firemen's Pension Board Members i CITY OF RENTON - FIREMEN'S PENSION FUND CASH & INVESTMENT ACTIVITY REPORT AS OF OCTOBER 31, 2009 Fireman's Pension Fund Comparison of Cash and Investment Activity 6 -- 02009 02008 5 w 4Or a 0 "5 II I c 3 0 2 I 1 Jan F -, Mar Apr May Jun Jul Aug Sep Oct Nov Dec CURRENT 2009 2009 LAST YEAR 2008 2008 ACTIVITY: MONTH YTD BUDGET CURR MO ACTUAL ADJ BUDGET BEGINNING CASH/INV BALANCE $4,222,353.74 $4,265,991.35 $3,895,540 $4,482,570.35 $4,694,232.48 $4,203,347 RECEIPTS: Fire Insurance Premium Tax 0.00 106,622.90 90,000 0.00 85,949.42 75,000 Investment Interest 1,134.67 210,519.98 200,000 599.82 17,965.67 200,000 DISBURSEMENTS: Fire Pension 35,071.71 372,974.12 500,000 41,011.77 512,262.83 552,400 Fire Pension Medical 1,251.94 10,829.70 20,000 808.27 9,572.61 20,000 Office/Operating Supplies 13.03 126.68 475 0.00 372.78 459 Actuarial/Firemen's Pens 0.00 3,200.00 0 0.00 0.00 0 Reimb General/Clerical&Acct 983.00 9,835.00 11,801 829.00 9,948.00 9,948 ENDING CASH/INV BALANCE $4,186,168.73 $4,186,168.73 $3,653,264 $4,440,521.13 $4,265,991.35 $3,895,540 CURRENT PREVIOUS LAST YEAR LAST YEAR ACTIVITY: MONTH MONTH CURR MO PREV MO CASH/State Investment Pool $1,101,594.25 $1,138,700.94 $590,077.75 $632,126.97 INVESTMENTS: CD's&State Investment Pool 0.00 0.00 454,767.46 454,767.46 Federal National Mortgage Assn 99,555.84 99,555.84 99,555.84 99,555.84 Treasury Strips&Zero Coupon Bonds 2,984,096.96 2,984,096.96 3,206,796.27 3,206,796.27 Interest Receivable 921.68 0.00 0.00 0.00 Interest Accrued 0.00 0.00 89,323.81 89,323.81 TOTAL CASH AND INVESTMENTS $4,186,168.73 $4,222,353.74 $4,440,521.13 $4,482,570.35 The State Investment Pool interest 0.4164% 0.4703% 2.4652% 2.3892% H:\FINANCE\FINPLAN\FIREPEN\1_Fire_Pension_2009.xls\Oct09 Page 1 11/12/2009 FIREMEN'S PENSION BOARD ',my PENSION/MEDICAL PAYMENTS FOR NOVEMBER, 2009 -��..,. V;m. . Recipient;, ,,-*F1 .4q;1, .�.�. .Pensian. w,:!,,Medical o a:�a��: ANKENY, Charlie (Captain) $135.71 135.71 ASHURST, James (Assistant Chief) $4,820.50 - 4,820.50 BARILLEAUX, Ray(Battalion Chief) - - BEATTEAY, Karlen (Widow) $231.70 231.70 BERGMAN, Claudette (Widow) $154.09 154.09 CHRISTENSON, Chuck (Firefighter) $259.09 259.09 GEISSLER, Dick (Fire Chief) - - GOODWIN, Charles (Captain) $4,231.00 480.32 4,711.32 GOODWIN, Donald (Firefighter) $1,018.60 1,018.60 HAWORTH, Constance (Widow) $2,910.13 2,910.13 HAWORTH,Jack(Firefighter) $3,191.50 526.77 3,718.27 HENRY,William, Jr. (Captain) $1,339.58 1,339.58 HURST, Gerald (Firefighter) $543.59 543.59 JONES, Evelyn M. (Widow) $250.62 250.62 LARSON, William (Firefighter) - - LAVALLEY, Theodele(Captain) $360.94 360.94 MATTHEW, James (Deputy Chief) - - MC LAUGHLIN, JACK(Battalion Chief) $1,002.95 1,002.95 NEWTON, Gary(Lieutenant) $273.45 273.45 NICHOLS, Gerald (Battalion Chief) $536.08 536.08 PARKS-ANDREASON,Arlene(Widow) $335.32 335.32 PARKS, John (Firefighter) $3,312.50 46.29 3,358.79 PHILLIPS, Bruce H. (Deputy Chief) $257.12 257.12 PRINGLE,Arthur(Captain) $481.28 481.28 PRINGLE, S. Joan (Widow) $2,500.14 2,500.14 RIGGLE, David E. (Firefighter D Step) $82.78 82.78 RUPPRECHT, Jim (Firefighter D Step) $117.72 117.72 SMITH, Leroy(Firefighter) $409.86 409.86 STROM, Doris (Widow) $3,191.50 3,191.50 TODD, Franklin (Firefighter) $469.71 469.71 TONDA, Lila Jean (Widow) $8.43 8.43 VACCA, Nick (Lieutenant) $311.71 311.71 WALLS, Camille(Widow) $145.64 145.64 WALLS, Mercedes (Widow) $115.77 115.77 WALSH, David (Firefighter) $1,065.19 1,065.19 WEISS, Larry(Battalion Chief) $768.23 768.23 WILLIAMS, Alta (Widow) - - WOOTEN, Marilyn E. (Widow) $239.28 239.28 .:zt:".';Total Expensesf Pension/Medical s $35;071:71- :`7,1$1;053.38: 4,° :$36;125:09 Prior Year Pension/Medical Payments: Total Pension Payments for November, 2008 41,952.86 Total Medical Bills Reimbursed in November, 2008 1.109.59 Total Expenses: Medical/Pension 43,062.45 4_SUMMARY 2009.XLS 11/12/2009 Nage Now FIREMEN'S PENSION BOARD MEDICAL BILLS TO BE REIMBURSED IN NOVEMBER, 2009 PAYMENTKt : ::Date '''" ���r,�s,=:amu. ,==�' �� � �" Pha`rmacylMedical Facility Amount of Bill- Page . .. :Names.:. �-' .-_ James Ashurst 0.00 2 Charles Goodwin Bartell Drugs 10/12/09 36.89 2 Charles Goodwin Bartell Drugs 10/14/09 9.89 2 Charles Goodwin Bartell Drugs 10/15/09 194.36 2 Charles Goodwin Bartell Drugs 10/19/09 59.14 3 Charles Goodwin Bartell Drugs 10/19/09 30.05 3 Charles Goodwin Bartell Drugs 11/02/09 149.99 480.32 5 Jack Haworth Harbor Drug Co. 01/12/09 5.00 5 Jack Haworth Harbor Drug Co. 01/15/09 5.00 5 Jack Haworth Harbor Drug Co. 01/23/09 5.00 5 Jack Haworth Harbor Drug Co. 01/23/09 5.00 5 Jack Haworth Harbor Drug Co. 01/23/09 5.00 5 Jack Haworth Harbor Drug Co. 01/26/09 5.00 5 Jack Haworth Harbor Drug Co. 01/27/09 5.00 5 Jack Haworth Harbor Drug Co. 01/27/09 4.22 5 Jack Haworth Harbor Drug Co. 02/24/09 5.00 5 Jack Haworth Harbor Drug Co. 02/24/09 30.00 6 Jack Haworth Harbor Drug Co. 02/27/09 5.00 6 Jack Haworth. Harbor Drug Co. 02/27/09 5.00 6 Jack Haworth Harbor Drug Co. 03/05/09 9.98 6 Jack Haworth Harbor Drug Co. 03/13/09 10.00 6 Jack Haworth Harbor Drug Co. 03/13/09 5.00 6 Jack Haworth Harbor Drug Co. 03/13/09 7.78 6 Jack Haworth Harbor Drug Co. 03/13/09 5.00 6 Jack Haworth Harbor Drug Co. 03/13/09 5.00 6 Jack Haworth Harbor Drug Co. 03/17/09 30.00 6 Jack Haworth Harbor Drug Co. 03/17/09 5.00 7 Jack Haworth Harbor Drug Co. 03/25/09 5.00 7 Jack Haworth Harbor Drug Co. 03/25/09 5.00 7 Jack Haworth Harbor Drug Co. 04/11/09 10.98 7 Jack Haworth Harbor Drug Co. 04/11/09 5.00 7 Jack Haworth Harbor Drug Co. 04/11/09 5.00 7 Jack Haworth Harbor Drug Co. 04/11/09 5.00 7 Jack Haworth Harbor Drug Co. 04/21/09 5.00 7 Jack Haworth Harbor Drug Co. 04/29/09 5.00 7 Jack Haworth Harbor Drug Co. 04/29/09 30.00 7 Jack Haworth Harbor Drug Co. 04/29/09 5.00 ' Jack Haworth Harbor Drug Co. 04/29/09 5.00 Jack Haworth Harbor Drug Co. 05/07/09 5.00 -ick Haworth Harbor Drug Co. 05/08/09 5.00 '' Haworth Harbor Drug Co. 05/14/09 5.00 '9worth Harbor Drug Co. 05/14/09 7.78 •orth Harbor Drug Co. 05/14/09 5.00 ,h Harbor Drug Co. 05/14/09 10.00 Harbor Drug Co. 05/26/09 5.00 Harbor Drug Co. 05/26/09 5.00 Harbor Drug Co. 05/27/09 5.00 Page 1 of 2 11/12/2009 Nor New FIREMEN'S PENSION BOARD MEDICAL BILLS TO BE REIMBURSED IN NOVEMBER, 2009 PAYMENT Page O= °= _" Name _ . . . .. w '%Pharmacy/Medical Facilify ;w' % Date ¢' ' Amount"of Bili r 9 Jack Haworth Harbor Drug Co. 06/15/09 5.00 9 Jack Haworth Harbor Drug Co. 06/15/09 5.00 9 Jack Haworth Harbor Drug Co. 06/15/09 5.00 9 Jack Haworth Harbor Drug Co. 06/15/09 5.00 9 Jack Haworth Harbor Drug Co. 06/23/09 5.00 9 Jack Haworth Harbor Drug Co. 06/23/09 5.00 9 Jack Haworth Harbor Drug Co. 06/25/09 5.00 9 Jack Haworth Harbor Drug Co. 07/11/09 5.00 9 Jack Haworth Harbor Drug Co. 07/11/09 5.00 9 Jack Haworth Harbor Drug Co. 07/11/09 5.00 10 Jack Haworth Harbor Drug Co. 07/11/09 10.00 10 Jack Haworth Harbor Drug Co. 07/24/09 5.00 10 Jack Haworth Harbor Drug Co. 07/24/09 7.78 10 Jack Haworth Harbor Drug Co. 07/24/09 5.00 10 Jack Haworth Harbor Drug Co. 07/24/09 5.00 10 Jack Haworth Harbor Drug Co. 08/03/09 30.00 10 Jack Haworth Harbor Drug Co. 08/04/09 15.47 11 Jack Haworth Harbor Drug Co. 08/10/09 5.00 11 Jack Haworth Harbor Drug Co. 08/10/09 5.00 11 Jack Haworth Harbor Drug Co. 08/13/09 5.00 11 Jack Haworth Harbor Drug Co. 08/27/09 5.00 11 Jack Haworth Harbor Drug Co. 08/27/09 5.00 11 Jack Haworth Harbor Drug Co. 08/31/09 5.00 11 Jack Haworth Harbor Drug Co. 08/31/09 5.00 11 Jack Haworth Harbor Drug Co. 09/09/09 10.00 11 Jack Haworth Harbor Drug Co. 09/09/09 5.00 11 Jack Haworth Harbor Drug Co. 09/15/09 5.00 12 Jack Haworth Harbor Drug Co. 09/29/09 7.78 12 Jack Haworth Harbor Drug Co. 09/29/09 5.00 12 Jack Haworth Harbor Drug Co. 09/29/09 5.00 12 Jack Haworth Harbor Drug Co. 09/29/09 5.00 12 Jack Haworth Harbor Drug Co. 10/01/09 5.00 12 Jack Haworth Harbor Drug Co. 10/12/09 5.00 12 Jack Haworth Harbor Drug Co. 10/12/09 5.00 12 Jack Haworth Harbor Drug Co. 10/12/09 5.00 526.77 14 John Parks Olympic Drug 09/02/09 6.28 14 John Parks Olympic Drug 09/01/09 8.41 14 John Parks Olympic Drug 09/02/09 1.39 14 John Parks Olympic Drug 09/14/09 3.84 14 John Parks Olympic Drug 09/14/09 9.40 14 John Parks Olympic Drug 10/02/09 12.38 14 John Parks Olympic Drug 10/02/09 0.75 14 John Parks Olympic Drug 10/02/09 3.84 46.29 ' !.: 1.._ '': 1' - ;r.,,' ; , '1,053.38 TOTAL .. . ... _ �• , ��:,„ . ... 3_2009 FP Medical.XLS Page 2 of 2 11/12/2009 '"t'' SEND CLAIM TO: City of Renton Finance Dept. -Fire Pension 1055 South Grady Way Renton,WA 98057 I+ +I NT CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE /l 6 4 2) DISABILITY RETIREE'S NAME (print) C#, R L-s if. 6"p®IJCv/it) 3) ADDRESS f' ilit ©,oeU6 ow.),4, - 4 6(4 Mg, 4) DISABILITY AT TIME OF RETIREMENT //A:,j C�2L/1i 1ji ) tfie-e.7-01- 10/0 5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.) (Effective 4/1/2008,pre-LEOFF retirees may submit all prescription drug expenses for reimbursement, whether or not related to the retirement disability,provided that the expense is not covered by another plan,source or insurance coverage. Supporting documentation for all must be attached.) 6 TOTAL AMOUNT OF CLAIM: ? Amount of total claim (above) that is related to the Retirement Disability: $1 U ,39/- 7) I certify that I have not been and will not be compensated by any other organization, insurance carrier or Medicare for the above-mentioned claim for reimbursement other than the City of Renton. I further certify that the above statements are complete and accurate to the best of my knowledge, and that any charges other than prescription drug charges, are related to my disability as determined at the time of my retirement from the Renton Fire Department. Signature: �� _ _ _ Note: Supporting documentation must be attached. P 1 1///h Nor wine ?!.2-4-1.-1,6)/\ P6111 /-1' Li- 714 C-S 6-66_bu), otev-P ( BARTELL DRUGS Washington's Own Druptorea RX# 45- 515918 E DR. LORCH,GERALD BARTELL DRUGS DATE: 10/15/09 R (425)251-5110 W 4OwnDsvgatorea� Rx# 45-503314 E DR. KATO NAME: CHARLES GOODWIN DATE: 10/12/09 R (425)255-9310 1414 MONROE AVE NE#306 NAME: CHARLES GOODWIN AGGRENOX CAP 200/25 1414 MONROE AVE NE#306 00597-0001-60 6493252434659 LISINOPRIL 5MG TABLET(*LUP) REFILL 1 QUANTITY 60.00 68180-0513-03 6442385234659 BARTELL DRUGS PRICE= $208.99 REFILL NO QUANTITY 100.00 j IVr bc>g WITH SR THE AMOUNT DUE 4194.36 BARTELL DRUGS PRICE= $40.99 BARTELL DRUGS#45 WITH SR THE AMOUNT DUE-$36.89 (425)793-1015 BARTELL DRUGS#45 4700 NE 4TH STREET (425)793-1015 RENTON,WA 98059 4700 NE 4TH STREET THANK YOU RENTON,WA 98059 WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR THANK YOU - REFILLS 24-48 HOURS IN ADVANCE WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR REFILLS 24-48 HOURS IN ADVANCE BARTELL DRUGS RX# 45-52038 a Own . KATO ) BARTELL DRUGS DATE: 10/19/09 N (425)255-9310 swash' .Own Dragstorasssssss�� RX# 45- 51966 2a E DR. LORCH,GERALD NAME: CHARLES GOODWIN DATE: 10/14/09 N (425)251-5110 1414 MONROE AVE NE#306 NAME: CHARLES GOODWIN TRAMADOL 50MG TABLET(AKY) 1414 MONROE AVE NE#306 65162-0627-11 6570592624659 ALLOPURINOL 100MG TABLET(*Q/ 00603-2115-32 6478226784659 REFILL NO QUANTITY 60.00 REFILL NO QUANTITY BARTELL DRUGS PRICE= $64.99 / moi/ l 30.00 J / BARTELL DRUGS PRICE= $10.99 WITH SR THE AMOUNT DUE 459.14 WITH SR THE AMOUNT DUE 4112 /v BARTELL DRUGS#45 (425)793-1015 BARTELL DRUGS#45 4700 NE 4TH STREET (425)793-1015 RENTON,WA 98059 4700 NE 4TH STREET RENTON,WA 98059 THANK YOU WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU THANK YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR REFILLS 24-48 HOURS IN ADVANCE WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR � � REFILLS 24-48 HOURS IN ADVANCE L� 71 `I Now' r- 19414,1tA' A.12,t1 ,0 e c4 BARTELL DRUGS w • � •__ ..u6468 E DR. BORROMEO-WES RX 45- 5203 1 E oR. FLO, GAYLE DATE: 11/02/09 R (425)899-3123 DATE: 10/19/09 N (425)251-5110 NAME: CHARLES GOODWIN NAME: CHARLES GOODWIN 1414 MONROE AVE NE#306 1414 MONROE AVE NE#306 GE 600MG TABLET *CA CARBIDOPA/LEVODOPA 25MG/100M TABLET(*CA 00093-0293-01 2371932708709 317 2-022545' 6571558054659 ,6 REFILL NO QUANTITY 60,00 0' REFILL 2 QUANTITY 540.00 BARTELL DRUGS PRICE= $149.99 BARTELL DRUGS PRICE= $33.39 WITH SR THE AMOUNT DUE:$30.05 BARTELL DRUGS#45 BARTELL DRUGS#45 (425)793-1015 (425)793-1015 4700 NE 4TH STREET 4700 NE 4TH STREET RENTON,WA 98059 RENTON,WA 98059 THANK YOU THANK YOU WE TRULY APPRECIATE YOUR BUSINESS. TO PROVIDE YOU WE TRULY APPRECIATE YOUR BUSINESS.TO PROVIDE YOU WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR WITH THE BEST SERVICE POSSIBLE PLEASE ORDER YOUR REFILLS 24-48 HOURS IN ADVANCE REFILLS 24-48 HOURS IN ADVANCE p,aiet -17-(0-, 6 1-Ifa 46(16 13°2 P 3 ''r"" SENDCLAIMTO: `40' City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton, WA 98057 rcY . .n . 12 -'NTL CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE d4 9 C Z.Dc7 2) DISABILITY RETIREE'S NAME (print) c- (D ) - " 1. ,' jP • Q S 3) ADDRESS/73I0q, 071 to cie63Z 4) DISABILITY AT TIME OF RETIREMENT „ s, 14- d t2 I- ft epi 3etitd 1 try 1i'c(t'I s 5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.) (Effective 4/1/2008,pre-LEOFF retirees may submit all prescription drug expenses for reimbursement, whether or not related to the retirement disability,provided that the expense is not covered by another plan,source or insurance coverage. Supporting documentation for all must be attached.) °i`ikd 1S157;75-771 •471 2uueT/ prob 6) TOTAL AMOUNT OF CLAIM: $ • 4 14.42 Amount of total claim (above) that is related to the Retirement Disability: $ "! 0 7) I certify that I have not been and will not be compensated by any other organization, • insurance carrier or Medicare for the above-mentioned claim for reimbursement other than the City of Renton. I further certify that the above statements are complete and accurate to the best of my knowledge, and that any charges other than prescription drug charges, are related to my disability as determined at the time of my retirement from the Renton Fire Department. Signature: Note: Sup r ng documentation must be attached. Value at the smiling'0' ---- -— ue et the smiling'0' ' 11I Val� RECEIPT ''® PICD J/G RECEIPT 1244 15th Ave.,Longview,WA98832 Ph.(360)423-3360 SAVE FOR INSURANCE 1244 15th Ave.,Longview,WA98632 Ph.(360)423-3360 SAVE FOR INSURANCE R. C908388 For: JOHN PARKS Rx# 910958 For JOHN PARKS OR TAX RECORDS OR TAX RECORDS 9-02-09 CRN:A0096451426891 1335 3RD AVE#109 9-14-09 CRN:A7096571026101 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 LONGVIEW,WA 98632 (360) 577-6684 ALPRAZOLAM 0.5MG TAB *** ALBUTEROL SULF HFA"(PROAIR) DR. RICHARDS,JOHNE 60 NDC: 72 3720-03 ZHA COPAY: $6.28 DR. RICHARDS,JOHN3E00579 20 ZHA COPAY: $9.40 II0IIIIII 111111111 I0IIII IIII 11111111111111 Price III 11111 llItlIII11I11II 11011 11111111 llllll Price J value nx me cmtnnp'O' Value et the smiling'0" DRUG RECEIPT �, DIMING RECEIPT SAVE FOR INSURANCE 124415th'Ave.,Lon SAVE FOR INSURANCE WA98632 Ph.(360)4233360 OR TAX RECORDS 124415th Ave.,Longview,WA98632 Ph.(360)423.3360 Roo' 879021 For: JOHN PARKS Rx# 910946 For: JOHN PARKS OR TAX RECORDS 9-01-09 CRN:A2096440989841 1335 3RD AVE#109 10-02-09 (.CAN:A0096759135471 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 LONGVIEW,WA 98632 (360) 577-6684 MIRTAZAPINE SOLTAB 45MG MIRTAZAPINE SOLTAB 45MG #30 NDC: 65862-0023-06 #30 NDC: 65862-0023-06 DR. RICHARDS,JOHN E ZHA COPAY: $8.41 DR. RICHARDS,JOHN E ZHA COPAY: $12.38 1111111 111111111 II I llll 11111111 01110111 Price 111111111 I 0I I IIIIII 1111111011 III 111111111 Prue J I Value et the smiling'0' Value et the lunging'0' 'lI' MCORVQ RECEIPT .�, I ' DRUG RECEIPT 1244 15th Ave.,Longview,WA98632 Ph.(360)423.3360 SAVE FOR INSURANCE 124415th Ave.,Lan ew WA98632 Ph.(360)4233380 SAVE FOR INSURANCE Bo C908387 For: JOHN PARKS ORTAX RECORDSC910948 OR TAX RECORDS 9-02-09 CRN:A0098453129771 1335 3RD AVE#109 Rx# For: JOHN PARKS LONGVIEW,WA 98632 (360) 577 6684 10-02-09 CRN:A0098757644111 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 ZOLPIDEM TAB 10MG *** - ZOLPIDEM TAB 10MG *** #30 DR. RICHARDS,JOHN3E8 5310.05 ZHA COPAY: $1.39 #30 NDC: JOHN3E8 .5310-05 ZHA COPAY: $0.75 11110111 I III III I 10 ft0ll 11111111111 III 01111 Pd.. liii 001111111110111 1111011 IlII 11011 II I0 I 111 Price J I ( Value at the smiling'0' Value et the smiling'0' YIIIPICORVG RECEIPT ASit` PICS RECEIPT 124415th Ave.,Longview,WA98632 Ph.(360)4233360 SAVE FOR INSURANCE 124415th Ave.,Longview,WA 98632 Ph.(360)423-3360 SAVE FOR INSURANCE OR TAX RECORDS Rx# 879020 For: JOHN PARKS OR TAX RECORDS Ro# 910968 For: JOHN PARKS 10.02.09 CRN:A6096755838091 1335 3RD AVE#109 9.14-09 CRN:A1096574407331 1335 3RD AVE#109 LONGVIEW,WA 98632 (360) 577-6684 LONGVIEW,WA 98632 (360) 577.6684 OMEPRAZOLE *** 20MG CAP LACTULOSE SOL 10GMI15 $ #60 NDC: 62175-0118-43 #1420 NDC: 00603-1378-58 DR. RICHARDS,JOHN E ZHA COPAY: $3.84 DR. RICHARDS,JOHNEZHA COPAY: $3.84 11111111 III 11111111111 111111111111111111 PriceIIIIIIIIII 111IIIIIIIIII 1 11111111111111111111111 Pri0eI Nome SENDCLAIMTO: `"°''' City of Renton Finance Dept.-Fire Pension 1055 South Grady Way Renton,WA 98057 c.)41( ,, CITY OF RENTON FIREMEN'S PENSION BOARD Pharmacy/Medical Claim Reimbursement Request 1) DATE 140 -2Z -0? 2) DISABILITY RETIREE'S NAME (print) \ a Jc t_.-briet LOOP M 3) ADDRESS PO. ebx 86'i' Ocean Shores WA 9&59 4) DISABILITY AT TIME OF RETIREMENT I OSS o S� h ih 1 ef- eYe 1 5) DESCRIPTION OF CLAIM: (Supporting documentation must be attached.) (Effective 4/1/2008,pre-LEOFF retirees may submit all prescription drug expenses for reimbursement, whether or not related to the retirement disability,provided that the expense is not covered by another plan,source or insurance coverage. Supporting documentation for all must be attached.) 6) TOTAL AMOUNT OF CLAIM: $ 563. *.-s- -6.11 Amount of total claim (above) that is related to the Retirement Disability: $ 250. OO 7) I certify that I have not been and will not be compensated by any other organization, insurance carrier or Medicare for the above-mentioned claim for reimbursement other than the City of Renton. I further certify that the above statements are complete and accurate to the best of my knowledge, and that any charges other than prescription drug charges, are related to my disability as determined at the time of my retirement from the Renton Fire Department. ,.- Signature: ? d./ 1,//i./ -or Note: Supporting documentation must be attached. 2 1• Harbor Drug Co.P ;t Harbor Drug Co.Prescriptions IL: 316 8th St. , `' 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.i ill(360) .. Hoquiam,WA 985, 24 Hr.Rx Refill(360)538-9978 RX# 661391 R KONN, D., MD RX#C678815 R MINN, D., MD HAWORTH,JACK 01/12/09 DS HAWORTH,JACK 01/26/09 DS BOX 864,OCEAN'SHOR:ES,WA 98551 ,. BOX 864,OCEAN SHORES,WA 98551 ISOSORBI MON ER 30MG.-ETHEX ZOLPIDEM 10 MG QTY# 15 NDC#58177-02-04 ETHEX QTY#30 NDC#60505-2605-08 APOTEX REF#WQFTWRM ''' - ' REF#3NNWPA7 1 REFILLS 4 REFILLS aCtP COW. COMC COPAY: $5 0 COPAY: $5.00 IlIIIIII�II1111IIII�I11011111111111111111111111I IIIIII MI III II II 1111111111111111111111111 1II III II 11111111111111111 11II H 0. �,. Harbor Drug Co.Prescriptions Harbor Drug Co.Prescriptions 11.\,. Harbor 316 8th St. Phone 360-532-3061 316 8th St. Phone 360-532-3061 = Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 666575 R MORRIS, R, MD RX# 681457 N MORRIS, R., MD HAWORTH,JACK 01/27/09 DS HAWORTH,JACK 01/15/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 LISINOPRIL 10 MG MUPIROCIN OINT. 2% QTY# 30 NDC#64679-0929-06 WOCKHARI QTY#22 NDC#00093-1010-42 TEVA USA Generic For: LISINOPRIL 10MG REF# 3NQQCW9 REF#3MXA3FF NO REFILLS NO REFILLS _ ,. COMC COMC COPAY: $5.00 111 111111 11 11 II II 11 11 li IVIIIII1IBIIIII III II 100 111111 III III II II 11111i II II it COPAY: $5.00 II Nil 11011101101 0110 II ..� Harbor Drug Co.Prescriptions Harbor Drug Co.Pres clns `r 316 8th St. Phone 360-532-3061 316 8th St. Pho 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 661391 R KONN, D., MD RX# 667974 R MORRIS, R., MD HAWORTH,JACK 01/23/09 JR HAWORTH,JACK 01/27/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 ISOSORBI MON ER 30MG.-ETHEX LEVOTHYROXINE 100MCG QTY# 15 NDC#58177-0222-04 ETHEX QTY#30 NDC#00527-1345-01 LANNETT Generic For: LEVOTHYROXINE 0.1 MG REF#3NFEQXP REF# 3NQPXRH NO REFILLS 2 REFILLS COMC COMC COPAY: $5.00 $4.22 II I I II11 II IIII II II II II II II II II II II III IIII II N�1 X111111 II I III IIII11111111111111111111111111110 11111 111 �,i.. Harbor Drug Co.Prescriptions �' Harbor Drug Co-Prescriptions esi 316 8th St. Phone 360-532-3061 << 316 8th St. Phone 360-532-3061 - Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 681457 R MORRIS, R., MD RX# 663065 R MORRIS, R., MD HAWORTH,JACK 02/24/09 JR HAWORTH,JACK 01/23/09 JR BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551, MUPIROCIN OINT.2% OMEPRAZOLE ER 20 MG CAPS QTY# 22 NDC#00093-1010-42 TEVA USA QTY# 30 NDC#60505065-01 APOTEX REF#3QA9MKC REF#3NFEPED NO REFILLS MAY REFILL COMC COMC COPAY: $5.00 COPAY: $5.00 INIll 111111111111110 II IIIII I 111 IIIII IIIIIII II 1111111111 II III IIIIII 1111111111111111111111111111 11111111111111111111 0 Harbor Drug Co.Prescriptions vo,Harbor Drug Co.Prescriptions. Phone 360-532-3061 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 680249 R MORRIS, R., MD RX# 660974 R MORRIS, R., MD HAWORTH,JACK 02/24/09 DS HAWORTH,JACK 01/23/09 JR BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 PATANOL OPHTHALMIC SOL. 1% AMLODIPINE 2.5 MG 1 QTY# 5 NDC#00065-0271-05 ALCON VIS QTY# 30 NDC#68382-0121-16 ZYDUS REF#3QARD9R REF#3NFERCK MAY REFILL 1 REFILLS COMC COMC COPAY: $30.00 COPAY: $5.00 II 1111 11111111111111111111 II III I II II II 1111 11 II II 111 II ��� 1 : ,111111111111 THIN1111111111 III III IN 1111111 • I 1:. Harbor Drug Co.Prescriptions ,t� Harbor Drug Co:Prescriptions fief 316 8th St. P' 360-532-3061 tSee 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx 8860)538-9978 -_. Hoquiam,WA 98550 , ,�+r.Rx Refill(360)538-9978 RX#C678815 R KONN, D., MD RX# 661391 R KOMI, D., MD HAWORTH,JACK 02/27/09 JR HAWORTH,JACK 03/13/09 JR BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 ZOLPIDEM 10 MG ISOSORBI MON ER 30MG.-ETHEX QTY# 30 NDC#60505-2605-08 APOTEX QTY# 15 NDC#58177-0222-04 ETHEX REF#3QFAPHX REF# 3Q7RREQ e 3 REFILLS NO REFILLS COMC COMC COPAY: $5.00 COPAY: $5.00 IF Illllll 111 ll ll llll 1111111111111llll llll ll ll ll III 11111111111111111111111.11111 111111111111111 II 22 . Harbor Drug Co.Prescriptions 2, . Harbor Drug Co.Prescriptions /fie' 316 8th St. Phone 360-532-3061 ", 316 8th St Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 660974 R MORRIS, R., MD RX# 681231 N MORRIS, R., MD/13l09 JR HAWORTH,JACK 02/27/09 JR HAWORTH,JACK BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 AMLODIPINE 2.5 MG FUROSEMIDE 20 MG QTY#30 NDC#68382-0121-16 ZYDUS QTY#60 NDC#00054-4297-31 ROXANE REF#3QFAPNT REF#3Q7RPCR NO REFILLS 6 REFILLS COMC COMCCOPAY: $5.00 COPAY: ;7.78 III 11 V MIN II III 1 II II II II II II I I I II II II i�I1111IIIIIIiIiIIiIIiIIIII11111111�111111111111111111111111111111111111iIIIliIIIiIII 111111111111111 Uig II nl .:.,.• Harbor Drug Co.Prescriptions 1 ��'; Harbor Drug Co.prey criptions `� 316 8th St. Phone 360-532-3061 �fe 316 8th St. , Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 e 30-532-3061 Hoquiam,WA 985s0 24 Hr.Rx Refill(360)538-9978 � �# 665430 R KONN, D.,MD RX# 684804 N LECHNER, J., MD RX03!13/09 JR HAWORTH,JACK 03/05/09 JR HAWORTH,J SHORES,WA 98551 ACK BOX 864,OCEAN SHORES,WA 98551 BOX 864,LOVASTATIN 20MG FERROUS GLUCONATE 324MG. NDC#00228 2634 50 ACTAV QTY# 90 NDC#00574 0508 01 PADDOCK QTY#30 , REF# 3Q7RKQE 2 REFILLS 1 REFILLS COMC COPAY: $5.00 PRICE: $9.98 IIS SII IIIIIIII I I 111111111111111111111111111111111111111111 11111 11111111111111111111111111111111111111MIIIII►!Nilllillllillllillllilllllllllllillllllilll ' , Harbor Drug Co.Prescriptions Phone 360-532-3061 St' Harbor Drug Co.Prescriptions tee 316 6th St. 24 Hr.ax Refill(360)538-9978 U 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 673318 R MORRIS, R., MD113/09 JR RX# 677524 R MORRIS, R., MD HAWORTH,JACK HAWORTH,JACK 03/13/09.1 R BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 AMLODIPINE 5 MG AMIODARONE HCI 200MGQTY#30 NDC#64679-0422-02 WOCKHARI QTY# 30 NDC#13107-0056-05 AUROBIND' ' Generic For:AMIODARONE 200 MG REF# 3Q7RMKQ I REF# 3Q7RMMN 1 REFILLS 3 REFILLS COMC COMC COPAY: $5.00 COPAY: $10.00 �II�IIIIIININIIIIIIIINIIIIIINIIIN011111111NIIIINIIIIIIINIIIIiIIiIIiNIIINIIIIIIIiNIIINilllllll 11111111111111101111111111111111111111131111 ''.. NOW Drug Co.Prescriptions L" harbor Drug Co.Prescriptions ,s.� 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 fry 3168th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 678209 R RUYLE, S., MD HAWORTH,JACK 3 17/09 DS03/17/09 DS AWORTH,JACK 684076N MORRIS, R., MD Bo 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 AZOPT 1% 10 ML NDC#00065 0275 10 ALCON VIS MUPIROCIN OINT.2% QTY# 10 QTY# 22 NDC#00093-1010-42 TEVA USA Generic For:AZOPT 5ML REF#3RCKMHK REF# 3RCMQQH 5 REFILLS 2 REFILLS COMC COPAY: $30.00 COMC CO PAY: $5.00 IIIINIIIIIIIIIIIIIIIIIIINilllllllilllliillllllllllllllllilllllllllllllllilllllllllllllllllllllllilllillill I I I IIIII I(III(III 111 IIIII III 1111111111110111 1 7,4406 g . Harbor Drug Co.Prescriptions z, Harbor Drug Co.Prescriptions �r 316 8th St. Phone 360-532-3061 `f 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx R '360)538-9978 Hoquiam,WA 98550 20 Rx Refill(360)538-9978 RX# 663065 R MORRIS, f7!!s/ID RX# 687189 N KOC D., MD HAWORTH,JACK 03/25/09 DS HAWORTH,JACK 04/11/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 OMEPRAZOLE ER 20 MG CAPS ISOSORBI MON ER 30MG.-ETHEX QTY# 30 NDC#60505-0065-01 APOTEX QTY# 15 NDC#58177-0222-04 ETHEX REF# 3RNHFWN REF#3TTRRKW _ MAY REFILL NO REFILLS COMC COMC COPAY: $5.00 COPAY: $5.00 IF I I1111II 11011 I II1I1I NII III 1110III II1101111 IIIII II 1111101111111 llil II II IIIIII II III T 111 III I11/MI .\t: Harbor Drug Co.Prescriptions .. Harbor Drug Co.Prescriptions :� 316 8th St. Phone 360-5324061 `i 316 8th St. Phene 360-5324061 -- Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 687876 N RUYLE, S., MD RX#C678815 R KONN, D., JACK 04/21/09 JR HAWORTH,JACK 03/25/09 DS BOX 864,OCEANSHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 DORZOLAMIDE 2%OPH SOL ZOLPIDEM 10 MG QTY# 10 NDC#60505-0567-01 APOTEX QTY#30 NDC#60505-2605-08 APOTEX Generic For:TRUSOPT 2% REF#3WFDCHP REF#3RNHF1R 6 REFILLS 2 REFILLS COMC COMC COPAY: $5.00 COPAY: $5.00 111111111111 I I ll�ll 1111111111111 IIIIIIINIIIIiIII IIIIIIIIIIIIIIIIIIIIIINIII III IIII I Mil111 1111 I IIS IIIIII IIIII Ill I IiI I IIII I1 I IN I I II l►I I II Iii IIII EMI MI --a." ,, . Harbor Drug Co.Prescriptions Harbor Drug Co.Prescriptions �4 316 8th St. Phone 360-532-3061° e 316 8th St. Phene 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9971 17'1Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 684804 R LECHNER, J., MD RX#C678815 R KONN, D., MD JACK* 04/29/09 D BOX 864, HAWORTH,JACK 04/11/09 DS BOX 864,OCEAN SHORES,WA 98551 OCEAN SHORES,WA 98551 FERROUS GLUCONATE 324MG. • ZOLPIDEM 10 MGQTY# 30 NDC#60505-2605-08 APOTE) QTY# 90 NDC#00574-0508-01 PADDOCk REF# 3WTQRE7 1 REFILLS 1 REFILLS COMC PRICE: $10.98 COPAY: $5.00 III 1 1111 IN II 111111111 III II II III 111111 I II II 1111111111111 11111111 111 111111 IIII III 11 11 1111 111111 II 1Harbor Drug Co.Prescriptions `� 316 8th St. Phone 360-532-3061 r riititui tuv. Ye Yy V V.■ e vdve■pawn.° = Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 3168th St. Phone 360-532-3061 RX# 680249 R MORRIS, R., MD Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 673318 R MORRIS, R., MD HAWORTH,JACK* 04/29/09 DS BOX 864,OCEAN SHORES,WA 98551 HAWORTH,JACK 04/11/09 DS PATANOL OPHTHALMIC SnL. 1% BOX 864,OCEAN SHORES,WA 98551 QTY# 5 NDC#0flC o-0271-05 ALCON VIS AMLODIPINE 5 MG QTY#30 NDC#64679-0422-02 WOCKHAR: REF# 3WTQRQ3 REF#3TTRHC9 MAY REFILL 1 REFILLS COPAY: $30.00 COMC COMC COPAY: 5.00 1111111111111111111111111111111111110 III1111111111111111$ 1111IINI11 111111111 1E11 11III 11011111111111111111111111 _ ',. Harbor Drug Co.Prescriptions Harbor Drug Co.Prescriptions Phone 360-532-3061 s: 316 8th St. L 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 �- Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 665430 R KONN, D., MD RX# 688269. N MORRIS, R-, 04/29/09 DS HAWORTH,JACK 04/11/09 DS HAo WORTH,JACK CHORES,WA9B551 BOX 864,OCEAN SHORES,WA 98551 AMLODIPINE 2.5 MG LOVASTATIN 20MG l QTY#30 NDC#68382-0121-16 ZYDUS QTY# 30 NDC#00228-2634-50 ACTAV REF#3TTRHER REF#3WTTADX NO REFILLS NO REFILLS COMC COMC COPAY: $5.00 COPAY: $5.00 1q 111 II 11 II 11111111 IIII III 11111111111111111 II11 IIN III 11 iuIIIIIIIIIIIIIIIilllllllllllllllllillllllllllllllllilllllllllllllllllilllllllllili 1111lillilllllllllllll t(.Y\i�`-r 1''; Harbor urug Go.Prescriptions ti► Harbor Drug Co.Prescriptions 'I 3168th St. 98550 24 H- Refill 360-532-3061 , ��r`. 316 8th St. Ph ane� ,3 2-3061 :� Hoquiam,WA 98550 24 Hr.Rx Refill(3>!1i/i538-9978 RX# 687189 R KON7'C"b., MD RX# 688270 N MORRIS, R., MD HAWORTH,JACK* 05/08/09 DS HAWORTH,JACK* 04/29/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 1364,OCEAN SHORES,WA 98551 ISOSORBI MON ER 30MG.-ETHEX OMEPRAZOLE ER 20 MG CAPS QTY# 15 NDC#58177-0222-04 ETHEX ;QTY# 30 NDC#60505-0065-01 APOTEX I REF# 3XETQQ9 REF#.WTTAHH 9 REFILLS NO REFILLS COMC COMC COPAY: $5.00 COPAY: $5.001111111111111IIIIIIIIIIINI11111101IIIlIIIIIIIIIIIIIIII1111IIIIIIIIIIIIIIIIIIIIIIIIIIIII! !NIIIINNI�II:0111111IIIIIIII111119IIIIIIIIIIIIIIIIIIIIIIII11I1IIiIIIIi�"II_IIN�II 1t; _ _ .: Harbor Drug Co.Prescriptions Harbor Drug Co.Prescriptions �� 316 8th St. Phone 360-532-3061 1`e� 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 689201 N KONN, D.,MD RX# 688875 N LECHNER, J., MD 05/14/09 DSt HAWORTH,JACK* 05/07/09 DS HAWORTH,JACK* BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 , — PROCTOSOL-HC CRM 2.5% RAN 10Z@ LOVASTATIN 20 MG QTY# 28.35 NDC#10631-0407-01 RANBAXY QTY#30 NDC#49884-0755-10 PARJi REF# 3XEC33C REF#3XNK9QT 2 REFILLS NO REFILLS COMC COMC COPAY: $5.00 COPAY: $5.00 IIIIIIIINII�lllllllllll�llllllillllllllillllilillllllilllllllllllllllllllllllllillllllllllllllllllllllll II I I II II I II I! I III I !I II li III II 1111 III I II II II -I a Harbor Drug Co.Prescripcons r, ---« `r 316 8th St. Phone 360-532-3061 �� �'i ..... r< MORRIS, R., MD Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 HAWORTH,JACK* 05/14/09 DS RX# 688269 R MORRIS, R., MD BOX 864,OCEAN SHORES,WA 9855105/26/09 DS FUROSEMIDE 20 MG 864 ,OCEAN HAWORTH,JACK BOX 864,OCSHORES,WA 98551 QTY# 60 NDC#00054-4297-31 ROXANE AMLODIPINE 2.5 MG REF#3XNH1R1 QTY# 30 NDC#68382-0121-16 ZYDUS 5 REFILLS COMC REF# 31DMHH1 1 REFILLS COPAY:III�IIINNI�IINIIIIIIIIIIINIIINIIIII NINIINIIIIIIINIINIIIINIINIIINIIIINIIIII I$7.78 COMC COPAY: $5.00 IIIlillilll III 11111111111111111111111111111111111111111111111111111II 1„... Harbor Drug Co.Prescriptions ,, Harbor Drug Co.Prescriptions 316 8th St. Phone 360-532-3061 `i 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 = Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 673318 R MORRIS, R., MD RX# 688270 R MORRIS, R., MD HAWORTH,JACK* 05/14/09 DS r HAWORTH,JACK* 05/26/09 DS BOX 864,OCEAN SHORES,WA 98551 AMLODIPINE 5 MG BOX 864,OCEAN SHORES,WA 98551 QTY#30 NDC#64679-0422-02 WOCKHARI OMEPRAZOLE ER 20 MG CAPS QTY# 30 NDC#60505-0065-0 1 APOTEX REF#3XNH3KA 1 REFILLS REF# 31DMHQH COMC 1 REFILLS COPAY: .$5.00 COMC COPAY: $5.00 II 111111111 II 1101 II I 111 11 III II 01111 111 111 11111111111 III 11111111 1111 I1111111111111I III 111111111111111111111111111Ill11011111IIII11111111II11111111111 �. nanny Drug Co.Prescriptions + nargrog co.Prescriptions 74:`� 316 6th St. Phone 360-5324061 316 8th St. Phone 360-532-3061 Hoquiam ,WA 98550 24 Hr.Rx Refill(360)538-9978 r + Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 IRX# 677524 R MORRIS, R., MD RX#C678815 R KONN, D., MD HAWORTH,JACK* 05/14/09 DS HAWORTH,JACK* 05/27/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 AMIODARONE HCI 200MG ZOLPIDEM 10 MG QTY# 30 NDC#13107-0056-05 AUROBIND, QTY# 30 NDC#60505-2605-08 APOTEX Generic For:AMIODARONE 200 MG REF#3XNH3ME REF# 31EQ1FQ 2 REFILLS NO REFILLS COMC COMC COPAY:III�NIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIINIIIIIIIIIIIIIIIIIIIII $10.00 INn III II COPAY: i $5.00 11111111111111111 111111 IN 11111 II 11111111111111111111111 Vide tb a 4 m•f uv....—S ,, . Harbor Drug Co.Prescriptions ,�;. Harbor Drug Co.Prescriptions ,fri 316 8th St. Phone 3' 432-3061 1.... Harbor 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(.',„� )8-9978 = Hoquiam,WA 98550 2? lac Refill(360)538-9978 RX# 689201 R KONN, D., MIMI" RX# 691017 N RU'h.rt, S., MD HAWORTH,JACK * 06/15/09 DS HAWORTH,JACK* 06/15/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 LOVASTATIN 20 MG DORZOLAMIDE 2%OPH SOL QTY#30 NDC#49884-0755-10 PAR QTY# 10 NDC#60505-0567-01 APOTEX REF#33WCDX3 REF#33WQQEW 11 REFILLS 6 REFILLS COMC COMC COPAY: $5.00 COPAY: $5.00 II I 111111111 1111 I 11111111111111111II III 1111111III II II III II11 IIII 11111 II 11 11 1 1 11 II 11 1111111 111 II 111 , . Harbor Drug Co.Prescriptions " Harbor Drug Co.Prescriptions `� 316 8th St. Phone 360-532-3061 fry 316 8th St. Phone 36C-532-3061 = Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 985508 24 Hr.Rx Refill(360)538-9978 RX#C 691568 N KONN, D., MD RX# 673318 R MORRIS, R., MD HAWORTH,JACK* 06/25/09 JR HAWORTH,JACK* 06/15/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 ZOLPIDEM 10 MG AMLODIPINE 5MG TAB QTY# 30 NDC#60505-2605-08 APOTEX QTY#30 NDC#65862-0102-05 AUROBINC Generic For:AMLODIPINE 5 MG REF# 37F977M REF#33WCD9A . 5 REFILLS 1 REFILLS COMC • COMC COPAY: $5.00 I COPAY:JIHInIIIIHIIIIIll111111111111111110111111111111111111111111 III _ 1, Harbor Drug Co.Prescriptions ` 316 8th St. Phone 360-532-3061 c Harbor Drug Co.Prescriptions Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 sal 316 8th St. Phone 360-532-3061 RX# 689201 R KON N, D., MD Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 HAWORTH,JACK* 07/11/09 RR RX# 687189 R KONN, D., MD06/15/09 DS BOX 864,OCEAN SHORES,WA 98551 HAWORTH,JACK* LOVASTATIN 20 MG BOX 864,OCEAN SHORES,WA 98551 QTY# 30 NDC#49884-0755-10 PAR ISOSORBIDE MONO 30MG QTY# 15 NDC#00143-2230-01 WEST-WAI REF# 39CE7TE Generic For ISOSORBI MON ER 30MG.-ETHEX 10 REFILLS REF#33WCEEX COMC I 8 REFILLS COPAY: $5.00 COMC COPAY: $5.00 II I 111011111 IIII 111 l ii ii i 1111111111111110II III Iillillll010I IIIIIIIIIIIIIIIIIIIIIIIIIII11111111111111111111111111111III IIIIIIIIIIIIIIIIIIIIIIIIIIII :1;: • Harbor Drug Co.Prescriptions fits 316 8th St. Phone 360-532-3061 11. . Harbor Drug Co.Prescriptions — Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 1 316 8th St. Phone 360-532-3061 RX# 687189 R KONN, D., MD Hoquiam,WA98550 24 Hr.Rx Refill(360)538-9978 RX# 688270 R MORRIS, R., MD HAWORTH,JACK* 07/11/09 RR BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN JACK* 06/23/09 JR ISOSOR MON ER TB 30MG KRE 100 BOX 864, ER 20,WAG CAPS QTY# 15 NDC#62175-0128-37 KREMERS OMEPRAZOLE ER 20 MG Generic For: ISOSORBI MON ER 30MG.-ETHEX QTY#30 NDC#60505-0065-01 APOTEX REF#39CE7T7 REF#37DTRWN 7 REFILLS NO REFILLSCOMC COMC COPAY: $5.00 I1I11IIIIII11111111111111111111111111111111II111111IIII11111111 COPAY: $5.00 11111 11111 11111 HNIT 1.1 1 Harbor Drug Co.Prescriptions Harbor Drug Co.Prescriptions bi 316 8th St. Phone 360-532-3061 316 8th St. Phone 360-5324061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refill(368)538-9978 RX# 673318 R MORRIS, R., MD RX# 688269 R MORRIS, R., MD HAWORTH,JACK* 07/11/09 RR HAWORTH,JACK* 06/23/09 JR BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 AMLODIPINE 5MG TAB AMLODIPINE 2.5 MG QTY# 30 NDC#65862-0102-05 A.UROBIND1 QTY#30 NDC#68382-0121-16 ZYDUS Generic For:AMLODIPINE 5 MG REF#39CE7WN REF#37DTRXX 1 REFILLS t NO REFILLS COMC COMC COPAY: $5.00 COPAY: $5.00 1111 111111101IIII11I11IIIIIIIIIIIIIIII1111111111II �� « 11111111111111111111111111311111111111111111111 ,,!. Harbor Drug Co.Prer—iptions „' Harbor Drug Co.Prescriptions Is 316 8th St. Phone 360-532-3061 L 316 8th St. Phlai, o0-532-3061 AM. Hoquiam,WA 985504,004 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx R0111360)538-9978 R RX# 688270 R MORRIS, R., MD X# 677524 R MORRIS, R., MD HAWORTH,JACK* 07/24/09 JR HAWORTH,JACK* 07/11/09 RR BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 e OMEPRAZOLE ER 20 MG CAPS AMIODARONE HCI 200MG QTY# 30 NDC#60505-0065-01 APOTEX QTY# 30 NDC#13107-0056-05 AUROBINDi Generic For:AMIODARONE 200 MG REF#'39T1PR1 REF# 39CE7XK NO REFILLS 1 REFILLS COMC COMC COPAY: $5.00 COPAY: $10.00 a lii Ili ii111111l iiIIIII Illi II Ilii 1111111111 110111111113 In IIIIII II IIII MIND III I II IIIH II li eye nicciiCirtc.. 1,, Harbor Drug Co.Prescriptions -`i 316 8th St. Phone 360-532-3061 HARBOR DRUG INC. Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 316 8th Street RX# 681231 R MORRIS, R., OD24/09 JR Hoquiam, Washington 98550 HAWORTH,JACK* 360-532-3060 BOX 864,OCEAN SHORES,WA 98551 FUROSEMIDE 20 MG QTY# 60 NDC#00054-4297-31 ROXANE Receipt# :1310290611 REF#39T1PLL Print Date :8/4/2009 3:43:21 PM 4 REFILLS Sale Date :8/4/2009 3:43:20 PM COMC Cashier :SR COPAY: $7.78 Station :RG3 IIIA IHIIIIIIIIIIIIIIIIll 1111111111111111111411113111 QTY PRICE DESC EXTPRICE ..,. Harbor Drug Co.Prescriptions 1 15.47 ZADITOR ANTIHI 15.47T lar 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 688269 R MORRIS, R., MD Sub Total $15.47 HAWORTH,JACK* 07/24/09 JR Tax $1 .28 BOX 864,OCEAN SHORES,WA 98551 Total $16.75 AMLODIPINE 2.5 MG QTY# 30 NDC#68382-0121-16 ZYDUS Cash $20.00 REF# 39T1FA, Change $3.25 NO REFILLS ___ __ COPAY: 5.00 COMC $ III 11 ll RIM 11111111111111111111111111IA IIThank You ! Save this receipt for Refunds/Exchanges .., Harbor Drug Co.Prescriptions ;Sial 3168th St. Phone360-532-3061 Indicates Qualified Healthcare Products Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 OHP TntA 1 ! 10.00 RX#C691568 R KONN, D., MD �� Harbor Drug Co.Prescriptions HAWORTH,JACK* 07/24/09 JR I.' 316 8th St. Phone 360-532-3061 BOX 864,OCEAN SHORES,WA 98551 .. Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 ZOLPIDEM 10 MG RX# 680249 R MORRIS, R., MD QTY# 30 NDC#60505-2605-08 APOTEX HAWORTH,JACK* 08/03/09 DS REF# 39T1 MX9 BOX 864,OCEAN SHORES,WA 98551 4 REFILLS PATANOL OPHTHALMIC SOL. 1% COMC QTY#5 NDC#00065-0271-05 ALCON VIS COPAY: $5.00 REF# 3AEQP1M 11ilillll illllllllllll 01011111 MI III IIIIIIIIIIIIIII I I iM MAY REFILL COMC • COPAY: $30.00 11011111111111111111111111111 11111111111111111111 2.,'? Drug1' Harbor Drug Co.Prescriptions Harbor Co.Ce.Prescr!wtiens ;►' 316 8th Stis Phone 360-532-3061 316 8th St. Phone---.532-3061 Hoquiam,WA 98550 ' 'Ir.Rx Refill(360)538-9978 ._ Hoquiam,WA 98550 24 Hr.Rx Refill 538-9978 RX# 687189 R KONN, D., MD' RX# 691 01 7 R R E, S., MD HAWORTH,JACK* 08/10/09 DS HAWORTH,JACK* 08/31/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 ISOSOR MON ER TB 30MG KRE 100 DORZOLAMIDE 2%OPH SOL QTY# 15 NDC#62175-0128-37 KREMERS QTY# 10 NDC#60505-0567-01 APOTEX Generic For:ISOSORBI MON ER 30MG.-ETHEX REF#3A7QR9P REF*3C7KM3C 6 REFILLS 5 REFILLS COMC COUIC COPAY: $5.00 COPAY: $5.00 1111,111 I II IIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIII IIIIIIIIIIIIIIIIII IIIIIIIIIIIIII IiIIIIIIIIIIIIIII IN lig ll 1101 III 1111 ! ll II till Ill 111111101 III 1 H 1111 -' Harbor Drug Co.Prescriptions ,, Harbor Drug Co.Prescriptions `' 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 -`' Ho Rx 8thSt. Phone 360532- RX#C 691568 R KONN, D., MD Hoquiam,WA 98550 24 Hr. Refill(360))538-997997 8 RX# 689201 R KONN, D., MD HAWORTH,JACK* 08/31/09 DS HAWORTH,JACK* 08/10/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 ZOLPIDEM 10 MG LOVASTATIN 20 MG QTY#30 NDC#60505-2605-08 APOTEX QTY# 30 N DC#49884-0755-1 0 PAR REF#3C7KMXL REF# 3A7QTDC 3 REFILLS 9 REFILLS COMC COMC COPAY: $5.00 COPAY: $5.00 IIIIIIIIIN11111IIIII11111ill IIIIIIIIIIN11III11IIII Ifill I Hill 111111111 IIIIIIVIIIIIIIIIIIII II 11111111111 MI Harbor Drug Co.Prescriptions te' 316 8th St. Phone 360-532-3061 . Harbor Drug Co.—Prescriptions = Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 `e' 3168th St. Phone 360-532-3061 RX# 677524 R MORRIS, R , MD Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 673318 R MORRIS, R., MD HAWORTH,JACK* 09/09/09 DS HAWORTH,JACK* 08/13/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 AMIODARONE HCI 200MG AMLODIPINE 5MG TAB QTY# 30 NDC#13107-00:.66-05 AUROBINDI QTY# 30 NDC#65862-0102-05 AUROBINDi Generic For:AMIODARONE 200 MG REF# 3DQLNWQ Generic For:AMLODIPINE 5 MG NO REFILLS REF# 3CDFTTA 1 REFILLS COMC COPAY: $10.00 COMC COPAY: $5.00 1111111111111111 III 11111 II 1111110111MI III 11 11111111 1111 11111 1111 I.11111 11111 1 11 11 111 111 11111 11 1111111111111 1!III Harbor Drug Co.Prescriptions •5,• Harbor Drug Co.Prescriptions sii 316 8th St Phone 360-532-3061 t 316 8th St. Phone 360-532-3061 • Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 '- Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 688269 R MORRIS, R., MD RX# 689201 R KONN, D., MD HAWORTH,JACK* 08/27/09 DS HAWORTH,JACK* 09/09/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 AMLODIPINE 2.5 MG LOVASTATIN 20 MG QTY# 30 NDC#68382-0121-16 ZYDUS QTY# 30 NDC#49884-0755-10 PAR REF# 3CWNLWN REF#3DQLN3E NO REFILLS8 REFILLS COMC COMC COPAY: $5.00 COPAY: $5.00 Ill II II I 1111 I 111111 11111111III II II 111 IIIIIIIIII Ill 11111111111111111111111111111 1111111111111111111NIIII1111111111111111 `; Harbor Drug Co.Prescriptions ,t • Harbor Drug Co.Prescriptions _ ' 316 8th St. Phone 360-532-3061 Ie' 316 6th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 694174 N MORRIS, R., MD RX# 688270 R MORRIS, R., MD HAWORTH,JACK* 09/15/09 DS HAWORTH,JACK* 08/27/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 AMLODIPINE 5MG TAB OMEPRAZOLE ER 20 MG CAPS QTY# 30 NDC#68382-0122-05 ZYDUS QTY# 30 NDC#60505-0065-01 APOTEX REF# 3D97HLK REF#3CWNLIW 2 REFILLS NO REFILLS COMC COMC COPAY: $5.00 COPAY: $5.00 NNN 11111111 11111 il III 1111 11 II lI 11 II Ill IIII 1! II 1! 13 II NIIIII�lI111111111111l1IIIII1111111111111 ..t' Harbor Drug Co..escriptions 4 Harbor brig Co.Prescriptions lit 316 8th St. Phone 360-532-3061 j Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 316 8th St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 RX# 681231 R MORRIS, R , MD RX# 688875 R LECHNER, J., MD HAWORTH,JACK* 09/28/09 RR HAWORTH,JACK* 10/01/09 DS BOX 864,OCEAN SHORES,WA 98551 BOX 864,OCEAN SHORES,WA 98551 FUROSEMIDE 20 MG PROCTOSOL-HC CRM 2.5% RAN 10Z@ QTY# 60 NDC#00054-4297-31 ROXANE QTY# 28.35 NDC#10631-0407-01 RANBAXY REF# 3EPM39P REF# DDWPKA1 3 REFILLS 1 REFILLS COMC COMC COPAY: $7.78 COPAY: $5.00 tI I I II IIII IIIII III I I II IIII 1 111111 111111 III IIII III 1111111.1111110 1 II 1111111 III I II III II 1111I1111111111 Call your doctor for medical advice about side effects.You may report side effertt m Enh+l.9M CN'MA %., Harbor Drug Co.PrescriptiOnS t`; H31arbor Drug Co.Prescriptions Phone 360-532-3061 t`i 316 11th St. St. Phone 360-532-3061 Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 Hoquiam,WA 98550 24 Hr.RxRefiil1360)538-9978 RX# 694174 R MORRIS, R., MD RX# 688269 R MORRIS; R., MD HAWORTH,JACK* 10/12/09 DS 09/28/09 RR BOX 864,OCEAN SHORES,WA 98551 HAWORTH,JACK* AMLODIPINE 5MG TAB BOX 864,OCEAN SHORES,WA 98551 AMLODIPINE 2.5 MGQTY#30 NDC#68382-0122-05 ZYDUS REF# DEAXMQR QTY#30 NDC#68382-0121-16 ZYDUS REF#3EPM3P3 1 REFILLS 1 REFILLS CONIC COMC COPAY: $5.00 COPAY: $5.00 1111111111111111111111111111�111101111111111111 II IIIIIIIIIIIIIIII1111111111I11111111itIIII11IIIIII IIIIIIIIIIIIIIIIIIIIII11h1111111111111111111111111111111III 1i Harbor Drug Co.Prescriptions Mn Call sour doctor for medical advice about side effects.You may report side effects to fDA at I.800-fDA-1088. Si 316 8th St. Phone 360-532-3061 Harbor Drug Co.Prescriptions Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 \;t4� 316 8th St Phone 360-532-3061 RX#C691568 R KONN, D., MD = Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 HAWORTH,JACK* 09/28/09 RR RX# 687189 R KONN, D., MD BOX 864,OCEAN SHORES,WA 98551 HAWORTH,JACK* 10/12/09 DS ZOLPIDEM 10 MG BOX 864,OCEAN SHORES,WA 98551 QTY# 30I NDC#60505-2605-08 APOTEX ISOSOR MON ER TB 30MG KRE 100 QTY# 15 NDC#62175-0128-37 KREMERS REF# 3EPM3X9 Generic For: ISOSORBI MON ER 30MG.-ETHEX 2 REFILLS REF# 3E9PLTL COMC 5 REFILLS COPAY: $5.00 COMC COPAY: $5.00 11111111111111111111111111111111111111111111111111111111111111111111111111II111111111111111111111111111 III 1111111111111111111111111111111111111111111111 �" Harbor Drug Co.Prescriptions Phone 360-532-3061 Ott! 316 8th St. 188. __ Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9478 Call your doctor for medical advice about side effects.You may report side effects to FDA at 1-800-fDA-1088. el RX# 688270 R MORRIS, R., MD MIN HAWORTH,JACK* 09/28/09 RR 22 Harbor Drug Co.Prescriptions BOX 864,OCEAN SHORES,WA 98551 Irtf 3168th St Phone 360-532-3061 OMEPRAZOLE ER 20 MG CAPS — Hoquiam,WA 98550 24 Hr.Rx Refill(360)538-9978 QTY# 30NDC#60505-0065-01 APOTEX RX# 689201 RKONN, D., MD * HAWORTH,JACK 10/12/09 DS I REF# 3EPM9L1 BOX 864,OCEAN SHORES,WA 98551 NO REFILLS LOVASTATIN 20 MG 1 COMC QTY#.30 NDC#49884-0755-10 PAR 1 COPAY: $5.00 REF# 3E9PLWX 1111111111111 111111111131111111111111111111 7 REFILLS COMC Call your doctor for medial advice about side effects.You may report side effectsto fDA at I.800•FDA•1088. COPAY: $5.00 II 11 111111 Illil I III 1111 IIII II II 111111111111 111 II II Call your doctor for medical advice about side effects.You may report side effects to fDA at 1.800-fDA-1088. PM "F