Health & Welfare Prescription Listing for

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Date Filled Pharmacy Prescription Retail Charge CoPay Amount Amount Saved

00/00/0000

$ .00

$ .00

$ .00

00/00/0000

$ .00

$ .00

$ .00

00/00/0000

$ .00

$ .00

$ .00

00/00/0000

$ .00

$ .00

$ .00

00/00/0000

$ .00

$ .00

$ .00

00/00/0000

$ .00

$ .00

$ .00

00/00/0000

$ .00

$ .00

$ .00