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📁 MARK'S DOC
🔗 Linked Evidence
Review_Division_Submission_3_of_3 — p.11
📄 Review Division Submission 3 of 3 | p.11
📄 Review Division Submission 3 of 3 | p.11
📝 Extracted Text (OCR)
6/14/26, 1:02 AM Go Back to your Member Profile Claim Details Learn more about your claims. Pacific Blue Cross To view claim details, select your search criteria and then press the Apply button. To search by Claim ID, you must provide the Service Date Range for results. Totals for Amount Claimed and Amount Paid will be refreshed based on the search results. Individual Show Claims Within Service Date Range Logout Mark Holand (DOB: Ser 24 Months } Claim ID ] Apply All Health Dental Drugs Service Date ¥ Name Expense/Item Amount Claimed Amount Paid Statement Date May 29, 2026 Mark Holand APO-BILASTINE TABLETS $55.38 $52.14 May 29, 2026 Details May 29, 2026 Mark Holand SERTRALINE $34.55 $27.65 May 29, 2026 Details May 29, 2026 Mark Holand PMS TRAZODONE HCL TAB $19.72 $14.62 May 29, 2026 Details 100MG May 29, 2026 Mark Holand PMS-RISPERIDONE $23.90 $18.43 May 29, 2026 Details May 27, 2026 Mark Holand CYCLOBENZAPRINE $19.91 $14.74 May 27, 2026 Details ‘Apr 28, 2026 Mark Holand ‘APO-BILASTINE TABLETS $55.38 $52.14 Apr 28, 2026 Details Apr 28, 2026 Mark Holand SUMATRIPTAN $46.91 $46.91 Apr 28, 2026 Details Apr 28, 2026 Mark Holand QUETIAPINE $19.13 $13.71 Apr 28, 2026 Details Apr 28, 2026 Mark Holand SERTRALINE $34.55 $27.65 Apr 28, 2026 Details Apr 28, 2026 Mark Holand PMS-RISPERIDONE $23.90 $18.43 Apr 28, 2026 Details ‘Apr 28, 2026 Mark Holand PMS TRAZODONE HCL TAB $19.72 $14.62 Apr 28, 2026 Details 100MG ‘Apr 01, 2026 Mark Holand SUMATRIPTAN $35.25 $35.25 Apr 01, 2026 Details Apr 01, 2026 Mark Holand APO-BILASTINE TABLETS $55.38 $52.14 Apr 01, 2026 Details Apr 01, 2026 Mark Holand QUETIAPINE $19.13 $13.71 Apr 01, 2026 Details Apr 01, 2026 Mark Holand PMS TRAZODONE HCL TAB $19.72 $14.62 Apr 01, 2026 Details 100MG ‘Apr 01, 2026 Mark Holand PMS-RISPERIDONE $23.90 $18.43 Apr 01, 2026 Details ‘Apr 01, 2026 Mark Holand SERTRALINE $34.55 $27.65 Apr 01, 2026 Details Mar 18, 2026 Mark Holand PMS TRAZODONE HCL TAB $17.02 $12.69 Mar 18, 2026 Details 100MG Mar 18, 2026 Mark Holand PMS-RISPERIDONE $19.45 $14.47 Mar 18, 2026 Details Mar 18, 2026 Mark Holand SERTRALINE $24.37 $18.77 Mar 18, 2026 Details Page 1 Total $3,036.01 $1,114.48 Grand Total $4,311.41 $2,004.16 https://service.pac.bluecross.ca/ACESWeb/Pages/Claims/Claims.aspx?MODULE=ALL