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📁 MARK'S DOC
🔗 Linked Evidence
Review_Division_Submission_3_of_3 — p.12
📄 Review Division Submission 3 of 3 | p.12
📄 Review Division Submission 3 of 3 | p.12
📝 Extracted Text (OCR)
6/14/26, 1:02 AM Pacific Blue Cross Service Date ¥ Name Expense/Item Amount Claimed Amount Paid Statement Date Mar 05, 2026 Mark Holand PMS TRAZODONE HCL TAB $17.02 $12.69 Mar 05, 2026 Details 100MG Mar 05, 2026 Mark Holand PMS-RISPERIDONE $19.45 $14.47 Mar 05, 2026 Details Mar 05, 2026 Mark Holand APO-TRAZODONE TABLETS. $17.02 $0.00 Mar 05, 2026 Details 100MG Mar 05, 2026 Mark Holand RISPERIDONE $19.45 $0.00 Mar 05, 2026 Details Mar 05, 2026 Mark Holand SERTRALINE $24.37 $18.77 Mar 05, 2026 Details Mar 04, 2026 Mark Holand QUETIAPINE $19.13 $13.71 Mar 04, 2026 Details Mar 04, 2026 Mark Holand QUETIAPINE $19.13 $0.00 Mar 04, 2026 Details Mar 04, 2026 Mark Holand Nicorette Gum 2 mg $95.24 $0.00 Mar 04, 2026 Details Mar 04, 2026 Mark Holand Nicorette Gum 2 mg $95.24 $0.00 Mar 04, 2026 Details Mar 04, 2026 Mark Holand Nicorette Gum 2 mg $95.24 $0.00 Mar 04, 2026 Details Feb 25, 2026 Mark Holand SUMATRIPTAN $35.25 $35.25 Feb 25, 2026 Details Feb 25, 2026 Mark Holand SUMATRIPTAN $71.17 $0.00 Feb 25, 2026 Details Feb 25, 2026 Mark Holand APO-BILASTINE TABLETS $55.38 $52.14 Feb 25, 2026 Details Feb 25, 2026 Mark Holand SUMATRIPTAN DF $49.46 $0.00 Feb 25, 2026 Details Feb 05, 2026 Mark Holand QUETIAPINE $17.25 $12.81 Feb 05, 2026 Details Jan 31, 2026 Mark Holand NURTEC ODT $219.39 $0.00 Jan 31, 2026 Details Jan 31, 2026 Mark Holand PANTOPRAZOLE $19.41 $14.44 Jan 31, 2026 Details Jan 31, 2026 Mark Holand APO PREDNISONE TAB 50MG. $15.71 $12.06 Jan 31, 2026 Details Jan 31, 2026 Mark Holand SUMATRIPTAN DF $49.46 $44.83 Jan 31, 2026 Details Jan 31, 2026 Mark Holand SUMATRIPTAN DF $110.84 $0.00 Jan 31, 2026 Details Jan 30, 2026 Mark Holand ‘APO-BILASTINE TABLETS $55.38 $27.14 Jan 30, 2026 Details Jan 30, 2026 Mark Holand AIMOVIG $632.40 $0.00 Jan 30, 2026 Details Jan 30, 2026 Mark Holand NURTEC ODT $219.39 $0.00 Jan 30, 2026 Details Jan 14, 2026 Mark Holand Nicorette Gum 2 mg $95.24 $0.00 Jan 14, 2026 Details Dec 22, 2025 Mark Holand ‘APO-BILASTINE TABLETS $54.23 $51.14 Dec 22, 2025 Details Nov 14, 2025 Mark Holand TEVA-SUMATRIPTAN DF $45.03, $40.71 Nov 14, 2025 Details Nov 14, 2025 Mark Holand APO-BILASTINE TABLETS $54.23 $51.14 Nov 14, 2025 Details Oct 06, 2025 Mark Holand APO-BILASTINE TABLETS $54.23 $51.14 Oct 06, 2025 Details Aug 19, 2025 Mark Holand TEVA-SUMATRIPTAN DF $104.05 $102.13 Aug 19, 2025 Details Aug 18, 2025 Mark Holand APO-BILASTINE TABLETS $55.40 $51.14 Aug 18, 2025 Details Page 1 Total $3,036.01 $1,114.48 Grand Total $4,311.41 $2,004.16 « First | « Previous | Page Lof2 | Next» | Last » ‘*@Pacc Blue Cross isthe registered tradename of PBC Health Benefits Society (PBC), an independent licensee of the Canadian Assodation of Blue Cross Plans (CABCP). Pacific Blue Cross and the cross design are trademarks of the CABCP. ‘lve Shield i 2 recistered trademark of Blue Cross Blue Shield Association. Insurance is sold through PacBlue Life Services Lid, dba Pacic Blue Cross Agency, a licensed insurance agency and wholly owned subsiciary of PBC. Insurance is underwritten by various underwriters. For information on underwriters vist pac.bluecross.ca/Disclosue. Al rights reserved, Privacy Statement |Legal Complaints | Security | Browser Requirements Browser Capabilities Contact | CUPE 1816 | 7,7.594.4 - ACES https://service.pac. bluecross.ca/ACESWeb/Pages/Claims/Claims.aspx? MODULE=ALL