🔗 Linked Evidence
PBC_MEDS — p.1
📄 PBC MEDS | p.1
📄 PBC MEDS | p.1
📝 Extracted Text (OCR)
6/14/26, 1:02 AM
Pacific Blue Cross
Go Back to your Member Profile Logout
Claim Details
tail
Learn more about your claims.
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
Mark Holand (DOB: Ser 24 Months { } To (
Claim ID
Apply
All Health Dental Drugs
Service Date V 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
1/2