🔗 Linked Evidence
PBC_MEDS_2 — p.1
📄 PBC MEDS 2 | p.1
📄 PBC MEDS 2 | p.1
📝 Extracted Text (OCR)
6/14/26, 1:03 AM Pacific Blue Cross
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Mark Holand (DOB: Ser 24 Months { } To (
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All Health Dental Drugs
Service Date V Name Expense/Item Amount Claimed Amount Paid Statement Date
Aug 18, 2025 Mark Holand TEVA-SUMATRIPTAN DF $133.21 $0.00 Aug 19, 2025 Details
Jul 19, 2025 Mark Holand APO-BILASTINE TABLETS 55.40 51.14 Jul 19, 2025 Details
Jun 16, 2025 Mark Holand APO-BILASTINE TABLETS 55.40 51.14 Jun 16, 2025 Details
May 27, 2025 Mark Holand TEVA-SUMATRIPTAN DF $133.21 $132.85 May 27, 2025 Details
May 20, 2025 Mark Holand PANTOPRAZOLE MAGNESIUM 26.24 22.81 May 20, 2025 Details
May 14, 2025 Mark Holand APO-BILASTINE TABLETS 55.40 51.14 May 14, 2025 Details
Mar 24, 2025 Mark Holand APO-BILASTINE TABLETS 55.40 51.14 Mar 24, 2025 Details
Feb 26, 2025 Mark Holand TEVA-SUMATRIPTAN DF $144.73 $132.85 Feb 26, 2025 Details
Feb 25, 2025 Mark Holand TEVA-SUMATRIPTAN DF $144.73 $0.00 Feb 26, 2025 Details
Feb 12, 2025 Mark Holand APO-BILASTINE TABLETS 55.40 51.14 Feb 12, 2025 Details
Jan 14, 2025 Mark Holand BLEXTEN 63.41 56.81 Jan 14, 2025 Details
Jan 14, 2025 Mark Holand BLEXTEN 63.41 $0.00 Jan 14, 2025 Details
Nov 22, 2024 Mark Holand TEVA-SUMATRIPTAN DF $144.73 $144.33 Nov 22, 2024 Details
Aug 06, 2024 Mark Holand TEVA-SUMATRIPTAN DF $144.73 $144.33 Aug 06, 2024 Details
Page 2 Total $1,275.40 $889.68
Grand Total $4,311.41 $2,004.16
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