HEALTHCARE ADJUSTMENT                                                
                                              Product/Sub Group-8 Digit                                              

INVOICE NUMBER:     230725589774                                           PAGE:               1 of 3            
BILL ACCOUNT NUMBER:CN02401002                                             PAID CLAIMS MONTH:  July 2023         
BILL ACCOUNT NAME:  Admiral Peary                                          CLAIMS PAID THRU:   07/21/2023        
CLIENT NUMBER:      0240                                                   BILL CYCLE:         3 of 4            
CLIENT NAME:        Admiral Peary                                          PREPARED DATE:      07/25/2023        

                Group                     Incurred             Provider Rate             Medical/Drug              Manual             Healthcare 
                                            Date                Adjustments                 Rebate              Adjustments           Adjustments
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Drug
  014267-01                              02/01/2023                        $                ($489.88)                     $             ($489.88)
  014267-01                              03/01/2023                        $              ($1,945.69)                     $           ($1,945.69)
  014267-03                              10/01/2022                        $                  $138.70                     $               $138.70
  014267-03                              12/01/2022                        $                  $554.82                     $               $554.82
  014267-03                              01/01/2023                        $                  $145.86                     $               $145.86
  014267-03                              02/01/2023                        $                ($979.33)                     $             ($979.33)
  014267-03                              03/01/2023                        $             ($21,961.16)                     $          ($21,961.16)
  014267-05                              01/01/2023                        $                 ($51.89)                     $              ($51.89)
  014267-05                              02/01/2023                        $                 ($21.72)                     $              ($21.72)
  014267-05                              03/01/2023                        $              ($6,609.55)                     $           ($6,609.55)
  014267-06                              02/01/2023                        $                  $146.41                     $               $146.41
  014267-06                              03/01/2023                        $                ($432.71)                     $             ($432.71)
  014267-07                              01/01/2023                        $                  $335.23                     $               $335.23
  014267-07                              02/01/2023                        $                  $125.80                     $               $125.80
  014267-07                              03/01/2023                        $              ($1,165.89)                     $           ($1,165.89)
  014267-08                              01/01/2023                        $                ($409.77)                     $             ($409.77)
  014267-08                              02/01/2023                        $                ($856.03)                     $             ($856.03)
  014267-08                              03/01/2023                        $              ($6,565.83)                     $           ($6,565.83)
  014267-12                              03/01/2023                        $              ($1,790.21)                     $           ($1,790.21)
  014267-13                              01/01/2023                        $                   $14.02                     $                $14.02
  014267-13                              03/01/2023                        $              ($1,026.93)                     $           ($1,026.93)
  014267-15                              03/01/2023                        $              ($1,617.25)                     $           ($1,617.25)
  014267-26                              02/01/2023                        $                ($148.97)                     $             ($148.97)
  014267-26                              03/01/2023                        $                ($148.97)                     $             ($148.97)
  014267-36                              01/01/2023                        $                ($376.95)                     $             ($376.95)
  014267-36                              02/01/2023                        $                ($270.82)                     $             ($270.82)

                                                                                                                                                PAGE:2 of 3
                                                                                                                                                            
                Group                     Incurred             Provider Rate             Medical/Drug              Manual             Healthcare 
                                            Date                Adjustments                 Rebate              Adjustments           Adjustments
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
  014267-36                              03/01/2023                        $              ($1,155.51)                     $           ($1,155.51)
  014267-37                              03/01/2023                        $                 ($55.19)                     $              ($55.19)
  014267- Total                                                        $0.00             ($46,619.41)                 $0.00          ($46,619.41)
Drug Total                                                             $0.00             ($46,619.41)                 $0.00          ($46,619.41)
                                                                                                                                                            
HDHP PPO
  014267-54                              01/01/2023                        $                   $14.02                     $                $14.02
  014267-54                              02/01/2023                        $              ($2,723.19)                     $           ($2,723.19)
  014267-54                              03/01/2023                        $              ($2,068.26)                     $           ($2,068.26)
  014267- Total                                                        $0.00              ($4,777.43)                 $0.00           ($4,777.43)
  017697-00                              01/01/2023                        $                  ($9.36)                     $               ($9.36)
  017697-00                              03/01/2023                        $              ($2,540.32)                     $           ($2,540.32)
  017697-01                              01/01/2023                        $                  ($9.36)                     $               ($9.36)
  017697-01                              03/01/2023                        $              ($6,420.30)                     $           ($6,420.30)
  017697-10                              03/01/2023                        $                ($990.72)                     $             ($990.72)
  017697- Total                                                        $0.00              ($9,970.06)                 $0.00           ($9,970.06)
  017728-00                              03/01/2023                        $                ($182.94)                     $             ($182.94)
  017728- Total                                                        $0.00                ($182.94)                 $0.00             ($182.94)
  104272-02                              01/01/2023                        $                   $14.02                     $                $14.02
  104272-02                              02/01/2023                        $                ($902.10)                     $             ($902.10)
  104272-02                              03/01/2023                        $              ($8,369.03)                     $           ($8,369.03)
  104272-09                              02/01/2023                        $                ($525.59)                     $             ($525.59)
  104272-09                              03/01/2023                        $                ($873.90)                     $             ($873.90)
  104272-12                              01/01/2023                        $                   $14.02                     $                $14.02
  104272-12                              03/01/2023                        $                ($638.63)                     $             ($638.63)
  104272-19                              01/01/2023                        $                   $14.02                     $                $14.02
  104272-19                              03/01/2023                        $                ($168.92)                     $             ($168.92)
  104272- Total                                                        $0.00             ($11,436.11)                 $0.00          ($11,436.11)
HDHP PPO Total                                                         $0.00             ($26,366.54)                 $0.00          ($26,366.54)
                                                                                                                                                            
Major Medical
  053264-01                              03/01/2023                        $                ($659.65)                     $             ($659.65)

                                                                                                                                                PAGE:3 of 3
                                                                                                                                                            
                Group                     Incurred             Provider Rate             Medical/Drug              Manual             Healthcare 
                                            Date                Adjustments                 Rebate              Adjustments           Adjustments
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
  053264- Total                                                        $0.00                ($659.65)                 $0.00             ($659.65)
Major Medical Total                                                    $0.00                ($659.65)                 $0.00             ($659.65)
Healthcare Adjustment Total                                                                                                          ($73,645.60)