ADDITIONAL ITEMS                                                   
                         Additional Item Description/Incurred Date/Product/Sub Group-8 Digit                         

INVOICE NUMBER:     230829580321                                           PAGE:               1 of 2            
BILL ACCOUNT NUMBER:CN02401002                                             PAID CLAIMS MONTH:  August 2023       
BILL ACCOUNT NAME:  Admiral Peary                                          CLAIMS PAID THRU:   08/25/2023        
CLIENT NUMBER:      0240                                                   BILL CYCLE:         4 of 4            
CLIENT NAME:        Admiral Peary                                          PREPARED DATE:      08/29/2023        

                                        Adjustment Description                                            Adjustment Amount                              
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Copay Armor
  06/23
    Drug
      014267-03                                                                                                       $426.17
      014267-05                                                                                                     $1,912.84
      014267- Total                                                                                                 $2,339.01
    Drug Total                                                                                                      $2,339.01
  06/23 Total                                                                                                       $2,339.01
Copay Armor Total                                                                                                   $2,339.01
                                                                                                                                                            
Payment Integrity Pre Pay Review
  02/23
    PPO
      014267-03                                                                                                     $4,456.83
      014267- Total                                                                                                 $4,456.83
    PPO Total                                                                                                       $4,456.83
  02/23 Total                                                                                                       $4,456.83
  05/23
    HDHP PPO
      017728-00                                                                                                        $77.97
      017728- Total                                                                                                    $77.97
    HDHP PPO Total                                                                                                     $77.97
  05/23 Total                                                                                                          $77.97
  06/23
    PPO
      014267-03                                                                                                    $10,727.20
      014267- Total                                                                                                $10,727.20

                                                                                                                                                PAGE:2 of 2
                                                                                                                                                            
                                        Adjustment Description                                            Adjustment Amount                              
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
    PPO Total                                                                                                      $10,727.20
  06/23 Total                                                                                                      $10,727.20
Payment Integrity Pre Pay Review Total                                                                             $15,262.00
                                                                                                                                                            
Additional Items Total                                                                                             $17,601.01