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

INVOICE NUMBER:     250729587807                                           PAGE:               1 of 2            
BILL ACCOUNT NUMBER:CN02401002                                             PAID CLAIMS MONTH:  July 2025         
BILL ACCOUNT NAME:  Admiral Peary                                          CLAIMS PAID THRU:   07/25/2025        
CLIENT NUMBER:      0240                                                   BILL CYCLE:         4 of 4            
CLIENT NAME:        Admiral Peary                                          PREPARED DATE:      07/29/2025        

                                        Adjustment Description                                            Adjustment Amount                              
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Copay Armor
  06/25
    Drug
      014267-03                                                                                                     ($998.21)
      014267-05                                                                                                     ($529.92)
      014267-26                                                                                                       $609.94
      014267- Total                                                                                                 ($918.19)
    Drug Total                                                                                                      ($918.19)
  06/25 Total                                                                                                       ($918.19)
Copay Armor Total                                                                                                   ($918.19)
                                                                                                                                                            
DRG Reviews
  04/25
    HDHP PPO
      017728-00                                                                                                       $433.78
      017728- Total                                                                                                   $433.78
    HDHP PPO Total                                                                                                    $433.78
  04/25 Total                                                                                                         $433.78
  05/25
    PPO
      014267-03                                                                                                    $35,408.54
      014267- Total                                                                                                $35,408.54
    PPO Total                                                                                                      $35,408.54
  05/25 Total                                                                                                      $35,408.54
DRG Reviews Total                                                                                                  $35,842.32
                                                                                                                                                            
Post Pay Audits

                                                                                                                                                PAGE:2 of 2
                                                                                                                                                            
                                        Adjustment Description                                            Adjustment Amount                              
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
  12/24
    PPO
      014267-03                                                                                                       $375.89
      014267- Total                                                                                                   $375.89
    PPO Total                                                                                                         $375.89
  12/24 Total                                                                                                         $375.89
Post Pay Audits Total                                                                                                 $375.89
                                                                                                                                                            
Additional Items Total                                                                                             $35,300.02