ENROLLMENT BASED ADMINISTRATIVE CALCULATION                                     
                                              Product/Sub Group-8 Digit                                              

INVOICE NUMBER:     250729587807                                           PAGE:               1 of 5            
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        

                      Group                                     Contracts                                    $ PCPM                    $ PCPM Admin Expense
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
Administrative Credit
    014267-01                                                          19                                  ($53.50)                             ($1,016.50)
    014267-03                                                         108                                  ($53.50)                             ($5,778.00)
    014267-05                                                          72                                  ($53.50)                             ($3,852.00)
    014267-06                                                          21                                  ($53.50)                             ($1,123.50)
    014267-07                                                          59                                  ($53.50)                             ($3,156.50)
    014267-08                                                          49                                  ($53.50)                             ($2,621.50)
    014267-12                                                           3                                  ($53.50)                               ($160.50)
    014267-13                                                          11                                  ($53.50)                               ($588.50)
    014267-15                                                          13                                  ($53.50)                               ($695.50)
    014267-19                                                           1                                  ($53.50)                                ($53.50)
    014267-26                                                           5                                  ($53.50)                               ($267.50)
    014267-34                                                           3                                  ($53.50)                               ($160.50)
    014267-36                                                          30                                  ($53.50)                             ($1,605.00)
    014267-37                                                          12                                  ($53.50)                               ($642.00)
    014267-54                                                          74                                  ($53.50)                             ($3,959.00)
014267- Total                                                         480                                                                      ($25,680.00)
  017697-00                                                            64                                  ($53.50)                             ($3,424.00)
    017697-01                                                          24                                  ($53.50)                             ($1,284.00)
    017697-10                                                           2                                  ($53.50)                               ($107.00)
017697- Total                                                          90                                                                       ($4,815.00)
  017728-00                                                            19                                  ($53.50)                             ($1,016.50)
017728- Total                                                          19                                                                       ($1,016.50)
  053264-01                                                             1                                  ($17.84)                                ($17.84)
    053264-01                                                           2                                  ($17.83)                                ($35.66)
053264- Total                                                           3                                                                          ($53.50)
  104272-02                                                           135                                  ($53.50)                             ($7,222.50)

                                                                                                                                                PAGE:2 of 5
                                                                                                                                                            
                      Group                                     Contracts                                    $ PCPM                    $ PCPM Admin Expense
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
    104272-09                                                           6                                  ($53.50)                               ($321.00)
    104272-12                                                          13                                  ($53.50)                               ($695.50)
    104272-19                                                           3                                  ($53.50)                               ($160.50)
104272- Total                                                         157                                                                       ($8,399.50)
Administrative Credit Total                                           749                                                                      ($39,964.50)
                                                                                                                                                            
Drug
    014267-01                                                          19                                     $5.00                                  $95.00
    014267-03                                                         108                                     $5.00                                 $540.00
    014267-05                                                          72                                     $5.00                                 $360.00
    014267-06                                                          21                                     $5.00                                 $105.00
    014267-07                                                          60                                     $5.00                                 $300.00
    014267-08                                                          49                                     $5.00                                 $245.00
    014267-12                                                           3                                     $5.00                                  $15.00
    014267-13                                                          11                                     $5.00                                  $55.00
    014267-15                                                          13                                     $5.00                                  $65.00
    014267-19                                                           1                                     $5.00                                   $5.00
    014267-26                                                           5                                     $5.00                                  $25.00
    014267-34                                                           3                                     $5.00                                  $15.00
    014267-36                                                          30                                     $5.00                                 $150.00
    014267-37                                                          12                                     $5.00                                  $60.00
014267- Total                                                         407                                                                         $2,035.00
Drug Total                                                            407                                                                         $2,035.00
                                                                                                                                                            
Facility
    053264-01                                                           1                                    $17.83                                  $17.83
053264- Total                                                           1                                                                            $17.83
Facility Total                                                          1                                                                            $17.83
                                                                                                                                                            
HDHP PPO
    014267-54                                                          74                                    $58.50                               $4,329.00
014267- Total                                                          74                                                                         $4,329.00

                                                                                                                                                PAGE:3 of 5
                                                                                                                                                            
                      Group                                     Contracts                                    $ PCPM                    $ PCPM Admin Expense
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
  017697-00                                                            64                                    $58.50                               $3,744.00
    017697-01                                                          24                                    $58.50                               $1,404.00
    017697-10                                                           2                                    $58.50                                 $117.00
017697- Total                                                          90                                                                         $5,265.00
  017728-00                                                            19                                    $58.50                               $1,111.50
017728- Total                                                          19                                                                         $1,111.50
  104272-02                                                           135                                    $58.50                               $7,897.50
    104272-09                                                           6                                    $58.50                                 $351.00
    104272-12                                                          13                                    $58.50                                 $760.50
    104272-19                                                           3                                    $58.50                                 $175.50
104272- Total                                                         157                                                                         $9,184.50
HDHP PPO Total                                                        340                                                                        $19,890.00
                                                                                                                                                            
Major Medical
    053264-01                                                           1                                    $17.83                                  $17.83
053264- Total                                                           1                                                                            $17.83
Major Medical Total                                                     1                                                                            $17.83
                                                                                                                                                            
PPO
    014267-01                                                          19                                    $53.50                               $1,016.50
    014267-03                                                         108                                    $53.50                               $5,778.00
    014267-05                                                          72                                    $53.50                               $3,852.00
    014267-06                                                          21                                    $53.50                               $1,123.50
    014267-07                                                          59                                    $53.50                               $3,156.50
    014267-08                                                          49                                    $53.50                               $2,621.50
    014267-12                                                           3                                    $53.50                                 $160.50
    014267-13                                                          11                                    $53.50                                 $588.50
    014267-15                                                          13                                    $53.50                                 $695.50
    014267-19                                                           1                                    $53.50                                  $53.50
    014267-26                                                           5                                    $53.50                                 $267.50
    014267-34                                                           3                                    $53.50                                 $160.50
    014267-36                                                          30                                    $53.50                               $1,605.00

                                                                                                                                                PAGE:4 of 5
                                                                                                                                                            
                      Group                                     Contracts                                    $ PCPM                    $ PCPM Admin Expense
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
    014267-37                                                          12                                    $53.50                                 $642.00
014267- Total                                                         406                                                                        $21,721.00
PPO Total                                                             406                                                                        $21,721.00
                                                                                                                                                            
Professional
    053264-01                                                           1                                    $17.84                                  $17.84
053264- Total                                                           1                                                                            $17.84
Professional Total                                                      1                                                                            $17.84
                                                                                                                                                            
Stop Loss Carve Out Fee
    014267-01                                                          19                                     $4.00                                  $76.00
    014267-03                                                         108                                     $4.00                                 $432.00
    014267-05                                                          72                                     $4.00                                 $288.00
    014267-06                                                          21                                     $4.00                                  $84.00
    014267-07                                                          59                                     $4.00                                 $236.00
    014267-08                                                          49                                     $4.00                                 $196.00
    014267-12                                                           3                                     $4.00                                  $12.00
    014267-13                                                          11                                     $4.00                                  $44.00
    014267-15                                                          13                                     $4.00                                  $52.00
    014267-19                                                           1                                     $4.00                                   $4.00
    014267-26                                                           5                                     $4.00                                  $20.00
    014267-34                                                           3                                     $4.00                                  $12.00
    014267-36                                                          30                                     $4.00                                 $120.00
    014267-37                                                          12                                     $4.00                                  $48.00
    014267-54                                                          74                                     $4.00                                 $296.00
014267- Total                                                         480                                                                         $1,920.00
  017697-00                                                            64                                     $4.00                                 $256.00
    017697-01                                                          24                                     $4.00                                  $96.00
    017697-10                                                           2                                     $4.00                                   $8.00
017697- Total                                                          90                                                                           $360.00
  017728-00                                                            19                                     $4.00                                  $76.00
017728- Total                                                          19                                                                            $76.00

                                                                                                                                                PAGE:5 of 5
                                                                                                                                                            
                      Group                                     Contracts                                    $ PCPM                    $ PCPM Admin Expense
_____________________________________________________________________________________________________________________________________________________________
                                                                                                                                                            
  053264-01                                                             1                                     $4.00                                   $4.00
053264- Total                                                           1                                                                             $4.00
  104272-02                                                           135                                     $4.00                                 $540.00
    104272-09                                                           6                                     $4.00                                  $24.00
    104272-12                                                          13                                     $4.00                                  $52.00
    104272-19                                                           3                                     $4.00                                  $12.00
104272- Total                                                         157                                                                           $628.00
Stop Loss Carve Out Fee Total                                         747                                                                         $2,988.00
                                                                                                                                                            
Enrollment Based Administrative Calculation Total                                                                                                 $6,723.00