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ADDENDUM C <br /> FEE SCHEDULE <br /> BASE FEES PEPM RATE <br /> UNITED STATES: <br /> N In-person E AP Services-Choose session model $1.54 <br /> ❑ 1-3 session ❑ 1-6 session <br /> ❑ 1-4 session ❑ 1-8 session <br /> ® 1-5 session ❑ 1-10 session <br /> Telephonic EAP Services <br /> N Legal Consultation&Financial Consultation Servicesl $0.05 <br /> Work/Life Servicesi <br /> Nurse advice Line Services' <br /> New Parent Support Servicest <br /> Employee Concern Line' <br /> Other: <br /> INTERNATIONAL: <br /> E AP Services-Insert session model <br /> ❑ 1- sessions <br /> Telephonic EAP Services <br /> WorkLife Referral Servicest <br /> Legal&Financial Referral Services' <br /> Other,Describe: <br /> SUPPLEMENTAL FEES <br /> United States <br /> _Additional In-person Sessions $ 90.00 per In-person Session <br /> _Additional Service Flours $ 230.00 per provider hour <br /> Mandatory Referrals2 $1600.00 per case <br /> CISAI Cancellation Fee $ 250.00 per scheduled hour <br /> International <br /> Describe: <br /> Describe: <br /> Communication Materials <br /> Brochures with 2 Wallet Cards $ 0.40 per unit—Estimate <br /> Posters $ 1.60 per unit—Estimate <br /> Services may only be selected if EAP services are purchased. <br /> '-Charge applies only if Sponsor selects the Telephonic EAP Service model and an Employee is referred for EAP <br /> services under a"last chance agreement"or similar arrangement. <br />