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Kaiser Permanente Sample Fee List
NORTHERN CALIFORNIA

Finding a health care plan that meets your needs is an important part of staying healthy. To help you
decide who to partner with as you choose a health care plan, we’ve created a Kaiser Permanente
Sample Fee List so you can see the charges for many of Kaiser Permanente’s services.
Understanding how much you might spend on health care helps give you peace of mind—so you can
concentrate on the things in life you enjoy. This list shows estimated member charges for some
commonly used medical services—such as office visits, lab tests, X-rays, and prescription
medicines—when provided at Kaiser Permanente medical centers, medical offices, pharmacies, and
other facilities. If you choose to become a Kaiser Permanente member, the charges for services may
be different when you receive care or services from a provider at a non–Kaiser Permanente facility,
even if the provider is under contract to provide services for Kaiser Permanente members.
As a Kaiser Permanente member, the amount of charges you pay out of your own pocket will depend
on your plan coverage and on factors such as whether or not your provider is a Kaiser Permanente
practitioner. Additionally, your benefit plan may cover services at different levels of copayment or
coinsurance.

As you consider partnering with us for your health care, you can use this list to help you:

• Estimate your out-of-pocket medical spending for the coming year based on the care and services you expect to use from our facilities. • Plan for unexpected health care costs. • Review your options during open enrollment. • Estimate the funds you may need for your health savings account, health reimbursement account or flexible spending account, if applicable.
For more information about our charges or about a service that’s not listed, contact our Deductible
Products Service Team at 1-800-390-3507, Monday through Friday, from 7 a.m. to 5 p.m.

These estimated member charges are valid as of January 2009 and are subject to change without notice.
Kaiser Permanente Estimated Charges Northern California
ESTIMATED CHARGE
Office visits (outpatient)
Office visit that includes a problem-focused history, exam, and simple Office visit that includes an expanded problem-focused history, exam, and simple medical decision for a new patient Office visit that includes a detailed history, exam, and low complex medical Office visit that includes a comprehensive history, exam, and moderately complex medical decision for a new patient Office visit that includes a comprehensive history, exam, and highly complex medical decision for a new patient Office visit by a non-physician provider for a minimal problem for an Office visit that includes a problem-focused history, exam, and simple medical decision for an established patient Office visit that includes an expanded problem-focused history, exam, and low complex medical decision for an established patient Office visit that includes a detailed history, exam, and moderately complex medical decision for an established patient Office visit that includes a comprehensive history, exam, and highly complex medical decision for an established patient Office visits (wellness)
Well-baby office visit, new patient (under 1 year)* Well-child office visit, new patient (1–11 years)* Well-child office visit, well-adult office visit new patient (12–39 years)* Well-adult office visit, new patient (40–64 years)* Well-adult office visit, new patient (65 and older)* Well-baby office visit, established patient (under 1 year)* Well-child office visit, established patient (1–11 years)* Well-child office visit, established patient (12–17 years)* *These services are typically covered at a copayment level and not subject to the deductible. For information about your coverage, please see your Evidence of Coverage. Emergency care by a physician
(excluding other fees such as X-rays, lab tests, or additional procedures)
Emergency care by a physician, extensive These estimated member charges are valid as of January 2009 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California
ESTIMATED CHARGE
Psychotherapy visits
Eye examinations
Eye exam, routine visit, established patient Eye exam and treatment, established patient Hearing services
Hearing screening test (pure tone, air only) Physical therapy services
Electric stimulation therapy, treatment only Physical therapy exercises, treatment only Physical therapy, hot and cold application, treatment only Physical therapy, ultrasound, treatment only Vaccines and other injections
These estimated member charges are valid as of January 2009 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California
ESTIMATED CHARGE
Vaccines and other injections (continued)
Therapeutic injection (administration only, does not include medication)* Therapeutic IV injection (administration only, does not include medication)* *These services are typically covered at a copayment level and not subject to the deductible. For information about your coverage, please see your Evidence of Coverage. Tests and procedures
Colonoscopy and removal of abnormal tissue using cautery Colonoscopy and removal of abnormal tissue using snare technique Colonoscopy and removal of colon tissue for examination Draining fluid from around swollen joint Sigmoidoscopy and removal of tissue for examination Surgically destroying an abnormal area of skin X-rays, CT scans, and other imaging studies
CT scan of stomach area, without dye $525 These estimated member charges are valid as of January 2009 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California
ESTIMATED CHARGE
X-rays, CT scans, and other imaging studies (continued)
Review of CT scan of the head or brain $425 Laboratory tests
These estimated member charges are valid as of January 2009 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California
ESTIMATED CHARGE
Laboratory tests (continued)
Laboratory chemistry test for creatine kinase $15 These estimated member charges are valid as of January 2009 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California

Charge per prescription for top 50 medications
DRUG DESCRIPTION
QUANTITY
ESTIMATED CHARGE
Amoxicillin 400mg/5ml suspension 100ml bottle Amoxicillin 500mg capsule (generic Amoxil) Azithromycin 250mg tablet (generic Zithromax) Cephalexin 500mg capsule (generic Keflex) Ciprofloxacin hydrochloride 500mg tablet (generic Cipro) Cyclobenzaprine 10mg tablet (generic Flexeril) Doxycycline hyclate 100mg tablet (generic Vibratab) Fluoxetine hydrochloride 10mg capsule (generic Prozac) Fluoxetine hydrochloride 20mg capsule (generic Prozac) Fluticasone propionate 50mcg nasal spray solution, 16 gram Glipizide 5mg tablet (generic Glucotrol) Glipizide 10mg tablet (generic Glucotrol) Guaifenesin with Codeine syrup 240ml bottle Hydrochlorothiazide 25mg tablet (generic Esidrix) Hydrocodone/Acetaminophen 10/325mg tablet Hydrocodone/Acetaminophen 5/500mg tablet Levothroid 100mcg tablet (generic Synthroid) Lisinopril 5mg tablet (generic Prinivil or Zestril) Lisinopril 10mg tablet (generic Prinivil or Zestril) Lisinopril 20mg tablet (generic Prinivil or Zestril) Lisinopril 40mg tablet (generic Prinivil or Zestril) These estimated member charges are valid as of January 2009 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California
DRUG DESCRIPTION (continued)
QUANTITY
ESTIMATED CHARGE
Lovastatin 40mg tablet (generic Mevacor) Metformin hydrochloride 500mg tablet (generic Glucophage) Naproxen 500mg tablet (generic Naprosyn) Nasarel 0.025% nasal spray solution, 25gm inhaler Novolin N 100 u/ml (NPH insulin), 10ml vial Omeprazole 20mg capsule (generic Prilosec) Prednisone 20mg tablet (generic Deltasone) SMZ-TMP double-strength 800/160mg tablet Trazodone hydrochloride 50mg tablet (generic Desyrel) Triamterene/Hydrochlorothiazide 75/50mg tablet Zolpidem tartrate 10mg tablet (generic Ambien) These estimated member charges are valid as of January 2009 and are subject to change without notice.

Source: http://www.stmarys-ca.edu/sites/default/files/attachments/files/KaiserSampleFeeList.pdf