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Kaiser Permanente Sample Fee List
NORTHERN CALIFORNIA

As your partner in health, we want to help you better manage your care. Staying on top of your
finances, such as how much you 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. 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, the charges
may be different.
The amount of charges you pay out of your own pocket will depend on your plan coverage and on
things such as whether or not your provider is a Kaiser Permanente practitioner. And your benefit plan
may cover services at different levels of copayment or coinsurance.

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. • Manage the balance of your Kaiser Permanente Custom Care HealthInvestor (HSA) or Kaiser Permanente Custom Care HealthBuilder (HRA) if you’re enrolled in an HSA-qualified plan or a plan paired with an HRA. (These products are not available in all regions. Contact Member Services for information about availability.) • Plan for unexpected health care costs. • Review your options during open enrollment. (You may want to choose another Kaiser Permanente benefit option that better fits your needs.) • Estimate the funds you may need for your flexible spending account, if applicable.
For more information about our charges not related to prescription drugs or for questions about a
service that’s not listed, call our Deductible Products Service Team at 1-800-390-3507.
For more information about prescription drug charges, call the Kaiser Permanente pharmacy near you.
You’ll find our pharmacies’ phone numbers listed on the member section of our Web site at kp.org,
in Your Guidebook to Kaiser Permanente Services, or on the label of your prescription filled at one of
our pharmacies.
These estimated member charges are valid as of January 2008 and are subject to change without notice.
Kaiser Permanente Estimated Charges Northern California
ESTIMATED CHARGE
Office visits
Office visits (wellness)
Well-baby office visit, new patient (under 1 year)* Well-child office visit, new patient (1–4 years)* Well-child office visit, new patient (5–11 years)* Well-child office visit, new patient (12–17 years)* Well-adult office visit, new patient (18–39 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 (1–4 years)* Well-child office visit, established patient (5–11 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 Psychotherapy visits
Eye examinations
Eye exam, routine visit, established patient Eye exam and treatment, established patient Hearing services
These estimated member charges are valid as of January 2008 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California
ESTIMATED CHARGE
Hearing services (continued)
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
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 These estimated member charges are valid as of January 2008 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California
ESTIMATED CHARGE
Tests and procedures (continued)
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 Review of CT scan of the head or brain $425 X-ray of chest (one view interpretation) $50 These estimated member charges are valid as of January 2008 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California
ESTIMATED CHARGE
X-rays, CT scans, and other imaging studies (continued)
Laboratory tests
Laboratory chemistry test for creatine kinase $15 These estimated member charges are valid as of January 2008 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California
ESTIMATED CHARGE
Laboratory tests (continued)
These estimated member charges are valid as of January 2008 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
Atenolol 25 mg tablet (generic Tenormin) 30 $9 Atenolol 50 mg tablet (generic Tenormin) 30 $9 Cephalexin 500 mg capsule (generic Keflex) 40 Ciprofloxacin HCL 500 mg tablet (generic Cipro) 20 Cyclobenzaprine HCL 10 mg tablet (generic Flexeril) 30 Doxycycline 100 mg tablet (generic Vibramycin) Famotidine 40 mg tablet (generic Pepcid) Fluoxetine HCL 10 mg capsule (generic Prozac) Fluoxetine HCL 20 mg capsule (generic Prozac) 30 Fluticasone propionate 50 mcg nasal spray solution, 16 g Fosamax plus Vitamin D 70/2800 mg tablet 4 Glyburide 5 mg tablet (generic Micronase or Diabeta) 60 Guaifenesin with Codeine syrup 120 ml bottle Guaifenesin/Pseudophedrine 600/120 mg tablet Hydrochlorothiazide 25 mg tablet (generic Esidrix) 30 Hydrocodone bitartrate/Acetaminophen 5/500 mg tablet Ibuprofen 600 mg tablet (generic Motrin) 100 $10 Ibuprofen 800 mg tablet (generic Motrin) 100 $17 Levothroid 0.1 mg tablet (generic Synthroid) Lisinopril 10 mg tablet (generic Prinivil or Zestril) 30 Lisinopril 20 mg tablet (generic Prinivil or Zestril) 30 Lisinopril 40 mg tablet (generic Prinivil or Zestril) 30 Lisinopril 5 mg tablet (generic Prinivil or Zestril) 30 Lovastatin 10 mg tablet (generic Mevacor) 30 $15 These estimated member charges are valid as of January 2008 and are subject to change without notice. Kaiser Permanente Estimated Charges Northern California
DRUG DESCRIPTION (continued)
QUANTITY
ESTIMATED CHARGE
Lovastatin 20 mg tablet (generic Mevacor) 30 $18 Lovastatin 40 mg tablet (generic Mevacor) 30 $23 Metformin HCL 500 mg tablet (generic Glucophage) Metoprolol tartrate 50 mg tablet (generic Lopressor) Nabumetone 500 mg tablet (generic Relafen) Naproxen 500 mg tablet (generic Naprosyn) Nasarel 0.025% nasal spray solution, 25 g inhaler Nifedipine 30 mg tablet (generic Adalat CC) Novolin N 100 u/ml (NPH insulin), 10 ml vial Omeprazole 20 mg delayed-release capsule Potassium chloride 10 mEq controlled-release tablet Promethazine with Codeine syrup 120 ml bottle Propoxyphene Napsylate/Acetaminophen 100/650 mg tablet Proventil HFA inhalation aerosol, 6.7 g inhaler QVAR 80.0 mcg actuation aerosol, 7.3 g inhaler Ranitidine HCL 150 mg tablet (generic Zantac) SMZ-TMP double-strength 800/160 mg tablet Trazodone 50 mg tablet (generic Desyrel) Triamcinolone Acetonide (topical) 0.1% cream Triamterene/Hydrochlorothiazide 75/50 mg tablet These estimated member charges are valid as of January 2008 and are subject to change without notice.

Source: http://prjinsurance.com/No%20Calif%20Sample%20Fee%20Schedule%20eff%2001-2008.pdf