Flexible Spending Account Worksheet

Estimate the out-of-pocket medical expenses (not covered by insurance) you anticipate paying during the year.

Pay Periods

How many pay periods do you have annually? *

#

 

Annual Expense Amounts

Periodic doctor office visits

$

Physicals and routine check-ups

$

Prescription drugs

$

Dental (check-up, cleaning, fillings, etc.)

$

Orthodontia (braces, exams, etc.)

$

Vision and eye care (exams, glasses, contacts, etc.)

$

Surgery (including corrective eye surgery)

$

Other eligible expenses

$

Out-of-pocket annual medical expenses *

=

Suggested contribution per pay period

=

Estimated income tax savings per pay period**

=