Flexible Spending Account Worksheet

Estimate the medical expenses you anticipate you will pay out of your own pocket (not covered by insurance) during the year.

Annual Expense Amounts:

Enter your number of pay periods per year

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**

*Beginning January 1, 2022, the maximum employee contribution permitted by tax law to a Healthcare FSA is $2,850 per calendar year. Reminder, whatever amount you contribute to your Healthcare FSA and do not receive as reimbursement for eligible medical expenses will be lost at the end of the plan year (or grace period if applicable). Therefore, it is important to be conservative when determining your annual contribution. Your annual contribution cannot exceed the maximum amount permitted in your plan by your employer. A Healthcare FSA is only for expenses incurred by you, your spouse, and your tax dependents during the plan year and grace period.

**This estimate assumes a federal and state combined income tax rate of 20%. Your specific tax savings may be different and you should consult your tax advisor for your specific situation.

ESB-2263-0122

American Fidelity Assurance Company
americanfidelity.com