Health FSA Worksheet

The following worksheet is provided to assist with the planning of your Health FSA contribution. Before making a decision, you may wish to review what you spent on health care last year. Be sure to include annual estimated expenses for health care services rendered in the upcoming calendar year that will not be reimbursed by your medical, dental or other benefit plans.

Type of Expense
(These are examples and do not make a complete list)		 Amount
per Year
MEDICAL EXPENSES, SUCH AS:
Health Plan Deductible:
Office Visit and Hospital Copayments:
Prescription Drug Copayments:
Over-the-Counter Supplies:
Over-the-Counter Drugs and Medicines (only with a doctor's prescription):
Hearing Aids:
Non-covered Medical Procedures:
Transportation (Essential to Medical Care):
Other Eligible Expenses (i.e., weight loss, smoking cessation, etc.):
DENTAL EXPENSES, SUCH AS:
Deductibles and Copayments:
Routine Check-ups, Cleaning and X-rays:
Orthodontia (braces, etc.):
Planned Dental Work (crowns, dentures, dental implants, etc.):
VISION CARE EXPENSES, SUCH AS:
Exams:
Eyeglasses:
Corrective Contact Lenses/Contact Lens Solutions:
Total Estimated Out-of-Pocket Health Care Expenses:
(MAXIMUM ALLOWED for 2024: $3,200)