The FSA Calculator will help you determine an appropriate Annual Health Care FSA Contribution Amount. And, it will automatically calculate estimated tax savings based on your Annual FSA Contributions.

Annual FSA expenses consist of all qualified expenses incurred by you, your spouse and your eligible dependents. FSA expenses are out-of-pocket expenses that are not covered by your benefit plan. Check out the IRS web site for a full list of all qualified expenses.

To Begin, please enter your Annual Household Income, Marital Status, Number of Exemptions, and select your number of annual Pay Periods. Then, enter the amount of out-of-pocket expenses you typically incur on a yearly basis for each of the qualified categories.

 
Enter amounts in whole dollars - no decimal points, or dollar signs (For example: 500).
Enter your Annual Household Income: $
Select your Marital Status:  
Select the number of Exemptions:  
Enter the number of Pay Periods you have per year:  
     
 
Please enter your annual FSA eligible medical expenses into the fields below(Example: 500).
1. Medical - Deductibles, Copayments, Coinsurance, Routine Exams.
Physician/Doctor: $
Osteopathic Physician: $
Chiropractor: $
Podiatrist: $
Other Health Practitioner: $
 
2. Prescription - Prescription Drugs(Covered & Non-Covered), Copayments, Coinsurance.
Pharmacy: $
 
3. Hospital - Deductibles, Copayments, Coinsurance.
Hospitals: $
 
4. Dental/Orthodontist - Deductibles, Copayments, Coinsurance, Routine Exams.
Dentist/Orthodontist: $
 
5. Vision - Prescription Eyeglasses & Contacts Lenses, Deductibles, Copayments, Coinsurance.
Optometrist: $
Ophthalmologist: $
 
6. Supplies - Contact Lens Supplies, Medical and Dental supplies
Medical/Dental/Vision: $
Orthopedic Goods: $
Hearing Aids: $
 
7. Laboratory - X-Ray/ Lab Fees
Medical/Dental laboratory: $

The tax savings computation is based on 2004 Tax Tables, assumes various tax deductibles, and does not consider state and local taxes. Actual savings will vary based on your individual tax situation. Please consult a tax professional for more information on tax implications of an FSA.