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Calculation Worksheet

Complete the chart below to itemize what you think your annual medical out-of-pocket expenses might be for you, your spouse, and/or your dependents. Reviewing what you spent last year is a great memory jogger to help you to determine how much of your salary you may want to contribute to your Medical FSA. When you have completed this chart, you can return to the Tax Savings Calculator by clicking the Continue to Calculator button. All of your totals from this chart will automatically be carried over to the calculator.

	Medical		Last Year	This Year
		Deductibles plus 100% of out-of-pocket expenses not covered by the medical plan
		Office visit co-payments/Prescription drugs
		Well baby care/Immunizations
		Physicals/Pap-smears
		Other
	Sub Total
	Dental
		Deductibles
		Crowns/Bridges/Dentures
		Orthodontia/Braces
		Exams/Fillings/X-rays
		Other
	Sub Total
	Vision
		Exams/Co-payments
		Frames/Lenses
		Contact lens & cleaning solutions
		Laser eye surgery
		Other
	Sub Total
	Hearing
		Exams/Hearing aids
		Batteries
	Sub Total
	Miscellaneous
		Chiropractic
		Physical therapy
		Acupuncture
		Other
	Sub Total
	Total Eligible Medical Out-of-Pocket Expenses

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