Flexible Spending Account Worksheet
Estimate your expenses
Projected Uninsured Plan Year Expenses
Medical and dental deductible ..........................................$______________
Medical insurance co-payments and coinsurance ............................ $______________
Dental insurance co-payments and coinsurance ............................. $______________
Immunizations, injections and vaccinations ................................$______________
Routine examinations .................................................$______________
Dental and orthodontic expenses ........................................$______________
Prescription drugs or co-payments .......................................$______________
Eye examinations, glasses and contacts ..................................$______________
Hearing examinations ................................................$______________
Transportation to and from medical provider ..............................$______________
Medically necessary elective surgery .....................................$______________
Other expenses .....................................................$______________
Total expenses ......................................................$______________
The above items are some common expenses. Please see the FSA List of Eligible and Ineligible Expenses for a more comprehensive list.
Calculate your savings
Estimated Tax Savings
Desired FSA Plan Year Election ......................................... $______________
Multiply the number above by 25% (estimated tax savings) ................... x______________
Estimated tax savings for the year ....................................... $______________
We want you to make a
smart annual FSA election.
To help you do this, we’ve
put together a worksheet
you can use to estimate your
expenses and savings.
Your total estimated costs
will help you determine
what election amount makes
sense for you.
Take it a step further by
calculating your estimated
tax savings using your total
projected expenses!
402 South Kentucky Avenue, Suite 500, Lakeland, FL 33801 | (855) 329-0095 | www.MyMidAmerica.com
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