Fillable Welfare 522.1- Health Care Expense Worksheet

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Welfare 522.1- Health Care Expense Worksheet

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Page 1 of 1 - Welfare-522 (12/2015)
P.O. Box 6980 West Jordan, UT 84084 ● (855) 399-3035 ● Fax (844) 438-1496 ● my.nbsbenefits.com
Health Care Expense Worksheet
Instructions
This worksheet is for estimating annual health care expenses only.
1. Enter your annual cost for each health care option you use
2. Add up the Total Annual Health Care Expense
3. Determine your yearly Number of Pay Periods = Weekly/52, Bi-Weekly/26, Semi-Monthly/24, Monthly/12
4. Divide the Total Annual Expense by the number of pay periods to calculate the amount needed to be withheld every pay period
1 Medical Care
Insurance Deductibles
$
Co-pays
$
Routine Exams
$
Prescriptions
$
Lab Expenses
$
Medical Equipment
$
Chiropractor Visits
$
Physical Therapy
$
Other
$
Total Annual Medical Care Expenses
$
2 Vision Care
Eye Exam
$
Glasses
$
Prescription Sun Glasses
$
Contacts
$
Contact Lens Solutions
$
Insurance Deductibles/Co-pays
$
Total Annual Vision Care Expenses
$
3 Dental Care
Cleanings
$
X-Rays
$
Crowns
$
Other
$
Total Annual Dental Care Expenses
$
4 Orthodontia Care
Orthodontia
$
Retainers
$
Total Annual Orthodontia Care Expenses
$
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Welfare 522.1- Health Care Expense Worksheet

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Completed 3 April 2022

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