Health Care Spending Account Worksheet

The following worksheet is provided to assist with the planning of your Health Care Spending Account 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:
Non-covered Prescriptions, such as: weight loss, smoking cessation, and human growth hormones.
Over-the-Counter Drugs and Medicines (to treat a medical condition):
Hearing Aids:
Non-covered Medical Procedures:
Transportation (Essential to Medical Care):
Other Eligible Expenses:
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: $5,000)