Flexible Spending Account (FSA)

Any money you contribute to your Flexible Spending Account (FSA) can be used to reimburse you for a number of eligible health care expenses. The information you enter in steps 1 and 2 will be carried over to the FSA Savings Calculator, which will then help calculate how much your FSA will help you save in the plan year.

Next to each eligible expense, estimate what you think your out-of-pocket costs will be for the plan year.

Please note: You may want to print this information to use when you sign up for benefits.

Deductibles
Copayments
Eye Exams
Eyeglasses/Contacts
Laser eye surgery
Chiropractic Treatment
Prescribed Medicines
Routine Physicals
Hearing Exams/aids
Dental Exams
Orthodontia Services
Psychiatric Treatment
Maternity Expenses
Other Eligible Expenses
Total Estimated Health Care Expenses