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FSA Worksheet

Use the link on the EBS Website called FSA Calculator for a complete, easy to use estimated expense worksheet. You can maximize your FSA Account by planning ahead carefully and using this helpful tool. The items to consider are also listed below:

Health Care Account
Annual Expense
Deductibles
$
Co-pays
$
Dental expenses not covered by insurance
$
Orthodontia $
Vision expenses (exams, glasses, lenses)
$
Hearing expenses (exams, hearing aids)
$
Prescription Drugs
$
Eligible over-the-counter items
$
Diabetic supplies
$
Therapy (physical, speech, chiro.)
$
Medical mileage
$
Other $
Total Estimated Health Care Expenses
$

Dependent Care Account

Annual Expense

Payment to dependent care facility

Payment to dependent care individual

Payment to adult care provider

Total Estimated Dependent Care Expenses
$
Total Health Care PLUS Dependent Care
$

Plan Level minimums and maximums apply. The total amount you elect will be deducted from your pay in equal installments each pay period.

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