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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