How Much Should
I Contribute?

When deciding how much to set aside for next year’s medical expenses, think about the following:

  • Does anyone in your family have any medical, dental or vision expenses that will not be covered by insurance?
  • Does anyone in your family need prescription eyeglasses, contact lenses and contact solution or cleaner?
  • Is anyone in your family currently in orthodontics (braces) or do you expect anyone to begin treatment in the next year?
  • Does anyone in your family have an ongoing illness that requires frequent doctor visits and/or medication?

Use this form to help estimate your annual Health Care Flexible Spending Account (FSA) or Health Savings Account (HSA) election.

Medical Expenses not covered by insurance Current Year’s Out-of-Pocket Expenses ($) Next Year’s Estimated Out-of-Pocket Expenses ($)
Annual Physical/Routine Exam
Copays/Coinsurance
Deductibles
Diabetic Supplies
Immunizations (flu shots, etc.)
Laboratory Fees
Maternity Expenses
Over-the-Counter Drugs
Prescription Drugs
Psychiatric/Psychologist Fees
Other:
Dental Expenses not covered by insurance
Check Ups/Cleanings
Copays/Coinsurance
Crowns/Bridges/Dentures
Deductibles
Fillings
Oral Surgery
Orthodontia (Braces)
Root Canals
Other:
Vision Expenses not covered by insurance
Contact Lenses
Contact Cleaners/Solutions
Copays/Coinsurance
Corrective Eye Surgery
Deductibles
Eye Exams
Eyeglasses
Other:
Total Out-of-Pocket Medical Expenses: Next Year’s Est.
Out-of-Pocket Expenses:

Election amount may not exceed your plan’s cap or the maximum contribution amount allowed by the IRS, whichever is less.

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Download an Election Worksheet PDF

Download our Election Worksheet to help estimate your annual FSA or HSA election.

DOWNLOAD PDF

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