FSA Modeling Tool

This modeling tool can help you determine how much you may wish to contribute to the plan. Although healthcare expenses can be difficult to predict, this modeling tool can help you make a reasonble estimate. Be sure to estimate carefully. Any money deposited will be forfeited according to IRS regulations if not spent before the end of your plan year.

Estimated annual healthcare expenses
Medical expenses such as:
Plan deductible	$
Office visit and hospital copayments	$
Prescription drug copayments	$
Over-the-counter drugs	$
Coinsurance	$
Other medical expenses not covered elsewhere	$
Dental expenses such as:
Plan deductible	$
Copayments	$
Coinsurance	$
Orthodontia expenses	$
Other dental expenses not covered elsewhere	$
Vision care expenses such as:
Plan deductible	$
Copayments	$
Coinsurance	$
Eyeglasses or contact lenses	$
Other vision expenses not covered elsewhere	$
Hearing expenses such as:
Hearing aids	$
Other hearing expenses not covered elsewhere	$
Total Expenses Indicated	$
Estimated Annual Tax Savings	$