Page 20 - Example
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Flexible Spending Accounts (FSAs) (continued)
Flexible Spending Account Worksheet
To estimate your healthcare expenses for the coming year, it’s helpful to look back at past expenses, think
about the ones you’re likely to have again, and anticipate any new expenses you may have. Expenses must
be for services received in the year for which you are making an election.
Remember, if an expense is covered by insurance, estimate only your out-of-pocket cost. If an expense is
not insured but is eligible under the Healthcare FSA, estimate enough to pay the entire bill. You can use the
template below to estimate your qualiied expenses or use Alex (https://beneits.myalex.com/glg/2019) our
decision support tool.
Estimated Unreimbursed Healthcare Expenses Annual Amount
Medical
Deductibles $
Coinsurance payments* Ofice visit copays, Doctor’s ofice visits, Prescription Drugs, Laboratory tests $
Splints, supports, corrective devices $
Hearing devices $
Therapy treatments (medical reasons only) $
Other expenses (name) $
Dental
Deductibles $
Coinsurance payments* $
X-rays/Cleaning/Fluoride treatments $
Fillings/Crowns/Bridges $
Dentures $
Orthodontia $
Vision
Deductibles $
Coinsurance payments* $
Examinations $
Lenses $
Frames $
Contact Lenses and Solutions $
Laser Eye Surgery $
Total Annual Unreimbursed Healthcare Expenses (Cannot exceed $2,650 per calendar year) $
Estimated Dependent Daycare Expenses Annual Amount
(necessary for you and your spouse to work)
Childcare/Daycare centers $
Childcare in home $
After-school care $
Preschool $
Care of other dependents $
Total Annual Dependent Daycare Expenses (Cannot exceed $5,000 per calendar year if single or
married iling Joint return or $2,500 per calendar year if married and iling separate tax returns, or $
earned Income of employee or spouse, whichever is less.)
* Please keep in mind any coordination of beneits with another group plan which would reduce your out-of-pocket expenses.
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Flexible Spending Account Worksheet
To estimate your healthcare expenses for the coming year, it’s helpful to look back at past expenses, think
about the ones you’re likely to have again, and anticipate any new expenses you may have. Expenses must
be for services received in the year for which you are making an election.
Remember, if an expense is covered by insurance, estimate only your out-of-pocket cost. If an expense is
not insured but is eligible under the Healthcare FSA, estimate enough to pay the entire bill. You can use the
template below to estimate your qualiied expenses or use Alex (https://beneits.myalex.com/glg/2019) our
decision support tool.
Estimated Unreimbursed Healthcare Expenses Annual Amount
Medical
Deductibles $
Coinsurance payments* Ofice visit copays, Doctor’s ofice visits, Prescription Drugs, Laboratory tests $
Splints, supports, corrective devices $
Hearing devices $
Therapy treatments (medical reasons only) $
Other expenses (name) $
Dental
Deductibles $
Coinsurance payments* $
X-rays/Cleaning/Fluoride treatments $
Fillings/Crowns/Bridges $
Dentures $
Orthodontia $
Vision
Deductibles $
Coinsurance payments* $
Examinations $
Lenses $
Frames $
Contact Lenses and Solutions $
Laser Eye Surgery $
Total Annual Unreimbursed Healthcare Expenses (Cannot exceed $2,650 per calendar year) $
Estimated Dependent Daycare Expenses Annual Amount
(necessary for you and your spouse to work)
Childcare/Daycare centers $
Childcare in home $
After-school care $
Preschool $
Care of other dependents $
Total Annual Dependent Daycare Expenses (Cannot exceed $5,000 per calendar year if single or
married iling Joint return or $2,500 per calendar year if married and iling separate tax returns, or $
earned Income of employee or spouse, whichever is less.)
* Please keep in mind any coordination of beneits with another group plan which would reduce your out-of-pocket expenses.
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