Flexible Spending Account(s) Worksheet

This worksheet will help you determine your yearly medical and daycare expenses. Enter the number of times you and your dependents incur the expense each year and the cost per occurrence. Use Tab to move between boxes and to automatically calculate total yearly cost of each type of expense.

Note: Values marked as "NaN" indicate incomplete form data. Values will calculate as you complete the form.

For questions about this form, please contact FlexPak at 1-866-353-9725 or flexpak@swerdlin.net.


Recurring Yearly Medical Expenses # of Times Cost Eligible Expenses
How many times do you and your dependents go to a doctor for a periodic health exam or illness? x =
$0.00
If your insurance plan has a separate copay, how many times do you and your dependents go to a specialist (i.e. gynecologist, dermatologist, neurologist, etc.) for an exam? x =
$0.00
How many times do you and your dependents go to a mental health doctor? x =
$0.00
How many times do you and your dependents have generic prescription drugs filled? x =
$0.00
How many times do you and your dependents have your brand name prescription drugs filled? x =
$0.00
How many times do you and your dependents have your mail order prescirption drugs filled? x =
$0.00
How many times do you and your dependents receive an eye exam each year? If the visit is not covered by an insurance co-payment, be sure to calculate the amount with your out-of-pocket cost. x =
$0.00
How many times do you and your dependents go to a dentist for a cleaning? x =
$0.00
How many times do you and your dependents go to a chiropractor? x =
$0.00

Once Yearly Medical Expenses Eligible Expenses
If you and your dependents have any planned surgeries for the upcoming plan year (i.e. vision correction, surgery where you will owe deductible, etc.), how much do you expect the cost to be?
If you and your dependents will need eyeglasses or contacts during the upcoming plan year, how much do you expect the cost to be?
If you and your dependents have any dental work planned (tooth fillings, crowns, root canals, etc.) for the upcoming year, how much do you expect the cost to be?
How much will you spend on over-the-counter drugs for the upcoming year?

For covered over-the-counter items, please see the List of Eligible Expenses for Medical FSAs


Total Eligible Medical Expenses
Total:
$0.00
Considering any other benefits you recieve (including those provided by a spouse's employer), how much of your total expenses would you elect into the medical FSA? Please also keep in mind your plan maximum which can be found on the front page of your enrollment kit.

Please note: This is only for planning purposes and is not your official enrollment into the plan.

Dependent Daycare # of Times Cost Eligible Expenses
If you have a dependent for whom you pay daycare (or elder care) expenses, how much will you spend on a weekly basis? 52 Weeks x =
$0.00
Considering the IRS maximum for this account is $5,000, how much of your total expenses would you elect into the dependent daycare FSA?

Please note: This is only for planning purposes and is not your official enrollment into the plan.


What Will Your Savings Be?
Planned Medical Election
$0.00
Planned Dependent Care Election
$0.00
Total Planned Election
$0.00
Household Earnings Estimated Taxation Percentage
Estimated Annual Tax Savings
$0.00

The Effect on Your Paycheck
Total election into Medical/Dependent Care FSA:
$0.00
Please enter your current Gross Paycheck Amount (amount before taxes & deductions):
Choose your current Payroll Frequency:
If this is a short plan year, please choose "Other" as your pay schedule, and manually enter the number of pay periods. Contact FlexPak or your HR department for the number. 
Your deduction per pay period:
$0.00
Your new Gross Paycheck Amount (after FSA deductions):
$0.00
Tax Rate (selected from above section):
-
Taxes:
-
Your new take home pay:
$0.00
Please enter your current take home pay:
Change in take home pay:
$0.00

Please note: This worksheet and its results are for planning purposes only, and may not be an exact calculation. Your actual change will also depend on any other deductions you may have.


Print a Copy of This Worksheet

If you would like a copy of this worksheet, please click the button to the right, and your browser will prompt you to print the document.