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Medical Expense Planner


This planner has been prepared to help you determine the amount of money, if any, you wish to allocate to a Health Care Flexible Spending Account. You will need to consider the expenses you expect to have for the upcoming plan year carefully. Review the expenses you normally have and any you can schedule for the upcoming plan year that are not covered, or will only be covered partially, by your medical plan.

Remember that this account is for all out-of-pocket medically necessary expenses for yourself, your spouse, and any qualifying dependent (whether insured through your group health plan or not), as long as you and your spouse file a joint tax return or you are a single parent.

Allowable Medical Expenses

Allowable OTC Expenses
Description Annual Amount
Deductibles (Your plan and your spouse's plan for Medical, Dental, and/or Vision)
Co-Payments/Co-Insurance (The amount you pay after insurance pays its portion)
Routine well visits (annual physicals, periodic check-ups and immunizations)
Dental expenses not covered by insurance (orthodontics, preventative, co-pays)
Vision expenses (cost of eye exams, glasses, contacts, and supplies, etc.)
Orthodontia
Hearing expenses (cost of exam, hearing aids, etc.)
Prescription Drugs/Permissible Over the COunter Medications
Diabetic Supplies
Therapy/Treatments (Physical Therapy, Chiropractic, Psychiatric, Speech, etc.)
Other Medically Necessary Unreimbursed Expenses
Total Planned Medical Expenses
Number of pay periods for the plan year
Amount to deduct each pay period

Resource Center

Ready-to-use tools to help you make the most of your Flores benefits.

Need assistance?

Contact an account manager at 800.532.3327

Monday – Friday from 8:30 a.m. to 5:00 p.m. EST.