This worksheet has been prepared to help you determine the amount of money, if any, you wish to allocate to your Medical Spending Account. You will need to consider very carefully what expenses you expect to have for the upcoming plan year. Review the expenses you normally have and any you can schedule for the upcoming plan year that are not covered at all or are only partially covered 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 are filing a joint tax return or you are a single parent.

Guide to Allowable
Medical Expenses
Guide to Allowable
OTC Expenses
DescriptionAnnual 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.)
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