See How the Flexible Benefits Plan Can Work for You!

Use this worksheet and planning guide to help you learn how to save money with this valuable benefit.

Calculate your family's health care expenses here

Determine expected out-of-pocket expenses for you, your spouse and/or dependent child:

Medical Expenses:
Annual deductibles
Physician Fees
Surgical Fees
X-ray/Lab
Prescription Drugs
Other predictable expenses
Dental Expenses:
Dentures
Examinations
Orthodontia
Restorative Work
Other
Vision Expenses:
Contact Lenses
Eye examinations
Eyeglasses
Contact Lens Solution
Miscellaneous:
Alternative Care
Hearing Aids
Psychiatrist/Psychologist
Diabetic Supplies
TOTAL EXPENSES =
Once you've determined your total expenses, you may elect a more conservative number to ensure that you will use up your total contributions during the plan year.

Calculate your family's dependent care expenses here

Determine expected out-of-pocket expenses for you, your spouse and/or dependent children:

Dependent Care Expenses:
Year-round expenses:
Before and after school expenses:
Summer-time expenses:
TOTAL EXPENSES =
The maximum allowed depenedent care reimbursement is $5000.

Once you've determined your total expenses, you may elect a more conservative number to ensure that you will use up your total contributions during the plan year.

Reimbursement is easy

To receive a reimbursement from your Flexible Benefits Plan, simply complete a claim form, attach the appropriate documentation and send your request to your plan administrator.

Use this worksheet to see how much you can SAVE

Pre-tax Deductions:
Payroll deductions for insurance premiums:
Health Care Expenses:
Dependendent Care Expenses:
Total pre-tax deductions =
Percent Savings:
Social Security Taxes:
Your Federal Income Tax Bracket:
Total percent tax =
Calculate your projected savings:
Total pre-tax deductions:
Total percent tax: x
TOTAL SAVINGS:

Rules to Remember

These are highlights of the IRS rules that apply to all the components of a Flexible Benefits Plan:

-	Your election is binding for the Plan Year
-	To be eligible for reimbursement, services must be rendered during the Plan Year
-	Contributions not used during the Plan Year may not be carried to another Plan Year
-	You may only make changes to your contributions if you have a qualified change of status (see your Plan Documentation for details)

Print Worksheet