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Flexible Benefit Plan
Medical Reimbursement
Account Calculator

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Please use this Calculator to estimate your Health Care Expenses not covered by Medical, Dental, or Vision Plans. You should estimate conservatively and use only those expenses that you can accurately predict. Any dollars that remain in your Reimbursement Account at the end of the Plan Year are forfeited by law to your employer, and you lose the money. Listed below are some categories of Health Care Expenses that you (and your family) may incur from year-to-year. Also, you should consider whether you will have expenses that do not repeat annually, such as large dental bills, pregnancy, etc. Eligible Health Care Expenses are defined in Section 213 (d) (1) of the Internal Revenue Code and are briefly described as including the diagnosis, cure, mitigation, treatment, or prevention of sickness or injury. Please use Section 213 as a reference in order to determine whether your employer will reimburse you from your Account for a particular expense.

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Expenses*:	Prior Year's	Estimated Current Year's

Deductible & Co-Payments	$	$
Doctor’s Office or Clinic Visits	$	$
Routine Physical Exams	$	$
Emergency Room Visits	$	$
Other Hospital Expenses	$	$
Immunizations/Well Baby Care	$	$
Prescription Drugs	$	$
Mental Health or Substance Abuse Services Provided by a Licensed Psychologist, Psychiatrist, Social Worker or Clinic	$	$
Dental Expenses, Including Orthodontia	$	$
Vision Care	$	$
Hearing Care	$	$
Other Medical Care Expenses	$	$

Total	$	$