Healthcare Savings Calculator

To calculate the Monthly and Annual savings possible using an FSA, estimate your Healthcare expenses for the Plan Year.  Include all expenses except insurance premiums for you and your spouse.
A. Healthcare Expenses
	Medical
		1. Deductibles / Co-Pays / Co-Insurance	$
		2. Prescription Drugs	$
		3. Mental Health Services	$
	Dental
		1. Deductibles / Co-Insurance	$
		2. Orthodontia	$
	Vision
		1. Exams / Eye Glasses	$
		2. Contacts / Contact Cleaning Solutions	$
	Other Health Expenses
		1. Chiropractic	$
		2. Hearing Aids	$
		3. Other - refer to health care list for eligible expenses	$
B. Annual Income           Include Spouse if Joint Filer			Less Than $21,525 $21,526-$25,750 $25,751-$34,550 $34,551-$43,050 $43,051-$52,025 $52,026-$62,450 $62,451-$72,600 $72,601-$79,275 $79,276-$89,150 $89,151-$104,050 $104,051-$130,250 $130,251-$141,575 $141,576-$144,400 $144,401-$158,550 $158,551-$283,150 Greater Than $283,150
C. Tax Filing Status			Single Married Filing Joint Married Filing Single     Head of Household

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Total Expenses		TAX-FREE INCOME	Monthly Savings		Annual Savings
Note: Your tax savings is based on marginal federal rates and FICA. For extra tax savings, multiply State income tax rates of 3% to 9% by the Total Expenses noted above.