Medical Spending Plan Estimated Expense Worksheet
Review all your expense vouchers, tax receipts, checkbook register and other records for the past two years. With these figures as a guide, estimate what expenses you will probably incur, and list them on the worksheet below. When you add all of the subtotals together, you'll have your estimated total medical expense amount. Remember, funds left over in the amount at the end of the year will be forfeited, so plan carefully.

Medical
Deductible: $
Coinsurance: $
Prescription Drugs: $
Office visit copayments: $
OB/GYN exams: $
Emergency room visits: $
Ambulance: $
Surgery(excluding cosmetic): $
Private hospital room: $
Private nurse: $
Well baby care: $
Physical therapy: $
Immunizations: $
Chiropractic services: $
Lab fees: $
Acupuncture: $
Oxygen: $
Durable medical equipment (such as crutches): $
Other: $
Other: $
Other: $
   
Subtotal: $
Dental
Deductible: $
Coinsurance: $
Dental exam: $
Cleaning: $
X-rays: $
Fillings: $
Root canal: $
Extractions: $
Oral surgery: $
Dentures: $
Fluoride treatments: $
Space Maintainers: $
Biteplate: $
   
Subtotal $
 
Vision/Hearing
Eye Exam: $
Laser vision correction (LASIK): $
Glasses: $
Contact lenses and solution: $
Braille books: $
Seeing eye dog: $
Hearing exam: $
Hearing aid: $
Phone for hearing impaired: $
Special TV for hearing impaired: $
   
Subtotal $
 
Total Expenses $

Calculations are based on a fixed set of variables. Actual figures may vary. This calculator is for estimating purposes only. Please call your broker or contact GIS for more information or for a more accurate representation of your tax savings.