Health Care Expense Worksheet
Medical Expenses
Estimated Annual Expense
1.
Number of Dependents under your Flexible Spending Account
2.
What is your annual deductible amount per person?
Total Annual Deductible
(multiply answers to questions 1 and 2)
3.
Number of times you or your dependents go to a physician annually?
4.
What is your physician copay amount?
Total Annual Physician Copay
(multiply answers to questions 3 and 4)
5.
Number of prescriptions purchased annually
(include oral contraceptives and maintenance medications)
6.
What is your prescription copay amount?
Annual Prescription Copay
(multiply the answers to questions 5 and 6)
7.
If your insurance coverage excludes or limits coverage for these services how much do you have to pay out of pocket?
Acupuncture
Chiropractic Treatment
Massage Therapy
Physical/Speech Therapy
Weight Loss Programs
(food expense is not covered)
Mental Health Treatment
Substance Abuse Treatment
Infertility Treatment
Stop Smoking Programs
Estimated Annual Expense For Which You Are Liable
8.
Do you require any of the following supplies?
Syringes
Alcohol Swabs
Condoms
Test Strips
Contact Lens Saline Solution or Enzymatic Cleaner
Braille Books and Magazines
Estimated Annual Expense For Which You Are Liable
9.
Do you have a condition that would require durable medical equipment?
Crutches
Hearing Aids
Artificial Limbs
Blood Pressure Monitor
Pregnancy Kit and Ovulation Monitors
Glucose Monitors
Orthopedic Shoes/Orthotics
Estimated Annual Expense For Which You Are Liable
Vision Expenses
1.
Number of dependents under your Flexible Spending Account
2.
What is your eye exam copay amount?
Total Eye Exam Copay Amount
(multiply the answers to questions 1 and 2)
3.
Do you anticipate purchasing prescription strength glasses, prescription strength sunglasses or contact lenses?
Estimated Annual Expense For Which You Are Liable
4.
Do you anticipate having LASIK or similar eye surgery?
Estimated Annual Expense For Which You Are Liable
Dental Expenses
1.
Number of dependents under your Flexible Spending Account
2.
What is your annual deductible amount per person?
Total Annual Dental Deductible
(multiply the answers to questions 1 and 2)
3.
Do you anticipate crown, bridge work, or denture expenses?
(Insurance typically reimburses these expenses at 50%)
Estimated Annual Expense For Which You Are Liable
4.
Do you anticipate dental implant expenses?
(Insurance typically does not reimburse this expense)
Estimated Annual Expense For Which You Are Liable
5.
Do you anticipate dental braces expenses?
(Insurance typically reimburses this expense at 50% up to a specified dollar limit)
Estimated Annual Expense For Which You Are Liable
Estimated Annual Expense For Which You Are Liable
(Add all amounts from shaded lines.)
Last updated Thursday, September 19, 2002 ©2007 ADP, Inc.
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