FSA Calculator

FSA Calculator

A. Health Care 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. Dependent Care Expenses
Care of disabled adults of any age and children to age 13 (Up to $5,000 per household, per calendar year;
married filing separately limit is $2,500)
$
C. Income
Annual Income (Include Spouse if Joint Filer)
D. Taxes
Tax Filing Status
E. Totals
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.