University Of Michigan Benefits Office

HRAA

Benefits Office

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Flexible Spending Accounts

Health Care

Health Care Expenses Worksheet

Flexible Spending Accounts
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Health Care Expenses Worksheet

Print the worksheet to help you estimate your health care expenses 2008, or use the SHPS online FSA calculator.

Health Care Expenses Worksheet

Health Care 2007 Expenses You Paid Estimated 2008 Expenses You Expect to Pay

Deductibles and Co-pays

Routine Physical Exams

Physician's Office/Clinic Visits

Dental Care (including co-pays, fluoride treatments, orthodontia)

Vision Care (exams, glasses, contacts, solutions)

Hearing Care/Hearing Aids

Prescription Drugs (including co-pays)

Over-the-counter medications

Immunizations/Well Baby Care

Mental Health Care

X-rays/Laboratory Tests

TOTAL

Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Benefits Office reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern. The University in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents.