NEW YORK STATE FLEX SPENDING ACCOUNT

A State Employee Benefit That Puts Money In Your Pocket

Health Care Spending Account Worksheet


Annual estimated expenses for services rendered in the upcoming Plan Year not reimbursed by your medical, dental or other plans.

Type of Expense Amount
per Year
MEDICAL EXPENSES, SUCH AS:
Health Plan Deductible:
Office Visit and Hospital Copayments:
Prescription Drug Copayments:
Routine Physicals:
Non-covered Prescriptions (e.g., birth control):
Hearing Aids:
Planned, Non-covered Medical Procedures:
Other Eligible Expenses:
DENTAL EXPENSES, SUCH AS:
Deductibles and Copayments:
Routine Check-ups, Cleaning and X-rays:
Orthodontia (braces, etc.):
Planned Dental Work (crowns, dentures, etc.):
VISION CARE EXPENSES, SUCH AS:
Exams:
Eyeglasses or Contact Lenses:
Total Estimated Out-Of-Pocket Health Care Expenses: