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Benefits Staff
Flexible Spending Calculator
If you know you will have medical expenses in the upcoming year, you may wish to take advantage of tax savings through our flexible spending program. Use the worksheet below to enter you medical expenses. The medical expenses you enter should not exceed the FSA's maximum contribution level of $5000 per plan year.
Enter your annual household income:
Select your marital status:
Single
Married
Select the number of exemptions:
0
1
2
3
4
5
6
7
8
9
10
Enter the number of pay periods you have per year:
12 (Monthly)
26 (Bi-Weekly)
Retirement Plan Contribution Level
0%
3%
4%
5%
6%
7%
8%
Annual Health Care Expenses
Please enter your annual FSA eligible medical expenses in the fields below.
1. Medical - Deductibles, Co-payments, Coinsurance, Routine Exams.
Physician/Doctor:
$
Osteopathic Physician:
$
Chiropractor:
$
Podiatrist:
$
Other Health Practitioner:
$
2. Prescription - Prescription Drugs Co-payments.
Pharmacy:
$
3. Hospital - Deductibles, Co-payments, Coinsurance.
Hospitals:
$
4. Dental/Orthodontist* - Deductibles, Co-payments, Coinsurance, Routine Exams.
Dentist/Orthodontist*:
$
*Orthodontic claims are subject to specific regulations. Call EBDS at 1-800-207-9310 for covered expense guidelines.
5. Vision - Prescription Eyeglasses & Contact Lenses, Deductibles, Co-payments, Coinsurance.
Optometrist/Ophthalmologist:
$
6. Supplies - Contact Lens Supplies, Medical and Dental Supplies
Medical/Dental/Vision:
$
Orthopedic Goods:
$
Hearing Aids:
$
7. Laboratory - X-Ray / Lab Fees
Medical/Dental Laboratory
$
Benefits Department · 200B Craig Hall · Pittsburgh, PA 15260 · 412-624-8160
webmaster@hr.pitt.edu
