1. Medical and dental deductible: $   Medical insurance co-payments and/or co-insurance: $   Immunizations, injections, and vaccinations: $   Routine Examinations: $   Medically necessary elective surgery: $   Prescription drugs of co-payments: $   Over the Counter Medication: $   Hearing Examinations: $   Transportation to and from medical provider: $   Dental Insurance co-payments and/or co-insurance: $   Dental and orthodontic expenses: $   Eye Examinations, glasses, and contacts: $   Other Expenses: $ 2. Total ESTIMATED, uninsured, medical expenses for the plan year: $ 0 3. Enter your desired plan year contribution: $   Number of paychecks received per year: $ 4. You will have this amount taken out of each paycheck and deposited into your Health Care Flexible Spending Account : $ 0       Total ESTIMATED tax savings:    $ 0