Estimate Your Eligible Expenses – Below is a partial list of eligible expenses to help you estimate your annual out-of-pocket healthcare cost:

Expenses Eligible for Reimbursement

Insurance Deductible

Insurance Co-payment

Prescription drug co-payments (including birth control)

Over the counter medical supplies

Routine physicals, including gynecological exam

Unreimbursed Dental expenses

Unreimbursed Orthodontia expenses

Unreimbursed Vision expenses

Hearing exams and hearing aids

Unreimbursed Chiropractic exams and treatment

Unreimbursed Occupational Therapy

Unreimbursed Psychiatric care

Special care for handicapped

Unreimbursed Therapy for Drug and Alcohol addiction

Transportation to receive health care (including 2010 mileage at 16.5 cents per mile)

Special durable medical equipment prescribed by a physician

Other expenses specifically prescribed by a physician for treatment of a specific diagnosis

Total Estimated Eligible Expenses

Some Expenses NOT Eligible for Reimbursement

Non-prescription medicines
Cosmetic Surgery
Health Club expenses to keep physically fit
Insurance premiums
Expenses reimbursed under another health plan
Teeth Bleaching

Additional information on deductible medical expenses may be found in IRS Publication 502 Medical and Dental Expense. That document is available on the Form Download page.

Health Care Reimbursement Account Worksheet

Expenses Eligible for Reimbursement

Some Expenses NOT Eligible for Reimbursement