Total Medical Expenses $

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3 This worksheet will help you determine the dollar amount you will spend for medical expenses during the plan year. In order to maximize your savings, please include expenses for you, your spouse and any of your dependents in your calculation. Medical Expenses not covered by Insurance Deductibles, co-pays, coinsurance Physician visits/routine exams Prescription Drugs Insulin/Syringes Annual physicals Chiropractic treatments Other: Annual Estimate Subtotal Medical Expenses $ Dental Expenses not covered by Insurance Checkups/cleanings Fillings Root Canals Crowns/Bridges/Dentures Oral Surgery Orthodontia Other: Subtotal Dental Expenses $ Vision/Hearing Expenses not covered by Insurance Exams Eyeglasses Prescription Sunglasses Contact Lenses & Cleaning Solutions Corrective Eye Surgery ( LASIK, cataract etc.) Hearing exams/hearing aids & batteries Subtotal Vision Expenses $ Total Medical Expenses $ 410 Archibald Street, Suite 100 Kansas City, MO

4 Qualified Expenses Acupuncture Alcoholism treatment Ambulance Birth control pills Braille books and magazines Chiropractors Coinsurance amounts and deductibles Contact lenses, solutions and cleaners Crutches and wheelchairs Dental treatment* Dermatologist visits* Eyeglasses (prescription); vision exams Guide dog or other animal aide Hearing devices and batteries Hospital services Immunizations (including flu shots) Infertility treatments Insulin Laboratory/diagnostic fees Language training for child with disability Laser eye surgery Learning disability Massage therapy (medical necessity)* Norplant insertion or removal Nursing services Nutritionist s expenses (medical necessity) Occlusal guards to prevent teeth grinding Orthodontia Over-the-counter drugs (require a prescription)* Pap smears Physical therapy Prescription drugs Prosthetics Psychologist Reading glasses Smoking cessation programs Sterilization TMJ related treatments Transplants Travel expenses related to medical care only Wigs (medical reasons only) X-ray fees Ineligible Expenses Burial expenses Cosmetic procedures (unless necessary to improve a deformity arising from congenital abnormality, personal injury from an accident or trauma, or a disfiguring disease) Dancing lessons Diapers or diaper service Ear piercing Electrolysis (see cosmetic procedures) Exercise equipment, unless prescribed for a specific medical condition Face lifts (see cosmetic procedures) Fitness programs for general health Funeral expenses Hair transplant (see cosmetic procedures) Health club dues Holistic or natural remedies Illegal operations and treatments Items paid or payable by insurance Items you intend to claim as a credit for income tax purposes Marriage counseling Maternity clothes Non-prescription sunglasses (sunclips) Nursing care for a normal, healthy baby Nutritional supplements (general good health) Overnight camp (Dependent Care) Premiums for group health coverage maintained through spouse s employer or individual insurance premiums Rogaine (see cosmetic procedures) Safety glasses (unless prescription) Swimming lessons Tanning salons and equipment Teeth whitening or bleaching (even if as a result of a congenital defect) Vision discount programs or warranty charges Vitamins (over-the-counter) Warranties for eyeglasses and/or hearing aids Weight loss programs and drugs (unless a medical necessity exists for a specific medical condition) * Items are eligible for reimbursement through a Health Care FSA or an HRA if they are treating a current or imminent medical condition. Some items may require additional documentation such as a letter of medical necessity or a prescription (for over-the-counter medications) from your medical provider. Please visit for more detailed information and a more comprehensive list of eligible expenses. 410 Archibald Street, Suite 100 Kansas City, MO

5 The Healthcare App that s made for mobile but designed for you. Want to check your healthcare account balances and submit receipts anywhere, anytime? There s an app for that! Flex Made Easy enables you to easily and securely access your healthcare spending accounts. You can view account balances and detail, submit healthcare account claims, and capture and upload pictures of your receipts anytime, anywhere on any iphone, Android or tablet device. You can also sign up to receive account alerts via text message. But wait, there s more to it... It takes a special understanding of use and purpose to design a mobile app for handheld devices like smartphones and tablets. So we ve focused on just that smart, purposeful design. And the result? A simple, intuitive experience for you. This means things like easy-in/easy-out access to common tasks like capturing receipts and viewing balances; and pictures and words where pictures and words make sense. Try it and you ll see how we re simplifying the business of healthcare. Flex Made Easy Mobile, the newest mobile app from Flex Made Easy, provides time-saving options 1 for you to: Check current health care account balances; FSA, HRA and HSA View account activity and receive alerts via text message View FSA, HRA and HSA transaction details File new claims with receipt images Review expense information Enter a new expense Submit health care claims and upload receipts using the mobile device s camera Manage expense receipts Promptly file claims for their reimbursement accounts The Flex Made Easy app provides you with seamless account access since it is an extension of the Flex Made Easy portal and doesn t require you to setup any additional credentials. Now by using your smartphone you can assess your HRA, HSA and FSA account balances, and you ll know how much money you have available to spend on qualified medical expenses at the time of purchase. 1 If supported or applicable to your account(s) SIMPLIFYING THE BUSINESS OF HEALTHCARE

6 Intuitive. Simple. Convenient. Flex Made Easy takes the hassle out of managing your consumer-driven healthcare accounts. Self-service functions put you in control. Conveniently manage your health care information when you want, from wherever you want. Whether on your couch or at the store, the Flex Made Easy App for iphone or Android smartphones makes it easy to manage your benefit accounts on the go. At Flex Made Easy, we work hard every day to help you get the most benefit from your HRA, HSA, and FSA accounts. Get started with Flex Made Easy in Minutes Simply download the Flex Made Easy App for your Android or iphone (also compatible with ipad and ipod touch ) and log in using the same password you use to access the Flex Made Easy consumer portal. SIMPLIFYING THE BUSINESS OF HEALTHCARE