Health Care Reimbursement Account Worksheet

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 (19 cents per mile in 2016; 17 cents per mile in 2017)
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.

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