I am a... Make a selection Active Employee COBRA Subscriber Active Employee on Leave of Absence w/out Pay Long-Term Disability Recipient Retiree Vested Subscriber Survivor Work-Related Disability Recipient

Number of Office Visits On average, how many times per year do you (including dependents) go to the doctor?
Number of Prescriptions Number of Prescriptions filled per year, at an average of $50 per prescription.
Other Healthcare Expenses Annual dollar amount for other healthcare expenses (Lab, X-Ray, Hospital, Skilled Nursing, Etc.)

Your Annual HSA Contributions for HD Plan Enter your Healthcare Savings Account annual contributions.
Employer's Annual HSA Contributions Your Employer's annual Healthcare Savings Account annual contributions. The employer contribution to your HSA may be prorated while on leave no pay status.
Total HSA Contributions Total Healthcare Savings Account annual contributions.
Your FSA Contributions for PPO Plan Total Flexible Spending Account annual contributions.

Max HSA Contributions The Total HSA Contributions cannot exceed the limits shown in the table above for your type of coverage.
Max FSA Contributions The Total FSA Contributions cannot exceed the limit shown above for all statuses.