VitaFlex Employee Guide: Expense Worksheets
Medical Reimbursement Plan Expenses Medical Expenses
Deductibles
Co-insurance & Co-payments
Prescription Drug Costs
Over-the-Counter Drug Costs
Expenses not fully-reimbursed under Health Plan
Chiropractic/Physical Therapy/Acupuncture Fees*
Medical Expense Total (Do not include any premiums.) *These expenses must be medically necessary and must include a medical diagnosis.
Dental Expenses
Deductibles
Co-insurance & Co-payments
Preventative Care (Exams and X-rays)
Basic Care (Fillings)
Major Care (Crowns and Bridges)
Orthodontia*
Dental Expense Total *Please refer to our website and read the "Orthodontia Reimbursement Guidelines" before electing for Orthodontia.
Vision Expenses
Eye Exams
Eyeglasses, Prescription Sunglasses & Contact Lenses
Contact Lens Supplies
Other Eligible Unreimbursed Medical Expenses
Medical Reimbursement Account Total
Your Marginal Tax Bracket (Typically between 15%-46%)
Dependent Care Reimbursement Plan Expenses
Dependent Day Care Expenses
In-home Childcare Expenses
After School Care or Eligible Summer Camp Expenses
Other Dependent Care Expenses
Dependent Care Reimbursement Account Total
Your Marginal Tax Bracket (Typically between 15%-46%)
