www.FlexMadeEasy.com 410 Archibald Street, Suite 100

Kansas City, MO 64111

www.FlexMadeEasy.com

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 Annual Estimate

Deductibles, co-pays, coinsurance $_________________ Physician visits/routine exams $_________________ Prescription Drugs $_________________ Insulin/Syringes $_________________ Annual physicals $_________________ Chiropractic treatments $_________________ Other:_____________________________________ $_________________

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 $

www.FlexMadeEasy.com 410 Archibald Street, Suite 100

Kansas City, MO 64111

www.FlexMadeEasy.com

* 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 www.FlexMadeEasy.com for more detailed information and a more comprehensive list of eligible expenses.

Qualified Expenses Ineligible 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

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)

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)

www.flexmadeeasy.com SIMPLIFYING THE BUSINESS OF HEALTHCARE

The Healthcare App

that’s made for mobile

but designed for you.

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