CURRENT PLAN QUALITIES
    
HSA PLAN QUALITIES
Current Deductible
$  
     Zip Code
 
Office Visit Copay
$
    Primary Gender
Copay for prescriptions
$
     Primary Age
 
ESTIMATED MEDICAL EXPENSES     Spouse Gender
Estimated number of office visits
 
     Spouse Age
 
Estimated number of prescriptions
 
     # of Children
 
Estimated Lab/x-ray and other expenses
$  
     Single or Family Plan?  
Emergency Room Expenses
$  
     Choose an HSA deductible
$
Expenses not subject to Ded.
(Eyecare, Dental etc.)
$  
     ESTIMATED MEDICAL EXPENSES
Total annual out-of-pocket expenses
$ 
    Estimated total medical expenses*
$ 
PREMIUM EXPENSES     PREMIUM EXPENSES
Monthly premium for current plan
$  
     Projected Monthly Premium
$
Annual premium of current plan
$ 
     Projected Annual Premium
$
        HSA CONTRIBUTIONS & TAX SAVINGS
        Total Annual Medical Expenses (w/premium)
$ 
        HSA Annual Contribution
($3,050 Ind. $6,150 Fam. Max.)
$  
        HSA Catch-up Contribution 
($1000 Max per person, age 55+)
$  
        Tax Savings (28% assumed)
$
Total Annual Expenses
$
    Total Annual Expenses
$
        Total Net Savings with HSA Plan $
        Balance in HSA $