Skip to content Priority Health
Sections

PriorityHSA Plan Worksheet

Sidebar Couple HSA Worksheet
Use this worksheet to forecast a year's expenses.  (If you have Priority Health coverage now, you can log in to your account to see the costs of your care and prescriptions this year to help you.)  Enter your estimated costs below. 

Sample Expenses Average costs based on prior years Projected expenses for coming plan year
Chiropractic Visits
Contact Lenses
Copayments / Deductibles
Dental (Braces, Dentures)
Diagnostic Fees (X-rays)
Doctor Fees
Eyeglasses
Hearing Aids
Insulin
Laboratory Fees
Medical Premiums
Pharmaceuticals / Drugs
Psychiatric Care
Surgical Fees
Other Miscellaneous
Total Prior Year Costs
Total Projected Expenses
Last modified 02/14/07