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| Amount Spent Out-of-Pocket | |||
|---|---|---|---|
| Adjusted Gross Income | $25,000 | ||
| Medical Expenses | $ 4,000 | $ 4.000 | |
| Medicine and Drugs | $ 450 | −250 | deductible |
|
|
|||
| Self-Paid Insurance Premiums | $ 350 | $ 3,750 | |
| Employer-Paid Insurance Premiums | $ 250 | × .25 | |
|
|
|||
| Deductible on Insurance Policy | $ 250 | = $937.50 | |
| Coinsurance Rate | 25% | + 250.00 | deduction |
|
|
|||
| $ 1,187.50 | |||
