diff --git a/changelog.d/schedule-a-pretax-premium-tests.changed.md b/changelog.d/schedule-a-pretax-premium-tests.changed.md
new file mode 100644
index 00000000000..8d0235f6187
--- /dev/null
+++ b/changelog.d/schedule-a-pretax-premium-tests.changed.md
@@ -0,0 +1 @@
+Add tests confirming that Schedule A medical expenses exclude health insurance premiums paid through pre-tax payroll deductions.
diff --git a/policyengine_us/tests/core/test_schedule_a_pre_tax_premium_invariants.py b/policyengine_us/tests/core/test_schedule_a_pre_tax_premium_invariants.py
new file mode 100644
index 00000000000..2d158a813f6
--- /dev/null
+++ b/policyengine_us/tests/core/test_schedule_a_pre_tax_premium_invariants.py
@@ -0,0 +1,264 @@
+"""Invariants for pre-tax payroll premiums and Schedule A medical expenses.
+
+IRC 213(a) allows "the expenses paid during the taxable year, not compensated
+for by insurance or otherwise, for medical care", above 7.5% of adjusted gross
+income. A premium paid by salary reduction under a section 125 cafeteria plan
+is paid by the employer, not the employee, and is excluded from wages under
+IRC 106(a) (Rev. Rul. 2002-3), so it is not an expense the taxpayer paid.
+
+pre_tax_health_insurance_premiums holds those premiums. The other premium
+inputs hold premiums not paid that way, and the two are disjoint: a premium is
+reported in one or the other, never both.
+
+Hypothesis draws batches of single and joint filers, each person with wages,
+pre-tax premiums, after-tax premiums and other medical expenses. The after-tax
+premiums are supplied either directly or as non-Medicare premiums. Each batch
+runs as one vectorized simulation, again with every pre-tax premium removed,
+and again with every pre-tax premium paid after tax instead.
+
+The invariants are stated for these filers only: wage earners under 65 who pay
+their own costs, with no self-employment (so no self-employed health insurance
+deduction), no Medicare premiums and no reimbursed expenses. Dependents are
+left out, because whether a dependent's own payments belong on the filer's
+Schedule A is a separate question.
+
+The YAML cases in itemized_medical_expenses.yaml pin hand-computed households. This
+file adds what YAML cannot express: relations between paired runs of the same
+generated households (invariant 5), and the same checks across a mixed batch
+in one vectorized simulation. For every batch:
+
+1. Exclusion: Schedule A medical expenses equal the filers' after-tax
+   premiums plus other medical expenses, whatever the pre-tax premiums are.
+2. One tax benefit per dollar: each person's wage exclusion is their pre-tax
+   premiums, up to their wages, and their Schedule A premiums are their
+   after-tax premiums. The two never cover the same dollar, and together they
+   never exceed the premiums paid.
+3. Differential: the deduction equals an independent numpy calculation, with
+   the 7.5% floor taken from the statute rather than the parameters.
+4. Bounds: 0 <= deduction <= Schedule A medical expenses.
+5. Payment method: paying the pre-tax premiums after tax instead raises
+   Schedule A medical expenses by exactly those premiums and wages by exactly
+   the wage exclusion, and never lowers the deduction. Removing the pre-tax
+   premiums leaves Schedule A medical expenses unchanged and never raises the
+   deduction.
+"""
+
+import numpy as np
+from hypothesis import HealthCheck, example, given, settings
+from hypothesis import strategies as st
+
+from policyengine_us import Simulation
+
+TOLERANCE = 0.1  # dollars; incomes are float32
+
+# IRC 213(a): "to the extent that such expenses exceed 7.5 percent of
+# adjusted gross income". The rate has applied since 2017.
+STATUTORY_FLOOR = 0.075
+YEARS = [2024, 2026]
+
+amounts = st.one_of(st.just(0.0), st.integers(1, 15_000).map(float))
+wages = st.one_of(st.just(0.0), st.integers(1, 200_000).map(float))
+
+
+@st.composite
+def people(draw):
+    return {
+        "wages": draw(wages),
+        "pre_tax": draw(amounts),
+        "after_tax": draw(amounts),
+        "other": draw(st.one_of(st.just(0.0), st.integers(1, 40_000).map(float))),
+        # Which input carries the after-tax premiums.
+        "direct": draw(st.booleans()),
+    }
+
+
+@st.composite
+def tax_units(draw):
+    return {"head": draw(people()), "spouse": draw(st.none() | people())}
+
+
+def _person(wages=0.0, pre_tax=0.0, after_tax=0.0, other=0.0, direct=False):
+    return {
+        "wages": wages,
+        "pre_tax": pre_tax,
+        "after_tax": after_tax,
+        "other": other,
+        "direct": direct,
+    }
+
+
+def _situation(units, year, treatment):
+    people, groups = {}, {"tax_units": {}, "households": {}, "marital_units": {}}
+
+    def add(name, values, role):
+        pre_tax = values["pre_tax"] if treatment == "drawn" else 0
+        after_tax = values["after_tax"]
+        if treatment == "paid_after_tax":
+            after_tax += values["pre_tax"]
+        people[name] = {
+            "age": {"head": 45, "spouse": 43}[role],
+            "is_tax_unit_head": role == "head",
+            "is_tax_unit_spouse": role == "spouse",
+            "employment_income": values["wages"],
+            "pre_tax_health_insurance_premiums": pre_tax,
+            "health_insurance_premiums": after_tax * values["direct"],
+            "health_insurance_premiums_without_medicare_part_b": after_tax
+            * (not values["direct"]),
+            "other_medical_expenses": values["other"],
+            # No modeled Medicare Part B premium, so the premiums are only
+            # the drawn ones.
+            "medicare_enrolled": False,
+        }
+
+    for i, unit in enumerate(units):
+        head = f"head_{i}"
+        add(head, unit["head"], "head")
+        members = [head]
+        if unit["spouse"] is not None:
+            spouse = f"spouse_{i}"
+            add(spouse, unit["spouse"], "spouse")
+            members.append(spouse)
+        groups["marital_units"][f"couple_{i}"] = {"members": members}
+        groups["tax_units"][f"tax_unit_{i}"] = {"members": members}
+        groups["households"][f"household_{i}"] = {
+            "members": members,
+            "state_code": {year: "TX"},
+        }
+    people = {
+        name: {key: {year: value} for key, value in values.items()}
+        for name, values in people.items()
+    }
+    return {"people": people, **groups}
+
+
+PERSON = [
+    "employment_income",
+    "irs_employment_income",
+    "medical_expense_health_insurance_premiums",
+]
+TAX_UNIT = [
+    "adjusted_gross_income",
+    "itemized_medical_expenses",
+    "medical_expense_deduction",
+]
+
+
+def _run(units, year, treatment):
+    sim = Simulation(situation=_situation(units, year, treatment))
+    out = {
+        name: np.asarray(sim.calculate(name, year), dtype=float)
+        for name in PERSON + TAX_UNIT
+    }
+    out["unit"] = sim.populations["tax_unit"].members_entity_id
+    return out
+
+
+def _members(units):
+    return [
+        person
+        for unit in units
+        for person in [unit["head"], unit["spouse"]]
+        if person is not None
+    ]
+
+
+def _check(units, year):
+    drawn = _run(units, year, "drawn")
+    unit = drawn["unit"]
+    members = _members(units)
+    pre_tax = np.array([person["pre_tax"] for person in members])
+    after_tax = np.array([person["after_tax"] for person in members])
+    other = np.array([person["other"] for person in members])
+    earned = np.array([person["wages"] for person in members])
+    np.testing.assert_array_equal(drawn["employment_income"], earned)
+
+    def unit_sum(values):
+        return np.bincount(unit, weights=values, minlength=len(units))
+
+    expenses = drawn["itemized_medical_expenses"]
+    deduction = drawn["medical_expense_deduction"]
+
+    # 1. Exclusion, against the drawn amounts.
+    np.testing.assert_allclose(expenses, unit_sum(after_tax + other), atol=TOLERANCE)
+
+    # 2. One tax benefit per dollar.
+    wage_exclusion = earned - drawn["irs_employment_income"]
+    schedule_a_premiums = drawn["medical_expense_health_insurance_premiums"]
+    np.testing.assert_allclose(
+        wage_exclusion, np.minimum(pre_tax, earned), atol=TOLERANCE
+    )
+    np.testing.assert_allclose(schedule_a_premiums, after_tax, atol=TOLERANCE)
+    assert (
+        wage_exclusion + schedule_a_premiums <= pre_tax + after_tax + TOLERANCE
+    ).all()
+
+    # 3. Differential against an independent calculation.
+    agi = drawn["adjusted_gross_income"]
+    expected = np.maximum(
+        unit_sum(after_tax + other) - STATUTORY_FLOOR * np.maximum(agi, 0), 0
+    )
+    np.testing.assert_allclose(deduction, expected, atol=TOLERANCE)
+
+    # 4. Bounds.
+    assert (deduction >= 0).all()
+    assert (deduction <= expenses + TOLERANCE).all()
+
+    # 5. Payment method.
+    removed = _run(units, year, "removed")
+    np.testing.assert_allclose(
+        removed["itemized_medical_expenses"], expenses, atol=TOLERANCE
+    )
+    np.testing.assert_allclose(removed["irs_employment_income"], earned, atol=TOLERANCE)
+    assert (removed["medical_expense_deduction"] <= deduction + TOLERANCE).all()
+
+    paid_after_tax = _run(units, year, "paid_after_tax")
+    np.testing.assert_allclose(
+        paid_after_tax["itemized_medical_expenses"] - expenses,
+        unit_sum(pre_tax),
+        atol=TOLERANCE,
+    )
+    np.testing.assert_allclose(
+        paid_after_tax["irs_employment_income"], earned, atol=TOLERANCE
+    )
+    assert (paid_after_tax["medical_expense_deduction"] >= deduction - TOLERANCE).all()
+
+
+# Each example is a batch of filers run three ways, at about 0.1 seconds.
+SETTINGS = dict(
+    max_examples=20,
+    deadline=None,
+    derandomize=True,
+    suppress_health_check=[HealthCheck.too_slow, HealthCheck.data_too_large],
+)
+
+EDGE_CASES = [
+    # Nothing paid.
+    {"head": _person(wages=50_000), "spouse": None},
+    # Pre-tax premiums only.
+    {"head": _person(wages=60_000, pre_tax=2_000, other=9_000), "spouse": None},
+    # Pre-tax premiums above wages: the wage exclusion stops at wages.
+    {
+        "head": _person(wages=1_000, pre_tax=2_500, after_tax=400, direct=True),
+        "spouse": None,
+    },
+    # Each spouse pays a different way.
+    {
+        "head": _person(wages=50_000, pre_tax=2_400, other=6_000),
+        "spouse": _person(wages=30_000, after_tax=1_800, other=1_000, direct=True),
+    },
+    # One spouse pays both ways.
+    {
+        "head": _person(wages=40_000, pre_tax=600, after_tax=300, other=250),
+        "spouse": _person(),
+    },
+]
+
+
+@settings(**SETTINGS)
+@example(year=2025, units=EDGE_CASES)
+@given(
+    year=st.sampled_from(YEARS),
+    units=st.lists(tax_units(), min_size=5, max_size=30),
+)
+def test_schedule_a_pre_tax_premium_invariants(year, units):
+    _check(units, year)
diff --git a/policyengine_us/tests/policy/baseline/gov/irs/income/taxable_income/deductions/itemizing/itemized_medical_expenses.yaml b/policyengine_us/tests/policy/baseline/gov/irs/income/taxable_income/deductions/itemizing/itemized_medical_expenses.yaml
index e9dfb1c6311..580d1f7e672 100644
--- a/policyengine_us/tests/policy/baseline/gov/irs/income/taxable_income/deductions/itemizing/itemized_medical_expenses.yaml
+++ b/policyengine_us/tests/policy/baseline/gov/irs/income/taxable_income/deductions/itemizing/itemized_medical_expenses.yaml
@@ -11,3 +11,163 @@
         members: [person1, person2]
   output:
     itemized_medical_expenses: 1_500
+
+# Premiums paid through pre-tax payroll deductions.
+#
+# IRC 213(a) allows "the expenses paid during the taxable year, not
+# compensated for by insurance or otherwise, for medical care". A premium paid
+# by salary reduction under a section 125 cafeteria plan is paid by the
+# employer, not the employee, and is excluded from wages under IRC 106(a)
+# (Rev. Rul. 2002-3). It is therefore not an expense the taxpayer paid.
+# IRS Publication 502 (2025), "Employer-Sponsored Health Insurance Plan":
+# "Don't include in your medical and dental expenses any insurance premiums
+# paid by an employer-sponsored health insurance plan unless the premiums are
+# included on your Form W-2, Wage and Tax Statement."
+#
+# pre_tax_health_insurance_premiums and the other premium inputs are disjoint:
+# a premium is reported in one or the other, never both. Schedule A therefore
+# counts the other premium inputs in full and never the pre-tax input.
+
+- name: Pre-tax payroll premiums reduce wages and are not Schedule A medical expenses.
+  period: 2025
+  input:
+    age: 40
+    employment_income: 60_000
+    pre_tax_health_insurance_premiums: 2_000
+    other_medical_expenses: 9_000
+  output:
+    # 60,000 - 2,000, for income tax and for FICA.
+    irs_employment_income: 58_000
+    payroll_tax_gross_wages: 58_000
+    adjusted_gross_income: 58_000
+    medical_expense_health_insurance_premiums: 0
+    # Counting the premium again would give 11,000.
+    itemized_medical_expenses: 9_000
+    # 9,000 - 7.5% of 58,000.
+    medical_expense_deduction: 4_650
+
+- name: A worker who pays premiums both ways counts only the after-tax premiums.
+  period: 2025
+  input:
+    age: 40
+    employment_income: 60_000
+    pre_tax_health_insurance_premiums: 2_000
+    health_insurance_premiums_without_medicare_part_b: 3_000
+    other_medical_expenses: 9_000
+  output:
+    irs_employment_income: 58_000
+    adjusted_gross_income: 58_000
+    # The 3,000 is not reduced by the 2,000: the inputs do not overlap.
+    medical_expense_health_insurance_premiums: 3_000
+    itemized_medical_expenses: 12_000
+    # 12,000 - 7.5% of 58,000.
+    medical_expense_deduction: 7_650
+
+- name: The directly supplied premium input likewise excludes pre-tax premiums.
+  period: 2025
+  input:
+    age: 40
+    employment_income: 60_000
+    pre_tax_health_insurance_premiums: 2_000
+    health_insurance_premiums: 3_000
+    other_medical_expenses: 9_000
+  output:
+    medical_expense_health_insurance_premiums: 3_000
+    itemized_medical_expenses: 12_000
+    medical_expense_deduction: 7_650
+
+- name: The same premiums paid after tax are medical expenses and do not reduce wages.
+  period: 2025
+  input:
+    age: 40
+    employment_income: 60_000
+    health_insurance_premiums_without_medicare_part_b: 5_000
+    other_medical_expenses: 9_000
+  output:
+    irs_employment_income: 60_000
+    payroll_tax_gross_wages: 60_000
+    adjusted_gross_income: 60_000
+    medical_expense_health_insurance_premiums: 5_000
+    itemized_medical_expenses: 14_000
+    # 14,000 - 7.5% of 60,000.
+    medical_expense_deduction: 9_500
+
+- name: A working Medicare enrollee counts Part B premiums but not pre-tax payroll premiums.
+  period: 2025
+  input:
+    age: 67
+    employment_income: 60_000
+    pre_tax_health_insurance_premiums: 2_000
+    medicare_enrolled: true
+    medicare_part_b_premium: 2_220
+    other_medical_expenses: 9_000
+  output:
+    irs_employment_income: 58_000
+    medical_expense_health_insurance_premiums: 2_220
+    itemized_medical_expenses: 11_220
+    # 11,220 - 7.5% of 58,000.
+    medical_expense_deduction: 6_870
+
+- name: Joint filers count one spouse's after-tax premiums and not the other's pre-tax premiums.
+  period: 2025
+  input:
+    people:
+      person1:
+        age: 40
+        is_tax_unit_head: true
+        employment_income: 50_000
+        pre_tax_health_insurance_premiums: 2_400
+        other_medical_expenses: 6_000
+      person2:
+        age: 40
+        is_tax_unit_spouse: true
+        employment_income: 30_000
+        health_insurance_premiums_without_medicare_part_b: 1_800
+        other_medical_expenses: 1_000
+    tax_units:
+      tax_unit:
+        members: [person1, person2]
+    marital_units:
+      marital_unit:
+        members: [person1, person2]
+  output:
+    irs_employment_income: [47_600, 30_000]
+    adjusted_gross_income: 77_600
+    medical_expense_health_insurance_premiums: [0, 1_800]
+    # 6,000 + 1,000 + 1,800.
+    itemized_medical_expenses: 8_800
+    # 8,800 - 7.5% of 77,600.
+    medical_expense_deduction: 2_980
+
+- name: An itemizer with pre-tax premiums deducts only the other medical expenses.
+  period: 2025
+  input:
+    age: 40
+    employment_income: 60_000
+    pre_tax_health_insurance_premiums: 2_000
+    other_medical_expenses: 30_000
+    # Isolate the medical deduction from modeled state and local taxes.
+    salt_deduction: 0
+  output:
+    adjusted_gross_income: 58_000
+    itemized_medical_expenses: 30_000
+    # 30,000 - 7.5% of 58,000.
+    medical_expense_deduction: 25_650
+    tax_unit_itemizes: true
+    # 58,000 - 25,650. Counting the premium again would give 30,350.
+    taxable_income: 32_350
+
+- name: A non-itemizer with pre-tax premiums gets the wage exclusion and the standard deduction.
+  period: 2025
+  input:
+    age: 40
+    employment_income: 60_000
+    pre_tax_health_insurance_premiums: 2_000
+  output:
+    adjusted_gross_income: 58_000
+    itemized_medical_expenses: 0
+    medical_expense_deduction: 0
+    tax_unit_itemizes: false
+    standard_deduction: 15_750
+    # 58,000 - 15,750.
+    taxable_income: 42_250