4 ELIGIBLE EXPENSES 8 NOT ELIGIBLE EXPENSES

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1 YOUR FLEXIBLE SPENDING ACCOUNT PROGRAM: KNOW WHAT S ELIGIBLE AND WHAT S NOT ELIGIBLE 4 ELIGIBLE EXPENSES 8 NOT ELIGIBLE EXPENSES 4 Copayments, coinsurance, & deductibles 4 Acupuncture 4 Alcoholism 4 Ambulance 4 Artificial limb 4 Artificial teeth 4 Bandages 4 Birth control pills 4 Body scan 4 Braille books and magazines 4 Breast reconstruction surgery 4 Car modifications for a disability 4 Chiropractor 4 Christian Science practitioner 4 Contact lenses & related supplies 4 Crutches 4 Dental treatment 4 Denture care 4 Diagnostic devices 4 Drug addiction 4 Durable medical equipment 4 Ear care 4 Eye care 4 Eyeglasses 4 Eye surgery 4 Fertility enhancement 4 First aid / medical supplies 4 Foot care 4 Guide dog or other service animal 4 Hearing aids 4 Home diagnostic tests or kits 4 Hospital services 4 Laboratory fees 4 Lactose intolerance 4 Learning disability 4 Massage therapy 4 Medications (prescribed) 4 Nursing services 4 Osteopath 4 Oxygen 4 Physical examination 4 Pregnancy test kit 4 Prosthesis 4 Psychiatric care 4 Psychoanalysis 4 Psychology 4 Special education 4 Sterilization 4 Stop-smoking programs 4 Surgery 4 Telephone for hearing impaired 4 Television for hearing impaired 4 Therapy 4 Transplants 4 Vasectomy 4 Wheelchair (for relief of sickness or disability) 4 Wig 4 X-Rays 8 Baby sitting, childcare, and nursing services for a normal, healthy baby 8 Cosmetic surgery 8 Dancing lessons 8 Diaper service 8 Electrolysis or hair removal 8 Exercise equipment 8 Exercise pools 8 Funeral expenses 8 Hair transplant 8 Health club memberships 8 Herbal supplements 8 Household help 8 Illegal drugs, surgery, and treatments 8 Insurance premiums 8 Items or procedures not approved by the FDA 8 Lodging 8 Maternity clothes 8 Mattresses 8 Meals 8 Medications from other countries 8 Naturopathic, holistic, and alternative treatments (limit to licensed providers of the healing arts) 8 Nutrition supplements 8 Over-the-counter items (see Over-the-Counter Eligibility) 8 Personal computers, tablets, Smartphones (including related software and applications) 8 Personal use items 8 Pillows 8 Prenatal vitamins 8 Prepayments 8 Shoes 8 Sleeping aids 8 Swimming lessons 8 Teeth whitening 8 Travel expenses (allow local mileage only) 8 Vacuum cleaners 8 Vitamins 8 Veterinary fees 8 Weight-loss programs 8 Whirlpools, exercise pools Please remember, some of the items that are eligible for Flexible Spending require a prescription or letter of medical necessity from your physician!

2 GUIDE TO FLEXIBLE SPENDING ELECTIONS Over-the-Counter Eligibility Type / Class of Drug or Product Allergy Prevention and Treatment Analgesics / Antipyretics Antacids and Acid Reducers Actifed, Allerest, Benadryl, ChlorTrimetron, Claritin, Contac, Nasalcrom, Sudafed Aspirin, Advil, Alleve, Ibuprofen, Naprosyn, Tylenol, Midol, Pamprin, Premysyn AXID AR, GasX, Maalox, Mylanta, Tums, Pepcid AC, Prilosec, OTC, Tagamet HB, Zantac Antibiotics (topical) Bacitracin, Triple Antibiotic Ointment Anticandial (yeast) Femstat 3, Gynelotrimin, Mycelex7, Monistat 3, Vagistat1 Antidiarrheal & Laxatives ExLax, Immodium AD, Kaopectate, PeptoBismol Antifungal Lamisil AT, Lotramin AF, Micatin Antihistamines Anti-itch Lotions and Creams Actidil, Actifed, Allerest, Benadryl, Claritin, ChlorTrimetron, Contac, Drixoral, Sudafed, Tavist1, Triaminic Bactine, Benadryl, Caldecort, Caladryl, Calamine, Cortaid, Hydrocortisone, Lanacort, Lamisil AT, Lotramin AF Asthma Medicines Bronitin Mist, Bronkaid, Bronkolixer, Primatene Band-Aids / Bandages Cold Sore / Fever Blisters Eligible without a prescription

3 Type / Class of Drug or Product Cold, Flu, Decongestants, and Sinus Remedies Actidil, Actifed, Advil Cold and Sinus, Afrin, Alka Seltzer Cold and Flu, Afrinol, Alleve Cold and Sinus, Children's Advil Cold, Contac, Dayquil, Dimetane, Dristan LongLasting, Drixoral, NeoSynephrine 12Hour, Nyquil, Orrivin, Pediacare, Sudafed, TavistD, Theraflu, Triaminic, Tylenol Cold and Flu, Cough Drops, Nasal Sprays, Throat Lozenges Contraceptives Spermicides Eligible without a prescription Cough Suppressants or Expectorants Robitussin, Vicks 44, Chloraspetic, Cough Drops, Throat lozenges Dehydration Pedialyte Dental Orajel Denture Care Poligrip Diaper Rash Balmex, Desitin Durable Medical Equipment Wheelchairs, Walkers, Crutches Ear Care Ear Candles, Ear Bulb Syringes, Ototek Loop, Hearing Aids Ear Care, Solutions Ear Drops, Ear Wax Removal Eye Care Contact Lens Supplies, Reading Glasses, Eye Patches Eye Drops Eye Drops Family Planning Ovulation Predictor Kits, Pregnancy Tests First Aid Kits Antisep tics, Bandages, Cold/hot Packs for injuries, Rubbing alcohol, Ace Wraps, Splints, Thermometers, Liquid Adhesives, etc. Eligible without a prescription

4 Type / Class of Drug or Product Foot Care Arch and Insole supports, Orthotic inserts Eligible without a prescription Foot Care Callous Removers, Athlete's Foot Products (see antifungal), Bunion Treatments, Blister and Corn Treatments Hemorrhoidal Preparations Preparation H, Hemorrhoid, Tronolane Home Diagnostic Tests or Kits Blood pressure (monitor and related equipment), Cholesterol, Diabetic Equipment and supplies, Colorectal Screenings, HIV test Lactose Intolerance DairyCare, Digestive Advantage, Lactaid, Menstrual Cycle Midol, Pamprin, Premysyn PMS Migraine Relief Advil Migraine, Motrin Migraine, Excedrin Motion Sickness Dramamine, Marizine NSAIDs Advil, Alleve, Ibuprofen, Motrin, Naprosyn, Naproxen Pediculicide (head lice) Nix, Rid Prenatal Vitamins Sunburn / Burn Relief Aloe Vera, Solarcaine Sleeping Aids Smoking Cessation Commit, Nicoderm CQ, Nicorette, Nicotrol Teething / Toothaches Orajel, Anbesol Topical Steroids Hydrocortisone Wart Removal Compound W, Dr. Scholl's Clear Away, WartOff

5 Dual purpose over-the-counter medicines and products may be reimbursed through your medical/dental Flexible Spending Account with a licensed health-care provider s note stating your specific diagnosis or medical condition, a recommendation to take the specific over-the-counter medicine to treat your condition, and documentation of the product and cost. Here are some examples: Type / Class of Drug or Product Reimbursable Use Excluded Use Acne Retin-A Chronic acne under treatment by a physician Occasional outbreak or blemish Calcium Cosmetics Dental Fluoride Dental Products Dietary / Nutritional Supplements Feminine Hygiene Fiber Supplements Herbal Supplements Homeopathic Remedies Calcium Carbonate, Caltrate, Tricalcium Phosphate, Calcium Citrate, Calcium Lactate, Calcium Gluconate Face soaps, creams, make up, perfumes, hair removal Dental floss, Toothpaste, Toothbrushes, Teeth whitening kits Protein bars, Power drinks, Ensure, Glucerna, Slimfast Benefiber, Metamucil, PeptoBismol Post-surgery or childbirth Routine use for general oral care Routine use for general health Incontinence Post-surgery Infants and toddlers Joint Supplements Glucosamine, Condroitin Mineral Calcium, Caltrate, Ferrous Sulfate, Feosol, Slow FE, Folic Acid OTC Hormone Therapy Peri-menopausal or menopausal symptoms Routine use for general health Snoring Cessation Breathe Right, Snorezz Sleep Apnea Toiletries Deodorant, Shampoo, Body sprays, Soaps, Moisturizers, Chapstick