The following is a summary of common expenses for Health Care Flexible Spending Accounts (FSAs), Dependent Care Flexible Spending Accounts (FSAs), Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs). Some plans restrict the eligible expenses, such as Limited Scope FSAs or Deductible Only HRAs. Please refer to your employer's Summary Plan Description (SPD) for your specific plan details. This list is not intended to be exhaustive and should only be used as a general guide. Expenses contained in this list may be denied if the supporting claims documentation is insufficient or shows that the expense was incurred for services not considered medically necessary. Payment of claims will be based on all applicable regulations, the employer's plan design and information on the claim form. All expenses must be substantiated by information from a third party. Due to frequent updates to the regulations governing FSAs, HRAs and HSAs, this list does not guarantee reimbursement, but instead is to be utilized as a guide for the submission of claims. : The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and AA Meetings, transportation to Health Care FSA, HRA, HSA Abortion Health Care FSA, HRA, HSA Acne treatment (RX) Health Care FSA, HRA, HSA Acupuncture/Acupressure Health Care FSA, HRA, HSA Adaptive Equipment (LM) Health Care FSA, HRA, HSA Adoption Fees Adoption, Pre-Adoption Medical Expenses Health Care FSA, HRA, HSA Adult Daycare After-School Care or Extended Day Programs (Supervised activities after school) Agency Fee (Paid in order to receive dependent care) Dependent Care Air Conditioner (CG) Health Care FSA, HRA, HSA Air Purifier (CG) Health Care FSA, HRA, HSA Airborne (RX) Health Care FSA, HRA, HSA Alcoholism Teatment Health Care FSA, HRA, HSA Allergy Medicines (RX) Health Care FSA, HRA, HSA Alli (RX) Health Care FSA, HRA, HSA Alternative Healers (RX) Health Care FSA, HRA, HSA Ambulance Health Care FSA, HRA, HSA Analgesics (RX) Health Care FSA, HRA, HSA Antacids / Acid Reducers (RX) Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 1
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Anti-Arthritics (RX) Health Care FSA, HRA, HSA Anti-Itch Creams (RX) Health Care FSA, HRA, HSA Anti-Snore guards (RX) Health Care FSA, HRA, HSA Antibiotic Ointments (RX) Health Care FSA, HRA, HSA Anti-Diarrheal (RX) Health Care FSA, HRA, HSA Antifungal Products (RX) Health Care FSA, HRA, HSA Antihistamines (RX) Health Care FSA, HRA, HSA Arch Supports Health Care FSA, HRA, HSA Arm Sling Health Care FSA, HRA, HSA Arthritis gloves Health Care FSA, HRA, HSA Artificial Limbs Health Care FSA, HRA, HSA Arts and Crafts Fee Aspirin (RX) Health Care FSA, HRA, HSA Artificial Reproductive Technologies (LM) Health Care FSA, HRA, HSA Assisted Living Asthma Treatments Health Care FSA, HRA, HSA Athletic Mouth Guards Au Pair Automobile Modifications (LM) Health Care FSA, HRA, HSA Baby Formula (Difference in cost between the special formula and regular formula will qualify) (LM) Health Care FSA, HRA, HSA Baby Oil Baby Powder Babysitter (Inside or outside participant's household) Back-up or Emergency Care Bactine (RX) Health Care FSA, HRA, HSA Bandages, elastic Health Care FSA, HRA, HSA Bandages, non-medicated Health Care FSA, HRA, HSA Bandages, medicated (RX) Health Care FSA, HRA, HSA Beds, Mattresses (LM) Health Care FSA, HRA, HSA Bedside Comodes Health Care FSA, HRA, HSA Before-School Care or Extended Day Programs (Supervised activities before school) Flexible Benefit Service Corporation 2
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Biofreeze (RX) Health Care FSA, HRA, HSA Birth Control Pills (RX) Health Care FSA, HRA, HSA Birth Control Devices (RX) Health Care FSA, HRA, HSA Birthing Classes Health Care FSA, HRA, HSA Blood Storage (LM) Health Care FSA, HRA, HSA Blood-Pressure Monitoring Devices Health Care FSA, HRA, HSA Blood-Sugar Test Kits and Test Strips Health Care FSA, HRA, HSA Boarding School Body Scans Health Care FSA, HRA, HSA Breast Pumps and Supplies Health Care FSA, HRA, HSA Breast reconstruction Surgery (Following mastectomy) Health Care FSA, HRA, HSA Breathe Rite Strips (RX) Health Care FSA, HRA, HSA Bug Spray Caffeine Pills Calamine Lotion (RX) Health Care FSA, HRA, HSA Callous Removers Health Care FSA, HRA, HSA Caltrate (RX) Health Care FSA, HRA, HSA Cane, Walking Health Care FSA, HRA, HSA Capital Expenses (LM) Health Care FSA, HRA, HSA Cardiac Therapy Health Care FSA, HRA, HSA Carpal Tunnel Wrist Supports Health Care FSA, HRA, HSA Cast Covers Health Care FSA, HRA, HSA Chairs, Ergonomic (Difference in cost between ergonomic chair and a regular chair would qualify) (LM) Health Care FSA, HRA, HSA Chairs, Reclining (Difference in cost between specialized recliner and a regular recliner would qualify) (LM) Health Care FSA, HRA, HSA Chauffeur Chelation Therapy Health Care FSA, HRA, HSA Childbirth Classes Health Care FSA, HRA, HSA Chiropractic Adjustments Health Care FSA, HRA, HSA Chondroitin (RX) Health Care FSA, HRA, HSA Cialis (RX) Health Care FSA, HRA, HSA Circumcision Health Care FSA, HRA, HSA Claritin (loratadine) (RX) Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 3
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Co-Payments Health Care FSA, HRA, HSA Cold Medicine (RX) Health Care FSA, HRA, HSA Cold Sore Medicine (RX) Health Care FSA, HRA, HSA Cold/Hot Packs Health Care FSA, HRA, HSA Companion Animals (LM) Health Care FSA, HRA, HSA Compression Stockings (RX) Health Care FSA, HRA, HSA Condoms Health Care FSA, HRA, HSA Contact Lenses Health Care FSA, HRA, HSA Contact Lens Solution Health Care FSA, HRA, HSA Controlled Substances (In violation of federal law) Cord Blood Storage (LM) Health Care FSA, HRA, HSA Corneal Ring Segments Health Care FSA, HRA, HSA Cosmetic Procedures (LM) Health Care FSA, HRA, HSA Cosmetics Cotton Balls Cough Drops/Suppressants (RX) Health Care FSA, HRA, HSA Counseling Health Care FSA, HRA, HSA CPAP Machine and Headgear Health Care FSA, HRA, HSA Crowns, Dental Health Care FSA, HRA, HSA Crutches Health Care FSA, HRA, HSA Custodial Care Day Camp Daycare (Children age 12 and under) Deductibles Health Care FSA, HRA, HSA Decongestants (RX) Health Care FSA, HRA, HSA Dental Care, cosmetic Dental Floss Dental Implants Health Care FSA, HRA, HSA Dental Sealants Health Care FSA, HRA, HSA Dental Treatment Health Care FSA, HRA, HSA Denture Brush Denture Cleaners Health Care FSA, HRA, HSA Dentures and Denture Adhesives Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 4
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Diabetic Socks (Difference in cost between special socks and regular socks will qualify) (RX) Health Care FSA, HRA, HSA Diabetic Supplies Health Care FSA, HRA, HSA Diagnostic Items and Services Health Care FSA, HRA, HSA Diaper Rash Ointments and Creams (RX) Health Care FSA, HRA, HSA Diapers or Diaper Service (LM) Health Care FSA, HRA, HSA Diarrhea Medicine (RX) Health Care FSA, HRA, HSA Diet Foods Dietary Supplements (RX) Health Care FSA, HRA, HSA Disabled Dependent, Care of Disabled Qualifying Child (Age 12 and under) Discount Programs Doula Health Care FSA, HRA, HSA Drug Addiction Treatment Health Care FSA, HRA, HSA Drug Overdose, treatment of Health Care FSA, HRA, HSA Drug Screening Health Care FSA, HRA, HSA Ear Piercing Ear Plugs (RX) Health Care FSA, HRA, HSA Ear Wax Removal Products (RX) Health Care FSA, HRA, HSA Eczema Lotions and Creams (RX) Health Care FSA, HRA, HSA Egg Donor Fees (LM) Health Care FSA, HRA, HSA Eggs and Embryos, storage fees (LM) Health Care FSA, HRA, HSA Elder Care Electrolysis or Hair Removal Electrolyte Replacements (RX) Health Care FSA, HRA, HSA Elevator (CG) Health Care FSA, HRA, HSA Epsom Salt (RX) Health Care FSA, HRA, HSA Exercise Equipment (LM) Health Care FSA, HRA, HSA Exercise Programs (LM) Health Care FSA, HRA, HSA Expectorants (RX) Health Care FSA, HRA, HSA Extended Daycare Eye Drops (RX) Health Care FSA, HRA, HSA Eye Examinations, Eyeglasses, Equipment, Materials, and Repair Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 5
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Face Creams Face Lifts Feminine Hygiene Products Fever-Reducing Medications (RX) Health Care FSA, HRA, HSA Fiber Supplements (RX) Health Care FSA, HRA, HSA FICA and FUTA taxes of Day-Care Provider Field Trips Finance Charges First Aid Cream (RX) Health Care FSA, HRA, HSA First Aid Kits Health Care FSA, HRA, HSA Fitness Programs (LM) Health Care FSA, HRA, HSA Flavoring for Medication Health Care FSA, HRA, HSA Flouride Rise (RX) Health Care FSA, HRA, HSA Flu Shots Health Care FSA, HRA, HSA Food (Difference in cost between special food and regular food would qualify) (LM) Health Care FSA, HRA, HSA Foreign Countries, Medical Care Received in Health Care FSA, HRA, HSA Funeral Expenses Gambling Problem Treatment (LM) Health Care FSA, HRA, HSA Gauze Pads Health Care FSA, HRA, HSA Genetic Testing (LM) Health Care FSA, HRA, HSA Glasses Health Care FSA, HRA, HSA Glucosamine (RX) Health Care FSA, HRA, HSA Glucose-monitoring equipment Health Care FSA, HRA, HSA Guide dog, other service animal Health Care FSA, HRA, HSA Hair Colorants Hair Removal and Transplants (LM) Health Care FSA, HRA, HSA Hand Lotion Hand Sanitizer (RX) Health Care FSA, HRA, HSA Headache Medications (RX) Health Care FSA, HRA, HSA Healing Ointments (RX) Health Care FSA, HRA, HSA Health Club Fees (LM) Health Care FSA, HRA, HSA Health Institute Fees (LM) Health Care FSA, HRA, HSA Health Screenings Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 6
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Hearing Aids Health Care FSA, HRA, HSA Heating Pad Health Care FSA, HRA, HSA Hemorrhoid Treatments (RX) Health Care FSA, HRA, HSA Herbs (RX) Health Care FSA, HRA, HSA Holistic or Natural Healers (Rx) Health Care FSA, HRA, HSA Home Diagnostic Kits / Tests Health Care FSA, HRA, HSA Home Improvements (LM) Health Care FSA, HRA, HSA Home Medical Equipment (LM) Health Care FSA, HRA, HSA Homeopathic Products (RX) Health Care FSA, HRA, HSA Hormone Replacement Therapy (HRT) (RX) Health Care FSA, HRA, HSA Hospital Services Health Care FSA, HRA, HSA Household Help Humidifier (RX) Health Care FSA, HRA, HSA Hydrotherapy (LM) Health Care FSA, HRA, HSA Hypnosis (LM) Health Care FSA, HRA, HSA Hysterectomy Health Care FSA, HRA, HSA Illegal Operations and Treatments Immunizations Health Care FSA, HRA, HSA Incontinence Supplies Health Care FSA, HRA, HSA Insect-Bite Creams and Ointments (RX) Health Care FSA, HRA, HSA Insulin Health Care FSA, HRA, HSA Insurance Premiums (Individually owned policy, including dental, health, long-term care, Medicare, short-term HRA medical, supplemental, vision and more.) In-Vitro Fertilization (LM) Health Care FSA, HRA, HSA Kindergarten Kleenex Lab Fees Health Care FSA, HRA, HSA Lactation Consultant (LM) Health Care FSA, HRA, HSA Lactose Intolerance Supplies (Rx) Health Care FSA, HRA, HSA Lamaze Classes Health Care FSA, HRA, HSA Language Training (Child with dyslexia or an otherwise disabled child) (LM) Health Care FSA, HRA, HSA Laser Eye Surgery; Lasik Health Care FSA, HRA, HSA Laser Hair Removal (LM) Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 7
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Late Fees Late Payment Fees Late Pickup Fee Latex Gloves Health Care FSA, HRA, HSA Laxatives (RX) Health Care FSA, HRA, HSA Lead-Based Paint Removal (Surfaces must be in poor repair and within a child's reach) Health Care FSA, HRA, HSA Learning Disabilities (LM) Health Care FSA, HRA, HSA Legal Fees (To authorize treatment for mental illness) (LM) Health Care FSA, HRA, HSA Levitra (RX) Health Care FSA, HRA, HSA Lice Treatments (RX) Health Care FSA, HRA, HSA Lifeline Screenings Health Care FSA, HRA, HSA Lifetime Care Liquid adhesive (For small cuts) Health Care FSA, HRA, HSA Lodging at a Hospital or Similar Institution Health Care FSA, HRA, HSA Lodging, other (Up to $50 per night) (LM) Health Care FSA, HRA, HSA Long-term Care Expenses Looking for Work (Care that enables the employee and/or spouse to look for work) Lotions Lubricants (Rx) Health Care FSA, HRA, HSA Lumbar Support Chair Cushions (RX) Health Care FSA, HRA, HSA Makeup Marijuana or other Controlled Substances (In violation of federal law) Massage Therapy (LM) Health Care FSA, HRA, HSA Mastectomy-Related Special Bras Health Care FSA, HRA, HSA Maternity Aids Health Care FSA, HRA, HSA Maternity Clothing Mattresses (RX) Health Care FSA, HRA, HSA Meals at a Hospital or Similar Institution (When included in the cost of inpatient care) Health Care FSA, HRA, HSA Meals not at a Hospital or Similar Institution Flexible Benefit Service Corporation 8
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Meals of a Companion Mederma (RX) Health Care FSA, HRA, HSA Medical Alert Bracelet or Necklace Health Care FSA, HRA, HSA Medical Information Plan (Plan that maintains electronic medical information) Health Care FSA, HRA, HSA Medical Records Charges Health Care FSA, HRA, HSA Medical Services Health Care FSA, HRA, HSA Medical Supplies Health Care FSA, HRA, HSA Medicated Lip Products (RX) Health Care FSA, HRA, HSA Menstrual Relief (RX) Health Care FSA, HRA, HSA Mentally Handicapped Special Home (LM) Midwives Health Care FSA, HRA, HSA Migrane Medications (RX) Health Care FSA, HRA, HSA Mileage Charged by Dependent Care Provider Mileage to Bring the Dependent to Daycare Milage Incurred Travelling for Medical Reasons Health Care FSA, HRA, HSA Mineral Supplements (RX) Health Care FSA, HRA, HSA Missed Appointment Fees Morning-After Contraceptive Pills (RX) Health Care FSA, HRA, HSA Motion Sickness Patches or Wristband RX Health Care FSA, HRA, HSA Motion Sickness Medications (RX) Health Care FSA, HRA, HSA Mouthwash Multivitamins (RX) Health Care FSA, HRA, HSA Nanny Nasal strips or sprays (RX) Health Care FSA, HRA, HSA Naturopathic Care (LM) Health Care FSA, HRA, HSA Nebulizer Health Care FSA, HRA, HSA Needle Container Health Care FSA, HRA, HSA Neti pots Health Care FSA, HRA, HSA Newborn Nursing Services (rmal and healthy baby) Nicotine gum or patches (RX) Health Care FSA, HRA, HSA rplant Insertion or Removal Health Care FSA, HRA, HSA Nursing Care and Services (Private Duty Nursing) (LM) Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 9
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Nursing Home Nutritional supplements (RX) Health Care FSA, HRA, HSA Nutritionist (LM) Health Care FSA, HRA, HSA Obstetrical Expenses Health Care FSA, HRA, HSA Occlusal guards Health Care FSA, HRA, HSA Occupational Therapy Health Care FSA, HRA, HSA Online or Telephone Consultation (Medical practitioner's fee) Health Care FSA, HRA, HSA Operations Health Care FSA, HRA, HSA Optometrist Health Care FSA, HRA, HSA Oral Care Products (e.g. Anbesol, Orajel) (RX) Health Care FSA, HRA, HSA Orthodontia Health Care FSA, HRA, HSA Orthopedic Shoes (Excess cost between orthopedic shoes and regular shoes will qualify) (RX) Health Care FSA, HRA, HSA Orthotic Inserts (Custom -made and over-the-counter) Health Care FSA, HRA, HSA Osteopath Fees Health Care FSA, HRA, HSA Over-the-Counter-Medications (RX) Health Care FSA, HRA, HSA Overnight Camp Ovulation Monitor Health Care FSA, HRA, HSA Oxygen and Equipment Health Care FSA, HRA, HSA Pain Relievers (RX) Health Care FSA, HRA, HSA Parking Fees and Tolls (Related to medical care received) Health Care FSA, HRA, HSA Pedialyte (RX) Health Care FSA, HRA, HSA Pedometer Pediculicide (e.g. Nix, Rid) (RX) Health Care FSA, HRA, HSA Penile Implants (LM) Health Care FSA, HRA, HSA Perfume Peroxide (RX) Health Care FSA, HRA, HSA Personal Grooming Items Personal Trainer Fees (LM) Health Care FSA, HRA, HSA Physical Exams Health Care FSA, HRA, HSA Physical therapy Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 10
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Pillows; Lumbar Support (LM) Health Care FSA, HRA, HSA Placement Fees (For finding a dependent care provider) Pregnancy Aids Health Care FSA, HRA, HSA Pregnancy test Kits Health Care FSA, HRA, HSA Prenatal Vitamins (RX) Health Care FSA, HRA, HSA Prepaid Fees for Dependent Care (Cannot be reimbursed until care is provided) Preschool/Nursery school Prescription Drug Discount Programs Prescription Drugs/Medicines (RX) Health Care FSA, HRA, HSA Prescription Drugs/Medicines (Obtained from other countries) Preventive Care Screenings Health Care FSA, HRA, HSA Probiotics (RX) Health Care FSA, HRA, HSA Product Replacement Plans/Warranties Propecia (LM) Health Care FSA, HRA, HSA Prosthesis Health Care FSA, HRA, HSA Psychiatric Care Health Care FSA, HRA, HSA Psychoanalysis (LM) Health Care FSA, HRA, HSA Psychological Care (LM) Health Care FSA, HRA, HSA Q-tips Radon Mitigation (LM) Health Care FSA, HRA, HSA Reading Glasses Health Care FSA, HRA, HSA Recliner Chairs (Difference in cost between specialized recliner and a regular recliner would qualify) (LM) Health Care FSA, HRA, HSA Reflexology (LM) Health Care FSA, HRA, HSA Registration Fee (Cannot be reimbursed until care is provided) Relative (Payments to a relative for dependent care) Retin-A (LM) Health Care FSA, HRA, HSA Rogaine (LM) Health Care FSA, HRA, HSA Rubbing alcohol (RX) Health Care FSA, HRA, HSA Safety Glasses (RX) Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 11
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Schools and Education, Residential (LM) Health Care FSA, HRA, HSA Schools and Education, Special (LM) Health Care FSA, HRA, HSA Screening Tests Health Care FSA, HRA, HSA Security System for the Home Seeing-Eye Dog/Other Service Animal Health Care FSA, HRA, HSA Self-Employment (Dependent care expense incurred in connection with) Shampoos Shaving cream or lotion Shipping and Handling Fees Health Care FSA, HRA, HSA Sick employee (Payments to dependent care provider when sick employee stays home) Sick-Child Facility Sinus Medications (RX) Health Care FSA, HRA, HSA Sleep Aids (RX) Health Care FSA, HRA, HSA Smoking-Cessation Medications (RX) Health Care FSA, HRA, HSA Smoking-Cessation Programs Health Care FSA, HRA, HSA Soaps Special Foods (Difference in cost between special food and regular food would quailfy) (RX) Health Care FSA, HRA, HSA Speech Therapy (LM) Health Care FSA, HRA, HSA Sperm Storage Fees (LM) Health Care FSA, HRA, HSA Spermicidal Foam (RX) Health Care FSA, HRA, HSA Spouse of Employee (Payments to a spouse for dependent care) Stem Cell Harvesting and/or Storage (LM) Health Care FSA, HRA, HSA Sterilization Procedures Health Care FSA, HRA, HSA Sterilization Reversal Health Care FSA, HRA, HSA St. Johns Wort (RX) Health Care FSA, HRA, HSA Student Health Fee Substance Abuse Health Care FSA, HRA, HSA Subway Fare (In connection with medical care received) Health Care FSA, HRA, HSA Summer Day Camp Summer School Flexible Benefit Service Corporation 12
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Sun Protective Clothing (Difference in cost between special clothing and regular clothing will qualify) (RX) Health Care FSA, HSA Sunburn Creams and Ointments (RX) Health Care FSA, HRA, HSA Sunglasses (RX) Health Care FSA, HRA, HSA Sunglasses, Clip-on (RX) Health Care FSA, HRA, HSA Sunscreen (Only SPF 30 and above will qualify) Health Care FSA, HRA, HSA Sunscreen, Cosmetics/Similar Products with Supply Fees Support Hose/TED stockings Health Care FSA, HRA, HSA Surgery Health Care FSA, HRA, HSA Surrogate/Gestational Carrier Expenses Tanning Salon/Equipment (LM) Health Care FSA, HRA, HSA Taxes on Medical Services and Products Health Care FSA, HRA, HSA Taxi Fare (In connection to medical care received) Health Care FSA, HRA, HSA Teeth Whitening Telephone for Hearing-Impaired Persons Health Care FSA, HRA, HSA Television for Hearing-Impaired Persons Health Care FSA, HRA, HSA Thermometers Health Care FSA, HRA, HSA Throat Lozenges (RX) Health Care FSA, HRA, HSA Toiletries Toll bridges (In connection with medical care received) Health Care FSA, HRA, HSA Toothache/Teething Pain Relievers (RX) Health Care FSA, HRA, HSA Toothbrushes Toothpaste Transplants Health Care FSA, HRA, HSA Transportation Expenses (In connection with medical care received) Health Care FSA, HRA, HSA Treadmill (LM) Health Care FSA, HRA, HSA Tuition Expenses Tuition for Special-Needs Program (LM) Health Care FSA, HRA, HSA Tutoring Programs UCR, Charges Above (If underlying expense is eligible) Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 13
: The expense is eligible for reimbursement. : The expense is not eligible for reimbursement under any circumstance. (RX): The expense is eligible for reimbursement if a doctor s prescription has been obtained prior to purchase. A copy of the prescription will be (LM): The expense may be eligible for reimbursement if a Letter of Medical Necessityis provided to Flex. The expense must be used to treat a (CG): Some items that require a Letter of Medical Necessity may result in home improvement. This applies when a "capital gain" is made and Ultrasound, Pre-Natal Health Care FSA, HRA, HSA Umbilical Cord Freezing/Storage (LM) Health Care FSA, HRA, HSA Unemployment (Dependent care that enables the employee and/or spouse to look for work) Vacation (Payments to dependent care provider for periods when employee is on vacation) Depdendent Care FSA Vaccines Health Care FSA, HRA, HSA Varicose Vein Treatment (LM) Health Care FSA, HRA, HSA Vasectomy Health Care FSA, HRA, HSA Vasectomy Reversal Health Care FSA, HRA, HSA Veneers Veterinary Services (For a guide dog or other service animal) Health Care FSA, HRA, HSA Viagra (RX) Health Care FSA, HRA, HSA Vitamins (RX) Health Care FSA, HRA, HSA Volunteer Work (Dependent care that enables employee and/or spouse to volunteer) Walkers Health Care FSA, HRA, HSA Warranties/Insurance on a Product Wart remover treatments (RX) Health Care FSA, HRA, HSA Water Flouridation (LM) Health Care FSA, HRA, HSA Water Pik Weight Loss Drugs (RX) Health Care FSA, HRA, HSA Weight-Loss Programs (LM) Health Care FSA, HRA, HSA Weight-Loss Surgery (LM) Health Care FSA, HRA, HSA Wheelchair/Wheelchair Accessories Health Care FSA, HRA, HSA Whirlpool Bath (LM) Health Care FSA, HRA, HSA Wigs (LM) Health Care FSA, HRA, HSA X-Ray Fees Health Care FSA, HRA, HSA Yeast Infection Medications (RX) Health Care FSA, HRA, HSA Flexible Benefit Service Corporation 14