FSA Expenses www.crosbybenefits.com Version: 04/19/2011 Please Note: Effective January 1, 2011, all over-the-counter (OTC) medications and drugs must be prescribed by a physician to be eligible for reimbursement. This change is effective January 1, 2011, regardless of your plan year. IMPORTANT: The following is a list of common medical, dental and vision related items and services. Crosby determines "" based on IRS guidance. Crosby's interpretation is subject to change without notice. This list is intended only as a general guideline because all submitted expenses will be reviewed on a case-by-case basis based on the documentation provided. *In most cases, a Dual Purpose item will require a medical practitioner note to verify medical necessity. A medical practitioner note may be written by a doctor of medicine, dentistry, podiatry, optometry, an authorized chiropractor, an alternative healer or other qualified medical practitioner and must contain the following: 1. date; 2. patient s name; 3. medical practitioner s name; 4. statement of medical necessity; 5. the prescribed treatment; and 6. the duration of treatment required. Item Example/Notations? OTC Medicine or Abortion Acne Treatment Proactive, Stridex, Clean & Clear Yes, Rx Required Acupuncture Adoption, Pre-Adoption Medical Expenses Air Conditioner Dual purpose* Air Purifier Dual purpose* Alcoholism Treatment Allergy Relief Oral Medications, Nasal Sprays & Patches Yes, Rx Required Alternative Dietary Substitutes Alternative Drugs & Medicines Alternative Healers Ambulance Analgesics Aspirin, Acetaminophen, Ibuprofen Yes, Rx Required Antacids & Heartburn Relief Alka-Seltzer, Mylanta, Milk of Magnesia Yes, Rx Required Antibiotic Creams & Ointments, Preparation H, Bacitraycin, Neosporin Yes, Rx Required Hemorrhoid Preparations Anti-Diarrheal Imodium, Pepto-Bismol Yes, Rx Required Anti-Itch & Hydrocortisone Creams Benadryl, Caladryl, Cortaid Yes, Rx Required Arthritis Pain-Relief Capzasin, Activon Yes, Rx Required Artificial Limbs Artificial Teeth Asthma Treatments Rx required if over-the-counter Automobile Modifications Babysitting & Child Care Not Bandages Elastic, Gauze Pads, Band Aids Behavioral Modification Programs Birth Control Pills Birthing Classes Blood Pressure Monitoring Devices Blood Sugar Test Kits & Test Strips Body Scans Page 1
Item Example/Notations? OTC Medicine or Braille Books & Magazines Breast Pumps Breast Reconstruction Surgery Following Mastectomy Calamine Lotion Prescription Required Yes, Rx Required Capital Expenses Carpal Tunnel Wrist Supports Cervical Pillow Chelation Therapy Chiropractors Chondroitin/Glucosamine Christian Science Practitioners Circumcision Co-Insurance Amounts Cold Medicines Tablets, Syrups, Drops, Lozenges Yes, Rx Required Cold/Hot Packs Condoms Contact Lenses, Materials & Equipment Contraceptives Co-Payments Cosmetic Procedures Not Cosmetics Makeup, Lipstick, Cotton Swabs, Cotton Not Balls, Baby Oil Counseling Marriage and couples counseling are Dual purpose* ineligible Crowns, Dental Crutches Dancing & Swimming Lessons Deductibles Dental Care Toothache Relief, Temporary Filling, Denture Adhesives Dental Floss, picks, brushes Not Dental Sealants Dental Treatments Denture Care Cleaners Not Dependent Care Expenses Not Diabetic Supplies Diagnostic Items & Services Diaper Rash Creams A&D Ointment, Desinex Yes, Rx Required Diapers Not Diarrhea Medicine Imodium, Kaopectate Yes, Rx Required Diet Food Not Dietary Supplements Disabled Dependent Care Expenses DNA Collection & Storage Doulah Not Drug Addiction Treatment Drug Overdose Treatment Dyslexia Ear Care Ear Drops, Ear Wax Removal Yes, Rx Required Ear Plugs Egg Donor Fees Eggs & Embryos Storage Fees Electrolysis or Hair Removal Not Exercise Equipment or Programs Page 2
Item Example/Notations? OTC Medicine or Eye Care Contact Lens Lubricating Drops, Contact Lens Solution, Eye Patches, Reading Glasses Eye Examinations Face Creams Not Face Lifts Not Family Planning Condoms, Contraceptive Creams, Pregnancy Test, Ovulation Predictor Kits Feminine Care Progesterone Cream, Estrogen Cream, Treatment of Vaginal Infections Feminine Hygiene Products Tampons, Pads, Feminine Washes Not Fertility Treatments Fiber Supplements First Aid Heat Wraps, Hot/Cold Packs, Compresses, Bandages, Tape, Gauze Dressing, Adhesive Pads, Band-Aids First Aid Kits Flu Shots Fluoridation Device or Services Foot Care - Non -Medicines and Arch & Insole Supports Yes, Rx Required Drugs Foot Care - OTC Medicines and Drugs Athlete's Foot Treatment, Nail & Foot Antifungal creams Yes, Rx Required Founder's Fee Funeral Expenses Gambling Problem Treatment Genetic Testing Glucose monitoring equipment Guide Dog: Other Aid Animals Hair Care Color, Shampoo, Conditioner, Brushes, Hair- Loss Products, i.e. Rogaine Not Not Not Hair removal & Transplants Not Hand Lotion Not Health Club Fees Health Institute Fees Hearing Aids & Its Batteries Hemorrhoid Treatments Yes, Rx Required Home Care Home Diagnostic Tests or Kits Blood pressure, cholesterol, diabetes, colorectal, HIV, urine test, thermometers Home Improvements Exit Ramps, Widening Doorways Homeopathic Medicines Yes, Rx Required Hormone Replacement Therapy Hospital Services Household Help Not Humidifier Illegal Operations, Treatments, Not Drugs Immunizations Inclinator Incontinence Supplies For example Depends and Serenity Pads Infertility Treatments Insulin Joint-Support Bandages & Hosiery Page 3
Item Example/Notations? OTC Medicine or Laboratory Fees Lactation Consultant Lactation Supplies Lamaze Classes For mother only. Expenses for the coach or significant other do not qualify. Language Training Laser Eye Surgery LASIK Late Fees For late payment of bills for medical services Not Laxatives Metamamucil Yes, Rx Required Lead-Based Paint Removal Learning Disability Instructional Fees Legal Fees, General Lodging at a Hospital or Similar Institution Lodging Not at a Hospital or Similar Institution Up to $50 per night if used primarily for and essential to medical care provided by a physician in a licensed hospital or medical care facility and there is no element of personal pleasure recreation or vacation in the travel Lodging of a Companion Will qualify if accompanying a patient for medical reason and all of the following conditions apply: up to $50 per night if used primarily for and essential to medical care provided by a physician in a licensed hospital or medical care facility and there is no element of personal pleasure recreation or vacation in the travel Lodging While Attending a Medical Conference Marriage Counseling Massage Therapy Mastectomy-Related Special Bras Maternity Clothes Mattresses Meals at a Hospital or Similar Institution Meals Not at a Hospital or Similar Institution Meals of Companion Meals; Attending a Medical Conference Medical Alert Bracelet or Necklace Medical Conference Admission, Transportation, Meals Medical Information Plan Charges Medical Monitoring & Testing Devices Medical Newsletter Medical Records Charges Rolfing, Craniosacral Therapy, Myofacial Release Not Not Not Not Not Not Not Dual Purpose Not Page 4
Item Example/Notations? OTC Medicine or Menstrual Pain Relievers For example, Midol Yes, Rx Required Mileage for Medical Appointment Expenses for Transportation Primarily for & Essential to Medical Care Mineral Supplements Dual Purpose Missed Appointment Fees Not Morning After Contraceptive Pills Motion Sickness Treatment Dramamine, Patches, Bracelets, Bonine Yes, Rx Required Mouthwash Nail Care & Personal Grooming Items Nasal Strips or Sprays Nursing Services Provided By A Nurse or Other Attendant Scissors, Nail Files, Nail Polish Wages, employment taxes and other amounts paid for nursing services generally will qualify. If person is providing household and personal services, these do not qualify. Not Not Nutritional & Dietary Supplements Bars, Milkshakes, Power drinks Occlusal Guards to Prevent Teeth Grinding Operations Optometrist Organ Donors/Transplants Orthodontia Orthopedic Shoes & Inserts Osteopath Fees Ovulation Monitor Oxygen Patterning Exercises Personal Hygiene Deodorant, Soap, Body Powder, Shaving Cream, Razors, Feminine Care, Sanitary Products Not Personal Trainer Fees Physical Exams Physical Therapy Pregnancy Test Kits Prenatal Vitamins if taken during pregnancy Pre-Payment Not Psychiatric Care Psychoanalysis Psychologist Radial Keratotomy Retin-A For Treatment of Acne Routine Dental Care Toothpaste, Toothbrush, Electric Toothbrush, Not Floss, Mouthwash Including Antibacterial Mouthwash & Fluoride Rinse, Breath Strips, Teeth-Whitening Rubber Gloves Rubbing Alcohol Safety Glasses Prescription Only Screening Tests Shampoo Treatments Relating to A200, Rid Yes, Rx Required Treatment of Lice Shipping & Handling Fees Skin Care Skin & Body Moisturizing Lotion, Lip Balm Not Page 5
Item Example/Notations? OTC Medicine or Sleep Aids Tylenol PM, Sominex, Unisom Yes, Rx Required Sleep Deprivation Treatment Smoking Cessation Medications Nicoderm, Nicorrett, Nicotine Gum, Smoking Cessation Patches Yes, Rx Required Smoking Cessation Programs Special Education Schools Special Home for Mentally Handicapped Sperm, Storage Fees Spermicidal Foam Stem Cell Harvesting & Storage Sterilization Procedures Stomach/Digestive Relief Pepto-Bismol, Imodium, Colace, Lactaid Yes, Rx Required Student Health Fees Not Sun Glasses Prescription Lenses Only Sun Screen Yes, Rx Required Sunburn Creams & Ointments Solarcaine Yes, Rx Required Supplements Surrogate Expenses Not Taxes on Medical Services & Products Teeth Whitening Not Telephone for Hearing-Impaired Persons Television for Hearing-Impaired Persons Therapy Thermometers Toiletries Moisturizers, Toothpaste, Lotions, Not Antiperspirant, Lip Balm, Perfume, Cologne Tooth & Mouth Pain Relief Oragel, Anbesol Yes, Rx Required Treadmill Tuition For Special Needs Program Ultrasounds Umbilical Cord, Freezing & Storage Urinary Pain Relief Yes, Rx Required Vaporizers Varicose Veins Treatment Vasectomy Vasectomy Reversal Veneers Not Veterinary Fees Viagra Vision Discount Programs Not Vitamins Walkers Wart Removal Medication Compound W Weight Loss Programs and/or Drugs Prescribed to Induce Weight Loss Wheelchair Wigs Page 6
Item Example/Notations? OTC Medicine or X-ray fees Page 7