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Eligible Expense Spotlight THE FSAFEDS VIDEO LIBRARY

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Services and Expenses Eligible for Reimbursement Under the FSAFEDS Program

For the FSAFEDS HCFSA and LEX HCFSA, services listed in this document as eligible (or that meet the "potentially eligible" requirements) are eligible for reimbursement, if the services are:

  • rendered by a health care professional appropriately licensed or certified in the state in which he or she practices; and
  • performed within the scope of the health care professional's license.

For the FSAFEDS DCFSA, services listed in this document as eligible (or that meet the "potentially eligible" requirements) are eligible for reimbursement, if the services are:

  • for an individual you claim as a dependent on your Federal Tax return who is under 13 or incapable of self-care; and
  • necessary to allow you and your spouse, if married, to work, look for work or attend school full-time.

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

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A Print this Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
ACNE TREATMENT
(Coverage Code 117)
HCFSA     X   Over-the-counter acne treatment products are eligible for reimbursement as long as the product’s primary purpose is for the treatment of acne. Cosmetics or other items that merely contain acne-fighting ingredients are not eligible. Eligible examples include:
  • Acne Free
  • Acnomel
  • Ambi Even & Clear
  • Bye Bye Blemish
  • Clean & Clear
  • Clearasil
  • Murad Acne Complex Kit
  • Nature's Cure Acne Treatment
  • Neutrogena Acne Treatment
  • OXY
  • Proactiv Solution
  • Stri-Dex
  • ZAPZYT Acne Treatment
  • Zeno Acne Clearing Device
Note: Generic and store brand equivalents of name brand acne treatments are also eligible. See the OTC Quick Reference Guide for information on submitting OTC expenses.
ACNE TREATMENT - Laser Therapy
(Coverage Code 117)
HCFSA   X     Laser therapy performed by a medical provider to treat acne is potentially eligible.
ACUPRESSURE
(Coverage Code 104)
HCFSA X        
ACUPUNCTURE
(Coverage Code 104)
HCFSA X        
ADAPTIVE EQUIPMENT
(Coverage Code 104)
HCFSA   X     Adaptive equipment for a major disability, such as a spinal cord injury, can be reimbursed.

Adaptive equipment to assist you with activities of daily living (ADL) for persons with arthritis, lupus, fibromyalgia, etc., can be reimbursed.

You will be responsible for providing third party documentation of cost comparisons with each request for reimbursement. See CAPITAL EXPENSES

ADOPTION FEES HCFSA       X Medical expenses incurred by your adopted child who is claimed as a dependent are eligible. Care must be for the adopted child and incurred while the child qualifies as your dependent. Your child's medical care expenses are eligible only during the adoption process as long as the child qualifies as your dependent.
AIR CONDITIONERS/AIR PURIFIERS
(Coverage Code 102)
HCFSA   X     See ALLERGY PRODUCTS
AIRWAY CLEARANCE VEST
(Coverage Code 102)
HCFSA X        
ALCOHOLISM/DRUG/SUBSTANCE ABUSE TREATMENT
(Coverage Code 104)
HCFSA X       Eligible expenses include:
  • Inpatient treatment, including meals and lodging provided by a licensed addiction center.
  • Outpatient care
  • Transportation expenses associated with attending outpatient meetings, including AA groups.
ALLERGY MEDICINES
(Coverage Code 117)
HCFSA     X   Over-the-counter allergy treatments are eligible for reimbursement. Examples include:
  • Actifed
  • Benadryl
  • Chlor-Trimeton
  • Claritin
  • Sudafed
  • Zyrtec
For more information on submitting OTC expenses see the OTC Quick Reference Guide.
ALLERGY PRODUCTS AND MITIGATION
(Coverage Code 102)
HCFSA   X     Eligible expenses include products and home improvements to treat severe allergies. Examples include:
  • Cost to remove carpet (but NOT the cost to replace flooring)
  • Electro-static air purifier
  • HEPA furnace filters and HEPA vacuum cleaner filters (only the difference in cost of the HEPA product minus the standard product can be reimbursed.)
  • Humidifier
  • Home/automobile air conditioners
  • Special vacuum cleaners for persons with respiratory problems (only the difference in cost of the special vacuum cleaner minus a standard vacuum can be reimbursed)
  • Special pillow cases, mattress covers, or other bedding barriers that provide protection against allergens to alleviate an allergic condition

Note: You will be responsible for providing third party documentation of cost comparisons with each request for reimbursement. See CAPITAL EXPENSES for important information and guidance.

ALTERNATIVE MEDICAL SERVICES,
PRODUCTS AND PROVIDERS
(Coverage Code 104)
HCFSA   X     Services must be prescribed and rendered by a licensed health care provider to treat a specific illness or disorder.
AMBULANCE
(Coverage Code 104)
HCFSA X        
ANALGESICS
(Coverage Code 117)
HCFSA     X   Examples include:
  • Advil
  • Aleve
  • Aspirin
  • Ibuprofen
  • Midol
  • Naprosyn
  • Pamprin
  • Tylenol

Topical examples include:

  • Aspercreme
  • BenGay
  • Icy Hot
  • Zostrix

For more information on submitting OTC expenses, see the OTC Quick Reference Guide.

ANTACIDS/ACID REDUCERS
(Coverage Code 117)
HCFSA     X   Examples include:
  • AXID AR
  • Gas-X
  • Maalox
  • Mylanta
  • Pepcid AC
  • Prilosec OTC
  • Tagament HB
  • Tums
  • Zantac 75
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
ANTI-ARTHRITICS
(Coverage Code 102)
HCFSA X       Examples include:
  • Glucosamine
  • Chondroitin
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
ANTIBIOTICS, topical
(Coverage Code 117)
HCFSA     X   Examples include:
  • Bacitracin
  • Neosporin
  • Triple Antibiotic Ointment
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
ANTICANDIDAL, yeast infection
(Coverage Code 117)
HCFSA     X   Examples include:
  • Femstat 3
  • Gyne-Lotrimin
  • Monistat
  • Mycelex-7
  • Vagistat-1
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
ANTI-DIARRHEAL
(Coverage Code 117)
HCFSA     X   Examples include:
  • Immodium AD
  • Kaopectate
  • Pepto-Bismol
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
ANTIFUNGAL
(Coverage Code 117)
HCFSA     X   Examples include:
  • Lamisil AT
  • Lotramin AF
  • Micatin
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
ANTIHISTAMINES
(Coverage Code 117)
HCFSA     X   See ALLERGY MEDICINES
ANTI-ITCH PRODUCTS, lotions or creams
(Coverage Code 117)
HCFSA     X   Examples include:
  • Bactine
  • Benadryl
  • Caldecort
  • Caladryl
  • Calamine
  • Cortaid
  • Hydrocortisone
  • Lanacort
Please note: This does not include healing ointments/lotions for extremely dry skin, such as Aquaphor, Eucerin or Cerave.

For more information on submitting OTC expenses, see the OTC Quick Reference Guide.

ASTHMA MEDICINES
(Coverage Code 117)
HCFSA     X   Examples include:
  • Bronitin Mist
  • Bronkaid
  • Bronkolixer
  • Primatene
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
AU PAIRS DCFSA X       If the expense, such as a placement fee is necessary in order to obtain care it may be reimbursable. However you must only apply the expense proportionately over the duration of the agreement to employ the au pair.

For example, for an annual agreement with an au pair who is paid weekly, 1/52nd of the placement fee would be reimbursable each week. The weekly fee as well as other work-related expenses may qualify as a dependent care expense, depending on your tax situation.

AUTOMOBILE MODIFICATIONS
(Coverage Code 104)
HCFSA   X     See ADAPTIVE EQUIPMENT

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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B Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
BABY FORMULA
(Coverage Code 102)
HCFSA   X     If your baby requires a special formula to treat an illness or disorder, the difference in cost between the special formula and routine baby formula can be reimbursed. You will be responsible for providing third party documentation of cost comparisons with each request for reimbursement.
BAND-AIDS/BANDAGES
(Coverage Code 102)
HCFSA X        
BATH TUB RAILS/GRIPS
(Coverage Code 104)
HCFSA X        
BEDS, box springs/foundations HCFSA       X  
BEDS, mattresses
(Coverage Code 999)
HCFSA   X     Only mattresses specifically described and prescribed by a physician to treat a specific medical condition will be considered. Reimbursement will be limited to a maximum amount of $700 for one mattress purchased every 10 years per participant and/or his or her eligible dependent(s). Any types of support for the mattress, like box springs or special foundations, are not eligible.

Hospital beds are eligible.

BEDSIDE COMMODES
(Coverage Code 102)
HCFSA X        
BEFORE AND AFTER-SCHOOL CARE DCFSA X       Child must be under age 13 or one who is incapable of self-care and can be claimed on your Federal Income Tax return.
BEHAVIORAL THERAPY
(Coverage Code 104)
HCFSA   X     Behavioral therapy used to treatment autism, learning disabilities and other behavioral conditions may be eligible for reimbursement.
BIRTH CONTROL
(Coverage Code 103)
HCFSA X       Birth Control Pills, including (but not limited to):
  • Demulen
  • Depo-Provera
  • Loestrin
  • Lo-Ovral
  • Mircette
  • Nuvaring
  • Ortho Novum
  • Ortho Tri Cylen
  • Ovcon
  • Ovral
  • Tri-Norinyl
  • Triphasil
  • Yasmin
  • Also Included:
    • Intrauterine Device (IUD)
    • Norplant
BIRTH CONTROL, over-the-counter drugs
(Coverage Code 117)
HCFSA     X   Birth Control, including (but not limited to):
  • Spermicides

For more information on submitting OTC expenses, see the OTC Quick Reference Guide.

BIRTH CONTROL, over-the-counter supplies
(Coverage Code 102)
HCFSA X       Birth Control, including (but not limited to):
  • Condoms
  • Ovulation Kits
BLOOD PRESSURE MONITORS
(Coverage Code 104)
HCFSA X       This includes:
  • Blood Pressure Monitor Docking Stations
  • Blood Pressure Monitor Watches
BLOOD STORAGE
(Coverage Code 104)
HCFSA   X     Blood storage is an eligible expense if you are storing blood for use during scheduled elective surgery. Storage fees should not exceed six months. The expense can only be reimbursed after services are rendered.
BODY SCANS
(Coverage Code 104)
HCFSA X        
BOUTIQUE PRACTICE/CONCIERGE/PRE-PAID PHYSICIAN FEES HCFSA       X Monthly or annual fees that your provider may charge for improved access, 24/7 availability and more “personalized” care are not considered medical care and cannot be reimbursed under a health care FSA.
BOUTIQUE PRACTICE/CONCIERGE/PRE-PAID PHYSICIAN FEES - Preventative Care HCFSA X       Preventative screenings and services rendered are eligible with an itemized statement. Please see the Clean Claim QRG for more information on submitting a claim.
BRADLEY CLASSES
(Coverage Code 104)
HCFSA X       See CHILDBIRTH CLASSES
BRAILLE BOOKS AND MAGAZINES
(Coverage Code 104)
HCFSA X       The cost difference of Braille books and magazines that exceeds the price for regular books and magazines is an eligible expense. You will be responsible for providing third party documentation of cost comparisons with each request for reimbursement.
BREAST PUMPS AND LACTATION SUPPLIES
(Coverage Code 102)
HCFSA X       These items are eligible, including:
  • Breast Pumps
  • Breast Pump Parts
  • Nursing Cream and Ointment
  • Nursing Pads and Shields
  • Storage Bags and Bottles
BRIS HCFSA       X  
BUS FARE
(Coverage Code 104)
HCFSA X       See TRANSPORTATION

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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C Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
CAMPS, summer or holiday (Day) DCFSA X      

This includes children under age 13, or any individual who is incapable of self-care and can be claimed on your Federal Tax return.

Payment in advance is not covered. You can only be reimbursed for expenses that have been incurred.

CAMPS, summer or holiday (Overnight) DCFSA       X

Overnight camps are not eligible expenses. Camps that include both day and overnight stays are not eligible even if the provider can separate the day and night expenses. Day care provided during evening/night hours is an eligible expense if you and your spouse work, look for work or attend school full-time during the evenings and nights, such that you need care for your eligible children. However, your children must return to your home during the day (the evening/night day care cannot be 24 hours). If there is any question about whether your camp and/or day care receipts are for eligible expenses, you may be contacted for clarification.

CAPITAL EXPENSE
(Coverage Code 104)
HCFSA   X     A capital expense (permanent or portable) can be reimbursed if its purpose is to provide medical care for you, your spouse or dependent.

Expenses for improvements or special equipment added to your home can be reimbursed if the main purpose of the item is medical care. How much is reimbursed depends on the extent to which the expense permanently improves the property and whether others benefit.

The amount paid for the improvement is reduced by the increase in the value of your home or property. The difference between the cost of the improvement minus the increased value equals the eligible expense. In addition, the cost should be divided by the number of individuals living in the household to determine the amount that is reimbursable for the person with the medical condition.

If the value of your home or property is not increased by the improvement, the entire cost is an eligible expense. Use the Capital Expense Worksheet to determine if your expense is eligible.

Examples of these expenses are:

  • Constructing entrance or exit ramps
  • Widening or otherwise modifying doorways, hallways and stairways
  • Installing railings, support bars, or other modifications to bathrooms
  • Kitchen modifications, including lowering cabinets and other equipment
  • Electrical and plumbing modifications
  • Exterior grading of the property to provide access to your home
  • Lead-based paint removal

IRS regulations require that the cost comparison between a standard item and an item prescribed by a health care provider be submitted from an independent third party. For instance, you may provide a store circular showing the cost of a comparable standard item when submitting a claim for the reimbursement of the difference on the prescribed item.

This list is not exhaustive. If expenses are similar to those listed above, and are incurred to adapt a personal residence to yours or your spouse’s or dependent’s condition, the expenses are eligible subject to the terms noted above. Expenses must be reasonable, and directly related to the medical condition. Costs that are incurred for architectural or aesthetic reasons are not eligible.

Please refer to IRS Publication 502 for additional information, including operation and upkeep.

CARPET REMOVAL
(Coverage Code 104)
HCFSA   X     See ALLERGY PRODUCTS AND MITIGATION.
CHAIRS, ergonomic HCFSA       X Ergonomic chairs are not eligible.
CHAIRS, reclining
(Coverage Code 104)
HCFSA   X     Reclining chairs that both elevate the legs and tilt the torso may be considered for reimbursement. The chair must be specifically prescribed by a physician to alleviate a specific medical condition and you must submit a fully completed Letter of Medical Necessity that clearly documents how the chair will alleviate the condition or diagnosis for the expense to be considered. Reimbursement will be limited to a maximum amount of $650 for one chair purchased every 10 years per participant and/or his or her dependents. No other types of chairs are eligible, including massage chairs that have a reclining feature.
CHILDBIRTH CLASSES
(Coverage Code 104)
HCFSA X       Childbirth classes such as Lamaze and Bradley are eligible for reimbursement.

Does not include:

  • Breastfeeding Classes
  • Newborn or New Infant Care Classes
  • Parenting Classes
CHIROPRACTIC
(Coverage Code 104)
HCFSA X       Services performed by a chiropractor are eligible such as:
  • Spinal Manipulation
  • TENS Treatment
  • TENS Unit for home use
  • Ultrasounds
CHONDROITIN
(Coverage Code 102)
HCFSA X       Also eligible in combination with Glucosamine.
CHRISTIAN SCIENCE PRACTITIONERS
(Coverage Code 104)
HCFSA X       Payments for medical care can be reimbursed.
CIRCUMCISION
(Coverage Code 104)
HCFSA X       A bris performed in the home by a Rabbi or non-licensed provider is not an eligible expense.
COBRA PREMIUMS HCFSA       X Under IRS rules, insurance premiums cannot be reimbursed under a Health Care FSA.
COCHLEAR IMPLANTS
(Coverage Code 104)
HCFSA X        
CO-INSURANCE
(Coverage Code 104)
HCFSA X       Cannot be reimbursed by secondary insurance or any other source.
COLD & FLU MEDICINES
(Coverage Code 117)
HCFSA     X   Examples include:
  • Actifed
  • Advil Cold and Sinus
  • Alka Seltzer Cold and Flu
  • Children's Advil Cold
  • Dayquil
  • Drixoral
  • Neo-Synephrine 12-Hour
  • Nyquil
  • Pediacare
  • Robitussin
  • Sudafed
  • Tavist-D
  • Theraflu
  • Triaminic
  • Tylenol Cold and Flu
  • Cough Drops
  • Nasal Sprays
  • Throat Lozenges
Please note: this does not include herbal cold remedies, such zinc or vitamin C drops.

For more information on submitting OTC expenses, see the OTC QRG.

COLD SORE MEDICINES
(Coverage Code 117)
HCFSA     X   Examples include:
  • Abreva
  • Herpecin
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
COMPRESSION HOSIERY/SOCKS, medically approved
(Coverage Code 104)
HCFSA X       Examples include:
  • Jobst Surgical Support Hose/Socks
CONTACT LENSES
(Coverage Code 303)
HCFSA
LEX HCFSA
X       Contact lens re-wetting drops are also eligible.
CO-PAYMENTS
(Coverage Code 104)
HCFSA X       Cannot be reimbursed by secondary insurance or any other source.
CORD BLOOD STORAGE
(Coverage Code 104)
HCFSA   X     Can be reimbursed if there is a specific medical condition that the cord blood is intended to treat. Indefinite storage is not an eligible expense. If you pre-pay for 12 months of storage, you may only be reimbursed when the expenses have been incurred. The amount can be pro-rated in order to file claims for reimbursement once the service is rendered.
COSMETIC DENTISTRY HCFSA       X Expenses for cosmetic dentistry, such as teeth whitening or bleaching, porcelain veneers, or bonding are not eligible for reimbursement unless the procedure is necessary to improve a deformity arising from a congenital abnormality, personal injury from accident or trauma, or to restore appearance related to treatment for another medical diagnosis or condition.
COSMETIC PROCEDURES HCFSA
LEX HCFSA
      X Cosmetic procedures to improve or enhance appearance are not eligible.
COSMETIC PROCEDURES (cont.)
(Coverage Code 104)
HCFSA
LEX HCFSA
  X     A cosmetic procedure or service necessary to improve a deformity arising from a congenital abnormality, personal injury from accident or trauma, or to restore appearance related to treatment for another medical diagnosis or condition can be reimbursed.
COUGH MEDICINES
(Coverage Code 117)
HCFSA     X   Examples include:
  • Chloraseptic
  • Cough drops
  • Mucinex
  • Robitussin
  • Throat lozenges
  • Vicks 44
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
COUNSELING
(Coverage Code 104)
HCFSA X       If counseling is provided to treat a medical or mental diagnosis and is rendered by a licensed provider.

Eligible expenses include psychotherapy, bereavement and grief counseling, sex counseling, etc.

COUNSELING (cont.) HCFSA       X Life coaching, career counseling and marriage counseling do not qualify.
CPAP DEVICES
(Coverage Code 104)
HCFSA X       This includes replacement parts, repairs and maintenance. Distilled water is not eligible.
CROWNS
(Coverage Code 202)
HCFSA
LEX HCFSA
X       See DENTAL CARE
CRUTCHES
(Coverage Code 104)
HCFSA X        

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  Back to top

D Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
DAY CARE DCFSA X      

This includes non-medical day care as well as in-home babysitters for children under age 13, and/or for any individual who is incapable of self-care and can be claimed on your Federal Tax return. You (and your spouse if married) must be working, looking for work (income must be earned during the year), or attending school full-time.

Activities (such as swimming lessons or arts and crafts) are not eligible expenses.

Payment for day care services that have not been incurred - are not eligible for reimbursement. Only expenses for day care that have been incurred are eligible for reimbursement.

You must include the provider's SSN or TIN with your claim. If you are unable to obtain this information, you must include a signed letter showing that you attempted to obtain this information. The letter must include the provider's name and mailing address.

DANCING LESSONS
(Coverage Code 104)
HCFSA   X     If prescribed for a specific medical condition, such as part of a rehabilitation program after surgery.
DEDUCTIBLES
(Coverage Code 104)
HCFSA X       Cannot be reimbursed by secondary insurance or any other source.
DEFIBRILLATOR, portable
(Coverage Code 104)
HCFSA X        
DENTAL MAINTENANCE ORGANIZATION (DMO) HCFSA
LEX HCFSA
      X See INSURANCE PREMIUMS
DENTAL CARE
(Coverage Code 202)
HCFSA
LEX HCFSA
X       Covered services include, but are not limited to:
  • Bridges
  • Cleanings
  • Crowns
  • Dental implants
  • Dentures
  • Endodontic care (root canal)
  • Extractions
  • Fillings
  • Orthodontia
  • Periodontal services
  • Routine prophylaxis
  • Sealants
  • Subepithelial connective tissue graft
  • X-rays
DIABETIC SUPPLIES
(Coverage Code 102)
HCFSA X       Diabetic socks are eligible, but only the cost difference between the diabetic socks and regular socks will be reimbursed. You will be responsible for providing third party documentation of cost comparisons with each request for reimbursement.
DIAPER RASH CREAMS
(Coverage Code 102)
HCFSA X       Examples include:
  • A+D Ointment
  • Aveeno Diaper Rash Cream
  • Balmex
  • Boudreaux's Butt Paste
  • Desitin
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
DIAPERS, DIAPER SERVICE HCFSA       X Not for routine care of a healthy newborn.
DIAPERS, DIAPER SERVICE (cont.)
(Coverage Code 104)
HCFSA   X     To relieve or ameliorate the effect of a particular illness or disease on you, your disabled child or dependent, who would not need this product “but for” the medical condition.
DOCTOR FEES
(Coverage Code 104)
HCFSA X       In addition to all expenses for care not reimbursed by any other source, eligible expenses include fees for:
  • Out-of-network providers
  • Charges by your physician for letters of medical necessity to schools, etc.
  • Physician tele-advice, including email communication
DOULAS
(Coverage Code 104)
HCFSA   X     If the doula is a licensed health care professional who renders medical care, his or her fees can be reimbursed. Typically doulas do not provide medical care. A licensed medical provider, such as the patient's OB/GYN must provide a statement detailing that a medical service was provided by the doula in order to be considered for reimbursement.
DRUGS HCFSA         See PRESCRIPTION DRUGS and OTC MEDICINES
DRUG ADDICTION, treatment of
(Coverage Code 104)
HCFSA X       Eligible expenses include:
  • Inpatient treatment, including meals and lodging provided by a licensed addiction center.
  • Outpatient care
  • Transportation expenses associated with attending outpatient meetings, including AA groups, if attending on a doctor’s advice.

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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E Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
EAR CARE, solutions
(Coverage Code 117)
HCFSA     X   Examples include:
  • Murine Ear Wax removal drops
  • Swim Ear drops
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
EAR CARE
(Coverage Code 102)
HCFSA X       Examples include:
  • Ear candles
  • Ear bulb syringes
  • Ototek loop
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
EAR PLUGS
(Coverage Code 104)
HCFSA   X     Must be prescribed to treat a specific medical condition, such as the presence of middle/inner ear tubes. Ear plugs for general health are not eligible.
EDUCATION
(Coverage Code 104)
HCFSA   X     Payments made to a special school for a mentally impaired or physically disabled person qualify as reimbursable if the main reason for using the school is its resources for relieving the disability. This includes teaching Braille to a visually impaired person, teaching lip reading to a hearing impaired person, and giving remedial language training to correct a condition caused by a birth defect.
ELDER CARE DCFSA X       Adult must live with you at least 8 hours a day and be claimed as a dependent on your Federal Tax return.

See DAY CARE

ELECTROLYSIS
(Coverage Code 104)
HCFSA   X      
ELECTROLYTE REPLACEMENTS
(Coverage Code 102)
HCFSA X       Examples include:
  • Pedialyte
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
EYE CARE
(Coverage Code 102)
HCFSA X       Examples include:
  • Eye patches
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
EYE DROPS
(Coverage Code 117)
HCFSA     X   Examples include:
  • Murine
  • Opcon
  • Patanol
  • Visine
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
EYEGLASSES/EYE EXAMS
(Coverage Code 303)
HCFSA
LEX HCFSA
X       Includes prescription sunglasses and reading glasses (even those purchased over-the-counter). Eyeglass frames only without prescription lenses are not eligible.
EXERCISE EQUIPMENT
(Coverage Code 104)
HCFSA   X      
EXERCISE PROGRAMS
(Coverage Code 104)
HCFSA   X     See also FITNESS PROGRAMS; WEIGHT LOSS PROGRAMS; GYM MEMBERSHIP.

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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F Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
FEMININE HYGIENE PRODUCTS
(Coverage Code 102)
HCFSA   X     Feminine hygiene products used post-surgery or after childbirth may be reimbursed.
FERTILITY ENHANCEMENT
(Coverage Code 102)
HCFSA X       Includes ovulation predictor kits and pregnancy tests.
FERTILITY TREATMENTS
(Coverage Code 104)
HCFSA X       Eligible medical expenses include (but are not limited to):
  • Artificial insemination (intracervical, intrauterine, intravaginal)
  • Egg donor and/or sperm donor charges for recipient
  • Embryo replacement and storage

  • (NOTE: Storage fees should not exceed 12 months. If you pre-pay storage for 12 months, you may only be reimbursed when the expenses have been incurred. The amount can be pro-rated in order to file claims for reimbursement once the service has been rendered.)
  • Embryo transfer
  • Fertility exams
  • FSH injections
  • Gamete Intrafallopian Transfer
  • In vitro/In vivo fertilization
  • Sperm implants
  • Sperm washing
  • Reverse vasectomy
FINANCE CHARGES HCFSA
LEX HCFSA
DCFSA
      X  
FIRST AID KIT/SUPPLIES
(Coverage Code 102)
HCFSA X       Examples include:
  • Antiseptics
  • Bandages
  • Cold/Hot Packs
  • Joint Supports
  • Liquid bandages
  • Peroxide
  • Rubbing Alcohol
  • Splints
  • Thermometers
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
FITNESS PROGRAMS
(Coverage Code 104)
HCFSA   X     Fees paid for a fitness program may be an eligible expense if prescribed by a physician and substantiated by his or her statement that treatment is necessary to alleviate a medical problem. You cannot be reimbursed for expenses that will be incurred in the future, even if the provider requires payment in advance for the entire period. You can provide a receipt for the entire period and several receipts incrementally that detail the dates of service, provider name and cost after the date of service that corresponds to each time increment.
FLUORIDE RINSE/PILLS/GELS
(Coverage Code 117)
HCFSA     X   Examples include:
  • Act
  • Colgate Phos-flur
For more information on submitting OTC expenses, see the OTC QRG.
FLU REMEDIES, homeopathic
(Coverage Code 102)
HCFSA   X     Examples include:
  • Oscillococcinum
  • Sambucol

For more information on submitting OTC expenses, see the OTC QRG.

FLU SHOTS
(Coverage Code 104)
HCFSA X        
FOAM RING CUSHION/DONUT PILLOW
(Coverage Code 104)
HCFSA X        
FOOD
(Coverage Code 104)
HCFSA   X    

Food may be eligible if prescribed by a medical practitioner to treat a specific illness or ailment and if the food does not substitute for normal nutritional requirements. However, the amount that may qualify for reimbursement is limited to the amount by which the cost of the special food exceeds the cost of commonly available versions of the same product.

Sugar-free and gluten-free foods are not eligible. Yogurt is not eligible.

FOOT CARE
(Coverage Code 102)
HCFSA X       Examples include:
  • Arch and insole supports
  • Bunion, blister and corn treatments
  • Callous removers
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
FUNERAL EXPENSES HCFSA       X  

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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G Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
GLUCOSAMINE
(Coverage Code 102)
HCFSA X       Also eligible in combination with Chondroitin.
GROUPON/LIVING SOCIAL COUPON HCFSA
LEX HCFSA
X       Discount coupons such as Groupon/Living Social for eligible expenses can be reimbursed. You must provide third party substantiation that the Groupon/Living Social deal was purchased, the terms of the Groupon/Living Social deal, as well as the documentation from the provider that includes the date of service and the amount charged.
GUIDE DOGS
(Coverage Code 104)
HCFSA X       See SERVICE ANIMALS
GYM MEMBERSHIP
(Coverage Code 104)
HCFSA   X     Fees paid for a gym membership may be an eligible expense if prescribed by a physician and substantiated by his or her statement that treatment is necessary to alleviate a medical problem. A copy of the contract is required with an LMN. You cannot be reimbursed for expenses that will be incurred in the future, even if the provider requires payment in advance for the entire period. You can provide a receipt for the entire period and several receipts incrementally that detail the dates of service, provider name and cost after the date of service that corresponds to each time increment.

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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H Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
HAIR LOSS TREATMENT
(Coverage Code 104)
HCFSA   X     May be eligible when used to treat hair loss due to a specific medical condition.
HAIR TRANSPLANT HCFSA       X See COSMETIC PROCEDURES
HANDICAP PARKING STICKER/TAG
(Coverage Code 104)
HCFSA X        
HAND SANITIZER
(Coverage Code 102)
HCFSA X       Examples include anti-bacterial gel or wipes, such as:
  • Germ-X
  • Nexcare
  • Purell
This does not include soaps, lotions or other personal hygiene items that include sanitizing ingredients; they are not eligible. For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
HEALING OINTMENTS
(Coverage Code 102)
HCFSA   X     Examples include:
  • Aquaphor
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
HEALTH SCREENINGS
(Coverage Code 104)
HCFSA X       See PREVENTIVE CARE SCREENINGS
HEARING AIDS
(Coverage Code 104)
HCFSA X       Includes batteries for the devices.
HEART RATE MONITORS
(Coverage Code 104)
HCFSA X       This includes Heart Rate Monitor Watches.
HEMORRHOIDAL TREATMENTS
(Coverage Code 117)
HCFSA     X   Examples include:
  • Preparation H
  • Tronolane
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
HOME DIAGNOSTIC KITS/TESTS
(Coverage Code 102)
HCFSA X       Examples include:
  • Cholesterol tests
  • Colorectal screenings
  • Diabetic equipment and supplies
  • HIV tests
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
HOME MEDICAL EQUIPMENT
(Coverage Code 104)
HCFSA   X     Home medical equipment may require a letter of medical necessity (LMN) for reimbursement. Items purchased for the home are not necessarily eligible if the physician is merely recommending the type of therapy (e.g., hyperbaric chamber, tanning bed, etc.) The LMN must specifically state that the item must be purchased for home use.
HOMEOPATHIC CARE
(Coverage Code 104)
HCFSA   X     Homeopathic care rendered by a licensed health care professional who provides this care for the treatment of a specific illness or disorder for you, your spouse or dependent can be reimbursed under a HCFSA. Supporting documentation must show the care was prescribed and signed by the licensed medical provider, even if a different provider renders the homeopathic care.
HOMEOPATHIC MEDICINES
(Coverage Code 117)
HCFSA   X X   Homeopathic medicines used for treatment of a specific illness or disorder can be reimbursed. For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
HORMONE REPLACEMENT THERAPY, OTC
(Coverage Code 117)
HCFSA   X X   For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
HORMONE REPLACEMENT THERAPY, PRESCRIPTION
(Coverage Code 103)
HCFSA X        
HOSPITAL BEDS
(Coverage Code 104)
HCFSA X        
HOUSEHOLD HELP HCFSA       X See NURSING CARE AND SERVICES
HOUSEHOLD HELP (cont.) DCFSA   X     See DAY CARE
HUMAN CHORIONIC GONADOTROPIN (hCG) DROPS HCFSA       X  
HUMAN CHORIONIC GONADOTROPIN (hCG) INJECTIONS
(Coverage Code 103)
HCFSA   X     The cost of hCG may only be reimbursed when used to treat a medical condition related to infertility.
HUMIDIFIERS
(Coverage Code 104)
HCFSA   X     See ALLERGY PRODUCTS AND MITIGATION, CAPITAL EXPENSES. You will be responsible for providing third party documentation of cost comparisons with each request for reimbursement.
HYDROTHERAPY
(Coverage Code 104)
HCFSA   X      
HYPNOBABIES HOME STUDY COURSE HCFSA       X  
HYPNOBIRTHING
(Coverage Code 104)
HCFSA   X      
HYPNOSIS
(Coverage Code 104)
HCFSA   X      

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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I Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
IMMUNIZATIONS
(Coverage Code 104)
HCFSA X       Common immunizations and vaccinations for adults and children are eligible, including:
  • Hepatitis A
  • Hepatitis B
  • HPV (Gardisil)
  • Influenza
  • Measles-mumps-rubella (MMR) booster
  • Pneumococcal (PPSV) vaccine
  • Polio (IVR)
  • Tdap Booster
  • Varivax (Chicken Pox)
  • Zostavax (Shingles)
INCONTINENCE PRODUCTS
(Coverage Code 102)
HCFSA X       Incontinence products used for a diagnosed medical condition may be reimbursed. Examples include:
  • Attends
  • Poise
For information on submitting OTC expenses, see the OTC Quick Reference Guide.
INSURANCE PREMIUMS HCFSA       X Under IRS rules, insurance premiums cannot be reimbursed under a health care FSA.
IN VITRO FERTILIZATION
(Coverage Code 104)
HCFSA X       See FERTILITY TREATMENTS

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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L Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
LAB FEES
(Coverage Code 104)
HCFSA X        
LACTATION CONSULTANT
(Coverage Code 104)
HCFSA X        
LAMAZE CLASSES
(Coverage Code 104)
HCFSA X       See CHILDBIRTH CLASSES
LASER EYE SURGERY
(Coverage Code 303)
HCFSA
LEX HCFSA
X       See VISION CARE
LASER HAIR REMOVAL HCFSA       X  
LASER THERAPY
(Coverage Code 104)
HCFSA   X     Laser therapy may be potentially eligible when used to treat the following medical conditions:
  • Acne
  • Jaundice
  • Mood Disorders
  • Onychomycosis
  • Pain Management
  • Psoriasis
  • Sinus-related disorders
  • Sleep Disorders
  • Wound Healing

PLEASE NOTE: This is not a comprehensive list of medical conditions which may be treated with laser therapy.
LATE PAYMENT FEES DCFSA       X  
LATE PICK-UP FEES DCFSA X        
LATEX GLOVES
(Coverage Code 102)
HCFSA   X      
LAXATIVES
(Coverage Code 117)
HCFSA     X   Examples include:
  • Dulcolax
  • Ex-lax
  • Kaopectate
  • Miralax
For information on submitting OTC expenses, see the OTC Quick Reference Guide
LEARNING DISABILITIES
(Coverage Code 104)
HCFSA   X     The portion of tuition/tutoring fees covering services rendered specifically for your child's severe learning disabilities caused by mental or physical impairments (such as nervous system disorders, or closed head injuries) and paid to a special school or to a specially-trained teacher may be reimbursed under a HCFSA if prescribed by a physician. Examples of eligible expenses include:
  • Remedial reading for your child or dependent with dyslexia
  • Testing to diagnose
LEGAL FEES
(Coverage Code 999)
HCFSA   X     Legal fees paid to authorize treatment for mental illness are eligible expenses.
LICE TREATMENT
(Coverage Code 117)
HCFSA     X   Examples include:
  • Nix
  • Rid
For information on submitting OTC expenses, see the OTC Quick Reference Guide
LIFELINE/MEDICAL ALERT SERVICES HCFSA       X  
LIFETIME CARE HCFSA       X Fees or advance payments made to a retirement home or continuing care facility are not eligible expenses.
LODGING
(Coverage Code 104)
HCFSA   X     Up to $50 per night/per person is potentially eligible if the following conditions are met:
  • The lodging is primarily for, and essential to, medical care
  • The medical care is provided by a doctor in a licensed hospital or medical care facility related to/equivalent to a licensed hospital
  • The lodging is not lavish or extravagant
  • There is no significant element of personal pleasure or leisure in the travel.
  • Expenses for food and beverages are not eligible.
LODGING, for companion
(Coverage Code 104)
HCFSA   X     Your companion’s lodging can be reimbursed if he or she is accompanying the patient (you or your eligible dependents) for medical reasons and it meets the criteria listed above. Meals are not eligible for reimbursement.

Example: Parents traveling with a sick child, up to $100 per night ($50 per person) may be reimbursed.

LODGING, special
(Coverage Code 104)
HCFSA   X     The cost of a special home or step-down facility for your mentally handicapped dependent, recommended by a psychiatrist to help your dependent adjust after inpatient mental health care to community living, can be reimbursed.
LONG-TERM CARE INSURANCE PREMIUMS HCFSA       X Under IRS rules, insurance premiums cannot be reimbursed under a HCFSA.
LONG-TERM CARE SERVICES HCFSA       X Refer to Section 106(c) of the IRS Code for more information.

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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M Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
MASSAGE THERAPY HCFSA X       Please submit your claim with supporting documentation which includes: the date(s) of service, your name or the name of your dependent who received the service, the type of service provided, the amount, and the name and address of the provider.
MATERNITY AIDS HCFSA         See PREGNANCY AIDS
MATERNITY CLOTHES HCFSA       X  
MEALS HCFSA       X  
MEDICAL ALERT BRACELET/NECKLACE/USB DATA CARD
(Coverage Code 104)
HCFSA X       Watches with medical alert identifications are not eligible.
MEDICAL INFORMATION
(Coverage Code 104)
HCFSA X       Amounts paid to a plan that maintains electronic medical information for you, your spouse or dependents are eligible for reimbursement under an HCFSA.
MEDICAL RECORDS
(Coverage Code 104)
HCFSA X       Costs associated with copying or transferring medical records to a new provider are eligible for reimbursement.
MEDICAL SAVINGS ACCOUNTS HCFSA       X  
MEDICAL SERVICES
(Coverage Code 104)
HCFSA X       Expenses for medical services prescribed by physicians or other health care providers acting within their scope of licensure can be reimbursed under a HCFSA.
MEDICAL SUPPLIES
(Coverage Code 104)
HCFSA X        
MEDICATED LIP PRODUCTS
(Coverage Code 117)
HCFSA     X   Medicated lip products that are used to treat severely dry, chapped lips or cold sores are eligible for reimbursement from your HCFSA. Examples include:
  • Blistex Medicated Lip Ointment
  • Carmex Medicated Lip Balm
  • Neosporin Lip Treatment
For information on submitting OTC expenses, see the OTC Quick Reference Guide. Non-medicated lip products with moisturizers are not eligible.
MENSTRUAL RELIEF
(Coverage Code 117)
HCFSA     X   Examples include:
  • Midol
  • Pamprin
  • Premysyn PMS
For information on submitting OTC expenses, see the OTC Quick Reference Guide.
MID-WIFE
(Coverage Code 104)
HCFSA X        
MIGRAINE RELIEF
(Coverage Code 117)
HCFSA     X   Examples include:
  • Advil Migraine
  • Excedrin
  • Motrin Migraine
For information on submitting OTC expenses, see the OTC Quick Reference Guide.
MILEAGE
(Coverage Code 120)
HCFSA X      

Beginning January 1, 2014 the mileage rate will be 23.5 cents per mile.

For 2013 dates of service, the mileage rate is 24 cents per mile.

You will need to round your amount to the nearest value. For instance, for a 7 mile trip at 23.5 cents per mile, the amount will calculate to $1.645. Using standard rounding logic, this would be reimbursed at $1.65. If the amount was $1.644, it would be $1.64.

If you are submitting only a mileage claim, you must include the provider’s name and address, the date(s) of service, type of service, and number of miles traveled.

If you are submitting a mileage claim along with a corresponding medical claim, you only need to provide the number of miles traveled.

See the Mileage Worksheet for a convenient list to submit along with your claim form.

If you are requesting reimbursement for parking as well as mileage, you must include a parking receipt which indicates date(s) of service and cost.

MINERALS
(Coverage Code 102)
HCFSA   X     Examples include:
  • Calcium
  • Caltrate
  • Feosol
  • Ferrous Sulfate
  • Folic Acid
For information on submitting OTC expenses, see the OTC Quick Reference Guide.
MISSED APPOINTMENT FEES HCFSA       X  
MOTION SICKNESS MEDICINES
(Coverage Code 117)
HCFSA     X   Examples include:
  • Bonine
  • Dramamine
  • Marizine
For information on submitting OTC expenses, see the OTC Quick Reference Guide.
MOTION SICKNESS WRISTBANDS
(Coverage Code 102)
HCFSA X        

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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N Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
NASAL SPRAY
(Coverage Code 117)
HCFSA     X   Nasal sprays that are used to alleviate snoring or reduce nasal congestion are eligible for reimbursement from your HCFSA with a prescription from your healthcare provider. Examples include:
  • Afrin Nasal Spray
  • Dristan Nasal Spray
For information on submitting OTC expenses, see the OTC Quick Reference Guide.
NASAL STRIPS
(Coverage Code 102)
HCFSA X       Nasal strips or supplies that are used to alleviate snoring or reduce nasal congestion are eligible for reimbursement from your HCFSA. Examples include:
  • Breathe Right
  • Snorezz
For information on submitting OTC expenses, see the OTC Quick Reference Guide.
NATUROPATHIC CARE
(Coverage Code 104)
HCFSA   X     Naturopathic care rendered by a licensed health care professional who provides this care for the treatment of a specific illness or disorder for you, your spouse or dependent can be reimbursed under a HCFSA.
NETI POT
(Coverage Code 102)
HCFSA X        
NEUROMUSCULAR RE-EDUCATION
(Coverage Code 104)
HCFSA X        
NEWBORN NURSING CARE HCFSA       X Nursing services for a normal, healthy newborn are not an eligible expense.
NURSING CARE AND SERVICES (private duty nursing)
(Coverage Code 104)
HCFSA   X     Nursing services are an eligible expense, whether provided in your home or another facility. The nurse need not be an R.N. or L.P.N., so long as the services rendered are of a kind generally performed by a nurse. These include services directly related to caring for and monitoring your, your spouse’s or dependent’s condition, including:
  • Preparing and giving medication
  • Changing dressings and providing wound care
  • Monitoring vital signs
  • Assessing responses to prescribed treatments, and documenting those assessments in written notes

If the individual providing nursing services also provides household and personal services, only those charges related to actual nursing care are eligible expenses.

NURSING HOME
(Coverage Code 104)
HCFSA   X     Expenses for medical care in a nursing home for you, your spouse and dependent(s), including meals and lodging may be reimbursed if the main purpose of the stay is to receive medical care.

If the primary reason for confinement is personal (i.e., you or your spouse or dependent needs assistance with activities of daily living, safety issues, etc.), only the portion of the cost that is directly related to medical care or nursing services may be reimbursed.

NUTRITIONIST
(Coverage Code 104)
HCFSA   X     Nutritional services related to the treatment and guidance of a specific diagnosis or medical condition can be reimbursed.

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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O Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
OCCLUSAL/BITE GUARDS
(Coverage Code 202)
HCFSA
LEX HCFSA
X       This does not include mouth guards used for sports activities.
OCCUPATIONAL THERAPY
(Coverage Code 104)
HCFSA X        
OPTOMETRIST
(Coverage Code 303)
HCFSA
LEX HCFSA
X        
ORAL CARE
(Coverage Code 117)
HCFSA     X   Examples include:
  • Anbesol
  • Biotene Dry Mouth Mouthwash
  • Orajel
  • Oral Balance
For information on submitting OTC expenses, see the OTC Quick Reference Guide.
ORTHODONTIA
(Coverage Code 203)
HCFSA
LEX HCFSA
X       See Orthodontia Quick Reference Guide for more information.
ORTHOPEDIC SHOES
(Coverage Code 104)
HCFSA   X     Only shoes custom-fitted to the wearer’s feet are eligible. Only the cost difference between the custom-made shoe and a regular comparable shoe is reimbursable. Mass produced shoes are not eligible. You will be responsible for providing third party documentation of cost comparisons with each request for reimbursement.
ORTHOTIC INSERTS
(Coverage Code 102)
HCFSA X       Custom-made and over-the-counter inserts are eligible for reimbursement.
OSTEOPATH
(Coverage Code 104)
HCFSA X        
OVER-THE-COUNTER MEDICINES/DRUGS
(Coverage Code 117)
HCFSA     X   For information on submitting OTC expenses, see the OTC Quick Reference Guide.
OVER-THE-COUNTER SUPPLIES
(Coverage Code 102)
HCFSA X       For information on submitting OTC expenses, see the OTC Quick Reference Guide.
OVER-THE-COUNTER SUPPLIES
(Coverage Code 102)
LEX HCFSA X       Eligible dental or vision over-the-counter expenses, such as denture adhesives, and contact lens cleaning, soaking solutions and lens cases may be reimbursed.
OVULATION MONITOR
(Coverage Code 102)
HCFSA X        
OXYGEN
(Coverage Code 104)
HCFSA   X      

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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P Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
PAIN RELIEVERS
(Coverage Code 117)
HCFSA     X   Examples include:
  • Advil
  • Aleve
  • Aspercreme
  • Aspirin
  • BenGay
  • Ibuprofen
  • Icy Hot
  • Midol
  • Naprosyn
  • Pamprin
  • Tylenol
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
PARENTAL FEES HCFSA       X Fees or premiums paid to participate in a state-funded assistance program for the medical care of disabled dependents are not eligible for reimbursement from your HCFSA.
PARKING FEES AND TOLLS
(Coverage Code 104)
HCFSA X       You must submit documentation of services rendered that correspond to the dates requested. See TRANSPORTATION
PATTERNING EXERCISES
(Coverage Code 104)
HCFSA   X     While these exercises are often done by family members, the expense to hire someone to perform patterning exercises is an eligible expense.
PENILE IMPLANTS
(Coverage Code 104)
HCFSA   X     Amounts paid for implants may be eligible if the diagnosis of impotence is due to organic causes, such as diabetes, post-prostatectomy complications, or spinal cord injury.
PERMANENT CONTACT LENSES
(Coverage Code 303)
HCFSA X       Examples include:
  • Corneal ring segments
  • Intacs
PERSONAL ITEMS HCFSA       X Items that are used for personal grooming and not to treat a specific medical condition are not eligible for reimbursement.
PHYSICAL THERAPY
(Coverage Code 104)
HCFSA X       Examples include:
  • Neurological Therapy
  • Orthopedic Therapy
  • Rehabilitation
PHYSICIAN FEES, Pre-paid HCFSA       X Pre-paid physician fees that cover the cost of services such as exams, physicals, screenings, check-ups and immunizations, are not eligible for reimbursement. A common example is an annual pre-paid fee to access the services of an on-staff physician. Also see BOUTIQUE PRACTICE/CONCIERGE/PRE-PAID PHYSICIAN FEES.
PILLOWS, lumbar support
(Coverage Code 102)
HCFSA   X     Pillows or cushions that provide lumbar support may be eligible for reimbursement if prescribed by a licensed health care provider to alleviate a specific medical condition.
PLACEMENT SERVICES DCFSA X       The up-front fee may qualify if it is an expense that must be paid in order to obtain care. However, the fee can only be reimbursed proportionately over the duration of the agreement to employ the dependent care provider, such as an au pair or a registration fee for a summer camp program. The weekly stipend, as well as other work-related expenses, may also qualify as an expense for the care of a qualifying individual.
POST-MASTECTOMY CLOTHING
(Coverage Code 104)
HCFSA X       Prosthetic bras and related clothing purchased after any surgical procedure related to breast cancer (lumpectomy, mastectomy, etc.) are eligible for expenses. Prosthetic bras and inserts are reimbursable at 100%. Tank tops or swimwear with built-in prosthetic bras are reimbursed up to 50% of the total cost not to exceed $75.
PREGNANCY AIDS
(Coverage Code 104)
HCFSA X       Items that relieve or reduce the discomfort of pregnancy may be reimbursed under a HCFSA. Examples include:
  • Maternity girdles
  • Elastic hosiery
  • Maternity support belts
PREGNANCY TESTS
(Coverage Code 102)
HCFSA X        
PRESCRIPTION DRUG DISCOUNT PROGRAM HCFSA       X Fees paid to get access to drugs at a reduced cost are not eligible for reimbursement under a HCFSA. Actual costs paid for prescription drugs are an eligible expense.
PRESCRIPTION DRUGS
(Coverage Code 103)
HCFSA X       Eligible expenses include deductibles, co-payments or co-insurance as well as the costs for prescription drugs that may not be covered under FEHB, such as drugs that treat erectile dysfunction. Your claim documentation must include either the name of the drug or a receipt indicating the item is a prescription along with the provider's name and the date of service.
PRESCRIPTION DRUGS - IMPORTED
(Coverage Code 103)
HCFSA   X     With rare exception, a prescription drug purchased outside of the United States is not eligible for reimbursement from an FSA. However, if the FDA has approved importing a prescription drug into the U.S. under the “Compassionate Use Act”, it may be an eligible expense. This includes drugs recommended for treatment of a serious condition for which effective treatment may not be available in the U.S., or to continue treatment of a serious condition that was begun in a foreign country. Please see the prescription drug FAQ on the Summary of Benefits for more information.
PREVENTIVE CARE SCREENINGS
(Coverage Code 104)
HCFSA X       If the tests are designed to assess symptoms of a medical diagnosis, they are eligible for reimbursement. Examples include clinic and home testing kits for blood pressure, glaucoma, cataracts, hearing, cholesterol, etc.
PROBIOTICS
(Coverage Code 102)
HCFSA   X     Probiotic supplements are not reimbursable if they are merely taken for general health. However, they may be reimbursable if recommended by a medical practitioner to treat a specific medical condition.

Examples include:

  • Culturelle
  • Flora Q
  • Sustenex

For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PROLOTHERAPY
(Coverage Code 104)
HCFSA X       Prolotherapy or injection therapy for joint pain is eligible.
PROSTHETICS
(Coverage Code 104)
HCFSA X        
PSYCHIATRIC SERVICES AND CARE
(Coverage Code 104)
HCFSA X        
PSYCHOANALYSIS
(Coverage Code 104)
HCFSA X        
PSYCHOLOGIST
(Coverage Code 104)
HCFSA X        
PULSE OXIMETER
(Coverage Code 104)
HCFSA X        

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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R Print This Section
Condition/Type of Service/Expense HCFSA Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
RADON MITIGATION
(Coverage Code 104)
HCFSA   X     If a physician requires radon mitigation in your home due to a medical condition caused or aggravated by an unacceptable level of radon, some expenses may be eligible. However, if the home’s value is increased due to the mitigation, some or all of the expenses may not be reimbursable. Use the Capital Expense Worksheet to determine how much of the expense is eligible. You will be responsible for providing third party documentation of cost comparisons with each request for reimbursement.

The cost of the test to determine if radon is present in the home is not eligible.

READING GLASSES
(Coverage Code 303)
HCFSA
LEX HCFSA
X       See EYEGLASSES
RETRIEVING TOOLS
(Coverage Code 104)
HCFSA X       Examples include:
  • EZ Grabber
  • Gopher
ROGAINE
(Coverage Code 117)
HCFSA   X X   For information on submitting OTC expenses, see the OTC Quick Reference Guide.

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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S Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
SALES TAX HCFSA         See TAXES
SCOOTERS
(Coverage Code 104)
HCFSA   X      
SERVICE ANIMALS
(Coverage Code 104)
HCFSA X       Expenses to train or procure any guide dog, signal dog, or other animal individually trained to provide assistance to you, your spouse or dependent with a disability can be reimbursed under a HCFSA. Expenses such as food, medications, vet visits, and dental care products needed for the care or maintenance of service animals are eligible expenses.

Please note, you must provide documentation to support the expense is for an actual service animal.

SHAMPOO, medicated
(Coverage Code 117)
HCFSA   X X   May be eligible when used to treat a specific medical condition.

Examples include:

  • Denorex
  • DHS Tar Shampoo
  • Nizoral

A Letter of Medical Necessity (LMN) from your physician must be signed by your health care practitioner, state your medical diagnosis, the name of the medicated shampoo that will treat the medical diagnosis and specify the length of time the medicated shampoo is required.

Please note, this does not include cosmetic-type shampoos.

SHIPPING AND HANDLING
(Coverage Code 104)
HCFSA X       Shipping and handling charges for medical needs, such as mail-order prescriptions and eligible over-the-counter items.
SHOWER CHAIRS
(Coverage Code 104)
HCFSA X        
SITZ BATH
(Coverage Code 104)
HCFSA X        
SLEEP AIDS
(Coverage Code 117)
HCFSA     X   Examples include:
  • Nytol
  • Sominex
  • Tylenol PM
  • Unisom
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
SMOKING CESSATION MEDICINES
(Coverage Code 117)
HCFSA     X   Examples include:
  • Commit
  • Nicoderm CQ
  • Nicorette
  • Nicotrol
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
SMOKING CESSATION PROGRAMS
(Coverage Code 104)
HCFSA X        
SPECIAL EDUCATION AND SCHOOLS
(Coverage Code 104)
HCFSA   X     See LEARNING DISABILITIES
SPECIAL FOODS
(Coverage Code 104)
HCFSA   X     If prescribed by a physician to treat a special illness or ailment, and not merely as a substitute for normal nutritional requirements.

The amount that can be reimbursed is limited to the amount that the special food exceeds the cost of commonly available versions of the same product.

SPECIALIZED EQUIPMENT OR SERVICES
(Coverage Code 104)
HCFSA         See ADAPTIVE EQUIPMENT
SPEECH THERAPY
(Coverage Code 104)
HCFSA X        
SPERM STORAGE
(Coverage Code 104)
HCFSA   X     Storage fees can be reimbursed if you, your spouse or dependent has a cancer or blood dyscrasia diagnosis that requires chemotherapy or whole body radiation which may affect future ability to conceive children. NOTE: Storage fees should not exceed 12 months. If you pre-pay for 12 months, you may only be reimbursed when the expenses have been incurred. The amount can be pro-rated in order to file claims for reimbursement after services are rendered.
STERILIZATION PROCEDURES
(Coverage Code 104)
HCFSA X        
STERILIZATION REVERSAL
(Coverage Code 104)
HCFSA X        
STUDENT HEALTH FEE HCFSA       X  
SUBSTANCE ABUSE
(Coverage Code 104)
HCFSA X       See ALCOHOLISM
SUBWAY FARE
(Coverage Code 104)
HCFSA X       See TRANSPORTATION
SUNBURN/BURN RELIEF
(Coverage Code 102)
HCFSA X       Examples include:
  • Aloe Vera
  • Solarcaine
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
SUN-PROTECTIVE CLOTHING
(Coverage Code 104)
HCFSA   X     Clothing that offers at least 30+ UVA and UVB sun protection for individuals with melanoma or other skin cancer, systemic lupus erythematosus (SLE), acute cutaneous lupus (ACLE) or other significant dermatologic conditions may be eligible with a letter of medical necessity from your doctor. The clothing is reimbursed for the difference between “normal” apparel and this specially-constructed clothing up to 33% of the total cost. The receipt must show the purchase was from an accredited sun-protective company such as Solumbra® or Coolibar®.
SUNSCREEN
(Coverage Code 102)
HCFSA X       Sunscreen products with an SPF 15 or higher are eligible. Lotions or cosmetics that contain ingredients to protect you from the sun and/or list a SPF are not eligible. For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
SUPPLEMENTS - CALCIUM
(Coverage Code 102)
HCFSA   X     Examples include:
  • Calcium Carbonate
  • Calcium Citrate
  • Calcium Gluconate
  • Calcium Lactate
  • Caltrate
  • Citrical
  • Tricalcium Phosphate
  • Viactiv
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
SUPPLEMENTS - DIETARY
(Coverage Code 102)
HCFSA   X     Examples include:
  • Ensure
  • Glucerna
  • Power drinks
  • Protein bars
Meal replacements are not eligible. Dietary supplements must be necessary to treat a specific medical condition.

For more information on submitting OTC expenses, see the OTC Quick Reference Guide.

SUPPLEMENTS - FIBER
(Coverage Code 102)
HCFSA   X     Examples include:
  • Benefiber
  • Metamucil
For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
SUPPLEMENTS - FISH OIL/OMEGA 3
(Coverage Code 102)
HCFSA   X     For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
SUPPLEMENTS - HERBAL
(Coverage Code 102)
HCFSA   X     Examples include:
  • Echinacea
  • Gingko Biloba
  • Milk Thistle
  • Soy
  • St. John's Wort
  • Turmeric
  • Valerian

For more information on submitting OTC expenses, see the OTC Quick Reference Guide.

SUPPLEMENTS - HORMONE, OTC
(Coverage Code 117)
HCFSA   X X   Supplements used for relief of peri-menopausal or menopausal symptoms may be reimbursed. For more information on submitting OTC expenses, see the OTC Quick Reference Guide.
SUPPLEMENTS - LACTOSE INTOLERANCE
(Coverage Code 102)
HCFSA X       Examples include:
  • DairyCare
  • Digestive Advantage
  • Lactaid
Please note: Lactose-free milk and/or food products are not eligible for reimbursement.

For information on submitting OTC expenses, see the OTC Quick Reference Guide.

SUPPLEMENTS - NUTRITIONAL
(Coverage Code 102)
HCFSA   X     Dietary, nutritional, and herbal supplements, vitamins, and natural medicines are not reimbursable if they are merely beneficial for general health. However, they may be reimbursable if recommended by a medical practitioner to treat a specific medical condition.
SURROGACY EXPENSES
(Coverage Code 104)
HCFSA X       Surrogacy expenses can be reimbursed only if the FSAFEDS participant is the surrogate.
SWIM/SKI GOGGLES, PRESCRIPTION HCFSA       X  

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

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T Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
TANNING SALON OR EQUIPMENT
(Coverage Code 104)
HCFSA   X     May be reimbursed under a HCFSA for treatment of certain skin disorders, such as eczema and psoriasis. The cost of the equipment must be divided by the number of individuals living in the household and is only reimbursable for the individual with the medical condition.

Expenses to improve general health and/or appearance are not eligible.

TAXES
(Coverage Code 104)
HCFSA X       Taxes on medical services and products may be reimbursed under a HCFSA. This includes local, state, service and other taxes.
TAXI FARE
(Coverage Code 104)
HCFSA X       See TRANSPORTATION
TEETH WHITENING HCFSA
LEX HCFSA
      X Teeth whitening products or services to enhance the brightness of your teeth are cosmetic and cannot be reimbursed.
TEETH WHITENING (cont.)
(Coverage Code 202)
HCFSA
LEX HCFSA
  X     Teeth whitening performed to restore function after an injury or trauma or to correct a congenital disease can be reimbursed.
TELEPHONE FOR HEARING IMPAIRED
(Coverage Code 104)
HCFSA X       The cost difference associated with purchasing or repairing special telephone equipment versus a standard telephone for you, your spouse or dependent with a hearing impairment are eligible for reimbursement under a HCFSA. You will be responsible for providing third party documentation of cost comparisons with each request for reimbursement.
TEMPORARY CONTINUATION OF COVERAGE (TCC) PREMIUMS HCFSA       X Under IRS rules, insurance premiums cannot be reimbursed under a health care FSA.
TOILET SEAT EXTENDERS
(Coverage Code 104)
HCFSA X        
TOOTHBRUSHES HCFSA       X Toothbrushes, including electric or battery-powered, are personal care items and not eligible for reimbursment.
TRAIN FARE
(Coverage Code 104)
HCFSA X       See TRANSPORTATION
TRANSPORTATION
(Coverage Code 104)
HCFSA   X    

Costs of transportation to/from locations of medical care/service may be eligible for reimbursement from your health care FSA, but only if certain requirements are met. Please click here for details.

TRANSPORTATION, to and from the day/elder care provider DCFSA       X Transportation to and from the day care or elder care location is not eligible.
TRICARE PREMIUMS HCFSA       X Under IRS rules, insurance premiums cannot be reimbursed under a health care FSA.
TRIPS HCFSA       X Excursions taken for a change in environment, general health improvement etc., even those taken on the advice of your health care provider are not an eligible expense.
TUITION EXPENSES OR FEES
(Coverage Code 104)
HCFSA   X     See LEARNING DISABILITIES

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  Back to top

U Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
UCR, CHARGES ABOVE
(Coverage Code 104)
HCFSA X       Medical expenses in excess of your plan’s usual, customary and reasonable (UCR) charges may be reimbursed under a HCFSA if the underlying expense is eligible.
ULTRASOUND, PRE-NATAL
(Coverage Code 104)
HCFSA X        

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  Back to top

V Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
VARICOSE VEINS TREATMENT/
SCLEROTHERAPY
(Coverage Code 104)
HCFSA X        
VASECTOMY
(Coverage Code 104)
HCFSA X        
VASECTOMY REVERSAL
(Coverage Code 104)
HCFSA X       See STERILIZATION REVERSAL
VISION CARE
(Coverage Code 303)
HCFSA
LEX HCFSA
X       Expenses such as eye exams, vision correction procedures, vision therapy and glasses or contact lenses are eligible. Eye glass cases are not eligible.
VISION DISCOUNT PROGRAMS HCFSA
LEX HCFSA
      X Fees paid to gain access to a vision network, or to a reduced fee structure are not an eligible expense under a HCFSA.

See INSURANCE PREMIUMS

VITAMIN B-12 INJECTIONS
(Coverage Code 104)
HCFSA   X      
VITAMINS
(Coverage Code 102)
HCFSA   X     Vitamins, dietary, nutritional and herbal supplements, and natural medicines are not reimbursable if they are merely taken for general health. However, they may be eligible if recommended by a medical practitioner to treat a specific medical condition.
VITAMINS, PRE-NATAL
(Coverage Code 102)
HCFSA X        

*Please note, all "potentially eligible health care expenses" require a letter of medical necessity from your health care provider in order to be considered eligible for reimbursement. The letter must include the diagnosis or symptoms for which you, your spouse, dependent or adult child through age 26 are being treated, along with specific information on how the product or service is intended to alleviate symptoms or improve function. Submitting a LMN for your claim does not guarantee that the expense will be reimbursed. You must submit a new LMN each year if the medical condition persists - they cannot be approved indefinitely.

As of January 1, 2011 eligible over-the-counter (OTC) products that are medicines or drugs (e.g., acne treatments, allergy and cold medicines, antacids, etc.) will only be eligible for reimbursement from your Health Care FSA with a physician's prescription that includes his or her address and license number, as stated in IRS Notice 2010-59. The only exception is insulin - which will not require a prescription. OTC products or items that are not considered medicines or drugs, such as bandages and nasal strips, will continue to be eligible without a prescription. For information on submitting OTC expenses, see the OTC Quick Reference Guide.

PLEASE NOTE: Eligible expenses listed here are subject to change without notice.

A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  Back to top

W Print This Section
Condition/Type of Service/Expense Account Type Eligible
Expense
Potentially
Eligible
Expense*
OTC
Prescription
Required
Not
Eligible
Additional Information
WALKERS
(Coverage Code 104)
HCFSA X        
WARRANTIES HCFSA
LEX HCFSA
      X Warranties that cover the replacement of items such as eyeglasses, hearing aids, or adaptive equipment are not eligible for reimbursement.
WART REMOVAL
(Coverage Code 117)
HCFSA     X   Examples include:
  • Compound W
  • Dr. Scholl's Clear Away
  • Wart-Off
For information on submitting OTC expenses, see the OTC Quick Reference Guide.
WATER FLUORIDATION
(Coverage Code 999)
HCFSA   X      
WEIGHT LOSS DRUGS, OTC HCFSA   X X   OTC drugs, such as Alli, are only potentially eligible. For information on submitting OTC expenses, see the OTC Quick Reference Guide.
WEIGHT LOSS PROCEDURES/SURGERY
(Coverage Code 104)
HCFSA X       Examples include:
  • Bariatric Surgery
  • Gastric Bypass
  • Lap Band Surgery
WEIGHT LOSS PROGRAMS
(Coverage Code 104)
HCFSA   X     Drugs, such as Phentermine, may be recommended as part of a weight loss program, in which case a Letter of Medical Necessity (LMN) signed by a health care provider is required. Food is not eligible, even if it is part of the weight loss program. See FOOD
WELL-BABY/WELL-CHILD CARE
(Coverage Code 104)
HCFSA X        
WHIRLPOOL BATHS
(Coverage Code 104)
HCFSA   X     You will be responsible for providing third party documentation of cost comparisons with each request for reimbursement. See CAPITAL EXPENSE
WHEELCHAIRS
(Coverage Code 104)
HCFSA X       Includes electric wheelchairs and replacement parts.
WIG
(Coverage Code 104)
HCFSA   X     The full cost of a wig purchased because the patient has lost all of his or her hair from disease or treatment.

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PLEASE NOTE: Eligible expenses listed here are subject to change without notice.