FSA Eligible Expenses: Health Care

Caring for the Handicapped

Lab Exams/Tests

Routine or Preventative Care

Automobile modifications*

Blood tests

Flu Shots

Language training for disabled child*

Body scans

Immunizations/Vaccinations

Mentally handicapped or disabled

Cardiographs

Physical exams

person's cost for special home*

Cholesterol testing

Specialists

Special Education for the blind

Laboratory fees

Christian Science Practitioner*

Tuition oat special school for

Mammograms

Chiropractor

handicapped

Radiology

Dermatologist

Urine/stool analysis

Nutritionist*

Child Birth and Well-Being

X-Rays

Osteopath

Childbirth expenses (Physician,

Psychiatrist

hospital, etc.)

Medical Equipment

Psychologist

Doula*

Artificial limb/prosthetics

Lactation consultant*

Autoette/wheelchair

Therapy

Lead-based paint removal*

Blood pressure monitor

Alcoholism treatments

Midwife services

Blood sugar test kit/strips

Drug dependency treatments

Pedialyte for child's dehydration*

Compression hosiery (for treatment of

Massage*

varicose veins)

Psychoanalysis*

Dental

Crutches

Physical therapy

Bridges

Custom orthotic

Smoking cessation programs

Crowns (non-cosmetic)

Diabetic supplies

Speech therapy

Dentures

Glucose monitoring test kit

Exams and teeth cleaning

Heating pads

Vision

Fillings

Hot/cold packs

Artificial eyes

Gum treatment

Medic-alert bracelet

Contact lenses and cleaning solutions

Implants

Nose Strips*

Eye drops

Occlusal guards

Orthopedic shoes* (to the extent the

Eye examinations

Oral surgery

cost exceeds that of normal shoes)

Eye surgery

Orthodontia

Prosthesis

Eyeglasses

Rood canals

Room vaporizer

Laser eye surgery/LASIK

X-Rays

Syringes

Prescription sunglasses

Wig*

Seeing eye dog and its upkeep

Family Planning

Birthing/Lamaze

Medical Procedures

Condoms

Acupuncture

Fertility treatments

Breast reconstruction surgery (following

Oral contraceptives

mastectomy due to disease)

Pregnancy test kit

Operations (non-cosmetic)

Prenatal vitamins*

Organ donor's medical expenses

Tubal ligation

Surgical fees

Vasectomy

Hearing

Medicines/Drugs

Other

Hearing aid devices and batteries

Fiber supplements*

Ambulance service

Hearing exams

Glucosamine/Chondroitin*

Co-insurance and co-pays

Telephone for the hearing impaired

Herbal supplements*

Deductible eligible expenses

Insulin

Hospital services

Prescription Drugs

Special food/beverage* (cost

difference from regular food

purchase)

Stem cell harvesting*

Transportation expenses incurred for

the rendering of medical services

Weight-loss program*

FSA Eligible Expenses: Health Care Over-the-Counter Items

Asthma flow meters

Eye drops

Nasal strips

Bandages

Eyeglasses

Nebulizers

Blood pressure monitors

First-Aid-Kits

Ointments

Callous and corn removers

Gauze and gauze pads

Rubbing alcohol

Cholesterol tests

Heart rate monitors

Sunburn cream

Contact lens solution

Heating pads

Supports and braces

Crutches

Hydrogen Peroxide

Thermometers

Cushions, pads, arch supports

Incontinence supplies for adults

Wart removal products

Denture care products

Medical bracelets and necklaces

Wound care products

Diabetes care:

Medical tape

Blood test strips, glucose kits,

monitors and testers

The IRS does not allow the following expenses to be reimbursed under FSAs, as they are not prescribed

by a physician for a specific ailment.

FSA Ineligible Expenses: Health Care

Baby-sitting and Child Care*

Hair Loss Medication

Maternity Clothes

Cosmetic Surgery/Procedures

Hair Transplant

Swimming Lessons

Dancing/Exercise/

Health Club Dues*

Teeth Bleaching or Whitening

Fitness Programs*

Insurance Premiums and Interest

Vitamins or

Diaper Service

Long-Term Care Premiums

Nutritional Supplements*

Electrolysis

Marriage Counseling

Exercise Equipment/

Personal Trainers

Over-the-Counter Items

Mailing Address:

The IRS allows certain over-the-counter (OTC) items to be

PO Box 730

reimbursed using your FSA dollars. As of January 1, 2011 some

25 Depot Street

of the items previously allowed will become ineligible for

Falmouth, MA 02540

reimbursement through your FSA plan due to changes with

Telephone:

Healthcare Reform. All OTC medicines and drugs will no longer

(877) 972-9765 toll free within MA

be allowed unless the participant obtains a prescription or

(508)457-0333 ex.103 or 105

Note of Medical Necessity from their doctor.

Fax:

If an employee has a Note of Medical Necessity or a prescription

(508)457-9994

for an OTC drug or medicine, they must submit this note to

PayPlans & Benefits annually to keep on file. Then, they must pay

Web:

at the point of service and submit a manual Reimbursement

www.payplansandbenefits.com

Request Form for reimbursement.

Employees can continue to use their FSA funds to purchase OTC items that are not considered a drug or a

medicine (e.g. bandages, wound care, contact lens solution). The Benny™ Prepaid Benefits Card can continue

to be used for these purchases.

FSA Eligible Expenses: Dependent Care

Eligible expenses under a Dependent Care FSA are defined

as those that enable the participant or the participant's spouse

to work or to look for work. For purposes of a Dependent Care

FSA plan, a "qualified dependent" must be under the age of 13,

unless mentally or physically handicapped. Per IRS regulations,

the service provider cannot be an individual under the age of 19

whom a personal tax exemption may be claimed and, a child

of the participant or spouse.

Eligible Expenses

Ineligible Expenses

After-school care or

Household expenses provided

Babysitting for social events

extended day programs

that a portion of such expenses

Educational expenses

Babysitters (not for social

is incurred to ensure a

Expenses deducted from

events)

qualifying dependent's

personal income tax

Caregivers for a disabled

well-being and protection

return (dependent care)

spouse or dependent who

Nursery schools

Kindergarten

lives with the participant

Transportation services provided

Overnight camps

Child care centers that care

by the dependent care provider

for six of more children and

that meet the IRS's definition

of a qualified day care center

Day camps

You must pay at the point of service and submit a manual Reimbursement Request Form for reimbursement.

Reimbursement Request Form

NOTE: This list is not meant to be all-inclusive. For a full list please refer to IRS Cods Section 213(d). Also, expenses marked with an asterisk (*) are potentially eligible expenses"

that require a Note of Medical Necessity from your health care provided to qualify for reimbursement.

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