Expenses on this list are deemed eligible or potentially eligible for reimbursement, if:

  • the expense qualifies as an eligible medical expense in accordance with Internal Revenue Code (IRC) Section 213 and;
  • the expense is listed on a claim form submitted with supporting documentation that meets the terms of the  Medical Expense Reimbursement (FSA) Plan Document

IRC Section 213 defines medical expenses as costs incurred for the diagnosis, cure, mitigation, treatment, or prevention of disease that affects any part or function of the body. Eligible expenses must be primarily to alleviate or prevent a physical or mental defect or illness. Amounts paid for acupuncture services rendered in connection with the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body are qualifying. Any ancillary services and/or products (e.g. herbs) for which expenses are incurred are not eligible.

LMN or OTC Requirements:

Please note, all “potentially eligible” medical expenses must be accompanied by a completed  FSA Letter of Medical Necessity Form (County form), a formal letter from a physician, or if applicable, a prescription issued by a physician. The form/letter must demonstrate that the medical expenses are being incurred as a direct result of a medical condition and that the recommended treatment meets the requirements of IRC Section 213.

Claims are subject to review and approval by EBSD and will be processed in accordance with IRC Section 213 and the County’s Medical Expense Reimbursement (FSA) Plan Document. If any discrepancy exists between this list, the IRC or FSA Plan Document, the IRC and FSA Plan Document will govern. For additional information regarding the Medical Expense Reimbursement (FSA) Plan, please visit the  FSA Plan’s webpage.

A

ExpensesEligiblePotentially Eligible Not Eligible
Acne TreatmentX
ExpensesAcne Treatment
Comments & Special Rules

Acne treatment is eligible as long as the product’s primary purpose is to treat the acne. Acne fighting ingredients are not eligible.

Activity TrackerX
AcupressureX
ExpensesAcupressure
Comments & Special Rules

Amounts paid for acupuncture services rendered in connection with the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body are qualifying. Any ancillary services and/or products (e.g. herbs) for which expenses are incurred are not eligible.

Adaptive EquipmentX
ExpensesAdaptive Equipment
Comments & Special Rules

Includes various items that assist individuals in performing activities of daily living. Examples include:

  • Shower bar handles/grips
  • Shower chairs
  • Sitz bath
  • Toilet seat extenders

Refer to the LMN Requirements for eligibility criteria.

AdoptionX
ExpensesAdoption
Comments & Special Rules

Medical expenses related to adoption. Adoption fees are not covered.

Air Conditioners/ Air Purifiers X
ExpensesAir Conditioners/ Air Purifiers
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Addiction Treatment/ ProgramsX
ExpensesAddiction Treatment/ Programs
Comments & Special Rules

Includes out of pocket expenses that are incurred for in/out patient treatments at centers for alcohol, substance abuse or any other addiction that may be considered detrimental to one’s health. Cost incurred for travel to obtain treatment may qualify as an eligible expense.

Refer to the LMN Requirements for eligibility criteria.

Allergy Medicines X
Allergy ProductsX
ExpensesAllergy Products
Comments & Special Rules

Expenses will not qualify if product would be purchased in absence of allergy (e.g. household items such as vacuum cleaner, pillow, etc.)

Refer to the LMN Requirements for eligibility criteria.

Allergy Treatment ProductsX
ExpensesAllergy Treatment Products
Comments & Special Rules

Hepa Filters, Air purifier, etc.

Refer to the LMN Requirements for eligibility criteria.

AmbulanceX
ExpensesAmbulance
Comments & Special Rules

Fees charged by the Cities, are an eligible expense.

AnesthesiaX
ExpensesAnesthesia
Comments & Special Rules

For non-cosmetic purposes.

Antacids/ Acid Reducers X
Antibiotics Ointments or CreamsX
ExpensesAntibiotics Ointments or Creams
Comments & Special Rules

Examples include:

  • Neosporin
  • Polysporin
Anti-DiarrhealX
AntifungalX
AntihistaminesX
Anti-Itch Ointments or Creams X
Arthritis/Osteoarthritis ProductsX
ExpensesArthritis/Osteoarthritis Products
Comments & Special Rules

Expenses incurred to treat and/or alleviate symptoms associated with arthritis/ osteoarthritis such as Chrondroitin and Glucosamine.

Refer to the LMN Requirements for eligibility criteria.

Artificial LimbX
Asthma Medicines/ Delivery DevicesX
ExpensesAsthma Medicines/ Delivery Devices
Comments & Special Rules

Delivery devices (e.g., inhalers and neubulizers, etc.) will qualify.

Athletic Treatments/ Braces X
Automobile Modifications X
ExpensesAutomobile Modifications
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

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B

ExpensesEligiblePotentially Eligible Not Eligible
Baby FormulaX
ExpensesBaby Formula
Comments & Special Rules

For example, if your baby requires a special formula to treat an illness or disorder. Please note: only the difference in cost between the special formula and routine baby formula can be reimbursed.

Refer to the LMN Requirements for eligibility criteria.

BactineX
Band-Aids/BandagesX
Beds, Box Springs/foundationsX
Beds, Mattresses X
Bedside CommodesX
Behavioral TherapyX
ExpensesBehavioral Therapy
Comments & Special Rules

For example, behavioral therapy used to treat autism, learning disabilities, and other behavioral conditions.

Refer to the LMN Requirements for eligibility criteria.

Birth ControlX
ExpensesBirth Control
Comments & Special Rules

For example, birth control that is prescribed by a physician and/or devices (e.g., IUD, Norplant insertion or removal).

Birth Control, Over-the-Counter Medications X
ExpensesBirth Control, Over-the-Counter Medications
Comments & Special Rules

Examples include Emergency Contraception (morning after pill) and Spermicides or products with spermicides.

Blood Pressure MonitorsX
Blood StorageX
ExpensesBlood Storage
Comments & Special Rules

Blood storage is an eligible expenses if you are storing blood for the use of a scheduled elective surgery. Storage fees should be temporary and should not exceed six months. The expense can only be reimbursed after services are rendered.

Refer to the LMN Requirements for eligibility criteria.

Body ScansX
ExpensesBody Scans
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Books, health-related X
ExpensesBooks, health-related
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

BotoxX
ExpensesBotox
Comments & Special Rules

For medical conditions.

Refer to the LMN Requirements for eligibility criteria.

Braille Books and Magazines X
Breast Feeding classes X
Breast Pump and Lactation SuppliesX
ExpensesBreast Pump and Lactation Supplies
Comments & Special Rules

Breast pump bras, nursing shawl/cover up, nursing bras and nursing shirts/dresses/garments are not eligible

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C

ExpensesEligiblePotentially Eligible Not Eligible
Cancer ScreeningsX
Car ModificationsX
ExpensesCar Modifications
Comments & Special Rules

For example, modifications such as special hand/pedal controls or wheelchair accessible modifications may be eligible.

Refer to the LMN Requirements for eligibility criteria.

Carpal Tunnel Wrist SupportsX
ExpensesCarpal Tunnel Wrist Supports
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Chairs, Ergonomic X
Childbirth Classes X
ExpensesChildbirth Classes
Comments & Special Rules

Childbirth classes such as Lamaze and Bradley are eligible for reimbursement. Does not include:

  • Breastfeeding Classes
  • Newborn or New Infant Care Classes
  • Parenting Classes
ChiropracticX
ExpensesChiropractic
Comments & Special Rules

Services performed by a chiropractor are eligible such as:

  • Spinal Manipulation
  • TENS Treatment
  • TENS Unit for home use
  • Ultrasounds

Note: Amounts paid for chiropractic services rendered in connection with the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body are qualifying. Any ancillary services (e.g. massage therapy) are not eligible, unless prescribed by a physician. See Massage Therapy for more information.

Cholesterol Test Kits and suppliesX
Classes, Health-related X
ExpensesClasses, Health-related
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Cold & Flu Medicines X
Cold Sore Medicines X
Cold Hot Packs X
Compression Hosiery/Socks, medically approved X
CondomsX
ExpensesCondoms
Comments & Special Rules

Includes male or female condoms. Eligibility for this product is distinguished from other birth control methods as this product is used for the prevention of disease.

Contact Lenses, Materials, Solutions, Cleaners and Equipment X
Co-Payments For Healthcare ServicesX
ExpensesCo-Payments For Healthcare Services
Comments & Special Rules

Copayments are expenses for Healthcare Services (medical, dental, vision, etc.) incurred by you, your spouse, or qualified dependent at the time services are rendered. Copayments, coinsurance, or healthcare plan deductible are eligible for reimbursement. Health Insurance premiums are not eligible. See Health Insurance Premiums for more information.

Cosmetic Dentistry X
ExpensesCosmetic Dentistry
Comments & Special Rules

For example:

  • Teeth whitening or bleaching
  • Porcelain venners
  • Bonding
Cosmetic Procedures X
ExpensesCosmetic Procedures
Comments & Special Rules

Expense may qualify if resulting from a medical condition. Cosmetic procedures to improve or enhance appearance do not qualify.

Refer to the LMN Requirements for eligibility criteria.

Cough Medicines X
CounselingX
ExpensesCounseling
Comments & Special Rules

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

Counseling (cont.) X
ExpensesCounseling (cont.)
Comments & Special Rules

Life coaching, career counseling and marriage counseling do not qualify.

CPAP DevicesX
ExpensesCPAP Devices
Comments & Special Rules

Eligible expenses include replacement parts, repairs and maintenance. Distilled water is not eligible.

CPR classesX
ExpensesCPR classes
Comments & Special Rules

Neither adult or child.

CrutchesX

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D

ExpensesEligiblePotentially Eligible Not Eligible
DecongestantsX
ExpensesDecongestants
Comments & Special Rules

Examples include:

  • Dimetapp
  • Sudafeds
Deductibles- HealthcareX
ExpensesDeductibles- Healthcare
Comments & Special Rules

Note: Expense must not have been reimbursed by secondary insurance or any other source to be eligible.

Defibrillator, PortableX
Dental Care/ TreatmentXX
ExpensesDental Care/ TreatmentX
Comments & Special Rules

Includes expenses incurred for the prevention and alleviation of dental disease. Preventive treatment includes the services of a dental hygienist or dentist for such procedures as teeth cleaning, application of sealants, and fluoride treatments to prevent tooth decay. Treatment to alleviate dental disease includes X-rays, fillings, braces, extractions, dentures, and treatment of other dental ailments and implants. Cosmetic Services/Treatments whose primary function is to improve one’s general appearance (e.g. teeth whitening, veneers) are not eligible.

Dental Floss X
DeodorantX
Diabetic Supplies X
ExpensesDiabetic Supplies
Comments & Special Rules

Glucose monitors/batteries, testing strips, syringe with needle, etc. Note: Diabetic socks are eligible, but only the cost difference between the diabetic socks and regular socks will be reimbursed. You are responsible for providing third party documentation of cost comparisons with each request for reimbursement.

Diaper Rash Ointments or CreamsX
ExpensesDiaper Rash Ointments or Creams
Comments & Special Rules

Types of expenses covered: Balmex, Desitin.

Diapers or Diaper ServiceX
ExpensesDiapers or Diaper Service
Comments & Special Rules

Diapers or Diaper services that are used to relieve the effects of a diagnosed medical condition does qualify.

Note: Disposable/Cloth diapers or a diaper service for care of a newborn does not qualify.

Refer to the LMN Requirements for eligibility criteria.

Diarrhea Medication X
Doctor FeesX
ExpensesDoctor Fees
Comments & Special Rules

This includes but is not limited to:

  • Charges by your physician for completion of medical paperwork or documentation, etc.
  • Physician tele-advice, including email communication

Please note: Retainer fees paid to a provider are not eligible. Retainer fees paid to a provider include any fees paid on a scheduled basis (e.g. monthly) to a provider whether or not treatment is received to retain provider for services. These are commonly known as concierge fees, access fees, or preferred treatment fees.

Drug Testing Kit For HomeX
ExpensesDrug Testing Kit For Home
Comments & Special Rules

In example, a drug testing kit may qualify if used to treat a medical condition such as drug addiction.

Refer to the LMN Requirements for eligibility criteria.

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E

ExpensesEligiblePotentially Eligible Not Eligible
Ear Products X
ExpensesEar Products
Comments & Special Rules

Includes products used to prevent or alleviate disease of the ear such as ear wax removal products or swimmer’s ear drops.

Ear PlugsX
ExpensesEar Plugs
Comments & Special Rules

Expense may qualify if incurred to treat a medical condition. For example, to protect surgically implanted ear tubes.

Refer to the LMN Requirements for eligibility criteria.

Electrolysis or Hair RemovalX
Electrolyte ReplacementsX
ExpensesElectrolyte Replacements
Comments & Special Rules

Examples include:

  • Pedialyte
  • Ceralyte
  • Infalyte
  • Oral Rehydration Salts
Epsom SaltX
ExpensesEpsom Salt
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Exercise Equipment, Programs, or Classes X
ExpensesExercise Equipment, Programs, or Classes
Comments & Special Rules

Qualifies only if required to treat an illness (such as obesity) diagnosed by a physician. The purpose of the expense must be to treat the disease rather than to promote general health, and the expense must not have been incurred in absence of a medical condition. For example, the purchase of home health equipment (e.g. weight bench) to gain muscle mass for general health, but not to treat disease that affects the body’s muscular structure does not qualify.

Refer to the LMN Requirements for eligibility criteria.

Eye Drops X
Eyeglasses/Eye ExamsX
ExpensesEyeglasses/Eye Exams
Comments & Special Rules

Includes prescription sunglasses and reading glasses (even those purchased over-the-counter). Eyeglass frames only without prescription lenses are not eligible. Eyewear Protection Plans are not an eligible expense.

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F

ExpensesEligiblePotentially Eligible Not Eligible
Face Creams X
Face LiftsX
FeesX
ExpensesFees
Comments & Special Rules

Charge card fee is an eligible expense. Fees provider charge to complete paperwork. Finance charges, late fees and cancellation fees are not eligible.

Feminine Hygiene Products X
ExpensesFeminine Hygiene Products
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Fertility TreatmentsX
ExpensesFertility Treatments
Comments & Special Rules

Will qualify to the extent that procedures are intended to overcome an inability to have children and are performed on you, your spouse, or other qualified dependent. Examples are IVF (in vitro fertilization—including temporary storage of eggs or sperm), surgery (including an operation to reverse prior surgery preventing someone from having children), shots, treatments, and GIFT (gamete intrafallopian transfer). Expenses paid to or for an in vitro surrogate usually do not qualify, nor do egg donor expenses unless preparatory to a procedure performed on you, your spouse, or other qualified dependent.

First Aid Kit/Supplies X
ExpensesFirst Aid Kit/Supplies
Comments & Special Rules

Examples include:

  • Antiseptics
  • Bandages
  • Cold/Hot Packs
  • Joint Supports
  • Liquid bandages
  • Peroxide
  • Rubbing Alcohol
  • Splints
  • Thermometers
Fitness Programs/ Classes X
ExpensesFitness Programs/ Classes
Comments & Special Rules

Qualifies only if required to treat an illness (such as heart disease) diagnosed by a physician. The purpose of the expense must be to treat the disease rather than to promote general health, and the expense must not have been incurred in absence of a medical condition. For example, membership with a fitness studio (e.g. spin-cycle studio) to perform cardio fitness exercises to maintain one’s general health, but not to treat disease that affects the body (e.g. heart disease) does not qualify.

Refer to the LMN Requirements for eligibility criteria.

Flu ShotsX
Fluoride Rinse/Pills/GelsX
ExpensesFluoride Rinse/Pills/Gels
Comments & Special Rules

Must be prescribed, even if available without a prescription. Examples include:

  • Act
  • Colgate Phos-flur
Foam Ring Cushion/Donut Pillow X
Foot CareX
ExpensesFoot Care
Comments & Special Rules

Examples include:

  • Arch and insole supports
  • Bunion, blister and corn treatments
  • Callous removers

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G

ExpensesEligiblePotentially Eligible Not Eligible
Genetic TestingX
ExpensesGenetic Testing
Comments & Special Rules

Testing done to detect/diagnose a medical condition or determine possible defects.

Refer to the LMN Requirements for eligibility criteria.

Glucose-monitoring EquipmentX
ExpensesGlucose-monitoring Equipment
Comments & Special Rules

Expenses incurred to purchase devices and/or product whose primary purpose is to prevent or monitor a medical condition. Examples of such devices/products are:

  • Blood Glucose Meter
  • Glucose Test Strips
Gym Membership Fees X
ExpensesGym Membership Fees
Comments & Special Rules

Only in very limited circumstances would fees paid to a gym/health club qualify. Qualifies only if required to treat an illness diagnosed by a physician. The purpose of the expense must be to treat the disease rather than to promote general health, and the expense must not have been incurred in absence of a medical condition. Prepaid gym memberships are not eligible unless consistent with the prescribed length of treatment or for the duration of the plan year, whichever is less. Ancillary fees such as personal trainer fees or any other additional fee for products or services will only be reimbursed if consistent with prescribed treatment plan. For more information, please refer to the FSA Summary Plan Description.

Refer to the LMN Requirements for eligibility criteria.

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H

ExpensesEligiblePotentially Eligible Not Eligible
Hair Colorants X
Hair Loss Treatment X
ExpensesHair Loss Treatment
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Hair TransplantX
Hand or Body Lotions/ CreamsX
Hand SanitizerX
ExpensesHand Sanitizer
Comments & Special Rules

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.

Health Insurance PremiumsX
ExpensesHealth Insurance Premiums
Comments & Special Rules

Health Insurance Premiums or retainer fees paid to a provider are not eligible. Insurance premiums include, but are not limited to COBRA, Tri-Care, or Medi-Care premiums. Retainer fees paid to a provider include any fees paid on a scheduled basis (e.g. monthly) to a provider whether or not treatment is received to retain provider for services. These are commonly known as concierge fees, access fees, or preferred treatment fees.

Hearing Aids/Implants X
ExpensesHearing Aids/Implants
Comments & Special Rules

You may include the cost of a hearing aid and batteries, repairs, and maintenance needed to operate. Implant devices such as Cochlear implants are eligible.

Heart Rate MonitorsX
ExpensesHeart Rate Monitors
Comments & Special Rules

Devices that monitor the heart rate will qualify as long as the product’s primary function is to monitor the heart rate. This does not include watches or activity trackers. See Heart Rate Monitor Watches for eligibility criteria.

Heart Rate Monitor Watches X
ExpensesHeart Rate Monitor Watches
Comments & Special Rules

Watches or activity trackers (e.g., Fitbit) may be eligible if the product’s primary purpose is to monitor a specific medical condition.  Refer to the LMN Requirements for eligibility criteria.

Hemorrhoidal Treatments X
Holistic, Naturopathic or Alternative Healers X
ExpensesHolistic, Naturopathic or Alternative Healers
Comments & Special Rules

Nontraditional healing treatments including dietary substitutes and drugs and medicines provided or recommended by holistic, naturopathic, or alternative healers may be eligible if provided to treat a specific medical condition or illness diagnosed by a physician. The purpose of the expense must be to treat the disease rather than to promote general health, and the expense must not have been incurred in absence of a medical condition.

The treatments must be legal and administered by a professional. Dietary Substitutes, Vitamins, and Drugs and Medicines recommended by an holistic, naturopathic, or alternative healers may qualify.

Refer to Special Foods, Vitamins, Supplements, and the LMN Requirements for eligibility criteria.

Home Improvements/ Capital ExpenseX
ExpensesHome Improvements/ Capital Expense
Comments & Special Rules

May qualify if undertaken to accommodate a disability. If the improvement is permanent and increases the value of the property, the expense will qualify only to the extent that the improvement cost exceeds the increase in property value. If the improvement doesn’t increase the property value at all, then the entire cost may qualify. Items that usually don’t increase property value include constructing entrance or exit ramps, widening or modifying doorways or hallways, installing railings or support bars to bathrooms, lowering or modifying kitchen cabinets or equipment, moving or modifying electrical outlets and fixtures, installing porch lifts, modifying fire alarms or smoke detectors, modifying other warning systems, and modifying stairways.

Refer to the LMN Requirements for eligibility criteria.

Home Medical EquipmentX
ExpensesHome Medical Equipment
Comments & Special Rules

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.

Refer to the LMN Requirements for eligibility criteria.

Hormone Replacement/Pellet TherapyX
ExpensesHormone Replacement/Pellet Therapy
Comments & Special Rules

For treatment of medical condition.

Refer to the LMN Requirements for eligibility criteria.

Hormone Replacement Therapy (HRT), OTC X
Hospital ServicesX
ExpensesHospital Services
Comments & Special Rules

Expenses of inpatient care (including meals for the patient and lodging) at a hospital or similar institution qualify if a principal reason for being there is to get medical care. Examples include hospitalization, treatment facility, health institutes, subacute or step-down facilities.

HumidifiersX
ExpensesHumidifiers
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

HydrotherapyX
ExpensesHydrotherapy
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

HypnosisX
ExpensesHypnosis
Comments & Special Rules

Will qualify if performed by a professional to treat a medical condition, or for other medical purposes (e.g., smoking cessation); won’t qualify if for general stress relief, personal enjoyment, or other personal purposes.

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I

ExpensesEligiblePotentially Eligible Not Eligible
ImmunizationsX
Incontinence Products X
ExpensesIncontinence Products
Comments & Special Rules

Products that are used to relieve the effects of a diagnosed medical condition does qualify.

Insect-bite Ointments and CreamsX
ExpensesInsect-bite Ointments and Creams
Comments & Special Rules

Examples include:

  • Benadryl
  • Cortaid
  • Calamine
InsulinX
ExpensesInsulin
Comments & Special Rules

Amounts paid for unprescribed drug is not reimbursable.

J

None.

K

None.

L

ExpensesEligiblePotentially Eligible Not Eligible
Lactation ConsultantX
Latex Gloves X
ExpensesLatex Gloves
Comments & Special Rules

May qualify if used to treat or alleviate a specific medical condition, and if the expense would not have been incurred “but for” the condition. Might also qualify where used to prevent a specific illness that is imminent (e.g., if a household member has a contagious disease).

Refer to the LMN Requirements for eligibility criteria.

LaxativesX
Learning DisabilitiesX
ExpensesLearning Disabilities
Comments & Special Rules

If prescribed by a physician, tuition fees paid to a special school and tutoring fees paid to a specialty trained teacher for a child who has learning disabilitIes will qualify.

Refer to the LMN Requirements for eligibility criteria.

Legal Fees X
ExpensesLegal Fees
Comments & Special Rules

Legal fees may qualify as medical care if they bear a direct or proximate relationship to the provision of medical care. For example, if the medical care could not have been provided without legal assistance.

Refer to the LMN Requirements for eligibility criteria.

Lice TreatmentX
Lip Products, MedicatedX
Liquid Adhesive Band-AidsX
Long-term Care Insurance PremiumsX
Long-term/ Lifetime Care ServicesX

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M

ExpensesEligiblePotentially Eligible Not Eligible
Marijuana or other controlled substances in violation of federal lawX
Masks, Disposable X
ExpensesMasks, Disposable
Comments & Special Rules

May qualify if used to treat or alleviate a specific medical condition, and if the expense would not have been incurred “but for” the condition. Might also qualify where used to prevent a specific illness that is imminent (e.g., if a household member has a contagious disease).

Refer to the LMN Requirements for eligibility criteria.

Massage TherapyX
ExpensesMassage Therapy
Comments & Special Rules

Qualifies only if required to treat an illness diagnosed by a physician. The purpose of the expense must be to treat the disease rather than to promote general health, and the expense must not have been incurred in absence of a medical condition. Note: Membership fees paid to a spa facility not eligible for reimbursement.

Refer to the LMN Requirements for eligibility criteria.

Mastectomy/Lumpectomy Related Services X
ExpensesMastectomy/Lumpectomy Related Services
Comments & Special Rules

The following expenses qualify as eligible when incurred in relation to any surgical procedure related to breast cancer (e.g. mastectomy/lumpectomy).

Breast Reconstruction: Surgery must be performed following a mastectomy for cancer. Expenses relative to the surgery and prosthesis are eligible.

Clothing: Prosthetic bras and clothing with built-in prosthetic bras purchased after any surgical procedure related to breast cancer are eligible for reimbursement.

Supporting documentation included with the claim for reimbursement should clearly indicate that the expense was incurred as a result of a mastectomy/lumpectomy for breast cancer.

Maternity Clothes X
Meals at a hospital or similar institutionX
ExpensesMeals at a hospital or similar institution
Comments & Special Rules

Note: Meals that are part of the cost of inpatient care at a hospital or similar institution will qualify if a principal reason for the recipient’s being there is to receive medical care. The meals must be furnished as a necessary incident to the individual’s continuing medical care.

Refer to the LMN Requirements for eligibility criteria.

Medical Alert/ Lifeline ServicesX
ExpensesMedical Alert/ Lifeline Services
Comments & Special Rules

Note: Meals that are part of the cost of inpatient care at a hospital or similar institution will qualify if a principal reason for the recipient’s being there is to receive medical care. The meals must be furnished as a necessary incident to the individual’s continuing medical care.

Refer to the LMN Requirements for eligibility criteria.

Medical Records Fees X
ExpensesMedical Records Fees
Comments & Special Rules

For example, fees associated with transferring medical records to a new medical practitioner will qualify.

Medical Alert Bracelet/Necklace/USB Data Card X
ExpensesMedical Alert Bracelet/Necklace/USB Data Card
Comments & Special Rules

Watches with medical alert identifications are not eligible.

Medical Information Plan Fees X
ExpensesMedical Information Plan Fees
Comments & Special Rules

Expenses paid to a computer data bank that retrieves and furnishes the information upon request to an attending physician is eligible.

Medical Monitoring and Testing Devices X
ExpensesMedical Monitoring and Testing Devices
Comments & Special Rules

Expenses incurred to purchase devices and/or product whose primary purpose is to prevent or monitor a medical condition. Examples of such devices/products are:

  • Blood pressure monitor
  • Heart rate monitor
  • Syringes
  • Glucose test strips
  • Blood glucose meter
  • Ovulation kit
  • Pregnancy test
Menstrual Relief X
ExpensesMenstrual Relief
Comments & Special Rules

Examples may include but are not limited to:

  • Midol
  • Pamprin
  • Premysyn PMS
Mid-wife Services X
ExpensesMid-wife Services
Comments & Special Rules

Note: Doula’s may also qualify if providing medical care for the mother and/or newborn.

Migraine Relief, OTCX
ExpensesMigraine Relief, OTC
Comments & Special Rules

Examples may include but are not limited to:

  • Advil Migraine
  • Excedrin Migraine
  • Motrin Migraine
MileageX
ExpensesMileage
Comments & Special Rules

Mileage may be claimed for expense for travel from your starting destination (e.g. work/home) to place of medical treatment (e.g. doctor’s office). The applicable medical standard mileage medical care rate issued by the IRS each year shall be used in determining per mile reimbursement rate. Please refer to claims reimbursement on the FSA webpage for more information.

Refer to the LMN Requirements for eligibility criteria.

Missed Appointment FeesX
MoisturizersX
Motion Sickness Medicines X
ExpensesMotion Sickness Medicines
Comments & Special Rules

Examples may include but are not limited to:

  • Bonine
  • Dramamine
  • Marizine
Motion Sickness Wristbands X
MouthwashX
ExpensesMouthwash
Comments & Special Rules

For example, a special mouthwash recommended by a medical practitioner for the treatment of gingivitis might qualify.

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N

ExpensesEligiblePotentially Eligible Not Eligible
Nasal Spray X
Nasal StripsX
Neuromuscular Re-educationX
Neurotherapy Treatments (Biofeedback) X
ExpensesNeurotherapy Treatments (Biofeedback)
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Night Guard/OcclusalX
ExpensesNight Guard/Occlusal
Comments & Special Rules

This does not include mouth guards used for sports activities.

Nursing Care and Services (private duty nursing) X
ExpensesNursing Care and Services (private duty nursing)
Comments & Special Rules

Wages, employment taxes, and other amounts you pay for in-home or facility nursing services (including extra costs for nurses’ room and board, if applicable) may qualify. The attendant doesn’t have to be a nurse, so long as the services are of a kind generally performed by a nurse. These include services connected with caring for the patient’s condition, such as giving medication or changing dressings, as well as bathing and grooming. But if the person providing nursing services also provides household and personal services, the amounts must be accounted for separately—only those for nursing services qualify. The care must be received by you, your spouse, or qualified dependent.

Note: Newborn nursing care absent a medical condition does not qualify.

Refer to the LMN Requirements for eligibility criteria.

NutritionistX
ExpensesNutritionist
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Nutritional SupplementsX

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O

ExpensesEligiblePotentially Eligible Not Eligible
Occlusal/Bite GuardsX
ExpensesOcclusal/Bite Guards
Comments & Special Rules

This does not include mouth guards used for sports activities.

Occupational Exams X
ExpensesOccupational Exams
Comments & Special Rules

Physical exams (e.g. sport physical) are not eligible.

Occupational TherapyX
ExpensesOccupational Therapy
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Oral Care ProductsX
ExpensesOral Care Products
Comments & Special Rules

Examples include:

  • Anbesol
  • Biotene Dry Mouth Mouthwash
  • Orajel
  • Oral Balance
Organ DonationX
ExpensesOrgan Donation
Comments & Special Rules

Includes surgical, hospital, and laboratory services as well as transportation expenses for organ donors.

OrthodontiaX
ExpensesOrthodontia
Comments & Special Rules

This includes, braces, invisalign and other aligners. A copy of the Contract or Financial Arrangement for Orthodontia Treatment for you, your spouse or qualified dependent may be attached to you initial claim form in which reimbursement is requested. If you do not have a contract or financial arrangement, you may submit a statement of service for each orthodontia expense incurred. For more information, please refer to the FSA Summary Plan Description.

Orthopedic Shoes X
ExpensesOrthopedic Shoes
Comments & Special Rules

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.

Refer to the LMN Requirements for eligibility criteria.

Orthotic InsertsX
ExpensesOrthotic Inserts
Comments & Special Rules

Custom-made and over-the-counter inserts are eligible for reimbursement.

Over the Counter Drugs/MedicinesX
ExpensesOver the Counter Drugs/Medicines
Comments & Special Rules

RX or LMN from doctor required.

Ovulation Monitor X
OxygenX

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P

ExpensesEligiblePotentially Eligible Not Eligible
Pain Relievers/ Fever Reducing MedicinesX
ExpensesPain Relievers/ Fever Reducing Medicines
Comments & Special Rules

Examples include:

  • Advil
  • Aspirin
  • Tylenol
Penile Implants X
ExpensesPenile Implants
Comments & Special Rules

For example, may be eligible if the diagnosis of impotence is due to a medical condition, such as diabetes, post-prostatectomy complications, or spinal cord injury.

Refer to the LMN Requir#lmn-requirementsements for eligibility criteria.

Personal Trainer FeesX
ExpensesPersonal Trainer Fees
Comments & Special Rules

Only in very limited circumstances would fees paid to a personal trainer qualify. Expenses must be incurred to treat a specific medical condition (e.g., rehabilitation after back surgery or treatment for obesity). The expense must not have been incurred “but for” the disease. (For example, if you contracted with a personal trainer before medical condition, then the fees would not qualify). When treatment is no longer needed, the fees no longer qualify. Prepaid trainer fees are not eligible unless consistent with the prescribed length of treatment or for the duration of the plan year, whichever is less. Treatment plan prescribed by physician must specify frequency of training sessions prescribed on a weekly or monthly basis.

Refer to the LMN Requirements for eligibility criteria.

Physical TherapyX
ExpensesPhysical Therapy
Comments & Special Rules

Examples may include but are not limited to:

  • Neurological Therapy
  • Orthopedic Therapy
  • Rehabilitation
Pillows, Lumbar Support X
ExpensesPillows, Lumbar Support
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Pregnancy Tests X
ExpensesPregnancy Tests
Comments & Special Rules

Amounts paid for kits to determine if you are pregnant or not are eligible.

Prenatal Vitamins X
ExpensesPrenatal Vitamins
Comments & Special Rules

Obstetricians routinely recommend prenatal vitamins for the health of unborn children. If taken during pregnancy (a medical condition), prenatal vitamins would be considered primarily for medical care. Vitamins taken at other times do not qualify.

Prescription Drug Discount Program FeesX
ExpensesPrescription Drug Discount Program Fees
Comments & Special Rules

Fees paid to get access to drugs at a reduced cost are not eligible for reimbursement. However actual costs paid for prescription drugs are an eligible expense.

Prescription DrugsX
Prescription Drugs and Medicines Purchased/Imported from other CountriesX
ExpensesPrescription Drugs and Medicines Purchased/Imported from other Countries
Comments & Special Rules

Purchasing/Importing prescription drugs from other countries generally will violate federal law. However, a drug or medicine may qualify for reimbursement if:

  1. it is purchased and consumed in the other country and is legal in both that country and the U.S. or
  2. the FDS announces that it can be legally imported by individuals.

Note: Claims for reimbursement for prescriptions ordered from (e.g. ordered/purchased online from Canadian pharmacy) or imported from another country must include a copy of prescription from a licensed physician in the U.S. to be eligible for reimbursement.

Refer to the LMN Requirements for eligibility criteria.

Preventive CareX
ExpensesPreventive Care
Comments & Special Rules

Colonoscopy, Blood Pressure, Diabetes and Cancer Screening.

ProbioticsX
ExpensesProbiotics
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

ProlotherapyX
ExpensesProlotherapy
Comments & Special Rules

Prolotherapy or injection therapy for joint pain is eligible.

 

ProstheticsX
Protein Bars/Shakes/Protein Powder X
ExpensesProtein Bars/Shakes/Protein Powder
Comments & Special Rules

RX or LMN from doctor required.

Refer to the LMN Requirements for eligibility criteria.

Psychiatric Services and CareX
PsychoanalysisX
ExpensesPsychoanalysis
Comments & Special Rules

Amounts paid for required training to a be psychoanalyst cannot be claimed.

Refer to the LMN Requirements for eligibility criteria.

PsychologistX
Pulse Oximeter X

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Q

None.

R

ExpensesEligiblePotentially Eligible Not Eligible
Radon MitigationX
ExpensesRadon Mitigation
Comments & Special Rules

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

Refer to the LMN Requirements for eligibility criteria.

Reading GlassesX
ExpensesReading Glasses
Comments & Special Rules

See Eyeglasses.

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S

ExpensesEligiblePotentially Eligible Not Eligible
Safety Glasses X
Sales TaxX
ExpensesSales Tax
Comments & Special Rules

Only tax imposed on qualified medical care services and products are eligible. This includes local, sales, service, and other taxes.

ScootersX
ExpensesScooters
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Service AnimalsX
ExpensesService Animals
Comments & Special Rules

Expenses of buying, training, and maintaining a service animal to assist an individual may qualify if the individual can show that he or she is using the service animal primarily for medical care to alleviate a mental defect or illness.

Shampoo, MedicatedX
ExpensesShampoo, Medicated
Comments & Special Rules

Cosmetic-type shampoos are not included. Examples include:

  • Denorex
  • DHS Tar Shampoo
  • Nizoral
Shipping and Handling FeesX
ExpensesShipping and Handling Fees
Comments & Special Rules

Shipping and handling charges for medical needs, such as mail-order prescriptions and eligible over-the-counter items are eligible.

Sinus MedicationsX
ExpensesSinus Medications
Comments & Special Rules

Examples may include but are not limited to:

  • Sudafed
  • Sinutab
  • Netipot
Sleep AidsX
ExpensesSleep Aids
Comments & Special Rules

Examples may include:

  • Nytol
  • Sominex
  • Tylenol PM
  • Unisom
Smoking Cessation MedicinesX
Smoking Cessation Programs X
Special Foods X
ExpensesSpecial Foods
Comments & Special Rules

Note: May qualify if used to treat a specific illness or ailment and if the foods do not substitute for normal nutritional requirements. Food modified for special diets (e.g., gluten-free) may also qualify, but only to the extent that the cost of the special food exceeds the cost of commonly available versions of the same product. You are responsible for providing third party documentation of cost comparisons with each request for reimbursement.

Refer to the LMN Requirements for eligibility criteria.

Speech Therapy X
Sperm StorageX
ExpensesSperm Storage
Comments & Special Rules

Fees for temporary (12 months or less) storage may qualify, but only to the extent necessary for immediate conception. Storage fees for undefined future conception are not eligible for reimbursement.

Refer to the LMN Requirements for eligibility criteria.

Stem Cell, Harvesting or Storage Fees X
ExpensesStem Cell, Harvesting or Storage Fees
Comments & Special Rules

May be eligible if there is an existing disease that the stem cells are intended to treat. Stem Cell storage fees should be temporary and not exceed 12 months. The expense can only be reimbursed after services are rendered.

Sterilization Procedures X
ExpensesSterilization Procedures
Comments & Special Rules

Expenses incurred for you, your spouse, or qualified dependent to receive sterilization procedures that prevent one from having children, such as a vasectomy or tubal ligation are eligible.

Refer to the LMN Requirements for eligibility criteria.

Sterilization ReversalX
ExpensesSterilization Reversal
Comments & Special Rules

Expenses incurred for you, your spouse, or qualified dependent to reverse the effects of a sterilization procedures that prevented one from having children, such as a vasectomy or tubal ligation are eligible.

Student Health Fee X
Sunburn/Burn ReliefX
ExpensesSunburn/Burn Relief
Comments & Special Rules

Will qualify if used to treat a sunburn (and not as regular skin moisturizers). Examples include:

  • Aloe Vera
  • Solarcaine
Sun-Protective Clothing X
ExpensesSun-Protective Clothing
Comments & Special Rules

Clothing that offers at least 30+ UVA and UVB sun protection for individuals. Only the cost difference between this specially constructed clothing and non-specialized clothing will be reimbursed. You are responsible for providing third party documentation of cost comparisons with each request for reimbursement. The receipt must show the purchase was from an accredited sun-protective company such as Solumbra® or Coolibara®.

Refer to the LMN Requirements for eligibility criteria.

SunscreenX
ExpensesSunscreen
Comments & Special Rules

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.

Suntan Lotion without SunscreenX
Supplements, Dietary/Nutritional X
ExpensesSupplements, Dietary/Nutritional
Comments & Special Rules

Examples include calcium, fiber, lactose intolerance, mineral, herbal and hormone.

Refer to the LMN Requirements for eligibility criteria.

Surgery/ Operations X
ExpensesSurgery/ Operations
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

Surrogacy or Gestational Carrier Expenses
Swim/Ski Goggles, Prescription X

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T

ExpensesEligiblePotentially Eligible Not Eligible
Telephone for Hearing ImpairedX
ExpensesTelephone for Hearing Impaired
Comments & Special Rules

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. You are responsible for providing third party documentation of cost comparisons with each request for reimbursement.

Thermometers (Medical) X
Throat LozengesX
Toothbrushes X
ExpensesToothbrushes
Comments & Special Rules

Electric toothbrushes/water picks require LMN. Regular toothbrushes are not an eligible expense.

ToothpasteX
Transportation/Travel ExpensesX
ExpensesTransportation/Travel Expenses
Comments & Special Rules

Transportation/Travel expenses incurred to treat or alleviate a disease may qualify. Transportation/Travel expenses include the cost incurred to travel by taxi, bus, train, airplane and ambulance. For travel by car (rental or owned) only mileage can be claimed in accordance with the medical care mileage rate established by the IRS each year. See ‘Mileage’ for more information.

Travel expenses incurred for lodging at a facility other than a hospital or similar institution (e.g. hotel) up to $50.00 per night, per individual (up to 2 individuals/$100.00 per night) may qualify. Meals are an eligible expense.

Transportation/Travel expenses may qualify if the following conditions are met:

  • transportation/travel expense is primarily for and essentially to medical care
  • medical care is provided by a physician in a licensed hospital or medical care facility equivalent to a licensed hospital
  • the lodging isn’t lavish or extravagant (e.g. luxury hotels)
  • there is no significant element of personal pleasure, recreation, or vacation included in the travel

Transportation/Travel expenses for a companion of an individual who meets above conditions may qualify if companion meets one of the following criteria:

  • parent of child that must be present at time of medical care
  • nurse or other person who gives injections, medications, or other treatments required by individual who is obtaining medical care and is unable to travel alone
  • individual who travels to visit a mentally ill dependent, if such visits are recommended as part of treatment

Please refer to the FSA Summary Plan Description for more information.

Refer to the LMN Requirements for eligibility criteria.

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U,V

ExpensesEligiblePotentially EligibleNot Eligible
Ultrasound, Pre-NatalX
ExpensesUltrasound, Pre-Natal
Comments & Special Rules

Will qualify if used as a diagnostic tool to determine fetal health and development. Will not qualify if for other purposes (e.g., to obtain prenatal snapshots).

Umbilical Cord Blood Storage FeesX
ExpensesUmbilical Cord Blood Storage Fees
Comments & Special Rules

May be eligible if there is an existing or imminently probable disease that the umbilical cord blood is intended to treat. For example, the cost of storing cord blood where a newborn has a birth defect and where the cord blood would be needed in the near future might qualify. Blood storage fees should be temporary and not exceed 12 months. The expense can only be reimbursed after services are rendered.

Refer to the LMN Requirements for eligibility criteria.

VaccinesX
VasectomyX
Vasectomy Reversal X
Vision CareX
ExpensesVision Care
Comments & Special Rules

Includes expenses incurred for the prevention and alleviation of vision disease and/or procedures/products to corrective vision. Preventive treatment includes the services of a optometrist or ophthalmologist for such procedures as eye exams, contact lens fitting, etc. Treatment to correct vision includes vision therapy, eyeglasses, contact lens, corrective vision surgery, etc. Cosmetic Services/Treatments whose primary function is to improve one’s general appearance (e.g. non prescription glasses/contacts) are not eligible. Eyewear Protection Plans are not an eligible expense.

Vision Correction Surgery X
ExpensesVision Correction Surgery
Comments & Special Rules

Examples include:

  • Lasik (laser) eye surgery
  • Permanent contact lenses
  • Radial Keratotomy
Vision Discount Program Fees X
Vitamin B-12 Injections X
ExpensesVitamin B-12 Injections
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

VitaminsX
ExpensesVitamins
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

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W, X

ExpensesEligiblePotentially Eligible Not Eligible
WalkersX
Wart Removal X
ExpensesWart Removal
Comments & Special Rules

Examples may include:

  • Compound W
  • Dr. Scholl’s Clear Away
  • Wart-off
Weight Loss Procedures/Surgery X
ExpensesWeight Loss Procedures/Surgery
Comments & Special Rules

Examples may include:

  • Bariatic Surgery
  • Gastric Bypass
  • Lap Band Surgery
Weight Loss Programs, Dietary Meal Plans and Drugs/Medicines X
ExpensesWeight Loss Programs, Dietary Meal Plans and Drugs/Medicines
Comments & Special Rules

Weight-loss programs will qualify if recommended by a physician to treat a specific medical condition (such as obesity, heart disease, or diabetes) and not simply to improve general health. However, food associated with a weight-loss program (such as special pre-packaged meals) do not qualify. Drugs and medicines used to induce weight loss must be prescribed by a physician to be eligible.

Refer to the LMN Requirements for eligibility criteria.

Well-Baby/Well-Child Care Exams X
WheelchairsX
Whirlpool Baths X
ExpensesWhirlpool Baths
Comments & Special Rules

Qualifies only if required to treat or alleviate an illness diagnosed by a physician. Items purchased for the home are not necessarily eligible if the physician is merely recommending the product (e.g., tanning bed, whirlpool bath, etc.). The LMN must specifically state that the item must be purchased for home use. Only the cost difference between the whirlpool bath and a standard bath will be reimbursed. You are responsible for providing third party documentation of cost comparisons with each request for reimbursement.

Refer to the LMN Requirements for eligibility criteria.

WigsX
ExpensesWigs
Comments & Special Rules

Refer to the LMN Requirements for eligibility criteria.

X-ray Fees X

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Y, Z

ExpensesEligiblePotentially Eligible Not Eligible
Yeast Infection Medications/AnticadidcalX

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