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Healthcare Eligible Expense Listing This list has been compiled for the convenience of our clients and participants and is designed to provide a general overview. Readers are cautioned to review their own employer-sponsored benefit plan descriptions and enrollment material for specific information or to consult with their employer or personal tax advisor as necessary. This information is subject to change at any time and without notice. Eligible medical care expenses include amounts paid for the diagnosis, cure, mitigation, treatment or prevention of disease, and for treatments affecting any part or function of the body. The expenses must be primarily to alleviate or prevent a physical or mental defect or illness. Expenses solely for cosmetic reasons are not generally expenses for medical care and may not be eligible. Expenses that are merely beneficial to one's general health are not expenses for medical care. In some cases, participants may be asked to provide a letter of medical necessity from your attending physician to substantiate their claim. IMPORTANT: Effective January 1, 2011, over-the-counter (OTC) medicines and drugs will require a written prescription (Rx) from your doctor in order to get reimbursed. Please keep this federal requirement in mind when using your healthcare account for expenses incurred on or after January 1, 2011. Items marked with (Rx Required) require a prescription as of January 1, 2011. Acne treatment, includes over-thecounter acne medications; excludes cost of regular skin care (Rx required – see notice above) Acupuncture Alcoholism treatment Allergy treatments (Rx required for OTC drugs – see notice above) Antacids (Rx required – see notice above) Artificial insemination Artificial limb/teeth Automobile modifications (if medically necessary) Battery-powered toothbrush (if medically necessary and prescribed by physician) Birth control prescriptions Blood pressure monitoring devices Bone density testing Braille books and magazines (excess of amount paid over cost of regular printed editions) bought for visually impaired person Breast pumps and supplies that assist lactation Childbirth expenses (physician, midwife Childbirth preparation classes (excludes portion of mother’s coach, feeding and newborn care) Chiropractor professional fees Cholesterol testing Christian Science Practitioner fees Circumcision Co-insurance, co-pay amounts and deductibles Cold Medicine (Rx required – see notice above) Computer data bank fees, medical history Condoms Contact lenses and cleaning solutions Crutches Deductibles Dental treatment (includes exams, xrays, fillings, root canals, gum disease treatment, crowns, bridges, dentures, implants, sealants, extractions, orthodontia; does not include cosmetic treatments such as teeth whitening, dental veneers, bonding, etc.) Dental veneers (for non-cosmetic reasons) Diabetic supplies (insulin, syringes, testing strips, glucometers) Diagnostic services and tests Diapers (if required due to medical condition) Drug dependency treatments Dyslexia treatment Genetic testing Guide dog or other animal used to assist persons with physical disabilities Gynecologists’ fees Health institute Health screening Hearing aids and batteries Home health care Home medical equipment Hospital services Immunizations In vitro fertilization Inclinator Infertility treatments Insulin and syringes Laboratory fees Fertility exams Lamaze classes (see childbirth classes) Language training for child with dyslexia or disabled child Laser eye surgery Lead-based paint removal Learning disability caused by mental or physical impairment, or nervous system disorders (treatment must be recommended by physician - see IRSPublication502 - Learning Disability) Legal fees (fees you pay that are necessary to authorize treatment for mental illness) Long-term care services Fertility treatments First Aid Kit Flu shots Fluoridation device (if medically necessary & prescribed by physician) Mastectomy-related special bras (the cost over & above the cost of a normal bra) Medic-alert bracelet Egg donor charges for recipient Eye surgery (cataract, LASIK, corneal rings, etc.) Eyeglasses, prescription (includes prescription sunglasses; also includes over-the-counter reading glasses) Eye examinations Medical equipment (crutches, wheelchairs, walkers) Medical records charges Medical Supplies (bandages, thermometers, hot/cold packs, nasal (breathe-right) strips, etc.) Medicines/Drugs (prescription drugs, see Over-the-counter Drugs/Medicines with a prescription, insulin; does not include cosmetic drugs) Mentally handicapped, special home for person adjusting from life in mental institution to community living Mileage or fares related specifically to an eligible medical visit to and from healthcare providers, hospitals and pharmacies. Effective July 1, 2011, the mileage rate for the use of a car (also vans, pickups or panel trucks), for eligible medical visits is $.235 per mile. Before July 1, 2011, the rate was $.19 per mile. The mileage rate for travel that occurred between 1/1/11 and 6/30/11 will remain at $.19 per mile. Actual fares for buses, taxis, trains and subways are reimbursable for the full cost Norplant insertion and removal Nursing home (if necessary for medical care and only the portion for medical services) Nursing services Nutritionist’s professional expenses (if treating a specific medical condition; not for weight loss for general health) Obstetrical expenses Occlusal guards to prevent teeth grinding Occupational therapy Optometrist fees Oral surgery Organ donation fees Orthodontia Orthopedic devices Orthopedic shoes (to the extent the cost exceeds that of normal shoes) Osteopath fees Over-the-counter Drugs/Medicines (Rx required – see notice above) *This includes but is not limited to allergy medicines, antacids, antidiarrhea, anti-fungal ointments and creams, antiseptic ointments and creams, cold medicines including sore throat sprays, lozenges, nasal sprays, cough syrups, cough drops, vapor rubs, eye drops, first-aid and antibiotic creams and ointments, gas relief medicines, hemorrhoid ointments and creams, laxatives, lice treatments, motion-sickness pills, pain relievers including arthritis pain, head/back pain and menstrual pain, sleep aids, stop smoking gums/patches, yeast infection products. (Note: Cosmetic items, vitamins, herbal and dietary supplements or items for general good health are not considered OTC drugs/medicines and are not eligible even with a prescription.) Over-the-counter items (such as crutches, bandages, OTC eyeglasses) Ovulation monitor Oxygen equipment Pain Relievers (Rx required – see notice above) Physical exams, routine physicals Physical therapy Physicians’ fees Pregnancy test, over-the-counter Prescription drugs (for non-cosmetic reasons) Prescription eyeglasses/sunglasses Prosthesis Psychiatrists’ fees (for medical reasons) Psychologists’ fees (for medical reasons) Psychotherapists’ fees (for medical reasons) Psychoanalysis Psychologist fees Radial keratotomy/Ortho keratology Reading glasses (prescription glasses or OTC glasses) Reconstructive surgery following mastectomy Reverse vasectomy Routine physicals Schools and education, special (for mentally impaired or physically disabled person - see IRSPublication502) Sick-child care facility (for medical care only) Sleep disorder and treatment Speech therapy Sterilization procedures (vasectomy or tubal ligation) Stop-smoking programs (including hypnosis, over-the-counter gums and patches will require a prescription) (Rx required – see notice above) Storage fees for embryo or sperm (fees for temporary storage of eggs or sperm only to extent used for immediate conception in current plan year) Storage fees for umbilical cord blood (fees for temporary storage only to extent used for medical condition in current plan year) Substance abuse treatment Sunglasses (only if medically required due to specific medical condition & obtained at direction of physician) Surgical fees (for legal operations not cosmetic in nature) Taxes charged for medical services and products Telephone consultations with a health care provider Telephone or Television for hearingimpaired persons, special equipment Therapy, physical or speech Transplants (donor expenses, if you pay those expenses) Transportation including mileage, fare for bus, taxi, train, plane and related travel expenses for person seeking treatment (See 'Mileage' and IRSPublication502 - Transportation and Trips) Vaccines, vaccinations Vasectomy Vitamins (only if necessary to treat a specific medical condition) and accompanied with a Letter of Medical Necessity) Walkers Weight-loss program (only if medically necessary to treat existing disease, such as heart disease, and undertaken under physician’s direction) Wheelchair Wigs (if purchased upon advice of physician for mental health of patient) X-ray fees Healthcare Ineligible Expense Listing This list has been compiled for the convenience of our clients and participants and is designed to provide a general overview. Readers are cautioned to review their own employer-sponsored benefit plan descriptions and enrollment material for specific information or to consult with their employer or personal tax advisor as necessary. This information is subject to change at any time and without notice. IMPORTANT: Starting January 1, 2011, certain over-the-counter (OTC) medicines and drugs will be considered ineligible expenses unless you have a written prescription from your doctor. Please keep this federal requirement in mind when you decide how much money you will put into your healthcare account. Adoption Fees Baby-Sitting, childcare or nursing services for a healthy baby Boutique practice fees, retainer fees, concierge fees Expenses not incurred during your period of coverage Facelifts or other similar cosmetic treatments (dermabrasion, chemical peels, etc.) Funeral expenses “No Show” charges for doctor or dentist visits Nursing services for healthy baby Nutrition supplements Hair transplant Paternity testing Health club membership dues Herbal supplements (dietary and nutritional supplements, vitamins, natural medicines, ect.) Household help Physical therapy treatments for general well-being Childbirth preparation classes (portion that pertains to mother’s coach, feeding and newborn care) Completing claim forms, fees for Controlled substances Cord Blood Collection (can be reimbursed if there is a specific medical condition that the cord blood is intended to treat) Cosmetic surgery or procedures; cosmetic prescription drugs such as Retin-A, Renove, Propecia, etc and cosmetics that contain acne fighting ingredients Counseling (marriage, family) Dancing lessons Dental veneers or bonding Diaper service Divorce expenses Domestic help Doula services Medical newsletters Medical savings account Illegal operations and treatments Insurance premiums Lactation consultant for general instruction Laetrile Lamaze/Childbirth classes-see Childbirth preparation classes Late payment fees Lens replacement insurance Lifetime care fees Liposuction or other similar cosmetic treatments Safety glasses Storage fees for embryo, sperm or umbilical cord blood, long term Student health fees Sun screen lotion Sunglasses, clip on Surrogate expenses Swimming lessons Tanning salons and equipment Tattoo removal Teeth bleaching/whitening for cosmetic purposes Temporary Continuation of Coverage (TCC) premiums Union dues Marriage, family counseling Ear piercing Electrolysis or hair removal Exercise equipment for general health Exercise/Fitness programs for general health Expenses reimbursed elsewhere or that may be reimbursable under any other source Massage therapy (unless recommended as medically necessary to treat a specific injury or illness; does not include therapy for stress or tension reduction) Marijuana Maternity clothes Mattress Meals while traveling to obtain medical care Vacuum cleaner for allergies Varicose veins, treatment of Vision discount programs Vision service agreements or lens replacement insurance Weight loss programs for general health or appearance; diet foods for weight loss Dependent Care Eligible Expense Listing This list has been compiled for the convenience of our clients and participants and is designed to provide a general overview. Readers are cautioned to review their own employer-sponsored benefit plan descriptions and enrollment material for specific information or to consult with their employer or personal tax advisor as necessary. This information is subject to change at any time without notice. Au pair expenses for dependent care (does not include travel expenses) Late pick-up fees Looking for work-expenses incurred to enable employee to look for work Baby-Sitter inside or outside household Nanny expenses Custodial childcare or eldercare expenses for qualifying individual Day camps, if primary reason for being there is the care and well-being of the child and is custodial in nature, and not educational. Daycare centers FICA and FUTA taxes of daycare provider Preschool/Nursery school for pre-kindergarten Sick-child care center to extent the care is not for medical services Summer day camps Temporary Absence such as for vacation or minor illness and required to pay provider weekly or monthly and the payment includes the short absence as well as work days Household employee whose services include care of qualifying person Work-related day care expenses- must allow you to work or look for work. You must be gainfully employed (earning income). This does not include volunteer work that is unpaid or for nominal pay. Dependent Care Ineligible Expense Listing This list has been compiled for the convenience of our clients and participants and is designed to provide a general overview. Readers are cautioned to review their own employer-sponsored benefit plan descriptions and enrollment material for specific information or to consult with their employer or personal tax advisor as necessary. This information is subject to change at any time without notice. Educational/ tuition expenses- kindergarten, first grade and above Expenses paid to child of participant Field trip expenses Household services (chauffeur, bartender, gardener) Incidental expenses (diaper, activities, ect. charges) Overnight camp (not even the portion attributed to the daytime cost) Payments for care where you are not the custodial parent (in divorce situations) Payments for care while you are off work because you are on a leave of absence Payments for care while you are off work because you are on maternity or other medical leave Payments for care while you are off work because you are on vacation unless required to pay weekly or monthly and the payment includes the short absence as well as work days Payment for care while you are off work because you are on vacation unless required to pay weekly or monthly and the payment includes the short absence as well as work days Payment for services not yet provided (advance payments) Registration fees/reservation fees/holding fees unless paid in order to obtain care and only if and when that provider is selected Transportation expenses unless furnished by the care provider to or from a place where care is provided Over-the-counter Eligible Expense Listing This list has been compiled for the convenience of our clients and participants and is designed to provide a general overview. Readers are cautioned to review their own employer-sponsored benefit plan descriptions and enrollment material for specific information or to consult with their employer or personal tax advisor as necessary. This information is subject to change at any time without notice. *The products listed here are examples, and do NOT constitute an endorsement or an exhaustive listing of reimbursable OTC products. IMPORTANT: Starting January 1, 2011, over-the-counter (OTC) medicines and drugs will require a written prescription (Rx) from your doctor in order to be reimbursed. The items in this listing will require a prescription unless otherwise noted. Please keep this federal requirement in mind when using your healthcare account for expenses incurred on or after January 1, 2011. Notice: The items marked with a “no Rx required” are considered to be OTC supplies (NOT OTC drugs or medicines) and do not require a prescription in order to be reimbursed. Abreva Ace wraps (no Rx required – see notice above) Acne Free Acnomel Actifed Advil Advil Cold & Sinus Advil Migraine Afrin Nose Drops Afrinol Alavert Aleve Aleve Cold & Sinus Alka Seltzer Allerest Aloe Vera Anbesol Antiseptics Anusol Aspirin Athlete’s foot products Axid Bacitracin Bactine Balmax Bandages (no Rx required – see notice above) Bayer Benadryl Ben Gay Benylin Betadine Breast pumps and supplies that assist lactation (no Rx required – see notice above) Bronitin Mist Bronkaid Bronkolixer Bunion, blister and corn treatments (non-medicated do not require Rx - see notice above) Bye Bye Blemish Caladryl Calamine Lotion Caldecort Callous removers (non-medicated) (no Rx required – see notice above) Cepacol (sore throat spray, drops, lozenges) Children’s Advil Cold Children’s Tylenol Chloraseptic Chlortrimeton Claritin Clean & Clear Cleaning & soaking solutions for contacts (no Rx required – see notice above) Clear Cough Clear Eyes Clearisil Colace Cold-Eeze Cold/Hot packs for injuries (no Rx required – see notice above) Commit (Smoking Cessation) Compound-W Condoms (no Rx required – see notice above) Congestac Contac Coricidin D Cortaid Cortizone Cream Cough Drops Cystex DairyCare Dairy Relief DayQuil Desitin Desinex Dimetane Dimetapp Diurex Dr. Scholl’s Clear Away (wart remover) Dramamine Dristan Drixoral Dulcolax Eardrops Ear wax removal Ecotrin Excedrin Ex-Lax Eye drops Eye patches (no Rx required – see notice above) Femstat 3 Fleets Prep Kit Flexall Gas-X Gynelotrimin Halls Defense Hemorrhoid Ointment Herpecin Hydrocortisone Ibuprofin Immodium Infant Tylenol Ipecac Ivy Block Joint supports (ankle, elbow, knee, wrist) (no Rx required – see notice above) Kaopectate Lactaid Lacteeze Lactrase Lamisil Lanacane Lanacort Lens storage cases (no Rx required – see notice above) Liquid adhesives (no Rx required – see notice above) Liquid Corn and Callous Removers Lotrimin Lozenges Maalox Marezine Micatin Midol Milk of Magnesia Mobigesic Mobisyl Monistat Motrin Motrin Migraine Mucinex Murad Acne Complex Kit Mycelex-7 Mylanta Mylicon MyoRx Naphcon-A Naprosyn Naproxen Nasal Spray Nasalcrom Nature’s Cure Acne Treatment Neosporin Neosynephrine Drops / Spray Nicoderm CQ Nicorette Nicotrol Nicodin Nix NyQuil Nytol Ocu Hist Orajel Otrivin Ovulation predictor kits (no Rx required – see notice above) OXY Pamprin Pediacare Pedialyte Pepcid AC Pepto Bismal Percogesic Peroxide Pin-X Poligrip (no Rx required – see notice above) Polysporin Pregnancy tests (no Rx required – see notice above) Premysyn PMS Preparation H Prilosec Primatene Proactiv Solution Reading glasses (no Rx required – see notice above) Releev Ricola Rid Robitussin brochures Rubbing alcohol Senokot Sinutab SinuCleanse Spermicides Splints (no Rx required – see notice above) Stri-Dex Sudafed Sinus Sudafed Tabs Sunburn relief Sunscreen with SPF 30 or higher Tagamet HB Tavist Thera Flu Thermometer (no Rx required – see notice above) Triaminic Triple antibiotic ointment Tronolane Tums Tylenol Tylenol Cold & Flu Uristat Vagistat Vicks 44 Vicks Pediatric Vicks Sinex Vicks Vapor Inhaler Vicks Vapor Rub Visine Wart-Off Witch Hazel Zantac 75 ZAPZYT Acne Treatment Zicam Over-the-counter Ineligible Expense Listing This list has been compiled for the convenience of our clients and participants and is designed to provide a general overview. Readers are cautioned to review their own employer-sponsored benefit plan descriptions and enrollment material for specific information or to consult with their employer or personal tax advisor as necessary. This information is subject to change at any time without notice. *The products listed here are examples, and do NOT constitute an endorsement or an exhaustive listing of reimbursable OTC products. IMPORTANT: Effective January 1, 2011, over-the-counter (OTC) medicines and drugs will require a written prescription (Rx) from your doctor. Please keep this federal requirement in mind when you decide how much money you will put into your healthcare account. Body sprays Hair removal Chapstick Make-up Moisturizers Mouthwash Creams Vitamins (without a letter of medical necessity) Dental Floss Deodorant Perfumes Ear plugs Shampoo Soaps Face soaps Teeth whitening kits Toothbrushes Toothpaste