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Flexible spending account expense guide or the UniAccount FSA SM This guide provides details about: Things that are — and are not — allowed expenses for the FSA. These lists are based on IRS rules. Keep in mind that these are general guidelines only. There are gray areas. For example, some expenses are allowed only if you have a doctor’s order. If in doubt, talk with a qualified accountant, tax advisor or financial planner. How to get reimbursed (paid back) from your FSA for an expense. Whenever you have an expense that you want to use your FSA for, be sure to keep a supporting document such as a detailed receipt. To get paid back, you may need to send this document along with a claim form. Health care FSA: Expense list Expense Description FSA Eligible Limited Notes FSA* Eligible Acne treatments Yes No Acupuncture Yes No Adoption, medical expense Potentially No Alcohol and drug rehab Yes No Allergy medicine Potentially No Prescription required. Allergy product and home improvements to treat severe allergies Potentially No If the product would be owned without the allergy, then the expense is not considered eligible. See Capital expenses. Alternative healers Potentially No Letter of medical necessity required. Ambulance transport Yes No Antacid Potentially No Prescription required. Antihistamine Potentially No Prescription required. Artificial limbs Yes No Artificial teeth Yes Yes Aspirin Potentially No Bandages Yes No Batteries for durable medical equipment Yes No 27557CAMENABC 03/12 Must be used to treat a specific medical condition. For medical expenses before an adoption is final, if the child was a legal dependent when the services were rendered. Need legal documents related to adoption. Prescription required. Must note usage of batteries on receipt. Expense Description FSA Eligible Limited Notes FSA* Eligible Birth control pills Yes No Blood pressure monitoring devices Yes No Blood sugar test kit and test strips Yes No Body scan/diagnostic testing Yes No Braille books and magazines Potentially No Breast reconstruction surgery following mastectomy Yes No Burn garment Yes No Capital expenses Potentially No Only the amount above the cost of regular printed material is reimbursable. Letter of medical necessity required. The main purpose must be for the medical care of the taxpayer, spouse, or dependent. The following information must be provided: A letter and/or prescription from a physician citing the medical necessity. A written certification that states the item is for the patient’s individual use, or the percentage of use in relation to other members of the household. Third-party appraisal of the participant’s home to substantiate the difference between cost of capital expenditure and the increase in value to the participant’s home (the cost of the appraisal is not reimbursable). Carpal tunnel wrist support Yes No Chelation (EDTA) therapy Yes No Childbirth classes Yes No Chiropractors Yes No Christian Science practitioner Yes No Circumcision Yes No COBRA premiums No No Coinsurance, copays and deductibles — dental Yes Yes Coinsurance, copays and deductibles — medical Yes No Coinsurance, copays and deductibles — vision Yes Yes Cold medicine Potentially No Cold packs Yes No Condoms Yes No Contact lenses, materials and equipment Yes Yes Contraceptives Yes No Controlled substances in violation of federal law No No Cosmetics No No Only if used to treat a medical condition such as lead poisoning. Letter of medical necessity required. Prescription required. Expense Description FSA Eligible Limited Notes FSA* Eligible Cosmetic prescriptions No No CPR classes Potentially No Letter of medical necessity required. Decongestants Potentially No Prescription required. Dental visits (not cosmetic) Yes Yes Cosmetic dental procedures are not eligible. Dentures Yes Yes Deodorant No No Diabetic supplies Yes No Diagnostic services Yes No Diapers and diaper service for newborns No No Diaper rash ointments and creams Yes No Diarrhea medicine Potentially No Prescription required. Dietary supplements Potentially No Letter of medical necessity required. Diet foods No No DNA collection and storage No No Doula (birthing coach) Potentially No Drug addiction treatment Yes No Drug overdose, treatment of Yes No Dual-purpose expenses (items that have both a medical and general/personal/cosmetic purpose) Potentially No Durable medical equipment Yes No Dyslexia Potentially No Letter of medical necessity required. Ear plugs Potentially No Letter of medical necessity required. Egg donor fees Yes No Eggs and embryos storage Yes No Electrolysis or hair removal No No Elevator Potentially No See Capital expenses. Exercises equipment or programs Potentially No Letter of medical necessity required. Expenses reimbursed by a health reimbursement account No No Eye examination, eyeglasses, equipment and materials Yes Yes Face cream and moisturizers No No Face lifts No No Family counseling Potentially No Feminine hygiene products No No Fertility treatments Yes No Fiber supplements Potentially No Letter of medical necessity required. Letter of medical necessity required. Only temporary storage is eligible. Letter of medical necessity required. Not unless recommended to treat a medical disorder. Letter of medical necessity required. Letter of medical necessity required. Expense Description FSA Eligible Limited Notes FSA* Eligible First aid cream Yes No First aid kits Yes No Flu shots Yes No Fluoridation devices Yes No Foods Potentially No Founder’s fee No No Gauze pads Yes No Genetic testing Potentially No GIFT Yes No Glucosamine Potentially No Glucose monitoring equipment Yes No Glucose tablets Yes No Guide dog, other animal aide Potentially No Hair colorants No No Hair removal and transplants No No Hand lotion No No Health club dues and fees No No Hearing aids Yes No Hemorrhoid treatment Potentially No Prescription required. Herbs Potentially No Letter of medical necessity required. Hormone replacement therapy (HRT) Potentially No Only if used to treat a medical condition. Hospital services Yes No Hot packs Yes No Household help No No Illegal operations and treatment No No Immunization Yes No Inclinator Yes No Incontinence supplies Yes No Insect bite creams and ointments Yes No Insulin Yes No Insurance premiums No No Laboratory fees Yes No Lactaid Potentially No Lactation consultation Yes No Lamaze classes Yes No Only the portion of the class covering the birthing process is eligible. Language training Potentially No Letter of medical necessity required. Lasik eye surgery Yes Yes Laxatives Potentially No See Special foods. If ordered for medical care. See Dual-purpose expenses. Letter of medical necessity required. Prescription required. Prescription required. Expense Description FSA Eligible Limited Notes FSA* Eligible Lead-based paint removal Potentially No Eligible if done to prevent a child who has or had lead poisoning from eating paint. The wall surface must be within the child’s reach. Letter of medical necessity required. Learning disability Potentially No If for a child with dyslexia or disabled child. But school fees for regular schooling normally don’t qualify. Lifetime care — advance payment No No Liquid adhesive for small cuts Potentially No Lodging at a hospital or similar institution (patient only) Yes No Lodging of a companion Yes No If accompanying a patient for medical treatment. Lodging not at a hospital or similar institution Yes No Up to $50 per night if the lodging is mainly for and essential to medical care. The service must be provided by a doctor in a licensed hospital or medical care facility equivalent to a licensed hospital. An extra $50 per night may be reimbursable for a parent or companion who must accompany the patient. Long-term care premiums No No Marijuana or other controlled substances in violation of federal law No No Marriage counseling No No Massage therapy Potentially No Letter of medical necessity required. Mastectomy-related special bras Potentially No Letter of medical necessity required. Maternity clothes No No Meals at a hospital or similar institution (patient only) Yes No Meals not at a hospital or similar institution No No Meals of companion No No Meals; attending a medical conference No No Medic Alert bracelet Yes No Medicare Part B premiums No No Medical conference admission Potentially No Medical information plan changes Yes No Medical monitoring and testing devices Yes No Medical newsletter No No Medical record charges Yes No Medical services Yes No Medicated lip balm Yes No Menstrual pain relievers Potentially No Motion sickness pills Yes No Mouthwash No No Nasal sprays Potentially No Prescription required. Nasal strips Potentially No Prescription required. Letter of medical necessity required. Product must be listed as either medicated or having an SPF for sun protection. Expense Description FSA Eligible Limited Notes FSA* Eligible Naturopathic healers No No Nebulizer Yes No Nicotine gum and patches Potentially No Nonprescription drugs used to treat a specific medical condition No No Nonprescription drugs used for general health and/or cosmetic purposes No No Nonprescription drugs — dual purpose No No Norplant insertion or removal Yes No Nursing home expenses No No Nursing services provided by a nurse or other attendant Yes No Nutritionist’s professional expenses Potentially No OB/GYN Yes No Occlusal guards Yes Yes Office visits — dental Yes Yes Office visits — medical Yes No Office visits — vision Yes Yes Operations — dental Yes Yes Legal operations only. Cosmetic procedures are not eligible. Operations — medical Yes No Legal operations only. Cosmetic procedures are not eligible. Operations — vision Yes Yes Legal operations only. Cosmetic procedures are not eligible. Optometrist Yes Yes Organ donors Yes No Orthodontia Yes Yes Orthopedic shoes and inserts Yes No Osteopath fees Yes No Over-the-counter (OTC) pregnancy test/ fertility Potentially No Ovulation monitor Potentially No Oxygen Yes No Pain relievers Potentially No Personal-only expenses No No Physical exams Yes No Physical therapy Yes No Podiatrist Yes No Pregnancy termination Yes No Pregnancy test kits Potentially No Prenatal vitamins Potentially No Prescription drugs used to treat a specific medical condition Yes No Letter of medical necessity required. Prescription required. Employment-related exams are not eligible. Legal terminations only. Expense Description FSA Eligible Limited Notes FSA* Eligible Prescription drugs used for general health and/or cosmetic purposes No No Prescription drugs — dual purpose Potentially No Only if used mainly to prevent or alleviate a physical or mental defect or illness. Prescription drugs imported from another country Yes No Prescribed by a doctor to address a medical condition. Prescription drug discount programs No No Prescription eyeglasses Yes Yes Propecia Potentially No Prosthesis Yes No Psychiatrist Yes No Psychoanalysis Yes No Psychologist Yes No Radial keratotomy Yes Yes Reading glasses Yes Yes Recliner chairs No No Retin-A Potentially No Reversal of tubal ligation or vasectomy Yes No Rogaine Potentially No Rubbing alcohol Yes No Safety glasses No No Sales tax on qualified medical expenses Yes No School and education residential No No School and education, special Potentially No Screening tests — dental or vision Yes Yes Screening test — medical Yes No Shipping and handling fees on eligible expenses Yes Yes Sick-child facility No No Sinus medications Potentially No Skin moisturizer No No Sleep deprivation treatment Potentially No Smoking cessation Potentially No Special foods Potentially No Spermicidal foam Potentially No Sperm storage fees Potentially No Temporary storage only. Letter of medical necessity required. St. John’s Wort Potentially No Letter of medical necessity required. Stem cell, harvesting and/or storage Potentially No Letter of medical necessity required. Only if hair loss is due to a medical condition. Letter of medical necessity required. Letter of medical necessity required. Only if hair loss is due to a medical condition. Only if recommended by a physician. Letter of medical necessity required. Prescription required. Letter of medical necessity required. Letter of medical necessity required. Expense Description FSA Eligible Limited Notes FSA* Eligible Sterilization procedures Yes No Student health fee No No Sunglasses clips No No Sunglasses (prescription) Yes Yes Sunglasses (nonprescription) No No Sunburn creams and ointments Potentially No Sunscreen Potentially No Supplies to treat a medical condition Yes No Surrogate expenses No No Take-home drug test Potentially No Take-home pregnancy test Yes No Take-home urinary tract infection test Yes No Teeth whitening No No Telephone for hearing impaired persons Yes No Therapy Yes No Thermometers Yes No Throat lozenges Potentially No Toiletries No No Toothache and teething pain relievers Potentially No Toothbrushes No No Toothpaste No No Transplants Yes No Transportation and travel expenses for person receiving dental care Yes Yes Contact UniAccount for mileage rates. Transportation and travel expenses for person receiving medical care Yes No Contact UniAccount for mileage rates. Transportation and travel expenses for person receiving vision care Yes Yes Contact UniAccount for mileage rates. Transportation of someone other than the person receiving dental or vision care Potentially Potentially Only for certain cases: A parent who must travel with a sick child getting medical care. A nurse or other person who gives medication or injections to a patient. Visits to a mentally ill dependent, if recommended as part of treatment. Transportation of someone other than the person receiving medical care Potentially No Only for certain cases: A parent who must travel with a sick child getting medical care A nurse or other person who gives medication or injections to a patient. Visits to a mentally ill dependent, if recommended as part of treatment Tubal ligation Yes No Prescription required. Prescription required. Expense Description FSA Eligible Limited Notes FSA* Eligible Umbilical cord freezing and storage Potentially No Vaccines Yes No Varicose vein, treatment of No No Vasectomy Yes No Veneer No No Vision discount programs No No Vitamins Potentially No Walker Yes No Wart remover treatment Potentially No Only to treat a medical condition. Prescription required. Weight-loss programs and/or drugs prescribed to induce weight loss Potentially No Letter of medical necessity required. Wigs Potentially No Only if hair loss is due to a medical condition. Letter of medical necessity required. Collection and storage indefinitely “in case needed” is not eligible for reimbursement. Letter of medical necessity required. *A limited FSA cannot be used for medical expenses. It is designed to work with a health savings account (HSA) that can be used for these expenses. Health care FSA: How to get paid back Option 1: Automatic payment If you have an Anthem plan, you may get paid back automatically. Here’s an example: 1.You go to the doctor and you pay a copay at the time of your visit. 2.Anthem processes a claim and decides that you have an out-of-pocket cost (the copay). 3.Anthem tells UniAccount, and UniAccount sends you a check for the copay amount (as long as you have money in your FSA). For Anthem HMO plan members, UniAccount can also do automatic payment for prescription drug copays and hospital coinsurance. Automatic payment only works if Anthem is your only plan and Anthem processes the claim. For anything else, you would need to send a claim form. Option 2: Send a claim form If you don’t get automatic payment, you can send a claim form to UniAccount. To download a form online, go to anthem.com/ca. You will need to send at least one supporting document along with your claim form. This could be: An Explanation of Benefits (EOB) from your insurance company. The EOB needs to show the date of service for your out-of-pocket expenses. An itemized statement from the service provider. The statement should include the patient’s name, dates of service, procedure descriptions, provider name, and charges for the service. Anything that doesn’t show this level of detail (such as an account balance statement or cancelled check) does not meet IRS rules for a form of proof. For prescription drugs, a pharmacy statement or detailed receipt. This should include the name of the pharmacy, patient’s name, date of fill, cost, Rx number and name of the drug. You can get FSA reimbursement for an over-the-counter (OTC) medicine only if you have a prescription for the medicine. Be sure to sign at the bottom of the claim form. You can send your claim form and supporting documents to UniAccount in one of two ways: Mail to: UniAccount P.O. Box 4381 Woodland Hills, CA 91365-4381 Fax to: 818-234-4730 Dependent care FSA: Expense list To be eligible, dependent care expenses must allow you and your spouse (if you’re married) to: Work (not including unpaid volunteer work or volunteer work for a nominal salary). Actively look for work. Spouses are considered to have worked if: They were a full-time student for at least five calendar months during the tax year. They were physically or mentally unable to care for themselves. Also keep in mind: An eligible dependent must be either: Under the age of 13 years old. Mentally or physically unable to care for themselves. You may not claim any other tax benefits for the tax-free amounts you get from the dependent care FSA. Expenses not paid with your FSA may be eligible for the dependent care credit. Talk to your tax advisor — the tax credit may work in your favor more than a dependent care FSA. For divorced parents: The custodial parent can be reimbursed from the dependent care FSA. The noncustodial parent cannot be reimbursed from the dependent care FSA. This rule applies even when the noncustodial parent is entitled to the dependency exception (for instance, because the custodial parent is not claiming it). Expense Description Dependent Care FSA Eligible Notes After-school care Yes Agency fees Potentially May be employment-related expenses if the participant is required to pay these fees to get care. Cannot be reimbursed until the care is provided. Forfeited fees are not eligible for reimbursement. Au pair Yes Amount paid for actual care of the dependent are eligible. Care for a spouse or other tax dependent who is physically or mentally incapable of self-care Potentially Person must live in the participant’s home at least eight hours a day. Care for person not residing with participant No Childcare placement fees No Early-morning care Yes Field trips/activity fees No Lesson in lieu of care No Material fees No Unless inseparable from the cost of care. Meals No Unless inseparable from the cost of care. Nanny Yes Only actual care of the dependent is eligible. Nursing home care for spouse or other tax dependent who is physically or mentally incapable of self-care No Unless inseparable from the cost of care. Expense Description Dependent Care FSA Eligible Overnight camp No Payments to the participant’s spouse or to the parent of the participant’s child who is not the participant’s spouse No Registration fees Potentially School tuition for kindergarten or above No Sick child facility Yes Summer day camp Yes Advance payment for the entire summer is not eligible. Expenses are eligible. Transportation expenses to/from care Potentially Only the cost of transportation to or from where care is given (e.g. to a day camp or to an after-school program not at the school). Tuition for pre-k/nursery school Yes Dependent care FSA: How to get paid back To get reimbursed for an expense, send a claim form to UniAccount. To download a form online, go to anthem.com/ca. If the provider signs the claim form, you don’t need to send an itemized statement. If the provider doesn’t sign the claim form, you’ll need to send an itemized statement with your claim form. This statement should include: The date(s) of service. Notes May be employment-related expenses if the participant is required to pay these fees to get care. Cannot be reimbursed until the care is provided. Forfeited fees are not eligible for reimbursement. Be sure to sign at the bottom of the claim form. You can send your claim form and itemized statement (if needed) to UniAccount in one of two ways: Mail to: UniAccount P.O. Box 4381 Woodland Hills, CA 91365-4381 Fax to: 818-234-4730 The dependent’s name and date of birth. Itemized list of charges. The provider’s name, address and Tax ID/SSN. Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.