| Which
expenses qualify?:
Reimbursement 
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Healthcare expenses that qualify
Healthcare expenses that do not
qualify
Dependant care expenses that qualify
Dependant care expenses that do
not qualify Healthcare
reimbursement limitation
The amount of healthcare reimbursement may not exceed the maximum allowed under
the plan. Please review your Summary Plan Description or see your Plan Administrator
for more information. The following healthcare expenses qualify
for reimbursement under a FSA Plan: Only healthcare expenses not reimbursed by insurance
or any other source can be claimed. A
• Abortion, legal
• Acne treatment (non-cosmetic) with physician’s
note†
• Acupuncture (excluding remedies and treatments prescribed
by acupuncturist)
• Air purifier with physician’s note†
• Alcoholism treatment
• Alternative healer services with physician’s note†
• Ambulance
• Artificial limbs/teeth B
• Birthing classes (portion related to birthing)
• Blood pressure monitor
• Blood sugar test kit
• Body scan
• Braille books and magazines
• Breast pump with physician’s note†
• Breast reconstruction surgery following a mastectomy C
• Chemotherapy
• Chiropractor
• Christian Science practitioner services
• Co-payments
• Coinsurance
• Computer storage of medical records
• Contact lenses and solutions
• Contraceptives
• Counseling
• Crutches D
• Deductibles
• Dental services (non-cosmetic)
• Dentures/artificial teeth
• Diagnostic fees and services
• Drug addiction/overdose treatment
• Drug and medical supplies E
• Ear plugs (for medical condition) with physician’s
note†
• Equipment for the handicapped
• Eye drops
• Eye examination
• Eye surgery (i.e. cataracts, LASIK, etc.)
• Eyeglasses (prescribed) F
• Fluoridation device
• Flu shots G
• Gambling addiction treatment
• Genetic testing (to determine medical defects) with physician’s
note†
• Glucose monitor H
• Hearing devices and batteries
• Hearing tests
• Holistic and natural healer services with physician’s
note†
• Home care nursing services
• Hormone therapy treatment for menopause with physician’s
note†
• Hospital expenses (non-cosmetic) I
• Immunizations
• Insulin L
• Laboratory fees
• Lactation consultant services with physician’s
note†
• Lamaze classes (portion related to birthing)
• Language training (for disabled individual) with physician’s
note†
• Laser eye surgery
• Learning disability expenses (fees to school or specially
trained tutor), with physician’s note† M
• Massage therapy with physician’s note†
• Medical conference (admission and transportation)
• Medical expenses in excess of usual, customary and reasonable
(UCR)
• Medical record charges N
• Nasal sprays
• Norplant (insertion or removal of device)
• Nutritionist expenses (for treatment of medical condition)
with physician’s note† O
• Obstetrical expenses
• Occlusal guard (to prevent teeth grinding)
• Occupational therapy
• Oral surgery
• Orthodontic expenses
• Orthopedic devices
• Over-the-counter medications (not to include nutritional
supplements, cosmetic care items or items primarily used
for general health)
• Oxygen P
• Pap smears
• Physical exams (not employment related)
• Physical therapy (for specific medical condition)
• Prescription medicines (non cosmetic)
• Prescription sunglasses
• Prenatal vitamins
• Prosthesis
• Psychiatric care
• Psychologist services R
• Radial keratotomy
• Routine physicals
• Rubdown (to treat a specific illness) with physician’s
note† S
• Safety glasses (prescription only)
• Schools and education (special) with physician’s
note†
• Screening test for medical diagnosis
• Seeing-eye dog (purchase, training and care of)
• Sick child facility (primary purpose of facility is medical
care)
• Sleep deprivation treatments with physician’s note†
• Smoking cessation program
• Sperm, storage fees (temporary storage no longer than
one year)
• Stem cell harvesting and storage, to treat a specific
and imminent medical condition
• Sterilization procedures
• Sunglasses (prescription)
• Supplies to treat a medical condition
• Surgical fee (non-cosmetic) T
• Taxes on medical services and products
• Therapy, for medical care only
• Transplant expenses (surgical, hospital, laboratory and
transportation expenses for organ donor)
• Transportation and travel expenses for person receiving
medical care U
• Umbilical cord (collection, freezing and storage for
imminent use to treat a specific medical condition) V
• Varicose vein treatment (non-cosmetic)
• Vaccines
• Vasectomy
• Viagra (to treat a medical condition)
• Vision correction procedures
• Vitamins (prescription) W
• Weight loss drugs/programs (associated with a
certain disease) with physician’s note† X
• X-rays †
Physician’s note must indicate the specific medical
condition, the medical item/treatment recommended to
treat the medical condition, the expected duration
of the condition and that the medical item is not for
cosmetic
purposes.
(top of page) The following
healthcare expenses do not qualify for reimbursement under
an FSA Plan: • Cosmetic surgery and
procedures
• Marriage and family counseling
• Weight loss programs for general health or appearance
• Premiums you or your spouse pay for insurance
coverage (payroll-deducted premiums sponsored by your
employer are eligible under the Premium Only Plan)
(top of page) The following dependent
care expenses qualify for reimbursement under an FSA Plan:
*Dependent care expenses are those
that are necessary for you and your spouse (if married)
to be gainfully employed. • Nanny expenses, for
services provided inside your home, are eligible to the
extent that they are attributable to dependent care expenses
and expenses of incidental household services.
• Dependent care expenses incurred for services
outside your home, providing they are incurred for the
care of a qualifying dependent that regularly spends at
least 8 hours per day in your home.
• Registration fees to a daycare facility are eligible
as long as the fees are allocable to actual care and not
described as materials or other fees.
• Nursery school expenses are eligible, even if
the school also furnishes lunch and educational services.
• Food and incidental expenses (diapers, activities,
etc.) may be eligible if part of dependent care charge.
• Expenses paid to a relative (e.g. child, parent,
or grandparent of participant) are eligible. However,
the relative cannot be under age 19 or a tax dependent
of the participant.
• FICA and FUTA payroll taxes of the daycare provider
are eligible.
• Dependent care expenses incurred to enable the
employee to find work are eligible.
• The reimbursement may not exceed the smaller of
the following limits:
• The maximum allowed under the plan
• $5,000 if you are filing a joint tax return, and
$2500 if separate returns are filed
• Your taxable compensation (after all compensation
reduction elections)
• If you are married, your spouse’s actual
or deemed earned income
(top of page)
The following
dependent care expenses do not qualify for reimbursement
under an FSA Plan: • Kindergarten fees are
almost always an education expense, and should never be
reimbursed under a dependent care plan.
• Elementary school expenses for a child in first
grade or higher are not eligible.
• Food, transportation, and incidental expenses
(diapers, activities, etc.) are not eligible if charged
separately from dependent care expenses.
• Expenses paid to a housekeeper, maid, cook, etc.
are not eligible, except where incidental to child or
dependent adult care.
• Mass transit and parking.
(top of page)
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