NOTEHealth Savings, Health Care Reimbursement and …pub/@eatonbenefits/... · Medical Service...

Medical Service Health Savings Account

(HSA)

Dental/Vision

Reimbursement Account

(DVRA)

Notes and Examples

In order to participate in this account

you must be participating in one of

Eaton's medical plan options

In order to participate in this account

you must be participating in one of

Eaton's medical plan options

Acne medicine (OTC drugs) Eligible if prescribed Ineligible Clean and Clear, Clearasil,

Stridex and Store Brand

Acne Medication.

Acne medicine (prescription

drugs)

Eligible Ineligible

Acne surgery Eligible Ineligible

Acupuncture Eligible Ineligible

Adoption medical expenses Eligible (if child is tax

dependent when services

are provided)

Ineligible

Air purification equipment Eligible if prescribed and/or

supported by a physician

statement

Ineligible Include products to treat

severe allergies such as

humidifier, vaporizers, air

filtration, replacement filter,

allergy home air system.

Alcoholism treatment Eligible Ineligible Include: meals and lodging

at inpatient facility; outpatient

care; transportation

associated with treatment.

NOTE: The list below is provided as a general guide regarding which expenses are typically considered reimbursable expenses

(Qualified Medical Expenses) under Health Savings, Health Care Reimbursement and Dental/Vision Reimbursement Accounts.

Qualified Medical Expenses are generally defined in IRS Code Section 213(d) as amounts paid for diagnosis, cure, mitigation,

treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body. This list is based on

information in IRS publications and additional legislative guidance released by IRS due to Health Care Reform. This list may not be

all inclusive, and your individual circumstances could impact whether the IRS would consider an expense to be a Qualified Medical

Expense. This list of expenes is not intended, nor should it be construed as legal or tax advice. Since the administration of Health Savings,

Health Care Reimbursement and Dental/Vision Reimbursement Accounts is a taxpayer responsibility, you are strongly encouraged to

consult your tax advisor and/or to review information available from the Internal Revenue Service (IRS) regarding eligible expenses.

You can find the most current versions of IRS Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans, and

IRS Publication 502, Medical and Dental Expenses (including the Health Coverage Tax Credit), online at www.IRS.gov, or request

copies at 800-829-3676.

Health Savings, Health Care Reimbursement and Dental/Vision Reimbursement Accounts

Page 1


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Alertness aid (OTC drugs) Eligible if prescribed Ineligible Examples: NoDoz, caffeine

pills.

Allergy and sinus medicine

(OTC drugs)

Eligible if prescribed Ineligible Examples: Actifed, Advil,

Afrin, Alavert, Benadryl,

Chlor-Trimeton, Claritin,

Tavist, Tylenol, Vicks,

Diphedyrl, Sudafed, Zicam,

Store Brands; includes pills,

drops, sprays.

Allergy products Eligible if prescribed and/or


statement

Ineligible Bed pads, sheets, pillows,

special vacuum and vacuum

filter. For home

improvements - see Capital

Expenditures.

Ambulance Eligible Ineligible

Anesthesiologist Eligible Ineligible

Anesthesiologist for a

cosmetic or ineligible

procedure

Ineligible Ineligible

Artificial insemination Eligible Ineligible See Fertility Treatments.

Includes fertility exams,

sperm implants, sperm

washing, embryo transfer

and reverse vasectomy.

Artificial limb Eligible Ineligible

Asthma medications (OTC

drugs)

Eligible if prescribed Ineligible Examples include: Bronkaid,

inhaler, inhaler refills,

Primatene Mist, Store

Brands.

Automobile (car)

modifications

Eligible if prescribed and/or


statement

Ineligible Modifications to automobile,

car or van to accommodate

disability including

wheelchair.

Page 2


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Autopsy Ineligible Ineligible Autopsy expenses of

deceased participant or

his/her dependent or spouse.

Babysitting related to

medical care or condition


Bandages and braces Eligible Ineligible Examples include: Ace

bandage wrap, liquid

adhesive, gauze pads,

dressing and TapeAce, Tru-

fit, Futuro, Band-Aid, 3M

Next Care, Curity, Dome,

Johnson & Johnson.

Bath and shower aids Eligible Ineligible Tub grab bar, shower

bench/chair/stool (Medline,

Nova).

Birth control pills Eligible Ineligible

Blepharoplasty (eyelid

surgery)

Eligible if non-cosmetic and

prescribed and/or supported

by a physician statement

Ineligible

Blood pressure monitor and

kits

Eligible Ineligible

Blood storage Eligible if prescribed and/or


statement

Ineligible Example: Storage for use

during a scheduled elective

surgery. See umbilical cord

for cord blood.

Body scans, health

screening

Eligible Ineligible

Botox Eligible if non-cosmetic and



Ineligible Ineligible as an expense for

cosmetic purposes.

Braille books and magazines Eligible Ineligible

Page 3


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Breast feeding consultation,

classes or coaching



statement

Ineligible

Breast feeding supplies Eligible Ineligible Examples of Breast Feeding

Supplies are: breast pump,

breast pads, breast milk

freezing bags, breast shells,

cooler tote bags for pumped

breast milk.

Breast milk supplement Eligible if prescribed and/or


statement

Ineligible Must demonstrate treatment

of medical condition, not

simply choice or

convenience.

Breast reconstruction

surgery after mastectomy

Eligible Ineligible

Bug repellent Eligible if prescribed and/or


statement

Ineligible

Cancellation fee of

orthodontia contract

Ineligible Ineligible Doesn't alleviate medical

condition.

Capital expenditures Eligible if prescribed and/or


statement

Ineligible Special equipment and

modifications to the home

including the appraisal. See

Publication 502 for a list of

improvements that IRS says

does not increase property

value (ramps, railings, etc.).

Chelation therapy (remove

heavy metals from the body)

Eligible Ineligible Most common forms of

heavy metal intoxication are

lead, arsenic or mercury.

Childbirth classes Eligible (to extent expense

relates to birth and not

childrearing)

Ineligible Total cost of class.

Page 4


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Chinese herbal doctor office

visit

Eligible (to extent treatment

is for a specific medical

condition)

Ineligible Alternative medical

treatment. Not drugs or

supplements. Must be legal

in the state.

Chiropractic care plans Ineligible Ineligible Acts as premiums.

Chiropractor Eligible Ineligible

Christian science practitioner

office visit

Eligible Ineligible Alternative medical


supplements.

Circumcision Eligible Ineligible Also eligible if performed by

a Rabbi or Moyel.

Coinsurance Eligible Eligible

Cold sore relief (OTC drugs) Eligible if prescribed Ineligible Examples include: Novitra,

Abreva, Store Brands.

Colonics Eligible if prescribed and/or


statement

Ineligible Colon cleansing/Colonics.

Example: Colonix

(hydrotherapy).

Contact Lenses, Solutions,

Supplies

Eligible Eligible

Contraceptives (devices) Eligible Ineligible Examples include: condoms

(durex, lifestyles, trojan),

films and diaphragms.

Contraceptives (OTC drugs) Eligible if prescribed Ineligible Examples include

spermicidal products such as

gels, Advantage-S, Encare,

Gyno II, Ortho, VCF.

Contraceptives (prescription

drugs)

Eligible Ineligible Examples include: birth

control pills, Norplant

including insertion and

removal.

Controlled substances Eligible if prescribed (as long

as legal)

Ineligible Darvon, Percocet, Ritalin and

Valium.

Copay Eligible Eligible

Page 5


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Cosmetic surgery Ineligible, unless prescribed

and/or supported by a

physician statement. See

Notes and Examples to the

right

Ineligible Must demonstrate that

surgery treats accepted

underlying medical condition

or injury.

Cosmetics Ineligible Ineligible Examples include: Olay,

Aveeno, Jergens, St. Ives,

L'Oreal, Neutrogena, Almay,

Cover Girl, Maybelline,

Cutex, Revlon, Sally Hansen,

Store Brands, face creams,

lotions, make-up, nail car,

Chapstick.

Cotton balls Ineligible Ineligible Examples include: cotton

balls, swabs, Q-Tips.

Cough and cold relief (OTC

drugs)

Eligible if prescribed Ineligible Examples include: pills,

sprays, Lozenges, rubs,

night time vapor plug,

Actifed, Dimetapp, Drixoral,

Robitussin, Sudafed,

Triaminic, Advil, Contrex,

Theraflu, Tylenol Flu,

Mucinex, Chloraseptic,

Zicam, Store Brands.

Counseling: behavioral

therapy



statement

Ineligible For an individual, group,

family, child, couple,

documentation must indicate

the specific type of

counseling such as

bereavement or

psychotherapy.

Page 6


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Counseling: bereavement,

grief

Eligible Ineligible For an individual, group,




counseling such as

bereavement or

psychotherapy.

Counseling: life, career,

marriage


Counseling: mental health,

psychoanalysis,

psychotherapy

Eligible Ineligible For an individual, group,




counseling such as

bereavement or

psychotherapy.

CPR classes Eligible if prescribed and/or


statement to treat a medical

condition

Ineligible Must treat an existing

medical condition.

Cranial technology Eligible Ineligible Generally, medical

equipment for infants - (or

adult) to correct

plagiocephaly (abnormal

head shape/flat head

syndrome).

Crowns (dental) Eligible Eligible

Crutches Eligible Ineligible Rent or buy.

Deductibles Eligible Eligible

Dental expenses (excludes

bleaching or whitening)

Eligible Eligible X-rays, fillings, extractions,

dentures, implants, crowns,

sealants and cleanings.

Page 7


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Dental treatment:

cosmetic/reconstructive

Eligible if non-cosmetic and





statement

Examples include: veneers,

bonding, teeth whitening,

bleaching or opalescence.

Color does not affect the

proper function of teeth and

therefore is not eligible.

Eligible with physician's

statement clearly

demonstrating that veneers

or bonding are needed for

proper tooth function.

Denture supplies Eligible Eligible Examples include: adhesives

or cleansers (Cushion Grip,

Dentemp, Ezo, Fixodent,

Polident, Sea-Bond, Super

Poli-Grip).

Dentures, repair and

treatment

Eligible Eligible Dentures: full, partial,

prosthesis.

Dental veneers or bonding

(cosmetic or non-medically

necessary)


Dermatologist Eligible Ineligible

Diabetes or diabetic

management class

Eligible Ineligible

Diabetes or diabetic

management medications

(OTC drugs)

Eligible if prescribed Ineligible Example: glucose tablets.

Diabetes or diabetic supplies Eligible Ineligible Monitoring system, insulin

pump, glucose kit, test strips,

lancets, syringes, alcohol

swabs (Accu-chek, Ascensia,

Freestyle, One Touch,

Precision, BD).

Page 8


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Diabetic supplies: insulin Eligible Ineligible

Diagnostic tests Eligible Eligible (as relates to dental

or vision)

Diapers or diaper service for

mentally or physically

impaired person



statement

Ineligible For healthy infants and/or

children - ineligible.

Diet drugs (OTC and

prescription)

Eligible if prescribed Ineligible Examples include: Dexatrim,

Alli. Food not eligible - see

Food.

Diet drugs (prescription) Eligible if prescribed and/or


statement

Ineligible Food not eligible - see Food.

Diet programs Eligible if prescribed and/or


statement


Membership and periodic

meeting fees for programs

such as Jenny Craig, Weight

Watchers, etc.

Digestive - stomach

medications (OTC drugs)

Eligible if prescribed Ineligible Examples include:

items/remedies such as Axid

AR, Pepcid, Prilosec,

Tagamet, Zantac, Tums,

Rolaids, Alka-Seltzer,

Maalox, Mylanta, Pepto-

Bismol, Phillips Gviscon, Gas-

X, Lactaid Pills, Bonine,

Dramamine, Emetrol, Store

Brands, Antacid, Acid

Reducers.

Doula, doolah, abdula Eligible [if prescribed and/or


statement ](to extent

provides medical care)

Ineligible

Drug addiction treatment Eligible Ineligible Include: meals, lodging, at

inpatient facility.

Page 9


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Drug tests or screenings Eligible Ineligible Including at home drug

test/screening.

Ear care (OTC drugs) Eligible if prescribed Ineligible Examples include: Swim-ear

and ear wax removal such as

Otix Drops.

Ear piercing Ineligible Ineligible

Ear plugs Eligible if prescribed and/or


statement

Ineligible

Education for learning

disability

Eligible if supported by a

physician statement

Ineligible The school, teacher or tutor

must specialize in teaching

learning-disabled children.

Education must be for

learning-disabled.

Egg donor expenses Eligible Ineligible

Electronic toothbrushes Ineligible Ineligible

Electro-dermal screening Eligible if prescribed and/or


statement

Ineligible Usually an ineligible

cosmetic procedure.

Employment taxes Eligible Ineligible For nursing or dependent

care services paid by

participant. Example: Social

Security tax, FUTA,

Medicare tax. Include only

the amount of taxes paid for

eligible services.

Epsom salt Eligible if prescribed and/or


statement

Ineligible

Exercise equipment Eligible if prescribed and/or


statement

Ineligible Not eligible if used for

general health

Eye drops (OTC drugs) Eligible if prescribed Eligible if prescribed Examples include: Visine,

Murine, Store Brands.

Eye exam Eligible Eligible

Page 10


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Eye surgery Eligible Eligible Eye surgery, radial

keratotomy, Lasik etc.

Eyewear: non-corrective Eligible if prescribed and/or


statement



statement

Nonprescription sunglasses,

clip-ons for glasses, vanity

contact lenses.

Eyewear: corrective Eligible Eligible Prescription lens (with and

without frames) including

progressive (bifocals,

trifocals) and polycarbonate

(plastic). Sunglasses, Rx.

Frames alone are eligible, do

not need to submit

supporting receipt for lenses

to reimburse frames. Rx

swim, Rx sport.

Eyewear: medical supplies

and repair

Eligible Eligible Lens cleaning supplies,

contact solution, contact

cleaning procedure, eyeglass

repair.

Eyewear: non-medical

supplies

Ineligible Ineligible Vanity supplies, misc.

options including cases,

sports wraps and chains.

Eyewear: protection plans,

warranties

Ineligible Ineligible BPP = Breakage Protection

Plan.

Face lift Ineligible Ineligible See cosmetic surgery.

Face mask Eligible if prescribed and/or


statement

Ineligible To prevent airborne

diseases. Brands such as

Liberty.

Page 11


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Feminine products Ineligible (unless to treat

medical condition)

Ineligible Feminine hygiene products

(personal use item) such as

FDA, Massengill, Summer's

Eve as well as sanitary

napkins, pads or tampons

such as Kotex, O.B., Playtex,

Tampax, Always, Stayfree.

Fertility treatments Eligible Ineligible Treatment that impacts the

participant or a dependent of

the participant. Expenses

paid to or for an in vitro

surrogate if surrogate is

dependent or participant.

Fiber supplements (OTC

drugs)

Eligible if prescribed Ineligible Citrucel, Metamucil, Fiber

Con.

First aid kits Eligible Ineligible Johnson & Johnson First Aid

Kit, American Medical

Association All Purpose First

Aid Kit.

Fluoridation device Eligible if prescribed and/or


statement

Eligible

Fluoride (OTC drugs) Eligible if prescribed Eligible Pills, fluoride, vitamins,

fluoride supplements.

Fluoride (prescription drugs) Eligible Eligible Pills, fluoride, vitamins,

fluoride supplements.

Available only by

prescription.

Fluoride treatment Eligible Eligible Fluoride treatment applied in

provider's office.

Page 12


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Food (for diet, weight loss) Ineligible Ineligible Examples include: Jenny

Craig, Weight Watchers,

Nutrisystem. Ineligible -

satisfies normal nutritional

needs.

Food (not for weight loss) Eligible if prescribed and/or


statement

Ineligible Must alleviate or treat an

illness such as allergies or

lactose intolerant. Wheat

free food for individuals who

are allergic to wheat.

Lactose intolerant food.

Typically excess over normal

cost is eligible. Ineligible as

an expense which satisfies

normal nutritional needs.

Foot therapy supplies Eligible Ineligible Examples include: Insoles

and arch support expenses.

Foot treatment medications

(OTC drugs)

Eligible if prescribed Ineligible Examples include: treatment

of athletes foot, anti-fungal,

bunions or spurs such as

Micatine, Fungi Care,

Lotrimin, Store Brands.

Funeral expenses Ineligible Ineligible

Genetic testing to determine

medical condition

Eligible Ineligible

Genetic testing to determine

sex of unborn child


Page 13


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Gloves Eligible if prescribed and/or


statement

Ineligible Disposable and

dermatological cotton and

latex gloves such as Cara,

Playtex, Safeskin, Kimberly-

Clark. Ineligible as an

expense for personal use.

Gym membership, fitness or

health club fees



statement

Ineligible To treat a medical condition

(e.g., diabetes or heart

disease), not for general

health

Hair growth medicines (OTC) Eligible if prescribed Ineligible Examples include: Nu Hair,

Rogaine, Store Brands.

Hair growth medicines

(prescription drugs)



statement

Ineligible Not covered by insurance.

Rogaine, Propecia.

Hair transplant Ineligible Ineligible

Hand sanitizer Eligible if prescribed and/or


statement

Ineligible

Hand-held showerhead Eligible if prescribed and/or


statement

Ineligible

Health insurance premiums Generally, ineligible (but

eligible for those 65 and

older; other than Medicare

supplemental policy)

Ineligible

Hearing aid insurance Ineligible Ineligible

Hearing aids and batteries Eligible Ineligible

Heat or cold pad, wraps or

packs

Eligible Ineligible For pain relief from

backache, arthritis,

menstrual, injuries, breast

feeding - examples are

ThermaCare, Cura Heat.

Page 14


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Hemorrhoid relief (OTC

drugs)

Eligible if prescribed Ineligible Examples include: Hemorid,

Anusol, Preparation H,

Nupercainal, Tucks, Store

Brands.

Home health care Eligible Ineligible At home nursing services.

Homeopathic care office visit Eligible (to extent providing

medical care)



supplements.

Hormone replacement

therapy (prescription drugs)

Eligible Ineligible

Hospital services Eligible Ineligible Include treatment, lodging,

meals.

Hot tub Eligible if prescribed and/or


statement

Ineligible To treat a medical

condition.Including portable.

Household help Ineligible Ineligible See nursing services.

Hypnotherapy, hypnosis Eligible if prescribed and/or


statement


Illegal drugs Ineligible Ineligible

Illegal operations, treatment Ineligible Ineligible If state and federal law

conflicts, apply federal law.

Immunization Eligible Ineligible Includes flu shot, vaccines.

Incontinence supplies Eligible Ineligible Examples include: Briefs,

guards, pads, bed pads,

shields, undergarments;

Depends, Poise, Serenity,

Store Brands.

Infant medicine dispenser Eligible Ineligible NUMI Med.

Infertility treatment Eligible Ineligible See fertility treatments.

Insulin Eligible Ineligible

Insurance premiums: long-

term disability coverage


Page 15


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Insurance premiums: age 64

or under, employer-

sponsored retiree health

insurance premiums

Ineligible Ineligible Example: Premiums for

employer-sponsored retiree

health insurance.


or under, Medicare part A, B,

Medicare HMO and D

premiums



or older, employer-

sponsored retiree health

insurance premiums

Eligible (but not Medicare

supplemental policy)

Ineligible Example: Premiums for

employer-sponsored retiree

health insurance.


or older, Medicare part A, B,

Medicare HMO and D

premiums

Eligible Ineligible Premiums for Medicare

supplemental policies such

as Medigap are not qualified

medical expenses.

Insurance premiums:

COBRA health care

continuation coverage

Eligible Ineligible

Insurance premiums: fixed

indemnity policies

Ineligible (if under age 65) Ineligible Including fixed indemnity

cancer or hospital policies.

Insurance premiums:

premiums for continuation

coverage while receiving

unemployment

compensation under federal

or state law

Eligible Ineligible

Insurance premiums:

premiums for employer

sponsored group health

coverage offered on a pre-

tax basis under the

employer's cafeteria plan


Page 16


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Insurance premiums:

qualified long-term care

insurance

Eligible Ineligible

Interest payments Ineligible Ineligible Generally interest/finance

charges would apply toward

ortho loan or contract.

Inversion therapy Eligible if prescribed and/or


statement

Ineligible Inversion table/therapy.

Invisalign (invisible braces) Eligible Eligible Clear removable aligners to

straighten teeth (braces).

Jock itch treatment (OTC

drugs)

Eligible if prescribed Ineligible Examples include: Tinactin,

Micatin, Lotrimin AF, Lamisil

AT, Cruex, Store Brands.

Labor, colic, or yoga ball Eligible if prescribed and/or


statement

Ineligible

Laboratory fees Eligible Eligible Must be a part of medical

care.

Lactation coaching,

consultation or classes



statement

Ineligible

Lamaze classes Eligible (to extent expense

relates to birth and not

childrearing)

Ineligible

Language training Eligible if prescribed and/or


statement

Ineligible To treat medical condition

(e.g., disabled or dyslexic

child).

Lasik eye surgery Eligible Eligible

Lead-based paint removal Eligible if prescribed and/or


statement

Ineligible Medical condition must be

lead poisoning or related.

Page 17


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Legal fees related to mental

illness

Eligible Ineligible Legal fees incident to

proceeding authorize

treatment for mental illness.

Lice treatment (OTC drugs) Eligible if prescribed Ineligible Examples include: Licefree,

Rid, Pronto, Store Brands.

Lodging for a companion

required to be present for

medical care



statement

Ineligible Eligible with physician's

statement documenting

medical need for travel

companion. Eligible with

proof of medical services.

Limit of $50.00 per night per

person.

Lodging for person receiving

medical care



statement

Ineligible Requires supporting

documentation

demonstrating the main

purpose is to receive medical

care. Limit of $50.00 per

night per person.

Long-term care medical

expenses (Qualified Long-

Term Care)

Eligible Ineligible

Long-term care room and

board (other than for medical

care)

Ineligible Ineligible Expenses for room, board.

Lubricants (OTC drugs) Eligible if prescribed Ineligible Examples include: K-Y,

Lubrin, Replens, Vagisil.

Ineligible as an expense for

personal use.

Maintenance, repair of

eligible medical equipment

Eligible Ineligible Hearing aids, wheelchairs,

etc.

Page 18


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Marijuana Ineligible Ineligible Even if legal in state, if state

and federal law conflict, we

apply federal law.

Massage, massage therapy Eligible if prescribed and/or


statement

Ineligible Includes Reiki & Rolfing.

Eligible if provided by a

chiropractor/chiropractor's

office or with a physician's

statement.

Mastectomy bra Eligible Ineligible

Maternity bra Ineligible Ineligible

Maternity clothing Ineligible Ineligible

Mattress and or box springs Eligible if prescribed and/or


statement

Ineligible Generally for allergies or

back problems, special

support, hypoallergenic.

MD VIP program or

concierge program

Ineligible Ineligible Ineligible as a premium.

Meals in hospital Eligible Ineligible Or similar situation while

inpatient, only the meals for

the person receiving the care

are eligible.

Medic alert bracelet,

necklace, service

Eligible Ineligible

Medical alert system Eligible if prescribed and/or


statement

Ineligible Expenses related for medical

condition (e.g., visually

impaired, deaf, disability).

Medical care received

outside of the USA

Eligible Eligible Must relate to medical care

which could be legally

provided within the U.S.

Documentation must be in

English and fees in U.S.

currency.

Page 19


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Medical conference or

classes



statement

Ineligible Relating to a chronic illness

for a participant, spouse or

dependent. The costs of the

medical conference must be

primarily for and necessary

to the medical care of the

participant, spouse, or

dependent. Include

admission and

transportation. See mileage.

Medical records fees Eligible Eligible Costs associated with

copying, storage or transfer

of medical records. (FMLA

paperwork, chart copies.)

Medical screening tests Eligible Ineligible EKG, cholesterol count.

Midwife Eligible Ineligible

Mileage Eligible Eligible Eligible with proof of medical

services performed that day;

pay actual expenses or IRS

mileage rate based on year

the expense was incurred.

Mileage rates: 1/1/2011 to

6/30/11- 19 cents; 7/1/2011 -

12/31/2011 - 23.5 cents;

2010 - 16.5 cents.

Naturopathic office visit Eligible if prescribed and/or


statement


treatment, not drugs or

supplements.

Nebulizers, CPAP, BiPAP Eligible Ineligible

Page 20


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Nicotine replacement (OTC

drugs)



statement

Ineligible Examples include: patches,

candy, gum, Endit, Lite'n Up,

Smoke Away, Venturi,

Nicorette, NicoDerm CQ,

Nicotrol Devices, Patches,

Gum, Lozenges.

Nursing home expenses for

actual medical treatment

Eligible Ineligible

Nursing home expenses for

room, board



statement (for medical care)

Ineligible Physician's statement must

state that primary reason for

being in home is for medical

treatment.

Nutritional counseling Eligible if prescribed and/or


statement


(e.g., diabetes or heart

disease). Nutritionist.

Occlusal guard Eligible Eligible Prevents teeth grinding.

Operations Eligible Ineligible See cosmetic surgery.

Optometrist Eligible Eligible

Opthalmologist fees (eye

exam, etc.)

Eligible Eligible

Organ donor Eligible Eligible Both donor and recipient.

Orthodontia Eligible Eligible

Orthotics Eligible Ineligible

Osteopath Eligible Ineligible

Oxygen Eligible Ineligible

Pain relievers (OTC drugs) Eligible if prescribed Ineligible Examples include: Aspirin,

Ibuprofen, Advil, Midol,

Motrin, Bayer, Doan's, Aleve,

Excedrin, Pamprin, Premsyn

PMS, Azo, Prodium, Tylenol,

Store Brands.

Pain relievers for cosmetic

surgery pain (OTC drugs)

Eligible if prescribed Ineligible Medicine treats the pain, not

the cosmetic surgery.

Page 21


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Pain relievers for cosmetic

surgery pain (prescription

drugs)

Eligible Ineligible Medicine treats the pain, not

the cosmetic surgery.

Parking sticker for

handicapped

Eligible Ineligible

Pedialyte (OTC drug) Eligible if prescribed Ineligible

Penile implants Eligible Ineligible

Periodontal Fees Eligible Eligible

Physical therapy Eligible Ineligible

Physicals, checkups Eligible Eligible (as expense relates

to dental or vision services)

Pill organizers, box or cutter Eligible Eligible Must be a reasonable

expense.

Pregnancy, ovulation tests Eligible Ineligible Examples include: At home

test, Accu-Clear, Answer,

E.P.T., Fact Plus Pro, Fact

Plus, First Response,

ClearBlue Easy, Early

Detect, Fertile Focus, Clear

Choice, Ovulite.

Prenatal care Eligible Ineligible Pregnancy, maternity care.

Prenatal vitamins (OTC

drug)

Eligible if prescribed Ineligible

Pre-payments, deposit for

surgery

Ineligible Ineligible Deposits, down payments.

May be considered for

reimbursement after service

has been incurred.

Prescription drug copay Eligible Ineligible

Prescription drugs: imported Ineligible Ineligible Exception: Drugs purchased

and consumed outside the

U.S., if the drug is legal in

both the U.S. and the other

country.

Private hospital room Eligible Ineligible

Page 22


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Prosthesis Eligible Ineligible Artificial limb.

Psychiatric care Eligible Ineligible

Radial keratotomy Eligible Eligible

Raised toilet seat Eligible Ineligible Medline, Nova.

Reflexology Eligible if prescribed and/or


statement

Ineligible This is a massage treatment.

Retin A and Tretinoin (OTC

drugs)

Eligible if prescribed (to treat

medical condition, not

cosmetic)

Ineligible Ineligible for cosmetic

purposes.

Retin A and Tretinoin


Eligible (to treat medical

condition, not cosmetic)

Ineligible Ineligible for cosmetic

purposes.

Rubbing alcohol (OTC drug) Eligible if prescribed Ineligible

Sales tax on eligible

expenses

Eligible Ineligible

Scales Ineligible Ineligible For weight, food or drugs.

Schools, teachers, tutors Eligible if prescribed and/or


statement

Ineligible The school, teacher or tutor

must specialize in teaching

learning-disabled children or

child with medical condition.

Service animal Eligible if prescribed and/or


statement

Ineligible Service animal for medical

condition. Eligible with a

physician's statement

indicating a working animal

trained to provide assistance

for participant, spouse or

dependent with a medical

condition. Includes

purchase, training and care.

Shipping, handling, and

delivery costs

Eligible Ineligible To obtain an eligible service

or supply.

Page 23


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Shoes (medically necessary) Eligible Ineligible Special shoes for medical

care such as orthopedic,

diabetic, etc.

Sitz bath Eligible Ineligible Product use is intended to

help relieve discomfort and

cleanse the perianal and

perineal area.

Skin tag removal Eligible if prescribed and/or


statement

Ineligible Removal of skin tags.

Sleep aid (OTC drugs) Eligible if prescribed Ineligible Examples include: Alluna,

Natrol, Nytol, Unisom, Store

Brands.

Smoking cessation programs Eligible Ineligible

Snoring aid supplies Eligible Ineligible Examples include: Nasal

Strips.

Speech therapy Eligible Ineligible

Speech training Eligible if prescribed and/or


statement

Ineligible For a child with a medical

condition affecting speech.

Sperm, egg or embryo

storage



statement

Ineligible Ineligible as an expense for

long-term storage. Eligible

as an expense for interim,

short-term storage of sperm,

egg, embryo. Must be

supported by a physician's

statement demonstrating

conception procedures are

immediate or currently in

process.

Sterilization Eligible Ineligible Includes both the sterilization

and reversal of sterilization.

Student health insurance

fees

Ineligible Ineligible Premiums.

Page 24


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Substance abuse treatment Eligible Ineligible Include: meals and lodging

at inpatient facility; outpatient

care; transportation

associated with treatment.

Sun block or sunscreen

(OTC drugs)

Eligible if prescribed Ineligible Examples include:

Coppertone, Hawaiian

Tropics, Bull Frog. Ineligible -

toiletries and cosmetics,

including moisturizer and

make-up even with SPF.

Sun or light box Eligible if prescribed and/or


statement

Ineligible Treats depression or

seasonal affective disorder

NOT a sunlight to get a

suntan.

Supplements: nutritional,

dietary or vitamin (OTC

drugs)



statement

Ineligible Examples include: Ensure,

Airborne, Acidophilus,

Coenzymes, Q-10, DHEA,

Fish Oils, Glucosamine and

Chondroitin, Probiotics,

Lecithin, Melatonin, MSM,

Omega-3, SAM-e, Shark

Cartilage, Echinacea, Flax

Seed Oil, Garlic, Ginkgo

Biloba, Herbs, Lutein.

Support hose Eligible if prescribed and/or


statement

Ineligible Includes surgical or support

hosiery and stocking.

Surgery Eligible Ineligible See cosmetic surgery.

Page 25


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Surgery equipment or

products

Eligible Ineligible Pre-/Post-Surgery products

such as Impact, Recover,

Peptinex, ReSource,

Tolerex, Vivonex. Must be

considered medical

equipment (i.e., high-

powered enema).

Swimming lessons Ineligible Ineligible

Syringes Eligible Ineligible

Teeth cleaning supplies Ineligible Ineligible Dental floss, manual

toothbrush, toothpaste;

electric and/or sonic

toothbrushes, Oral B, Reach,

Braun.

Telephone for hearing

impaired

Eligible Ineligible Include entire purchase and

repair if separate unit from

telephone.

Television equipment for

hearing impaired

Eligible Ineligible Displays the audio part of the

television programs as

subtitles for hearing

impaired. Includes repair if

separate unit from television.

Termination of pregnancy Eligible Ineligible

Therapy Eligible if prescribed and/or


statement

Ineligible

Thermometers Eligible Ineligible Ear, oral, rectal.

Toilet paper, tissues Ineligible Ineligible

Toiletries Ineligible Ineligible

Toothache remedies (OTC

drugs)

Eligible if prescribed Eligible if prescribed Examples include: Orajel,

Zilactin, Red Cross,

Orabase, Den Tek, Dents,

Store Brands.

Page 26


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Topical products (OTC

drugs)

Eligible if prescribed Ineligible Examples include: BenGay,

Arth-Rx, Dr. Holt's, Flexall,

IcyHot, Jointflex, Joint-Ritis,

PR5, Mentholatum, Stopain,

Hydrogen Peroxide, Bactine,

Neosporin, Polysporin,

Iodine, Desitin Diaper Rash,

Benadryl, Anti-itch Cream,

Dermarest, Itch-X, Store

Brands.

Transplants Eligible Ineligible Organ transplant; both donor

and recipient.

Transportation expense for

another person traveling with

part., spouse or dependent,

who is unable to travel alone

for medical care.



statement

Ineligible Eligible with physician's

statement documenting

medical need for travel

companion. Include:

Parking, tolls, airfare,

mileage. Does not include

transportation for the

purpose of visiting spouse or

dependent in hospital. See:

Mileage.

Transportation expense for

person receiving medical

care.

Eligible Ineligible Eligible with proof of medical

services. Includes: Parking,

tolls, airfare. See: Mileage.

Transportation to visit

spouse or dependent in

hospital


Page 27


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Umbilical cord blood, stem

cell harvesting and storage



statement

Ineligible Not eligible for preventive

purposes, must relate to

existing medical condition of

newborn. Storage must be

for current ongoing

treatment.

Urinals and bed pans Eligible Ineligible Medline.

Uvuloplasty,

uvulopalatoplasty



statement

Ineligible Must indicate medical

condition, not merely

snoring.

Vaccines, vaccinations Eligible Ineligible Includes flu shot, vaccines.

Varicose vein treatment Eligible if prescribed and/or


statement

Ineligible Expenses related to the

removal or treatment of

varicose or spider veins.

Vasectomy or vasectomy

reversal

Eligible Ineligible

Visident Eligible Eligible Visiting dental service

generally for the

homebound.

Vision discount programs Ineligible Ineligible

Vision therapy Eligible Eligible Provided to treat dyslexia

and other visual/neurological

disorders.

Vitamins, supplements (OTC

drugs)

Eligible if prescribed Ineligible Examples include: Ensure,

Airborne, Acidophilus,

Coenzymes, Q-10, DHEA,

Fish Oils, Glucosamine and

Chondroitin, L-Carnitine,

Lecithin, Melatonin, MSM,

Omega-3, SAM-e, Shark

Cartilage, Echinacea, Flax

Seed Oil, Garlic, Ginkgo

Biloba, Herbs, Lutein,

Menopause.

Page 28


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Vitamins, supplements


Eligible Ineligible Vitamins and/or vitamin

supplements available ONLY

by prescription.

Walker, cane Eligible Ineligible

Warranties Ineligible Ineligible Usually for hearing aids or

eyeglasses, extended

warranties, maintenance

agreements.

Wart treatment (OTC drugs) Eligible if prescribed Ineligible Examples include:

Compound W, Dr. Scholl's,

Pedifix, Wart-off, Store

Brands.

Weight loss medicine (OTC

and prescription drugs)

Eligible if prescribed Ineligible Examples include: Alli,

Dexatrim.

Weight loss medicine

(prescription required)



statement

Ineligible Not covered by insurance.

Meridia.

Weight loss programs Eligible if prescribed and/or


statement


Membership and periodic

meeting fees for programs

such as Jenny Craig, Weight

Watchers, etc.

Wheelchairs, motorized Eligible Ineligible Purchase, operating costs,

accessories and upkeep all

eligible (e.g., Autoette).

Wigs Eligible if prescribed and/or


statement

Ineligible

Wrist support or stabilizer

(carpal tunnel)

Eligible Ineligible Ace, Tru-Fit, Futuro.

X-ray fees Eligible Eligible

Yeast infection remedies

(OTC drugs)

Eligible if prescribed Ineligible Examples include: Monistat,

Vagistate 3, Vaginex,

Mycelex 3.

Page 29


(HSA)

Dental/Vision


(DVRA)

Notes and Examples

Yoga, pilates, tai chi Eligible if prescribed and/or


statement

Ineligible

9/20/2016

Page 30

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