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Reimbursable items under a Flexible Spending Account lotion

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Reimbursable items under a Flexible Spending Account lotion

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									    Reimbursable items under a Flexible Spending Account:
Items reimbursed with a receipt. Quantities allowed may be limited. Receipt must contain the vendor, name of medical
item, date of purchase and amount of purchase. Only health care expenses not reimbursed by insurance can be claimed. If
you use your Flex Prepaid Card, you do not need to turn in a receipt unless we request one. Remember to keep all receipts.
■   Antacids/acid reducers                       ■   Electrolyte drinks for child’s dehydration   ■   Orthodontic expenses
■   Acne treatments (non-cosmetic)               ■   Eye drops and products                       ■   Ovulation monitor
■   Allergy medicine                             ■   Eyeglasses                                   ■   Pain relief medicines
■   Ambulance not paid by insurance              ■   First aid cream, kits, lotion, ointment,     ■   Physician expenses not paid by insurance
■   Analgesics/pain relievers                        sprays                                       ■   Pregnancy test kits
■   Anti-diarrhea/anti-gas medicine              ■   Flu medicines                                ■   Prenatal vitamins
■   Antibiotic cream                             ■   Hearing aids and batteries                   ■   Prescription drugs and medicines
■   Antihistamines/decongestants                 ■   Hemorrhoid cream, ointment,                  ■   Reading glasses
■   Aspirin                                          suppositories                                ■   Ringworm treatments
■   Athlete’s foot cream, ointment, lotion       ■   Hydrogen peroxide                            ■   Rubbing alcohol
■   Bandages/Band-aids®                          ■   Incontinence supplies                        ■   Screening kit (detect cancer, HIV, etc)
■   Calamine lotion                              ■   Insulin                                      ■   Sinus medicines
■   Carpal tunnel wrist supports                 ■   Insect bite cream, lotion, ointment          ■   Stomach and intestinal medicines
■   Chiropractic care not paid by insurance      ■   Jock itch cream, lotion, ointment            ■   Smoking cessation aids*
■   Cold medications, cough drops, cough         ■   Laser eye surgery                            ■   Sunburn cream, lotion, ointment
    syrups                                       ■   Laxatives                                    ■   Sunscreen
■   Cold/hot packs for injuries                  ■   Lice treatments                              ■   Taxes on medical services and products
■   Contact lens cleaning solution               ■   Medic alert necklace and bracelet            ■   Thermometers (ear, mouth or rectal)
■   Cortisone cream                              ■   Menstrual cycle discomfort medicine          ■   Throat lozenges and sprays
■   Diabetic supplies                            ■   Migraine medicine                            ■   Wart remover treatments
■   Deductible and copayments                    ■   Motion sickness medicine                     ■   Wound cleaning solutions
■   Dental expenses (not cosmetic)               ■   Muscle or joint pain products                ■   X-ray fees not paid by insurance
■   Diagnostic devices                           ■   Nasal sprays and nasal strips
■   Diaper rash cream, lotion, ointment          ■   Optometrist expenses
*Certain requirements must be met for these items to be reimbursed.


                                                                             Reimbursable with a physician’s letter
    Items not reimbursable:
                                                                             of medical necessity:
■   Body spray                       ■ Herbal medicines to                Items reimbursed with a receipt when accompanied by
■   Chap stick, lip balm               improve and maintain               a physician’s letter. Quantities allowed may be limited.
■   Cosmetics                          general health                     Receipt must state vendor, name of medical item, date of
■   Dental floss                     ■ Make-up                            purchase and amount of purchase.
■   Dental rinse                     ■ Moisturizer
■   Deodorant                        ■ Mouthwash                          ■ Dietary suplements or herbal medicines to treat specific
■   Diapers (baby or diaper          ■ Perfume                              medical conditions
    service)                         ■ Personal use items                 ■ Ear plugs for medical conditions
■   Dietary supplements to           ■ Shampoo                            ■ Feminine hygiene products in certain situations
    improve and maintain             ■ Shaving brushes and creams         ■ Fiber supplements if taken to treat specific medical conditions
    general health                   ■ Soap                               ■ Glucosamine/chondroitin for arthritis or other medical condition
■   Eye cream                        ■ Toothbrushes (including            ■ Hormone treatment and therapy for menopause symptoms
■   Face cream                         electric)                          ■ Lactose intolerance medication
■   Feminine hygiene products        ■ Toothpaste                         ■ Medicated shampoo and soap
    in most situations               ■ Vitamins for general health        ■ Orthopedic shoes and inserts
■   Hand lotion                      ■ Teeth whitening and                ■ St. John’s Wort (for depression)
                                       bleaching products                 ■ Vitamins to treat specific medical conditions
                                                                          ■ Weight-loss drugs to treat diagnosed diseases

                                                                                                         3816 S Elmwood Avenue, Suite 100
                                                                                                         Sioux Falls, SD 57105
                                                                                                         Toll-Free: 1 (866) 791-0982
                                                                                                         Fax: (605) 322-4688
                                                                                                         FlexibleSpending@Avera.org
MKT-FORM-107 (1/10)

								
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