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P.O. Box 70168  Springfield, OR 97475 Examples of Eligible and Ineligible Expenses
The following expenses are commonly requested for reimbursement from Flexible Spending Accounts (FSAs). This list is not comprehensive and is subject to change. In order for any expense to be eligible under your FSA, supporting documentation from your healthcare provider is required. Documentation must include: • the date the service was incurred (not necessarily equal to the date of payment), • a brief description of the service or product, and • the name of the provider or place of purchase. All expenses must be incurred for medical care, and not cosmetic or general health purposes. To be considered an eligible expense, any items listed as "Potentially eligible" will require a Letter of Medical Necessity or prescription from your healthcare provider. The letter or prescription must include the item prescribed, condition being treated, and duration of treatment. For your convenience,form is available at ManleyPlan.com under Forms. Please note: Healthcare reform places restrictions on over-the-counter (OTC) medicines. Effective January 1,
2011, most OTC medicines and drugs (excluding insulin) will require a Letter of Medical Necessity or
prescription from your healthcare provider. Please note this ruling does not affect all OTC items, only those
considered medicines or biologicals.
Expense Type
Eligibility
Comments and Special Rules (if applicable)
AA meetings/
Transportation expenses associated with outpatient care or attending meetings of Alcoholism
an AA group qualify. Expenses for inpatient treatment (including meals and treatment
lodging), at a center for alcohol addiction will also qualify. Acne treatment
Because acne is considered a disease, the cost of acne treatment will generally qualify, although over-the-counter (OTC) acne medications must be prescribed if incurred after December 31, 2010. However, the cost of regular skin care (face creams, etc.) does not qualify. And when the expense has both medical and cosmetic purposes (e.g., Retin-A, which can be used to treat both acne and wrinkles), a note from a medical practitioner recommending the item to treat a specific medical condition is normally required. See Drugs and medicines; Cosmetic procedures; Cosmetics; Retin-A; Toiletries. Acupuncture
Adaptive
To show that the expense is primarily for medical care, a Letter of Medical equipment
Necessity is required. Where applicable, only amounts above the cost of the regular version of the item will qualify. Depending on the nature of the item, other special rules may apply. Adoption, pre-
Medical expenses incurred before an adoption is finalized will qualify, if the child adoption
qualifies as your tax dependent when the services/items are provided. Adoption fees and other nonmedical expenses incurred in connection with adoption expenses
assistance are not eligible under the Healthcare FSA. The primary purpose must be to treat or alleviate a medical condition and the conditioners
expense must not have been incurred “but for” the condition. To show that the and purifiers
expense is primarily for medical care, a Letter of Medical Necessity is required. If it is attached to a home (such as central air conditioning), only the amount spent that is more than the value added to the property will qualify. Examples: Alavert, Claritin, Zyrtec. Requires Letter of Medical Necessity or medicine
prescription from your healthcare provider if incurred after December 31, 2010. Page 1 of 17
Expenses generally won't qualify if the product would be owned even without treatment
allergies, such as a pillow or a vacuum cleaner. However, an item necessary to products;
treat a severe allergy will qualify. The excess cost of a special version of an household
otherwise personal item (e.g., a vacuum cleaner with a HEPA filter) over the normal cost of the item will qualify if a special version of the item is necessary for improvements
treatment. To show that the expense is primarily for medical care, a Letter of allergies
Alternative

Drugs and medicines recommended by alternative healers to treat a specific healers, dietary
medical condition also can qualify as medical care. To show that the expense is substitutes,
primarily for medical care, a Letter of Medical Necessity is required. Expenses for and drugs and
food or a substitute for food that the person would normally consume in order to medicines
meet nutritional requirements are not eligible. Ambulance
Analgesics
Examples: Advil, Aspirin, Motrin, Tylenol. Requires Letter of Medical Necessity or Prescription from your healthcare provider if incurred after December 31, 2010. Antacids
Examples: Maalox, Prilosec OTC, Zantac. Requires Letter of Medical Necessity or Prescription from your health care provider if incurred after December 31, 2010. Antibiotic
Examples: Bacitracin, Neosporin. Requires Letter of Medical Necessity or ointments
prescription from your healthcare provider if incurred after December 31, 2010. Antihistamines
Examples: Benadryl, Claritin. Requires Letter of Medical Necessity or prescription from your healthcare provider if incurred after December 31, 2010. Anti-itch
Examples: Benadryl, Cortaid, Ivarest. Requires Letter of Medical Necessity or prescription from your healthcare provider if incurred after December 31, 2010. Arthritis gloves Eligible
Artificial limbs
Artificial teeth
Requires Letter of Medical Necessity or prescription from your healthcare provider Includes asthma medications and delivery devices (e.g., inhalers and nebulizers). treatments
Automobile
To show that the expense is primarily for medical care, a Letter of Medical modifications
Necessity is required. Expenses of operating a specially equipped car do not qualify. Babysitting and Ineligible
Babysitting, child care, and nursing services for a normal, healthy baby do not child care
Requires Letter of Medical Necessity or prescription from your healthcare provider Bandages,
Bandages, for
torn or injured
skin

Birth-control
Prescription birth-control pills are eligible. See also Contraceptives.
Birthing
Expenses for instruction that relates to birth, and not child rearing/care, are eligible for reimbursement. The fee may need to be apportioned to exclude instruction in these topics. Expenses for the coach or significant other do not qualify. Page 2 of 17
Blood storage
Fees for temporary storage (12 month max) for use during a scheduled surgery are eligible. Fees for indefinite storage, just in case the blood might be needed, would not be eligible. Blood-pressure
monitors
Blood-sugar
test kits and
test strips

Body scans
Books, health-
Will qualify if recommended to treat an illness (such as asthma or diabetes) diagnosed by a physician. The purpose of the expense must be to treat the disease, not to promote general health. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Braille books
Only amounts above the cost of regular printed material will qualify. and magazines
Breast pumps
Will qualify to the extent that surgery was done following a mastectomy for cancer. reconstruction
This is an exception to the rules regarding cosmetic procedures. following
mastectomy

Calamine lotion Potentially
Requires Letter of Medical Necessity or prescription from your healthcare provider Improvements or special equipment added to a home or other capital expenditures expenses
may qualify if the primary purpose of the expenditure is medical care and the expense would not be incurred “but for” this purpose. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. The amount of the expense that would qualify depends on the extent to which the expense permanently improves the property. Carpal tunnel
wrist supports
May qualify if used primarily to treat a specific medical condition. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Chelation
Will qualify if used to treat a medical condition such as lead poisoning. Chiropractors
Chondroitin
Will qualify if used for arthritis treatment, not simply prevention. Christian
practitioners
Circumcision
Classes, health-
Will qualify only if recommended to treat an illness diagnosed by a physician. The purpose of the expense must be to treat the disease rather than to promote general health. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Page 3 of 17
COBRA premiums are not qualifying expenses for the Healthcare FSA premiums
Coinsurance
Will qualify unless reimbursed by another source, such as secondary insurance. Cold medicine
Requires Letter of Medical Necessity or prescription from your healthcare provider Cold/hot packs Eligible
Only cold/hot packs sold as medical supplies will qualify; those sold for other purposes won't qualify. Compression
Qualifies when used to treat circulatory conditions. Won't qualify if used for Contact lenses,
Materials and equipment needed for using lenses (saline solution and enzyme materials, and
cleaner) qualify if the lenses are needed for medical purposes. Contact lenses for equipment
cosmetic purposes (for example, to change one's eye color) do not qualify. Contact lens insurance would not qualify. Contraceptives
Examples: Spermicidal foam, Morning-after pill. Requires Letter of Medical Necessity or prescription from your healthcare provider if incurred after December 31, 2010. Controlled
Any substance that violates federal law (e.g., the Controlled Substances Act) would substances in
not qualify even if a state law allows its use with a physician's prescription (for violation of
example, marijuana prescribed to treat a specific medical condition). federal law
Copayments
Will qualify unless reimbursed by another source, such as secondary insurance. Cosmetic
Most cosmetic procedures do not qualify as they are directed at improving the procedures
patient's appearance. Examples include face lifts, hair transplants, hair removal, teeth whitening, and liposuction. There is an exception, however, for procedures necessary to ameliorate a deformity arising from congenital abnormality, personal injury from accident or trauma, or disfiguring disease—these may qualify. Cosmetics
Cosmetics are used primarily for personal purposes, and are intended for cleansing, beautifying, promoting attractiveness, or altering the appearance. These types of expenses are not eligible for reimbursement. Examples include skin moisturizers, perfumes, lipsticks, fingernail polish, eye and facial makeup, shampoos, permanent waves, hair colors, toothpastes, and deodorants. Requires Letter of Medical Necessity or prescription from your healthcare provider suppressants
Counseling
Will qualify if for a medical reason. Couples, marriage, or family counseling does not qualify. Crowns, dental
Will not qualify if they are obtained for a cosmetic reason. See Cosmetic Crutches
Will qualify whether purchased or rented. Generally the cost of dancing lessons does not qualify, even if recommended by a medical practitioner, if the lessons are to improve general health. But the expense might qualify if recommended by a medical professional to treat a specific medical condition (such as part of a rehabilitation program after surgery). To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Page 4 of 17
Decongestants
Requires Letter of Medical Necessity or prescription from your healthcare provider Deductibles
Will qualify unless reimbursed by another source, such as secondary insurance. Dental floss
Dental sealants
Includes services for such procedures as teeth cleaning, application of sealants, treatment
and fluoride treatments to prevent tooth decay, X-rays, fillings, braces, extractions,
dentures, and treatment of other dental ailments. Reimbursements for orthodontia
will require an ortho contract. Teeth whitening/bleaching, veneers, and other
cosmetic dental treatments are not eligible.
Dentures and
denture
adhesives

Deodorant
Dependent care Ineligible
Such expenses won't qualify, even if they are incurred so that you can receive expenses
Diabetic socks
Qualifies when used to treat diabetic conditions. Won’t qualify if used for personal Diabetic
supplies
Diagnostic

Includes a wide variety of procedures to determine the presence of a disease or items/services
dysfunction of the body, such as tests to detect stroke, diabetes, osteoporosis, thyroid conditions, and cancer. Diaper rash
Requires Letter of Medical Necessity or prescription from your healthcare provider ointments
Diapers or
Regular diapers or diaper services for newborns do not qualify. Diapers or diaper diaper service
services used to alleviate a diagnosed medical condition may qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Diarrhea
Requires Letter of Medical Necessity or prescription from your healthcare provider medicine
Diet foods
Costs of special foods to treat a specific disease (such as obesity) do not qualify to the extent that they satisfy ordinary nutritional requirements. Thus, the costs of food associated with a weight-loss program, such as special pre-packaged meals, do not qualify. The cost of dietary, nutritional, or herbal supplements, as well as vitamins and supplements
natural medicines do not qualify if they are merely beneficial for general health. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Disabled
Such expenses will qualify if the expenses are for medical care of the disabled dependent care
dependent. Note that some disabled dependent care expenses that qualify as expenses
medical expenses may also qualify as work-related expenses for purposes of the dependent care tax credit under Code §21 or for reimbursement under a dependent care assistance program under Code §129 Code §129. You must not use the same expenses for more than one purpose. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Page 5 of 17
DNA collection
Generally will not qualify. Temporary storage may qualify under some and storage
circumstances, such as where the DNA is collected as part of the diagnosis, treatment, or prevention of an existing or imminent medical condition. Will only qualify to the extent that the doula provides medical care for the mother or child. Services such as emotional support, parenting information, child care, and housekeeping will not qualify. Drug addiction
Amounts paid for both inpatient and outpatient treatment at a center for drug treatment
Drug overdose,
treatment of
Drug testing
Kits that test for the presence of controlled substances won't qualify, as they do not kits for home
treat a medical condition. However, if the drug testing kit is used in the course of treating a medical condition or addiction, it may qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Drugs and
Must be primarily for medical care, legally procured, and generally accepted as medicines
medicines and drugs. In addition, expenses incurred after December 31, 2010 will qualify only if the medicine or drug is prescribed or is Insulin. For OTC medicines to be allowed, a prescription from your healthcare provider or letter of medical necessity is required. Dyslexia
To show that the expense is primarily for medical care, a Letter of Medical Ear piercing
Ear plugs
Will qualify if recommended by a medical practitioner for a specific medical condition. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Requires Letter of Medical Necessity or prescription from your healthcare provider products
Eczema

Requires Letter of Medical Necessity or prescription from your healthcare provider treatment
Egg donor fees
Amounts paid for the egg donor fee, an agency fee, an egg donor's medical and psychological testing, and the legal fees for preparation of the egg donor contract will qualify. Fees for temporary storage qualify, but only to the extent necessary for immediate embryo storage eligible
conception. To show that the expense is primarily for medical care, a Letter of Electrolysis
Elevator
Installing an elevator upon the advice of a physician so that a person with heart disease won't have to climb stairs may be medical care to the extent of the amount in excess of value enhancement to the property. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Exercise
Qualifies only if required to treat an illness (such as obesity) diagnosed by a equipment or
physician. The purpose of the expense must be to treat a disease (not to promote programs
general health), and the expense must not have been incurred “but for” this purpose. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Expectorants
Requires Letter of Medical Necessity or prescription from your healthcare provider Page 6 of 17
Eye drops
Requires Letter of Medical Necessity or prescription from your healthcare provider Eye exams,
Materials and equipment needed for using and cleaning the eyeglasses, and eyeglasses,
reading glasses purchased over-the-counter are also eligible. and equipment
Face creams
Face lifts
Feminine
Such expenses generally won't qualify, as they are ordinarily considered as being products
Fertility
Will qualify to the extent that procedures are intended to overcome an inability to treatments
have children and are performed on you, your spouse, or your dependent. Expenses paid to or for an in vitro surrogate usually do not qualify, nor do egg donor expenses unless preparatory to a procedure performed on you, your spouse, or a dependent. Fever-reducing
Requires Letter of Medical Necessity or prescription from your healthcare provider medications
Requires Letter of Medical Necessity or prescription from your healthcare provider supplements
First aid cream
Requires Letter of Medical Necessity or prescription from your healthcare provider First aid kits
Qualifies only if required to treat an illness (such as obesity) diagnosed by a programs
physician. The purpose of the expense must be to treat a disease (not to promote general health), and the expense must not have been incurred “but for” this purpose. Health clubs memberships effective prior to being diagnosed with a qualifying medical condition will not qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Dates of visits to the health club will need to be obtained from a health club employee. Flu shots
Fluoridation
services
Fluoride rinses
Requires Letter of Medical Necessity or prescription from your healthcare provider To show that the expense is primarily for medical care, a Letter of Medical thickeners
Special foods to treat a specific disease, such as obesity, will not qualify if they are used as a substitute for regular nutritional requirements. Food prescribed by a medical practitioner to treat a specific disease that does not substitute for normal nutritional requirements may be eligible for reimbursement of the amount in which the food exceeds the cost of regular versions of the item. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Founder's fee
Founder's fees paid under an agreement with a retirement home do not qualify for reimbursement. expenses
Page 7 of 17
Gambling
To show that the expense is primarily for medical care, a Letter of Medical problem,
treatment for
Gauze pads
Genetic testing
To the extent that testing is done to diagnose a medical condition or to determine possible defects this will qualify. However, testing done to determine the sex of a fetus would not qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Glucosamine
Will qualify if used for arthritis treatment, not simply prevention. Glucose-
Blood-glucose meters and glucose test strips are diagnostic items and are monitoring
equipment
Hair colorants
Hair removal
Hand lotion
Hand sanitizer
Won’t qualify if used for general health purposes or other personal reasons (e.g., as a toiletry). Requires Letter of Medical Necessity or prescription from your healthcare provider if incurred after December 31, 2010. Headache
Examples: Advil, Aspirin, Tylenol. Requires Letter of Medical Necessity or medications
prescription from your healthcare provider if incurred after December 31, 2010. Health club
Fees incurred upon the advice of a medical practitioner to treat a specific medical condition (e.g., rehabilitation after back surgery or treatment for obesity) may qualify. The expense must not have been incurred “but for” the disease (for example, if you belonged to the health club before being diagnosed, then the fees would not qualify). When treatment is no longer needed, the fees would no longer qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Health institute
Qualifies only if the treatment at the health institute is prescribed by a physician. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Hearing aids
Hemorrhoid
Example: Preparation H. Requires Letter of Medical Necessity or prescription from treatments
your healthcare provider if incurred after December 31, 2010. To show that the expense is primarily for medical care, a Letter of Medical Improvements or special equipment added to a home (for example, an Elevator or improvements
Inclinator) or other capital expenditures may qualify if the primary purpose of the (such as exit
expenditure is medical care for you (or your dependent) and the expense would not be incurred “but for” this purpose. To show that the expense is primarily for medical widening
care, a Letter of Medical Necessity is required. The amount of the expense that would qualify depends on the extent to which the expense permanently improves doorways, etc.)
Will qualify if used primarily for medical care (for example, to treat menopausal replacement
symptoms such as hot flashes, night sweats, etc.). Won't qualify if primarily for therapy (HRT)
maintaining general health. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Hospital
Expenses of inpatient care (plus meals and lodging) at a hospital or similar services
institution qualify if a principal reason for being there is to get medical care. Household help Ineligible
Page 8 of 17
Humidifier
To show that the expense is primarily for medical care, a Letter of Medical Hypnosis
Will qualify if performed by a professional to treat a medical condition, or for other medical purposes (e.g., smoking cessation); won’t qualify if for general stress relief, enjoyment, or other personal purposes. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Won't qualify, even if they are rendered or prescribed by licensed medical operations and
treatments
Immunizations

Inclinator
May qualify to the extent of the amount in excess of value enhancement to the property, if the primary purpose of the expenditure is medical care for you (or your spouse or dependent) and the expense would not be incurred “but for” this purpose. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Incontinence
Items used to relieve adult incontinence will qualify. supplies
Insect-bite
Examples: Benadryl, Cortaid. Requires Letter of Medical Necessity or prescription creams and
from your healthcare provider if incurred after December 31, 2010. ointments
Equipment needed to inject the insulin, such as syringes or insulin pumps, also qualify. Insurance
premiums
IVF (in vitro
Will qualify to the extent that procedures are intended to overcome an inability to fertilization)
have children and are performed on you, your spouse, or your dependent. Expenses paid to or for an in vitro surrogate usually do not qualify, nor do egg donor expenses unless preparatory to a procedure performed on you, your spouse, or a dependent. Laboratory fees Eligible
Lactation
To show that the expense is primarily for medical care, a Letter of Medical consultant
Example: Lactaid. Requires Letter of Medical Necessity or prescription from your intolerance
healthcare provider if incurred after December 31, 2010. Lamaze classes Eligible
Language
Such expenses will qualify for a child with dyslexia or an otherwise disabled child. training
But amounts paid for regular schooling normally don't qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Laser eye
surgery; Lasik
Late fees
Fees or finance charges for late payment of a medical bill are not eligible for reimbursement. Laxatives
Example: Ex-Lax. Requires Letter of Medical Necessity or prescription from your healthcare provider if incurred after December 31, 2010. Page 9 of 17
Lead-based
The expense of removing lead-based paints from surfaces in the participant's paint removal
home to prevent a child who has (or has had) lead poisoning from eating the paint would qualify. The surfaces must be in poor repair (peeling or cracking) or be within the child's reach; the cost of repainting the scraped area does not qualify. If instead of removing the paint, the area is covered with wallboard or paneling, these items will be treated as capital expenses. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Learning
If prescribed by a physician, tuition fees paid to a special school and tutoring fees disability,
paid to a specially trained teacher for a child who has learning disabilities caused instructional
by mental or physical impairments will qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Legal fees in
May qualify if the legal fees are in connection with a medical procedure performed connection with eligible
fertility
treatments

Legal fees,
May qualify if the legal fees are in connection with a medical procedure performed upon you (or your spouse or dependent), or to authorize treatment of a mental illness. Fees for management of a guardianship estate for conducting the affairs of the person being treated or other fees that aren't necessary for medical care do not qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Lipsticks
Liquid adhesive Eligible
for small cuts
Lodging not at
Up to $50 per night will qualify if these conditions are met: The lodging is primarily a hospital or
for and essential to medical care; the medical care is provided by a physician in a licensed hospital or medical care facility related to a licensed hospital; the lodging institution
isn't lavish or extravagant; and there is no significant element of personal pleasure, recreation, or vacation in the travel. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Lodging of a
Will qualify if accompanying a patient for medical reasons and all of the conditions companion
listed above are also met. For example, if a parent is traveling with a sick child, up to $100 per night ($50 for each person) will qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Long-term care
Long-term care services, even those that a chronically ill individual requires and services
that are prescribed by a licensed healthcare practitioner under a plan of care, cannot be reimbursed on a tax-free basis, even if they otherwise qualify as medical care expenses. Marijuana or
other controlled
substances in
violation of
federal law

Qualifies when used as a first aid item. Won’t qualify if used for general health disposable
The costs of a massage to improve general health or stress don't qualify. If the massage therapy was recommended by a physician to treat a specific injury or trauma, then it would qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Page 10 of 17
Mastectomy-
related special
bras

Maternity
clothes
Mattresses

In rare cases, a portion of the expenditure might qualify if a unique type of mattress is prescribed by a physician to treat a specific medical condition. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Medical alert
bracelet or
necklace
Medical

Expenses for admission and transportation to a medical conference qualify, if they conference
relate to a chronic disease suffered by you, your spouse, or your dependent and if admission,
the conference is primarily for and essential to the person in need of medical care. transportation,
The expenses of meals and lodging while attending the conference don't qualify. To show that the expense is primarily for medical care, a Letter of Medical meals, etc.
Expenses paid to a plan to keep medical information electronically for you, your information
spouse, or your dependents are eligible. plan charges
Examples of such devices are blood-pressure monitors, syringes, glucose kit, monitoring and
testing devices
Medical records Eligible
Fees associated with transferring medical records to a new medical practitioner will Menstrual pain
Example: Midol, Pamprin. Requires Letter of Medical Necessity or prescription relievers
from your healthcare provider if incurred after December 31, 2010. Mentally
The cost of keeping a mentally handicapped person in a special home (not a handicapped,
relative's home) on a psychiatrist's recommendation to help that person adjust from special home
life in a mental hospital to community living may qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. To show that the expense is primarily for medical care, a Letter of Medical supplements
appointment
fees
Moisturizers

Examples: Bonine, Dramamine. Requires Letter of Medical Necessity or sickness pills
prescription from your healthcare provider if incurred after December 31, 2010. Mouthwash
Nail polish
Nasal strips or
Nasal sprays or strips used to treat sinus problems qualify as being primarily for medical care, as would those that are used to prevent sleep apnea. Requires Letter of Medical Necessity or prescription from your healthcare provider if incurred after December 31, 2010. Nicotine gum or Potentially
Examples: Nicoderm, Nicorette. Requires Letter of Medical Necessity or prescription from your healthcare provider if incurred after December 31, 2010. Page 11 of 17
Won't qualify if the baby is normal and healthy. services for a
baby
Nursing

These expenses generally will qualify, whether provided in the participant's home services
or another facility. The attendant doesn't have to be a nurse, so long as the provided by a
services are of a kind generally performed by a nurse. These include services nurse or other
connected with caring for the patient's condition, such as giving medication or attendant
changing dressings, as well as bathing and grooming. If the person providing nursing services also provides household and personal services, the amounts must be accounted for separately - only those for nursing services qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Nutritional
These will not qualify if they are used merely to benefit general health. To show supplements
that the expense is primarily for medical care, a Letter of Medical Necessity is required. Nutritionist's
May qualify if the treatment relates to a specifically diagnosed medical condition professional
and not for general health. To show that the expense is primarily for medical care, expenses
a Letter of Medical Necessity is required. Obstetrical
expenses
Occlusal
guards to
prevent teeth
grinding
Occupational

One-a-day
vitamins
Operations
Qualifies if the operations are legal and not cosmetic. Optometrist
Organ donors
Orthodontia
Please see Guidelines for Orthodontia Reimbursements located in the Forms section. Orthopedic
Will qualify if used to treat injured or weakened body parts. Orthopedic
Won't qualify if used for personal or preventive reasons. If used to treat or alleviate a specific medical condition, only the excess cost of the specialized orthopedic shoe over the cost of a regular shoe will qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Osteopath fees
Ovulation
This includes the expenses of oxygen and oxygen equipment for breathing problems caused by a medical condition. Pain relievers
Examples: Advil, Aspirin, Tylenol. Requires Letter of Medical Necessity or prescription from your healthcare provider if incurred after December 31, 2010. Personal trainer Potentially
Will qualify if a medical practitioner has recommended a supervised exercise regimen in order to treat a disease or injury and if incurred for a limited duration. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Page 12 of 17
Petroleum jelly
Example: Vaseline. May qualify if used to treat or alleviate a specific medical condition. Won't qualify if used to maintain general health or for other personal reasons (e.g., as a toiletry or a cosmetic). Requires Letter of Medical Necessity or prescription from your healthcare provider if incurred after December 31, 2010. Physical exams Eligible
Physical
therapy
Pregnancy

tests
Prenatal

Obstetricians routinely recommend prenatal vitamins for the health of unborn vitamins
children. If taken during pregnancy (a medical condition), prenatal vitamins would be considered primarily for medical care. Vitamins taken at other times generally do not qualify. Prepayments
Payments for services/items that have not yet been incurred/obtained are not reimbursable. Prescription
Fees paid for a card that provides a discount on drugs are not eligible. The actual drug discount
programs
Prescription
Will not qualify if used for primarily cosmetic purposes. Prescription
Importing prescription drugs from other countries generally will violate federal law. drugs and
A drug or medicine may qualify for reimbursement if it is purchased and consumed medicines
in the other country and is legal in both that country and the U.S., or the FDA obtained from
announces it can be legally imported by individuals. other countries
Preventive care
Will qualify if the tests are used for medical diagnoses. Examples include hearing, screenings
Probiotics
Requires Letter of Medical Necessity or prescription from your healthcare provider Propecia
Will not qualify if purchased for cosmetic purposes or for baldness associated with normal aging. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Prosthetics
Psychiatric
care
Psychoanalysis
Eligible
Psychologist
Will qualify if the expense is for medical care, and not just for the general improvement of mental health, relief of stress, or personal enjoyment. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. glasses
Rehydration

solution
Won't qualify if purchased for cosmetic purposes (for example, to reduce wrinkles). May qualify if recommended by a medical practitioner for a specific medical condition (e.g., acne vulgaris). To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Page 13 of 17
Will not qualify if purchased for cosmetic purposes or for baldness associated with normal aging. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Wil qualify when purchased for first-aid purposes. Rubdowns
To show that the expense is primarily for medical care, a Letter of Medical Safety glasses
Will qualify only if prescription lenses. Schools and
Some payments made to a residential school or program to treat an individual for education,
behavioral, emotional, or addictive conditions will qualify if a principal reason for residential
attending the program is to receive medical care. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Schools and
Payments for a mentally or physically disabled person to attend a special school education,
will qualify if a principal reason for attending the school is to alleviate the disability. Includes teaching Braille to a visually impaired person, teaching lip reading to a hearing-impaired person, and remedial language training to correct a condition caused by a birth defect. If a child is at a school because the courses or disciplinary methods have a beneficial effect on the child's attitude, the expenses won't qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Screening tests Eligible
Will qualify if the tests are for medical diagnoses. Expenses for buying, training, and maintaining a service animal used by a physically disabled person would qualify; including the expenses of food, medications, dental care, and veterinary fees for such animals. Shampoos
Shaving cream
or lotion
Shipping and
Shipping and handling fees incurred to obtain an item that constitutes medical care handling fees
Example: Sudafed. Requires Letter of Medical Necessity or prescription from your medications
healthcare provider if incurred after December 31, 2010. Sleep treatment Eligible
Smoking-
Requires Letter of Medical Necessity or prescription from your healthcare provider cessation
if incurred after December 31, 2010. See also Drugs and medicines; Nicotine
medications
gum or patches.
Smoking-
Amounts paid for a smoking-cessation (stop-smoking) program would qualify. See cessation
Smoking-cessation medications.
programs
Speech therapy Eligible
Sperm, storage
Fees for temporary storage qualify, but only to the extent necessary for immediate conception. Storage fees for undefined future conception aren't considered to be for medical care. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. St. John's Wort Potentially
Will qualify if used primarily for medical care and not to maintain general health. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Page 14 of 17
Stem cell,
Qualifies if there is a specific, imminent medical condition that the stem cells are harvesting
intended to treat. Collection and storage indefinitely, just in case an item might be and/or storage
needed, is not eligible. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Sterilization
procedures
Student health
A fee for the cost of belonging to the program won't qualify. Expenses for specific creams and
Will qualify if used to treat a sunburn (and not as regular skin moisturizers), but ointments
must be prescribed if incurred after December 31, 2010. Sunglasses
Sun-protective
Won’t qualify if used to maintain general health or for other personal reasons. (SPF) clothing
Qualifies if used to treat or alleviate a specific medical condition, but only the excess cost of the specialized garment over the cost of ordinary clothing will qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Sunscreen
Requires Letter of Medical Necessity or prescription from your healthcare provider Support braces Eligible
Will qualify if used for injured/weakened body parts. Surgery for cosmetic reasons are not eligible. Surrogate or
Such expenses won't qualify, even if they are for medical care of the gestational
surrogate/gestational carrier or her unborn child. carrier
expenses
Swimming

Generally the cost of swimming lessons does not qualify, even if recommended by a medical practitioner, if the lessons are to improve general health. But the expense might qualify if recommended by a medical professional to treat a specific medical condition (such as part of a rehabilitation program after surgery). To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Tanning salons
These will qualify if recommended for a specific medical condition, such as a skin and equipment
disorder. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Local, state, service, or other taxes on medical services and products are eligible. medical care
Teeth whitening
Potentially
Won't qualify if tooth discoloration is simply the result of aging and the whitening is done for cosmetic purposes. But if tooth discoloration was caused by disease, birth defect, or injury, expenses for teeth whitening might qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Telephone for
The expenses of buying and repairing special telephone equipment for a hearing- hearing-
impaired
persons
Television for

Equipment that displays the audio part of television programs as subtitles for hearing-
hearing-impaired persons will qualify. The amount that qualifies is limited to the impaired
excess of the cost over the cost of the regular item. Page 15 of 17
Will qualify if provided for medical care (and not for the general improvement of
mental health, relief of stress, or personal enjoyment). To show that the expense is
primarily for medical care, a Letter of Medical Necessity is required. See also
Counseling for additional information.
Thermometers
Requires Letter of Medical Necessity or prescription from your healthcare provider lozenges
Toiletries
A toiletry is used in the process of dressing and grooming oneself and therefore is not medical care. Toothache and
Requires Letter of Medical Necessity or prescription from your healthcare provider teething pain
relievers
Toothbrushes
Won't qualify even if a dentist recommends special types to treat a medical and toothpaste
condition. These items are used primarily for general health and would still be used without a medical condition. Thus, they are not primarily for medical care. Transplants
Transportation
A disabled individual's commuting costs to and from work are personal expenses costs to and
from work
Transportation
Will qualify if the transportation is primarily for and essential to medical care. expenses for
Includes car and rental car expenses; bus, taxi, train, plane, and ferry fares; and person to
ambulance services. Instead of actual car expenses, the standard mileage rate for receive medical
use of a car to obtain medical care is allowed. (Contact Customer Service for current rate.) Parking fees and tolls also qualify. Transportation
Will qualify in some cases. Transportation expenses of the following persons will of someone
qualify: (1) a parent who must go with a child who needs medical care; (2) a nurse other than the
or other person who gives injections, medications, or other treatment required by a patient who is traveling to get medical care and is unable to travel alone; and (3) an receiving
individual who travels to visit a mentally ill dependent, if such visits are recommended as part of treatment. medical care
Ultrasound,
prenatal
Umbilical cord,
Might qualify if there is a specific medical condition that the umbilical cord is freezing and
intended to treat. Collection and storage indefinitely, just in case it is needed, is not storing of
medical care. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Vaccines
Varicose veins,
Such expenses won't qualify if the procedure merely improves appearance. May treatment of
qualify if the procedure promotes the proper function of the body or prevents/treats an illness or disease. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Vasectomy
Such expenses are generally for cosmetic purposes. correction
procedures
Vision discount
Ineligible
Fees paid for access to a vision network or discounted rate are not eligible. programs
Page 16 of 17
Vitamins
Won't qualify if used to maintain general health (e.g., one-a-day vitamins). May qualify if recommended by a medical practitioner for a specific medical condition (for example, a prescribed dosage of Vitamin B-12 daily to treat a specific vitamin deficiency). To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Wart remover
Example: Compound W. Requires Letter of Medical Necessity or prescription from treatments
your healthcare provider if incurred after December 31, 2010. Weight-loss
Will qualify if the weight-loss program is recommended by a physician to treat a programs
specific medical condition and is not simply to improve general health. The costs of and/or drugs
food associated with a weight-loss program (such as special pre-packaged meals) prescribed to
would not qualify, since it just meets normal nutritional needs. To show that the induce weight
expense is primarily for medical care, a note from a medical practitioner recommending it to treat a specific medical condition is required. To expedite reimbursement for weight-loss programs, please also provide proof of participation/dates of attendance from a representative of the program facility. Wheelchair
A wig is prescribed by a physician for the mental health of a patient who has lost all of his or her hair from disease or treatment will qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. X-ray fees
Yeast infection
Examples: Monistat. Requires Letter of Medical Necessity or prescription from your medications
healthcare provider if incurred after December 31, 2010. Such expenses generally won't qualify. However, if a camp is a special therapeutic program and treats a specific disability, then the expense might qualify. To show that the expense is primarily for medical care, a Letter of Medical Necessity is required. Page 17 of 17

Source: http://www.cocc.edu/uploadedfiles/departments_/human_resources/employee_resources/examples_eligible_expenses%202011.pdf

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