Microsoft word - hsa eligible expenses

Health Savings Account (HSA)
(only available with the Aetna HealthFund medical plan option)
Examples of Eligible and Ineligible Health Care Expenses
Eligible for Reimbursement
Not Eligible for Reimbursement
Co-payments for office visits and hospital stays charged by HMOs, POSs Cosmetic surgery or treatments to improve your appearance (if Co-payments for prescription drugs and products charged under Oxy’s Prescription Drug Program, HMOs, POSs, PPOs, dental plans, vision Day-care expenses for your child or for a disabled member of plans or any other employer-sponsored health care plan your household (these expenses may be eligible under a Annual deductibles under any health care insurance plan Your out-of-pocket share of covered health care expenses not paid by Expenses paid directly to the provider or reimbursed to you any company-sponsored health care benefit plan Charges in excess of usual and customary limits under health care plans Dietary weight-loss aids, unless prescribed in writing by a
Weight-loss programs undertaken at a physician’s direction to treat an existing disease such as obesity or hearth disease) Exercise equipment, unless prescribed in writing by a
Diagnostic services (e.g. body scans) as prescribed by a physician Smoking cessation programs, patches and gum Prescription glasses and contact lenses and most corrective visionsurgeries such as Lasik Some health insurance premiums, such those for Medicare & MedicareAdvantage and COBRA coverage, and qualified long-term carepremiums Other Over-the-Counter Medications and Products
Eligible for Reimbursement
Not Eligible for Reimbursement
Cold and allergy medications (like Claritin®, NyQuil®, Dristan®, Personal hygiene products such as deodorant, soap, body Antacids, digestive, urinary pain relief, laxative and motion sickness Vitamins, nutritional and dietary supplements like vitamins, medications (such as Pepcid®, Prilosec® and Dramamine®) unless prescribed in writing by a physician
Analgesics for fever and pain relief (like aspirin, Tylenol®, Motrin® and Sleep aid products, unless prescribed in writing by a physician
Cosmetics, including make-up, Q-tips®, cotton balls and Antibiotic, hydrocortisone, pain, itch relief, anti-fungal creams and Skin care products like sun block, sun tan products, Eye care products including contacts, saline solution and eye lubricant moisturizers, lip balm and acne treatments Hair care products like shampoo, conditioner and hair loss First aid products like Band-aids®, dressings, heat wraps, and Dental care products like toothpaste, floss, mouthwash, fluoride and plaque rinses, whitening/breath strips, denture Medical monitoring and testing equipment for diabetes, blood pressure Personal grooming products like combs, brushes, clippers, Shampoo treatments for psoriasis and lice Family planning products like pregnancy tests, IUDs and Vaginal infection and incontinence products Baby care products like formula, baby food, diapers, creams,lotions, and powders.
Eligible expenses are based on IRS guidelines contained in You may obtain a copy of this publication through the IRS web site at If you are
unsure if a particular expense is eligible for reimbursement or have questions about Aetna’s claim filing
process, you may also call Aetna at 800-334-0299 or log on to Aetna Navigator. You may link to Aetna
through the OxyLink site at or log on directly to .


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