Flexible spending accounts
Flexible Spending Accounts
Medical expenses include payments you make for the diagnosis, treatment or prevention of disease or for treatment affecting any part
or function of the body and the amounts you pay for transportation to get medical care.
The following is a partial listing of medical expenses, which are allowed and disallowed through your Flexible Reimbursement in
general; the medical expenses that are allowable deductions on your federal income tax (IRC Section 213(d)) are also reimbursable
expenses through your flexible spending account.
It is possible that changes in the IRS rules can affect the Allowed and or Disallowed Expenses categories. Allowed Expenses
Cosmetic surgery (expenses exceptions if medically
Coinsurance (co-pays and deductibles for health,
Dancing lessons, swimming lessons, etc., even if
recommended for the general improvement of your
Face creams, moisturizers, suntan lotions
Insulin and equipment needed to inject the insulin
Hair transplant (i.e. Rogaine, Propecia)
Massage therapy with letter stating medical necessity
Insurance premiums –for individual and/or spouses
Nursing services-connected with caring for the patient
health, dental, and/or policies covering loss of
Medicated shampoos and soaps (unless prescribed by
Prescription eyeglasses, sunglasses, Contact Lenses
and solutions associated with their care
Psychoanalysis received as part of training to be a
Psychoanalysis, Psychiatric & Psychological
Vitamins and supplements for maintaining general
Transportation-amounts primarily for and essential to
Weight-loss program and/or drugs to induce weight loss when prescribed for a specific diagnosis
How to File a Claim:
To receive reimbursement for eligible expenses, mail OR fax (not both) a completed claim form along with IRS-required
documentation of the expense which will include all of the following:
1. Date of service/purchase 4. Name of person receiving services
2. Name of provider of service 5. Type of service/supply provided
3. Amount charged for each service/supply or the amount not reimbursed by insurance
All individual receipts should be taped on an 8 ½ x 11 piece of paper to expedite claim processing. * Cancelled checks do not qualify as third-party documentation and are not accepted by the IRS.
Be sure to provide all information requested on the form. The form must be signed or it will be returned.
Dependent /Day Care Expenses
Dependent/daycare expenses include payments you make for the care of a child under 13 and/or a dependent regardless of age who
requires care due to an inability to care for him or herself, to enable you (and, if married, your spouse) to remain gainfully employed.
Those dependents unable to care for themselves must spend at least 8 hours a day in your home for the care to be eligible, and you
must declare them as a dependent (or have the ability to declare them as a dependent except for their level of gross income) on your
Federal tax return. Reimbursement for amounts cannot be claimed if paid to your spouse, anyone you claim as a tax dependent, or
your child under age 19. Any expenses reimbursed through your account cannot be claimed for income tax purposes. Allowed Dependent/Daycare Expenses
Disallowed Dependent/Daycare Expenses
Services solely for the purpose of household cleaning
In-home child and dependent care services
Daycare for children past their 13th birthday
Any other qualified dependent care expenses as defined by the IRS.
Please remember day care expenses must be incurred to be eligible for reimbursement.
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Top 10 by DIN by Sponsor/Policy/Class/Division/Subdivision Report Total Total Claims Paid Drug Name Chemical Entity Therapeutic Category Brand/Generic Status Provincial Formulary Biological Drug Cost Dispensing Total Eligible Total Claims Paid Sequence Submitted Top 10 Drugs $10,401.22 $10,401.22 $5,998.52 $5,998.52 All Drugs $