Qualified Expenses

Over-the- counter items, drugs or medications must be medically necessary. Items marked (Rx) require a doctor's prescription beginning 1/1/2011.

Antiseptics
Items marked (Rx) require a doctor's prescription beginning 1/1/2011

- Antiseptic wash or ointment for cuts or scrapes (Rx) - Antiseptic mouthwash (Rx) - Benzocaine Swabs (Rx) - Boric acid powder (Rx) - First aid wipes (Rx) - Hydrogen peroxide (Rx) - Iodine tincture (Rx) - Rubbing alcohol (Rx) - Sublimed sulfur powder (Rx)

Cold, Flu, Asthma and Allergy Medications
Items marked (Rx) require a doctor's prescription beginning 1/1/2011

- Allergy medications (Rx) - Bronchodoliator/Expectorant tablets (Rx) - Bronchial asthma inhalers (Rx) - Cold relief syrup, tablets and drops (Rx) - Cough relief syrup, tablets and drops (Rx) - Flu relief syrup, tablets and drops (Rx) - Homeopathic sinus medications (Rx) - Medicated chest rub (Rx) - Nasal decongestant spray, drops or inhaler (Rx) - Sinus and allergy nasal spray (Rx) - Vapor patch cough suppressant (Rx)

Diabetes
Items marked (Rx) require a doctor's prescription beginning 1/1/2011

- Diabetic lancets - Diabetic needles - Diabetic supplies - Diabetic syringes - Diabetic test strips - Glucose meters - Glucose tablets (Rx)

Ear/Eye Care
Letter of Medical Necessity required from a physician (LOMN)
Items marked (Rx) require a doctor's prescription beginning 1/1/2011

- Airplane ear protection (LOMN) - Ear drops for swimmers (Rx) - Ear water-drying aid (Rx) - Ear wax removal drops (Rx) - Homeopathic earache tablets (Rx) - Contact lens solution

Health Aids
Items marked (Rx) require a doctor's prescription beginning 1/1/2011

- Anti-fungal treatments (Rx) - Denture adhesive - Diuretics and water pills (Rx) - Hemorrhoid relief (Rx) - Incontinence supplies - Lice control (Rx) - Medicated bandages - Motion sickness tablets (Rx) - Respiratory stimulant ammonia (Rx) - Sleeping aids (Rx)

Pain Relief
Items marked (Rx) require a doctor's prescription beginning 1/1/2011

- Arthritis pain reliever (Rx) - Bunion and blister treatments (Rx) - Itch relief (Rx) - Orajel® (Rx) - Pain relievers, aspirin and non-aspirin (Rx) - Throat pain medications (Rx)

Personal Test Kits

- Cholesterol tests - Colorectal cancer screening tests - Home drug tests - Ovulation indicators - Pregnancy tests

Skin Care
Items marked (Rx) require a doctor's prescription beginning 1/1/2011

- Acne medications (Rx) - Anti-itch lotion (Rx) - Bunion and blister treatments (Rx) - Cold sore and fever blister medications (Rx) - Corn and callus removal medications (Rx) - Diaper rash ointment (Rx) - Eczema cream (Rx) - Medicated bath products (Rx) - Wart removal medications (Rx)

Stomach Care
Items marked (Rx) require a doctor's prescription beginning 1/1/2011

- Acid reducers (Rx) - Antacid gum, liquid and tablets (Rx) - Anti-diarrhea medications (Rx) - Gas prevention tablets and drops (Rx) - Ipecac syrup (Rx) - Laxatives (Rx) - Pinworm treatment (Rx) - Prilosec® (Rx) - Upset stomach medications (Rx)

Over-the- Counter items
Letter of Medical Necessity required from a physician (LOMN)
Items marked (Rx) require a doctor's prescription beginning 1/1/2011

- Adhesive or elastic bandages - Blood pressure meter - Cold or hot compresses - Eye drops (Rx) - Foot spa (LOMN) - Gauze and tape (LOMN) - Gloves and masks (LOMN) - Herbs (Rx) - Leg or arm braces - Massagers (LOMN) - Minerals (Rx) - Multivitamins (Rx) - Saline nose drops (Rx) - Special supplements (Rx) - Special teeth cleaning system (Rx) - Thermometers - Vitamins (Rx)

Over-the- counter items that DO NOT qualify for reimbursement under an FSA plan:

- Aromatherapy - Baby bottles and cups - Baby oil - Baby wipes - Blistex® / Chapstick® - Breast enhancement system - Cosmetics - Cotton swabs - Dental floss - Deodorants - Facial care - Feminine care fragrances - Hair regrowth - Insoles - Low "carb" foods - Low calorie foods - Oral care - Petroleum jelly - Shampoo and conditioner - Skin care - Spa salts - Sun tanning products - Toothbrushes - Over-the-Counter items, drugs or medications that are not medically necessary, or are not prescribed by your physician or health practitioner.

Limitation on qualified expenses:
Your plan may restrict the reimbursement of one or more of these items. Check with your plan administrator. The total amount of all eligible expenses paid may not exceed the maximum allowed under the plan. Please review your Summary Plan Description or see your plan administrator for more information.