DENTAL and MEDICAL EXPENSES: For each expense listed that is or may be covered under an insurance plan, submit your bills to the insurance company(ies) and then submit the insurance company statement of benefits showing the amount of expenses not covered by insurance with this form. For other expenses attach an itemized statement. For prescription drugs, attach the pharmacy statement or label. Keep a copy of all documentation for your records. For covered over-the-counter items a cash register tape with the name of the drug imprinted by the store register is required:
***NEW*** The health care reform legislation signed into law by the President impacts over-the-counter (OTC) purchases with Health Care Flexible Spending Accounts beginning in January of 2011. OTC drugs, medicines and biologicals remain eligible, but only with a letter of medical necessity from a medical provider.
Our debit card provider will be updating the eligible products criteria to reflect movement of these items from the “Eligible” to “Non-Eligible” category. NOTE: Because these items now require a doctor’s directive, these items can no longer be purchased by the debit card program; however, they could be reimbursed by filing a paper claim with a doctor’s letter of medical necessity.
DEPENDENT CARE EXPENSES: For each dependent care expense listed, attach a third party statement or complete the Dependent Care Provider Acknowledgement, provider signature is required. The qualified dependent who spends at least eight hours a day in your home must be age 12 or under; or any other qualified dependent person, who is physically or mentally incapable of self care (such as a disabled parent or older child) regardless of age. A doctor’s statement of disability is required. Qualified expenses are for care only. Educational expenses, registration and activity fees are not reimbursable.