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Microsoft word - examples of eligible expenses.doc

EXAMPLES OF ELIGIBLE EXPENSES

Abortions,
Insurance companies for eligible Obstetrical OVER-THE COUNTER DRUGS

Over-the counter medicines may be reimbursable under your Health
Reimbursement Account, depending upon whether the item treats a specific
medical condition or is used for a person’s general good health. If the item is
obviously used to treat a medical condition (such as Claritin), it will be
reimbursed without question. If the item could be used for good health, a
statement of medical necessity from your physician or alternate health care
provider will be required before payment will be made.
Type of Expense
Examples
IRS Ruling
Acne Medication
Allowed as treatment
Neutrogena, Noxzema, Oxy, Phisoderm, Stridex Allergies
Actifed, Advil, Afrin, Alavert, Allerest, Benadryl, Allowed as treatment
CholorTrimeton, Claritin, Dimetapp, Diphedryl, Motrin, Nasal Crom, Sudafed, Tavist, Tylenol, Vicks Allowed as treatment
of an illness.
Cold Sores
Allowed as treatment
of an illness.
Actifed, Advil, Aleve, Alka-Seltzer Plus, Cepecol, Allowed as treatment
Chloraseptic, Ciricidin, Cold-Eeze, Comtrex, Contac, Dimetapp, Drixoral, Halls, Ludens, Neo-synephrine, Profen IB, Ricola, Robitussin, Sucrets, Sudafed, Theraflu, Triaminic, Tylenol, Vicks Day Quil, Vicks Vaporub, Zicam, Zinc Drops Cosmetics
Almay, Aveeno, CoverGirl, Cutex, Jergens, Not allowed
L’Oreal, Maybelline, Olay, Revlon, Sally Hansen, St. Ives Cuts and Itching
Bactine, Balmax, Benadryl Anti-itch Cream, Allowed as treatment
Caladryl, Campho-Phenique, Cortaid, Demarest, Destin Diaper Rash, Hydrocortisone, Hydrogen Peroxide, Iodine, Itch-X, Lanacane, Neosporin, Polysporin, Psoriasin gel, Witch Hazel Dentures
Allowed as treatment
of an illness
Diabetes
Allowed as treatment
of an illness.
Supplements
necessity from your physician is required. Digestive
Alka-Seltzer, Axid AR, Bonine, Carters, Castor Allowed as treatment
Remedies
Oil, Citrucel, Correctol, Dramamine, Dulcolax, Emetrol, Ex-lax, Fleet Enema, Gas-X, Gaviscon, Imodium, Kaopectate, Lactaid pills, Maalox, Metamucil, Mylanta, Pepcid, Pepto-Bismol, Phillips, Prilosec, Rolaids, Tagamet,Tums,Zantac Eye and Ear
Allowed as treatment
Problems
Foot Treatments
Allowed as treatment
of an illness.
Hair Growth
Not allowed
Treatment
Hemorrhoids

Anusol, Hemorid, Nupercainal, Preparation H, Allowed as treatment
Bilberry, Cholestene, DHEA, Echinacea, Estroven, Homeopathic or
Fish Oil, Flax Seed Oil, Garlic, Genseng, Gingko Naturopathic
Biloba, Glucosamine and Chondroitin, Goldenseal, remedies
Grape Seed, Herbs, Joint Juice Knox Nutra Joint, L- Argine, L-Carnitine, Lecithin, Lutein, Maca, Melatonin, Milk thistle, MSM, Ocuvite, Omega-3.6.9, Osteo Bi Flex, Papaya Enzyme, SAM-e, Shark Cartilage, St. Illegally Procured
Laetril, Marijuana, Imported from Canada Not allowed
Jock Itch
Cruex, Lamisil AT, Lotrimin AF, Micatin, Tinactin Allowed as treatment
of an illness.
Allowed as treatment
of an illness.
Minerals and
Antioxidants, Calcium, Chromium Picolinate, Vitamins
Folic Acid, Iron Lysine, Magnesium, Menopause Supplements, Multi-Vitamins, Niacin Potassium, Pain Relief
Advil, Aleve, Arth-Rx, Aspercreme, Aspirin, Azo, Allowed as treatment
BenGay, Doan’s, Epsom Salt, Excedrin, Flexall, Ibuprofen, IcyHot, Jointflex, Joint-Ritis, Mentholatum, midol, Motrin, Pamprin, Premysin PMS, Prodium, Stopain, Tylenol Sleeping Aids
Alluna, Excedrin PM, Natrol, Nytol, Unisom Not allowed
Endit, Lite’n up, NicoDerm CQ, Nicorette, Allowed as treatment
Cessation
Sun Block
Not allowed
Toiletries
Aim, Anti-Plaque, Aquafresh, Arrid, Aveno, Baby Not allowed
Powder, Ban, Barbasol, Biotene, Caress, Close-Up, Coast, Colgate, Crest, Degree, Denorex, Dial, Dove, Eucerin, Gillette, Gleem, Head & Shoulders, Jergens, Listerine, L’Oreal, Mitchum, Nads, Nair, Nivea, Panteen, Pepsodent, Plax, Plus+White, Rembrandt, Scope, Sensodyne, Shower to Shower, Skintimate, St. Ives, Suave Thermasilk, Tom’s of Main, Viadent, Vita-K Toothache
Allowed as treatment
of an illness.
Compound W, Dr. Scholl’s, Pedifix, Wart-off Allowed as treatment
of an illness.
Weight Loss
A statement of medical necessity from your physician is required or you must indicate “treatment of obesity” on your claim form. Yeast Infection
Monistat, Mycelex3, Vaginex, Vagistate 3 Allowed as treatment
of an illness.
EXAMPLES OF HEALTH CARE EXPENSES THAT DO NOT
QUALIFY FOR REIMBURSEMENT
• Unnecessary cosmetic surgery and health care expenses incurred for the primary purpose of enhancing the appearance • The salary expense of a licensed practical nurse incurred in connection with the care of a normal and healthy newborn • Household and domestic help (even though recommended by a qualified physician due to an Retiree's or dependent's inability to perform physical • Costs for sending a problem child to a special school for anticipated benefits the child may receive from the course of study and the disciplinary methods • Any expense incurred in connection with an illegal operation or treatment • Health club dues unrelated to the treatment of obesity, YMCA dues, steam • Social activities, such as dance lessons or classes (even though recommended • Membership fees or costs associated with weight loss programs for purposes • Vitamins taken for general health purpose • Automobile insurance premiums including the segment of premiums providing medical care for persons injured through accident by a Retiree's car • Vacations for travel taken for purposes of general health, a change in environment, improvement of morale, etc., or taken to relieve physical or mental discomfort not related to a particular disease or physical defect • PPO discounts or negotiated rates as you are not liable for them
• Long-Term Care insurance contracts and Lifetime Care fees

• Prescriptions imported from outside the United States

Source: http://www.bac1mn-nd.org/pdf/Examples.pdf

Consent form

PRETTY IN INK CONFIDENTIAL CONSENT AND RELEASE AGREEMENT PLEASE PRINT Name/Releasor: ________________________________ Today’s Date: _________ D.O.B.: __________ Home Phone: ____________________ Address: __________________________________________________City, State, Zip: _______________________________________________ Cell Phone Number: _________________________________________

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