• Over-the-Counter Medicines
• Prescriptions and Co-Pays
• Doctor's Fees and Co-Pays
• Vision Services and Supplies

• Dental Services and Supplies
• Health Improvement Programs
• Health Related Expenses and Equipment
• Limitation on Qualified Expenses

Over-the-Counter Medicines (Rx): Require a doctor's prescription

Over-the-counter items, drugs or medications must be medically necessary.

• Antiseptics
• Cold, Flu, Asthma, and Allergy Medications
• Diabetic supplies
• Ear/Eye Care
• Health Aids
• Pain Relief

• Personal Test Kits
• Skin Care
• Stomach Care
• Dual use items that require a letter from health practitioner to qualify

Prescriptions and Co-Pays

Prescription medications qualify unless they are reimbursed by insurance. Co-pays for prescription medications qualify.

Doctor's Fees and Co-Pays

Co-pays and other payments to doctors and health care providers qualify unless they are reimbursed by insurance:

• Doctor office co-pays
• Emergency room co-pays
• Out-patient surgery co-pays
• Inpatient admission co-pays
• Office visits
• Routine check ups
• Routine physicals and other non-diagnostic services or treatments
• Psychologist and psychiatrist fees
• Obstetrics and fertility
• Chiropractor and podiatrist fees
• Orthodontist and dentist fees
• Periodontist and endodontist fees

• Physician and Osteopath fees
• Acupuncture fees
• Eye exams
• Christian Science practitioner's fees
• Radiology
• Surgical fees
• Lab fees
• Diagnostic fees
• X-rays and MRI
• Weight loss programs and fees pertaining
  to a specific disease
• Reconstructive surgery in connection
  with birth defects, disease or accident

Doctor's fees that DO NOT qualify:

• Cosmetic surgery and procedures unless it is for reconstruction due to disease, birth defect or accident
• Dental bleaching
• Marriage and family counseling
• Weight loss programs for general health or appearance

• Over-the-counter items, drugs, or medications that are not medically necessary, or are not prescribed by your physician or health practitioner

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Vision Services and Supplies

Vision services and supplies qualify unless they are reimbursed by insurance:

• Vision co-pays
• Office visits and routine eye exams
• Prescribed sunglasses and eyeglasses
• Contact lenses, solutions and supplies
• Corrective eye surgery

• LASIK surgery
• Cataract surgery
• Optometrist fees
• Physician and Ophthalmologist fees
• Surgical fees and x-rays

Vision services and supplies that DO NOT qualify:

• Cosmetic surgery and procedures unless it is for reconstruction due to disease, birth defect or accident
• Over-the-counter items, drugs or medications that are not medically necessary, or are not prescribed by your physician or health practitioner

Dental Services and Supplies

Dental services and supplies qualify unless they are reimbursed by insurance:

• Co-payments
• Dental fillings, crowns, and bridges
• Deductibles
• Dentures
• Diagnostic fees
• Endodontist fees
• Oral surgery

• Orthodontist and dentist fees
• Periodontist fees
• Prescribed medicines
• Routine checkups
• Dental sealants
• Surgical fees
• X-rays

Dental services and supplies that DO NOT qualify:

• Cosmetic surgery and procedures unless it is for reconstruction due to disease, birth defect or accident
• Over-the-counter items, drugs, or medications that are not medically necessary, or are not prescribed by your physician or health practitioner

Health Improvement Programs (Rx): Require a doctor's prescription

Health improvement programs that qualify unless they are reimbursed by insurance:

• Physical and speech therapy
• Weight-loss programs (for specific disease)
• Quit-smoking programs, patches and gums (Rx)
• Alcoholism and drug treatment
• Special schooling for a disabled child
• Body scans

• Reconstructive surgery associated with birth defect, disease or accident
• Home drug tests
• Cholesterol tests and monitors
• Home blood tests
• Gastric bypass surgery

Health improvement programs that DO NOT qualify:

• Weight-loss programs for general health or appearance
• Cosmetic surgery and procedures unless it is for reconstruction due to disease, birth defect or accident
• Dental bleaching

• Marriage and family counseling
• Over-the-counter items, drugs or medications that are not medically necessary, or are not prescribed by your physician or health practitioner

Health Related Expenses and Equipment

Generally, the following items require a doctor's prescription to qualify. Health related expenses and equipment that qualify unless they are reimbursed by insurance:

• Humidifiers and vaporizers
• First aid bandages, gloves and masks
• Hot and cold compress packs and wraps
• Oxygen
• Pill boxes
• Shower protection for casts, prostheses, etc.
• Therapeutic support gloves
• Elevated toilet seat
• Thermometers
• Special school for disabled child

• Artificial limbs and braces
• Arches and orthopedic shoes
• Wigs for hair loss caused by disease
• Shower bars and safety handles
• Hearing devices and batteries
• Crutches and canes
• Wheelchairs, walkers and shower chairs
• Medical alert bracelet and fees
• Bedpans and ring cushions
• Travel to doctors or health care facilities
• Ambulance expenses

Health Care expenses that DO NOT qualify

• Expenses and equipment that are not medically necessary or are not prescribed by
  your health practitioner
• Weight-loss programs for general health or appearance

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 qualified expenses paid may not exceed the maximum allowed under the plan. Please review your Summary Plan Description or contact your plan administrator for more information.

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