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Limited Purpose FSA

Name Plan
Chiropractic care No 
Co-payment (medical, in-network) No 
Contact lenses and solutions Yes 
Dental Yes 
Hospital fees No 
Lab (medical) No 
Menstrual care products (Liners, Pads, Tampons, Cups, Menstrual undergarments) No 
Mileage (for travel to/from eligible health care) No 
Office visit (medical) No 
Orthodontia Yes 
Over-the-counter (drugs and medicines) No 
Psych / therapy No 
Rx (prescription) No 
Telehealth / remote care Yes 
Vision Yes 
X-ray (medical) No 
Acne treatments (over-the-counter) No 
Acupuncture No 
Adoption (medical expenses related to) No 
Adoption fees No 
Alcoholism treatment No 
Allergy & sinus medicine and products (over-the-counter) No 
Allergy medication No 
Allergy treatments and products No 
Alternative dietary supplements (for treatment of a medical condition) No 
Alternative drugs, medicines and treatment products (for treatment of a medical condition) No 
Alternative healers (for treatment of a medical condition) No 
Ambulance and emergency health services No 
Anesthesia (for non-cosmetic purposes) No 
Antacid (over-the-counter) No 
Antibiotic ointment (over-the-counter) No 
Aspirin or other pain reliever (over-the-counter) No 
Asthma medicines or treatments (over-the-counter) No 
Athletic treatments / braces No 
Bandages and related items (over-the-counter) No 
Birth control (over-the-counter) No 
Birth control (prescription) No 
Blood pressure monitor No 
Body scans No 
Braille books and magazines (difference in cost only) Yes 
Breast pump (for a lactating woman) No 
Breast reconstruction surgery (following mastectomy) No 
Breastfeeding classes No 
COBRA premiums (dental; paid with after-tax dollars only) No 
COBRA premiums (medical; paid with after-tax dollars only) No 
COBRA premiums (other; paid with after-tax dollars only) No 
COBRA premiums (prescription; paid with after-tax dollars only) No 
COBRA premiums (vision; paid with after-tax dollars only) No 
CPR classes (adult or child) No 
Canker & cold sore treatments (over-the-counter) No 
Car modifications (as required for a medical condition diagnosed by a licensed health care professional) No 
Chest rubs (over-the-counter) No 
Child or newborn care instruction No 
Childbirth classes (charges for mother only) No 
Chiropractic office visit or treatment No 
Cholesterol test kits and supplies No 
Christian Science practitioners No 
Co-insurance (dental, in-network) Yes 
Co-insurance (dental, out-of-network) Yes 
Co-insurance (medical, in-network) No 
Co-insurance (medical, out-of-network) No 
Co-insurance (prescription, in-network) No 
Co-insurance (prescription, out-of-network) No 
Co-insurance (vision, in-network) Yes 
Co-insurance (vision, out-of-network) Yes 
Co-payment (dental, in-network) Yes 
Co-payment (dental, out-of-network) Yes 
Co-payment (vision, in-network) Yes 
Co-payment (vision, out-of-network) Yes 
Cold & flu medicine (over-the-counter) No 
Cold cream (over-the-counter) No 
Compression or anti-embolism socks, stockings or hose No 
Concierge medical fees (billed for actual services received) No 
Concierge medical fees (billed for future availability of services, with no services actually received) No 
Condoms No 
Contraceptives (over-the-counter) No 
Contraceptives (prescription) No 
Cord blood storage (for future treatment of a birth defect or known medical condition) No 
Cord blood storage (for unidentified future use) No 
Corn and callus remover (over-the-counter) No 
Corneal keratotomy Yes 
Cosmetic procedures or surgery No 
Cosmetic procedures or surgery for birth defects, accidents, and/or disease No 
Cough drops & sore throat lozenges (over-the-counter) No 
Cough syrup (over-the-counter) No 
Counseling (for treatment of a medical condition) No 
Counseling (marriage) No 
Crutches, canes, walkers or like equipment (purchase or rental) No 
Dancing lessons (for treatment of a medical condition) No 
Deductible (dental, in-network) Yes 
Deductible (dental, out-of-network) Yes 
Deductible (medical, in-network) No 
Deductible (medical, out-of-network) No 
Deductible (prescription, in-network) No 
Deductible (prescription, out-of-network) No 
Deductible (vision, in-network) Yes 
Deductible (vision, out-of-network) Yes 
Dental Co-insurance (in-network) Yes 
Dental Co-insurance (out-of-network) Yes 
Dental Co-payment (in-network) Yes 
Dental Co-payment (out-of-network) Yes 
Dental insurance / plan premiums (paid with after-tax dollars only) No 
Dental products for general health No 
Dental veneers Yes (Letter) 
Dentures, bridges, etc. Yes 
Dermatology treatments and products No 
Diabetic monitors, test kits, strips and supplies No 
Diagnostic services (dental or vision) Yes 
Diagnostic services (other than dental or vision) No 
Diaper rash ointments and creams No 
Diapers and diaper services No 
Dietary supplements (for treatment of a medical condition) No 
Doula or birthing coach No 
Drug addiction treatment No 
Drugs (imported) No 
Drugs (prescription) No 
Dyslexia treatment No 
Ear drops & wax removal (over-the-counter) No 
Educational classes or tuition No 
Electrolysis No 
Emergency kits (over-the-counter) No 
Exercise equipment or program (as treatment for a medical condition diagnosed by a licensed health care professional) No 
Eye drops and treatments (over-the-counter) Yes 
Eye examinations Yes 
Eye related equipment/materials Yes 
Eye surgery or treatment to correct vision Yes 
Eyeglasses (over-the-counter) Yes 
Eyeglasses (prescription) Yes 
Face lifts No 
Feminine hygiene care (Deodorants, General Cleansing products, Feminine spray) No 
Fertility monitor (over-the-counter) No 
Fertility treatment (for employee, spouse or dependent) No 
Fertility treatment (for non-dependent surrogate) No 
First aid kits (over-the-counter) No 
Fitness programs (as treatment for a medical condition diagnosed by a licensed health care professional) No 
Flu shots No 
Funeral expenses No 
Gastrointestinal medication (over-the-counter) No 
Guide dog (dog, training, care) Yes (Letter) 
Hair regrowth products No 
Hair removal No 
Hair transplant No 
Hair treatments No 
Hand lotion (over-the-counter) No 
Health club dues (as treatment for a medical condition diagnosed by a licensed health care professional) No 
Health insurance / plan premiums (paid with after-tax dollars only) No 
Health plan claim from dental plan provider (total not covered by that plan) Yes 
Health plan claim from vision plan provider (total not covered by that plan) Yes 
Health savings account (HSA) contributions No 
Hearing Aid Batteries No 
Hearing Aids No 
Herbal or homeopathic medicines (over-the-counter) No 
Home improvements (as required for a medical condition diagnosed by a licensed health care professional) No 
Hospital (fixed indemnity) insurance premiums No 
Hospital services and fees No 
Household help No 
Humidifier, air filter and supplies No 
Illegal operations or substances No 
Immunizations No 
Incontinence supplies No 
Individual dental insurance / plan premiums (paid with after-tax dollars only) No 
Individual insurance / plan premiums (paid with after-tax dollars only) No 
Individual medical insurance / plan premiums (paid with after-tax dollars only) No 
Individual prescription insurance / plan premiums (paid with after-tax dollars only) No 
Individual vision insurance / plan premiums (paid with after-tax dollars only) No 
Infertility treatment (for employee, spouse or dependent) No 
Insulin, testing materials and supplies No 
Insurance / plan premiums (paid with pre-tax dollars) No 
Insurance or health insurance / plan premiums (paid with after-tax dollars only) No 
Laboratory fees No 
Lactose intolerance (over-the-counter) No 
Lamaze classes (charges for mother only) No 
Laser eye surgery Yes 
Lasik Yes 
Late payment fees charged by health care provider No 
Laxatives (over-the-counter) No 
Learning disability treatments No 
Lice treatment (over-the-counter) No 
Listening therapy No 
Lodging (limited to $50 per night for patient to receive medical care and $50 per night for one caregiver) No 
Long term care premiums (up to IRS tax-free limit, see IRS Publication 502) No 
Long term care services No 
Long term disability insurance premiums No 
Magnetic therapy (over-the-counter) No 
Massage therapy (for treatment of a medical condition) No 
Mastectomy-related special bras No 
Maternity clothes No 
Medical Co-insurance (in-network) No 
Medical Co-insurance (out-of-network) No 
Medical Co-payment (in-network) No 
Medical Co-payment (out-of-network) No 
Medical abortion No 
Medical equipment (for treatment of medical condition) and repairs No 
Medical insurance / plan premiums (paid with after-tax dollars only) No 
Medical literature, books, pamphlets or audio No 
Medical monitoring and testing devices No 
Medical records charges No 
Medical savings account (MSA) contributions No 
Medical supplies (for treatment of a medical condition) No 
Medicare Part B insurance / plan premiums No 
Medicare alternative insurance / plan premiums (vs. Part A & Part B, paid with after-tax dollars only) No 
Medicare supplement policy premiums No 
Medicines (over-the-counter) No 
Medicines (prescription) No 
Midwife No 
Mileage (for travel to / from anything other than eligible care) No 
Modified equipment (difference in cost only) No 
Monitors & test kits (over-the-counter) No 
Motion & nausea No 
Nasal sprays No 
Nasal strips (over-the-counter) No 
No show fees charged by health care provider No 
Non-prescription drugs and medicines (for non-cosmetic purposes) No 
Norplant insertion or removal No 
Nursing services (wages and taxes) No 
Nutritional supplements (for treatment of a medical condition) No 
OB/GYN fees No 
Occlusal guards to prevent teeth grinding Yes 
Occupational therapy (related to a medical condition or disability) No 
Office visits (chiro) No 
Office visits (dental) Yes 
Office visits (medical) No 
Office visits (psych/therapy) No 
Office visits (vision) Yes 
Operations (for non-cosmetic purposes) No 
Operations (for vision and dental only) Yes 
Opthamologist fees for medical eye condition Yes 
Opthamologist fees for routine eye care Yes 
Optometrist fees Yes 
Oral care (over-the-counter) No 
Organ transplants (recipient and donor) No 
Ortho keratotomy Yes 
Orthodontia (braces and retainers) Yes 
Orthopedic & surgical supports No 
Orthopedic shoes and inserts (difference in cost only of specialized orthopedic shoe over like non-specialized shoe) No 
Orthotics No 
Over-the-counter acne treatments No 
Over-the-counter allergy & sinus medicine No 
Over-the-counter antacid No 
Over-the-counter antibiotic ointment No 
Over-the-counter aspirin or other pain reliever No 
Over-the-counter asthma medicines or treatments No 
Over-the-counter bandages and related items No 
Over-the-counter canker & cold sore treatments No 
Over-the-counter chest rubs No 
Over-the-counter cold & flu medicine No 
Over-the-counter cold & flu prevention No 
Over-the-counter cold cream No 
Over-the-counter cough drops & sore throat lozenges No 
Over-the-counter cough syrup No 
Over-the-counter health care products (eligible) No 
Over-the-counter health care products (not eligible) No 
Over-the-counter medication (including for motion sickness, sleep aids and sedatives) No 
Over-the-counter products for dental, oral and teething pain Yes 
Over-the-counter products for general dental care No 
Ovulation monitor (over-the-counter) No 
Oxygen No 
Pain reliever (over-the-counter) No 
Parental fees (billed for actual services received for disabled children) No 
Parental fees (billed for future availability of services, with no services actually received for disabled children) No 
Personal use items (toothbrush, toothpaste, etc.) No 
Physical exams No 
Physical therapy No 
Physician retainer fee (for on-call or concierge services) No 
Pregnancy tests (over-the-counter) No 
Prescription Co-insurance (in-network) No 
Prescription Co-insurance (out-of-network) No 
Prescription Co-payment (in-network) No 
Prescription Co-payment (out-of-network) No 
Prescription drugs (for non-cosmetic purposes) No 
Prescription drugs for cosmetic purposes No 
Prescription drugs for hair regrowth No 
Prescription insurance / plan premiums (paid with after-tax dollars only) No 
Propecia (for treatment of a medical condition) No 
Prosthesis No 
Psychiatric care No 
Psychoanalysis No 
Psychologist fees No 
Radial keratotomy (RK) Yes 
Reading glasses (over-the-counter) Yes 
Reconstructive surgery (following accident or medical procedure or condition) No 
Removal of benign mole, cyst or tumor No 
Retainer fee (to physician for on-call or concierge services) No 
Retin-A (for non-cosmetic purposes) No 
Rogaine or other hair regrowth medications (even if prescribed) No 
Sales tax, shipping and handling fees (for any eligible expense) Yes 
Smoking cessation (programs / counseling) No 
Smoking cessation drugs (prescription) No 
Smoking cessation gum or patches (over-the-counter) No 
Special equipment No 
Special foods (gluten-free, salt-free or other for treatment of a medical condition; difference in cost only) No 
Special school (for mental and physical disabilities) No 
Speech therapy No 
Spermicidals No 
Sterilization No 
Student health fees for dental services (billed for actual services received) Yes 
Student health fees for dental services (no services actually received, billed for future availability of services) No 
Student health fees for medical services (billed for actual services received) No 
Student health fees for medical services (no services actually received, billed for future availability of services) No 
Student health fees for prescription services (no services actually received, billed for future availability of services) No 
Student health fees for prescriptions (billed for actual services received) No 
Student health fees for vision services (billed for actual services received) Yes 
Student health fees for vision services (no services actually received, billed for future availability of services) No 
Sunglasses (over-the-counter) No 
Sunglasses (prescription) Yes 
Sunscreen with SPF 15+ and "broad spectrum", sunburn creams and ointments (over-the-counter) No 
Sunscreen with SPF <15 or suntan lotion (over-the-counter) No 
Supplies (for treatment of a medical condition) No 
Surgery (for non-cosmetic purposes) No 
Swimming lessons (for treatment of a medical condition) No 
Teeth bleaching or whitening No 
Teeth grinding prevention devices Yes 
Therapy (for treatment of a medical condition) No 
Toothache and teething pain reliever (over-the-counter) Yes 
Toothpaste, medicated (difference in cost only of medicated toothpaste over the standard toothpaste) No 
Toothpaste, toothbrush, floss, etc. No 
Transgender treatments / surgery No 
Transportation, parking and related travel expenses (essential to receive eligible care) No 
Transportation, parking and related travel expenses, for non-eligible expenses No 
Tubal ligation No 
Tuition or educational classes No 
Tuition or educational classes (for a specific medical condition) No 
UV protection clothing No 
Urological products No 
Vaccinations No 
Varicose vein removal surgery (for medical care) No 
Vasectomy No 
Viagra and similar prescription medications No 
Vision Co-insurance (in-network) Yes 
Vision Co-insurance (out-of-network) Yes 
Vision Co-payment (in-network) Yes 
Vision Co-payment (out-of-network) Yes 
Vision insurance / plan premiums (paid with after-tax dollars only) No 
Vitamins (over-the-counter, for general health purposes) Yes (Letter) 
Vitamins (prescription) No 
Walking aids (canes, walkers, crutches and related supplies) No 
Warranties or other charges for future anticipated services (with none actually received) No 
Wart removal treatments (over-the-counter) No 
Weight loss counseling No 
Weight loss drugs (for treatment of a medical condition) No 
Weight loss foods No 
Weight loss program (for treatment of a medical condition) No 
Weight loss program (to improve or maintain general health) No 
Wheelchair and repairs No 
Wound care (over-the-counter) No 
X-ray fees (dental) Yes 
X-ray fees (medical) No