ELIGIBLE FSA HEALTH CARE EXPENSES

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M.A. Services PO Box 587 Pittsford, NY 14534 1-800-836-8100 ELIGIBLE FSA HEALTH CARE EXPENSES Below is a list of items that are accepted for reimbursement by a Flexible Spending Account with an appropriate diagnosis A Acupuncture Alcoholism treatment Acne treatment Allergy medication Adoption (medical expenses related to) Ambulance and emergency health services B Anesthesia Antacids Anti-Diarrheal Band-Aids / Bandages Birth control Blood pressure monitor Blood sugar test kits Body scans Breast pumps and lactation supply Childbirth classes Chiropractor Christian science practitioners C Co-insurance Compression stockings Condoms Contact lenses and cleaning solutions Co-payments Counseling C-pap Devices Crutches Cough Medicines Deductibles Dental Care (for non cosmetic purposes) Dentures, bridges, etc. D E Diabetic supplies Diagnostic services Drug addiction treatment Drugs (prescription) Doctor fees Dyslexia treatment Ear care Eye examinations Eye surgery or treatment to correct vision Eyeglasses Eyeglasses (prescription) Eye drops

F Fertility enhancement Fertility treatment First aid kit / supplies Flu shots Foot care Foam ring cushion / donut pillow G Glucosamine Guide dogs H I L M Health screenings Hearing aids and batteries Heart rate monitors Home diagnostic tests Hormone replacement therapy (prescription) Hospital services and fees Immunizations Infertility treatment Insulin, testing materials and supplies Laboratory fees Lamaze classes Laser / Lasik eye surgery Laxatives Medical alert bracelet or necklace Lice treatment Medical records Medical services and supplies Medicines (prescription) Mid-wife Mileage 23 cents per mile for medical care Migraine relief Monitors and test kits Motion sickness medicines N Nasal spray Nasal strips Nebulizer Neti Pot Nicotine gum and patches

OB/GYN fees Occlusal guards Occupational Therapy O Optometrist Orthodontia Orthotic inserts Osteopath Organ transplants Over the counter medicines or drugs Over the counter supplies Out of network fees Ovulation monitor P Pain Relievers Pregnancy aids and tests Parking fees and tolls for medical visits Prescription drugs (non-cosmetic) Physical therapy Preventive care screenings Psychiatric services and care Psychoanalysis Psychologist R Reading glasses Removal of benign mole, cyst or tumor Retrieving tools S Sleep aids Smoking cessation programs Speech therapy Sterilization Substance abuse Subway fare for medical visits T U V Sunglasses (prescription) Sunscreen w/30 SPF or higher Surrogacy expenses Taxi fare for medical visits Train fare for medical visits Tubal ligation Ultrasound Urological products Vaccinations Vaporizer / humidifier Vasectomy and reversal Viagra Vision care

W X Walking aids (canes, crutches, walkers) Wart removal treatment Weight loss procedures / surgery Wheelchair and repairs Well child visits Wound care non medicine X-ray fees (dental and medical) POTENTIALLY ELIGIBLE FSA HEALTH CARE EXPENSES All potentially eligible expenses require a letter of medical necessity from your health care provider to be considered for reimbursement. This form can be found on our website www.flexbene.com. Submitting the letter of medical necessity does not guarantee that the expenses will be reimbursed. A new letter is required every year. A B C D E F Air purifier Alternative healers Automobile modifications Behavioral therapy Blood storage Breast reduction Calcium supplements Dietary supplements Electrolysis Cord blood storage Dietician Exercise equipment Fiber supplements Fish oil Fitness programs G Gym membership

H L M N O P S V W Hair loss treatment Herbal supplements Homeopathic medicines Lactation consultant Laser therapy Lodging primarily for and essential to medical care provided by a doctor, hospital or medical care facility, up to $50 per night Massage therapy Minerals Nursing care and services Nutritional supplements Nutritionist Orthopedic shoes Personal trainer Special Equipment Vitamin B-12 injections Weight loss program Oxygen Probiotics Sperm storage Vitamins Wigs

ELGIBLE FSA DEPENDENT CARE EXPENSES Eligible Dependent Care Expenses are for a child under the age of 13 or other dependents that are physically and mentally incapable of taking care of themselves. Adult day care center After school care Au Pair Babysitting (must be work related and not provided by your own dependent) Before school care Camp (not overnight) Child care Daycare center Educational services (for preschool, not kindergarten or above) Elder care Extended care Indirect expenses (agency, application, placement fees, deposits) Nanny Nursery school Preschool Senior day care Summer day camp (not overnight) Tuition (nursery school or preschool)

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