Extensive Health FSA Eligible Expense List
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1 Extensive Health FSA Expense List ITEM A Acne Treatment Acupuncture Air Purifier Alcoholism Treatment Allergy Medicine Analgesics (Advil, Tylenol, Aspirin) Antacids Antibiotic Ointment Antihistamines Anti-Itch Creams Asthma Delivery Device/Medications B Babysitting and Childcare Bandages (elastic, Ace, Band-Aids, Curad) Batteries, Hearing Aid Birth-control pills Birth-control, Condoms Blood Pressure Monitors Blood-sugar test kits, and stips Breast Pumps * under the Dependent Care Assistance FSA
2 C Cancer Screening Car Seats Childbirth Classes Chiropractors Chondroitin Circumcision Co-insurance amounts Cold Medicine Cold/Hot Packs Cold Sore Medicine Compression Hose Contact Lenses, Materials, and Equipment Co-payments Cosmetics (moisturizers, perfumes, lipstick, etc.) Cosmetic Procedures Cough Suppressants Counseling, Individual Counseling, Family or Group CPAP (continuous positive airway pressure device) Crutches D Decongestants Dental Floss Dental Sealants Dental Services and Procedures
3 D Continued Dentures and Denture Adhesives Diabetic Supplies Diagnostic Items Diaper Rash Ointments and Creams Diaper, Disposable Diaper, Services Diarrhea Medicine Diet Foods Dietary Supplements Doula Drug Addiction Treatment Drug Testing Kits (OTC) E Ear Plugs Ear Wax Removal Eczema Treatments Electrolysis or Hair Removal Exercise Equipments and Programs Eye Drops Eye Exams, Eyeglasses, Equipment and Materials F Face Lifts Feminine Hygiene Products Fertility Treatments Fiber Supplements First Aid Cream Fitness Programs
4 F Continued Flu Shots Founder's Fees Funeral Expenses G Gauze Glucosamine Glucose-monitoring Equipment Guide Dog H Hair Removal/Transplants Hand Lotion Hand Sanitizer Headache Medicine Health Club Fees Health Institute Fees Hearing Aids Hemorrhoid Treatments Herbs Holistic, or Natural Healers Hormone Replacement Therapy Hospital Service Household Help Humidifier Hydrotherapy Hypnosis
5 I Immunizations Incontinence Supplies Infant Formula Infertility Treatments Insect Repellent Insulin In Vitro Fertilization (IVF) L Laboratory Fees Lactation Consultant Lactose Intolerance Tablets Lamaze Classes Language Training Lasik/Laser Eye Surgery Laser Hair Removal Late Fees (late payments for medical service) Latex Gloves Laxatives Learning Disability, Instructional Fees Lice Treatment Liquid Bandages (e.g. New-Skin) Lodging at a Hospital, or Similar Lodging for Medical Conference M Masks, Disposable Massage Therapy Masectomy-related Special Bras
6 M Continued Maternity Clothes Medical Alert Bracelet, or Necklace Medical Information Plan Charges Medical Monitoring and Testing Devices Medical Records Charges Menstrual Pain Relievers Midwife Mineral Supplements Missed Appointment Fees Moisturizers "Morning-after" Contraceptive Pill Motion Sickness Pills Motion Sickness Wristbands Mouthwash N Nasal Spray and Strips Naturopathic Healers Nicotine Gum, Patch, Inhalers Norplant Insertion or Removal Nursing Services for a Baby Nursing Services by a Nurse or Other Attendant O Obstetrical Expenses Occlusal Guards (Prevent Teeth Grinding) Occupational Therapy Online or Telephone Consultation Operations
7 O Continued Optometrist Organ Donors Orthodontia Orthopedic Shoe Inserts Osteopath Fees Over-The-Counter Drugs Ovulation Monitor Oxygen P Pain Relievers Personal Trainer Fees Petroleum Jelly Physical Exams Physical Therapy Pregnancy Test Kits Prenatal Vitamins Prepayments Prescription Drug Discount Programs Prescription Drugs and Medicines Obtained from Other Countries Preventive Care Screenings Probiotics Propecia Prosthesis Psychiatric Care Psychoanalysis Psychologist
8 R Radial Keratotomy Reading Glasses Rehydration Solution (e.g. Pedialyte) Rogaine Rubbing Alcohol S Safety Glasses Scooter, Electric Screening Tests Service Animal, to Assist Individual with Mental Health Disabilities Shipping and Handling Fees Sinus Medication Sleep-Deprivation Treatment Smoking-Cessation Medication Smoking-Cessation Programs Speech Therapy Stem-cell, Harvesting and /or Storage Sterilization Procedures Student Health Fees Sunburn Cream, Ointment, Medicated (e.g. Solarcaine) Sunglasses (Non-Prescription) Sunglasses (Prescription) Sunscreen (30 SPF and Higher) Sunscreen (29 SPF and Lower) Suntan Lotion without Sunscreen Support Brace Swimming Lessons
9 T Taxes on Medical Services and Products Teeth Whitening Telephone Equipment for Persons With Hearing or Speech Disabilities Televisions for Persons With Hearing Disabilities Thermometers Throat Lozenges Toothache and Teething Pain Relievers Toothbrushes Toothpaste Transplants Transportation Costs of Disabled Individual Commuting To and From Work Transportation Expenses for Person to Receive Medical Care Transportation of Someone Other Than the Person Receiving Medical Care Treadmill Tuition Evidencing Separate Breakdown for Medical Expenses U Umbilical Cord Blood Storage V Vaccines Varicose Vein, Treatment of Vasectomy Vasectomy, Reversal Veneers
10 V Continued Veterinary Fees Viagara Vision Correction Procedures Vitamins W Walkers Wart Remover Treatments (e.g. Compound W) Weight-Loss Programs and/or Drugs Prescribed to Induce Weight Loss Wheelchair Wigs -ray Fees Yeast Infection Medications
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MEDICAL HISTORY Date Name Age Date of birth: Email: Address City State Zip Home Phone Work or CellPhone Preference number for contact (appointment reminders or other) Primary Physician s Name and Number
ARE YOU? PsA TREAT YOUR SYMPTOMS WITH FOUR DOSES A YEAR. RECOGNIZE THE FOUR SIGNS OF PsA.
PsA STELARA is a prescription medicine approved to treat adults 18 years and older with active psoriatic arthritis (PsA), either alone or with methotrexate. WHICH YOU ARE YOU? RECOGNIZE THE FOUR SIGNS