Eligible Expenses Guide - Premera Blue Cross

USE OF HSA AND FSA FUNDSE ligible Expenses GuideUse these tables to determine which products and services are considered qualified medical Expenses under IRS rule. They also provide information on what supplementary documentation you may need to provide for your Expenses or retain in case of an audit. See the last page for rules regarding (12-12-2018)Please see page 17 for a list detailing Eligible Dependent Care FSA requiredDoctor s directive, letter of medical necessity, or prescription requiredHSA FundsKeep required documentation with your tax FundsSubmit required documentation with your manual claim or keep for your records if your expense was automatically reimbursed (or streamlined) from your health EligibilitySupplementary Documentation*Acne treatmentYes, with prescription. Cosmetics, moisturizers, or other items that merely contain acne-fighting ingredients are not Eligible .

Breast reconstruction surgery following mastectomy Yes, to the extent that surgery was done following a mastectomy due to cancer. This is an exception to the general rules regarding cosmetic procedures. Calcium Yes, with prescription. Cane, walking Yes, if used to relieve sickness or disability.

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