Over-the-Counter (OTC) Items
SAMPLE CHART OF ELIGIBLE EXPENSES Please note that this is not a complete list, but is intended to provide Plan participants with examples to help determine what OTC items may be an eligible expense. Limited Medical FSA/HRA Plan participants should check their Plan Highlights to see if OTC items are eligible.
Download Over-the-Counter (OTC) Items
Information
Domain:
Source:
Link to this page:
Documents from same domain
REIMBURSEMENT CLAIM FORM (Please Print Clearly)
forms.benefitresource.comMedical expenses were incurred only for an immediate medical purpose. I understand that these expenses must qualify for reimbursement under the Internal Revenue Code and cannot be claimed as *If your plan offers the extended grace period allowed by IRS regulations, you must check Yes if you wish to have this expense reimbursed from the prior ...
Claim Form - Benefit Resource, Inc.
forms.benefitresource.comrelated to essential medical care (16 cents/mile for 2021; Rate subject to IRS changes), parking, and tolls from your FSA or HRA. Certification of Medical Necessity: Submit with a completed claim form once per year to receive reimbursement for dual …
Related documents
FSA Eligible Expense List - Optum
www.optum.comUsing a flexible spending account (FSA) is a great way to pay for eligible expenses with income tax-free dollars. The following lists are not all-inclusive but will highlight some common eligible expenses for your health care FSA, limited purpose FSA or dependent care FSA. The Internal revenue service (IRS) decides which expenses can be paid ...