Flexible Savings Account

Flexible Spending Account Qualified Medical Expenses A flexible spending account can be used to pay for qualified medical expenses.

Eligible medical expenses • Acupuncture • Laser eye surgery and LASIK • Artificial limbs • Legal sterilization • Bandages, gauze pads and liquid adhesive for minor cuts • Mileage to and from doctor appointments (27 cents • Birth control and contraceptive devices per mile) • Birthing and lamaze classes, child rearing not included • Nasal strips (payable for mothers only, not coaches or spouses) • Optometrist or ophthalmologist fees • Blood pressure monitor • Peroxide • Breast pumps and lactation supplies • Physical therapy (as medical treatment) • Chiropractic therapy, exams and adjustments • Physician’s fee for hospital services • Contact lenses and contact lens solution • Pregnancy test • Contact lenses • Prenatal vitamins • Copayments • Prescribed drugs and medications • Crutches (purchased or rented) • Psychotherapy and psychological services • Deductibles and coinsurance • Rubbing alcohol • Denture adhesive • Sales tax on eligible expenses • Diabetic supplies • Services connected with donating an organ • Eye exam • Sleep apnea services and products (as prescribed • Eyeglasses, contacts or safety glasses (prescription by physicians) only, warranties are not reimbursable) • Smoking cessations programs and nicotine patches • First aid kits • Suppositories • Flu shots • Thermometer • Hearing aids and hearing aid batteries (warranties are • Treatment for alcoholism or drug dependency not reimbursable) • Vaccinations • Heating pads • Wrist support and elastic wraps • Hot and cold packs • X-ray fees • Incontinence supplies • Infertility treatments

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Eligible dental expenses Eligible expenses for the disabled • Braces and orthodontic services (For contracted • Automobile equipment for the disabled and installation orthodontia treatment, please provide contract of costs in excess of the cost of an ordinary automobile, service with reimbursement form.) includes device for lifting a mobility-impaired person into • Cleaning an automobile • Copays and coinsurance • Braille books and magazines in excess of cost of regular editions • Crowns • Note taker costs for a hearing impaired child in school • Deductibles • Service dog (purchase, training and maintaining costs) • Dental implants • Special devices such as a tape recorder or typewriter for the • Dentures adhesives visually impaired • Filling • Visual alert system in the home or other items such as a Over-the-counter drug expenses special phone required for the hearing impaired Internal Revenue Service guidelines allow you to use your • Wheelchair or autoette (operation and maintenance costs) FSA to pay for over-the-counter drugs only if you have a prescription from your physician.

Note: Refer to the Reimbursement documentation section for documentation requirements. Product labels and packaging do not qualify as third-party documentation. Stockpiling of over-the-counter drugs is not allowed by the IRS. HealthEquity, Inc. defines stockpiling as five or more products purchased on the same date. Reimbursement documentation Complete, sign and submit a Healthy Blue FSASM Reimbursement Form to receive reimbursement for eligible qualified medical expenses. Make sure to include your health care provider’s signature and Tax ID number on the form. You must also include supporting documentation. Standard documentation includes one of the following: • An itemized receipt or statement • Your Blue Cross Explanation of Benefit Payments statement

A canceled check does not meet IRS regulations for proper documentation of an eligible expense. Documentation for over-the-counter drugs A pre-printed cash register receipt that includes the dates of the service, provider name, amount of purchase, and name and description of the product is acceptable documentation for over-the-counter drugs. You must have a prescription from your physician to use your HRA to pay for over-the-counter drugs.

Expenses requiring additional documentation To receive reimbursement for the expenses noted on the next page, the expense must be incurred to treat a diagnosed medical condition. You must submit a Letter of Medical Necessity form in addition to the standard documentation. The form must be signed by a physician and must include the diagnosis and medical necessity of the treatment. Please attach the Letter of Medical Necessity form to your Healthy Blue FSASM Reimbursement Form. You can access both forms through Member Secured Services at bcbsm.com. Just select the Forms and Docs tab from your online Personal Desktop.

HealthEquity, Inc. is an independent company partnering with Blue Cross Blue Shield of Michigan to provide health care spending account administration services. The following expenses require this documentation: • Acne treatments and medication • Massage treatment • Cosmetic surgery, cosmetic dentistry or other cosmetic • Medicated shampoo, conditioner and soap procedures (covered if necessary to ameliorate a deformity • Nursing services for care of a special medical ailment arising from a congenital abnormality, disfiguring disease and personal injury from accident or trauma) • Orthopedic inserts or shoes (excess cost of ordinary shoes) • Diet (special diets and cost of special food taken as • Oxygen equipment and oxygen substitute for regular diet) • Propecia® and Rogain® (only eligible for a medical condition) • Dietary and fiber supplements • Speech therapy • Ear plugs • Sunscreen or suntan lotion • Estrovin® • Support hose • Eye drops • Varicose vein treatment • Exercise equipment and fees • Veneers • Glucosamine • Vitamins and supplements • Lotion or skin moisturizers • Wigs (for mental health condition of individual who loses hair because of disease) Ineligible expenses The following expenses are not eligible for reimbursement: • Athletic mouth guards • Lanyards • Auto insurance providing medical coverage • Marriage counseling • Chapstick® and lip balm • Maternity clothes • Contribution to state disability funds • Mattress • Cosmetic supplies (makeup, facial soaps and creams, • Medicare premiums moisturizers, etc.) • Mobile telephone used for personal calls as well as • Deodorant calls to physician • Dental floss • Nursemaids or practical nurses who render general • Diaper service care for healthy infants • Diaper supplies • Pajamas and slippers purchased to wear in hospital • Divorce expenses when doctor or psychiatrist recommends • Personal use items (toothbrush, vacuum, pillow, divorce shampoo, mattress, etc.) • Distilled water purchased to avoid drinking fluoridated city • Physical treatment unrelated to specific health problems water or for use in medical equipment (massage for general well-being, stress, depression, or chiropractic wellness program) • Domestic help includes companion, babysitter, chauffeur, etc., who primarily render nonmedical services • Private hospital rooms • Electrolysis and hair removal • Safety glasses (non-prescription) • Eye drops for general comfort • Sunglasses (non-prescription and sun clips) • Eyeglass case • Teeth whitening • Foods purchased to replace nutrition or for general health • Toiletries needs such diet foods • Toothbrush (includes prescribed electric ones) • Hand sanitizer • Toothpaste • Health club or athletic club membership fees • Vacuum cleaner purchased by individual with dust allergy • Herbal supplements • Warranties • Illegal treatment or medications • Weight loss drugs and programs for general well-being

CF 11602 NOV 12 R009594