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The following list represents expenses that are frequently submitted for reimbursement under a Limited Purpose Flexible Spending Accounts (LPFSA) and are generally eligible under the LPFSA. These items have been separated into three parts: dental, vision and preventive care. The lists are not intended to be exhaustive and are intended only to be used as a general guide. Consequently, expenses contained in this generally eligible list may be denied if the supporting claims documentation is insufficient or shows that the expense was incurred for services not considered eligible under the LPFSA. Payment of claims will be based on the rules set out in the applicable regulations, your employer’s plan design and on the information in the required substantiation documentation. DENTAL EXPENSES:
Alveoloplasty
Amalgam
Primary or Permanent
Anesthesia
Anterior Restoration
Apexification Periradicular Surgery
Bacteriologic Studies
Biscupid Restoration
Bitewing X-rays
Bone Replacement Grafts
Bridges
Including repair and maintenance
Combined Connective Tissue and Pedicle Graft
Crowns
Including repair and maintenance
Dentures
Including repair and maintenance
Distal Wedge
Extraction of Teeth
Free Soft Tissue Graft Procedure
Frenulectomy
Frenuloplasty
Full Mouth Debridement
Gingival Flap Procedure
Gingivectomy
Gingivoplasty
Incision and Drainage of Cyst
Intaoral X-rays
Molar Restoration
Occlusal Adjustment Occlusal Nightguard
Office Visit
Oral Evaluation
Orthodontics Two ways of submitting/paying claims: by reimbursing up to the full amount of the treatment equal to the participant's annual election, minus any previous reimbursements, once the initial treatment has begun or reimbursing over the entire orthodontia treatment period (e.g. monthly) Osseous Surgery
Over the Counter (OTC) Items for Dental Care
Eligible for items pertaining to denture care but NOT for routine items such as toothpaste, mouthwash, dental floss, etc.
Panoramic X-ray
Pedicle Soft Tissue Procedure
Periodontal Maintenance
Periodontal Scaling
Prophylaxis
Proximal Wedge
Pulp Cap
Direct or indirect
Pulp Therapy
Pulp Vitality Test
Pulpal Debridement
Removal of Cyst
Resin-Based Composite
Root Canal
Soft Tissue Allograft
Space Maintainer and Maintenance
Subepithelial Connective Tissue Procedure
Surgical Tooth Revisions Procedure
Therapeutic Pulpotomy
Teeth Cleaning
Tooth Sealant
Topical Application of Flouride
VISION EXPENSES:
Eye Examinations
Frames
If in conjunction with prescription lenses
Laser Vision Correction Procedures
Lenses
Prescription only
Over the Counter (OTC) Products for Eye Care
Refractions
Sunglasses
Prescription only
Vision Training
Where recommended by an M.D. or O.D.
PREVENTIVE CARE EXPENSES:
Cancer Screening
Breast Cancer (Mammogram)
Cervical Cancer (Pap Smear)
Colorectal Cancer
Prostate Cancer (e.g. PSA Test)
Skin Cancer
Oral Cancer
Ovarian Cancer
Testicular Cancer
Thyroid Cancer
Heart and Vascular Diseases Screening
Abdominal Aortic
Aneurysm
Carotid Artery
Stenosis Coronary Heart Disease
Hemoglobinopathies Hypertenstion
Lipid Disorders (Cholesterol)
Immunizations
Infectious Diseases Screening
Bateriuria
Chlamydial Infection
Gonorrhea
Hepatitis B Virus Infection
Hepatitis C
Human Immunodeficiency Virus (HIV) Infection
Syphilis
Tuberculosis Infection
Mental Health Conditions and Substance Abuse Screening
Dementia
Depression
Drug Abuse
Problem Drinking
Suicide Risk
Family Violence
Metabolic, Nutritional and Endocrine Conditions Screening
Anemia, Iron Deficiency
Dental and Periodontal Disease
Diabetes Mellitus
Obesity in Adults
Thyroid Disease
Musculoskeletal Disorders Screening
Osteoporosis
Obesity Weight-Loss Programs
Obstetric and Gynecologic Conditions Screening
Bacterial Vaginosis in Pregnancy
Gestational Diabetes Mellitus
Home Uterine Activity Monitoring
Neural Tube Defects
Preclampsia
Ph Incompatibility
Rubella
Ultrasonography in Pregnancy
Pediatric Conditions Screening
Child Development Delay
Congenital Hypothyroidism
Lead Levels in Childhood and Pregnancy
Phenylketonuria
Scoliosis, Adolescent Idiopathic
Periodic Health Examinations
Routine Examinations
Routine Prenatal Care
Tests and Procedures
Associated with periodic health evaluations, annual physicals and routine examinations
Tobacco Cessation Programs
Vision and Hearing Disorders Screening
Glaucoma
Hearing Impairment in Older Adults
Newborn Hearing
Well-Child Care
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