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The following list represents expenses that are frequently submitted for reimbursement under Limited Purpose Flexible Spending Accounts (LPFSA) and are generally ineligible for reimbursement 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 ineligible list may be reimbursable if the supporting claims documentation shows that the expense was incurred for eligible LPFSA expenses. 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:
Cosmetic Services
Dental Floss
Mouthwash
Routine Care Over the Counter (OTC)
Teeth Whitening
Toothpaste
Veneers May be eligible if provider provides letter demonstrating use is for medical condition rather than for cosmetic purposes
VISION EXPENSES:
Cosmetic Contact Lenses Lenses used to change the appearance of eye color
Cosmetic Services or Products
Frames Used in conjunction with non-prescription lenses
Lenses Non-prescription
Sunglasses Non-prescription
Over the Counter (OTC) Items Not used for eye care
PREVENTIVE CARE EXPENSES:
All services or products used in the treatment of any existing condition
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