ADP Automatic Data Processing
FSA Services  
Ineligible Expenses

 

 

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