Date: may 20, 2005

Limited Flexible Spending Account (“FSA”)

Who should enroll in the Limited FSA Plan?
If you are participating in the Health Savings Account, you must enroll in the Limited FSA Plan if
you wish to participate under an FSA Plan for the renewing Plan Year that runs from October 1,
2013 through September 30, 2014. Although you are not required to participate in the Limited
FSA, you should do so if you want to enroll in the Health Care Reimbursement Program and
make HSA contributions (or want to remain eligible for any discretionary employer contributions
to your HSA).

What expenses can be claimed under a Limited FSA?
Under the modified FSA, the HealthCare Reimbursement Program will only reimburse you for
“medical care” (as defined in the Tax Code) that is dental, vision, orpreventive care.”

Examples of Dental and Vision Expenses

Dental procedures that are not for cosmetic purposes and not covered by your insurance (checkups, fillings, crowns) Routine eye exams, procedures, lasik eye surgery

What are some ineligible expenses under a Limited FSA?

Your co-payments, deductibles and co-insurance payments for any expenses not related to preventive care Cosmetic dental procedures (veneers, teeth whitening service or products)
Are prescriptions and over-the-counter products eligible under a Limited FSA?
Drug costs, including over-the-counter drugs may be reimbursed if they are considered for
dental, vision, or preventive care expenses. Drugs or medications will fall within the guidelines
when they are taken by a person who has developed risk factors for a disease that has not yet
manifested itself or has not been clinically apparent (no symptoms yet developed). The drugs
could also be taken to prevent the recurrence of a disease from which a person has recovered.
Post Office Drawer 8188, Virginia Beach, Virginia 23450
Toll Free (800) 437-3539

Examples of preventive care eligible expenses:

1. The treatment of high cholesterol with cholesterol-lowering medications to prevent heart disease or the treatment of recovered heart attack or stroke victims. 2. Drugs or medications used as part of procedures providing preventive care services such as obesity, weight-loss and tobacco cessation programs. 3. Screenings: Cancer, Heart and Vascular diseases, Infectious diseases, Mental Health conditions, Substance Abuse, Metabolic, Nutritional, and Endocrine conditions, Musculoskeletal disorders, Obstetric and Gynecologic conditions, Pediatric conditions and Vision and Hearing disorders.
Helpful hints on the administration of a Limited FSA
Diagnosis information to determine whether a particular medication (that may also be used to
treat an existing condition) is being prescribed for preventive purposes may be requested to
determine whether a drug or medication is being used to prevent or treat an illness.
Letters of medical necessity for Limited FSAs must specifically state that the medication is being
used to prevent an illness. In example #1 above, a letter could state that “Mary needs to take
Lipitor to prevent heart disease due to the fact that she has a family history of heart disease.”
A letter of medical necessity for prevention of an illness will also be required for any OTC drug.
If you have any additional questions regarding what is or isn’t covered under a Limited FSA Plan, please contact Flexible Benefit Administrators, Inc. at (800) 437-3539 or Post Office Drawer 8188, Virginia Beach, Virginia 23450
Toll Free (800) 437-3539



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