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OTC Quick Reference Guide

Over-the-counter (OTC) medical supplies and doctor-prescribed OTC medicines are reimbursable
under a Health Care Flexible Spending Account (HCFSA) when the OTC product is used for
medical purposes
. Tri-Star allows the same expenses as those allowed by the IRS. Below is a
description of the three IRS-defined categories, followed by product examples for each.
Hospital Sisters Health Systems participants: Contraceptives and OTC medicines are not an
allowed expense under the Plan.

Eligible OTC Medical Supplies
 Qualifying expenses include medical supplies that alleviate or treat injuries or illness for you and
your dependents. These products cannot be simply cosmetic in nature, or merely beneficial to your general health. Claims for OTC medical supplies must include an adequate receipt accompanied by the Tri-Star claim form. An adequate receipt must include the name of the product, the date, and the amount paid. You do not need to provide a letter of medical necessity from a medical provider in order to receive reimbursement.  If your employer offers an FSA debit card with your HCFSA, items on the Eligible OTC Medical Supplies list below should qualify for purchase using the card (not dual-purpose or excluded lists).
Dual-Purpose OTC Medicines (items you can purchase without a doctor’s prescription) & OTC
Products
 Qualifying expenses include medicines that alleviate or treat injuries or illness for you and your
dependents that are prescribed by a physician for a condition that already exists. Claims for OTC
non-prescription medicines must include an adequate receipt accompanied by the Tri-Star claim
form. An adequate receipt must include the name of the medicine or product, the date, and the
amount paid. You must provide a written prescription from a licensed physician in order to
receive reimbursement indicating the medical condition and prescribing this item as
treatment for that condition.

 If you have a condition that requires a specialized general purpose item (i.e. special laundry detergent due to allergies) and you have a letter of medical necessity, you can claim the difference in cost between the specialized detergent and the regular detergent. You must also submit a statement or printout showing the cost of a “comparable” non-medicated product.
Excluded Items
 OTC products that are not medical supplies, are purchased without a doctor’s diagnosis and
supporting prescription or that merely benefit your general health are NOT reimbursable.
Reimbursement for qualifying OTC medical supplies still must follow the existing rules
regarding FSAs. The
expense(s) must:
o Be incurred during your period of coverage o Not be reimbursed through another plan o Be substantiated by a detailed receipt
Please note that stockpiling OTC supplies (purchasing more than a 12 month supply) is not
allowed and that requests for quantities deemed to be stockpiling will be denied.

Eligible OTC Medical Supplies include medical supplies that alleviate or treat an illness or injury for you and your
qualified dependents. You do not need to provide a statement from your physician in order to receive reimbursement.
Note: Some items on this list do not qualify due to restrictions in your Plan. (See exception noted above for Hospital
Sisters Health System.) Please refer to your employer’s Plan Document for more information.
Item or Product
Examples
Contact Lens Supplies
Cleaning and soaking solutions, Lens storage cases Contraceptive/Family Planning
Ovulation predictor kits, Pregnancy tests, Spermicides, Condoms Dental/Denture Care
First Aid/Medical Supplies
Bandages, First aid kits, Cold/hot packs for injuries, Joint supports (ankle, elbow, knee, wrist), Ace wraps, Splints, Thermometers, Liquid adhesives Foot Care
Hearing Aids
Home Diagnostic Tests or Kits
Blood pressure (monitor and related equipment), Cholesterol tests, Diabetic equipment and supplies, Colorectal screenings, HIV test, Pregnancy tests
Dual-Purpose OTC Medicines and Products
may be reimbursed under a HCFSA only if prescribed by your physician to
treat an existing medical condition. A copy of the written prescription from your licensed physician must be filed with each
claim and supporting documentation.
Item or Product
Examples
Actifed, Alavert, Benadryl, Chlor-Trimeton, Claritin, Drixoral, NasalCrom, Sudafed, Triaminic, Medications/Antihistamines
Analgesics/Antipyretics (pain
Aspirin, Arthritis Pain Relievers, Back Pain Relievers, Ibuprofen, Menstrual & PMS Relief, Naproxen, Sodium, Urinary Pain Relievers Antacids and Acid Reducers
Alka-Seltzer, Gas-X, Maalox, Mylanta, Pepcid AC, Pepto-Bismol, Prilosec OTC, Rolaids, Tums Anti-arthritics
Arthritis Pain Relievers, Glucosamine Chondroitin Antibiotics (topical)
Campho-phenique, Neosporin, Polysporin, Tincture First Aid Anticandial (yeast)
Clotrimazole, Gyne-Lotrimin, Monistat, Vagistat-1 Antidiarrheal and Laxatives
Dulcolax, Ex-Lax, Immodium A-D, Kaopectate, Pepto-Bismol Antifungal (jock itch, athletes
Lamisil AT, Lotramin AF, Micatin, Tinactin foot)
Anti-itch Lotions and Creams
Benadryl, Caladryl, Calamine, Cortaid, Hydrocortisone, Ivarest, Lanacane, Lamisil AT, Lotramin AF Asthma Medicines
Caltrate, Tricalcium Phosphate, Calcium Carbonate, Citrate, Lactate, or Gluconate Canker or Cold Sore/Fever
Blister
Cold, Flu, Decongestant and
Actifed, Advil Cold and Sinus, Afrin, Alka Seltzer Cold and Flu, Sinus Remedies
Aleve Cold and Sinus, Children’s Advil Cold, Contac, Dayquil, Dimetane, Dristan Long-Lasting, Mucinex, Neo-Synephrine 12-Hour, Nyquil, Sudafed, TheraFlu, Triaminic, Tylenol Cold and Flu, Cough suppressants, Nasal Sprays, Medicated Lozenges Cough Suppressants or
Robitussin, Vicks, Chloraseptic, Mucinex, Cough suppressants, Medicated Lozenges Expectorants
Diaper Rash
Dietary Supplements
Protein bars, Power drinks, Ensure, Glucerna Fiber Supplements
First Aid/Medical Supplies
Antiseptics, Witch Hazel, Peroxide, Rubbing alcohol Foot Care
Callous removers (some), Athlete’s Foot products (see anti-fungal), Bunion, blister and corn Healing Ointment
Hemorrhoidal Preparations
Homeopathic Remedies
The products listed here are examples, and do NOT constitute an endorsement or an exhaustive listing of reimbursable OTC products.
Tri-Star Systems
www.tri-starsystems.com
Rev 10/2010
Incontinence Supplies
Joint Supplements
Lactose Intolerance
Lactaid, Lactase Enzymes, Lactose Relief Medicated Lip Products
Abreva Cold Sore, Campho-phenique antiseptic gel, Carmex Medicated Lip Balm Menstrual Cycle
Migraine Relief
Advil Migraine, Motrin Migraine, Excedrin Minerals
Calcium, Caltrate, Ferrous Sulfate, Feosol, Slow FE, Folic Acid, Magnesium, Potassium Motion Sickness
Advil, Aleve, Ibuprofen, Motrin, Naprosyn, Naproxen OTC Hormone Therapy
Pediculicide (lice treatment)
Skin Care
Sleeping Aids
Sunscreen
Note: Lotions or cosmetics that contain ingredients to protect you from the sun and/or list a SPF Teething/Toothaches
Topical Steroids
Vitamins
Wart Removal
Compound W, Dr. Scholls Clear Away, Wart-Off Weight Loss

Excluded Items
Item or Product
Examples
Cosmetic Products
Face soaps, Creams, Make-up, Perfumes, Hair removal Dental Products
Dental floss, Toothpaste, Toothbrushes, Teethwhitening kits, Dual Purpose Items Listed Above
Excluded if not accompanied by a written prescription from a licensed physician Toiletries
Deodorant, Shampoo, Body sprays, Soaps, Moisturizers The products listed here are examples, and do NOT constitute an endorsement or an exhaustive listing of reimbursable OTC products.
Tri-Star Systems
www.tri-starsystems.com
Rev 10/2010

Source: http://www.tri-starsystems.com/site/participant/Forms/OTC.pdf

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