Fillable Form Gc-15 (2-14) - Otc Reimbursement Claim Form (Page 2 of 2) in pdf

Form Gc-15 (2-14) - Otc Reimbursement Claim Form Page 2

Download a blank fillable Form Gc-15 (2-14) - Otc Reimbursement Claim Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Gc-15 (2-14) - Otc Reimbursement Claim Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Over-the-Counter (OTC) Medical Expense Reimbursements

The list below is not intended to be all-inclusive, but is rather to answer frequently asked questions regarding OTC expenses.

This list is subject to change per IRS rulings or interpretation changes. OTC medicines indicated in Section II when purchased

on or after 1/1/2011 must be prescribed by a physician in order to be reimbursed by an FSA. For more details on the Over the

Counter expense list please visit:

Eligible Medical Expenses for Reimbursement reimbursable without prescription.

Band Aids

Eye Care (contact lens solution, patches)

Family planning (condoms, contraceptive creams, pregnancy test, ovulation predictor kits, etc.)

Home diagnostic tests or kits (blood pressure, cholesterol, diabetes, colorectal cancer, HIV, urine test, thermometers, etc.)

Incontinence products (Depends, Serenity pads, etc.)

Joint-support bandages and hosiery, e.g., knee or elbow supports

Vaporizers and humidifiers

II. Eligible Medical Expenses for Reimbursement when prescribed by a licensed health care professional. A Prescription is required with

each request for reimbursement. The prescription must include the patient’s name and be written, signed and dated by the licensed

health care professional.

Acid Controllers

Allergy and Sinus

Antibiotic Products

Anti-Diarrheals

Anti-Gas

Anti-Itch and Insect Bite

Antiparasitic Treatments

Baby Rash Ointments/Creams

Cold Sore Remedies

Cough, Cold and Flu

Digestive Aids

Feminine Anti-Fungal/Anti-Itch

Hemorrhoidal Preps

Laxatives

Motion Sickness

Pain Relief

Respiratory Treatments

Sleep Aids and Sedatives

Smoking Cessation Products

Stomach Remedies

III. Not Reimbursable (merely beneficial to good health)

Cosmetics (makeup, lipstick, cotton swabs, cotton balls, baby oil, etc.)

Denture care (e.g., cleansers)

Hair care (color, shampoo, conditioner, brushes, hair-loss products e.g., Rogaine)

Nail care and personal grooming items (scissors, nail files, etc.)

Personal hygiene products (deodorant, soap, body powder, shaving cream, razors, feminine care, etc.)

Routine dental care (toothpaste, toothbrush, electric toothbrush, floss, mouthwash including antibacterial mouthwash and fluoride rinse, breath strips,

teeth-whitening, etc.)

Vitamins and Supplements or other homeopathic medicines (may be eligible with evidence of medical necessity)

Skin care (facial cleanser, skin and body moisturizing lotion, etc.)

GC-15 (2-14) J