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Spending Account Information

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Money in your pocket


For each expense listed that is or may be covered under an insurance plan, submit your bills to the insurance company(ies) and then submit the insurance company statement of benefits showing the amount of expenses not covered by insurance with this form.

For other expenses attach an itemized statement.

For prescription drugs, attach the pharmacy statement or label. Keep a copy of all documentation for your records. 

For covered over-the-counter (OTC) items, a cash register tape with the name of the drug imprinted by the store register is required. OTC drugs, medicines and biologicals are eligible only if accompanies with a letter of medical necessity from a medical provider. Such items cannot be purchased by the debit card program, but can be reimbursed by filing a paper claim with all require documentation.


For each dependent care expense listed, attach a third party statement or complete the Dependent Care Provider Acknowledgement, provider signature is required. The qualified dependent who spends at least eight hours a day in your home must be age 12 or under; or any other qualified dependent person, who is physically or mentally incapable of self-care (such as a disabled parent or older child) regardless of age. A doctor’s statement of disability is required. Qualified expenses are for care only. Educational expenses, registration and activity fees are not reimbursable.

 Out Of Pocket

Some qualifying expenses include:

  • Doctors visits, deductibles and copays
  • Prescription drugs
  • Vision care, laser vision correction surgery, eyeglasses or lenses
  • Dental care, orthodontic expenses
    Physical therapy, chiropractic care
  • Diabetic supplies, bandaids, firstaid kits

For a full list of expenses eligible for reimbursement click on Listing of Eligible & Non-Eligible Expenses.

For more information on approved merchanges and products, visit