Antiseptics Items marked (Rx) require a doctor's prescription as of 1/1/2011

• Antiseptic wash or ointment for cuts or scrapes (Rx)
• Antiseptic mouthwash (Rx)
• Benzocaine swabs (Rx)
• Boric Acid powder (Rx)

• First aid wipes (Rx)
• Hydrogen Peroxide (Rx)
• Iodine tincture (Rx)
• Rubbing Alcohol (Rx)
• Sublimed Sulfur powder (Rx)

Cold, Flu, Asthma, and Allergy Medications
Items marked (Rx) require a doctor's prescription as of 1/1/2011

• Allergy medications (Rx)
• Bronchodilator/expectorant tablets (Rx)
• Bronchial asthma Inhalers (Rx)
• Cold relief liquid, tablets and drops (Rx)
• Cough relief liquid, tablets and drops (Rx)
• Flu relief liquid, tablets and drops (Rx)

• Homeopathic sinus medications (Rx)
• Medicated chest rub (Rx)
• Nasal decongestant spray, drops or inhaler (Rx)
• Sinus and allergy nasal spray (Rx)
• Vapor patch cough suppressant (Rx)

Diabetes Items marked (Rx) require a doctor's prescription as of 1/1/2011

• Diabetic lancets
• Diabetic needles
• Diabetic supplies
• Diabetic syringes

• Diabetic test strips
• Glucose meters
• Glucose tablets (Rx)

Ear/Eye Care Letter of Medical Necessity required from a physician (LOMN)
Items marked (Rx) require a doctor's prescription as of 1/1/2011

• Airplane ear protection (LOMN)
• Ear drops for swimmers (Rx)
• Ear water-drying aid (Rx)

• Ear wax removal drops (Rx)
• Homeopathic earache tablets (Rx)
• Contact lens solution

Health Aids Items marked (Rx) require a doctor's prescription as of 1/1/2011

• Anti fungal treatments (Rx)
• Denture adhesive
• Diuretics and water pills (Rx)
• Hemorrhoid relief (Rx)
• Incontinence supplies

• Lice control (Rx)
• Medicated bandages
• Motion sickness tablets (Rx)
• Respiratory stimulant ammonia (Rx)
• Sleeping aids (Rx)

Pain Relief Items marked (Rx) require a doctor's prescription as of 1/1/2011

• Arthritis pain reliever (Rx)
• Bunion and blister treatments (Rx)
• Itch relief (Rx)
• OrajelŪ (Rx)

• Pain relievers, aspirin and non-aspirin (Rx)
• Throat pain medications (Rx)

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Personal Test Kits

• Cholesterol tests
• Colorectal cancer screening tests
• Home drug tests

• Ovulation indicators
• Pregnancy tests

Skin Care Items marked (Rx) require a doctor's prescription as of 1/1/2011

• Acne medications (Rx)
• Anti-itch lotion (Rx)
• Bunion and blister treatments (Rx)
• Cold sore and fever blister medications (Rx)

• Corn and callus removal medications (Rx)
• Diaper rash ointment (Rx)
• Eczema cream (Rx)
• Medicated bath products (Rx)

Stomach Care Prescription (Rx) required as of 1/1/2011

• Acid reducing gum, liquid and tablets (Rx)
• Anti-diarrhea medications (Rx)
• Gas prevention tablets and drops (Rx)
• Ipecac syrup (Rx)

• Laxatives (Rx)
• Pinworm treatment (Rx)
• Upset stomach medications (Rx)

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Dual use items that require doctor's letter
Letter of Medical Necessity required from a physician (LOMN)
Items marked (Rx) require a doctor's prescription as of 1/1/2011

• Adhesive or elastic bandages
• Blood pressure meter
• Cold or hot compresses
• Eye drops (Rx)
• Foot spa (LOMN)
• Gauze and tape (LOMN)
• Gloves and masks (LOMN)
• Herbs (Rx)
• Leg or arm braces

• Massagers (LOMN)
• Minerals (Rx)
• Multivitamins (Rx)
• Saline nose drops (Rx)
• Special supplements (Rx)
• Special teeth cleaning system (LOMN)
• Thermometers
• Vitamins (Rx)

Over-the-counter items that DO NOT qualify:

• Aromatherapy
• Baby bottles and cups
• Baby oil
• Baby wipes
• Breast enhancement system
• Cosmetics
• Cotton swabs
• Dental floss
• Deodorants
• Feminine care fragrances
• Hair regrowth
• Low "carb" foods

• Low calorie foods
• Oral care
• Petroleum jelly
• Shampoo and conditioner
• Skin care
• Spa salts
• Sun tanning products
• Tooth brushes
• Over-the-counter items, drugs, or medications that are not medically necessary, or are not prescribed by your physician or health practitioner

Limitation on qualified expense

Your plan may restrict the reimbursement of one or more of these items. Check with your plan administrator. The total amount of all qualified expenses paid may not exceed the maximum allowed under the plan. Please review your Summary Plan Description or see your plan administrator for more information.

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