Over-the-Counter items, drugs and medications must be medically necessary.

Antiseptics (Rx): requires a doctor's prescription.

• 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)

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Cold, Flu, Asthma and Allergy Medications (Rx): requires a doctor's prescription.

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

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

Diabetes (Rx): requires a doctor's prescription.

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

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

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Ear/Eye Care
(Rx): requires a doctor's prescription. (LOMN): Letter of Medical Necessity required from a physician.

• 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 (Rx): requires a doctor's prescription.

• Antifungal 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 (Rx): requires a doctor's prescription.

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

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

Personal Test Kits

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

• Ovulation indicators
• Pregnancy tests

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Skin Care (Rx): requires a doctor's prescription.

• 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)
• Wart removal medications (Rx)

Stomach Care (Rx): requires a doctor's prescription.

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

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

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Over-the-Counter (OTC) items
(Rx): requires a doctor's prescription. (LOMN): Letter of Medical Necessity required from a physician.

• 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 for reimbursement:

• 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

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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.