The following PDF forms contain fill-able fields and automatic calculations, but must be printed and mailed or faxed after completion. Select the form based on your benefit enrollment.
Please use only the forms that correspond to your employer’s plan as designated in the Summary Plan Description (SPD).
The following PDF forms contain fill-able fields and automatic calculations, but must be printed in order to be retained as a record. Use these forms to help determine annual election amounts.
The following PDF forms contain fill-able fields and automatic calculations, but must be printed and mailed or faxed after completion.
Note to Participants: Use only the forms that correspond to your employer’s plan as designated in the Summary Plan Description (SPD).
To assist you in determining your Flexible Spending Account – FSA Dependent Daycare election, the following worksheet can be used as a guide to help determine your annual Dependent Daycare assistance costs.
Please note: qualifying expenses are those incurred for the care and well-being of your dependent(s) so that you or you and if married, you and your spouse may be gainfully employed.
Your Medical FSA Plan is used to help pay for uninsured, out-of-pocket medical expenses. The worksheet below helps you estimate your annual out-of-pocket medical expenses and can be a valuable tool when determining your annual election.
This list is NOT comprehensive and is intended only as a guide to reimbursable expenses as governed by IRS Section 213(d). To find out about a specific item not mentioned here, contact a myCafeteriaPlan representative or use myCafeteriaPlan’s Online Request for Information.
Please note: cosmetic services and preventative medicines (such as vitamins) are not covered unless prescribed by a physician.
The following is a high level list of Over-the-Counter (OTC) items that may be eligible for purchase with FSA, HSA or HRA dollars depending on your plan. Baby Electrolytes Denture Adhesives, Repair, and Cleansers Diabetes Testing and Aids Diagnostic Products Elastics/Athletic Treatments Eye Care Family Planning Feminine Care First Aid Dressings and Supplies Incontinence Products Medication Reading Glasses and Maintenance
The following is a list of potentially eligible items. Baby/Child to Age 13 Dental Eyes Hearing Lab Exams/Tests Medical Equipment/Supplies Medical Procedures/Services Medications Obstetrics Practitioners Therapy The list above is not meant to be an all-inclusive list of potentially eligible FSA, HSA and HRA expenses, as other expenses not specifically mentioned may also qualify. Expenses marked with an asterisk (*) are “potentially eligible expenses” that require a Note of Medical Necessity from your health care provider to qualify for reimbursement. Each plan is different; for additional information specific to your plan, check your Summary Plan Document or contact myCafeteriaPlan. Disclaimer: Every effort has been made to present this information accurately, however, this is just a summary overview. An overview means that details, explanations, and qualifiers are left out. This information is intended only to provide general guidance. You should not rely on it as a complete explanation of this topic.
The following is a list of ineligible items.
Eligible OTC Items*
Hearing Aid/Medical Batteries
Eligible Items*
Cafeteria FSA Ineligible Expenses
The following instructions are for receipt requests (Flex Card transactions) only. DO NOT use a traditional (paper) claim form. Doing so may result in the expense being tagged as a duplicate (ineligible) item.