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OVER-THE-COUNTER (OTC)
QUICK REIMBURSEMENT GUIDE
WHAT IS AN OVER-THE-COUNTER ITEM?
Over-the-counter (OTC) medicines and products are reimbursable under a Flexible Spending Account (FSA), Limited
Expense Care Flexible Spending Account (LEX FSA) (dental and vision expenses only), and Health Reimbursement
Account (HRA) when the OTC product is used for medical purposes. Below is a description of the three IRS-defined
categories, followed by product examples for each.
1.
Eligible OTC Medical Care Expenses
Eligible items include medicines or products that alleviate or treat injuries or illness for you and your dependents. These drugs and products are not cosmetic in nature, or merely beneficial to your general health. Claims for OTC medicines and products must include an adequate receipt that states the name of the medicine or product, the date, and the amount paid. If your supermarket or pharmacy receipt does not include this information, you will need to copy the label from the product or its packaging, circle the correct amount on your receipt, and submit this information with your signed claim form. You do not need to provide a statement from a medical provider or indicate a diagnosis in order to receive reimbursement. 2. Dual-Purpose Products
Certain OTC products are considered dual-purpose, such as vitamins and supplements. That’s because for some
individuals, the product is used to alleviate a medical condition, while others use the product for general health and well-
being. These products may be eligible for reimbursement, but require a Letter of Medical Necessity (LMN) stating your
specific diagnosis or medical condition, a recommendation to take the specific OTC medicine to treat your
condition, and documentation of the product and cost. Polycomp can provide you information regarding the LMN
to assist you in submitting this information.

3.
Excluded Items
OTC products that are not medicines or that merely benefit your general health are NOT reimbursable, such as vitamins without a LMN. Reimbursement for OTC medicines still follows the existing rules regarding your plan. The expense(s) must: 9 The OTC drug is for you, your spouse or your dependent. 9 The expense is incurred during the plan year. 9 Submit a detailed store receipt which includes the name of the product. If the receipt does not show the product name, you must also include a copy of the product label or container cover. 9 The reimbursement does not include unreasonable stockpiling. ELIGIBLE OTC MEDICAL CARE EXPENSES
Type/Class of Drug or
Examples of Eligible OTC Medical Care Expenses
Acne Treatment
Acne Free Acnomel Ambi Even & Clear Bye Bye Blemish Clean & Clear Clearasil Murad Acne Complex Kit Nature’s Cure Acne Treatment Neutrogena Acne Treatment OXY Proactiv Solution Stri-Dex ZAPZYT Acne Treatment Zeno Acne Note: Generic and store brand equivalents of name brand acne treatments are also eligible. Allergy Prevention and
Actifed Allerest Benadryl Chlor-Trimeton Claritin Contac NasalCrom Sudafed Treatment
Analgesics/Antipyretics
Aspirin Advil Aleve Ibuprofen Naprosyn Tylenol Midol Pamprin Antacids and Acid
AXID AR Gas-X Maalox Mylanta Tums Pepcid AC Prilosec OTC Reducers
Anti-arthritics
Antibiotics (topical)
Bactine Neosporin Triple antibiotic ointment Anticandial (yeast)
Femstat 3 Gynelotrimin Mycelex-7 Monistat 3 Vagistat-1 Antidiarrheal and
Ex-Lax Immodium AD Kaopectate Pepto-Bismol Laxatives
Antifungal
Antihistamines
Actifed Allerest Benadryl Claritin Chlor- Trimeton Contac Drixoral Sudafed Tavist Triaminic Anti-itch Lotions and
Bactine Benadryl Caldecort Caladryl Calamine Cortaid Hydrocortisone Lanacort Asthma Medicines
Bronitin Mist Bronkaid Bronkolixer Primatene Cold Sore/Fever Blister
Cold, Flu,
Actifed Advil Cold and Sinus Afrin Alka Seltzer Cold and Flu Afrinol Aleve Cold and Decongestant and
Sinus Children’s Advil Cold Contac Dayquil Dimetane Dristan Long- Sinus Remedies
Lasting Drixoral Neo-Synephrine 12-Hour Nyquil Otrivin Pediacare Sudafed Tavist-D Thera-flu Triaminic Tylenol Cold and Flu Cough Drops Nasal Sprays Lozenges Contact Lens Supplies
Cleaning and soaking solutions Lens storage cases Contraceptive/Family
Ovulation predictor kits Pregnancy tests Spermicides Condoms Planning
Cough Suppressants or
Robitussin Vicks 44 Chloraseptic Mucinex Cough drops Throat lozenges Expectorants
Dehydration
Dental/Denture Care
Diaper Rash
First Aid/Medical
Antiseptics Witch Hazel Peroxide Bandages First aid kits Cold/hot packs for Supplies
injuries Joint supports (ankle, elbow, knee, wrist) Rubbing alcohol Ace wraps Splints Foot Care
Arch and insole supports Callous removers Athlete’s Foot products (see anti-fungal) Hand Sanitizer
This does not include soaps, lotions or other personal hygiene items that include sanitizing Hemorrhoidal
Preparations
Home Diagnostic Tests
Blood pressure (monitor and related equipment) Cholesterol Diabetic equipment and supplies Colorectal screenings HIV test Pregnancy tests Lactose Intolerance
DairyCare Dairy Relief Lactaid Lacteeze Lactrase Medicated Lip Products
Blistex Medicated Lip Ointment Carmex Medicated Lip Balm Neosporin Lip Treatment Menstrual Cycle
Migraine Relief
Motion Sickness
Nasal Strips or Sprays
Note: Nasal strips or sprays to alleviate snoring or reduce nasal congestion are eligible. Advil Aleve Ibuprofen Motrin Naprosyn Naproxen Pediculicide
Pre-natal Vitamins
Skin Care
Sleep Aids
Smoking Cessation
Commit Nicoderm CQ Nicorette Nicotrol Sunscreen
Note: Lotions or cosmetics that contain ingredients to protect you from the sun and/or list a Teething/Toothaches
Topical Steroids
Wart Removal
Compound W Dr. Scholl’s Clear Away Wart-Off DUAL-PURPOSE PRODUCTS
Type/Class of Drug or
Examples of Dual-Purpose Products
Reimbursable Use
Excluded Use
Dental fluoride
Dietary Supplements
Feminine Hygiene
Fiber Supplements
Healing Ointment
Homeopathic Remedies
Incontinence
Joint Supplements
Minerals
OTC Hormone Therapy
Vitamins
Weight Loss Drugs or
Programs
EXCLUDED ITEMS
Type/Class of Drug or Product
Examples of Excluded Items
Cosmetic Products
Face soaps Creams Make-up Perfumes Hair removal Dental Products
Dental floss Toothpaste Toothbrushes Teeth whitening kits Mouthwash Herbal Supplements
Toiletries
Deodorant Shampoo Body sprays Soaps Moisturizers Chapstick Vitamins
The products listed here are examples, and do NOT constitute an endorsement or an
exhaustive listing of reimbursable OTC products.

Source: http://pcm000.dev2.toplingo.com/uploads/Documents/Our%20Services/Retirement%20Plans/Forms/OTC%20Guide.pdf

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