When is additional documentation required? Certain expenses cannot be reimbursed under a Limited Purpose FSA unless a licensed health care practitioner states in writing to Navia Benefit Solutions that the service or product is medically necessary. Navia will need a Letter of Medical Necessity (LMN) for the items below before they can be reimbursed. Not all items requiring an LMN are on this list. For a complete list, and to download a printable copy of the LMN, go to pebb.naviabenefits.com or call Navia Benefit Solutions at 1-800-669-3539. Contacts and Eyeglasses Lasik Dental crowns Veneers Fluoridation services Vitamins & supplements Orthodontia Orthodontia expenses Unlike other Limited Purpose FSA expenses, which are deemed incurred when the services occur, orthodontia expenses are considered incurred when paid. Therefore, only payments made during your eligibility period or plan year (whichever ends first) may be reimbursed. Proof of payment to an orthodontia provider or a completed Orthodontia Contract is required for reimbursement. You can download a printable copy of the Orthodontia Contract by visiting pebb.naviabenefits.com or calling Navia Benefit Solutions at 1-800-669-3539. Stockpiling IRS regulations prohibit you from receiving a reimbursement from your Limited Purpose FSA for a large quantity of any item in any one transaction. Buying more than three of the same item in any one transaction is considered stockpiling and will not be reimbursed. Ineligible expenses The following expenses are not eligible under a Limited Purpose FSA. Under no circumstances will the following items be reimbursed. Do not submit claims for these items; they will be denied. For a complete list, visit pebb.naviabenefits.com or call Navia Benefits Solutions at 1-800-669-3539. Medical expenses Electric toothbrush/picks Late fee Missed appointment fee Teeth whitening An expense is also not eligible for reimbursement under a Limited Purpose FSA if the expense has already been reimbursed under this plan or by any other source. When submitting an expense for reimbursement you will also be required to certify that you will not seek or be reimbursed for the expense by any other source or insurance. How do I get reimbursed? Navia Benefit Solutions will send you a claim form when you enroll in the Limited Purpose FSA. Submit your claim and documentation to Navia Benefit Solutions for reimbursement. The documentation must show the: • Provider’s name • Name of the person receiving the service or expense • Dates of service • Cost • Type of expense or description of the services You can use bills from your providers or statements from your insurance company as documentation. Do not submit copies of canceled checks or credit or debit card receipts. Your documentation will not be returned. Remember that: • Expenses must occur during the plan year while you are an active participant in the plan. You may not submit claims for services incurred after your employment has ended, after you lose eligibility for the Limited Purpose FSA, after you revoke your election because of a life event, or after you have retired. 5