Limited Purpose FSA eligible expenses

Eligible Expenses for your Limited Purpose FSA The Limited Purpose Flexible Spending Arrangement (FSA) covers dental and vision care expenses for you, your spouse, or your qualified dependents. Below is a list of common expenses that may be eligible for reimbursement and ineligible expenses. Not all eligible or ineligible items are on this list. For a full list, visit pebb.naviabenefits.com/benefits/expenses or call Navia Benefit Solutions at (800) 669-3539. You are responsible for providing sufficient, accurate information when submitting claims for reimbursement. To ensure compliance with IRS requirements, Navia Benefit Solutions reserves the right to require additional documentation for any claim. Common Eligible Expenses Contact lenses and solutions Guide dog training and care Dental copayments or coinsurance Lasik Dental services Prescription sunglasses Dentures Reading glasses Eye drops and treatments Orthodontia Eyeglasses Vision care Common 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. For a full list, visit pebb.naviabenefits.com or call Navia Benefit Solutions at (800) 669-3539. Electric toothbrush/picks Hygiene products Late fees Medical expenses Missed appointment fees Teeth whitening Vitamins and supplements