Please enter the patient’s total out-of-pocket expenses that are FSA reimbursable. This amount will be submitted on the patient’s behalf to their FSA administrator for reimbursement.

FSA is a healthcare savings account that allows members to set aside pre-tax dollars to use for out-of-packet medical expenses, including vision.

Eligible out-of-pocket expenses* for FSA reimbursement includes, but is not limited to: – Copays – Non – covere lens options – Frame overage – Contact lens solution – Additional precription glasses not covered by the benefit – Plano sunglasses not covered by the benefit ( if deemed medically necessary by the doctor)

EXAMPLE: Copays: $20 Frame Overage: $50 Contact Lens Solution: $20 TOTAL Eligible OOP: $90 (This is the amount to enter into the FSA area. )

Questions? Call us at 773-697-7370