Forms

• Flexible Compensation Plan Employee Authorization Agreement

• Health Reimbursement Arrangement (HRA) Payment Request Form

• PharmaCare Direct Member Reimbursement Form

• Request for Reimbursement from Employee Flexible Compensation Account

• Supplemental Claim Statement

• Flex Debit Card Receipt Form

Information below on the use of FSA debit cards and a list of FSA-eligible and ineligible over-the-counter (OTC) purchases after 1-1-2011

Benny Card FSA OTC Purchases 1-1-2011

Benny Card Revised Handout on OTC Purchases, 1-20-2011

FSA List of Eligible-Ineligible Items Rev. 4--2011