Submitting 125 Plans

Please follow the guidelines below when completing your claims supporting statement in order to receive your reimbursement check promptly:


Make sure your employer’s name is on the top of the Claims Supporting Statement.

  •  You can submit the prescription bag tag that contains the patients name, date filled, prescription name and the co-pay amount. If you prefer, you can submit a print out from the pharmacy with your prescription listed by submitting each individual bag tag for your prescription.


  • You can submit a copy of the provider’s walk-out statement with the date of service, patients name, and the procedure. If you do not get one from your physician, please ask for one. You can also submit a copy of your Explanation of Benefits (EOB) from your health insurance plan.


  • For statements you receive after all insurance payment have been applied, please make sure the invoice has the date of service, patients name and the amount due.


  • Over-the-counter drugs, need a written prescription or a letter of medical necessity, in order to be reimbursed from your flexible spending account. Vitamins fall into this category as well, even if purchased at a chiropractor’s office.


  • Please do not highlight anything on the statement or receipt, especially if you fax your request. The highlighting makes the item unreadable and dark. Please circle the item instead.


For Dependent Care (Day Care) reimbursement: (Funds available after deducted from pay)

  • Please submit a statement/ receipt from your daycare provider with your child(ren) name(s), and the dates of service, amount you paid and their tax id number.


REMINDER: Claims are processed by the date of service is performed, not the date they are billed or paid for. This standard is set by the IRS who governs the regulations for the flexible spending account. 


Unacceptable documentation:

  • Cash register receipts for prescriptions
  • Credit/ Debit card machine receipts
  • Copies of cancelled checks
  • Unreadable receipts/ provider statements/ EOBs