Fillable How Much Do You Spend? (City of Council Bluffs)

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How Much Do You Spend? (City of Council Bluffs)

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BROWSE CITY OF COUNCIL BLUFFS (IA) FORMS

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EBS M008 (10/2011)
How Much Do You Spend?
In order to help you estimate your annual out-of-pocket expenditures, we have included a listing of potential medical or health related expenses
that qualify for reimbursement under an EBS Flex Plan. For a complete list of eligible expenses please visit the EBS website, www.ebs-tpa.com
.
Deductible Medical Expenses
Your Annual
Estimated
Amount
Ambulance
$
Organ Transplant (including donor’s expenses)
$
Arch supports
$
Orthopedic shoes
$
Artificial limbs
$
Oxygen and oxygen equipment
$
Birth Control Pills (by prescription)
$
Pediatrician
$
Blood tests
$
Prenatal care
$
Blood transfusions
$
Prescription medicines
$
Braces
$
Psychiatrist
$
Chiropractor
$
Psychologist
$
Contact Lenses
$
Special school costs for the handicapped
$
Contraceptive devices (by prescription)
$
Sterilization
$
Crutches
$
Therapy equipment
$
Dental Treatment
$
Transportation expenses (relative to health care)
$
Dermatologist
$
Vaccines
$
Diagnostic fees
$
Vasectomy
$
Drug addiction therapy
$
Vitamins (if prescribed)
$
Drugs (prescription)
$
X-rays
$
Elastic hosiery (prescription)
$
Eyeglasses
$
Eligible Over-the-Counter Expenses
Guide dog
$
The following are examples of the OTC items that will remain
Gynecologist
$
available without a doctor’s prescription.
Hearing aids and batteries
$
Band-aids
$
Hospital bills
$
Birth Control
$
Hydrotherapy
$
Braces & Supports
$
Insulin treatment
$
Catheters
$
Lab tests
$
Contact Lens Supplies & Solutions
$
Lodging (away from home for outpatient care)
$
Denture Adhesives
$
Neurologist
$
Diagnostic Test & Monitors
$
Obstetrician
$
Elastic Bandages & Wrap
$
Ophthalmologist
$
First Aid Supplies
$
Optician
$
Insulin & Diabetic Supplies
$
Optometrist
$
Ostomy Products
$
Oral surgery
$
Reading Glasses
$
Wheelchairs, Walkers, and Canes
$
Employee Benefit Systems Third Party Administration Services
EBS
help:
can
Contact
Us
Employee Benefit Systems 214 North Main Street PO Box 1053 Burlington, IA 52601
Phone: 800-373-1327 Fax: 319-758-6271 flex@ebs-tpa.com
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How Much Do You Spend (City of Council Bluffs)

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Completed 5 August 2020

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