Prescription for Over‐the‐Counter Medication
For Flexible Spending Account Plan Year 2015
Instructions: Mark or fill in the appropriate over‐the‐counter medication and take to your practitioner for
signature on reverse side. This prescription must be presented each time a request for reimbursement is made and will be good for one year. Eligible expenses must still be for the treatment or diagnosis of a condition, and cannot be for general health maintenance or cosmetic in nature.
Patient Name: / Date:Patient Address: / DOB:
Directions (circle one)
Antiseptics / Triple antibiotic ointment / PRN (as needed) per package instructions
First Aid wipes/antiseptic wash / PRN (as needed) per package instructions
Tincture of Iodine / PRN (as needed) per package instructions
Rubbing Alcohol / PRN (as needed) per package instructions
Hydrogen Peroxide / PRN (as needed) per package instructions
Other / PRN (as needed) per package instructions
Cold, Flu / Theraflu / PRN (as needed) per package instructions
Tylenol Cold/Cough and Cold / PRN (as needed) per package instructions
Advil Cold/Cough and Cold / PRN (as needed) per package instructions
Mucinex/Mucinex‐D / PRN (as needed) per package instructions
Vicks Vaporub (metholatum) / PRN (as needed) per package instructions
Robitussin / PRN (as needed) per package instructions
DayQuil/NyQuil / PRN (as needed) per package instructions
Sore throat lozenges/spray / PRN (as needed) per package instructions
Pedialyyte / PRN ((as needed)) pper ppackagge instructions
Other / PRN (as needed) per package instructions
Other / PRN (as needed) per package instructions
Allergy, Asthma / Benadryl / PRN (as needed) per package instructions
Primatene Mist / PRN (as needed) per package instructions
Zyrtec/Zyrtec‐D (cetirizine) / PRN (as needed) per package instructions
Claritin (loratidine) / PRN (as needed) per package instructions
Zicam / PRN (as needed) per package instructions
Sudafed (pseudoephedrine) / PRN (as needed) per package instructions
Other / PRN (as needed) per package instructions
Ear/Eye Care / Swim‐Ear / PRN (as needed) per package instructions
Ear wax removal system / PRN (as needed) per package instructions
Lubricating eye drops / PRN (as needed) per package instructions
Other / PRN (as needed) per package instructions
Analgesics/Pain Relief / Aspirin / PRN (as needed) per package instructions
Advil (ibuprofen) / PRN (as needed) per package instructions
Aleve (naproxen sodium) / PRN (as needed) per package instructions
Tylenol (acetaminophen) / PRN (as needed) per package instructions
Chidren's Tylenol / PRN (as needed) per package instructions
Icy Hot / PRN (as needed) per package instructions
AlkaSeltzer / PRN (as needed) per package instructions
Other / PRN (as needed) per package instructions
(Continued on reverse side)
Skin Care Benadryl itch cream PRN (as needed) per package instructions hydrocortisone cream/ointment PRN (as needed) per package instructions
Benzoyl peroxide PRN (as needed) per package instructions
Clearasil PRN (as needed) per package instructions
Other
PRN (as needed) per package instructions
Stomach Care Prilosec PRN (as needed) per package instructions
Tagamet PRN (as needed) per package instructions
Tums PRN (as needed) per package instructions
bisacodyl tablets PRN (as needed) per package instructions
Emetrol PRN (as needed) per package instructions
Other
Vitamins/Supplements Multivitamins (A diagnosis is required Prenatal Vitamins for ALL vitamins and Vitamin A
supplements) Vitamin B (complex, 3, 6, 12)
Vitamin C Vitamin D Vitamin E Vitamin K
Glucosamine Chondroitin
Other
PRN (as needed) per package instructions
Diagnosis (required for vitamins and supplements)
Miscellaneous Other
Other Other Other Other Other Other Other
PRN (as needed) per package instructions PRN (as needed) per package instructions PRN (as needed) per package instructions PRN (as needed) per package instructions PRN (as needed) per package instructions PRN (as needed) per package instructions PRN (as needed) per package instructions PRN (as needed) per package instructions
Prescribed by: Substitution Permitted As Written
# Refills:
Note to Patient/Employee: This prescription must accompany all requests for reimbursement for over‐the‐ counter medications.