FSA coverage is narrower than you might think, and the IRS publishes a specific list of what counts

A Flexible Spending Account (FSA) covers medical expenses that you pay out of your own pocket — but only those the IRS has approved. The list includes common things like copays, deductibles, prescription drugs, and dental work, but excludes others that feel medical, like cosmetic procedures, gym memberships, or most over-the-counter vitamins. The IRS updates this list periodically, and what your employer's plan covers can be narrower still, so you need to check both the federal rules and your own plan document.

The core rule is this: an expense must be for diagnosis, treatment, or prevention of a disease or condition affecting the structure or function of your body. Expenses for general health or appearance do not count, even if they make you feel better. If you are unsure whether something is covered, your plan administrator can tell you in writing — and that answer matters, because using FSA money on an ineligible expense means you pay taxes on it plus a penalty.

Key Takeaways

  • FSA covers copays, coinsurance, deductibles, prescription drugs, dental care, vision care, and medical equipment like crutches or hearing aids.
  • FSA does not cover cosmetic procedures, gym memberships, most vitamins and supplements, or over-the-counter drugs unless prescribed by a doctor.
  • Your employer's FSA plan may be more restrictive than the IRS rules, so you must check your plan document or call your plan administrator.
  • Using FSA money on an ineligible expense triggers income tax plus a 20 percent penalty on the amount spent.

Medical expenses FSA definitely covers

Copays and coinsurance are covered — these are the portions of your medical bill you pay after insurance. Deductibles are covered too, meaning you can use FSA money to reach your deductible and then have insurance kick in. Prescription medications are covered, as are insulin and other drugs you inject or inhale. Over-the-counter drugs are covered only if a doctor writes a prescription for them, which is rare but possible.

Dental work is covered: cleanings, fillings, root canals, crowns, orthodontia, and extractions all count. Vision care is covered: eye exams, glasses, contact lenses, and contact solution are all may be able to access. Medical equipment is covered: crutches, wheelchairs, hearing aids, blood pressure monitors, glucose meters, and orthopedic braces all may have access to. Mental health treatment is covered: therapy, psychiatry, and inpatient treatment for substance use disorder all count.

Preventive care is covered: vaccinations, cancer screenings, and annual physicals are may be able to access. Fertility treatment is covered: in vitro fertilization, artificial insemination, and related procedures count. Chiropractic care is covered if a doctor refers you. Acupuncture is covered if a doctor refers you. Transportation to medical appointments is covered if you have a serious illness or injury.

Medical expenses FSA does not cover

Cosmetic procedures are not covered — this includes teeth whitening, Botox, dermal fillers, hair removal, and cosmetic surgery. The exception is if the procedure is reconstructive, meaning it repairs damage from injury, disease, or birth defect. A nose job for appearance does not count; a nose job to repair a deviated septum that blocks breathing might, depending on your plan.

Gym memberships and fitness classes are not covered, even if your doctor recommends exercise. Weight loss programs are not covered unless they treat a specific disease like obesity-related diabetes, and even then your plan may exclude them. Most vitamins and supplements are not covered, including multivitamins, vitamin D, and herbal remedies. The exception is if a doctor prescribes a specific supplement to treat a diagnosed deficiency or condition.

Over-the-counter drugs without a prescription are not covered — this includes pain relievers, cold medicine, allergy medicine, antacids, and laxatives. Sunscreen is not covered. Toothpaste and mouthwash are not covered. Feminine hygiene products are not covered. Diapers and incontinence products are not covered. Cosmetic dentistry like veneers or whitening is not covered unless it is part of reconstructive work.

What your plan document says matters more than the IRS list

The IRS publishes a general list of may be able to access expenses, but your employer's FSA plan can be more restrictive. Some plans exclude certain dental procedures, cap vision benefits, or do not cover fertility treatment. Some plans have a list of approved vendors and will not reimburse you if you use someone else. Some plans require prior authorization before you have a procedure, meaning you must get written approval from the plan before you pay, or you will not be reimbursed.

Your plan document is the contract that governs what you can spend on. It is usually available on your employer's benefits website or from your human resources department. If you cannot find it, call your plan administrator — the phone number is on your FSA card or in your benefits materials. Ask them directly whether a specific expense is covered under your plan. Get the answer in writing if possible, because if you spend the money and they later say it was not covered, you will owe the taxes and penalty.

How to know if something is covered before you spend

The safest approach is to ask your plan administrator in advance. Call the number on your FSA card or your benefits materials and describe the expense. Tell them the specific procedure, provider, or product you are considering. Ask whether it is covered under your plan. Write down the date, time, and name of the person you spoke to, and what they told you. If they say yes, ask them to send you a written confirmation.

If the plan administrator says no, you have a choice: you can pay out of pocket with after-tax money, or you can ask your doctor whether they will prescribe the item or procedure. A doctor's prescription can change the status of some expenses — for example, a multivitamin is not covered, but a prescribed vitamin D supplement for deficiency might be. This is worth asking about before you give up on using your FSA money.

If you spend FSA money on something that turns out to be ineligible, you will owe income tax on that amount plus a 20 percent penalty when you file your taxes. This is not something the plan administrator catches — it is your responsibility. Keep all receipts and documentation, because if you are audited, you will need to show what you spent the money on.

Common items that confuse people

Prescription sunscreen: If a dermatologist prescribes sunscreen to treat a skin condition like photosensitivity or a history of skin cancer, it is covered. Over-the-counter sunscreen is not.

Prescribed vitamins: A vitamin prescribed by a doctor to treat a specific deficiency or condition is covered. A multivitamin you buy on your own is not.

Therapy for mental health: Covered. Therapy for life coaching or career counseling is not.

Fertility treatment: Covered by most plans, but some exclude it. Check your plan document.

Acupuncture and chiropractic: Covered only if referred by a doctor. Self-referral does not count.

Teeth whitening: Not covered. Teeth cleaning by a hygienist is covered.

Wigs after hair loss: Covered if the hair loss is from a medical condition or treatment like chemotherapy. A wig for appearance is not.

What happens if you use FSA money on an ineligible expense

If you spend FSA money on something the IRS does not allow, you have to pay income tax on that amount when you file your taxes. You also owe a 20 percent penalty. So if you spend $500 on an ineligible expense and you are in the 24 percent tax bracket, you will owe $500 × 0.24 = $120 in income tax, plus $500 × 0.20 = $100 in penalty, for a total of $220 in taxes and penalties on top of the $500 you already spent.

The plan administrator does not report this to the IRS automatically. It is your responsibility to report it when you file your taxes. If you do not report it and the IRS audits you, you will owe the taxes, the penalty, and interest on top of that. The safest approach is to ask before you spend, and if you are unsure, pay out of pocket with after-tax money instead.

Frequently Asked Questions

Can I use my FSA to pay for my spouse's medical expenses?

Yes, if your spouse is a dependent on your tax return. You can use your FSA to pay for your spouse's copays, prescriptions, dental work, and other may be able to access medical expenses. You cannot use it for a spouse's expenses if they are not your dependent.

Are over-the-counter pain relievers covered if I have a prescription?

Yes. If your doctor writes a prescription for ibuprofen, acetaminophen, or another over-the-counter drug, it becomes may be able to access for FSA reimbursement. Without a prescription, over-the-counter drugs are not covered. This is an unusual situation, but it does happen.

Is my FSA money forfeited if I don't use it by the end of the year?

Most FSA plans follow a "use it or lose it" rule, meaning money left in your account at the end of the plan year is forfeited. Some plans offer a grace period of up to 2.5 months into the next year, or a carryover of up to $610 (the amount changes yearly). Check your plan document to see which rule applies to you.

Can I get reimbursed for medical expenses I paid for in a previous year?

No. You can only be reimbursed for expenses you incur during the plan year your FSA is active. If you paid for something last year, you cannot use this year's FSA money to reimburse yourself, even if you did not claim it before.

What if my doctor says a cosmetic procedure is medically necessary?

The IRS decides whether something is covered, not your doctor. If your doctor says a nose job is medically necessary to fix a breathing problem, it may be covered — but you need to get written confirmation from your plan administrator before you have the procedure. The plan administrator will ask for documentation from your doctor about the medical necessity.