541- 485-7488
800-422-7038 toll free
www.pacificsource.com/PSA

E-mail: psamembership@pacificsource.com

IMPORTANT THINGS TO KNOW:

Because FSAs offer tax advantages, the accounts are subject to strict IRS rules:

• 2022 maximums: FSA $2,750 and DCAP $5,000.
• If you sign up for an FSA for the 2022 plan year, claims may be incurred through March 15, 2023 and must be submitted by June 15, 2023.
• If you signed up for an FSA for the 2021 plan year, claims may be incurred through March 15, 2022 and must be submitted by June 15, 2022.
• You cannot transfer funds from one FSA to another.
• You cannot use these accounts to reimburse expenses incurred by domestic partners or their children.

PacificSource Administrators Resources

How much should you contribute to your flexible spending account? Use PacificSource's handy expense worksheet to help you estimate.

Want to manage your account online? Create your MyFlex account to submit/view claims, submit documentation, and more.

• Instructions to set up your MyFlex account
  • PSA Mobile App

You can also submit a claim by fax or mail using the FSA Reimbursement Form

• Fax: (866) 446-6090
• PacificSource Administrators
  PO Box 2797
  Portland, OR 97208-2797

Want to know more about your flexible spending account? Check out these great resources:

• FSA Information Summary Sheet
• Examples of Eligible Expenses
• FSA User’s Guide
• Benny Card Guide
• FSA Grace Period FAQ
• Flexible Spending Account Summary Plan Description
• FSA Summary of Material Modification - 2020 and 2021

Other Useful Forms:

• Letter of Medical Necessity
• Direct Deposit Authorization (to have reimbursed funds directly deposited into your bank account)
• Dependent Care Recurring Expense Form (to have dependent care funds automatically reimbursed to you)