Medical Flexible Spending Accounts (FSA) allow you to set aside pre-tax payroll deductions each pay check to pay for out of pocket medical, dental and vision expenses for you and your family. During open enrollment you will estimate the amount you think you will need during the year. This amount will be taken out of each paycheck. Your full annual election will be available to you at the beginning of the plan year.

Money remaining in your FSA account(s) will not be returned to you at the end of the plan year. Any amount remaining after the end of the runoff or grace period, if your employer offers one, will be forfeited. Because of the use-it-or-lose-it rule, it is important for you to carefully estimate your out-of-pocket medical FSA and dependent day care expenses for the upcoming plan year.

The maximum you can set aside each year is $2700.

With a Medical FSA, you can set aside part of your pay on a pre-tax basis to pay for eligible medical expenses, such as:

• Prescriptions
• Co-payments
• Deductibles

PLAN INFORMATION

FORMS

• Medical FSA Claim Form
• Medical FSA Claim Form – Spanish
• Direct Deposit Authorization Form
• Benefits Card Application
• Letter of Medical Necessity Claim Form