CAPABILITY OVERVIEW

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27 Odessa R-VII School District 2017
Odessa R-VII
2017Benefits Enrollment Worksheet
In order to expedite your enrollment, it is recommended that you complete this worksheet. Any missing information could slow
down your enrollment experience.
Legal Name SSN Relationship Gender Date ofBirth
Medical
Yes / No
Dental
Yes/No
Vision
Yes/No
MEDICAL – HUMANA
QHDHP BASE PPO BUY-UP PPO
Retiree Only  $497.21  $588.71  $643.74
Retiree + Spouse  $994.41  $1,177.42  $1,287.49
Retiree + Child(ren)  $1,019.27  $1,206.86  $1,319.68
Family  $1,402.12  $1,660.17  $1,815.36
Would you like to receive future benefits and enrollment communication electronically?
Yes. Please provide your email address: ______________________________
No
VISION – SUPERIOR
Employee Only  $8.93
Employee + Spouse  $15.17
Family  $25.19
Waive 
DENTAL – DELTA DENTAL OF MO:
Retiree Only  $35.29  $44.03
Retiree + Spouse  $69.11  $86.24
Retiree + Child(ren)  $99.90  $124.52
Family  $133.57  $166.68
Waive 