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29│A
NNUAL
L
EGAL NOTICES
29
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 of
Birth
Medical
Yes / No
Dental
Yes/No
Vision
Yes/No
MEDICAL – HUMANA
QHDHP
BASE PPO
BUY-UP PPO
Employee Only
$0
$0
$55.03
Employee + Spouse
$497.20
$588.71
$698.78
Employee + Child(ren)
$522.06
$618.15
$730.97
Family
$904.91
$1,071.46
$1,226.65
HSA - Optum:
Only available with the QHDHP plan. Not available if you or your spouse are contributing to a FSA.
If you want to contribute to the Healthcare Account, you may elect to have your contributions deducted
on a pre-tax basis. Do you want to participate?
Yes – Employee Contribution Amount $____________/paycheck (2017 tax year limits
$3,400/individual or $6,750/family). This is the combination of any employer + employee
contributions). This election amount can be changed as often as monthly if desired – you must
change in accounting/payroll.
The District will contribute $91.50 per month for the 2017-2018 plan year.
No
DENTAL – DELTA DENTAL OF MO:
VISION – SUPERIOR
Employee Only
$35.29
$44.03
Employee Only
$8.93
Employee + Spouse
$69.11
$86.24
Employee + Spouse
$15.17
Employee + Child(ren)
$99.90
$124.52
Family
$133.57
$166.68
Family
$25.19
Waive
Waive