CAPABILITY OVERVIEW

Tonganoxie USD #464

Tonganoxie USD#464

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 – AETNA

QHDHP

BASE PPO

BUY-UP PPO

Employee Only



$530.02



$557.18



$570.95

Employee + Spouse



$1,171.88



$1,232.60



$1,260.31

Employee + Child(ren)



$848.35



$892.16



$912.83

Family



$1,375.38



$1,446.75



$1,478.86

Waive



DENTAL – DELTA DENTAL OF KS:

BASE

BUY-UP

Employee Only



$31.51



$35.29

Employee + Spouse



$63.02



$70.59

Employee + Child(ren)



$50.42



$56.46

Family



$108.05



$121.02

Waive



VISION – SUPERIOR

MATERIALS ONLY

FULL BENEFITS

Employee Only



$6.47



$8.41

Employee + Spouse



$12.80



$16.66

Employee + Child(ren)



$12.56



$16.31

Family



$19.10



$24.81

Waive

