English | Español | Korean About United FUGI Insurance Plan Universal Drug  Universal Classic Universal Protection EZ Life Insurance Plan   Overview   HMO Dental   Excel Plan   Value Health   Value Med   Flex Plan   Union Plan   UNION PLAN Dental/Vision and/or Medical Benefits For All hourly Employees, Part-time and Full-time, who are not eligible for the company's major medical plan, and their dependents. ▪ Issue Ages: 0 - 63 ▪ Doctor visits ▪ Injury coverage ▪ Illness coverage ▪ Accidental death benefit ▪ Prescriptions ▪ EAP / NurseLine ▪ Dental / vision ▪ Dental/Vison Plan Cost Per Paycheck Employee $4.25 Employee + 1 $8.20 Family $12.15 $25 per person annual deductible Maximum Covered Charge ORAL EXAMINATION D0120 Periodic Oral Exam* $17 D0140 Limited Oral Exam/Problem Forcuses $27 D0150 Comprehensive Oral Exam+ $27 D9110 Emergency - Palliative Treatment $38 X-RAY AND PATHOLOGY D0210 Entire Dental Series (Intraoral) Including Bitewings**   $40 D0220 Single Film - Initial $7 D0230 Single Film - Each Additional $7 D0240 Intra-Oral Occlusal Film** $10 D0250 Extraoral - First Film $11 D0260 Extraoral - Each Additional $9 D0270 Bitewing Film, One* $8 D0272 Bitewing Films, Two* $12 D0274 Bitewing Films, Four* $17 PROPHYLAXIS AND FLUORIDE D1110 Prophylaxis for age 14 and over* $30 D1120 Prophylaxis for age under 14* $20 D1203 Tropical Applic of Fluoride, Child* $12 D1204 Tropical Applic of Fluoride, Adult* $30 D1351 Sealant, Per Tooth $16 AMALGAM RESTORATION FOR PRIMARY/PERMANENT TEETH D2140 Amalgam Filling - 1 Surface $35 D2150 Amalgam Filling - 2 Surfaces $45 D2160 Amalgam Filling - 3 Surfaces $56 D2161 Amalgam Filling - 4 Surfaces $64 SYNTHETIC RESTORATIONS D2330 Composite Resin - 1 Surface $42 D2331 Composite Resin - 2 Surfaces $55 D2332 Composite Resin - 3 Surfaces $67 D2335 Composite Resin - 4 or more Surfaces $69 D2390 Composite Resin Crown, Anterior $77 D2391 Composite Resin - 1 Surface Posterior $50 D2392 Composite Resin - 2 Surfaces Posterior $68 D2393 Composite Resin - 3 Surfaces Posterior $85 EXTRACTIONS D7140 Extraction - Erupted tooth or exposed root $39 D7220 Removal Impacted Tooth - Soft Tissue $45 D7230 Removal Impacted Tooth - Partially Bony $70 D7240 Removal Impacted Tooth - Completely Bony $85 D7241 Removal Impacted Tooth - Completely Bony w/Unusual Surgical Complications $85 D7250 Removal Residual Tooth Roots $30 D7510 Incision & Drainage of Abscess $45 D9220 General Anesthesia $52 PERIODONTICS D4341 Scaling and Root Planing, Per Quadrant $72 D4355 Full Mouth Debridement to Enable Comprehensive Periodontal Evalutation $50 D4910 Periodontal Maintenance $53 ENDODONTICS D3220 Therapeutic Pulpotomy $20 D3310 Root Canal - Anterior $125 D3320 Root Canal - Bicuspid $135 D3330 Root Canal - Molar $140 FOOTNOTES * Limited to once every 6 months + Limited to once every 12 months ** Limited to once every 3 years ▪ Medical Plan Level 1 Level 2 Cost Per Paycheck Employee $8.95 Employee + 1 $21.85 Family $33.05 Cost Per Paycheck Employee $16.30 Employee + 1 $40.30 Family $61.10 ILLNESS Level 1 Level 2 Physician Office Visit Co-Pay* Per Visit   $15   $10 Outpatient Basic Medical Expense Benefit Amount Per Year Paid at Deductible Per Year   $1,000 80% $50   $1,500 80% $100 Non-Emergency Care in Emergency Room* Amount Per Year Paid at Deductible Per Occurrence   $500 50% $100   $500 50% $100 In-Hospital Medical Expense Benefit Daily In-Hospital Benefit Amount Per Year Paid at Maximum Amount Per Day Maximum Number of Days Supplemental In-Hospital Surgery Amount Per Year Paid at Supplemental Maternity Benefit Maximum Per Occurrence     $10,000 100% $100 100   N/A N/A   N/A     $25,000 100% $100 100   $1,500 100%   $1,500 INJURY     Accident Medical Benefit Amount Per Year Paid at Maximum Per Occurrence Deductible Per Occurrence Maximum Occurrences Per Year     $5,000 80% $2,500 $50 2     $10,000 80% $5,000 $100 2 Accident Death Benefit Amount Paid   $10,000   $15,000 PRESCRIPTION     Prescription Discount Name Brand or Generic   Discount   Discount Prescription Benefit* Deductible - Generic Deductible - Brand Maximum Amount Per Year   N/A N/A N/A   $15 $25 $300 EMPLOYEE ADDISTANCE     EAP / NurseLine Yes Yes *The paid benefit amount will court toward the outpatient basic medical expense coverage year maximum. The benefits above are provided by policy form SHR-POL-01 and SHR-POL-02. **** Underwritten by The MEGA Life and Healht Insurance Company.   About Us | Privacy Policy | Contact Us Copyrightⓒ 2006 United First Universal Group, Inc. All rights reserved.