Physicians Mutual Insurance Company®
This affordable dental insurance helps pay for over 400 covered procedures.
View some of the most common procedures and what percentage each plan helps cover — or browse the full list of covered procedures below.
Covered procedures at a glance
Take a quick look at what percentage each dental plan pays for commonly
used services.
This chart shows examples of some of the most-commonly used dental
procedures and what percentage each plan covers when receiving care
from an in-network provider.
See the full list of covered procedures beneath this chart.
| Covered procedure Type | Waiting Period | Economy Plan Coverage | Standard Plan Coverage | Preferred Plan Coverage | Premier Plan Coverage | |
|---|---|---|---|---|---|---|
| pm_checkmark_rounded | Cleanings | None | 100% | 100% | 100% | 100% |
| pm_checkmark_rounded | Routine Exams | None | 100% | 100% | 100% | 100% |
| pm_checkmark_rounded | Dental X-rays | None | 100% | 100% | 100% | 100% |
| pm_checkmark_rounded | Fillings for cavities | None | 25% | 40% | 55% | 70% |
| pm_checkmark_rounded | Minor oral surgery procedures and sedation | None | 25% | 40% | 55% | 70% |
| pm_checkmark_rounded | Simple tooth extractions | None | 25% | 40% | 55% | 70% |
| pm_checkmark_rounded | Root canals | 12 months | 25% | 40% | 55% | 70% |
| pm_checkmark_rounded | Crowns | 12 months | 25% | 40% | 55% | 70% |
| pm_checkmark_rounded | Dentures | 12 months | 25% | 40% | 55% | 70% |
100% coverage for preventive care is only available when you see an
in-network dentist.
The 25%/40%/55% are averages of the maximum allowable charge. 70% is what
we’ll pay of the maximum allowable charge.
See list of all covered procedures
Looking for specific dollar amounts? Browse our comprehensive list of all
covered procedures.
The chart below shows the covered dental procedures Physicians Mutual
Insurance Company pays benefits for, as well as the maximum expense
paid for each.
Customers with this coverage have access to discounts through the
Ameritas Classic PPO Network.
- Each plan pays 100% for preventive (type I) services when you see an in-network provider.
- The Premier Plan (Schedule 4) pays 70% of the maximum allowable charge for basic (type II) and major (type III) services.
- The other three plans – Preferred (Schedule 3), Standard (Schedule 2) and Economy (Schedule 1) – pay a set dollar amount, for basic and major services. With these three plans, the amounts shown for basic and major services are the same regardless of provider participation.
- For Participating Providers, the amount paid will not exceed the Maximum Allowable Charge. For Non-Participating Providers, the amount paid will not exceed the amount of the actual charge for the procedure.
Covered procedures may vary by state and are subject to change. No
benefits are payable for a procedure that is not listed.
If you have any questions, give us a call at
1-800-228-9100.
Type I - Preventive100% covered preventive care only at network providers. | |
|---|---|
Code D0120 Description Periodic oral evaluation – established patient. ECO STA PRE PRM | 100% |
Code D0145 Description Oral evaluation for a patient under three years of age and counseling with primary caregiver. ECO STA PRE PRM | 100% |
Code D0150 Description Comprehensive oral evaluation – new or established patient. ECO STA PRE PRM | 100% |
Code D0180 Description Comprehensive periodontal evaluation – new or established patient. ECO STA PRE PRM | 100% |
| Two evaluations will be allowed in a Policy Year. A D0120, D0145, D0150 or D0180 counts toward this maximum allowance. D0150 and D0180 will be limited to once per provider. | |
Code D0210 Description Intraoral – complete series of radiographic images. ECO STA PRE PRM | 100% |
Code D0330 Description Panoramic radiographic image. ECO STA PRE PRM | 100% |
| D0210 or D0330: One of these procedures will be allowed in a 5-year period.* | |
Type II - Basic |
|---|
Code D0140 Description Limited oral evaluation - problem focused. ECO STA PRE PRM** $11 $18 $25 70% |
Code D0170 Description Re-evaluation - limited, problem focused (established patient; not post-operative visit). ECO STA PRE PRM** $11 $18 $25 70% |
| D0140 and D0170: Coverage is limited to accidental injury only. If not due to an accident, will be considered as a D0120 and count toward this maximum allowance. |
Code D0472 Description Accession of tissue, gross examination, preparation and transmission of written report. ECO STA PRE PRM** $18 $28 $38 70% |
Type III - Major |
|---|
Code D3220 Description Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament. ECO STA PRE PRM** $23 $36 $49 70% |
| Limited to the treatment of primary teeth: |
Code D3221 Description Pulpal debridement, primary and permanent teeth. ECO STA PRE PRM** $23 $36 $49 70% |
Code D3222 Description Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development. ECO STA PRE PRM** $38 $61 $84 70% |
Code D3230 Description Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration). ECO STA PRE PRM** $38 $61 $84 70% |
Code D3240 Description Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration). ECO STA PRE PRM** $38 $61 $84 70% |
Type I - Preventive100% covered preventive care only at network providers. | Maximum Covered Expense | ||||
|---|---|---|---|---|---|
| Code | Economy Schedule 1 | Standard Schedule 2 | Preferred Schedule 3 | Premier Schedule 4 | |
| D0120 | Periodic oral evaluation – established patient. | 100% Covered | |||
| D0145 | Oral evaluation for a patient under three years of age and counseling with primary caregiver. | 100% Covered | |||
| D0150 | Comprehensive oral evaluation – new or established patient. | 100% Covered | |||
| D0180 | Comprehensive periodontal evaluation – new or established patient. | 100% Covered | |||
| Two evaluations will be allowed in a Policy Year. A D0120, D0145, D0150 or D0180 counts toward this maximum allowance. D0150 and D0180 will be limited to once per provider. | |||||
| D0210 | Intraoral – complete series of radiographic images. | 100% Covered | |||
| D0330 | Panoramic radiographic image. | 100% Covered | |||
| D0210 or D0330: One of these procedures will be allowed in a 5-year period.* | |||||
Type II - Basic | Maximum Covered Expense | ||||
|---|---|---|---|---|---|
| Code | Economy Schedule 1 | Standard Schedule 2 | Preferred Schedule 3 | Premier Schedule 4** | |
| D0140 | Limited oral evaluation - problem focused. | $11 | $18 | $25 | 70% |
| D0170 | Re-evaluation - limited, problem focused (established patient; not post-operative visit). | $11 | $18 | $25 | 70% |
| D0140 and D0170: Coverage is limited to accidental injury only. If not due to an accident, will be considered as a D0120 and count toward this maximum allowance. | |||||
| D0472 | Accession of tissue, gross examination, preparation and transmission of written report. | $18 | $28 | $38 | 70% |
Type III - Major | Maximum Covered Expense | |||||
|---|---|---|---|---|---|---|
| Code | Economy Schedule 1 | Standard Schedule 2 | Preferred Schedule 3 | Premier Schedule 4** | ||
| D3220 | Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament. | $23 | $36 | $49 | 70% | |
| Limited to the treatment of primary teeth: | ||||||
| D3221 | Pulpal debridement, primary and permanent teeth. | $23 | $36 | $49 | 70% | |
| D3222 | Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development. | $38 | $61 | $84 | 70% | |
| D3230 | Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration). | $38 | $61 | $84 | 70% | |
| D3240 | Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration). | $38 | $61 | $84 | 70% | |
* The frequency is measured forward from the last covered date of service for the procedure.
** 70% of the maximum allowable charge