Benefit Design — eKlotho Inc

Select Product: Active · Commercial · HMO Plan Year: 2025 · Last modified: Apr 1, 2025

Medical

Pharmacy

Dental

Vision

Behavioral Health

Deductible ConfigurationAnnual deductible amounts

Individual Deductible (In-Network)

Family Deductible (In-Network)

Individual Deductible (Out-of-Network)

Family Deductible (Out-of-Network)

Out-of-Pocket Maximum

Individual OOP Max (In-Network)

Family OOP Max (In-Network)

Individual OOP Max (Out-of-Network)

Family OOP Max (Out-of-Network)

Copay Structure by Service Category

Service Type	In-Network Copay	Out-of-Network	Coinsurance (In-Net)	Applies to Deductible
Preventive Care		Not covered
Primary Care Visit (PCP)
Specialist Visit
Emergency Room
Inpatient Hospital
Outpatient Surgery
Urgent Care

Pharmacy Tier StructureRetail 30-day supply

Tier 1 — Generic

Retail 30-day

Mail Order 90-day

Specialty

Tier 2 — Preferred Brand

Retail 30-day

Mail Order 90-day

Specialty

Tier 3 — Non-Preferred Brand

Retail 30-day

Mail Order 90-day

Specialty

Tier 4 — Specialty

Retail 30-day

Mail Order 90-day

Specialty Copay

Pharmacy Deductible & OOP

Pharmacy Deductible (Individual)

Pharmacy OOP Max (Individual)

Dental Benefit Configuration

Annual Deductible

Annual Maximum Benefit

Preventive (Class I)

Basic Restorative (Class II)

Major Restorative (Class III)

Orthodontia

Vision Benefit Configuration

Eye Exam (per year)

Frames Allowance

Contact Lenses Allowance

LASIK Discount

Behavioral Health Benefit ConfigurationMental Health Parity Compliant

Outpatient Therapy Copay

Inpatient Psychiatric

Substance Use Treatment

Session Limit

Telehealth Therapy

Crisis Intervention