My Hawaii Wellness

Exclusions List

EUTF Supplemental Medical & Prescription Drug Plan

Exclusions List: (Download Document)

This EUTF supplemental plan does not pay for taxes, your primary group health plan’s deductible or enrollment fees, services not specified as Covered Expenses, and services or benefits not paid by your primary group health plan. Any charges after reaching the plan maximum in your primary group health plan are excluded from reimbursement. Plan exclusions include but are not limited to the following:


Hair loss


Hearing aids

Behavior testing

Homemaker services

Benefits not covered by your primary group health plan



Massage therapy

Bionic devices


Blood or blood products

Oral travel immunizations/medications

Charges for donor sperm or ova

Over the counter drugs

Charges in excess of the eligible/allowable rates negotiated between any group health/medical plan and the provider or entity providing the service to the employee-beneficiary

Personal convenience items


Photo-refractive keratectomy

Complications of a non-covered procedure

Physical Examinations Related to

    •  Employment

    •  Insurance

    •  Licensing

    •  Court-order such as parole or probation

Cosmetic surgery

Prescription drug charges in excess of the benefit maximum or annual prescription drug benefit maximum

Cost of storing or processing sperm

Oral travel immunizations/medications

Counseling for Bereavement, Genetic, Sexual Identification

Provider is an Immediate Family Member

Custodial care

Radial keratotomy

Dental Care Services

Rest cure

Disposable take home supplies

Reversal of voluntary sterilization

Expenses or care for cosmetic surgery performed mainly to change a person’s appearance

Routine foot care (unless medically necessary)

Expenses or care that are not medically necessary or not prescribed by a licensed physician

Self-help or self-cure

Expenses exceeding the maximum benefit amount allowed under this plan or your primary group health plan.

Services for which the patient has no responsibility to pay due to:

    •  Military or service-related condition

    •  Workers’ Compensation liability

    •  Automobile related condition

Expenses incurred after your termination date of this plan

Services not medically necessary

Expenses incurred prior to your coverage effective date of this plan

Sleep therapy

Expenses not listed (eligible) under Covered Expenses in this plan.

Stand-by time

Expenses paid or payable under any other source including insurance plan/policy


   •  Services for or transportation of a living donor

   •  Mechanical or non-human organs

   •  Organ purchase

Experimental or investigational services

Travel and lodging cost

Eye exams, eye exercises (Routine)

Weight reduction programs

Eyeglasses; corrective lenses



Gender reassignment

Government covered services (Medicaid, Medicare, QUEST)

Group health plan deductibles that you have to satisfy in your primary group health plan