My Hawaii Wellness

Plan Summary

EUTF Supplemental Medical & Prescription Drug Plan

This EUTF supplemental plan provides reimbursement of eligible out-of-pocket medical expenses for active employee-participants who are primarily covered under a non EUTF health plan.

Plan Year: 7/1/2021 – 6/30/2022  (Download Document)

Schedule of Benefits

Plan Type: Group supplemental medical and prescription drug plan is a secondary payer.

Plan Year Maximum: $2,750 per covered participant     |     Prescription Drug Sublimit: $250 per covered participant

Prescription Drug Benefit

The maximum reimbursement for prescription drug copayment charges is $20 per 30-day supply, $40 per 60-day supply, and $60 per 90-day supply. Reimbursements for prescription drug copayment charges shall not exceed $250 per plan year per covered participant. Reimbursements for prescription drug copayments count towards the $2,750 Plan Year Maximum.

Eligible Medical ExpensesThose out-of-pocket medical, hospital and surgical expenses listed under Covered Expenses. Some exclusions apply.

Covered Expenses

Preventive Care

•  Colorectal Screening
•  Immunizations
•  Newborn & Well-Baby Care
•  Prostate Screening
•  Routine Mammogram
•  Routine Office Visit/Exam (One Per Year)
•  Routine Pap Smear
•  Routine Well-Woman Exam

Physician Services

•  Consultations
•  Office, hospital and emergency room visits
•  Physician Assistants and Nurse Midwives working under the direct supervision of a physician
•  Routine Obstetrical Care
•  Surgeon, assistant surgeon and anesthesia

Hospital and Facility Services

•  Ambulatory Surgical Center
•  Birthing Center
•  Emergency Room
•  Inpatient Anesthesia Services
•  Inpatient Hospital Room and Board
•  Outpatient Hospital Ancillary Services
•  Skilled Nursing Facility

Other Services

•  Ambulance
•  Appliances and Braces
•  Behavioral Health Services (In and Outpatient)
•  Cardiac Rehabilitation (Short-Term)
•  Dialysis and Related Supplies
•  Durable Medical Equipment
•  Home Therapies and Home Health Care
•  Hospice Care
•  Inhalation (or Respiratory) Therapy
•  Injections
•  Physical Therapy
•  Prosthetics
•  Speech Therapy
•  Tissue and Organ Transplants


•  Allergy Testing
•  Diagnostic Laboratory and Pathology
•  Radiology, CT Scans, Ultrasound and Nuclear Medicine

Chemotherapy and Radiation Therapy