A Florida Blue health plan covers the ten essential health benefits required by the Affordable Care Act, which means every individual and family marketplace plan includes doctor visits, hospital care, emergency services, maternity and newborn care, mental health and substance use treatment, prescription drugs, lab work, preventive screenings, rehabilitative services, and pediatric dental and vision. What Florida Blue covers beyond that baseline, and how much you pay for it, depends on the specific plan you choose and whether you stay in network.
The Ten Essential Health Benefits
Every Florida Blue qualified health plan sold on the marketplace includes the categories of care that federal law requires:
- Ambulatory (outpatient) services
- Emergency services
- Hospitalization, including surgery and overnight stays
- Pregnancy, maternity, and newborn care
- Mental health and substance use disorder services, including counseling and psychotherapy
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care for children
Birth control and breastfeeding support are also required.1Florida Blue. The Essentials Adult dental and vision care are not on this list, which is why they are not automatically part of a medical plan.
Preventive Care at No Cost
When you see an in-network provider, a long list of preventive services is covered with no copay, deductible, or coinsurance.2Florida Blue. Yearly Wellness Checkup That includes:
- Adult screenings for blood pressure, cholesterol, diabetes, HIV, hepatitis, and sexually transmitted infections, plus cancer screenings such as mammograms and colonoscopies
- Well-woman visits, FDA-approved contraception, prenatal visits, breastfeeding support, and breast pumps
- Well-child visits, standard immunizations, developmental and behavioral screenings, and lead and vision screenings
- Vaccinations across all ages: flu, pneumonia, Tdap, HPV, hepatitis A and B, shingles, and COVID-19
- Tobacco cessation, obesity counseling, and depression screening
One caveat matters at the billing desk. If your wellness visit turns into diagnosing or treating a specific problem, your provider can bill that part separately, and your copay or deductible may apply to that portion.2Florida Blue. Yearly Wellness Checkup
Prescription Drugs
Prescriptions are organized into tiers, and plans use anywhere from two to seven of them. A typical four-tier structure charges roughly $10 for generics, $25 for preferred brands, $50 for non-preferred brands after a $500 drug deductible, and $150 for specialty drugs after that same deductible.3Florida Blue. Coverage Requirements and Limitations
Three utilization rules can affect whether a given drug is covered or how much of it you can get. Some medications require prior authorization before the plan pays. Step therapy requires you to try a lower-cost alternative first. Quantity limits cap how much can be dispensed in a given time frame. These rules are updated quarterly.4Florida Blue. Medication Guide
Maintenance medications can be filled in 90-day supplies through home delivery. Select brand-name insulins run $0 to $5 for a 30-day retail supply, or $0 to $10 for a 90-day home delivery supply.3Florida Blue. Coverage Requirements and Limitations
Mental Health and Substance Use Treatment
Behavioral health coverage includes individual, family, and group therapy; outpatient, inpatient, and residential treatment for mental health conditions and substance use disorders; intensive outpatient programs; hospital-based care; and medication management.5Florida Blue. Substance Use Disorders Federal law requires that these limits be no more restrictive than those for medical care.6Florida Blue. Behavioral Health
Florida Blue uses Lucet to administer behavioral health. You can call Lucet to find a licensed therapist, psychologist, psychiatrist, or counselor, with appointments typically available within a week, in person or virtually.6Florida Blue. Behavioral Health Couples or marriage therapy is generally not covered unless it is tied to a diagnosable mental health condition for one of the participants.5Florida Blue. Substance Use Disorders
Maternity and Newborn Care
Pregnancy, labor, delivery, and postpartum care are all covered. Many providers bill a single global maternity fee that bundles routine prenatal visits, the delivery, and postpartum checkups together, while diagnostic tests and lab work are billed separately.7Florida Blue. Maternity Care
Covered services include prenatal screenings such as gestational diabetes testing, genetic screening, and ultrasounds; hospital stays for both vaginal and cesarean deliveries, including anesthesia; newborn assessments and vaccinations during the hospital stay; postpartum follow-up visits; breastfeeding support; and one breast pump per delivery. Doula services are not covered. For high-risk pregnancies, Florida Blue offers Healthy Addition, a no-cost nurse-support program. A newborn must be added to the plan within 30 days of birth.7Florida Blue. Maternity Care
Telehealth and Virtual Visits
Virtual care is covered for a range of non-emergency conditions, including colds, allergies, headaches, skin rashes, anxiety, depression, and minor injuries. You can connect by phone, video, or chat with primary care doctors, specialists, or mental health professionals, and many plans offer virtual primary care visits for as low as $0.8Florida Blue. Virtual Health
If your regular doctor does not offer virtual visits, Florida Blue contracts with Teladoc for 24/7 access to board-certified physicians, mental health appointments, and dermatology consults. Virtual visits with in-network providers cost the same as an in-person office visit of the same type. The $0 virtual visit benefit does not apply to HSA plans.9Florida Blue. Teladoc Virtual Visits Overview Flyer
Emergency and Urgent Care
Emergency room visits are covered under every Florida Blue plan. Federal law requires that emergency care be paid at in-network rates even when the hospital is out of network, and the No Surprises Act protects you from balance billing in emergency situations.10Memorial Healthcare System. Florida Blue Insurance Information
In-network urgent care is also covered, and some plans offer $0 or reduced copays at Value Choice urgent care locations for the first two visits of the year. Out-of-network urgent care is generally not covered unless you are receiving care out of state.11Florida Blue. Summary of Benefits and Coverage
Durable Medical Equipment
Florida Blue covers durable medical equipment that is medically necessary, prescribed by a physician, and appropriate for home use, such as wheelchairs, CPAP machines, and prosthetics. Many high-cost items require prior authorization, and equipment should be sourced from an in-network DME provider for best coverage. The plan reserves the right to decide whether renting or purchasing an item is more cost-effective. Equipment designed mainly for convenience or comfort, such as humidifiers or home fitness gear, is typically excluded.12Florida Blue. Durable Medical Equipment Coverage
What Requires Prior Authorization
Certain services must be approved by Florida Blue before they happen, or coverage can be denied. The categories that commonly require pre-approval include advanced imaging (CT, MRI, PET), certain injectable and oncology drugs, cardiology procedures, sleep studies, hip and knee surgeries, spine care, radiation oncology, and some outpatient procedures like cataracts and colonoscopies when performed in hospital outpatient settings.13Florida Blue. Prior Authorization for Medical Services Emergency services generally do not need prior authorization. Standard requests are decided within about 15 calendar days, urgent requests within 72 hours, and denials can be appealed.14Florida Blue. Prior Authorization – Providers
Dental, Vision, and Hearing
Adult dental and vision care are not essential health benefits, so a Florida Blue medical plan does not include them automatically. Standalone BlueDental plans cover at least two exams and cleanings per year at little or no cost in network, and BlueVision plans include an annual eye exam with a $10 copay.15Florida Blue. Dental and Vision Health Vision benefits are administered through Davis Vision and include eye exams, glasses, contact lenses, and discounts on second pairs and LASIK.16Florida Blue. Vision Insurance Pediatric dental and vision are included in medical plans as part of the essential health benefits.
Hearing aids are not covered under individual and family plans. Discount programs through Beltone and TruHearing are available to members.17Florida Blue. Hearing Aids
Coverage When You Travel
Emergency and urgent care are covered while you are out of state, as is any care Florida Blue has already pre-approved. The BlueCard Program lets you use participating providers in other Blue Cross and Blue Shield networks nationwide.18Florida Blue. Where to Get Care For international trips, Florida Blue directs members to Blue Cross Blue Shield Global Solutions for single-trip, multi-trip, and expat plans, and BlueCard Worldwide provides 24-hour international medical assistance, including referrals, translation, and case monitoring.19Florida Blue. National and International Coverage Comparison
What Florida Blue Does Not Cover
Exclusions are similar across plans and typically include:
- Cosmetic surgery and complications arising from it
- Experimental or investigational treatments
- Long-term custodial care focused on daily living assistance rather than medical treatment
- Weight loss programs, unless tied to a medically necessary treatment
- Routine foot care such as corn removal or toenail trimming, unless related to a condition like diabetes
- Work-related injuries, which fall under workers’ compensation
- Non-evidence-based treatments and off-label prescriptions
Adult dental and vision, as noted, are excluded from medical plans unless purchased separately. Some state employee plans also exclude infertility treatment and habilitation services.20Florida Blue. State of Florida Employees Standard PPO SBC 2025 Because exclusions vary by plan, your Summary of Benefits and Coverage document is the definitive source for your situation.21Florida Blue. What Is Health Insurance
How Plan Type Affects What Is Covered
The essential benefits list sets what is covered, but your plan type sets who you can see and how much you pay. HMO plans (myBlue) require a primary care physician and referrals, with no coverage outside the network except in emergencies. PPO plans (BlueOptions) let you see any provider without a referral, including out of network at higher cost. EPO plans (BlueSelect) do not require referrals but generally keep you in network. POS plans (BlueCare) use a primary care physician for coordination but still allow out-of-network care at higher cost.22Florida Blue. Types of Health Plans23Florida Blue. Individual and Family Products High-deductible versions of these plans pair lower premiums with higher deductibles and can be paired with a Health Savings Account; unused HSA funds roll over each year.
Medicare Coverage Through Florida Blue
Medicare members have separate options. Florida Blue sells Medicare Advantage plans in all 67 Florida counties in HMO and PPO formats, bundling everything Original Medicare covers with additional benefits.24Florida Blue. Florida Blue Medicare Releases 2026 Plan Options Those extras include dental, vision, and hearing coverage, SilverSneakers, over-the-counter medication allowances, and HealthyBlue Rewards of up to $100 for preventive screenings and healthy activities.25Florida Blue. Medicare Advantage Two 2026 standalone Part D plans use a six-tier formulary, and once you reach the $2,100 out-of-pocket threshold, covered Part D drugs drop to $0 under catastrophic coverage.26Florida Blue. Prescription Drug Plans Medicare Supplement plans are also available; under Plans G and N, for example, skilled nursing facility care for days 1 through 99, home health care, and hospice care all carry a $0 copay.27Florida Blue. Medicare Supplement Plan Comparison