Health care coverage: insulin.

Senators Wiener and Wahab propose new limits on insulin costs for Californians, capping monthly out-of-pocket expenses at $35 per 30-day supply through amendments to state health plan and insurance regulations. The legislation phases in cost-sharing restrictions, with large group plans implementing caps in 2026 and individual/small group plans following in 2027.

The bill eliminates step therapy requirements for insulin coverage and mandates that health plans include at least one insulin option for each drug type in their formularies. For tiered prescription plans, the $35 cap applies to Tier 1 and Tier 2 insulin medications, though plans must ensure access to higher-tier options at the capped rate when clinically necessary.

These provisions build upon existing requirements for diabetes care coverage, maintaining mandates for supplies like blood glucose monitors, testing strips, and insulin pumps. The legislation includes exemptions for high-deductible health plans when federal regulations require maintaining deductibles for insulin coverage. Health plans must continue providing diabetes self-management training and medical nutrition therapy through licensed professionals, with cost-sharing for these services remaining aligned with standard physician visit rates.