Health care coverage: insulin.

Senators Wiener and Wahab spearhead a measure that anchors its core change in reducing the financial burden of insulin by imposing a $35 cap on copayments, coinsurance, deductibles, or other cost sharing for a 30‑day insulin supply in large‑group plans starting January 1, 2026, with the same cap applying to individual or small‑group plans beginning January 1, 2027, and by prohibiting step therapy as a prerequisite to insulin coverage. The authors frame the proposal as a direct response to rising insulin costs and access barriers for people who rely on the medication daily.

To implement these changes, the bill would amend the Health and Safety Code to require coverage for a broad set of diabetes management items and prescription medicines when medically necessary, including blood glucose monitors and testing strips, monitors designed for the visually impaired, insulin pumps and supplies, ketone testing strips, lancets, pen delivery systems, podiatric devices, insulin syringes, and visual aids; and it would require coverage for insulin, prescribed diabetes medications, and glucagon. Copayments and deductibles for these benefits would be limited to those established for similar benefits within the plan. For large‑group plans, at least one insulin for each drug type in all forms and concentrations would need to be on the formulary, and the 30‑day insulin cap would apply with tiered formularies limiting the cap to insulin in Tier 1 or Tier 2 for individual or small‑group plans; if no Tier 1 or 2 insulin is clinically appropriate, higher‑tier insulin would be capped at $35 for a 30‑day supply. The measure also prohibits step therapy for insulin coverage, with certain federal‑law‑driven allowances for FDA‑approved insulin types, and includes special considerations for high deductible health plans and state labeling of insulin.

The bill makes parallel amendments to the Insurance Code to require disability insurers issuing policies on or after January 1, 2000 to provide the same equipment, supplies, and prescription coverage when medically necessary, including the same list of devices and medications and the same cost‑sharing caps, formulary requirements, and step‑therapy prohibitions. It also obligates insurers to cover diabetes outpatient self‑management training, education, and medical nutrition therapy delivered by licensed professionals, with copays not exceeding those for physician office visits, and to disclose covered benefits in the policy’s evidences of coverage. As with health plans, the statute preserves prohibitions on reducing or eliminating coverage and notes exclusions for certain types of coverage, including vision‑only, dental‑only, accident‑only, specified disease, and some ancillary products, while aligning with existing regulatory frameworks.

The bill’s findings emphasize the prevalence of diabetes in California, the reliance on insulin for survival, and rising prices that contribute to underuse among those who need therapy. Authors assert that managing diabetes can prevent complications and costly emergency care, framing the policy as a means to constrain out‑of‑pocket costs while expanding access to essential management tools and services. The measure also situates itself within California’s regulatory structure by building on the Knox‑Keene Act for health plans and analogous provisions for insurers, while incorporating severability and a fiscal note process. Together, the provisions create a broad framework intended to align cost sharing, formulary practices, and access to diabetes management resources across large‑group, individual, and small‑group markets, with specified carve‑outs and implementation details that reflect current federal and state regulatory constraints.