California manufacturing their own insulin is one hell of a market disruption and a much better alternative to a copay cap. The $35/mo cap looks good on paper but it's nothing more than a cost shift to the plan sponsor. The PBM is not going to willingly eat that cost even though they get kickbacks on the list price from Sanofi, Eli Lilly, and the other manufacturers. Plan sponsors already pay below acquisition for brand name drugs and it's one of the reasons why we're dropping TRICARE at the end of the year. My patients love the dirt cheap copays but I can't subsidize them at the same time they use a health plan funded by the government that refuses to tell the pharmacy the source of their price tables on the basis that it's proprietary.
Here's an example I can use to relate what I'm talking about. Let's say you own a home and you have a major foundation issue. Your home insurance company says they'll cover it but completed repairs can only be authorized at their contractor negotiated price of $2,000. You talk to every contractor in your zip code and the ones around it and they're all telling you that this repair is minimum $15,000. You call the insurance company to ask them where you can find this contractor who will do it for $2,000 and they tell you "Sorry, that's proprietary information. You'll just have to keep searching for that contractor we negotiated with. He's out there somewhere!". Health plans won't even give us the names of wholesalers where they contracted with to get medication prices. They don't have to give us their contract terms but they won't even give us the name of the companies where they derived this price list from. It's one of the reasons why I love the Cost Plus/Blueberry Pharmacy model. The price at the point of sale is the price of the drug. No kickbacks, no negotiated rebates, none of that stuff. If California ends up doing something like that, there will be people begging to get involved whether as a patient or a provider.