商保创新药目录调整申报启动 以协商机制推动多方联动

Core Viewpoint - The National Healthcare Security Administration (NHSA) has officially initiated the adjustment application process for the 2025 National Basic Medical Insurance, Maternity Insurance, and Work Injury Insurance drug catalog, along with a newly established commercial health insurance innovative drug catalog [1][2]. Group 1: Policy Implications - The inclusion of commercial health insurance in the national drug catalog system marks a significant breakthrough in China's multi-tiered medical security system, providing a regulatory foundation for commercial health insurance to enhance the accessibility of innovative drugs [5]. - The new commercial insurance catalog emphasizes a negotiation mechanism centered on information symmetry and professional support, which is crucial for collaboration between pharmaceutical companies and insurance providers regarding drug value recognition, pricing logic, and risk assessment [6]. Group 2: Innovative Drug Coverage - The "2025 China Innovative Drug and Medical Device Multi-Payment White Paper" indicates that currently, disease insurance accounts for 50% of commercial insurance payouts for innovative drugs, with million medical insurance at 22%, and other types making up the remainder [7]. - The key to designing products is to incorporate innovative drugs into a "sustainable protection structure" rather than treating them as merely high-priced medications [7]. Group 3: Recommendations for Improvement - Industry experts suggest focusing on three areas: introducing real-world evidence and stratified population data for better identification of payee groups, creating a combination of "basic insurance + commercial insurance + pharmaceutical company co-payment," and standardizing and automating the process from drug catalog to claims rules through a platform mechanism [7]. - There is a call for enhancing patient experience, process transparency, and claims efficiency as part of the catalog evaluation criteria to ensure that the catalog is accessible, implementable, and efficient in claims processing [8].