四问首版商保创新药目录

Core Viewpoint - The release of the first commercial health insurance innovative drug directory in China, which includes 19 innovative drugs, marks a significant step in building a multi-tiered medical security system, set to be implemented on January 1, 2026 [1] Group 1: Purpose of the Innovative Drug Directory - The establishment of the commercial health insurance innovative drug directory aims to alleviate the financial burden on patients by allowing high-value innovative drugs, which are not included in basic medical insurance, to be compensated through commercial health insurance [2] - This directory provides a clear policy interface and guidance on the range of drugs for commercial health insurance to participate in innovative drug coverage [2] Group 2: Focus Areas of the First Batch of Drugs - The first batch of 19 drugs comes from 18 companies, primarily focusing on new mechanisms and targets, including 9 first-class new drugs, which complement the basic medical insurance directory [3] - The drugs cover treatments for rare diseases such as CAR-T cell therapy, Gaucher disease, short bowel syndrome, and neuroblastoma, filling gaps in the current basic medical insurance coverage [3] Group 3: Understanding the "Three Exclusions" Principle - The "Three Exclusions" principle allows related drugs to be exempt from basic medical insurance self-payment rate assessments, excluded from monitoring for alternative products in centralized procurement, and their usage cases are not included in disease-based payment statistics [4] - This policy alleviates concerns for medical institutions regarding the use of innovative drugs, enabling patients to obtain these drugs directly in hospitals and settle through commercial insurance, thus enhancing drug accessibility [4] Group 4: Direct Benefits to Consumers - The release of the commercial health insurance innovative drug directory is expected to promote existing products like inclusive commercial health insurance, million medical insurance, and special drug insurance, making it easier for patients to access high-value drugs and receive compensation through commercial insurance [5] - Insurance companies benefit from a negotiated discount mechanism on the prices of drugs in the directory, which helps reduce their claims costs, and the directory provides a vetted list of drugs, lowering the selection and risk management costs in product design [5] - Cities like Beijing, Shanghai, and Guangzhou are exploring one-stop settlement services combining medical insurance and commercial insurance, which is expected to further enhance claims efficiency and user experience [5]