医保门诊特定药品支付标准优化“更新”

Core Viewpoint - The Henan Province is optimizing its basic medical insurance outpatient specific drug payment standards, adding 66 new national negotiated drugs to the special drug management scope, and adjusting the payment standards for previously included drugs [1][2]. Group 1: New Drug Inclusion and Management - 66 national negotiated drugs will be included in the special drug management scope starting January 1, 2026, including drugs for cancer and rare diseases [2]. - The existing 295 special drugs will be reorganized, and some payment standards will be adjusted to ensure uniform execution across the province [2]. Group 2: Payment and Reimbursement Policies - Outpatient medical expenses for special drugs within the limit will be covered by the basic medical insurance without a threshold for payment [3]. - Special drug expenses will count towards the annual maximum payment limit of the basic medical insurance fund [3]. Group 3: Special Drug Management Classification - Special drugs are categorized into three classes based on their usage: urgent care drugs, long-term treatment drugs, and those with broad indications [4]. - For urgent care drugs, patients may receive treatment first and submit reimbursement claims later under specific conditions [4]. Group 4: Treatment Cycle and Institutional Management - The treatment cycle for special drugs is generally one year, with procedures in place for continuing treatment if necessary [5]. - Designated medical institutions for special drugs will be determined by each insurance area, ensuring proper oversight [5]. Group 5: Inter-Region Recognition of Benefits - Special drug benefits will be mutually recognized across the province, allowing for seamless transitions for insured individuals moving between different insurance areas [7]. - Patients can change to different formulations of the same drug without reapplying, provided they meet certain conditions [7].