医保“双目录”！2025年医保目录调整：首度纳入商保创新药目录！推同步结算、数据协同...

Core Viewpoint - The article discusses the introduction of a "Commercial Insurance Innovative Drug Directory" as part of the 2025 medical insurance directory adjustment, marking the beginning of a dual-directory era for medical insurance and commercial health insurance in China [1][10][11]. Group 1: Introduction of the Dual-Directory System - The 2025 medical insurance directory will for the first time include a "Commercial Insurance Innovative Drug Directory," allowing innovative drugs that are not covered by medical insurance to be reimbursed by commercial insurance [2][10]. - This adjustment aims to clarify the boundaries of basic medical insurance coverage and enhance the collaboration between commercial health insurance and basic medical insurance [21][24]. Group 2: Features of the Commercial Insurance Innovative Drug Directory - The "Commercial Insurance Innovative Drug Directory" will focus on innovative drugs that have high innovation levels, significant clinical value, and substantial patient benefits, which exceed the coverage of basic medical insurance [24]. - The directory will allow companies to apply for inclusion in either the medical insurance directory or the commercial insurance directory, or both simultaneously [27][28]. Group 3: Payment and Collaboration Mechanisms - The article highlights the importance of synchronizing settlements and data collaboration between medical insurance and commercial health insurance, facilitating a smoother reimbursement process for patients [4][39]. - The introduction of the "three exclusions" support for the commercial insurance innovative drug directory will ensure that these drugs are not subject to certain basic medical insurance metrics, allowing for more flexible pricing negotiations [31][32]. Group 4: Growth of Commercial Health Insurance - Since 2014, the commercial health insurance sector has experienced rapid growth, with premium income reaching 97.73 billion by the end of 2024, more than six times the amount from a decade ago, reflecting a compound annual growth rate of approximately 20% [41]. - The article notes that the claims for medical insurance have also seen significant increases, with medical claims accounting for 44% and critical illness claims for 36% of total payouts in 2024 [43].