南方财经全媒体记者 孙诗卉 实习生 徐若萱 2025年12月7日，国家医保局与人力资源社会保障部联合发布了《国家基本医疗保险、生育保险和工伤保险药品目录（2025年）》（以下简称 2025年医保目录）及首版《商业健康保险创新药品目录》（以下简称《商保创新药目录》），两份目录均将于2026年1月1日起正式实施。 作为构建多层次医疗保障体系的里程碑事件，业内人士表示，此次"双目录"的同步发布，意味着我国医药支付体系正式进入"基本医保+商业健 康险"双轮驱动的新阶段。 长期以来，商业健康险在特药责任设计上存在"专业性不足"的痛点。资深从业者迈伦向21世纪经济报道记者指出，保险公司缺乏药物经济学专 家，自行制定目录难度极大。此次《商保创新药目录》的制定相当于为保险行业提供了一份官方背书的、高质量的"药品池"，极大地降低了产 品开发的准入门槛和信息不对称风险。 对于消费者而言，这一政策不仅夯实了基础用药的保障底线，更使得此前因价格高昂而难以企及的百万级CAR-T疗法、前沿阿尔茨海默病药物 等高值创新药，有了实质性的支付解决方案。 承接医保"溢出"创新药支付需求 长期以来，我国创新药商业化面临着"进院难、支付难"的结构性 ...

Core Viewpoint - The introduction of a dual-track payment system for innovative drugs in China, combining basic medical insurance and commercial health insurance, marks a significant shift in the industry, providing a structured approach to address the payment challenges faced by high-priced innovative drugs [2][5][34]. Summary by Sections Introduction - The release of the new medical insurance directory and the first commercial health insurance directory for innovative drugs signifies the establishment of a dual-track payment system in China [2]. Innovative Drug Payment Mechanism - The reliance on a single payment channel through medical insurance has become unsustainable due to rising costs and the increasing number of high-priced innovative drugs [5]. - The latest medical insurance directory adds 114 new drugs, with 50 being class 1 innovative drugs, achieving a negotiation success rate of 88%, the highest ever [5]. Commercial Health Insurance Directory - The first commercial health insurance directory includes 19 high-value innovative drugs, providing a structured payment pathway for drugs previously excluded from medical insurance [8][20]. - This directory signals a shift in the payment structure, where both basic medical insurance and commercial insurance will share the payment responsibilities for innovative drugs [8][21]. Challenges in Medical Insurance - Despite the expansion of the medical insurance directory, high-priced innovative drugs still face significant barriers to entry due to strict cost-effectiveness evaluations and negotiation mechanisms [10][11]. - The trend indicates that medical insurance is moving towards risk control rather than merely expanding coverage [10][16]. Filling the Payment Gap - The introduction of the commercial health insurance directory is a necessary response to the limitations of the medical insurance system, providing a payment avenue for high-value drugs that have been excluded [18][21]. - The directory includes drugs with high clinical value and costs, addressing the long-standing payment vacuum in the market [18][20]. Growth Opportunities for Innovative Drugs - The commercial health insurance directory opens new growth avenues for high-priced innovative drugs, allowing for a broader patient reach and a more structured payment approach [23][24]. - The directory is expected to enhance the commercial health insurance market, with high-value innovative drugs becoming a core differentiator in product offerings [24]. Structural Bottlenecks for Commercial Health Insurance - There are significant barriers to the short-term adoption of the commercial health insurance directory, including data insufficiency, product risk acceptance, and user payment behavior [28][29][30]. - The lack of real-world data on innovative drug usage complicates pricing and risk assessment for insurance companies [29]. Conclusion - The dual-track payment system represents a structural change in the payment landscape for innovative drugs, but challenges remain in achieving widespread accessibility and effective implementation [34][35]. - The commercial health insurance system is expected to play an increasingly important role in providing payment solutions for innovative drugs, although it will take time to fully realize its potential [36].

复旦大学公共卫生学院副院长、复旦大学医学技术评估研究中心教授陈英耀表示："对于创新药物和疗 法，国家政策是鼓励为有价值的创新买单。多层次医疗保障体系建设的工作持续推进，商业健康保险也 为创新药支付提供了更丰富和多元的支持路径。" 这也映射着我国多层次医疗保障体系在创新药可及性领域迈出的重要一步。自今年起，国家医保部门首 次探索"商业健康保险"联动医保目录机制，聚焦创新程度高、临床价值大、患者获益显著的药物，旨在 通过医保与商业险的协同发力，进一步提高人民群众对重大疾病创新疗法的可负担性和可及性。 无论是卫材公司的仑卡奈单抗还是礼来的多奈单抗，患者一年的治疗费用均需超过10万元。高昂的治疗 费用一度让不少阿尔茨海默病（AD）患者家庭在希望与绝望间徘徊，直到首版商保创新药目录为这种 困境带来了转机。 日前，在2025创新药高质量发展大会上，我国首版《商业健康保险创新药品目录》正式发布。两款近年 来最具突破性的阿尔茨海默病对因治疗药物——仑卡奈单抗注射液和多奈单抗注射液双双入选。 有券商医药行业分析师也对21世纪经济报道记者指出，此次多奈单抗（记能达®）、仑卡奈单抗（乐意 保®）纳入首版商业保险创新药目录，标志着A ...

无论是卫材公司的仑卡奈单抗还是礼来的多奈单抗，患者一年的治疗费用均需超过10万元。高昂的治疗 费用一度让不少阿尔茨海默病（AD）患者家庭在希望与绝望间徘徊，直到首版商保创新药目录为这种 困境带来了转机。 日前，在2025创新药高质量发展大会上，我国首版《商业健康保险创新药品目录》正式发布。两款近年 来最具突破性的阿尔茨海默病对因治疗药物——仑卡奈单抗注射液和多奈单抗注射液双双入选。 复旦大学公共卫生学院副院长、复旦大学医学技术评估研究中心教授陈英耀表示："对于创新药物和疗 法，国家政策是鼓励为有价值的创新买单。多层次医疗保障体系建设的工作持续推进，商业健康保险也 为创新药支付提供了更丰富和多元的支持路径。" 这也映射着我国多层次医疗保障体系在创新药可及性领域迈出的重要一步。自今年起，国家医保部门首 次探索"商业健康保险"联动医保目录机制，聚焦创新程度高、临床价值大、患者获益显著的药物，旨在 通过医保与商业险的协同发力，进一步提高人民群众对重大疾病创新疗法的可负担性和可及性。 面对医保目录"保基本"的定位与突破性创新药高昂价格之间的矛盾，国家医保局作出了制度性回应。 今年6月30日，国家医保局会同国家卫生健康委 ...

Core Insights - The Chinese innovative drug sector is experiencing significant opportunities, with a surge in business development (BD) transactions and supportive policies for commercial health insurance [1][2] Group 1: Business Development Transactions - The total amount of external licensing transactions for innovative drugs in China is expected to reach nearly $66 billion in the first half of 2025, surpassing the total of $51.9 billion for the entire year of 2024, indicating BD's role as a major growth accelerator for the industry [1] - The current period is characterized as a "harvest season" for BD transactions in the innovative drug sector [1] Group 2: Policy Support for Innovative Drugs - The National Financial Regulatory Administration released guidelines on September 30 to promote high-quality development of health insurance, emphasizing flexible and effective payment support for innovative drugs and devices [1] - The establishment of a commercial insurance innovative drug directory, led by the National Medical Insurance Administration, aims to create a "second channel" for innovative drug payments, with the first version of expert review results already published [1] Group 3: Challenges in Payment Systems - Experts highlight that the diversification of drug payment solutions, while alleviating economic burdens on patients, has introduced challenges such as inconsistent application processes and settlement cycles across different payment channels [1] - Traditional commercial insurance claims processes are complicated, with issues like excessive documentation, long waiting periods, and significant upfront payment pressures on patients [1] Group 4: Innovations in Payment Solutions - The industry is accelerating innovation, with a focus on one-stop settlement solutions for medical insurance and commercial insurance [2] - Ping An Group has developed "Ping An Medical Health Payment," the first product in China utilizing medical insurance data for seamless claims processing, eliminating the need for patients to make upfront payments [2] - The "One Code Direct Payment" platform by Meixin Health expands the direct payment network to major hospitals nationwide, integrating various payment methods into a single interface, significantly simplifying the payment process for patients [2] Group 5: Systematic Development of Payment Framework - The trend of policy guidance and platform integration signifies a new phase in the construction of the innovative drug payment system, transitioning from mere policy guidance to systematic and institutional development [3] - Third-party management platforms, already a mature model in international commercial health insurance, are expected to provide standardized services in areas such as eligibility verification, medication management, payment settlement, compliance tracking, cost control, and fraud prevention [3]

Core Insights - The National Healthcare Security Administration (NHSA) has released the initial review list for the "Commercial Insurance Innovative Drug Directory," marking a significant step in integrating commercial insurance with the national medical insurance system [2][3] - The list includes various high-value innovative drugs, such as CAR-T therapies and rare disease medications, which are expected to enhance market confidence and improve patient outcomes [2][6] Group 1: Commercial Insurance Directory - A total of 141 applications were received for the commercial insurance innovative drug directory, with 121 drug names passing the initial review [3] - The directory features expensive high-value innovative drugs, including CAR-T therapies, which have an average price in the million yuan range [3][4] - Some CAR-T products are being submitted for both basic medical insurance and commercial insurance, providing a second chance for reimbursement if they fail in the first round [4][5] Group 2: Rare Disease Medications - The commercial insurance directory includes 51 products for 52 rare diseases, potentially allowing patients to access previously unaffordable "orphan drugs" through commercial insurance [6] - The example of nusinersen for spinal muscular atrophy (SMA) illustrates the significant cost reduction from nearly 700,000 yuan to approximately 33,000 yuan after entering the insurance system [6] - The number of rare disease drugs in China is expected to increase, with 210 drug development pipelines projected for 2024, 38% of which are in Phase III clinical trials [6][7] Group 3: Market Dynamics and Future Outlook - The integration of commercial insurance with the national medical insurance system is seen as a flexible approach to facilitate access to high-value innovative drugs [7] - The expected results from national negotiations on drug pricing will be announced between October and November 2025, while the commercial insurance directory is set to be finalized by the end of September [7] - The evolving landscape indicates a narrowing gap between the availability and affordability of innovative treatments for patients [7]

Group 1 - The Hong Kong innovative drug sector is experiencing significant growth, with the Hang Seng Hong Kong Stock Connect Innovative Drug Index rising by 4.1% as of 14:55, and notable increases in individual stocks such as CanSino Biologics-B up over 9%, Innovent Biologics up over 8%, and Lepu Biopharma-B up over 7% [1] - The National Healthcare Security Administration announced the approval of 534 drugs for the 2025 National Basic Medical Insurance, Maternity Insurance, and Work Injury Insurance drug list, marking a record high. Additionally, 121 out of 141 drugs in the newly established commercial insurance innovative drug list passed the review, achieving a pass rate of over 80% [1] - The innovative drug payment system is rapidly taking shape, attracting market attention towards investment opportunities in the industry. The recent revision of the Hang Seng Hong Kong Stock Connect Innovative Drug Index excludes CXO companies, resulting in a "pure" innovative drug index with a 100% purity rate [1] Group 2 - The Hang Seng Innovative Drug ETF (159316) is currently the only product tracking this index, with a net inflow of 540 million yuan in the past month, doubling its size to 1.17 billion yuan compared to a month ago, providing investors with precise opportunities for industry development [2]

Core Viewpoint - The evolution of commercial health insurance paradigms will reshape product and service models, enhancing its role in the innovative drug protection system, as outlined in the "Several Measures to Support the High-Quality Development of Innovative Drugs" released by the National Healthcare Security Administration and the National Health Commission on July 1, 2025 [1] Group 1: Positioning and Responsibilities - The "Several Measures" clarify the functional positioning and responsibilities of basic medical insurance and commercial health insurance in the innovative drug payment system, emphasizing that commercial health insurance will take on the mission of high-value protection [2][3] - The current structure of "惠民保" (benefit insurance) is limited by its design and funding, which restricts its ability to provide sustainable high-value drug protection, as it primarily operates within the basic medical insurance framework [2][3] Group 2: Payment System Optimization - The "Three Exclusions" mechanism proposed in the "Several Measures" provides a clear path for commercial health insurance to participate in the innovative drug payment system, allowing for the payment of self-funded drugs by commercial insurance [4][5][6] - The mechanism includes exemptions from basic medical insurance self-funded rate indicators, exclusion from centralized procurement monitoring, and the ability for certain drugs to be independently funded by commercial health insurance after review [4][5][6] Group 3: Transformation of Commercial Health Insurance - The "Several Measures" drive a transformation of commercial health insurance from a traditional risk manager to a medical value integrator, prompting a systemic overhaul of product logic, pricing mechanisms, and service models [7] - The evolution includes a shift from insuring only healthy individuals to covering those with pre-existing conditions, enhancing inclusivity in the insurance system [7] - There is a move towards more precise product design, allowing for tailored coverage based on disease classification, treatment pathways, and patient characteristics [7][8] Group 4: Internationalization and Global Market Opportunities - The "Several Measures" signal support for market-oriented payment mechanisms, creating opportunities for the internationalization of commercial health insurance alongside the export of Chinese innovative drugs [9][10] - The flexibility of commercial health insurance allows for collaboration with reinsurance companies and local payers to implement innovative drug protection solutions abroad, enhancing accessibility [9][10]

Core Insights - The article discusses the financial burden of innovative cancer treatments in China, highlighting the challenges patients face in affording these high-cost medications, which can reach hundreds of thousands of yuan annually [1][2] - The "White Paper on Multi-Payment for Innovative Drugs and Devices (2025)" indicates that in 2024, China's innovative drug sales are expected to reach 162 billion yuan, with a significant portion of costs falling on patients and limited contributions from commercial health insurance [1][2][5] Payment Structure - In 2024, the expected sales of innovative drugs in China will be 162 billion yuan, with the medical insurance fund covering approximately 71 billion yuan (44%), personal cash payments around 78.6 billion yuan (49%), and commercial health insurance contributing only 12.4 billion yuan (7.7%) [1][2][5] - The current payment structure shows a high burden on individuals and insufficient support from commercial health insurance, which is critical for the sustainable development of innovative drugs [2][5] Role of Commercial Health Insurance - The article emphasizes that while "Hui Min Bao" (a popular supplementary insurance) has grown rapidly, it primarily covers basic medical expenses and has limited capacity to support high-value innovative drugs due to its low premium structure [3][5][6] - Experts suggest that commercial health insurance needs to expand its coverage and payment capabilities to alleviate the financial burden on patients and support the innovative drug industry [4][6][10] Policy Developments - Recent measures from the National Medical Insurance Administration aim to enhance the role of commercial health insurance in supporting innovative drugs, proposing a multi-layered payment system that includes charity donations and mutual aid [8][9] - The "Three Exclusions" policy allows commercial health insurance to cover innovative drugs without being counted against basic medical insurance metrics, thus providing more flexibility for hospitals and insurers [9][10] Future Directions - The article suggests that the future of innovative drug payments will involve a collaborative model where basic insurance covers essential drugs, supplementary insurance addresses high-value drugs, and commercial health insurance fills the gaps [6][10] - As Chinese innovative drugs gain international approval, there is potential for cross-border insurance products to support these drugs in overseas markets, although challenges remain in terms of recognition and reimbursement [17][19]

Core Viewpoint - China's pharmaceutical innovation is undergoing a historic transformation, driven by the collaboration of medical insurance, healthcare, and pharmaceutical sectors, aiming to shift from a "generic drug powerhouse" to an "innovative drug stronghold" [1] Group 1: Policy Measures - The National Healthcare Security Administration and the National Health Commission released measures to support high-quality development of innovative drugs, marking a significant step in China's healthcare strategy [1][2] - A series of policy documents were issued to establish a pricing negotiation process for innovative drugs, indicating a strategic arrangement for a multi-tiered medical security system [2] Group 2: Market Dynamics - In 2024, China's basic medical insurance fund had a total income of 34,809.95 billion yuan and total expenditure of 29,675.92 billion yuan, with commercial health insurance covering less than 8% of innovative drug costs [3] - The innovative drug market in China is projected to reach 1,620 billion yuan, highlighting the underutilization of commercial health insurance in supporting innovative drug development [3] Group 3: Insurance and Pharmaceutical Collaboration - The guidelines for the insurance directory focus on "clinical value-cost effectiveness," encouraging pharmaceutical companies to shift from "Me-too" to "First-in-class" drug development [4] - The establishment of a commercial health insurance directory for innovative drugs aims to alleviate the financial burden on basic medical insurance while providing new payment channels for innovative drugs [4][5] Group 4: Benefits of the New Framework - The new insurance directory benefits pharmaceutical companies by expanding patient access and accelerating capital recovery for further innovation [5] - Commercial insurance companies can leverage shared information from medical insurance to expand their health insurance business at lower costs, ultimately benefiting patients by reducing medical expenses [5] Group 5: Future Directions - The dynamic adjustment of the commercial health insurance directory and pricing mechanisms represents a process of balancing interests among various stakeholders, including patients, pharmaceutical companies, and insurance providers [6] - The integration of medical insurance and commercial health insurance is expected to evolve towards a collaborative regulatory framework, enhancing the overall healthcare system in China [8]