每经记者｜甄素静 每经编辑｜陈俊杰 "今年是商保创新药目录首次评审，无论医保局还是评审专家都极为认真谨慎，特别是罕见病用药是评 审中关注的重点领域。"近日，对外经济贸易大学保险学院副院长孙洁对《每日经济新闻》记者表示。 为了让更多参保人能够及时用上新上市的创新药，今年除了基本医保目录调整外，还新增了商保创新药 目录，主要用于纳入超出保基本定位、暂时无法被纳入基本目录，但创新程度高、临床价值大、患者获 益显著的创新药。 近日，2025年国家医保目录调整首次增设的商保创新药目录进入关键评审阶段，55个药品进行投票评 审；投票后，最终会筛选出25~30个药品进入下一步协商定价环节，其中涵盖多款罕见病特效药与CAR- T疗法等高价创新药。作为此次商保创新药目录评审专家，孙洁详细介绍了目录评审的过程、规则，以 及对罕见病用药的影响。 一类新药会获得倾斜，药品价格与成本测算是重要环节 商保创新药目录可以理解为基本医保目录的"补充"，一些基本医保暂时不能报销的创新药将有望纳入， 弥补基本医保目录的空白，为参保人健康保障"加码"。在药品申报方面，在5年内批准上市的新通用名 或治疗罕见病的独家药品均可申报商保创新药目录。企业可 ...

Core Viewpoint - The National Healthcare Security Administration (NHSA) has completed the expert review for the 2025 National Basic Medical Insurance (BMI) catalog and the commercial insurance innovative drug catalog, marking the eighth adjustment since its establishment and the first inclusion of a commercial insurance innovative drug catalog [1][2]. Group 1: CAR-T Products Approval - Five CAR-T products have successfully passed the expert review and will be included in both the basic medical insurance and commercial insurance innovative drug catalogs, laying the groundwork for future negotiations and access [1][2]. - The approval of these CAR-T products is seen as a positive signal, indicating the regulatory body's commitment to improving access to cutting-edge therapies [1][3]. - The review process emphasized the innovation level, efficacy, and the ability to fill treatment gaps, with CAR-T therapies receiving unanimous approval [2][5]. Group 2: Impact on Patients and Companies - The introduction of the commercial insurance innovative drug catalog is expected to significantly reduce out-of-pocket expenses for patients, making high-cost CAR-T treatments more accessible [3][4]. - Companies view the catalog as a "second channel" for innovative drugs, alleviating pricing pressure during negotiations with basic medical insurance and potentially expanding market share [4][5]. - The collaboration between pharmaceutical companies and insurance providers is anticipated to evolve towards deeper cooperation, exploring mechanisms like outcome-based payments and risk-sharing [4][5]. Group 3: Future Outlook - Companies express cautious optimism regarding the inclusion of CAR-T products in the commercial insurance innovative drug catalog, supported by policy direction, clinical value, and practical experience [5][6]. - The ongoing expansion and optimization of the commercial insurance catalog are expected to further benefit patients in need of CAR-T therapies [6].

自2018年国家医保局成立，今年是国家医保谈判（下称"国谈"）常态化开展以来的第八个年头，今年亦 首次增设商业健康保险创新药品目录（下称"商保创新药目录"）。这一举措，为创新程度高、临床价值 大、患者获益显著，但因超出"保基本"定位暂时无法纳入基本目录的药品，增添了新选择。 专家评审结果公布当日，正值2025第十四届中国罕见病高峰论坛在武汉举办。与会者不仅聚焦罕见病立 法、多元支付等话题，亦对商保创新药目录的出台能否进一步解决罕见病支付端的难题进行了诸多探 讨。 武汉大学董辅礽经济社会发展研究院教授，武汉大学全球健康研究中心主任毛宗福指出，全球范围来 讲，罕见病用药治疗更多是政府主导的保障体系，国民健康保障支撑体系也是在多层次保障体系当中去 解决。从目前来看，中国的罕见病用药支付一部分靠基本医保的过渡和衔接，同时在商保创新药目录中 提供特殊的规则，促使商保跟上商保创新药目录的进展和节奏，在管理体系上、运营模式上也在做调整 和迭代。他认为，对于有药可治的，尤其是创新程度高、临床价值大，而且患者的获得感比较强的这一 部分罕见病用药，应该会比较快进展。 一位参与2025年国家基本医保目录及商保创新药目录评审环节的人 ...

一位参与本次商保创新药目录评审的专家向经济观察报介绍，本次专家评审由医保局主持召集，其中包 括医保局、保司、高校、第三方技术公司等不同领域人士。总体来说，经专家评审筛选出来的药品比例 不高，但覆盖面较广，有几类创新药会被优先考虑纳入商保创新药目录，例如已纳入地方惠民保和商业 健康险的药品、一类创新药、创新程度高且患者获得感较强的药品等。 多位专家告诉经济观察报，5款CAR-T药物均通过了专家评审。CAR-T药物以"天价"闻名，每针的价格 在100万元左右，即便叠加各种优惠，每针价格也在50万元左右。此前，CAR-T药物曾多次尝试进入基 本医保目录，均失败。 商保创新药目录需要经过多轮专家评审。一位专家透露，他参与评审时，拿到的名单里共有55个药品， 已不足通过形式审查名单的一半，这些药品还需要继续被筛选。他估计，创新药目录专家评审环节，最 终通过的药品会在30个以下。 9月20日，国家医保局公告，2025年国家基本医保目录及商保创新药目录调整专家评审工作已结束。 2025年是国家医保局成立以来第8次进行医保目录调整，也是首次在基本医保目录之外增设商保创新药 目录。 据8月12日国家医保局公布的名单，2025年 ...

专家评审结束之后，将进入谈判/竞价/价格协商阶段，在这个阶段，企业需要提交相关材料，国家医保 局将开展测算评估，组织专家通过职工/居民医保基金测算、药物经济学等方法开展评估，提出基本目 录医保支付标准的评估意见。 同时也要加强与企业的信息沟通。就药品测算评估的思路和重点与企业进行面对面沟通，收集企业意见 建议和诉求。 9月20日上午，国家医保局发布公告，2025年国家基本医保目录及商保创新药目录调整专家评审工作已 结束，医保局将于近期在北京组织召开企业现场沟通会，与拟谈判、竞价及价格协商企业进行面对面交 流。 今年的医保目录调整是国家医保局成立以来进行的第8次，也是首次在基本医保目录之外增设商保（商 业健康保险）创新药目录。 今年共有534个药品通过基本医保目录的形式审查，121个药品通用名通过商保创新药目录的形式审查， 包括定价百万元的抗癌药CAR-T（嵌合抗原受体T细胞）在内，多款高价创新药冲刺商保创新药目录， 寻求创新药多元支付的新途径。 国家医保局公告称，评审结果为"拟谈判新增""拟竞价新增""拟价格协商"的目录外药品，表明该药品被 纳入了2025年国家基本医保目录及商保创新药目录谈判/竞价/价格协商 ...

Core Points - The National Healthcare Security Administration (NHSA) announced changes to the drug list for basic medical insurance, with six drugs undergoing form review changes, including two drugs that did not pass the review [1][3] - The two drugs that failed the review are injectable risperidone microspheres and injectable triptorelin, both of which are exclusive products from Zhejiang Shengzhao Pharmaceutical Co., Ltd. and Ipsen, respectively [2][3] - The injectable risperidone microspheres have a global market size of $490 million in 2022, with expectations to reach 920 million yuan in China by 2030 [3] Drug Review Changes - Six drugs had their form review results changed, with injectable risperidone microspheres and injectable triptorelin being excluded from the basic medical insurance directory [3][4] - Injectable risperidone microspheres, approved in February 2023, is the first generic version in China for treating mental disorders, while injectable triptorelin was approved in 2023 for treating precocious puberty and prostate cancer [3][4] Commercial Health Insurance Innovations - The newly established commercial health insurance innovative drug directory has gained attention, with 121 drugs passing the form review, including CAR-T and nuclear medicine therapies [5] - CAR-T therapy has faced challenges in entering the insurance directory due to high costs, but five CAR-T products have now passed the form review for the commercial health insurance directory [5] - Nuclear medicine, known for its precision in targeting cancer cells, has also seen several products approved, including technetium-99m and fluorine-18 labeled drugs [6] Future Developments - Negotiations and price discussions for the drug directory adjustments will take place from September to October, with results expected to be announced in November [7]

智通财经APP获悉，港股恒生指数涨0.63%，涨158点，报25156点；恒生科技指数涨0.56%。港股早盘成 交1841亿港元。 中信证券近期研报指出，国家医保局启动商保创新药目录调整工作，标志着商保创新药目录进入实质性 落地阶段。医疗健康产业有望迎来戴维斯双击，估值体系有望重塑。恒生生物科技指数涨3.73%。成份 股中，微创机器人-B（02252）涨8%；信达生物（01801）涨超7%；药明生物（02269）涨6.7%；石药 股份（01093）涨超6%。 黄金股集体走高，近期金价迎来多重催化，多家黄金矿企中报亮眼。中国黄金国际(02099)涨10%；赤峰 黄金(06693)涨6.97%；招金矿业(01818)涨5.98%。 国泰君安国际(01788)涨超15%，公司正式在香港地区推出加密货币交易服务。 荣昌生物(09995)再涨超13%，核心产品放量带动营收高增，上半年亏损同比显著收窄。 阜博集团(03738)涨8.65%，上半年盈利同比翻倍增长，公司强化订阅与增值双引擎。 瑞浦兰钧(00666)涨6%，公司携手阪和兴业株式会社，正式布局日本储能市场。 科笛-B(02487)涨超21%，战略调整拖累上半年 ...

Core Insights - The high cost of innovative drug treatments, such as CAR-T cell therapy, is a growing concern for patients and their families, with single treatment costs exceeding one million yuan [1][2] - There is an increasing societal focus on ensuring that expensive innovative drug treatments do not hinder patient access to necessary care [2][3] Payment System Development - The establishment of a sustainable and efficient payment system is crucial for the widespread application of innovative drugs [2][3] - Recent government policies aim to support the inclusion of innovative drugs in basic medical insurance and commercial health insurance directories, enhancing payment capabilities [2][12] - The multi-payment system for innovative drugs includes commercial health insurance, charity funds, and high-end medical insurance, which helps reduce the financial burden on patients [2][3] Market Growth and Trends - China's innovative drug market reached approximately 162 billion yuan in 2022, with a year-on-year growth of 16% [4] - The trend of new drugs being launched in China has increased significantly, with 29% of new drugs debuting in China in 2023, up from 9% in 2017 [4] Challenges in Coverage - Basic medical insurance currently covers only 16% to 25% of the innovative drugs applied for, indicating a gap in coverage [5][6] - Despite the establishment of a universal healthcare system, basic insurance is insufficient to cover high-priced innovative drugs, necessitating the exploration of new payment models [6][9] Insurance and Policy Initiatives - The commercial health insurance sector is expected to provide approximately 12.4 billion yuan in compensation for innovative drugs in 2024, with direct reimbursements amounting to 6.6 billion yuan [3][7] - The introduction of the commercial insurance innovative drug directory is seen as a significant step towards integrating commercial insurance with the pharmaceutical industry [13][14] Collaborative Efforts - Various stakeholders, including insurance companies, pharmaceutical firms, and local governments, are working together to address challenges in the innovative drug payment system [17][20] - New models of risk-sharing and payment mechanisms are being explored to enhance the accessibility of innovative drugs [18][19] Regulatory Framework - The establishment of clear regulatory frameworks and operational guidelines is essential for the effective implementation of the multi-payment system for innovative drugs [9][19] - The "three exclusions" policy aims to facilitate the integration of commercial insurance with innovative drug coverage, impacting pricing negotiations and compliance [19][20]

Group 1 - The core viewpoint of the article highlights the introduction of several high-value "star drugs" in the commercial health insurance innovative drug directory, which is expected to create new payment channels and benefit a broader patient population [1][2] - The National Healthcare Security Administration (NHSA) has initiated the adjustment of the commercial health insurance innovative drug directory, marking a significant step towards a multi-layered and balanced payment structure in the healthcare industry [1][2] - According to Frost & Sullivan, the share of commercial health insurance payments is projected to reach 16.3% by 2030, more than doubling from 2024, indicating a growing trend in the market [2] Group 2 - The construction of a diversified medical payment system faces challenges, including fragmented reimbursement rules and payment proportions across different payment methods, which complicates the payment process [2][3] - The "Yima Direct Payment" platform by Meixin Health exemplifies how platform companies are effectively addressing these challenges by integrating various payment solutions and streamlining complex claims processes [3] - The importance of ensuring that innovative drugs are accessible post-launch, including prescription transmission and direct payment capabilities, is emphasized as a critical factor for commercial insurance [2][3]

Core Viewpoint - The high cost of innovative drug treatments, such as CAR-T cell therapy, is a growing concern, prompting discussions on how to ensure accessibility without imposing financial burdens on patients and their families [1][2][3] Payment System for Innovative Drugs - The establishment of a sustainable and efficient payment system for innovative drugs is crucial for their widespread application [3] - Recent policies have been introduced to support the inclusion of innovative drugs in basic medical insurance and commercial health insurance directories, aiming to enhance payment capabilities [3][4] - By 2024, commercial health insurance is expected to cover approximately 12.4 billion yuan for innovative drugs, with direct reimbursements amounting to 6.6 billion yuan [4] Market Growth and Challenges - China's pharmaceutical market has become the second largest globally, with an annual growth rate exceeding 3%, driven primarily by innovative drugs [6] - The market size for innovative drugs reached approximately 162 billion yuan in the previous year, reflecting a year-on-year growth of 16% [6] - Basic medical insurance currently covers only 16% to 25% of the innovative drugs applied for, indicating a significant gap in coverage [7] Policy Support and Developments - Various policies have been enacted to support the development of innovative drugs and establish a multi-channel payment system [12][14] - The introduction of the commercial health insurance innovative drug directory is seen as a strategic move to enhance the integration of insurance and pharmaceutical industries [15][16] Collaborative Efforts and Innovations - Insurance companies and pharmaceutical firms are exploring new payment models, including risk-sharing mechanisms based on treatment efficacy [21][22] - Local governments are facilitating the design and underwriting challenges faced by commercial insurance in the innovative drug payment sector [21][24] Future Directions - The successful implementation of the "three exclusions" policy, which allows innovative drugs in the commercial insurance directory to be excluded from certain payment metrics, is critical for compliance and pricing negotiations [23] - There is a need for a collaborative ecosystem involving government, insurance companies, and pharmaceutical firms to transform commercial insurance from a traditional compensator to a health management and payment innovator [24]