Core Viewpoint - The probability of rare disease patients receiving compensation from commercial insurance is extremely low, akin to the likelihood of an average person contracting a rare disease. The demand for better coverage from commercial insurance is highlighted, especially as basic medical insurance has started to cover some high-cost medications for rare diseases [2][3]. Summary by Sections Rare Disease Patient Insurance Challenges - Rare disease patients face significant challenges in obtaining commercial insurance coverage due to strict underwriting criteria and the exclusion of pre-existing conditions. Even government-backed health insurance options have seen drastic cuts in coverage for pre-existing conditions [2][3][4]. - The National Healthcare Security Administration reported that there are approximately 100 rare disease medications included in the national insurance directory, covering 42 types of rare diseases, with a projected payment of 8.6 billion yuan for these medications in 2024, accounting for 7.7% of total payments during the agreement period [2]. Commercial Insurance Market Dynamics - Approximately half of the 40 innovative drugs submitted for commercial insurance in the second half of the year are for rare diseases. However, insurance companies remain cautious about covering rare disease patients due to the inherent risks associated with genetic and hereditary conditions [3][4]. - The commercial insurance market traditionally excludes congenital diseases and genetic disorders from coverage, which poses a significant barrier for rare disease patients. The risk associated with known hereditary conditions makes it difficult for insurers to price policies effectively [4][5]. Risk Assessment and Pricing Issues - The lack of precise research on the mechanisms of specific rare diseases complicates risk assessment for insurers, leading to higher premiums and conservative coverage terms. Insurers are concerned about the potential for adverse selection if they lower underwriting standards for rare disease patients [6][7]. - The commercial health insurance market is likened to a reservoir that must balance inflow (new premiums) and outflow (claims). The small patient base for rare diseases makes it less attractive for insurers to develop tailored products, as the risk and treatment costs vary significantly across different rare diseases [5][6]. Coverage Gaps and Patient Experiences - While some commercial insurance products do cover specific hereditary diseases, the majority still exclude them, leaving patients with limited options. The coverage for rare diseases is often inadequate, with high deductibles and low reimbursement rates for outpatient treatments [7][10]. - The integration of rare disease medications into commercial insurance products is becoming a selling point, but the actual coverage and reimbursement rates remain unclear. Many patients report significant out-of-pocket expenses despite having insurance [10][11]. Regulatory and Market Developments - The National Healthcare Security Administration's dual-directory negotiations for innovative drugs have led to a higher proportion of rare disease medications being submitted for commercial insurance. However, insurers may lack the motivation to include high-cost rare disease treatments due to the associated risks [10][11]. - The lack of a clear directory for rare disease medications complicates the process for hospitals and insurers, leading to delays and rejections in coverage for necessary treatments [12].

Core Viewpoint - The article discusses the complexities and varying attitudes of pharmaceutical companies towards the newly introduced innovative drug directory in the context of commercial health insurance, highlighting the potential market impact and the challenges faced by companies in navigating pricing and inclusion in the directory [3][4][31]. Group 1: Innovative Drug Directory and Market Dynamics - Over 100 drugs have been reported for inclusion in the innovative drug directory, indicating a significant interest from pharmaceutical companies [1][4]. - The innovative drug directory is seen as a bright spot in the policy landscape, with the Hang Seng Innovative Drug Index rising by 60.27% and the Wind Innovative Drug Index increasing by 23.93% in the first half of 2025 [4]. - The expectation of market growth driven by the innovative drug directory may be overly optimistic, as the actual sales impact of the commercial health insurance and the "policy for price" approach remains uncertain [5][6]. Group 2: Pharmaceutical Companies' Attitudes - Pharmaceutical companies exhibit three main attitudes towards the innovative drug directory: "participation-focused," "minimum guarantee," and "wanting to enter but hesitant" [17][19]. - Many companies are cautious about entering the directory due to concerns over pricing negotiations and the uncertain volume of sales from the commercial health insurance [19][20]. - The perception that entering the directory may not significantly enhance sales, especially for companies that have already penetrated the market, contributes to their hesitance [22][23]. Group 3: Financial Implications and Market Size - The commercial health insurance, known as Huiminbao, has a scale of nearly 20 billion, but its contribution to innovative drug sales is viewed as minimal, akin to "a drop in the ocean" [6][7]. - Huiminbao's reimbursement for innovative drugs is estimated to be around 2 billion, translating to approximately 4 to 6 billion in sales for pharmaceutical companies [7][8]. - The distribution of the reimbursement "cake" among the drugs included in the innovative drug directory is expected to be competitive, with a limited number of drugs likely to capture the majority of the funds [8][10]. Group 4: Challenges in Market Access - The innovative drug directory aims to facilitate market access through policies like direct listing and "three exclusions," but the actual implementation and effectiveness of these policies remain in question [29][30]. - Companies express skepticism about whether the proposed policies will lead to significant changes in market access, especially given the complexities involved in hospital procurement processes [30][31]. - The article highlights the ongoing challenges faced by pharmaceutical companies in navigating the regulatory landscape and achieving meaningful market penetration despite the introduction of supportive policies [24][25].

4月22日， 2025年度上海城市定制型商业补充医疗保险"沪惠保"正式开启投保窗口，由上海 市医疗保障局指导，国家金融监督管理总局上海监管局监督，上海市大数据中心提供技术支 持，上海市保险同业公会协调，由中国太保寿险首席承保，联合国寿寿险、人保健康、新华保 险、平安健康、太平财险、建信人寿、交银人寿、工银安盛人寿等8家保司共同承保。 自2021年推出以来，"沪惠保"始终坚持"政府指导、商业运作、惠民利民"原则，保障、服务 历经多轮升级迭代，而今已步入第五个年度。 2025版"沪惠保"继续面向上海基本医保参保人员开放，在坚持不限年龄、不限职业、不限健 康状况的参保条件基础上，保费维持129元/人，五大保障责任项，仍包含责任一特定住院自费 医疗费用保险金（包括自费耗材、药品、检查检验、治疗，不限目录），责任二国内特定高额 药品费用保险金，责任三质子、重离子医疗保险金，责任四海外特殊药品费用保险金，责任五 CAR-T治疗药品费用保险金，起付线、赔付比例与上年保持一致，最高仍可享310万元医疗保 障。 与2024年相比，2025年"沪惠保"实现"一增、一享"，保障责任力度更强，健康服务覆盖更 广： 一增： 进一步扩增 ...

Core Viewpoint - The 2025 version of "Hu Hui Bao" continues to enhance its medical insurance offerings for Shanghai residents, maintaining low premiums while expanding coverage and improving service experiences [1][2]. Group 1: Insurance Product Features - The 2025 "Hu Hui Bao" insurance remains open to all Shanghai basic medical insurance participants, with a premium of 129 yuan per person, covering five major responsibilities including specific hospitalization expenses, high-cost domestic drugs, proton and heavy ion medical expenses, overseas special drug expenses, and CAR-T treatment drug expenses [1][2]. - Compared to 2024, the 2025 version has increased the number of covered domestic special drugs from 41 to 48, while maintaining 28 overseas special drugs and expanding CAR-T treatment drugs from 3 to 4 [1][2]. Group 2: Service Enhancements - The service experience for the 2025 "Hu Hui Bao" has been upgraded, continuing existing benefits such as a 10% discount at over 2000 designated pharmacies and online consultation discounts with top-tier specialists, while adding a new 10% discount for original research drugs [2]. - The personal account family mutual aid has been expanded to allow the use of medical insurance personal account balances for a wider range of relatives, including siblings and grandparents [2]. Group 3: Claims and Support Services - Since its launch, "Hu Hui Bao" has continuously improved its claims services, achieving a 90% application rate for electronic medical data and optimizing average case closure time to the same day [3]. - The program has provided approximately 16.3 million yuan in advance payments for 93 insured individuals, alleviating the financial burden of high medical costs [3]. Group 4: Enrollment and Accessibility - The enrollment window for the 2025 "Hu Hui Bao" is open until June 30, 2025, with coverage effective from July 1, 2025, to June 30, 2026, allowing participants to enroll through various online platforms or by contacting service representatives for assistance [4]. Group 5: Claim Case Examples - A 26-year-old insured individual received approximately 670,000 yuan in claims for treatment of brain glioblastoma, demonstrating the program's extensive coverage for high-cost medical treatments [5]. - A 61-year-old insured individual benefited from the proactive claims service, receiving 16,700 yuan for hospitalization due to a urinary system disease, showcasing the efficiency of the claims process [6].