2026.01.07 本文字数：2031，阅读时长大约4分钟 作者 |第一财经 林志吟 从本月起，首版《商业健康保险创新药品目录》（下称"商保创新药目录"）开始在各地启用。 作为普惠型商业健康保险产品代表之一，惠民保近年来得到普及。而惠民保参保者，尤其是一些重疾患 者，到底能从商保创新药目录获益多少？ 首版商保创新药目录在医保目录之外，收录了19种临床价值突出但超出医保支付能力的创新药。从治疗 领域看，这些药品覆盖肿瘤、罕见病、神经退行性疾病及代谢类疾病多个关键领域，具体包括CAR-T治 疗药物、阿尔茨海默症治疗药品、神经母细胞瘤和戈谢病等罕见病治疗药品，填补了基本医保目录空 白。 从目前看，商保创新药目录的落地，能让惠民保参保者获益多少，要取决于惠民保产品承接、相关创新 药进院情况等。 进入商保创新药目录的创新药，最后的推广使用要落实在医院端，当前看，这些高价高值创新药在打通 入院"最后一公里"上，仍有障碍。 有CAR-T药企对第一财经记者表示，他们进入商保创新药目录的CAR-T药物，目前还未看到可以直接入 院的。 有创新药进入商保创新药目录的罕见病药企对第一财经记者表示，产品能否入院，要看每家医院的要求 ...

2026.01. 07 本文字数：2031，阅读时长大约4分钟 作者 | 第一财经 林志吟 从本月起，首版《商业健康保险创新药品目录》（下称"商保创新药目录"）开始在各地启用。 作为普惠型商业健康保险产品代表之一，惠民保近年来得到普及。而惠民保参保者，尤其是一些重疾 患者，到底能从商保创新药目录获益多少？ 首版商保创新药目录在医保目录之外，收录了19种临床价值突出但超出医保支付能力的创新药。从 治疗领域看，这些药品覆盖肿瘤、罕见病、神经退行性疾病及代谢类疾病多个关键领域，具体包括 CAR-T治疗药物、阿尔茨海默症治疗药品、神经母细胞瘤和戈谢病等罕见病治疗药品，填补了基本 医保目录空白。 以CAR-T药物为例，有血液肿瘤医生对第一财经记者表示，对于一些真正难治的血液瘤患者而言， CAR-T是较好的治疗手段，在没有这类疗法之前，一些患者的中位生存期只有半年，但有了这种治 疗手段后，有部分患者的生存期可以提高到五年及五年以上，但CAR-T疗法费用高昂，无法在患者 中得到普及。商保支付的话，可以减轻患者费用负担。 从目前看，商保创新药目录的落地，能让惠民保参保者获益多少，要取决于惠民保产品承接、相关创 新药进院情况等 ...

从本月起，首版《商业健康保险创新药品目录》（下称"商保创新药目录"）开始在各地启用。 作为普惠型商业健康保险产品代表之一，惠民保近年来得到普及。而惠民保参保者，尤其是一些重疾患 者，到底能从商保创新药目录获益多少？ 首版商保创新药目录在医保目录之外，收录了19种临床价值突出但超出医保支付能力的创新药。从治疗 领域看，这些药品覆盖肿瘤、罕见病、神经退行性疾病及代谢类疾病多个关键领域，具体包括CAR-T治 疗药物、阿尔茨海默症治疗药品、神经母细胞瘤和戈谢病等罕见病治疗药品，填补了基本医保目录空 白。 以CAR-T药物为例，有血液肿瘤医生对第一财经记者表示，对于一些真正难治的血液瘤患者而言， CAR-T是较好的治疗手段，在没有这类疗法之前，一些患者的中位生存期只有半年，但有了这种治疗手 段后，有部分患者的生存期可以提高到五年及五年以上，但CAR-T疗法费用高昂，无法在患者中得到普 及。商保支付的话，可以减轻患者费用负担。 值得注意的是，该产品也标注称"必须为住院期间使用，且合并在住院医疗费用中一并结算并上传到国 家医保平台的全自费药品费用才可纳入"。 换言之，如果进入商保创新药目录的创新药无法顺利入院的话，参保的患 ...

今年1月1日，《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"新版 国家医保药品目录"）和首版《商业健康保险创新药品目录（2025年）》（以下简称"商保创新药目 录"）同步执行。其中，商保创新药目录共纳入19种药品，5款价格百万元级的CAR-T肿瘤治疗药品悉数 在列。随着这一政策正式落地，商业健康险能否接好高值药支付的"接力棒"，直接关乎多层次医疗保障 的惠民实效。 《金融时报》记者注意到，新年伊始，北京、河北、浙江、湖北等地纷纷开启首版医保"双目录"制 度，积极打通商业健康保险的衔接通道。在业内人士看来，这标志着医保与商保在破解高值创新药支付 难题上迈出实质步伐，商保补充作用被进一步激发，更多百姓有望用上"天价药"。政策利好下，商保公 司也可参照商保创新药目录加速产品创新、更新赔付范围，与基本医保形成保障合力。 商业保险填补创新药保障空白 进入2026年1月，医保商保药品"双目录"迎来启动关键节点，地方政策衔接、险企产品适配、技术 服务支撑的联动效应持续释放，"医保+商保"的协同医疗保障正从制度设计走向实操落地。 据《金融时报》记者观察，全国多地医保部门通过一系列政策举措为商保创新 ...

Core Viewpoint - The article emphasizes the acceleration of innovation in the pharmaceutical and medical device industries in China, driven by supportive policies and a shift from generic to innovative drug development, which is expected to enhance the industry's quality and global competitiveness [2][3][5]. Policy Support for Innovation - Since 2020, numerous favorable policies have been introduced to improve the ecosystem for innovative drugs, focusing on research standards, review and approval systems, patent protection, and reimbursement mechanisms [2]. - The "14th Five-Year Plan" highlights the importance of supporting innovative drugs and medical devices, indicating their critical role in national health and economic development [3][5]. Clinical Trials and Market Dynamics - The number of clinical trials for innovative drugs in China has surpassed 1,900, outpacing the US, Europe, and Japan, reflecting a significant increase in research quality and efficiency [3][8]. - By 2024, 39 innovative drugs approved for the first time in China were domestically developed, increasing from 31% in 2020 to 42% in 2024, indicating a strong trend towards domestic innovation [3][5]. Medical Insurance and Payment Systems - The narrowing surplus of the national medical insurance fund has created a mismatch between the commercialization of innovative drugs and their approval timelines, necessitating improvements in the commercial insurance system [8][27]. - The "15th Five-Year Plan" aims to establish a multi-tiered medical insurance system, which is expected to enhance the role of commercial health insurance in providing payment support for innovative drugs [27][32]. Medical Devices and Technological Innovation - The approval of innovative medical devices has increased by 43% from 2016-2020 to 2021-2024, driven by improved regulatory mechanisms and support for high-end medical device innovation [10][13]. - The article notes that while domestic brands are gaining global competitiveness, the industry still faces challenges in achieving systematic original innovation and key technology breakthroughs [13][19]. Emerging Technologies - The application of AI and brain-machine interfaces in healthcare is progressing towards industrialization, with the establishment of preliminary frameworks for clinical applications and payment rules [14][18]. - The integration of high-quality data flow in healthcare is anticipated to enhance the clinical benefits of new technologies, improving resource utilization and patient outcomes [18][19]. Biomanufacturing Developments - The biomanufacturing sector in China is transitioning from a "follower" to a "runner" stage, with significant advancements in technology and policy support, laying a solid foundation for future growth [19][20]. - The article highlights the importance of focusing on high-value, environmentally friendly products, such as biodegradable materials, to expand market opportunities [22][26].

Core Insights - Recently, Shanghai Waigaoqiao Group's subsidiary, Shanghai Waigaoqiao Biomedical Industry Development Co., Ltd., signed a strategic cooperation agreement with Shanghai Meixin Health Technology Group Co., Ltd. [1] - The collaboration aims to leverage each party's resources and strengths to innovate a multi-payment mechanism involving "medical insurance + commercial insurance + corporate co-payment" [1] - The focus is on promoting the implementation and accessibility of innovative drug and medical device payments in real-world scenarios, exploring new models for the synergistic development of commercial insurance and the biomedical industry [1]

Core Insights - The industry has not reached a consensus on the relationship between negotiated discount prices and claims for innovative drugs under commercial insurance [1][2] - The first version of the commercial insurance innovative drug directory is set to be released on the first weekend of December and will be implemented starting January 1 of next year [1] - A total of 121 drugs have been reviewed through the commercial insurance innovative drug directory this year, with around 80 drugs applying for both the basic medical insurance directory and the commercial insurance innovative drug directory [1] Group 1: Expectations and Challenges - Different stakeholders have varying expectations from the commercial insurance innovative drug directory; pharmaceutical companies hope to expand coverage through discount commitments, while commercial health insurance companies aim to manage high-cost drug reimbursement risks [1][2] - Two main challenges identified include clarifying the relationship between negotiated prices and claims responsibilities, and establishing a clear mechanism for pharmaceutical companies to return discounts to insurers [2][5] Group 2: Pricing Mechanisms - The introduction of the commercial insurance innovative drug directory aims to enhance the payment capabilities for innovative drugs and strengthen the associated policy framework [3] - The National Healthcare Security Administration (NHSA) proposes a mechanism for price confidentiality, allowing pharmaceutical companies to negotiate discounts with insurers while keeping the negotiated prices confidential [3][4] Group 3: Implementation and Operational Challenges - The successful implementation of the directory requires addressing challenges related to the existing actuarial models of commercial insurance products and compliance with industry regulations [7][8] - The path for returning discounts from pharmaceutical companies to insurers remains unclear, with the NHSA requiring the industry to explore solutions within three months of the directory's launch [9][10] Group 4: Opportunities and Market Dynamics - The directory's introduction provides an opportunity for insurers to engage directly with pharmaceutical companies, enhancing negotiation capabilities [14] - The complexity of discount return mechanisms and price confidentiality may still involve intermediaries, indicating potential challenges in the practical application of these agreements [14]

Core Viewpoint - The article emphasizes the accelerating role of commercial health insurance in the payment for innovative drugs and medical devices, driven by recent policy measures aimed at enhancing the multi-tiered medical security system in China [1][4]. Group 1: Policy Developments - The National Healthcare Security Administration and the National Health Commission have issued measures to support the high-quality development of innovative drugs, including the establishment of a "commercial health insurance innovative drug directory" [1]. - Local governments, such as Shanghai and Chengdu, have introduced supportive policies to facilitate the integration of innovative drugs into insurance coverage, addressing the affordability and accessibility of these treatments [1][2]. Group 2: Market Insights - The innovative drug and medical device market in China is projected to reach approximately 1.62 trillion yuan (about 1620 billion yuan) in 2024, with commercial health insurance contributing only 124 billion yuan (7.7% of the total) [1]. - If the share of commercial health insurance payments increases to 44% by 2035, the market size could reach 440 billion yuan, significantly alleviating the financial burden on patients [2]. Group 3: Challenges and Recommendations - Despite policy incentives, commercial health insurance faces challenges such as inadequate data sharing and payment integration with basic medical insurance, which hampers product design and scalability [3]. - Recommendations to enhance commercial health insurance's support for innovative drugs include improving funding efficiency, optimizing product design, establishing a unified drug directory, and leveraging technology to enhance payment and management efficiency [3]. Group 4: Future Outlook - The gradual implementation of policies is expected to allow commercial health insurance to play a larger role in the payment system, fostering a complementary and collaborative relationship with basic medical insurance [4]. - The development of a multi-channel payment mechanism for innovative drugs is crucial for both patient welfare and the health of the pharmaceutical industry [4].

Core Viewpoint - The recent measures released by Shanghai's financial and healthcare regulatory bodies aim to enhance the synergy between commercial health insurance and the biopharmaceutical industry, promoting high-quality development through 18 specific initiatives [1][2]. Group 1: Policy Measures - The 18 measures are designed to create a "dual empowerment" mechanism between commercial health insurance and biopharmaceutical innovation, addressing product innovation, payment mechanisms, service models, and regulatory innovation [1][3]. - The measures include establishing a multi-party payment mechanism involving health insurance, commercial insurance, charitable organizations, and pharmaceutical companies to facilitate the clinical application of innovative drugs and devices [3][4]. - The policy encourages the use of innovative drugs listed in the commercial insurance directory without counting them towards the basic medical insurance's out-of-pocket rate, alleviating concerns for medical institutions [3][4]. Group 2: Data Empowerment - The measures propose upgrading health data sharing capabilities to support product design, actuarial pricing, and risk assessment for commercial insurance [4][5]. - The initiative aims to integrate health insurance data into commercial insurance settlements, ensuring comprehensive coverage across various medical institutions [4][5]. - By utilizing shared data, the policy seeks to provide precise pricing for specific groups, enhancing the diversity of insurance products [4][5]. Group 3: Service Models - The measures promote a full-cycle health management service model, encouraging collaboration between commercial insurance and medical institutions to provide comprehensive health services [5][6]. - This approach aims to shift the focus from post-claim reimbursement to proactive health management, improving the continuity and effectiveness of health services [5][6]. Group 4: Regulatory Innovation - The measures propose a "regulatory sandbox" pilot mechanism for innovative commercial health insurance products, ensuring compliance and sustainability while preventing misuse of policies [5][6]. - The focus is on balancing the interests of various stakeholders, including regulatory bodies, pharmaceutical companies, and insurance providers, to facilitate effective policy implementation [6][7]. Group 5: Implementation Challenges - The successful implementation of these measures requires addressing challenges such as defining the scope of "innovative drugs" and establishing negotiation mechanisms between insurance institutions and pharmaceutical companies [6][7]. - Ensuring data security during the sharing process is critical, as it involves sensitive personal and medical information [6][7]. - Coordination among multiple departments is essential for effective policy execution, necessitating a structured approach to manage diverse interests [7][8].

Core Points - Shanghai has introduced measures to promote the high-quality development of commercial health insurance, aimed at supporting innovation in the biopharmaceutical industry and enhancing public health insurance services [1] - The measures include 5 areas and 18 specific actions to improve the accessibility and affordability of innovative drugs and medical devices, addressing the diverse health protection needs of citizens [1] Summary by Categories Policy Measures - The measures focus on deepening the payment mechanism for innovative drugs and medical devices, facilitating their entry into hospitals, directories, and prescriptions [1] - Cases involving innovative drugs within the scope of commercial health insurance will not be included in the disease-based payment range, encouraging insurance companies to use clinical trial data for pricing [1] Technological Integration - Shanghai will enhance the functionality of the "Shanghai Insurance Code" to optimize the synchronous settlement model between public health insurance and commercial insurance [1] - The initiative aims to improve direct compensation service processes and establish an active compensation system that integrates medical, health insurance, and commercial insurance data [1] Impact on Health Insurance - The introduction of these measures is expected to further establish commercial health insurance as a crucial pillar of the public health protection system, providing citizens with more comprehensive, diverse, and convenient health coverage [1]