12月13日，全国医疗保障工作会议在北京召开。会议明确提出，2026年要支持商业健康保险发展，健全多层次医疗保障体系，并特别强调 要"积极落地商保创新药品目录"，在个人充分授权和确保数据安全基础上，为有需要的商业健康保险产品提供"医保+商保"一站式清分结算服 务。 而在稍早前的12月7日，国家医保局与人力资源社会保障部联合发布《国家基本医疗保险、生育保险和工伤保险药品目录》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》），并宣布将于2026年1月1日起正式实施。 然而，政策落地对保险赔付来说并非坦途。对于商业保险机构而言，仍然面临着如何将《商保创新药目录》转化为具体的产品责任？如何解决 定价数据匮乏、医院准入壁垒及资金合规流转等现实难题？ 5款百万元国产C A R -T均入选 首版《商保创新药目录》共纳入19种药品，精准聚焦于"高精尖"与"高价"领域。 包括5款国产CAR-T产品、神经母细胞瘤和戈谢病等罕见病特 效药，以及阿尔茨海默病治疗药物。 | 药品 | 药企 | 中国上市 | 适应证 | 创新性、公平性等 | | --- | --- | --- | --- | --- | | 1 伊匹 ...

【文/王力 编辑/周远方】 每年12月，医药圈都要经历一场大考。 12月7日，2025年国家医保药品目录正式发布：114种药品新晋入场，50种是货真价实的1类创新药，谈判成功率飙到88%，创七年新高。 与此同时，首版商保创新药目录横空出世，5款百万级CAR-T细胞疗法、阿尔茨海默病新药等19种高价创新药首次获得制度化支付通道。此外，全球瞩目的 降糖新药替尔泊肽以糖尿病适应症入局，再到新型失眠药、罕见病用药的持续扩容，这份目录的每一处更新都牵动着患者、药企与投资者的神经。 数据显示，本轮目录调整新增药品数量再创新高，创新药从获批上市到纳入医保的等待时间较五年前明显压缩。更值得关注的是，本轮调整首次将细胞治疗 等前沿疗法纳入商保谈判范围，同时在代谢性疾病、中枢神经系统疾病、罕见病等领域实现重大突破，标志着中国医保从"保基本"向"保基本+补高端"的战 略升级。这既是对患者"用得上、用得起"好药诉求的回应，也为本土创新药企的高质量发展注入了强劲信心。 百万神药破冰：5款CAR-T杀入商保，阿尔茨海默病新药同框登场 如果说基本医保是稳扎稳打，那商保创新药目录就是这次调整的最大惊喜。 | 指标 | 2025 年 | | ...

首版商保创新药目录已于近日揭晓，最终有19个药品成功纳入，这里面就包括了6款罕见病用药，后者 共覆盖神经母细胞瘤、戈谢病、短肠综合征等5种疾病。 该目录纳入的药品具有创新程度高、临床价值大、患者获益显著且超出基本医保保障范围等特征，旨在 为商业健康保险、医疗互助等多层次医疗保障体系提供参考。 不过，随着目录落地，如何吸引到更多的商业保险来承接？这仍有待观察。虽然惠民保在探索罕见病创 新药用药保障上迈出了重要一步，但也面临保障扩面、待遇提升的现实困境。 6款罕见病药物纳入 在罕见病用药保障上，惠民保仍面临挑战。 罕见病大多具有病理复杂、病症危害大、相关治疗药品研发难度大、成本高、售价高的特点，极易导致 患者因病返贫、致贫。 这次纳入罕见病药物短肠综合征创新药注射用替度格鲁肽，该药于2024年2月在中国获批，成为中国首 个治疗短肠综合征的人胰高血糖素样肽2（GLP-2）类似物，填补了短肠综合征治疗领域长期无可使用 的肠康复治疗药物的空白。 短肠综合征是指因各种原因引起广泛小肠切除或旷置后，肠道有效吸收面积显著减少，残存的功能性肠 管不能维持患者的营养或儿童生长需求，出现以腹泻、酸碱/水/电解质紊乱、以及营养吸收和 ...

12月7日，用于治疗短肠综合征成人和1岁及以上儿童患者的消化领域创新产品注射用替度格鲁肽被纳入 《商业健康保险创新药品目录》（以下简称"商保创新药目录"）。此前，注射用替度格鲁肽已在广东 省、山东省等全国30个省市的惠民保项目中实现覆盖。 首版商保创新药目录重点纳入了创新程度高、临床价值大、患者获益显著且超出基本医保保障范围的药 物，旨在为商业健康保险、医疗互助等多层次医疗保障体系提供参考。作为国内首个获批用于短肠综合 征的人胰高血糖素样肽-2(GLP-2)类似物，注射用替度格鲁肽不仅填补了长期以来肠康复治疗领域的药 物空白，更将通过多层次惠民政策，切实减轻患者经济负担，提升用药可及性，为患者及其家庭点燃希 望。 据了解，短肠综合征是指因各种原因引起广泛小肠切除或旷置后，肠道有效吸收面积显著减少，残存的 功能性肠管不能维持患者的营养或儿童生长需求，出现以腹泻、酸碱/水/电解质紊乱、以及营养吸收和 代谢功能障碍为主的症候群。由于肠道被大幅 "截短"—正常成人的小肠约有3-8.5米，短肠综合征患者 的小肠长度往往小于2米，甚至不到1米——他们也形象地被称为 "短肠人"。据2023年数据显示，我国 成人患病率约为0 ...

备受创新药产业界关注的首版商保创新药目录清单终于"出炉"，共计纳入18家创新药企的19种新药。 另据国家医保局此前披露信息，今年共有121个药品通用名通过商保创新药目录的形式审查，参与商保创新药目录价格协商的药品共24个。 也就是说，从通过形式审查到最终入选，首版商保创新药目录"宽进严出"，入选率约16%。 这大致符合业界预期。曾有多名地方医保部门和商保公司人士对第一财经表示，对于最可能率先衔接商保创新药目录的商保产品——惠民保，特药清单俨 然成为标配，大部分地方惠民保特药目录已涵盖50~100种药品，部分城市还会单独设置CAR-T药品保障清单。在此背景下，一旦商保创新药目录发布， 地方或需要对已完成精算的惠民保产品再度调整特药目录。 与此同时，每年进入基本医保目录的创新药数量保持增势，"国谈药"进院压力仍较大。按照国家医保局政策，谈判药品和商保创新药目录内药品均可不 受"一品两规"限制，不得以医保总额限制、医疗机构用药目录数量限制、药占比等为由影响药品落地，且均有望被医保支付方式改革中的特例单议政策所 惠及。 在此背景下，如果商保创新药目录涵盖药品数量过多，反而不易于落地。更不要说在原先地方惠民保的特药使用 ...

Core Insights - The first version of the commercial health insurance innovative drug directory has been released, including 19 new drugs from 18 innovative pharmaceutical companies, with a roughly equal share of domestic and imported drugs [3][4] - Approximately 70% of the drugs included are oncology treatments, featuring five high-cost CAR-T products, indicating a significant focus on cancer therapies [3][4] - The inclusion of rare disease medications and Alzheimer's treatments in the directory is expected to enhance commercial insurance payment options and facilitate hospital access [3] Summary by Sections Inclusion Criteria - A total of 121 drug names passed the review for the commercial health insurance innovative drug directory, with only 19 ultimately included, resulting in an acceptance rate of about 16% [6] - The directory aims to balance the number of drugs included to ensure effective implementation and avoid overwhelming the system [8] Drug Characteristics - The drugs in the directory generally have a small patient base or clear indications, minimizing the risk of clinical misuse [10] - High innovation and the ability to fill clinical gaps are common traits among the selected drugs, particularly in rare diseases and pediatric treatments [11] - The directory includes a significant number of oncology drugs, with 14 out of 19 being cancer treatments, primarily targeting niche patient populations [11][12] Market Dynamics - The CAR-T products included represent over half of the CAR-T therapies available in China, highlighting their importance in the market [12] - The directory's structure allows for multiple similar drugs to coexist, enhancing patient choice and supporting real-world evidence accumulation [13][14] - The focus on rare disease treatments is evident, with at least five rare diseases represented in the directory, including neuroblastoma and Gaucher disease [14] Future Implications - The directory is expected to influence local health insurance products, prompting adjustments to existing special drug lists in various regions [16][17] - The commercial health insurance sector is encouraged to design new products and adjust reimbursement strategies based on the directory to better meet patient needs [17]

12月7日，2025年国家首版商保创新药目录在广州发布，首批纳入19种高价值创新药，涵盖肿瘤、罕见病、神经退行性疾病等多 个关键治疗领域。记者从"深圳惠民保"承保机构获悉，作为深圳本土普惠型商业健康保险，"深圳惠民保"已率先在2025年度保 障中将这19种创新药全部纳入保障范围。 | 19款药品 | | | --- | --- | | 纳入首批商保目录 | | | 约能名称 | 1541 | | 甲苯磷酰胺注射液 | 天津红日健达康医药科技有限公司 | | 复过的他漫司他片 | 和记黄埔医药(上海)有限公司 | | 注射用户 上一起 | 南京绿叶制药有限公司 | | 那西妥单抗注射液 | 赛生医药江苏有限公司 | | 盐酸沙丙蝶哈片 | 山东新时代药业有限公司 | | 仑卡奈单抗注射液 | 卫材(中国)药业有限公司 | | 多奈单抗法射液 | 礼来贸易有限公司 | | 达妥昔单抗B法射液 | 百济神州(北京)生物科技有限公司 | | 注射用泽尼达妥单抗 | 百济神州(北京)生物科技有限公司 | | 注射用替度格鲁肽 | 武田(中国)国际贸易有限公司 | | 瑞基奥仑赛注射液 | 上海药明巨诺生物科技有限公司 ...

Core Viewpoint - The recent adjustments to the national basic medical insurance directory and the introduction of the commercial insurance innovative drug directory mark significant steps towards enhancing access to innovative treatments in China, particularly for high-cost therapies like CAR-T drugs [2][6]. Summary by Sections National Basic Medical Insurance Directory Adjustments - A total of 114 new drugs were added to the basic medical insurance directory, including 50 first-class innovative drugs [2]. - The total number of drugs in the basic medical insurance directory has increased to 3,253, comprising 1,857 Western medicines and 1,396 traditional Chinese medicines [3]. - New inclusions cover various fields such as oncology, chronic diseases, mental health, and pediatric medications, with several rare disease treatments also added [3]. Commercial Insurance Innovative Drug Directory - The commercial insurance innovative drug directory aims to include high-innovation drugs that exceed the basic insurance scope but offer significant clinical value and patient benefits [6]. - A total of 121 drugs underwent formal review for the commercial insurance directory, with 24 entering price negotiation, ultimately resulting in 19 drugs from 18 companies being included [6]. - Notable inclusions are five CAR-T therapies, which previously cost over one million yuan per injection, making them unaffordable for many patients [6]. Performance of Pharmaceutical Companies - Several leading pharmaceutical companies have reported their successes in the 2025 national medical insurance negotiations, with Heng Rui Pharmaceutical having 20 drugs included, contributing 7.554 billion yuan to their total revenue [5]. - Innovent Biologics announced that 7 of its new drugs were included in the updated national medical insurance directory, with 12 of its 17 innovative drugs now covered [5]. Specific Drug Inclusions - The directory includes drugs for Alzheimer's disease, such as the monoclonal antibodies from Eisai and Eli Lilly, and several rare disease treatments [7]. - Some high-profile drugs, like Novo Nordisk's semaglutide and Bristol-Myers Squibb's nivolumab, were not included despite passing the formal review [8]. Implementation Timeline - The new directory is set to be officially implemented nationwide on January 1, 2026 [9].

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]

Core Insights - The 2025 Shenzhen Huimin Insurance program has seen a record participation of over 6.15 million individuals, with coverage extending from July 1, 2025, to June 30, 2026, providing a full year of protection [1] - The program maintains its inclusive nature by allowing participation without restrictions on age, occupation, or health status, and now includes Shenzhen residents with cross-regional medical insurance [1] - The insurance premium has remained stable at 88 yuan per person per year for three consecutive years, while significant upgrades to coverage have been introduced for the 2025 plan [2] Participation and Coverage - The program has attracted participation from nearly 26,000 enterprises, covering over 1.05 million employees, reflecting corporate commitment to employee welfare [2] - The maximum age of participants has reached 113 years, while the youngest is just five days old, showcasing the program's broad demographic reach [1] Benefit Enhancements - The 2025 plan features a substantial reduction in deductibles, with some treatment deductibles lowered by 4,000 yuan compared to the previous year, and a maximum reduction of 28.6% for continuous participants [2] - New coverage includes self-paid hospitalization treatments, with specific advanced medical procedures now eligible for claims, and the reimbursement limit for rare diseases has been increased to 600,000 yuan per year [2] Claims and Payouts - The program has already facilitated claims for participants, with the first payout occurring the day after the coverage became effective, indicating a lower threshold for claims [3] - A notable case involved a participant with significant medical expenses, where the insurance covered 31,066.26 yuan after the initial reimbursement from Shenzhen medical insurance [3][4]