2026.01. 08 本文字数：3880，阅读时长大约6分钟 作者 | 第一财经 吴斯旻 今年1月1日起，首版商保创新药目录正式落地。在北京，与该目录同一天落地的是"第二批DRG付费 新药新技术除外支付名单"，纳入前述目录的达妥昔单抗β注射液赫然在列。 除外支付，更通俗地来说，就是对住院病例使用创新药的费用单独按实结算，不占用医保打包支付中 对应病组额度。 在国家医保局承诺对纳入商保创新药目录内药品执行的"三除外"政策中，"相关商业健康保险保障范 围内的创新药应用病例可不纳入按病种付费范围"被业界普遍视为对商保创新药目录内药品"进院"最 为利好也是最难执行的一条。 正如前述达妥昔单抗β注射液的案例，目前，北京、上海、浙江等省份为支持新药新技术应用而发布 的地方版激励清单中，已可见少数与商保创新药重叠的"身影"。但针对绝大多数商保创新药和更多医 保统筹地区，商保创新药的住院使用，仍面临与其他高倍率病例争夺特例单议名额的不确定性。 同时，创新药"进院"不仅仅要"进住院部"，也要"进门诊"。多名受访业界人士坦言，商保创新药的门 诊用药激励还处于政策空白阶段。 截至1月8日，据第一财经不完全统计，全国已有至少28个 ...

今年1月1日起，首版商保创新药目录正式落地。在北京，与该目录同一天落地的是"第二批DRG付费新 药新技术除外支付名单"，纳入前述目录的达妥昔单抗β注射液赫然在列。 除外支付，更通俗地来说，就是对住院病例使用创新药的费用单独按实结算，不占用医保打包支付中对 应病组额度。 在国家医保局承诺对纳入商保创新药目录内药品执行的"三除外"政策中，"相关商业健康保险保障范围 内的创新药应用病例可不纳入按病种付费范围"被业界普遍视为对商保创新药目录内药品"进院"最为利 好也是最难执行的一条。 正如前述达妥昔单抗β注射液的案例，目前，北京、上海、浙江等省份为支持新药新技术应用而发布的 地方版激励清单中，已可见少数与商保创新药重叠的"身影"。但针对绝大多数商保创新药和更多医保统 筹地区，商保创新药的住院使用，仍面临与其他高倍率病例争夺特例单议名额的不确定性。 同时，创新药"进院"不仅仅要"进住院部"，也要"进门诊"。多名受访业界人士坦言，商保创新药的门诊 用药激励还处于政策空白阶段。 截至1月8日，据第一财经不完全统计，全国已有至少28个省份明确当地定点医疗机构要在2月底前召开 药事会。 商保创新药"进院"细则待明确 要么纳入商 ...

除外支付，更通俗地来说，就是对住院病例使用创新药的费用单独按实结算，不占用医保打包支付中对 应病组额度。 在国家医保局承诺对纳入商保创新药目录内药品执行的"三除外"政策中，"相关商业健康保险保障范围 内的创新药应用病例可不纳入按病种付费范围"被业界普遍视为对商保创新药目录内药品"进院"最为利 好也是最难执行的一条。 正如前述达妥昔单抗β注射液的案例，目前，北京、上海、浙江等省份为支持新药新技术应用而发布的 地方版激励清单中，已可见少数与商保创新药重叠的"身影"。但针对绝大多数商保创新药和更多医保统 筹地区，商保创新药的住院使用，仍面临与其他高倍率病例争夺特例单议名额的不确定性。 同时，创新药"进院"不仅仅要"进住院部"，也要"进门诊"。多名受访业界人士坦言，商保创新药的门诊 用药激励还处于政策空白阶段。 商保创新药的门诊用药激励还处于政策空白阶段。 今年1月1日起，首版商保创新药目录正式落地。在北京，与该目录同一天落地的是"第二批DRG付费新 药新技术除外支付名单"，纳入前述目录的达妥昔单抗β注射液赫然在列。 截至1月8日，据第一财经不完全统计，全国已有至少28个省份明确当地定点医疗机构要在2月底前召开 药事 ...

Core Viewpoint - The implementation of the new national basic medical insurance drug list and the first commercial health insurance innovative drug list in Beijing on January 1, 2026, introduces 114 new drugs into the basic insurance reimbursement scope and 19 innovative drugs into the commercial insurance list, significantly benefiting patients [1][2]. Group 1: New Drug Inclusion - The new national medical insurance directory includes a total of 3,253 drugs, with 114 new drugs added, covering critical treatment areas such as cancer, chronic diseases, and rare diseases [1]. - Notable new drugs include the anti-cancer drug Lurbinectedin for triple-negative breast cancer, the diabetes medication Tirzepatide, and treatments for rare diseases like Langerhans cell histiocytosis [1]. Group 2: Commercial Insurance Drug List - The commercial insurance list includes 19 innovative drugs, focusing on high innovation, significant clinical value, and substantial patient benefits beyond the basic insurance coverage [1]. - Included innovative treatments are CAR-T cell immunotherapy products, biological agents for Alzheimer's disease, and specific drugs for Gaucher disease and short bowel syndrome [1]. Group 3: Patient Impact - An 8-year-old boy with high-risk neuroblastoma became one of the first beneficiaries of the new policy, with his treatment costs significantly reduced from tens of thousands of yuan annually to being partially covered by commercial insurance [2]. - The inclusion of GD2 antibody therapy in the commercial insurance list allows families to shift from full out-of-pocket expenses to insurance reimbursement, alleviating financial burdens [2]. Group 4: Transition Period and Adjustments - A 6-month transition period is established for drugs removed from the old national medical insurance directory, allowing them to still be reimbursed until June 30, 2026 [3]. - The Beijing Medical Insurance Bureau has mandated timely adjustments in drug supply at medical institutions and updates to the insurance information system to ensure patient access to necessary medications [3].

Core Insights - The newly released commercial insurance innovative drug directory includes 19 drugs, with 6 specifically for rare diseases, addressing conditions such as neuroblastoma and Gaucher disease [1][3] - The directory aims to provide a reference for multi-tiered medical insurance systems, but attracting more commercial insurance participation remains a challenge [1][6] Summary by Sections Rare Disease Drug Inclusion - The innovative drug for short bowel syndrome, injection of teduglutide, is set to be the first GLP-2 analog approved in China, filling a long-standing gap in treatment options [3][4] - Gaucher disease, affecting approximately 3,000 patients in China, now has a locally developed enzyme replacement therapy, injection of velaglucerase alfa, included in the directory [5] Challenges in Commercial Insurance - The increasing pressure on basic medical insurance funds makes it unrealistic to rely solely on them for rare disease drug coverage, highlighting the need for commercial insurance products like Huiminbao [6][8] - Huiminbao has made strides in covering certain rare disease drugs, but the number of drugs and policies available for rare diseases still needs improvement [8] Future Directions - Experts suggest that a multi-tiered approach involving basic insurance, commercial insurance, and charitable support is essential for effective rare disease drug coverage [9][10] - The focus should shift from post-reimbursement to comprehensive service and long-term health management for rare disease patients [10]

Core Insights - The first national commercial insurance innovative drug directory for 2025 has been released, including 19 high-value innovative drugs covering key treatment areas such as oncology, rare diseases, and neurodegenerative diseases [1][3][4] - Shenzhen's "Shenzhen Huiminbao" has proactively included all 19 innovative drugs in its coverage for 2025, significantly reducing out-of-pocket expenses for insured residents when using these drugs [1][2][3] Summary by Sections National Drug Directory - The newly published commercial insurance innovative drug directory serves as a supplement to basic medical insurance, focusing on drugs with high innovation, significant clinical value, and substantial patient benefits that exceed the coverage of basic medical insurance [1][4] - Included drugs feature CAR-T therapies for cancer treatment, medications for rare diseases like Gaucher disease, and drugs for Alzheimer's disease, which has garnered significant public attention [1][4] Shenzhen Huiminbao - "Shenzhen Huiminbao" has achieved full coverage of the 19 innovative drugs, providing a crucial supplement to the existing medical insurance framework in Shenzhen [1][4] - The insurance plan supports a "one-stop settlement" service, alleviating the financial burden on insured individuals when seeking medical treatment [2][4] - The program has been operational for three years, maintaining a public welfare characteristic with no restrictions on age, occupation, or health status, allowing for an annual premium of 88 yuan for coverage exceeding 4 million yuan [5] - As of 2025, the number of insured individuals has surpassed 6.15 million, with a total of over 18 million insured instances in three years [5]

Core Insights - The first version of the commercial 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 [1][2] - Approximately 70% of the drugs included are oncology treatments, featuring five high-cost CAR-T products, indicating a significant focus on cancer therapies [1][8] - The inclusion of rare disease medications and Alzheimer's treatments in the directory is expected to enhance commercial insurance payment opportunities and favorable policies for hospital access [1][10] Summary by Category Drug Inclusion - A total of 19 drugs have been included in the first commercial insurance innovative drug directory, with a selection rate of about 16%, aligning with industry expectations [4][6] - The directory features a mix of oncology drugs, rare disease treatments, and Alzheimer's medications, with a notable emphasis on high-priced innovative drugs [1][8] Market Dynamics - The directory's limited number of drugs (around 20) is seen as a strategic move to facilitate implementation and avoid complications in local insurance products [6][10] - The commercial insurance market is expected to leverage the directory to enhance patient access to high-value drugs, particularly in the oncology sector [9][11] Regulatory and Policy Framework - The National Healthcare Security Administration (NHSA) encourages local insurance departments to support the integration of the commercial insurance innovative drug directory into retail pharmacies and monitor pricing [7][14] - The directory aims to provide a reference for various commercial insurance entities, allowing them to negotiate with innovative drug companies without the need for exclusive selections [11][14] Patient Impact - The drugs listed in the directory are characterized by a small patient base or specific indications, minimizing the risk of clinical misuse and aligning with commercial insurance risk management strategies [8][13] - The directory includes several drugs for rare diseases, which are expected to fill clinical gaps and provide essential treatments previously unavailable in China [12][13]

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 first version of the commercial 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 [1][2] - The directory focuses heavily on oncology drugs, which account for 70% of the list, including five CAR-T products, and also includes rare disease medications and Alzheimer's treatments [1][11] Summary by Category Drug Inclusion - A total of 121 drug generic names passed the review for the commercial insurance innovative drug directory, with only 19 drugs ultimately selected, resulting in an acceptance rate of approximately 16% [6] - The directory includes a variety of drugs, with a significant number targeting rare diseases and high-cost innovative treatments [12][14] Market Dynamics - The commercial insurance innovative drug directory is expected to enhance the payment space for rare disease treatments and provide policy advantages for hospital access [1][11] - The directory's limited number of drugs aims to facilitate implementation, as having too many drugs could complicate market entry [8][11] Drug Characteristics - The drugs in the directory generally have a small patient base or clear indications, minimizing the risk of clinical misuse, and are often high-value innovative drugs that fill clinical gaps [11][12] - The directory includes multiple oncology treatments, particularly those for rare or difficult-to-treat cancers, which are expected to have a significant market impact [12][13] Commercial Insurance Implications - The commercial insurance innovative drug directory serves as a reference for various commercial insurance entities, allowing them to negotiate with innovative drug companies without the need for exclusive selections [14] - The directory is anticipated to support the development of multi-tiered medical insurance systems, encouraging commercial insurance companies to design new products based on the directory [16]

Core Insights - The release of the 2025 National Basic Medical Insurance, Maternity Insurance, and Work Injury Insurance Drug Catalogs marks a significant step in enhancing drug accessibility and innovation in China, with a total of 114 new drugs added to the basic insurance catalog, including 50 innovative drugs, achieving an overall success rate of 88%, up from 76% in 2024 [1][5][9]. Summary by Sections Basic Medical Insurance Drug Catalog - A total of 114 new drugs were successfully added, with 50 classified as innovative drugs, reflecting an overall success rate of 88% [5][9]. - The total number of drugs in the national insurance catalog now stands at 3,253, including 1,857 Western medicines and 1,396 traditional Chinese medicines, with significant improvements in coverage for critical areas such as cancer, chronic diseases, mental health, rare diseases, and pediatric medications [5][9]. - The catalog includes drugs that fill gaps in basic insurance coverage, such as treatments for triple-negative breast cancer, pancreatic cancer, and other major diseases [9]. Commercial Health Insurance Innovative Drug Catalog - The first edition of the Commercial Health Insurance Innovative Drug Catalog includes 19 drugs, with a focus on high clinical value and innovation, particularly in oncology, rare diseases, and chronic conditions [11][12]. - Notable inclusions are CAR-T therapies and treatments for rare diseases like neuroblastoma and Gaucher disease, as well as Alzheimer's disease medications [11][12]. - The catalog emphasizes the distinction between basic insurance, which focuses on essential and proven therapies, and commercial insurance, which supports cutting-edge innovations [11][12]. Future Implications - The introduction of these catalogs is expected to enhance clinical medication standards and boost confidence in pharmaceutical R&D, ensuring better healthcare and injury treatment for the public [8]. - The ongoing adjustments to the drug catalogs reflect a commitment to improving the accessibility of innovative drugs and encouraging pharmaceutical companies to invest in research and development [10][11].