context: The National Healthcare Security Administration announced the 2025 national medical insurance drug catalogue, adding 114 drugs. This is the first commercial health insurance innovative drug catalogue with 19 drugs signals PRC's medical security system shift from single to dual catalogue structure. The catalogue aims to cover highly innovative drugs with significant clinical value that currently fall outside basic medical insurance's scope, though implementation challenges remain.
This adjustment added 114 drugs including 50 class one innovative drugs, with an overall success rate of 88 percent, significantly higher than 2024's 76 percent. 19 drugs entered the first commercial health insurance innovative drug catalogue, which will take effect from 1 January 2026.
However, the commercial insurance innovative drug catalogue is not paid by medical insurance, with commercial health insurance's own weak scale, insurance companies' concerns about rising claims ratios and financial regulatory departments' participation willingness casting doubt on the catalogue's effectiveness in relieving pharmaceutical enterprises' payment predicaments.
Since the 2025 Huimin Bao has basically begun payment collection, which might need another year of waiting to proceed with the new drug list.
The 2025 national medical insurance drug catalogue included drugs filling basic medical insurance protection gaps, such as medications for major diseases (i.e. cancer), rare diseases, chronic disease and autoimmune diseases.
The commercial insurance innovative drug catalogue exhibits three characteristics
- embodies innovation support orientation
- included drugs like CAR-T, TCE therapy and bispecific antibodies
- demonstrates priority field attention
- including drugs adapting to population ageing trends like Alzheimer's disease plus rare disease medications frequently affecting children like Gaucher disease and neuroblastoma
- establishes basic medical insurance and commercial insurance protection boundaries
- basic medical insurance adhering to basic protection positioning mainly considering safe, reliable, definitively effective drugs with relatively mature target mechanisms, while commercial insurance emphasises innovative, cutting-edge drugs
Huang Xinyu 黄心宇 National Healthcare Security Administration Medical and Pharmaceutical Service Management Department director introduced that although medical insurance does not reimburse drugs in the commercial insurance innovative drug catalogue, the commericial catalogue has the advantage of
- being excluded from basic medical insurance self-payment quota (for hospitals)
- unaffected by centralised procurement favouritism towards the lowest bidding price
- excluded from DIP/DRG
Industry experts believe that the commercial insurance innovative drug catalogue serves as a transitional period: after three to five years of real-world clinical data verification, the drugs might be included in medical insurance eventually.
For pharmaceutical enterprises, drugs are incorporated into the entire security system, thereby revitalising their cash flows. Through the catalogue's release, enterprises can access more relevant data, such as conducting differentiated research and development layouts based on regional disease spectrum characteristics and epidemiological data.
However, commercial health insurance with its own narrow funding pools can provide limited support. Huimin Bao products mostly have no deductibles for CAR-T products but set reimbursement caps. Additionally, with a limited volume, if unable to exchange volume for price, price negotiation value for drugs on the new catelogue may mainly manifest in backend network listing, hospital entry and special case negotiations. How much price reduction magnitude can benefit patients remaining to be observed.