High-value innovative drugs welcome a new payment channel: By 2025, the commercial insurance catalog will be included in the national medical insurance negotiation for the first time.

On November 2nd, the highly anticipated national medical insurance drug negotiation entered its fourth day. As the negotiation for the basic medical insurance catalog drugs nears its end, today will also see the negotiation of innovative drugs for the commercial insurance catalog. This year marks the 8th adjustment of the medical insurance catalog since the establishment of the National Medical Insurance Administration. Unlike previous years, this year's catalog adjustment has, for the first time, added the Commercial Health Insurance Innovative Drug Catalog (referred to as the "Commercial Insurance Innovative Drug Catalog"). The two catalogs will complement each other differentially: the basic medical insurance mainly includes essential, safe, effective, and reasonably priced basic drugs, aiming to achieve "basic coverage for all"; while the commercial insurance innovative drug catalog focuses on innovative drugs that go beyond the "basic coverage" scope, are temporarily unable to be included in basic medical insurance, but have high levels of innovation, clinical value, and significant patient benefits. Although the drugs in the commercial insurance innovative drug catalog are not covered by the basic medical insurance fund, the National Medical Insurance Administration has explicitly stated that it will promote the use of this catalog in multi-level medical insurance systems such as commercial health insurance and medical mutual aid. At the same time, several supporting measures will be launched simultaneously, such as exempting commercial insurance catalog drugs from the basic medical insurance out-of-pocket rate assessment, and not including eligible cases in the payment range based on disease types, to alleviate the management pressure on medical institutions using high-value innovative drugs. According to the work plan, companies can choose to apply for the commercial insurance catalog separately or simultaneously apply for both catalogs. If a drug meets the inclusion criteria for both catalogs as determined by expert evaluation, it will take priority in the basic medical insurance negotiation; if the negotiation is unsuccessful, it will then move to the price negotiation phase of the commercial insurance catalog. The establishment of the commercial insurance innovative drug catalog is crucial as it provides a new access pathway for "high-priced drugs" that are currently difficult to enter the basic medical insurance through price reduction. According to the list published by the National Medical Insurance Administration, a total of 121 drugs have passed the form review through the commercial insurance catalog, including 5 CAR-T cell therapy drugs with individual prices exceeding one million yuan. Before this, such high-value innovative drugs were always excluded from basic medical insurance. Of the 5 CAR-T therapies, 3 of them applied to both catalogs simultaneously. However, passing the form review (initial review) is only the first step. One CAR-T company informed a reporter from the "Science and Technology Innovation Board Daily" that despite their product being applied to both catalogs and passing the initial review, it was rejected in the subsequent expert evaluation stage, so it will not participate in the basic medical insurance negotiation but will directly enter the commercial insurance catalog negotiation. In addition, through the 121 drugs that have passed the initial review, it can be seen that the coverage of the commercial insurance innovative drug catalog mainly focuses on disease areas with heavy burdens and urgent clinical needs. Tumor drugs account for the highest proportion, with over 40, followed by rare disease drugs totaling 35. As the aging population increases, the social burden of Alzheimer's disease becomes increasingly prominent. The list of initial reviews also includes two milestone innovative drugs - Roche's aducanumab and Weiqi's lunacannumab. The establishment of the commercial insurance innovative drug catalog provides a more flexible market access pathway for high-value innovative drugs, attracting nearly 30 multinational pharmaceutical companies to actively participate, as well as leading domestic pharmaceutical companies such as Jiangsu Hengrui Pharmaceuticals, BEIGENE, Sino Biopharmaceutical, Shanghai Fosun Pharmaceutical, and China Resources Pharmaceutical. The new opportunities brought by the commercial insurance innovative drug catalog have also been recognized by vaccine companies. Among the 121 drugs on the list, there is only one vaccine product. Although, according to the reporter of the "Science and Technology Innovation Board Daily," this quadrivalent influenza subunit vaccine ultimately stopped at the expert review, the company's actions still open up new ideas for the market access of preventive biological products like vaccines. As a new institutional attempt, the "debut" of the commercial insurance innovative drug catalog this year is destined to be a process of "crossing the river by feeling the stones," so many implementation steps will have uncertainties. For example, in terms of scheduling, participating companies have reflected that they only learned of the specific negotiation time just before the negotiation. This exploratory process also represents uncertainty in core mechanisms such as price negotiation and integration with insurance products, as all parties gradually explore and adapt in practice. The industry generally expects that at this stage, the commercial insurance innovative drug catalog will most likely first be implemented through universal insurance products like "people's convenience insurance" in various regions. Although the specific model is still under exploration, the direction of providing additional payment channels for high-value innovative drugs is already clear. As someone told the reporter, "Although the actual landing effect of the initial phase is yet to be observed, this big step forward undoubtedly injects new hope into the industry, and the future is worth looking forward to." This article is reprinted from Cailian Press, GMTEight Editor: Chen Yufeng.