商业健康保险创新药品目录（以下简称“商保创新药目录”）是基本医保“保基本”之外完善创新药补充保障的重要制度安排。本研究以18种商业健康保险创新药品（以下简称“商保创新药”）为研究对象,基于9个地方惠民保产品目录纳入情况、31个省份医疗机构和零售药店终端配备数据,以及药企、医疗机构、保险公司和第三方运营服务机构（Third-Party Administrator, TPA）访谈资料,分析商保创新药目录落地中的现实表现和障碍因素。结果显示,样本惠民保产品对目录药品已形成一定承接,但不同产品、区域和药品类型之间存在差异;零售药店在终端配备中发挥着重要补位作用,但医院端配备覆盖率不足和院内外衔接不畅仍较突出;支付理赔环节仍面临直付结算、处方流转、票据处理、折扣兑现和系统接口等堵点;多部门监管责任分工仍需进一步明确。建议围绕目录承接、终端配备、支付理赔和监管协同等关键环节,完善分类承接、院内外配备衔接、支付理赔服务和多主体协同治理机制,为优化商保创新药目录落地机制提供参考。
Abstract
The Innovative Drug List for Commercial Health Insurance is an important institutional arrangement for expanding supplementary coverage for innovative drugs. It complements the basic medical insurance system, which is designed to ensure basic coverage. Focusing on a sample of 18 innovative drugs listed for commercial health insurance, this study examines the implementation of the innovative drug list for commercial health insurance and the institutional barriers it faces. The analysis draws on three key data sources: drug inclusion in nine local city-customized commercial health insurance products, data on drug availability in medical institutions and retail pharmacies across 31 provincial-level regions, and interviews with key stakeholders, including pharmaceutical companies, medical institutions, insurers, and third-party administrators (TPAs). Results indicate that the sampled city-customized commercial health insurance products have incorporated some of the listed drugs, although the extent of inclusion varies substantially across insurance products, geographic regions, and drug categories. Retail pharmacies play an important supplementary role in drug availability, while limited availability in hospitals and weak hospital-pharmacy coordination remain prominent challenges. The payment and claims process continues to face operational barriers, including difficulties in direct settlement, prescription transfer, invoice processing, fulfillment of negotiated discounts, and interoperability between information systems. In addition, the roles of different parties need to be more clearly defined. This study suggests improving mechanisms for drug inclusion, hospital-pharmacy coordination, payment and claims services, regulatory coordination, and cooperation among different parties, so that it can inform improvements to the implementation of the Innovative Drug List for Commercial Health Insurance.
关键词
商保创新药目录 /
药品零售 /
惠民保 /
支付理赔
Key words
innovative drugs covered by commercial health insurance /
pharmaceutical retail /
city-customized commercial health insurance /
payment and claims settlement
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
参考文献
[1] 中共中央,国务院.关于深化医疗保障制度改革的意见[EB/OL].(2020-03-05)[2026-05-27].https://www.nhsa.gov.cn/art/2020/3/5/art_14_2812.html.
[2] 国家医疗保障局,人力资源社会保障部.关于印发《国家基本医疗保险、生育保险和工伤保险药品目录》以及《商业健康保险创新药品目录》(2025年)的通知[EB/OL].(2025-12-07)[2026-05-27].https://www.nhsa.gov.cn/art/2025/12/7/art_104_18970.html.
[3] 李珍,王怡欢.论基本医疗保险与商业健康保险的定位与衔接[J].中国卫生政策研究,2020,13(1):9-14.
[4] 中再寿险,镁信健康,波士顿咨询公司.中国创新药械多元支付白皮书:2025[R/OL].(2025-03-05)[2026-05-27].https://pdf.dfcfw.com/pdf/H3_AP202503051644069297_1.pdf.
[5] 严睿,王恩楠,徐怀伏.惠民保特定高额药品保障现状与趋势分析[J].健康发展与政策研究,2025,28(5):540-545.
[6] 国家医疗保障局办公室.关于氢溴酸他泽司他片有关事项的通知[EB/OL].(2026-03-09)[2026-05-27].https://www.nhsa.gov.cn/art/2026/3/9/art_109_19847.html.
[7] 国家医疗保障局,国家卫生健康委.关于印发《支持创新药高质量发展的若干措施》的通知[EB/OL].(2025-07-01)[2026-05-27].https://www.nhsa.gov.cn/art/2025/7/1/art_104_17058.html.
[8] 国家医疗保障局.国谈药及商保创新药配备机构查询[EB/OL].(2026-03-02)[2026-05-27].https://fuwu.nhsa.gov.cn/nationalHallSt/#/search/allocation-mechanism-search.
[9] Braun V, Clarke V.Using thematic analysis in psychology[J]. Qualitative Research in Psychology, 2006, 3(2): 77-101.
[10] Varvasovszky Z, Brugha R.A stakeholder analysis[J]. Health Policy and Planning, 2000, 15(3): 338-345.
[11] Schmeer K.Guidelines for conducting a stakeholder analysis[R]. Bethesda, MD: Partnerships for Health Reform, Abt Associates Inc., 1999.
[12] 陈新峰,刘莎莎,张毅.CAR-T细胞治疗的临床关键问题和对策[J].中国肿瘤生物治疗杂志,2025,32(1):9-13.
[13] Wang X, Li S C, Yue X, et al.Patient access to orphan drugs covered by medical insurance in China: real-world evidence from patient survey[J]. Value in Health Regional Issues, 2023, 34: 71-77.
[14] 张晓星,周婷婷,潘杰.国内外罕见病用药保障模式的评述[J].中国卫生政策研究,2020,13(11):18-23.
[15] Cummings J, Apostolova L, Rabinovici G D, et al.Lecanemab: appropriate use recommendations[J]. The Journal of Prevention of Alzheimer's Disease, 2023, 10(3): 362-377.
[16] Rabinovici G D, Selkoe D J, Schindler S E, et al.Donanemab: appropriate use recommendations[J]. The Journal of Prevention of Alzheimer's Disease, 2025, 12(5): 100150.
