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.
Key words
innovative drugs covered by commercial health insurance /
pharmaceutical retail /
city-customized commercial health insurance /
payment and claims settlement
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