China's commercial insurance innovative drug catalog has achieved certain progress in terms of drug availability, insurance coverage, and payment settlement. However, its full implementation still confronts a series of challenges. From a process-oriented perspective analysis reveals that constraints within the public hospital management system and inefficient electronic prescription circulation have resulted in low clinical accessibility of drugs in the catalog. Additionally, the absence of standards for “insurance suitability” assessments and inadequate coordination among relevant departments have delayed the adoption of mainstream products such as million-yuan medical insurance. Furthermore, unclear compliance pathways for drug discounts and rebates, as well as ambiguous financial processing rules, impede the implementation of payment settlement models. It is recommended that the 2026 revision of the commercial insurance innovative drug catalog should optimize the entry mechanism, strengthen real-world evidence support, and enhance “insurance suitability” assessments. During the implementation process, coordinated efforts should focus on the three core stages of drug access—"hospital admission - insurance coverage - claims settlement". First, improving drug supply at medical institutions by refining evaluation exemptions and exploring mechanisms to compensate for pharmaceutical services; second, strengthening interdepartmental collaboration to promote tiered product coverage based on city-customized commercial health insurance; and third, removing bottlenecks in drug payment and settlement by exploring the conversion of discount rates into shared risk ratios between pharmaceutical companies and insurers.
Key words
innovative drugs /
commercial insurance innovation drug catalog /
discounts and rebates
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