How do patients benefit when high-priced drugs are covered by commercial insurance? Breaking through the "last mile" of innovative drug implementation… these bottlenecks need to be cleared⋯⋯

The Daily Economic News Reporter | Tu Yinghao The Daily Economic News Editor | Liao Dan

This year’s Government Work Report mentions “Launching the Commercial Health Insurance Innovative Drug List.”

By 2025, the National Healthcare Security Administration and other departments will continue to introduce policies supporting the high-quality development of innovative drugs. At the end of the year, the “Commercial Health Insurance Innovative Drug List” was released, including 19 high-value innovative drugs not covered by medical insurance into the commercial insurance protection scope for the first time, promoting a dual-track payment system where medical insurance “covers basic needs” and commercial insurance “covers high-value” and “supports innovation.”

This move provides a new approach to solving the “payment difficulty” for high-value innovative drugs and makes commercial health insurance an important support for the development of innovative drugs and devices. However, after the list’s implementation, innovative drugs still face multiple bottlenecks in clinical application. How to bridge this “last mile” and truly benefit patients with high-value innovative drugs has become a key issue for the industry to address.

Annual compound growth rate of 70%, health insurance claims for innovative drugs and devices have increased for four consecutive years

Driven by policy support and market demand, the average annual compound growth rate of commercial health insurance over the past decade has exceeded 20%, with over 11,000 medical insurance products currently on sale.

In recent years, commercial health insurance has continuously expanded its coverage and enhanced its health protection services. Industry insiders point out that ten years ago, the industry included CAR-T therapies costing over one million yuan in its responsibility list. Today, most mainstream medical insurance products on the market cover new technologies, drugs, and devices, including targeted cancer therapies and proton and heavy ion therapies, which are high-value technologies.

Preliminary estimates indicate that in 2025, the total claims paid by commercial health insurance for innovative drugs and devices will reach about 14.7 billion yuan, with a rapid growth rate over four years and a compound annual growth rate of 70%.

For the work in 2026, the Government Work Report proposes to accelerate the development of commercial health insurance, promote the high-quality development of innovative drugs and medical devices, and better meet the diverse medical and medication needs of the people.

According to Axel Tianping’s CEO, Zuo Weihao, this opens a new development space for the insurance industry, encouraging market participants like AXA to accelerate the development of commercial health insurance and promote medical innovation. By including innovative drugs and devices, providing quality medical resources, and offering full-cycle health management, it can work together with basic medical insurance to protect people’s health.

Lang Liliang, Senior Vice President and Chief Business Officer of Magnesium Health, told the Daily Economic News that this year’s Government Work Report explicitly states “accelerate the development of commercial health insurance” and closely links it with the high-quality development of innovative drugs. This is a precise deployment for building a multi-layered healthcare security system and points the way for high-quality development of the health industry. “Commercial health insurance is an important pillar of China’s multi-layered healthcare security system. It is not only an effective supplement to basic medical insurance but also a vital bridge connecting patients with high-quality medical resources.”

In Lang Liliang’s view, commercial health insurance is both an “accelerator” and a “stabilizer” for the high-quality development of innovative drugs and devices. By building market-based payment guarantees, expanding coverage for innovative drugs and devices, and improving a diversified payment ecosystem, commercial health insurance can significantly improve the accessibility and affordability of innovative therapies, stabilize the innovation returns for pharmaceutical companies, and further incentivize R&D investment, forming a positive cycle of “coverage expansion—drug and device innovation—patient benefits.”

Last year’s first version of the list was implemented. How to solve the “last mile” problem of innovative drugs?

With the accelerated iteration of biomedical technology, China ranks second globally in the number of innovative drugs launched. However, high-value innovative drugs still face prominent issues of “difficult hospital admission and payment.”

At the 2025 High-Quality Development Conference for Innovative Drugs, the first version of the commercial insurance innovative drug list was officially released. Although the list has been implemented, innovative drugs still face the “last mile” problem in clinical application: insufficient prescription basis for doctors, limited risk control measures by commercial insurance companies, and weak patient benefits.

During the two sessions this year, Sun Jie, member of the National Committee of the Chinese People’s Political Consultative Conference and Vice Dean of the Insurance School at the University of International Business and Economics, suggested granting commercial health insurance companies the authority to develop medication guidelines and clinical pathways for high-value innovative drugs. This would form a new collaborative governance pattern of “medical insurance sets the direction, commercial insurance sets standards, hospitals implement.” Empowering specialized health insurance companies as strategic buyers and payers of high-value innovative drugs, with negotiation and pricing rights, and also making them the creators of medication guidelines and clinical pathways, can effectively improve the accessibility and affordability of list-listed drugs.

It is reported that the first version of the commercial insurance list includes 19 high-value innovative drugs, covering 5 CAR-T therapies (targeted cancer treatments), multiple treatments for malignant tumors, and rare diseases, focusing on high-value drugs not yet covered by basic medical insurance.

“Of the 19 drugs, 17 are injections, which require administration by medical staff in hospitals. However, some hospitals, following their management standards, refuse to allow patients to purchase injections externally and return to the hospital for injection,” Sun Jie said. Therefore, hospital provisioning of drugs listed in the commercial insurance list is a key step to bridging the “last mile” of innovative drug implementation.

Focusing on hospital-side bottlenecks, Sun Jie proposed three suggestions: from performance evaluation, funding access, and payment mechanisms, to comprehensively remove hospitals’ concerns and institutional constraints on drug use, clearing obstacles for the inclusion of listed drugs into hospitals.

Specifically, first, optimize the performance monitoring indicators of tertiary public hospitals, explicitly removing commercial insurance list drugs from expense indicators and adding indicators for the proportion of innovative drug use; second, allow public hospitals to accept commercial insurance funds beyond fiscal allocations, medical insurance funds, and patient payments, and establish a co-payment mechanism involving medical insurance, commercial insurance, and patient contributions; third, on the basis of DRG/DIP (Diagnosis-Related Group/Diagnosis-Related Payment) systems excluding certain payments, establish a bonus payment mechanism for the 19 drugs in the commercial insurance list.

Zhou Yanfang, a National People’s Congress deputy and Director of the ESG Office at China Pacific Insurance’s Strategic Research Center, suggested including the provisioning status of commercial insurance innovative drugs in the performance assessments of national key clinical departments and leading hospitals to incentivize medical institutions to ensure “access and prescription” of listed drugs. Simplify approval processes for medical review committees and encourage hospitals to “willingly and quickly adopt.”

Meanwhile, promote full interconnection between the commercial insurance list and the “dual-channel” pharmacy settlement system. Relying on the national medical insurance information platform, establish a one-stop instant settlement mechanism for commercial insurance innovative drugs, ensuring patients can purchase drugs at outside pharmacies without prepayment and with post-reimbursement, reducing the need for patients to make multiple trips.

Enhance coverage of惠民保 (People’s Benefit Insurance), and promote deep integration with the commercial insurance list

With its low premiums and broad coverage,惠民保 (People’s Benefit Insurance) has played an increasingly important role in alleviating high medical costs and preventing families from falling into poverty due to illness. Its core innovative component is the coverage of special drugs, directly supporting the commercialization of innovative drugs.

The “2025 Urban Customized Commercial Medical Insurance (惠民保) Knowledge Graph” shows that among the 169 basic traditional惠民保 products currently operated, 137 include coverage for special drugs, accounting for over 80%. On average, each惠民保 product covers 41 types of special drugs across 28 indications. Industry experts generally believe that while惠民保 is rapidly expanding, its coverage of innovative drugs still has significant gaps, making it difficult to match the development of the innovative drug industry and patient clinical needs.

Sun Jie noted that current惠民保 drug lists have limited coverage, typically including dozens of drugs, which is narrow compared to the hundreds of approved innovative drugs on the market. This results in many urgently needed innovative drugs remaining outside coverage, unable to meet insured patients’ demand for diverse and personalized treatment options. Additionally, limited funding pools and premium restrictions constrain the inclusion of high-value innovative drugs.

To address this, Sun Jie suggested promoting惠民保’s upgrade to improve its coverage of innovative drugs. She recommended expanding惠民保’s coverage of innovative drugs across regions, increasing the number of drugs outside basic medical insurance coverage. She also encouraged commercial insurance companies to develop innovative drug insurance products linked with惠民保, such as “special drug insurance” for drugs outside the list or higher-coverage "upgraded"惠民保.

She further proposed adopting the experience from the innovative drug list, implementing joint price negotiations and shared payments. Led by惠民保 insurers, multiple commercial insurers could jointly negotiate prices with pharmaceutical companies, covering not only settlement prices but also payment terms and coverage scope. Exploring volume-price agreements and efficacy-based payment agreements is also encouraged. “This data-driven dynamic adjustment mechanism can ensure efficient use of insurance funds and motivate pharmaceutical companies to continuously provide clinical evidence, creating a virtuous cycle,” Sun Jie said.

Notably, some local governments have already taken the lead by promoting deep integration between惠民保 and the national commercial insurance innovative drug list, providing practical examples for nationwide implementation.

On March 3, the Shanghai Municipal Government held the 2026 Shanghai Health and Medical Security Work Conference, guiding the upgrade of the 2026 “Shanghai惠民保,” promoting the launch of exemplary commercial group insurance products, improving policies for individual account-based commercial health insurance, and strengthening support for innovative drugs and devices in line with the national commercial insurance innovative drug list. Policies on listing, insurance coverage, hospitalization, and payment for innovative drugs and devices are being improved to accelerate clinical application. New models for cross-border drug and device transactions are being explored, and regular “medical insurance—medical enterprise” face-to-face activities are being conducted.