The mid-year policy implementation window has opened as scheduled, marking the substantive advancement of the 2026 National Drug Reimbursement List adjustment, a process that guides the direction of the trillion-yuan pharmaceutical market.
On June 9th, the National Healthcare Security Administration issued a critical notice regarding the application process for this year's list update. According to the "2026 National Basic Medical, Maternity, and Work-Related Injury Insurance Drug List and Commercial Health Insurance Innovative Drug List Adjustment Work Plan", the online application portal officially closed at 20:00 on June 10th, after which the system would no longer accept submission materials.
Data shows that as of 17:00 on June 9th, 80 drugs within the list whose agreements are set to expire had not yet completed the application process. The National Healthcare Security Administration reminded relevant pharmaceutical companies to ensure submission before the deadline, as failure to do so would directly impact the renewal process for the corresponding drugs. Meanwhile, drugs outside the list intending to apply also needed to complete their online submissions promptly.
That same morning, PICC Health and its subsidiary PICC Health Management Co., Ltd., held a strategic cooperation agreement signing ceremony in Shenzhen with China Resources Health Group Co., Ltd. and other subsidiaries under China Resources Group. The collaboration spans eight key areas, including the commercial insurance drug list, insurance product operations, insurance development for individuals with pre-existing conditions, commercial insurance service center construction, corporate health services, health check-up upgrades, risk reduction and health big data cooperation for insurance clients. This partnership aims to explore an innovative model for the coordinated development of "insurance + healthcare + health management + technology".
Graded Access Implementation
The commercial insurance innovation drug list is paving a direct pathway for entry into the basic medical insurance system.
During a prior official policy briefing, the National Healthcare Security Administration clarified the core rule of the dual-list linkage: the 2026 basic medical insurance list will fully accept direct applications from drugs listed in the commercial insurance innovation drug catalog, formally implementing the "commercial insurance exploration, medical insurance follow-up" graded access model.
This signifies that after a new drug or medical device launches, it can first be applied clinically through commercial insurance channels to accumulate real-world data and scale down production costs. Once its clinical value is fully validated, it can then be sequentially applied for inclusion in the basic medical insurance system, forming a positive access loop characterized by "market validation first, policy universal coverage as a safety net".
Industry observers view the coordinated linkage between the basic medical insurance and commercial insurance lists as the most groundbreaking institutional innovation in this round of adjustments. Long Ge, co-founder and general manager of Zhongtuobang, analyzed that the commercial insurance innovation drug list has become a preparatory channel for innovative drugs to enter basic medical insurance. Drugs within this list have completely broken the previous five-year application period policy restriction. Coupled with the implementation of the pre-application mechanism, this not only significantly lowers the entry barrier for innovative drugs into basic medical insurance but also sends a stable, predictable long-term policy signal to the pharmaceutical industry and capital markets.
Since the nationwide implementation of the first edition of the commercial insurance innovation drug list on January 1st this year, the empowering effect of the policy has continued to be released. City-specific inclusive medical insurance products across various regions have been the first to adapt. Taking Shenzhen's惠民保 as an example, this product achieves full coverage of the commercial insurance innovation drug list. Eligible insured individuals can normally claim reimbursement for related expenses, and the accompanying one-stop settlement service further simplifies the medical treatment and claims process.
From May 1st to June 30th, "Suzhibao", the nation's first group-specific惠民保 product guided by the Suzhou Municipal Healthcare Security Administration, was officially launched for sale to enterprises and institutions in Suzhou. Its coverage scope focuses on out-of-pocket medical expenses, complementing the basic medical insurance. It notably covers all drugs in the first edition of the commercial insurance innovation drug list and部分 Suzhou-local specialty drugs. Concurrently, the product stipulates that "this insurance is a group policy for employees; individuals cannot purchase it directly. Insured employees must be covered by urban employee basic medical insurance and, in principle, be under 65 years of age."
Industry veterans point out that since 2026, many惠民保 products have employed multiple measures to strictly control claims risk, such as setting single-drug reimbursement caps, optimizing CAR-T drug coverage lists, lowering reimbursement ratios, and refining免责 clauses for pre-existing conditions. This intuitively reflects the sustained pressure that high-priced innovative drugs place on the refined operations of commercial health insurance.
The commercial insurance innovation drug list is not a safe harbor but a payment testing ground. Basic medical insurance adheres to the core principles of ensuring basic coverage and broad reach while balancing the sustainability of fund operations. Commercial insurance, on the other hand, places greater emphasis on benefit design, claims risk management, market willingness to pay, and the accessibility of drug availability.
Inclusion in the commercial insurance innovation drug list is merely the first step, followed by multiple subsequent challenges: how insurers will incorporate it into formal benefit coverage, whether medical institutions can conduct clinical use compliantly, if patient claims processes are smooth, whether overall claims ratios can be maintained within a reasonable range, and if real-world application data can support long-term payment models. These are all pressing questions that need answers. Without effective data on real-world use, actual claims, and落地 accessibility, innovative drugs will lack solid footing for further inclusion in the basic medical insurance list.
Deep Reshaping of Commercial Insurance's Role
Behind the expansion of payment channels lie hidden risk control challenges.
For domestic innovative pharmaceutical companies, the deep-seated value of the dual-list linkage reform lies in fundamentally broadening the commercialization channels for high-value innovative drugs, constructing a diversified and sustainable market monetization system.
According to data released by the National Medical Products Administration, during the "14th Five-Year Plan" period, the number of innovative drug approvals in China surged, and out-licensing transactions repeatedly hit new highs.
Data shows that in 2025, China approved 76 innovative drugs for marketing, surpassing the 48 approved in 2024. By the end of 2025, the total annual transaction value for Chinese innovative drug out-licensing deals reached $135.655 billion across 157 transactions, far exceeding the $51.9 billion and 94 transactions for the entirety of 2024.
China's innovative drug transaction value is catching up with that of the United States, with mega-deals frequently appearing. The total number of clinical studies in China already ranks first globally, with储备 innovative drug research accounting for about 30% of the global total, exceeding 50% in some fields. China's innovative drug sector is poised for explosive growth over the next five years.
Zhang Xiaodong, founder and CEO of MedTrust, believes that China possesses the world's largest patient population, giving the Chinese market itself the potential to nurture world-class pharmaceutical companies. If the scale of China's commercial health insurance market can reach approximately 50% of that of the United States over the next 5 to 10 years, China's biopharmaceutical industry has the opportunity to give rise to the next trillion-yuan market.
Recently, the "China Innovative Drugs and Devices Multi-Payer Payment White Paper 2026 Edition", jointly released by China Re Life and MedTrust, shows that the total payment pool for innovative drugs in China in 2025 was approximately 195 billion yuan. Of this, basic medical insurance paid 90.5 billion yuan, accounting for 46.4%; patient out-of-pocket payments were 89.3 billion yuan, accounting for 45.8%. Basic medical insurance remains the core pillar of the innovative drug payment system, undertaking the central function of普惠保障.
Simultaneously, the payment support capacity of commercial health insurance is continuously strengthening, becoming an important incremental market for innovative drug落地. White paper data indicates that in 2025, the payment scale for innovative drugs and devices by commercial health insurance reached 15.2 billion yuan, a year-on-year increase of 23%. Within this, medical insurance paid 8.2 billion yuan and critical illness insurance paid 7 billion yuan.
Within the medical insurance细分板块, city-specific inclusive medical insurance products paid out 1.8 billion yuan for innovative drugs in 2025, remaining基本持平 with 2024. Individual medical insurance products paid out 5.3 billion yuan for the full year, a 40% increase from 2024. Enterprise supplementary medical insurance paid out 1.1 billion yuan,基本持平 with 2024.
Looking at the experience of mature international markets, no developed country's innovative drug market relies on a single payer. Taking the United States as an example, commercial insurance, government Medicare/Medicaid, and Pharmacy Benefit Managers form a diversified payment system. After a new drug launches, pharmaceutical companies can simultaneously engage with multiple insurers, PBMs, and employer benefit plans, allowing for more flexible pricing. Patients pay through insurance, with co-payments typically around 20%, meaning most patients do not forgo treatment due to drug costs. Commercial health insurance accounts for over 35% of total healthcare expenditure and is the primary source of payment for innovative drugs.
Although development paths differ across European countries, they similarly adhere to multi-payer models. Germany sets a 12-month free pricing window for innovative drugs, during which药企 can negotiate with the statutory health insurance fund. If no agreement is reached, a专业仲裁机构 intervenes. In the UK, the National Institute for Health and Care Excellence conducts cost-effectiveness assessments to determine if a drug is included in the public healthcare system. Drugs not included can still be accessed by patients through out-of-pocket payment or commercial insurance. France, Italy, and other countries also have similar多元报销 mechanisms.
In China, constrained by the core定位 of "ensuring basic, broad coverage" and the底线 of medical insurance fund balance, basic medical insurance cannot independently bear the payment pressure for high-value innovative drugs. Building a diversified medical payment system shared by basic medical insurance, commercial insurance, and多方共担 has become an inevitable choice for the high-quality and sustainable development of the pharmaceutical industry.
Advisory List Demonstrates Institutional Flexibility
Balancing多方 interests ensures long-term industry development.
During the official policy briefing, the National Healthcare Security Administration clarified that "the commercial insurance innovation drug list is an advisory list, not mandatory. The coverage scope and benefits of commercial health insurance are market behaviors." This arrangement clearly delineates the boundaries of rights and responsibilities for all parties: regulators fully respect the development规律 of the insurance industry, do not强制 insurers to include listed drugs in their coverage, provide companies with sufficient time for product design and actuarial calculations, and avoid rushing or强迫推进.
Wang Pingyang, Vice President of the Zhejiang Medical Security Research Association and Chairman of the Commercial Supplementary Medical Insurance Committee, believes that the institutional巧思 of the dual-list coordinated reform is核心体现在 in the differentiated positioning of the commercial insurance innovation drug list as "advisory, non-mandatory", which is also key to understanding the logic of this round of multi-level medical insurance system reform.
In his view, the flexible advisory list model is a pragmatic institutional arrangement by regulators to balance the demands of multiple stakeholders. The pharmaceutical industry urgently needs policy empowerment to boost innovation momentum, the insurance industry needs strict control of claims risk for稳健经营, and the general public eagerly anticipates降低 the使用门槛 for high-value innovative drugs to achieve普惠可及. With these多重诉求交织, rigid mandatory policies cannot adapt to the complex market现状.
Simultaneously, the commercial insurance innovation drug list inherently faces an internal balancing dilemma regarding value orientation: if it侧重于 supporting pharmaceutical innovation, the list筛选 will优先考量 clinical value and innovation attributes,适度放宽准入 standards and扩大覆盖范围; if it侧重于适配 the稳健发展 of the insurance industry, it will重点核查 the insurability and controllability of drugs, strictly adhering to the底线 of claims risk. These two development导向对应完全不同的筛选 rules and准入 standards, making it difficult to完全统一 the interests of all parties. The advisory list恰好成为 the optimal institutional solution for balancing innovation incentives and risk prevention, preserving space for pharmaceutical innovation while safeguarding the底线 of the insurance industry's稳健经营.
The construction of a multi-level medical security system is a systematic, long-term project that cannot be achieved overnight. As the coordinated mechanism between the basic medical insurance and commercial insurance lists continues to optimize, the refined operational level of commercial health insurance持续提升, and domestic pharmaceutical innovation活力充分迸发, the联动深度 and协同广度 of the two保障 systems will further expand,助力 the healthcare payment ecosystem and the医药创新 industry to empower each other and progress steadily.
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