Summary of Key Points
Half a year after the initial list of innovative drugs covered by commercial health insurance was established, pharmaceutical companies have realized that not only has there been no increase in drug sales, but they have also faced higher discounts demanded by insurers, increased costs, and difficulties in getting rare disease medications included in the insurance coverage programs. As a result, their enthusiasm for applying to the commercial insurance directory has significantly declined (the number of applications dropped from 141 in 2026 to 61). Many pharmaceutical companies are now focusing on trying to get their drugs included in the national medical insurance directory, with some even stating that they will not introduce drugs for which prices cannot be reduced. Meanwhile, the insurance industry association is working on a new drug coverage list (including over 100 medications, targeting million-dollar medical insurance plans), but pharmaceutical companies are still hesitant due to concerns about hospital access and other issues.
Commercial Insurance Directory Becomes a Troublesome Issue
Pharmaceutical companies hoped that being included in the commercial insurance directory would boost sales, but instead, they have encountered the following problems:
- Insurers demanding high discounts: After inclusion, insurers require substantial discounts at each transaction, using an unreasonable calculation method. For example, for a drug costing 600,000 yuan, if the insurer pays 50% (300,000 yuan), the company might offer a discount of 30,000 yuan, but the insurer still expects 70,000 to 80,000 yuan, which is much higher than the previous sponsorship fees.
- Increasing sponsorship fees for insurance policies: While previously, small batches of policies for the welfare insurance program only required a few thousand yuan in sponsorship, insurers are now asking for significantly more and even demanding that pharmaceutical companies share the risks (for instance, only allowing coverage for two patients per year, with any excess costs falling on the company).
- Greater challenges for rare disease medications: Insurers are wary of the high claim risks associated with rare diseases, either refusing to cover these medications or offering low compensation rates (usually 20%-30%), leaving patients unable to afford the treatment even with subsidies (with a maximum out-of-pocket cost of 50,000 yuan).
As a result, pharmaceutical companies' costs have soared, yet sales have not increased.
Pharmaceutical Companies Shift Their Focus: National Medical Insurance as the Better Option
After careful consideration, pharmaceutical companies have realized that national medical insurance is a more reliable option:
- Greater sales potential with medical insurance: Medical insurance has a wider coverage, and sales increase significantly when drugs are included. In contrast, the impact of being in the commercial insurance directory is minimal (for example, medications for Alzheimer's disease and cancer have not seen significant sales boosts).
- It's more cost-effective to help patients directly: For a 600,000 yuan drug, if the insurer pays 30% (180,000 yuan), of which 70,000 to 80,000 yuan comes from the company's sponsorship and the insurer only pays 100,000 yuan, it might be better to subsidize the patient directly, saving on the costs associated with negotiating for inclusion in various welfare insurance programs.
- Decline in application enthusiasm: The number of applications to the commercial insurance directory dropped from 141 in 2026 to 61. Many companies now say they will prioritize national medical insurance and will not bring drugs whose prices cannot be reduced to China.
Differentiated Treatment for Medications
The situation for different types of medications in the commercial insurance directory varies greatly:
- Cancer medications: These are relatively easy to include but difficult to get prescribed in hospitals. Although insurers are willing to include them to attract customers, the actual process of getting them prescribed remains a challenge.
- Rare disease medications: Insurers are reluctant to cover these due to high claim risks, either refusing to include them or offering low compensation rates, making it hard for patients to access the necessary treatment.
The main reason for this is that insurers focus solely on financial considerations: Cancer medications, with lower risk, can generate more insurance sales, while rare disease medications pose higher claims risks and are therefore less profitable.
New Coverage List in the Works, but Companies Are Cautious
The insurance industry association is working on a new drug coverage list (including over 100 medications for million-dollar medical and group insurance plans), but pharmaceutical companies remain cautious:
- Limited progress: Only preliminary discussions about risk-sharing have taken place so far, with no specific implementation plan (such as how to coordinate hospital access).
- Major concern: Hospital access: Since drugs included in the national medical insurance directory still face difficulties in getting prescribed in hospitals, and since the insurance association and commercial insurers are not part of the medical or health systems, they lack the resources to coordinate hospital approval. Pharmaceutical companies fear that even with the new list, medications may still not be available to patients, and sales will not increase.
In summary, while the commercial insurance directory has promising potential, the reality is far from ideal. Pharmaceutical companies have not seen the expected increase in sales and have instead faced increased costs. National medical insurance remains the primary focus for them. For commercial insurance to play a significant role in drug coverage, it needs to address key issues such as reducing company costs, controlling insurer risks, and ensuring smooth hospital access.