Author｜Zhou Yanli &#34;Former Deputy Secretary and Vice Chairman of the China Insurance Regulatory Commission&#34;
Article｜&#34;China Finance&#34; Issue 5, 2026
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In recent years, the country has adhered to a people-centered approach, paying close attention to public health, continuously improving the medical security system, emphasizing the role and function of commercial health insurance, and promoting rapid development of commercial insurance at an annual growth rate of about 20%, with the coverage population continuously expanding, now exceeding 1.3 billion people. On one hand, the &#34;Basic Medical Insurance for Urban Employees and Urban and Rural Residents&#34; and &#34;Urban Customized Medical Insurance&#34; undertaken by commercial insurance have played an important role in filling gaps; on the other hand, the research on the commercial drug insurance catalog (hereinafter referred to as commercial drug insurance) is a reflection of the continuous deepening of insurance services in commercial health insurance, providing policy basis and practical exploration for the construction and development of China's multi-level medical security system.
The Triple Core Value of Commercial Drug Insurance Catalog Construction
The &#34;Suggestions of the Central Committee of the Communist Party of China on Formulating the 15th Five-Year Plan for National Economic and Social Development&#34; (hereinafter referred to as &#34;Suggestions&#34;) emphasizes, &#34;Accelerate the construction of a Healthy China,&#34; &#34;Implement a health priority development strategy, improve the policy system for health promotion, enhance the effectiveness of the patriotic health campaign, and increase life expectancy and health levels,&#34; and &#34;Improve the coordinated development and governance mechanism of medical care, medical insurance, and pharmaceuticals.&#34; These policy measures provide strong support for promoting the high-quality development of commercial health insurance, serving the Healthy China strategy, and achieving the modernization of China.
Currently, China is at a critical stage of advancing the construction of a Healthy China. The &#34;Suggestions&#34; clearly include health insurance as a core construction content of the multi-level medical security system, while the commercial health insurance drug insurance catalog (hereinafter referred to as commercial drug insurance catalog) serves as an important link connecting medical care, pharmaceuticals, and insurance, and its construction level directly relates to the protection effectiveness of commercial health insurance, as well as the quality of the implementation of the Healthy China strategy. In July 2025, the National Medical Insurance Administration and the National Health Commission jointly launched the innovative drug catalog for commercial health insurance, marking the transition of China's medical security system from &#34;institutional framework construction&#34; to &#34;functional deep integration,&#34; with the commercial drug insurance catalog being an important carrier of this transformation. From a practical perspective, the construction of the commercial drug insurance catalog has three core values.
First, it fills protection gaps and addresses the accessibility challenges of high-value innovative drugs. Currently, cutting-edge innovative drugs such as CAR-T cell therapy and bispecific antibodies are often not included in the basic medical insurance catalog due to their high prices and limited clinical data, yet these drugs are often &#34;lifesaving drugs&#34; for patients with severe or rare diseases. The commercial drug insurance catalog focuses on drugs that are not covered by medical insurance but have significant clinical value, establishing protection channels through market mechanisms to effectively reduce the catastrophic medical expenditure risk for patients.
Second, it empowers industrial innovation and builds an ecosystem for the coordinated development of pharmaceuticals and insurance. The commercial drug insurance catalog provides a market access path and stable payment expectations for innovative drugs, guiding insurance funds to become patient capital supporting the research and development of innovative drugs, and promoting the pharmaceutical industry to transform into new productive forces
Third, promote the transformation of commercial insurance, upgrading from &#34;post-compensation&#34; to &#34;full-process health management.&#34; Relying on the research of the drug medical insurance catalog construction, commercial insurance can extend the service chain, building a closed loop of &#34;protection + drugs + health management,&#34; helping commercial health insurance break free from homogeneous competition and move towards a high-quality development stage.
Promote precise services and high-quality development of commercial health insurance
The construction of the commercial insurance drug catalog is of great significance, but it should also be recognized that it is still in the initial stage and faces many practical challenges. First, the lack of unified standards in catalog formulation leads to prominent fragmentation issues. Currently, commercial insurance drug catalogs are mostly formulated by insurance companies themselves, with inconsistent screening standards and significant differences in coverage, and some catalogs tend to &#34;emphasize marketing over protection,&#34; making it difficult to form scale effects and a synergy of protection. Second, the collaborative mechanism between medical insurance and commercial insurance catalogs is not well established. Although the &#34;dual catalog&#34; parallel model has been initially established, there are still barriers in areas such as access connection, data sharing, and payment coordination, and a gradient protection closed loop of &#34;commercial insurance exploration, medical insurance relay&#34; has not yet formed. Third, data barriers restrict the refined management of the drug medical insurance catalog. Commercial insurance companies lack sufficient clinical data and drug efficacy data support, leading to insufficient precision in catalog access evaluation, pricing calculation, and risk control, affecting protection efficiency and sustainability. Fourth, the supporting system is not perfect. The drug price negotiation mechanism, inter-departmental regulatory mechanism, and diversified co-payment mechanism are not yet mature, and some medical institutions, due to concerns about cost control assessments, have low enthusiasm for the clinical application of drugs in the commercial insurance catalog, affecting the implementation effect of the catalog.
Therefore, during the &#34;14th Five-Year Plan&#34; period, it is necessary to base on the strategic requirements of Healthy China, promote the research on the construction of commercial insurance drug medical insurance catalogs, and focus on the following aspects of work to promote precise services and high-quality development of commercial health insurance.
First, establish a standardized and regulated system for the formulation of commercial insurance drug medical insurance catalogs. Standardization is the premise for the commercial insurance drug medical insurance catalog to exert scale effects. On the one hand, it is necessary to accelerate the establishment of a nationwide unified core screening standard for commercial insurance drug medical insurance catalogs, clarifying the core principles of &#34;clinical value priority, significant patient benefit, controllable insurability,&#34; focusing on including rare disease drugs not covered by medical insurance, innovative cancer drugs, etc.; at the same time, establish a dynamic adjustment mechanism to regularly update based on factors such as clinical data of drugs and price changes, achieving an optimization cycle of &#34;entry and exit.&#34; The first commercial health insurance innovative drug catalog in 2025 included 19 drugs, of which 9 are Class 1 new drugs, and nearly half are cutting-edge therapies, which is a selection logic worth promoting. On the other hand, it is necessary to standardize the catalog management process, introduce third-party professional institutions to participate in catalog evaluation, and invite experts from multiple fields such as medicine, pharmacy, and actuarial science to form an evaluation committee, ensuring the scientificity, fairness, and transparency of catalog formulation, avoiding distortion issues caused by corporate competition and marketing drives.
Second, deepen the collaborative linkage of the &#34;dual catalog&#34; and build a multi-level protection closed loop. Medical insurance and commercial insurance are not mutually exclusive but are complementary and synergistic. It is necessary to improve the division of labor mechanism of &#34;medical insurance covers the basics, commercial insurance supplements the frontiers,&#34; with basic medical insurance focusing on clinically essential basic drugs, and the commercial insurance catalog focusing on filling the protection gaps in high-value, niche, and cutting-edge areas, forming a protection network that covers all scenarios of drug demand
In addition, a gradient access mechanism of &#34;commercial insurance first, then medical insurance&#34; should be established, allowing new drugs to be included in the commercial insurance catalog first to accumulate real-world data. Once sufficient clinical value evidence is available and prices become reasonable, negotiations can be conducted to include them in the basic medical insurance catalog, achieving a smooth connection of the protection levels. In terms of implementation, efforts should be made to promote the listing of drugs in the commercial insurance catalog, manage them in reference to the drugs negotiated under medical insurance, include them in the &#34;medical insurance drug cloud platform&#34; for monitoring, and encourage designated pharmacies to be equipped simultaneously, thereby bridging the &#34;last mile&#34; of drug supply. The assessment mechanism for medical institutions should be optimized to implement the &#34;three exclusions&#34; policy for drugs in the commercial insurance catalog, which means they will not be included in the basic medical insurance self-payment rate indicators, will not be monitored as alternative varieties in centralized procurement, and may not be included in the medical insurance payment scope by disease after review, eliminating clinical application concerns for hospitals.
Third, break down data barriers and build a digital foundation for precise protection. Data is the core element for the refined management and precise service of the commercial insurance drug catalog. Therefore, based on the medical insurance information platform, a secure data sharing mechanism between medical insurance and commercial insurance should be established, opening necessary clinical medication data, settlement data, and efficacy data to eligible commercial insurance companies to support catalog access evaluation, product pricing, claims services, and more. It is understood that pilot projects in cities like Shanghai and Guangzhou have verified the value of data interconnectivity. In Shanghai, 12 tertiary hospitals have achieved &#34;one-stop instant claims&#34; for 'medical insurance + commercial insurance', reducing the claims processing time from 7 working days to 30 minutes, and providing medication reminder services through data analysis to improve patient survival rates. Based on this, these successful experiences should be promoted to drive nationwide data interconnectivity and settlement collaboration between &#34;medical insurance + commercial insurance,&#34; allowing insured individuals to complete both medical and commercial insurance settlements simultaneously upon discharge, enhancing the protection experience. Commercial insurance companies should be encouraged to collaborate with medical institutions and pharmaceutical companies to conduct real-world studies, optimize catalog structures based on data, and develop personalized and scenario-based insurance products, transforming from &#34;passive compensation&#34; to &#34;proactive health management.&#34;
Fourth, innovate payment and pricing mechanisms to enhance the sustainability of protection. A reasonable payment and pricing mechanism is key to the long-term operation of the commercial insurance drug catalog. On one hand, a market-oriented negotiation mechanism between commercial insurance companies and pharmaceutical companies should be established, drawing on the experience of the U.S. PBM (Pharmacy Benefit Manager) model and Australia's PBS (Pharmaceutical Benefits Scheme), to lower drug prices through bulk purchasing and long-term agreements. Explore a &#34;price confidentiality + risk-sharing&#34; mechanism for innovative drugs with uncertain efficacy, establishing a dynamic pricing mechanism based on real-world efficacy to balance patient accessibility, pharmaceutical company profits, and insurance sustainability. On the other hand, explore a multi-party co-payment model for ultra-high-value drugs with million-level treatment courses, constructing a multi-party burden-sharing mechanism of &#34;medical insurance + commercial insurance + corporate assistance + charitable funds&#34; to further reduce the patient out-of-pocket ratio. In addition, commercial insurance companies should innovate product forms, developing special critical illness insurance and other products around the commercial insurance catalog, deeply integrating catalog drug protection with health management services, and launching bundled solutions of &#34;insurance + drugs + rehabilitation follow-up&#34; to enhance product added value and competitiveness
Five key areas to improve the supporting system and strengthen full-chain supervision. The construction of the commercial insurance drug medical insurance catalog is a systematic project that requires collaboration among multiple departments and the improvement of supporting measures. First, strengthen policy coordination. The National Healthcare Security Administration, the National Financial Regulatory Administration, the National Health Commission, and the National Medical Products Administration should establish a regular communication mechanism to coordinate the advancement of catalog construction, drug approval, payment settlement, and industry supervision, forming a policy synergy. Second, enhance industry supervision, standardize the catalog usage behavior of commercial insurance companies, and strictly prohibit exaggerating the scope of coverage and misleading consumers. Comprehensive supervision should be conducted on the clinical application and cost settlement of drugs within the catalog to prevent moral hazards and adverse selection. Third, promote international cooperation by drawing on advanced experiences in the construction of global commercial insurance drug catalogs, such as the rapid access mechanism for innovative drugs in U.S. commercial insurance and the drug price negotiation model in Australia, optimizing system design in line with China's national conditions. At the same time, support Chinese innovative drugs in &#34;going global&#34; and participate in the construction of the global healthcare security system. Fourth, strengthen publicity and guidance to popularize knowledge about the coverage scope and application process of the commercial insurance drug medical insurance catalog, enhancing public awareness. Additionally, guide all sectors of society to correctly understand the supplementary protection role of commercial insurance and create a favorable development atmosphere.■
(Editor: Zhang Yifan)
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Zhou Yanli published an article in "China Finance" emphasizing the important role of commercial health insurance in promoting the national medical security system. In recent years, commercial health insurance has developed at an annual growth rate of 20%, covering more than 1.3 billion people. The article points out that the construction of the commercial insurance drug catalog is a reflection of deepening insurance services and is directly related to the implementation of the Healthy China strategy. The innovative drug catalog jointly launched by the National Medical Security Administration and the National Health Commission marks the deep integration of the functions of the medical security system, with core value in filling coverage gaps and improving the accessibility of high-value innovative drugs

Zhou Yanli: Promote Precise Services for Commercial Health Insurance