These 8 types of medications can no longer be covered by medical insurance.

Release date:

2020-09-02

According to a document from the National Healthcare Security Administration, the "Provisional Measures for Drug Management under Basic Medical Insurance" (hereinafter referred to as the "Measures") will come into effect on September 1, 2020.

It is important to note that the "Basic Medical Insurance Drug List" formulated in the Measures specifies eight categories of drugs that are not eligible for inclusion in the list. They are as follows:

1. Medicines that primarily serve a nourishing and restorative function;

2. Medicines containing medicinal materials from nationally precious and endangered wild animals and plants;

3. Health-care products;

4. Preventive vaccines and contraceptive medications;

5. Medicines primarily designed to enhance sexual function, treat hair loss, aid in weight loss, improve skin beauty, help quit smoking, and reduce alcohol consumption;

6. Medicines that cannot be charged separately due to being included in clinical treatment programs or other reasons;

7. Alcohol-based preparations, tea-based preparations, various fruit-flavored preparations (excluding pediatric medications in special cases), oral dissolving tablets, and orally administered effervescent tablets (except in specially regulated circumstances), etc.;

8. Other medications that do not comply with the basic medical insurance drug regulations.

If these drugs cannot be included in the catalog, it also means that医保 (medical insurance) will not cover the costs of these 8 categories of medications. Simply put, retail pharmacies will no longer be able to accept medical insurance card payments for these items.

Individual medical insurance accounts banned from using funds for health supplements.

Just recently, the National Healthcare Security Administration once again clarified in its "Guiding Opinions on Establishing and Improving the Mechanism for Outpatient Co-payment under the Basic Medical Insurance for Employees (Draft for Comments)" that the scope of personal account usage must be standardized.

According to regulations, personal accounts may not be used for expenses such as public health costs, sports and fitness activities, or wellness and health-care services—items that fall outside the scope of basic medical insurance coverage.

However, the scope of use for individual medical insurance accounts has also been relaxed accordingly. According to the draft for comments, these personal accounts can now be used to pay for medical expenses personally borne by the employee, their spouse, parents, and children when seeking treatment at medical institutions designated under the basic medical insurance program, as well as for expenses incurred when purchasing medicines and medical consumables at designated retail pharmacies—again, covering costs that the individual is responsible for.

A large number of drugs are set to be removed from national health insurance coverage.

Additionally, according to the Measures, the medical security administrative department shall establish and refine a dynamic adjustment mechanism, with adjustments made annually in principle. The adjustment factors include the demand for drug coverage under basic medical insurance, the revenue and expenditure status of the basic medical insurance fund, affordability, and priorities in catalog management, among other considerations.

According to the requirements of the "Measures," drugs listed in the "National Drug List" will be directly removed from the list after expert review if any of the following circumstances apply:

1. Medicines whose drug approval documents have been revoked, suspended, or canceled by the pharmaceutical regulatory authorities;

2. Medicines listed on the negative list by relevant authorities;

3. Medicines that, after comprehensive consideration of clinical value, adverse reactions, drug cost-effectiveness, and other factors, are assessed to have risks outweighing their benefits;

4. Medicines that have entered the National Reimbursement Drug List through fraudulent or other irregular means;

5. Other circumstances stipulated by the state that require direct transfer-out.

Medicines listed in the National Drug Formulary may be removed from the list after undergoing prescribed procedures, including expert review, if they meet any of the following criteria:

1. Medicines in the same therapeutic area that are significantly overpriced or excessively costly without a reasonable justification;

2. Clinical value is uncertain, and the drug can be better replaced by alternatives;

3. Other drugs that do not meet criteria such as safety, efficacy, and cost-effectiveness.

Meanwhile, the National Healthcare Security Administration and three other departments have issued the "Notice on Doing a Good Job in Basic Medical Insurance for Urban and Rural Residents in 2020," which clearly states: efforts should be made to gradually standardize the scope of drug reimbursement under basic medical insurance, establish a monitoring mechanism to ensure the implementation of negotiated drugs, and formulate three-year plans for phasing out supplementary drug lists in each province.

As required, the locally added items in the medical insurance catalog must be phased out over a three-year period, with 40% of the items removed in the first year, another 40% in the second year, and the remaining 20% in the third year.

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