Catalogue of medical insurance drug coverage, which drugs are included in the medical insurance scop

Legal analysis: The drugs included in the scope of basic medical insurance are divided into two categories: Class A and Class B. Class A drugs refer to drugs that are basically unified across the country and can ensure the basic needs of clinical practice.

The cost of such drugs is included in the scope of basic medical insurance** and is paid according to the standard of basic medical insurance.

The list of Class B drugs is adjusted by the provinces, autonomous regions and municipalities directly under the Central Government according to their own conditions, and such drugs are first paid by employees for a certain percentage of the cost, and then included in the scope of basic medical insurance, and paid according to the standard of basic medical insurance.

The following drugs are not covered by the basic medical insurance:

1. Drugs that mainly play the role of nutrition and nourishment;

2. Some animals and animal organs, dried (water) fruits that can be used for medicine;

3. All kinds of liquor preparations brewed with Chinese herbal medicines and Chinese herbal decoction pieces;

4. Fruit-flavored preparations and oral effervescent agents in various drugs;

5. Blood products and protein products (except for special indications, first aid and rescue); (6) Other drugs that are not paid for by basic medical insurance** as stipulated by the social insurance administrative department.

Legal basis: Article 28 of the Social Insurance Law of the People's Republic of China Article 28 Medical expenses that meet the standards of basic medical insurance drug lists, diagnosis and treatment items, medical service facilities, and emergency and rescue shall be paid from the basic medical insurance in accordance with national regulations.

Legal analysis: Class A is a guaranteed drug, which can be reimbursed by 100%; The reimbursement ratio of Class B drugs is set by each locality in the medical insurance drug catalog, and the Class A catalog is the guarantee catalog, in which the drugs are 100% reimbursed. Medical insurance drugs refer to the basic medical insurance drugs, and the specific scope is managed through the formulation of the "Basic Medical Insurance Drug Catalog".

The principle of determining the "Drug Catalogue" is: based on the national basic medical insurance drug catalogue, adhere to the clinically necessary, safe and effective, reasonable, easy to use, market guarantee, medical insurance can afford the drugs. At the same time, it is necessary to consider not only the basic needs of clinical practice, but also the economic differences and medication habits between regions, and pay equal attention to Chinese and Western medicines.

Drugs included in the Drug List must specify one of the following conditions:

1) Drugs included in the Pharmacopoeia of the People's Republic of China (current edition);

2) Drugs that meet the standards promulgated by the State Drug Administration;

3) Commodities officially imported with approval from the State Drug Administration;

The following drugs cannot be included in the scope of basic medical insurance:

1) Drugs that mainly play a nutritional tonic role;

2) Some animals and animal organs, dried (water) fruits that can be used for medicine;

3) All kinds of liquor preparations brewed with Chinese herbal medicines and decoction pieces of Chinese medicine;

4) Fruit-flavored preparations and oral effervescent agents in various types of drugs;

5) Blood products and protein products (except for special indications, first aid and rescue);

6) Other drugs that are not paid by the basic medical insurance according to the labor and social security administrative departments at or above the provincial level.

Legal basis: Social Insurance Law of the People's Republic of China

Article 26 The treatment standards of basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with the provisions of the State.

Article 27 Individuals who participate in the basic medical insurance for employees, when they reach the statutory retirement age, the cumulative contributions reach the number of years prescribed by the State, and they will no longer pay the basic medical insurance premiums after retirement, and enjoy the basic medical insurance benefits in accordance with the provisions of the State; If the number of years prescribed by the state has not been reached, the fee can be paid until the number of years prescribed by the state.

Article 28 In line with the basic medical insurance drug list, diagnosis and treatment items, medical service facility standards and medical expenses, emergency and rescue medical expenses, in accordance with the provisions of the State from the basic medical insurance **.

Article 29 The part of the medical expenses of the insured persons that should be paid by the basic medical insurance** shall be directly settled by the social insurance agency and the medical institution and the drug business unit.

The administrative department of social insurance and the administrative department of health shall establish a system for the settlement of medical expenses for medical treatment in other places to facilitate the insured persons to enjoy basic medical insurance benefits.

Article 30 The following medical expenses are not included in the scope of payment of basic medical insurance**

1) It should be paid out of work-related injury insurance**;

2) It shall be borne by a third party;

3) It should be borne by public health;

4) Seeking medical treatment outside the country.

Medical expenses shall be borne by the third party in accordance with the law, and if the third party does not pay or the third party cannot be determined, the basic medical insurance shall pay in advance. After the basic medical insurance** is paid in advance, it has the right to recover from a third party.

Legal analysis: The drugs listed in the Drug Catalogue include Western medicines, Chinese patent medicines (including ethnic medicines, the same below), and traditional Chinese medicine decoction pieces (including ethnic medicines, the same below). Western medicine and Chinese patent medicine are listed in the list of drugs approved for payment by basic medical insurance**, and the drug name is a generic name and the dosage form is indicated.

The decoction pieces of traditional Chinese medicine are listed in the list of drugs that are not paid by basic medical insurance**, and the name of the drug adopts the name of the pharmacopoeia.

Legal basis: "Interim Measures for the Management of the Scope of Drug Use of Basic Medical Insurance for Urban Employees".

Article 5 The drugs listed in the Drug Catalogue include Western medicines, Chinese patent medicines (including ethnic medicines, the same below), and Chinese herbal decoction pieces (including ethnic medicines, the same below). Western medicine and Chinese patent medicine are listed in the list of drugs approved for payment by basic medical insurance**, and the drug name is a generic name and the dosage form is indicated. The decoction pieces of traditional Chinese medicine are listed in the list of drugs that are not paid by basic medical insurance**, and the name of the drug adopts the name of the pharmacopoeia.

Article 6 The Western medicines and proprietary Chinese medicines in the Drug Catalogue shall be selected on the basis of the National Essential Drugs and shall be divided into "Category A Catalogue" and "Category B Catalogue". The drugs in the "Class A Catalog" are clinically necessary, widely used, with good efficacy, and the lowest drugs in the same category. The drugs in the "Category B Catalogue" are drugs that can be used in clinical use, have good efficacy, and are slightly higher than those in the "Category A Catalogue" drugs.

Article 7: The "Category A Catalogue" is to be uniformly formulated by the state, and must not be adjusted in all localities. The "Category B Catalogue" shall be formulated by the state, and all provinces, autonomous regions and municipalities directly under the Central Government may make appropriate adjustments according to the local economic level, medical needs and drug habits, and the sum of the number of varieties added and decreased shall not exceed 15% of the total number of drugs in the "Category B Catalogue" formulated by the state.

All provinces, autonomous regions and municipalities directly under the Central Government may limit the drugs that are easy to abuse and highly toxic in the "Category B Catalog" of the "Drug Catalogue" of their provinces (autonomous regions and municipalities directly under the Central Government) according to their clinical indications and hospital levels.

The Drug Catalogue is divided into three parts: Western Medicine, Chinese Patent Medicine and Chinese Medicine Decoction Pieces. Among them, the Western medicine part and the Chinese patent medicine department are missing and divided into access laws, which stipulates that the drugs that are allowed to pay for the basic medical insurance are divided into categories A and B, and the payment of work-related injury insurance and maternity insurance is not divided into categories A and B; The exclusion method is used for the decoction pieces of traditional Chinese medicine, and it is stipulated that the ** branch base is not a drug that does not pay the fee. The specific payment standards for the expenses incurred by the insured persons in the use of Western medicines, proprietary Chinese medicines and Chinese herbal decoction pieces outside the catalogue shall be implemented in accordance with the relevant provisions of basic medical insurance, work-related injury insurance and maternity insurance.

1. The scope of drug use of provincial basic medical insurance is mainly the drugs in the "Henan Provincial Basic Medical Insurance Drug Catalogue", including Western medicine, Chinese patent medicine (including ethnic medicine), and traditional Chinese medicine decoction pieces (including ethnic medicine). The hospital preparations of the provincial designated medical institutions have been reviewed, and those that meet the requirements are also included in the scope of the provincial basic medical insurance.

2. Western medicines and proprietary Chinese medicines in the Drug Catalogue are divided into "Class A Catalogue".

1. The scope of drug use of provincial basic medical insurance is mainly the drugs in the "Henan Provincial Basic Medical Insurance Drug Catalogue", including Western medicine, Chinese patent medicine (including ethnic medicine), and traditional Chinese medicine decoction pieces (including ethnic medicine). The hospital preparations of the provincial designated medical institutions have been reviewed, and those that meet the requirements are also included in the scope of the provincial basic medical insurance.

2. Western medicines and proprietary Chinese medicines in the Drug Catalogue are divided into "Category A Catalogue" and "Category B Catalogue". The drugs in the "Class A Catalog" are clinically necessary, widely used, with good efficacy, and the lowest drugs in the same category. The drugs in the "Class B Catalog" are drugs that can be used in clinical practice, have good efficacy, and are slightly higher than those in the "Class A Catalog" drugs.

3. For the drugs that are easy to abuse and toxic in the "Category B Catalog", they shall be limited according to the clinical indications, hospital level, department and roller stool physician level, and the designated medical institutions and their staff shall use drugs according to the restricted scope of use. When the insured travelers are first aid and rescue, the level of the doctor on duty can not be restricted, but the designated medical institutions must provide relevant certification materials when settling with the provincial social medical insurance center.

4. The expenses incurred by the basic medical insurance participants in the use of the drugs in the "Drug Catalog" shall be paid according to the following principles:

1) The expenses incurred in the use of "Class A Catalogue" drugs shall be paid according to the provisions of basic medical insurance.

2) The expenses incurred in the use of "Class B Catalogue" drugs shall be paid by the insured persons in a certain proportion first, and then paid according to the provisions of basic medical insurance.

3) The expenses incurred in the use of traditional Chinese medicine decoction pieces, except for the varieties that are not paid by the basic medical insurance, are paid according to the provisions of the basic medical insurance.

4) Hospital preparations approved for inclusion in the payment scope of provincial basic medical insurance are divided into Class A preparations and Class B preparations. The expenses incurred by the insured persons in the use of Class A preparations shall be paid in accordance with the provisions of basic medical insurance. The expenses incurred in the use of Class B preparations shall be paid by the insured persons in accordance with the provisions of basic medical insurance after paying a certain percentage of their own expenses.

5. The expenses incurred by the insured persons for the use of blood and protein products for first aid and rescue shall be paid by the insured persons first, and the remaining expenses shall be paid according to the provisions of the basic medical insurance.

6. In the agreement between the Provincial Medical Insurance Center and the designated medical institutions, the proportion of drug costs to total medical expenses, the proportion of self-financed drugs to total drug costs, and the drug preparation rate of drugs in the Drug Catalogue are clarified.

Legal analysis: Category 1 Category A, which can be fully included in the scope of medical insurance reimbursement and reimbursed according to the local medical insurance ratio (100%);

In the second category of class B, the use of such drugs requires individuals to bear part of the cost according to a certain proportion, and the remaining part is included in the scope of medical insurance reimbursement and reimbursed according to the proportion of medical insurance; The social security reimbursement ratio for Class B drugs is: after the individual pays 10% first, and then reimburses in the same proportion as Class A drugs.

The third category of category C, this part of the medicine is not reimbursed, and all of them are borne by the individual.

"Class A" drugs are necessary for clinical use, are widely used, have good efficacy, and are the lowest drugs in the same category; Formulated by the state in a unified manner, all localities shall not adjust, and the expenses incurred in the use of "Class A drugs" shall be paid in accordance with the provisions of basic medical insurance.

"Class B" drugs are available for clinical use, with good efficacy, and are slightly higher than "Class A" drugs in the same category; "Category B drugs" are formulated by the state, and the provinces, municipalities and districts are appropriately adjusted according to the local economic level, medical needs and drug habits, but cannot exceed the "Category B drugs" formulated by the state, and the total number of 15 expenses unrelated to medical insurance, that is, the so-called Category C expenses, are all paid in cash.

Legal basis: "Interim Measures for the Administration of Drug Use in Basic Medical Insurance" Article 24 Western medicines and Chinese patent medicines in the national "Drug Catalogue" are divided into "Class A drugs" and "Class B drugs". "Class A drugs" are drugs that are clinically necessary, widely used, have definite efficacy, and have lower or lower costs among similar drugs.

"Class B drugs" are drugs that can be used clinically, have definite efficacy, and are slightly more expensive than "Class A drugs" in the same category. During the agreement period, the negotiated drugs will be included in the management of "Class B drugs".

The national medicines and preparations of medical institutions included in the "Drug Catalogue" by the provincial medical security departments in accordance with national regulations shall be included in the management of "Class B drugs".

The "A and B classification" of traditional Chinese medicine decoction pieces shall be determined by the provincial medical security administrative department.

The scope of medical insurance drugs simply means that drugs that can be reimbursed by medical insurance.

From March 1, 2023, the National Catalogue of Drugs for Basic Medical Insurance, Work-related Injury Insurance and Maternity Insurance (2022) has been officially implemented, which contains a total of 2,967 Western medicines and Chinese patent medicines, including 1,586 Western medicines and 1,381 Chinese patent medicines. The number of new 108 off-list drugs** decreased through negotiations, involving 23 clinical groups, including 56 chronic disease drugs (hypertension, diabetes, psychiatric diseases and other tumor drugs, 17 anti-infective drugs, 7 rare disease drugs, etc.); Among them, 22 are for children, 2 are for new crown **, and 2 are essential drugs for the country.

The latest version of the medical insurance drug catalogue includes drugs in the fields of anti-high-lead tumors, new crown drugs, rare diseases, etc., and good drugs in the fields of chronic diseases such as diabetes and chronic obstructive pulmonary disease are also included. In terms of new crown ** medication, Azvudine tablets and Qinglung Detox Granules have successfully entered the new version of the National Medical Insurance Drug Catalog.

Specifically, you can inquire through the "National Medical Insurance Drug Catalogue Query" page of the [National Model Government Service Platform].