Principles and conditions for determining the drug list of basic medical insurance

Medication within the scope of social security refers to medication within the scope of social security reimbursement catalogue. According to the National Catalogue of Drugs for Basic Medical Insurance, Work Injury Insurance and Maternity Insurance (20 17 Edition), there are 2535 kinds of drugs used in social security in the catalogue. Compared with the registered drugs of190,000, the drugs in the social security catalogue only account for 1. 1%. Drugs reimbursed by social security are divided into three categories: Class A drugs, Class B drugs and Class C drugs, among which the drugs covered by basic medical insurance are Class A and Class B drugs.

Class A drugs refer to drugs that are basically unified throughout the country and can ensure the basic needs of clinical treatment. The clinical use time is relatively short and the safety is slightly lower, so it is marked with a red warning. The expenses of such drugs are included in the payment scope of the basic medical insurance fund, and the expenses are paid according to the basic medical insurance payment standard. The list of Class B drugs shall be adjusted by all provinces, autonomous regions and municipalities directly under the Central Government according to their own conditions. These drugs are marked as green because of their longer clinical use, higher safety and less side effects. The expenses of such drugs are paid by employees according to a certain proportion, and then included in the scope of payment of the basic medical insurance fund, and paid according to regulations. Class C drugs and medical insurance are not reimbursed, and all are borne by individuals. Such as health care drugs.

Legal basis:

National Drug List of Basic Medical Insurance, Work Injury Insurance and Maternity Insurance in Ministry of Human Resources and Social Security (version 20 17).

First, strict drug list payment regulations. The drug list is divided into four parts: common cases, western medicine, Chinese patent medicine and Chinese herbal pieces. Each example is an explanation and explanation of the format, name and dosage form of the drug list, and the limited payment scope. Western medicine includes chemicals and biological products, Chinese patent medicines include Chinese patent medicines and ethnic medicines, and Chinese herbal medicines are not paid by the fund according to the exclusion law. The expenses incurred by the insured in using western medicine, Chinese patent medicine and Chinese herbal pieces outside the catalogue shall be paid according to the relevant provisions of basic medical insurance, industrial injury insurance and maternity insurance. The basic medical insurance, industrial injury insurance and maternity insurance funds will not be paid if the anti-HIV drugs provided by the state free of charge and the anti-tuberculosis drugs, anti-malaria drugs and anti-schistosomiasis drugs involved in national public health projects are used by the insured and fall within the scope of public health payment.

Two, standardize the adjustment of the provincial drug list. The competent departments of social insurance of all provinces (autonomous regions and municipalities) shall not make adjustments to Class A drugs in the drug list, and the adjustments to Class B drugs shall be strictly implemented in accordance with existing laws, regulations and documents. Drug list adjustment should adhere to the expert evaluation mechanism, adhere to fairness, impartiality and openness, do a good job in the prevention and control of integrity risks, and should not charge enterprises in any name or adopt any form of local protectionism. The administrative department shall not interfere with the expert evaluation results.

All provinces (autonomous regions and municipalities) shall publish the drug list of local basic medical insurance, industrial injury insurance and maternity insurance before July 3, 20 17. The adjusted quantity (including transfer-in, transfer-out and adjustment of limited payment scope) shall not exceed 15% of the national quantity of Class B drugs. All provinces (autonomous regions and municipalities) shall report the adjustment of Class B drugs to the Ministry for the record as required.

All co-ordination areas should implement the new drug list within 1 month after the release of the drug list of basic medical insurance, industrial injury insurance and maternity insurance in this province (autonomous regions and municipalities), and update the list of hospital preparations included in the scope of fund payment in accordance with relevant regulations.

Third, improve the management of drug list use. According to the use of drugs in medical institutions and retail pharmacies within the jurisdiction, all co-ordination areas should do a good job in the corresponding work of drugs in the catalogue and update and improve the drug database of the information system in a timely manner. All provinces (autonomous regions and municipalities) should combine the direct settlement of medical treatment in different places, speed up the application of social insurance drug classification and code industry standards, establish and improve the unified drug database of the whole province (autonomous regions and municipalities), and realize the unified management of western medicine, Chinese patent medicine, hospital preparations and Chinese herbal pieces within the province.

All localities should incorporate the implementation and use of drug lists by designated medical institutions into the scope of management and assessment of designated service agreements in combination with prescription management measures, clinical technical operation specifications, clinical diagnosis and treatment guidelines, and guiding principles for clinical application of drugs formulated by the drug list management regulations and health and family planning departments. Establish and improve the basic medical insurance medical service intelligent monitoring system and social insurance drug monitoring and analysis system, focusing on monitoring drugs with large dosage, high cost and possible unreasonable use, and announce the monitoring results to the society in an appropriate way. Give full play to the role of pharmacists and encourage medical institutions to take effective measures to promote clinical rational drug use.

All provinces (autonomous regions and municipalities) shall, in accordance with the requirements of drug price reform, speed up the formulation of payment standards for generic names of medical insurance drugs. All co-ordination areas can further improve the management measures for classified payment of medical insurance drugs. For drugs that mainly play an auxiliary therapeutic role in Class B drugs, the proportion of individual self-payment can be appropriately increased to widen the gap with other Class B drugs. For off-catalog drugs necessary for clinical first aid and special disease treatment, a declaration system for designated medical institutions can be established, and the corresponding audit management measures can be clarified, and reported to the higher human resources and social security department for the record.

Four, explore the establishment of medical insurance drug negotiation access mechanism. Our department will negotiate the drugs to be negotiated determined by experts according to the relevant rules, and the eligible drugs will be included in the scope of medical insurance payment, and the list will be released separately.