Is there a specific medicine for social security reimbursement?

In order to ensure the implementation of the policy of benefiting the people by using medical insurance for outpatient special drugs (special drugs), facilitate the insured people to seek medical treatment and purchase drugs, and standardize the management of the use of special drugs, recently, the Municipal Medical Insurance Bureau publicized the list of designated medical institutions, responsible doctors and outpatient special drugs used in the basic medical insurance in 20021the whole city.

At present, the city has identified 27 designated hospitals, 19 designated pharmacies, and 342 doctors are responsible for the use of special drugs. According to the Notice of the Office of Shanxi Provincial Medical Security Bureau on Further Improving the Management of the Use of Drugs Negotiated by the State, 95 kinds of drugs negotiated by the State for medical insurance are included in the management scope of special drugs for basic medical insurance in our city.

In other words, insured patients can be reimbursed according to regulations after using special drugs. This issue of social security edition takes you to know the reimbursement of specific drugs.

What is a specific drug?

Special drugs refer to some high-cost drugs in the integrated medical insurance drug list in our province, and the fixed-point drug supply management in outpatient clinics and pharmacies is implemented.

What are the special drug protection objects?

Participate in the basic medical insurance for urban workers, serious illness insurance for employees (including large medical expenses subsidies and medical expenses subsidies for civil servants) and basic medical insurance and serious illness insurance for urban and rural residents, which meet the requirements for the use of special drugs.

What is the reimbursement rate for special drugs?

The medical expenses incurred by the insured patients shall be paid by the basic medical insurance pooling fund for urban workers and urban and rural residents, serious illness insurance for employees and serious illness insurance for urban and rural residents in accordance with the prescribed proportion. The reimbursement rate for urban workers is 60%, and that for urban and rural residents is 50%.

How do you manage the use of special drugs?

The use of special drugs is provided by designated medical institutions and retail pharmacies, and the measures for the administration of responsible doctors are implemented.

Designated medical institutions for special drugs should have corresponding technical qualifications and strength, and in principle have the ability to detect genes. Clinicians who use anti-tumor targeted drugs should have corresponding technical qualifications for the treatment of malignant tumors.

Designated retail pharmacies for special drugs should have the ability and experience in drug management and service, and have complete cold chain facilities and equipment.

The responsible physician shall be elected by the designated medical institution of special medicine, with senior titles, and shall be filed in the medical insurance agency. The responsible physician is responsible for the medical services of insured patients at all stages of treatment, including diagnosis, prescription, signing referral opinions and follow-up; Responsible for the evaluation and confirmation of the follow-up medication for the development of insured patients; Responsible for the education and consultation on the process of drug treatment for insured patients. The responsible physician should carefully check the identity of the insured patient in the process of receiving the consultation, ensure that the person's card is consistent, truly record the condition, prescription time and dosage, and use the drug in strict accordance with the indications and clinical indications of the drug.

What procedures and materials are needed to apply for special drugs?

When the insured patients apply for special drug treatment, they must bring the disease information to the designated medical institutions for special drugs, and the responsible doctor will examine and confirm the disease information, and fill out the Application Form for the Use of Special Drugs in Yuncheng Basic Medical Insurance (special drug approval form).

Insured patients carry the Approval Form for Special Drugs and related materials to the medical insurance department of designated medical institutions for registration and entry into the medical insurance system. The medical insurance system automatically passes the record.

Required information: 1. Disease information: outpatient medical records, diagnosis suggestions, inpatient medical records, pathological diagnosis, special laboratory index results reports, etc. It should be noted that the above information must be stamped with the special seal for medical records or diagnosis management of the unit.

2. Other materials: my social security card, a copy of my ID card, and three one-inch bareheaded color photos with red background.

After the application is approved, how can the insured patients purchase drugs and submit reimbursement?

Insured patients hold the Application Form for the Use of Special Drugs in Yuncheng Basic Medical Insurance, and the responsible doctors apply for the prescription of special drugs (the prescription must indicate the usage, dosage, dosage form and specifications of the drugs) and social security cards, and purchase drugs at the selected designated medical institutions or retail pharmacies. Medical expenses are directly reimbursed, and patients only need to pay their own expenses, and the reimbursement part is settled by the medical insurance agency.

How do foreigners use special drugs?

Insured patients who live in other places for a long time need to be identified and evaluated by the doctors in charge of designated medical institutions in our city. Those who meet the requirements can apply for the Approval Form for Special Drugs of Yuncheng Basic Medical Insurance or the Evaluation Form for the Use of Special Drugs (hereinafter referred to as the Evaluation Form), purchase drugs at the place of residence, and the expenses will be paid by the individual, and then be reimbursed by the medical insurance agency in the insured place according to the regulations.

What should I do if the patient needs to continue to use it after a treatment cycle?

Insured patients who use special drugs after approval can enjoy the corresponding medical insurance benefits within a treatment cycle (the longest is not more than 12 months) according to the policy.

At the end of a treatment cycle, it is necessary to continue to use special drugs for treatment and reapply and evaluate.

How to audit and evaluate insured patients?

Designated medical institutions shall, in accordance with the requirements of routine evaluation of the efficacy of special drugs or diseases, establish an evaluation mechanism for the use of special drugs, and timely evaluate and adjust the latest drug use plan according to the physical condition, disease change, medication cycle, clinical needs, management requirements and treatment cycle of insured patients who use special drugs. The evaluation results are recorded in the form of "evaluation form", and signed by the responsible doctor for confirmation, and then the registration procedures are performed. When the responsible doctor needs to carry out the necessary examination when evaluating the condition, he should choose the items with low cost and easy operation as far as possible to reduce the economic burden of patients, and it is strictly forbidden to carry out "combined" examination and inspection.

Insured patients do not enjoy timely assessment conditions or exceed the assessment time limit for more than one month, suspend or cancel special drug treatment.

After review, insured patients who do not meet the clinical medical diagnostic standards and special drug treatment regulations will no longer enjoy special drug treatment.

What should I do if the patient needs to change the special medicine because of his illness during the treatment of special medicine?

During the period when the insured patients enjoy the special drug treatment, if the special drug treatment scheme needs to be changed due to their illness, the responsible physician shall timely evaluate the payment conditions and medical routine limited by the medical insurance special drug treatment. After passing, submit the evaluation form to the medical insurance department of the designated medical institution for change. The medical department can enter the medical insurance information system in time, and the insured patients can continue to enjoy the treatment of special drugs.

Under what circumstances does the medical insurance fund for purchasing special drugs not pay?

1. The special drug expenses incurred by the insured patients have not been audited and filed;

2. Special drug expenses incurred by insured patients in non-designated medical institutions or prescriptions of doctors without responsibility;

3. The insured patients failed to meet the corresponding clinical medical diagnosis standards after review and evaluation, or failed to review within the prescribed time limit (more than one month after review).

4 beyond the medical insurance payment standard and payment scope.

5 bills lost proof, copies of bills, failure to provide necessary materials and other special drug expenses.

How to strengthen the standardization of the use of special drugs?

Medical insurance agencies should immediately carry out special inspections on the abnormal use of special drugs, and find that there are irregularities such as fraud, over-prescription, false invoicing, drug dressing change, etc., and doctors violate the rules, cancel their medical insurance prescription rights and notify the hospital where they are located; If the designated retail pharmacy violates the regulations, it shall terminate the medical insurance designated service agreement of the store, and shall not apply for the designated retail qualification of special drugs (including chain pharmacies) within 3 years; If the insured individual violates the rules, the illegal expenses will not be reimbursed and the medical insurance benefits will be stopped for 6 months. Those suspected of violating the law shall be handed over to the judicial department for handling.