Selective uptake of medicines outside China's National Reimbursement Drug List by commercial specialty-drug rosters: a multi-product audit of the 2020–2025 negotiation cohorts

In China, nearly everyone is covered by a basic health insurance system that acts as a massive safety net, paying for a vast array of medicines. However, this system has a specific list of approved drugs, and it cannot afford to include every new, expensive medicine the moment it is invented. To fill the gaps, the country has encouraged a second layer of protection: commercial health insurance. This includes two main types. The first is a low-cost, government-guided plan available to city residents, often called "huimin bao," which acts as a supplement to the basic system. The second is high-limit commercial insurance, sold directly by private companies to individuals, designed to cover very expensive treatments that the basic system might not touch. A key question for patients and policymakers has been whether these commercial plans are actually stepping in to cover the most expensive, innovative drugs that the basic system rejects, or if they are simply covering the same medicines that are already on the official list.

A team of researchers set out to answer this by looking at the actual lists of drugs covered by fourteen different commercial insurance products across the country. They focused on the years between 2020 and 2025, a period when the national system was reviewing thousands of new drug applications. The researchers gathered every single medicine that had been formally reviewed for inclusion in the national list but was ultimately left out. They then checked to see if any of these rejected medicines appeared on the specific, named lists of drugs covered by the commercial insurance products they studied. They did not look at general promises to cover "any drug"; they looked only at the concrete lists where specific medicine names were written down.

The investigation revealed a clear pattern. Of the medicines that the national system had not included, only a small fraction appeared on the commercial lists. Specifically, out of 578 ingredients that were never on the national list, only 74 were found on the commercial rosters. This means that roughly one in eight of the drugs rejected by the national system found a home in these commercial plans. In contrast, drugs that were already accepted by the national system were much more likely to appear on commercial lists, showing up about one in four times. This suggests that while commercial insurance does pick up some of the drugs the basic system leaves behind, it is not a blanket solution for all of them.

The study also uncovered who exactly was getting covered. The commercial lists were heavily concentrated on a specific type of medicine: high-priced treatments for cancer and rare diseases. The researchers found that if a drug was a first-of-its-kind innovation, or if it cost more than 500,000 yuan a year to treat a patient, it was very likely to be on a commercial list. Conversely, older, cheaper medicines or those for common infections were rarely included. The data showed that the more times a drug company applied to get a medicine onto the national list, the more likely that medicine was to eventually appear on a commercial list, even if it never made it onto the national one. This suggests that commercial insurers are paying close attention to the same rigorous review process that the government uses, waiting to see which drugs are persistent and high-value before adding them to their own coverage.

Timing was another crucial piece of the puzzle. The researchers tried to determine when these commercial lists added a drug relative to the government's decision. For the few cases where they could trace the dates, they found that commercial insurers usually waited until after the government had made its decision to reject a drug before adding it to their own lists. In only one instance did a commercial plan list a drug before the government had even considered it. This indicates that the commercial system is largely reactive, stepping in to cover the high-cost, high-innovation drugs that the national system has already decided it cannot afford, rather than running a parallel, independent track that discovers new medicines first.

Ultimately, the research paints a picture of a multi-layered system where the commercial sector plays a specific, targeted role. It does not cover the entire universe of rejected medicines, but it does provide a safety net for the most expensive and innovative therapies, particularly in the field of cancer treatment. The lists are not random; they are carefully curated to include the drugs that have survived the most intense scrutiny and carry the highest price tags. For patients, this means that while the basic system covers the vast majority of needs, the commercial options are specifically designed to catch the most difficult, costly cases that fall through the cracks, ensuring that the most advanced treatments remain accessible to those who can afford the supplementary coverage.