The Beijing Municipal Medical Insurance Bureau has released the list of the first batch of novel drugs and technologies that will enjoy payment outside of the China Health-care Security Diagnosis Related Groups (CHS-DRG) payment scheme. A total of 24 payment items are included, featuring small molecule inhibitors such as olaparib, osimertinib, ibrutinib, alectinib, zanubrutinib, and niraparib, as well as programmed-death ligand PD-(L1) inhibitors like durvalumab, nivolumab, pembrolizumab, camrelizumab, and atezolizumab. The list also encompasses anti-tumor antibodies and antibody-drug conjugates (ADCs) such as daratumumab, trastuzumab emtansine, and brentuximab vedotin, alongside autoimmune disease biologics like ustekinumab and rare disease therapies including nusinersen and eltrombopag olamine. Additionally, four diagnostic consumables and two diagnosis and treatment programs are included.
Payment Rules for New Drugs and Technologies
The rules governing the payment for these new drugs and technologies are as follows:
- Cases utilizing new drugs and technologies on the excluded payment list that meet the condition that the total cost of the case exceeds twice the average cost of the DRG group (excluding) and that the proportion of the new drug and technology cost to the total case cost is more than 64% (excluding) will be excluded from payment.
- Case settlements will be based on the payment standards of the original disease group, with new drugs and technologies reimbursed according to the difference between the actual expenses incurred and the average drug cost, consumables cost, or diagnosis and treatment fee of the disease group payment standards.
- The first batch of new drugs and technologies will be exempt from payment in 2024, 2025, and 2026. During this validity period, drugs with the same generic name as the excluded payment drugs do not need to be declared for direct exclusion payment. Newly registered self-pricing diagnosis and treatment projects belonging to the excluded payment list also do not require filing for direct excluded payments.
- Payments for drugs will be made exclusively according to the 10-digit National Reimbursement Drug List (NRDL) drug classification and code, while consumables will be paid based on the 27-digit NRDL medical consumables classification and code. Diagnosis and treatment projects will be paid according to the Beijing project code.
Clarifications on Payment Validity Period
The Beijing Municipal Medical Insurance Bureau has clarified that during the validity period of the exclusion payment, if diagnosis and treatment items are transferred to a unified pricing system and the price adjustment does not meet the data verification standards, the exclusion payment will be canceled. Furthermore, if generic drugs and consumables (including similar types) are included in the national or local centralized procurement scope, the exclusion payment will also be canceled. After the expiration of the payment validity period, these items will be included in the DRG payment based on usage data.-Fineline Info & Tech
