The "National Basic Medical Insurance, Work Injury Insurance and Maternity Insurance Drug Catalog" (referred to as the "Drug Catalog") is the standard for basic medical insurance and maternity insurance funds to pay drug costs.
Clinicians' prescribing according to the condition, and insured persons' purchase and use of drugs are not restricted by the "Drug Catalog".
The scope of drug expenses paid by the work-related injury insurance fund shall be based on this catalog.
1. The cost incurred by the medical insurance pooling fund for the drugs in the "Drug Catalog" must be paid by a doctor's prescription or hospitalization order. The expenses incurred by insured patients purchasing drugs themselves must be paid from a personal account or paid by the individual themselves.
For children or adult insured persons with clinical evidence of intellectual disability, the expenses incurred by using over-the-counter drugs with the same name and dosage form as the listed drugs prescribed by a doctor or ordered by a hospital doctor can be paid by the unified fund according to regulations.
2. The "Remarks" column stipulates a limited payment range for some drugs, which means that the drug expenses incurred by insured persons under certain conditions can be paid by basic medical insurance or maternity insurance funds according to regulations.
Work-related injury insurance is not subject to limited payment scope when paying for medicines.
The handling agency should verify relevant evidence before paying the fee.
1. Drugs marked with "▲" in the "Remarks" column are only for outpatient use by insured persons and will be paid by the medical insurance fund when purchasing drugs at designated pharmacies.
2. Drugs with indications marked in the "Remarks" column refer to the insured person who uses the drug if the indications are limited and there are corresponding clinical signs and symptoms, laboratory and auxiliary examination evidence, and corresponding clinical diagnosis basis.
Expenses incurred may be paid as stipulated.
The limitation of indications is not a modification of the legal instructions for drugs. Clinicians should use drugs rationally according to the condition.
3. For drugs marked as second-line drugs in the "Remarks" column, there should be evidence that first-line drugs are ineffective or intolerable when paying.
3. The "Remarks" for the negotiated drugs during the agreement period stipulate the limited payment scope, specifications and payment standards for the drug. The payment standards include all fees paid by the medical insurance fund and insured persons simultaneously.
4. Drugs marked "Limited to work-related injury insurance" in the "Remarks" column are drugs that are only covered by work-related injury insurance funds and do not fall within the payment scope of basic medical insurance and maternity insurance funds.
5. Drugs marked as "Maternity Limited Insurance" in the "Remarks" column are drugs that can be paid for by the maternity insurance fund, and can also be paid for birth-related expenses incurred by insured persons in urban and rural areas.
6. When drugs included in the national free AIDS treatment program are used by insured persons who are not within the scope of the national free AIDS treatment to treat AIDS, the basic medical insurance fund can pay for them in accordance with regulations.
When the anti-tuberculosis and anti-schistosomiasis drugs involved in the national public health project are used by insured persons who are not within the scope of national public health payment, the basic medical insurance fund can pay according to regulations.
7. Insured persons who use "parenteral nutrients" No. 254-266 in the Western Medicine Section are required to undergo nutritional risk screening. If it is clear that there is nutritional risk, payment can be made.
Patients with functional digestive tracts will not be charged for use.
8. Insured persons who use "Enteral Nutritional Agents" No. 1206-1219 in the Western Medicine section must undergo nutritional risk screening to find out that they have nutritional risks, and they must be severely hospitalized patients who cannot supplement adequate nutrition through normal diet.
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9. Traditional Chinese medicine pieces marked with "□" mean that they will not be paid when used alone, and prescriptions composed entirely of these pieces will not be paid.