Toripalimab and Pembrolizumab Added to Zhuhai's Supplementary Medical Insurance Reimbursement List for Cancer Therapies

On May 21, China Life Insurance Company Limited Zhuhai Branch issued a “Notice on Clarifying the Drug List for the Self-Paid Malignant Tumor Drugs under the Supplementary Medical Insurance in Zhuhai City (Third Batch).”

According to the notice, Junshi Biosciences’ toripalimab injection (Tuoyi) and MSD’s pembrolizumab injection (Keytruda) are currently both included in the reimbursement list.

Among these, Toripalimab Injection is a newly included product. Since March 2, 2019, eligible insured individuals have been entitled to benefits under the self-paid medication program for malignant tumors. Its indication is for the treatment of unresectable or metastatic melanoma in patients who have previously failed systemic therapy.

Pembrolizumab injection is a PD-1 monoclonal antibody product that had previously been included. Furthermore, the documents released this time indicate that the indication for lung cancer has been added to its reimbursement coverage. Specifically, it is indicated for “first-line treatment of metastatic non-squamous non-small cell lung cancer (NSCLC) with negative epidermal growth factor receptor (EGFR) gene mutations and negative anaplastic lymphoma kinase (ALK), in combination with pemetrexed and platinum-based chemotherapy.”

Publicly available information shows that Zhuhai had previously released two batches of catalogs, which included lenalidomide capsules (Revlimid).

Notably, the inclusion of the two PD-1 inhibitors in the reimbursement list does not strictly constitute coverage under the basic medical insurance scheme; rather, it falls under supplementary medical insurance outside the basic medical insurance framework.

It originated from the “Boundless Love” supplementary medical insurance project, which was announced by the Zhuhai Municipal Human Resources and Social Security Bureau on December 13, 2018, and officially implemented in 2019. The annual premium is RMB 190 per person, payable using funds from the individual medical insurance account or in cash. In terms of benefits, it is divided into four major components:

First, for insured persons, 90% of the approved inpatient medical expenses incurred within a social insurance year that exceed RMB 600,000 but do not exceed RMB 1 million shall be reimbursed. Second, for insured persons with malignant tumors, 90% of the cumulative eligible out-of-pocket expenses for anti-tumor self-paid drugs exceeding RMB 10,000 but not exceeding RMB 300,000 shall be reimbursed; newly diagnosed and recurrent malignant tumors within the insurance year are each eligible for one-time compensation for PET-CT scans, with a reimbursement rate of 60%. Third, 90% of the cumulative eligible out-of-pocket portion of inpatient medical expenses exceeding RMB 30,000 but not exceeding RMB 300,000 shall be reimbursed. Fourth, a cash subsidy of RMB 20,000 shall be provided to insured persons upon their first diagnosis of any of the ten specified critical illnesses.

Cheng Zhitao, Deputy Director of the Zhuhai Municipal Human Resources and Social Security Bureau, previously stated that the project operates on a self-financing basis and will not compromise the security of the social insurance fund. It is evident that, with the gradual adjustment of the national medical insurance catalogue and the improvement of supplementary medical insurance mechanisms, an increasing number of oncology drugs will be included in the reimbursement scope. For pharmaceutical companies, the immediate priorities are to expand into more indications with clinical value and to rapidly establish integration with various insurance schemes.