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抗肿瘤药品的限制支付范围与说明书适用范围的差异分析

赵德华 ，龙小庆，王继生，范红英，刘 阳[绵阳市第三人民医院（四川省精神卫生中心）临床药学科，四川 绵
＊
阳 621000]

中图分类号 R95；R979.1 文献标志码 A 文章编号 1001-0408（2023）05-0520-05
DOI 10.6039/j.issn.1001-0408.2023.05.02

摘 要 目的 对抗肿瘤药品的医保限制支付范围与说明书适用范围之间的差异进行分析，以期更好地执行医保药品的支付政
策。方法 对比分析《国家基本医疗保险、工伤保险和生育保险药品目录（2022年）》中抗肿瘤药品的限制支付范围与说明书适用
范围之间的差异，并探讨差异内容的循证依据，同时对限制支付范围进行解读。结果 118个药品具有限制支付范围，限制支付范
围类别主要包括限基因检测结果证据、限适应证、限二线及以上治疗、限支付疗程、限专科医师处方、限医疗机构等级等。有43个
药品的限制支付范围与说明书存在差异，其中31个药品的说明书范围大于支付范围，7个药品的说明书超出了支付范围的适用范
围但有指南推荐；其余75个药品的限制支付范围与说明书保持一致。二线及多线治疗为使用一线药品无效或不能耐受；局部晚
期、晚期或转移性肿瘤与肿瘤分期存在一定关系，但不同肿瘤有不同的判定标准；全身系统治疗的定义为患者采用药物进行全身
治疗；限基因检测结果则要求检测结果呈阳性或阴性；此外，6个中药注射剂限医疗机构等级，2个药品支付不超过12个月，来那度
胺和枸橼酸伊沙佐米联用时医保基金只支付其中1种药品。结论 部分抗肿瘤药品的限制支付范围与说明书不一致。医保部门
应依据临床用药实际和诊疗指南推荐，扩大相关药品的支付范围；同时准确和详细地制定限制支付范围，以便临床和医保人员准
确理解药品的限制支付范围，从而充分保障患者的参保利益。
关键词 抗肿瘤药品；医保；药品目录；限制支付范围；药品说明书

Analysis on the difference between the payment limitations of anti-cancer drugs and the application scope
of drug indications
ZHAO Dehua，LONG Xiaoqing，WANG Jisheng，FAN Hongying，LIU Yang[Dept. of Clinical Pharmacy， the
Third People’s Hospital of Mianyang （Sichuan Mental Health Center）， Sichuan Mianyang 621000， China]

ABSTRACT OBJECTIVE To analyze the difference between the payment limitations of anti-cancer drugs and application scope
of drug instructions， so as to better implement the payment policy of medical insurance drugs. METHODS The differences between
the payment limitations of anti-cancer drugs and application scope of drug instructions in the National Catalogue of Drugs for Basic
Medical Insurance， Industrial Injury Insurance and Maternity Insurance （2022） were compared and analyzed； the evidence-based
basis of the difference was discussed， and the scope of limited payment was interpreted. RESULTS Totally 118 drugs had payment
limitations； limitations scope mainly included limited evidence of gene detection results， limited indications， limited second-line
and above treatment， limited payment duration， limited specialist prescription， limited medical institution grade， etc. Among them，
43 drugs had differences between the payment limitations and drug instructions， and the indications of 31 drugs were greater than
payment limitations； for seven drugs， the drug indications beyond the payment limitations were recommended by the guidelines.
The payment limitations of 75 drugs were consistent with drug instructions. The second-line and multi-line treatment was ineffective
or intolerable with first-line drugs. There was a certain relationship between locally advanced， advanced or metastatic tumor and
tumor stage， but different tumors had different criteria. Systemic treatment mainly referred to systemic treatment with drug. The
results of limited genetic test required that the result was positive or negative. In addition， six kinds of TCM injections were limited
to the level of medical institutions； the payment of two drugs did not exceed 12 months； when lenalidomide was combined with
isazomide citrate， the medical insurance only paid for one of the drugs. CONCLUSIONS The payment limitations of some anti-
cancer drugs are inconsistent with the drug indications. The drug payment limitations should be expanded according to the actual
situation of clinical medication and the recommendations of guidelines. At the same time， the payment limitations should be
formulated accurately and in detail， thus clinical and medical insurance staff can understand it and fully protect the interests of
patients.
KEYWORDS anti-cancer drugs； medical insurance； drug
＊第一作者 主管药师，硕士。研究方向：临床药学。电话：0816-
list； payment limitations； drug instruction
2278591。E-mail：zhaoyaoshi0566@163.com

· 520 · China Pharmacy 2023 Vol. 34 No. 5 中国药房 2023年第34卷第5期