Legal analysis: The medicines in the Basic Medical Insurance Drug List are divided into "Category A List" and "Category B List".
1. The drugs in the "Class A Catalog" are those that are clinically necessary, widely used, have good therapeutic effects, and are low-priced among similar drugs.
2. The medicines in the "Category B List" are those that are available for clinical use, have good therapeutic effects, and are slightly more expensive than those in the "Category A List". Expenses incurred by basic medical insurance participants for the use of "Class A List" drugs are paid in accordance with the provisions of basic medical insurance. Costs incurred for the use of drugs on the "Class B list" are first paid by the insured person as a percentage of his or her own expenses, and then paid in accordance with the provisions of the basic medical insurance plan. These costs can only be paid by the integrated fund if they are included in the scope of the basic medical insurance drug list, diagnostic and treatment item list, and meet the standards of medical service facilities. If the expenses are within the scope of the catalog of diagnostic and therapeutic items paid by the basic medical insurance, the insured person shall first pay a certain percentage of the expenses out of his own pocket, and then the expenses shall be paid in accordance with the provisions of the basic medical insurance. Basic medical insurance medical service facilities refer to the living service facilities provided by designated medical institutions, which are necessary for the participants in the process of receiving diagnosis, treatment and nursing care, and their costs mainly include inpatient bed fees and outpatient (emergency) observation bed fees. The basic medical insurance fund will not pay for the daily necessities, in-hospital transportation supplies and utilities that are already included in the in-patient bed fee or out-patient (emergency) observation bed fee, and the designated medical institution shall not charge the insured person separately.
Legal basis: "Regulations of the People's Republic of China on Basic Medical Insurance for Urban Workers"
Article 28: Individual accounts shall be used to pay for medical expenses outside the scope of payment by the integrated fund; in the event of insufficient payment from the individual account, the individual shall be responsible for the payment himself/herself.
Article 29 Medical fees for hospitalization for serious illnesses shall be paid as follows:
(1) The starting standard shall be controlled, in principle, at 9-11% of the average annual social wage of employees in cities, counties and autonomous counties in the preceding year.
(b) The maximum payment limit is in principle controlled at 3-5 times of the average annual social wage of employees in cities, counties and autonomous counties in the previous year.
(3) Medical fees above the threshold and below the maximum payment limit are mainly paid by the integrated fund, with a certain percentage borne by individuals. The proportion of medical expenses borne by retirees is appropriately taken care of.
The scope of serious diseases, the specific criteria for the starting standard and the maximum payment limit, and the proportion of medical expenses above the starting standard and below the maximum payment limit to be shared shall be determined by the provincial people's government.
Article 30 The coordinated fund shall not pay for medical expenses below the starting payment standard and above the maximum payment limit.