Executive Summary:
This document addresses concerns regarding the denial of prescribed medicines to Central Government Health Scheme (CGHS) beneficiaries. It outlines existing government guidelines for medicine prescription and procurement, clarifies the process for including new drugs in the CGHS formulary, and details the comprehensive grievance redressal mechanisms available to beneficiaries. The document also highlights the Ministry's efforts to improve service delivery through Information Technology.
Key Points / Main Content:
Medicine Prescription and Availability:
* CGHS medicines are prescribed from the CGHS formulary.
* Non-formulary medicines exceeding ₹1500/week require pre-approval from the Additional Director (MSD for Delhi NCR, City AD for others).
* CGHS provides prescribed medicines via alternative brands from Wellness Centres or the exact brand via Authorized Local Chemist (ALC).
* Beneficiaries cannot purchase medicines from the open market for reimbursement.
* High-cost/restricted medicines (e.g., anticancer, immunotherapy drugs) have defined approval mechanisms involving the Additional Director, Director CGHS, and the Standing Technical Committee (STC).
Inclusion of New Drugs:
* Provision exists for timely inclusion of high-cost/restricted drugs into the online restricted medicine list based on the frequency of approved cases.
Grievance Redressal Mechanisms:
* In-House Grievance Module: Online portal for submitting grievances related to medical reimbursement claims, medicine availability, plastic card issuance delays, online appointment issues, and general Wellness Centre grievances.
* Centralized Call Centre: Toll-Free number 18002088900 provides immediate responses and complaint registration.
* CPGRAMS Integration: CGHS is integrated with the Centralized Public Grievance Redress and Monitoring System (CPGRAMS).
* Physical/Written Submissions: Grievances can be submitted via emails, letters to CGHS Wellness Centres/Directorate, or walk-in complaints at offices.
* CGHS Panchayats: Community grievance resolution forums coordinated by the Additional Director, involving open interaction with stakeholders (mainly pensioners).
* Advisory Committees:
* Local Advisory Committee (LAC): Composed of CMO In-Charge, Area Welfare Officer, pensioner representative, Resident Welfare Association (RWA) representative, and chemist; resolves grievances at the Wellness Centre level monthly (2nd Saturday).
* Zonal Advisory Committee (ZAC): Composed of AD, AWO, pensioner rep, CMO RH, Admin Officer, representative from empanelled hospital, resolves grievances zonally monthly (4th Saturday).
Use of Information Technology:
* Electronic Medical Records (EMR) are available for beneficiaries.
* Medicine tracking feature is available.
* Integration with payment gateway enables online payment of CGHS contributions for pensioners.
Impact Analysis:
CGHS Beneficiaries:
* Impact: Clarification of medicine prescription and procurement procedures, access to multiple grievance redressal mechanisms, and improved service delivery through IT initiatives.
* Action Required: Utilize available online and offline grievance redressal mechanisms for issues faced, and leverage IT services like EMR and online payment options.
Chief Medical Officers (CMOs) and CGHS Staff:
* Impact: Need to adhere to established guidelines for medicine prescription, pre-approval processes, and inclusion of new drugs. Responsibility for addressing grievances through various redressal mechanisms and participating in advisory committees.
* Action Required: Follow guidelines for medicine prescription and approval, participate actively in grievance redressal processes, and stay updated on IT-based service delivery improvements.
Additional Directors (ADs):
* Impact: Responsible for pre-approving non-formulary medicines, overseeing high-cost medicine approvals (along with the Director CGHS and STC), coordinating CGHS Panchayats, and participating in Zonal Advisory Committees.
* Action Required: Ensure efficient and timely processing of medicine approvals, actively participate in grievance resolution forums, and coordinate CGHS Panchayat activities.
Key Entities Referenced
CGHS: Central Government Health Scheme, a health service scheme in India for government employees and pensioners.
Ministry of Health and Family Welfare: The Indian government ministry responsible for health policy in India.
Delhi NCR: The National Capital Region, which includes Delhi and its surrounding areas in adjacent states.
Additional Director MSD: An administrative position within the CGHS, responsible for medicine supply and distribution.
Standing Technical Committee STC: A committee involved in the approval process for high-cost or restricted medicines within the CGHS.
Centralized Public Grievance Redress and Monitoring System CPGRAMS: A Government of India platform for citizens to lodge and track grievances related to public services.
Wellness Centre: CGHS facilities providing medical services and medicines to beneficiaries.
Electronic Medical Records EMR: Digital medical records of CGHS beneficiaries accessible through the CGHS website.
GOVERNMENTOFINDIA
MINISTRYOFHEALTH AND FAMILYWELFARE
DEPARTMENTOFHEALTH AND FAMILYWELFARE
LOK SABHA
UNSTARREDQUESTION NO. 3236
TO BE ANSWERED ON08THAUGUST,2025
DENIALOFPRESCRIBED MEDICINES TOCGHS BENEFICIARIES
3236. SHRIMANI A:
SHRINAVASKANI K:
SHRISELVAM G:
SHRIC N ANNADURAI:
Will the Ministerof HEALTH AND FAMILYWELFAREbe pleasedtostate:
(a) whether the Government is aware that CGHS beneficiaries are often denied life-saving or
essential post-operative medicines prescribed by specialist doctors, on the ground that such
medicinesare not included inthe CGHS indentlist;
(b) if so, whether the Government has issued any guidelines allowing CGHS beneficiaries to
purchase such medicines from the open market and claim reimbursement, if so, the details
thereof;
(c) whether the Government has laid down any mechanism for timely inclusion of new or
essential drugs prescribed byempanelled hospitals or specialists inthe CGHS medicinelist, if so,
the detailsthereof;
(d) whether the Chief Medical Officer (CMO) is bound to provide written reasons for denial of
prescribed medicines to a patient and if so, the details thereof alongwith the rules or guidelines
governingsuch action;
(e) whether the Government monitors such denials and any action being taken against the CMO
for non-complianceor failure toprovide medicines,if so, the detailsthereof; and
(f) whether the Government proposes tostrengthen the grievanceredressal mechanism for CGHS
beneficiariesinthe country,if so, the details thereof?
ANSWER
THE MINISTER OFSTATE IN THE MINISTRYOFHEALTH AND
FAMILYWELFARE
(SHRIPRATAPRAO JADHAV)
(a)to(f): As per Government guidelines, CGHS medicines are prescribed from the CGHS
formulary. Non-formulary medicines costing over ₹1500/week require pre-approval from the
respective Additional Director (MSD for Delhi/NCR, City AD for others) before indenting
through the AuthorizedLocal Chemist.
As per issued instructions, CGHS supplies prescribed medicines via alternative brands
from Wellness Centres if available, or indents the exact brand via ALC if unavailable. CGHSbeneficiaries are not permitted to purchase such medicines from the open market for
reimbursement.
Guidelines are established for the issuance of high-cost or restricted medicines (such as
anti-cancer and immunotherapy drugs), which include a defined approval mechanism involving
the Additional Director, Director CGHS, and the Standing Technical Committee (STC)
depending on the cost and type of medicine. Provision also exists for timely inclusion of such
drugs intothe online restricted medicinelist based on frequencyof approvedcases.
The CGHS hasa robust grievanceredressal mechanismsinplace.
1.In-House Grievance Module
a. CGHS hasdevelopeda dedicated online grievancemodule.
b. Accessible via the CGHS web portal,this enablesdirect submission of grievances
relatedto:
i. Medical reimbursement claims(MRC)
ii. Medicine availability
iii. Plasticcardissuance delays
iv. Online appointmentissues
v. General WellnessCentre grievances
2.CentralizedCall Centre
a. Toll-Free Number: 1800-208-8900.
b. Provides immediate response to common issues and registers complaints for
follow-up.
3.CPGRAMS Integration
CGHS is available with the Centralized Public Grievance Redress and Monitoring
System(CPGRAMS): https://pgportal.gov.in
4.PhysicalandWritten Submissions
a. Emails
b. LetterstoCGHS WellnessCentres or Directorate
c. Walk-incomplaintsat offices
5.CGHS Panchayats
a. Communitygrievanceresolution forum, conductedincitiesunderCGHS.
b. Coordinatedbythe Additional Director.
c. Includes open interaction with stakeholders (mainly pensioners) to resolve
persistent andsystemic issues.
6.AdvisoryCommittees
(a)LocalAdvisory Committee (LAC)
i. Constitution: CMO In-Charge, Area Welfare Officer, pensioner
representative,Resident WelfareAssociation (RWA) rep,andchemist.
ii. Purpose:Resolve grievanceslocally at the WellnessCentre level.
iii. Frequency:2ndSaturday of everymonth(b) ZonalAdvisory Committee (ZAC)
i. Constitution: AD, AWO, pensioner rep, CMO RH, Admin Officer,
representative from empanelled hospital.
ii. Frequency:4thSaturday of everymonth
Ministry has undertaken the task of leveraging the use of Information Technology to
improve the service delivery. The website features include; availability of Electronic Medical
Records (EMR) for beneficiaries, Medicine tracking feature, integration with payment gateway
for online paymentof CGHS Contribution for Pensioners.
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