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Why are there changes to cancer treatment financing?

Before 1 September 2022, MediShield Life paid up to $3,000/month for all cancer drugs and Integrated Shield Plans (IPs) often covered costs above that on an as-charged basis (i.e., no claim limit), with a small co-payment. 

Such a design meant that drug companies had no incentive to charge lower prices for drug treatments that cost less. As a result, we ended up paying higher prices for many cancer drugs compared to other countries such as Australia, South Korea and United Kingdom. 

The changes to cancer treatment financing allow us to negotiate lower prices for cancer drugs, and ensure that cancer treatment costs and insurance premiums remain affordable for Singaporeans in the long term. 

How will the new Cancer Drug Treatment benefit impact my claims from 1 September 2022?

MediShield Life and MediSave will only cover treatments on the Cancer Drug List (CDL) from 1 September 2022. Each cancer drug treatment on the CDL will have its own MediShield Life claim limits and MediSave withdrawal limits. 

You may refer to the Cancer Drug List for the list of cancer drug treatments that are claimable under MediShield Life and MediSave, and their respective claim and withdrawal limits. Please consult your doctor if you wish to find out whether the treatment that you are undergoing is on the CDL. 

The CDL will only come into effect for Integrated Shield Plans (IPs) on 1 Apr 2023, upon renewal or application. If you have an IP, you will continue to be covered under your current policy terms until it is renewed on or after 1 Apr 2023. 

Does the Cancer Drug List also apply to inpatient cancer drug treatments?

Currently, the Cancer Drug List does not apply to inpatient cancer drug treatments as these are covered separately under the inpatient claim limits for MediShield Life and MediSave, together with other costs incurred during the inpatient stay. 

Is there support for patients already undergoing cancer drug treatment that is not on the Cancer Drug List when the changes kicked in?

We encourage you to discuss with your doctor if there are suitable alternatives on the Cancer Drug List (CDL) that are subsidised and covered by insurance. However, if switching treatments is not feasible, there is support to help existing patients see through their current course of treatment:

• MOH will provide additional financial support for all Public Healthcare Institution (PHI) patients without an Integrated Shield Plan (IP), and who had started treatments that are unsubsidised or not on the CDL before 1 Sep 2022. If you are a subsidised patient and still face difficulties affording your bills, you can approach a Medical Social Worker (MSW) in your PHI for financial assistance such as MediFund. 
• If you have an IP that is being renewed between 1 Apr 2023 and 30 Sep 2023, and have received cancer drug treatment between 1 Jan 2023 and 31 Mar 2023, insurers have committed to preserve your current IP coverage until 30 Sep 2023.  
• If you are a private patient, you can also approach your doctor to refer to subsidised care in a PHI, where you can apply for financial assistance. The PHI's medical team will review your treatment plan and provide financial counselling (e.g., eligibility for subsidies) before you decide whether to transfer to a PHI. 

IP riders may also cover selected treatments beyond the CDL, though the extend of coverage may vary. A summary of each insurer's IP and rider coverage for cancer drug treatments/services can be found here. You may wish to check with your insurer should you have further queries on your IP and rider coverage.

What are the criteria for inclusion in the Cancer Drug List?

Generally, the Cancer Drug List comprises of drugs that are clinically proven and more cost-effective in treating a particular cancer. A drug is clinically proven if it is registered with the Health Sciences Authority (HSA) for the particular clinical indication and has met the required standards of safety, quality and efficacy. A drug is cost effective if it provides good value in treating the particular cancer as compared to the existing standard of care, in terms of health benefits to the patient and cost.

Who assesses the cost-effectiveness of cancer drug treatments?

Companies are responsible for demonstrating the clinical- and cost-effectiveness of cancer drug treatments through the company-led submission process to the Agency for Care Effectiveness (ACE), Singapore’s national Health Technology Assessment (HTA) agency. 

Based on the evidence and companies’ price proposals, the MOH Drug Advisory Committee (DAC), chaired by the Director of Medical Services in MOH and comprising senior public sector doctors, pharmacists and MOH representatives, makes recommendations to MOH for subsidy and MediShield Life coverage. 

More details on the processes and methods can be found on ACE’s website.

How can I apply for treatments to be added to the CDL?

Companies are responsible for providing evidence submissions and price proposals for their cancer drug treatments to be assessed for inclusion on the CDL in parallel with their assessment for regulatory approval by HSA. More information can be found here

Clinicians can also request ACE to evaluate treatments for potential inclusion on the list using the attached application form.  Clinicians who wish to leverage this route should prioritise treatments that are not submitted for HSA's approval due to the small patient pool in Singapore but are (i) considered standard of care for a rare cancer or (ii) for a specific subgroup of patients with no suitable registered treatment alternatives, and (iii) approved by at least one reference overseas regulatory authority.

All drug applications should be endorsed by the Chairman of the Medical Board (or equivalent body e.g. Medical Director) of the clinician’s institution before submission to MOH_DAC_Secretariat@moh.gov.sg. If you wish to check if a treatment is under evaluation prior to completing the form, please contact the MOH DAC Secretariat in the abovementioned email address. 

What happens if cancer drugs are subsequently removed from the CDL?

The CDL will be updated every 4 months. Generally, treatments will remain on the CDL unless there are strong reasons to remove them. Treatments may also have their claim limits adjusted (e.g. if a generic or biosimilar becomes available) or removed (e.g. if the pharmaceutical manufacturer increases the price to non-cost-effective levels). 

Where there is a change in the CDL, the prevailing limits or listing based on the date of treatment will apply. If the patient had received a non-CDL treatment before the treatment was listed / after the treatment was delisted, there would be no MediShield Life, MediSave or Integrated Shield Plan payout. MOH will provide sufficient notice to medical institutions and insurers to implement any changes to the CDL, and patients are encouraged to discuss switching to alternative subsidised treatments on the list with their doctors, where possible.

Can a patient claim for cancer drug services from the Cancer Drug Services limit if he is receiving a treatment that is not on the CDL?

Yes, patients may claim for cancer drug services from the annual Cancer Drug Services limit even if the service was rendered for a cancer treatment not on the CDL (i.e. the claim limit is not specific to treatments on the CDL).

I am prescribed a drug that is not on the Cancer Drug List. Can I claim for the drug under the Cancer Drug Services Limit?

The cancer drug services limit is meant to cover ancillary services that patients may require as part of their cancer drug treatment.

If the drug you are prescribed is a supportive medication to manage the symptoms and side effects of of your cancer drug treatment (e.g. antibiotics to reduce risk of infection, pain medication or anti-nausea medication), it is claimable under the Cancer Drug Services limit. 

However, if the drug is used for the treatment of the cancer / tumour itself (e.g. chemotherapy, immunotherapy or targeted therapy), it should be claimed under the Cancer Drug Treatment limit instead. Cancer Drug Treatments that are not listed on the Cancer Drug List are not eligible for MediShield Life, MediSave and Integrated Shield Plan claims and should not be claimed under Cancer Drug Services limit.

How are claim limits sized when more than one cancer drug is used in the treatment?

In general, the MediShield Life (MSHL) claim limits for cost-effective treatments are set based on the post-subsidy bills for subsidised patients in Public Healthcare Institutions (PHIs).

The Cancer Drug List (CDL) includes treatments that involve a single drug or multiple drugs (i.e. combination treatments).

For combination treatments, the applicable MSHL claim limit depends on whether the combination treatment has been assessed to be cost-effective:
• If the combination treatment is cost-effective, the MSHL claim limit is sized to be sufficient to cover the post-subsidy cost of the entire combination in PHIs.
• If the combination treatment is not cost-effective, it may be listed on the CDL subject to negotiations with the drug companies. However, the claim limit would be pegged to the highest individual claim limit of the drugs in the combination. Doctors and patients are encouraged to use treatments that have been assessed to be cost-effective.

Why is the claim limit for a particular combination treatment not the sum of all the claim limits for individual drugs in that combination?

If that particular combination treatment is cost-effective, the MediShield Life (MSHL) claim limit has already been sized to be sufficient to cover the post-subsidy cost of the entire combination in Public Healthcare Institutions (PHIs). In some cases, the claim limit for the entire combination is the same as the highest-cost drug in that combination because the cost of the other drugs in the PHIs are low, and can be adequately covered by that same claim limit.

If that particular combination treatment is not cost-effective, the MSHL claim limit is pegged to the highest individual claim limit of the drugs in the combination. Doctors and patients are encouraged to use treatments that have been assessed to be cost-effective, for which MSHL claim limits would be sized for.

What happens if I have to change treatment in the middle of the month? Does it mean that the new treatment is not claimable?

For patients who have to switch treatment in the middle of the month, both treatments would be claimable up to the higher of the MediShield Life, MediSave and Integrated Shield Plan claim limits applicable for each individual treatment.

My cancer drug treatment is on a 3-weekly cycle. Is the cancer drug limit sufficient for months when I need to undergo 2 rounds of treatment?

For cost-effective cancer drug treatments on 3-weekly cycles, the MediShield Life claim limits have typically been sized to cover the post-subsidy costs of two treatment courses in a month. For other drug treatments, the MediShield Life limit has been sized to cover the monthly cost of the cost-effective alternative.