SINGAPORE – The six-month extension of insurance coverage for patients with Integrated Shield Plans (IPs) who are undergoing cancer treatments not on the Cancer Drug List (CDL) ends on Saturday.

A spokesman for the Ministry of Health (MOH) said: “Patients who are currently receiving transitional support but who are unable to complete their current course of (non-CDL) treatment may contact their IP insurers to check on their coverage after Sept 30.”

The CDL was introduced in 2022 to try to stem the escalating cost of cancer treatments. Cancer treatments in 2021 amounted to $275 million, more than double the $110 million spent in 2017.

The CDL comprises treatments that are both clinically proven and more cost-effective.

Cancer treatments not on the CDL do not receive government subsidy, nor can claims be paid for with MediSave. They also cannot be covered by MediShield Life or IP health insurance.

Some pharmaceutical companies had to reduce the price of their drugs to get on the list. As a result, drug cost for the public sector has fallen by 30 per cent on average.

The lower prices are not reflected in the private sector.

The CDL, which started with 270 cancer treatments in August 2021, will have a total of 368 approved treatments by November, MOH told The Straits Times.

CDL became effective for MediShield Life policyholders on Sept 1, 2022, and for IP policyholders on April 1, 2023, upon the renewal of their insurance policies.

IPs had committed to covering non-CDL treatments until the end of September, to allow those who were already being treated for cancer to complete their regimen.

MOH also separated insurance claims for cancer drugs and cancer services. MediShield covers between $200 and $9,600 per month for drugs and up to $3,600 a year for cancer services, which include the doctor’s consultation fee, laboratory tests, scans and other medicines that might be needed for conditions such as nausea or infection.

For people with IPs, coverage ranges from double to five times the MediShield Life limits, depending on their insurer and plan.

However, coverage is generally much higher for those who have bought riders. These are separate policies originally meant to pay the portion of bills not covered by the IPs. They are paid for in cash, unlike IPs, which are paid by MediSave up to an age-based limit.

Less than half have riders.

Now, riders also pay for some non-CDL treatments. The type of treatment and the amount covered vary with insurers.

For drugs used in non-CDL treatments, coverage by riders ranges from $30,000 a year to $360,000 a year. For cancer services, the range goes from no additional cover to “as charged”.

Dr Choo Su Pin, an oncologist in private practice, said the CDL has made it clearer to both doctors and insurers what is or is not covered.

But she added: “There is more paperwork now, as we have to check if something is on the list. Also, different insurers have different coverage, so we are constantly having to check this. Sometimes this can be confusing.”

Several oncologists say that if patients with advanced cancer do not have riders, the majority of them are now unlikely to be able to afford treatment in the private sector.

The highest IP coverage for cancer services is $18,000 a year. Some cancers cause infections that require expensive antibiotics. These patients may also need scans, blood culture and blood transfusion.

One way to get insurance to pay is for the patient to be admitted, since claim limits for patients who are hospitalised are different. But most patients do not want to spend days in hospital several times a year.

One oncologist in private practice said he had referred three patients with no riders to the public sector as their insurance was no longer able to pay the bulk of their treatment costs.

Ms Koh Ee Miang, 47, who was diagnosed with a rare cancer of the bile duct three years ago, is grateful that she had bought a rider for her IP. She no longer responds to standard treatments and has been on non-CDL treatments for about two years.

Her IP insurer, Great Eastern, covers up to $120,000 a year for her non-CDL treatment, and provides as charged coverage for cancer services.

She has a 16-year-old daughter who is very close to her, so she is determined to survive as long as possible, even though the treatment sometimes causes diarrhoea, and she feels nauseated and tired.

As cancer of the bile duct is not common, there is no incentive for drug companies to conduct trials to prove their drugs’ effectiveness in treating this cancer. Without such proof, the treatments are considered “off-label” and are generally not included in the CDL – even if they work.

Oncologists often turn to off-label drug use when patients no longer respond to conventional treatments. A drug is off-label if it has not yet received official regulatory approval, or is an approved drug that is not listed for use against a particular cancer.

The MOH spokesman said the CDL includes 18 off-label treatments that have been approved by other reference countries’ drug regulatory authorities. He added: “Since the CDL was introduced, over 90 per cent of new cancer patients use treatments that are in the list.”

But none of the off-label treatments on the list are for bile duct cancer.