High-Cost Drug Risk Is Now a Business Risk

This has real implications for employers who sponsor benefit plans.

For years, many employer plans relied on Alberta Blue Cross Non-Group coverage as the first payor for certain high-cost medications. That wasn’t a loophole — it was deliberate design. It helped keep catastrophic drug costs off private plans, stabilizing renewals and protecting budgets.

But the ground is shifting.

Recent legislative changes being advanced in Alberta — for example, amendments in the Health Statutes Amendment Act that clarify private plans and employer plans as payors of last resort — are part of a broader trend that reshapes who pays first when expensive therapies are needed. Under these evolving rules, public coverage is stepping back, and private plans are stepping forward as primary payors for high-cost drugs. 

At the same time, even government-sponsored programs like non-group drug coverage are adjusting copays and cost structures in response to escalating healthcare costs. 

This shift means that exposure to high-cost drug claims is coming back onto employer plans — not as an occasional outlier, but as a predictable and growing element of your plan’s financial experience.

Traditionally, benefits management has focused on:

• Coverage design
• Carrier selection
• Annual pricing negotiations
   

Those are still important — but they don’t get to the heart of the new challenge.

Today, benefits strategy must also include:

• Financial risk management
• Sustainability planning
• Long-term cost governance
• Active business risk control
   

High-cost drugs — including biologics, specialty therapies and personalized medicines that can cost hundreds of thousands (or even millions) per patient per year — are no longer “manageable by exception.” They are a structural cost driver that will touch more plans more often.

We help employers transition from traditional insurance-centred thinking to a benefit risk management framework built for today’s realities:

• Strategic plan design that anticipates high-cost exposures
• Prior authorization and clinical risk controls
• Financial modelling and scenario planning
• Governance structures that bring transparency and accountability
   

This isn’t about cutting care — it’s about protecting your plan’s ability to deliver care sustainably, year after year.

Benefits have become a business risk. We help you manage it like one.

If you'd like to learn more, we'd love to chat! Schedule a risk review.

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This overview reflects current and emerging trends in Alberta and Canadian prescription drug policy, informed by the following publicly available sources:

• Government of Alberta
  Health Statutes Amendment Act (Bill 11) and related legislative updates affecting drug coverage coordination and payor responsibility.
• Alberta Blue Cross
  Non-Group Coverage program materials, plan coordination guidelines, and public communications regarding coverage structure and cost-sharing.
• Canadian Institute for Health Information (CIHI)
  National data on prescription drug spending, specialty drug growth, and cost drivers in employer-sponsored benefit plans.
• Patented Medicine Prices Review Board (PMPRB)
  Reports on high-cost and specialty drug trends in Canada.
• Conference Board of Canada
  Research on employer-sponsored benefits, drug plan sustainability, and private–public cost shifting in healthcare.
• Canadian Life and Health Insurance Association (CLHIA)
  Industry insights on extended health benefits, high-cost drug claims, and plan sustainability pressures.