Changes to how Alberta’s government-sponsored drug programs work with private insurance took effect Oct. 1, requiring private benefit plans to be billed first for claims eligible under both private and government-sponsored coverage.
The changes were made through Bill 11, the Health Statutes Amendment Act, 2025 (No. 2). They make the government the payer of last resort.
Private and public plans can still pay portions of the same prescription providing a person has not exhausted their annual private benefits.
The change can shift more prescription costs onto private plans, depending on their coverage terms. It does not necessarily change how much each plan pays in every case.
Raising questions
The change is raising questions among some seniors who have both government and private coverage.
For 77-year-old Calgary resident Beverley Scott, the biggest frustration has been trying to get clear answers about how the changes work and why the government made them.
“I want to know why they’re changing it. They had to do the research. They had to spend the money to do the research on should they change it. If so, how?” asked Scott.
“I want to know what brought this on when we’ve got so many other things that, in this world, we’re having to deal with. Why are they picking on this particular situation for our seniors?”
Scott says she contacted the provincial government, Alberta Blue Cross and her MLA seeking an explanation. She says a government response received Sept. 30 included information about immunization and measles — subjects she had not asked about — along with information printed from the government’s website.
Coverage for Seniors program
Alberta’s Coverage for Seniors program is premium-free. Alberta Blue Cross administers the program and its claims on behalf of the provincial government.
Under the program, eligible prescription drugs are subject to a co-payment of 30 per cent of the prescription cost, to a maximum of $35 per prescription.
People who coordinate an employer or personal benefits plan with a Government of Alberta-sponsored plan may be more likely to reach their private plan’s annual maximum sooner. Some people may then have out-of-pocket costs for expenses not covered by either their private or public coverage.
Impact variable
Randy Howden, a pharmacist and owner of The Medicine Shoppe in Calgary, says the impact will depend on each patient’s coverage.
“I don’t think immediately we’ll see too much of a change,” said Howden
“If patients have only government coverage; it won’t affect them in any way,” he added.
The real effect says Howden will be felt by those with both the government plan and separate private insurance coverage.
“Under the new way of doing things with Bill 11, their private plan will go first, and so what might happen is they might reach their maximum coverage, and then they will only have the Alberta government plan for the rest of the year or the time period.”
Once private benefits run out, patients could become responsible for co-payments previously covered by their private plan, or the full cost of medications covered by neither plan.
It will also lead to higher costs for those private insurers. For many that will be reflected in premiums.
As an employer, Howden says his own benefits provider has told him that’s coming down the pike.
“We’ve already been told by our private plan provider that they would expect that in the next few years we’ll see increases to our premiums because of more use of the private plans.”
Lack of public understanding
Howden says a lack of public understanding has also left pharmacy teams responsible for explaining the changes.
“Some people may have to pay copays that they’ve never had to pay previously, and some people may not understand why the change has happened,” said Howden.
The Alberta government didn’t educate the public about this, they’ve really put it onto the pharmacy teams to educate the public about what it means for each individual person.”
The Bill 11 changes arrived alongside a new pharmacy agreement and other changes involving pricing and dispensing, Howden says. He says managing those changes while preparing for flu and COVID-19 vaccinations has added to pharmacies’ workload, and he urges patients to ask questions and be patient with staff.
Chris Gallaway with Friends of Medicare says the broader concern is what happens over time as more costs that were previously paid first by the public plan are charged to private insurance.
“Premiums will have to go up, or coverage will have to be cut. There’s no other option, because we’re downloading those costs from the public onto these private plans,” Gallaway told CTV News.
Gallaway said the effect will differ depending on the terms and limits of individual insurance plans, but he expects employers, workers and retirees to ultimately face increased costs.
“You know, this idea of the payer of last resort is very insurance language, you know, but the day-to-day reality is it’s going to cost people more in their premiums, in their co-pays, and it’s going to cost employers more to provide benefits to their workers.”
Questions
CTV News sent the Ministry of Primary and Preventative Health Services a detailed request for clarification about the changes, asking:
- “What benefit does the province expect this change to provide?”
- “What impact does the province expect it to have on employers and employer-sponsored drug plans?”
- “What benefit does the change provide to seniors receiving prescription drug coverage?”
- “What benefit does the province expect the change to provide to Albertans more broadly?”
- “What options are available to seniors whose private drug plans have annual or lifetime coverage limits and who may exhaust those benefits more quickly because their private insurer is now the primary payer?”
- “Could you please clarify how co-payments will work in those circumstances and whether seniors could face increased out-of-pocket costs as a result of this change?”
- “I would appreciate any additional information the province can provide about the policy rationale, anticipated financial impact and protections available to seniors affected by the change.”
Province responds
The ministry’s response did not explain how co-payments would be calculated or address potential premium increases and costs to employers and seniors. It said government coverage would remain available when private coverage is unavailable or exhausted:
“Beginning Oct. 1, Albertans with both private and government-sponsored drug coverage will access their benefits through a coordinated approach that uses private or employer-sponsored plans first, with government coverage continuing to support eligible Albertans when private coverage is unavailable or exhausted. The changes align Alberta with other provinces and help ensure public coverage remains available for those who need it most.”
Those who rely solely on government-sponsored drug coverage will not be affected by the payment-order change.
Bill 11 prevents employers from terminating, reducing or modifying specified drug and supplemental health benefits for active employees solely because of their age.
The legislation does not freeze premiums or place limits on how much the cost of those plans could increase.
Alberta Blue Cross’s website provides an example showing how the new payment order could work when both plans continue to provide coverage.
In an example published on its Bill 11 information page, Alberta Blue Cross describes a senior with a private Retiree plan and Coverage for Seniors submitting a $100 claim for a drug on the Alberta Drug Benefit List.
Prior to Oct. 1, the government plan paid $70 and the private plan paid the remaining $30. Under the new arrangement, the private Retiree plan pays the $30 first and the government-sponsored Coverage for Seniors plan pays the remaining $70. In both cases, the senior pays nothing out of pocket, provided the private plan’s annual maximum has not been reached.
