Cost is a key consideration when building a plan, but keeping that plan affordable over time matters just as much.
Our approach combines innovative cost-management strategies with effective fraud prevention to help protect plan sustainability.
Pressure on group plans today is increasingly concentrated among a small number of high-cost drug claims. Targeted, data-driven cost management strategies help focus efforts where the financial impact is greatest, while preserving access to care.
Over 30%
of costs for private drug plans were linked to specialty therapies
2%
of claims are for high-cost drugs
$25.4M
paid in benefits to our top 25 claimants
We draw on the scientific and clinical expertise of our in-house team to ensure a rigorous and informed management approach.
This strategy is one of the most effective ways to offset rising drug costs.
Savings range from 20 to 40%, depending on the reference biologic and the number of insureds affected.
Biologic drug (brand name)
A therapeutic product derived from living organisms or their cells. Biologic drugs are large, complex molecules and highly variable. They are used to treat chronic, inflammatory, metabolic or oncologic conditions.
Biosimilar drug
A biologic drug highly similar to an already authorized biologic. Approved by Health Canada through rigorous comparability testing, biosimilars have no clinically meaningful differences in safety, efficacy or quality.
Chemical drug (brand name)
A chemically synthesized small-molecule medicine with a defined and reproducible structure, allowing predictable effects and the development of identical generic versions once patent protection expires.
Generic drug
A lower-cost version of a brand-name drug with the same active ingredient, strength and therapeutic effect, though nonactive elements may differ.
We know that a smooth and successful transition depends on how change is managed for plan members.
That includes providing affected plan members with advance notice, clear communications, online resources, transparent exemption criteria and reasonable timelines.
This ensures people have the information and time needed to consult their care teams.
For an example of the resources available to plan members, see our FAQ on transitioning to biosimilars.
For high-priced therapies without biosimilar or generic alternatives, PLAs provide another way to manage costs.
Rebates, price caps or shared-risk mechanisms offset a portion of the cost, helping plans maintain access to innovative treatments while reducing their financial impact.
Our program helps ensure medications are medically necessary and cost-effective.
Coverage decisions consider scientific and clinical evidence, Health Canada-approved indications, treatment guidelines, expert recommendations, therapeutic value, cost and effective lower-cost alternatives.
Step therapy is a sequenced treatment pathway, beginning with a clinically appropriate, cost-effective therapy and progressing to more costly treatment options when the initial therapy isn’t suitable or effective.
This year, our cost-control efforts resulted in significant savings by focusing on mandatory biosimilar substitution and expanding our product listing agreements (PLAs).
$105M
in total annual savings
$75M from biosimilars
$30M from PLAs
We make it easier for plan members to navigate their health benefits, with services and support designed around their needs.
We also cover a range of health topics on our blog.
The same medication doesn’t always come with the same price tag. Our Client Centre features a drug price comparison tool that lets plan members compare prices at local pharmacies and see where they could save.
Prior authorization comes with paperwork, but finding the right form shouldn’t be complicated. Our online search tool lets members check requirements and find the right form based on their medical condition.