In Western Canada, specialty drugs’ share of private plans’ costs is
23%, due to pharmacare programs in three provinces automatically acting as first payer for prescription drugs after an income-based out of-pocket deductible, climbing to
38% in Atlantic Canada.
As much as
60% of the current pipeline is focused on specialty medications, according to a 2020 report from Express Scripts Canada, with about
50% of drugs in the pipeline designed for oral administration, continuing a shift in costs from provincial to private plans.
This framework is two-tiered, as a Green Shield Canada report notes — each insurer places eligible high-cost drug claims from their fully-insured plans into their proprietary extended health-policy protection plan pools. The pooling threshold, typically upwards of $10,000, is negotiated between plan sponsor and carrier.