If you are an Alberta based organization or have employees residing in Alberta, there are three significant benefit plan developments that could affect future claims costs and plan administration:
- Alberta Bill 11 and Payor of Last Resort Legislation
- Increased pharmacy dispensing fees
- The arrival of generic semaglutide (Ozempic®) products
Alberta Bill 11 and Payor of Last Resort Legislation
The most significant change is Alberta Bill 11.
Effective October 1, 2026, when a claim is eligible under both a private benefit plan and a government sponsored program, the claim must be submitted to the private plan first before government coverage applies. This shifts employer and personal benefit plans into the role of primary payer for many drug and health claims as noted below.
- Prescription drugs
- Ambulance services
- Clinical psychological services
- Home nursing care
- Chiropractic services
- Prosthetic and orthotic benefits
- Mastectomy prosthesis
- Hospital accommodation
The legislation also eliminates age discrimination for active employees over 65. Private group benefit plans are not allowed to reduce, terminate, or modify prescription drug and supplemental health coverage for active employees simply because they turn age 65.
As a result of these legislative changes, plan sponsors are required to document and process employment statuses as follows:
- Employers must maintain accurate Active/Retired status information for Alberta members.
- Employment status updates must continue to be submitted through normal enrolment maintenance processes.
- Failure to maintain accurate status information could impact benefit administration
For employers, that raises several important considerations:
- If your plan has health annual maximums, these benefits can be reached sooner
- Active employees over age 65 must be added back to plans where age-based Extended Health limits currently exist.
- Employers that have relied on Alberta Blue Cross Non-Group Coverage or Alberta Coverage for Seniors in the past will become responsible as the first payer.
- Plan wording, eligibility rules, communication strategies, and renewal budgeting may all need to be reviewed.
- Bill 11 does not restrict employers in terms of what they choose to cover. Organizations can continue to use tools such as restricted formularies, drug maximums, and other plan design limits. The key requirement is that coverage for active employees cannot change solely because they turn 65.
- Health Care Spending Accounts are not considered private coverage and do not need to be used before the province pays.
Pharmacy Dispensing Fees Increasing October 1, 2026
Another change Alberta employers should be aware of is the upcoming increase to pharmacy dispensing fees, the first increase in more than a decade.
As of October 1, 2026, dispensing fees will increase from $12.15 to $12.35 for prescriptions under 84 days and from $12.15 to $13.50 for prescriptions of 84 days or more.
The new fee structure is intended to encourage longer duration fills for maintenance medications, reducing the number of dispensing events over time. The additional costs will flow through to the plan’s claims experience if there is no dispensing fee cap while plan members may see higher out of pocket costs if their pharmacy charges dispensing fees above the plan maximum.
What could this mean financially?
In a recent publication, Alberta Blue Cross estimates:
- Drug claims could increase by approximately 2% to 5% of paid drug and health claims combined.
- Extended Health claims could increase by up to 0.4%.
- Higher pharmacy dispensing fees may add another 0.10% to 0.15%.
There is some good news.
Generic versions of semaglutide (aka Ozempic) have entered the Canadian market at approximately 35% of the cost of the brand name product, which Alberta Blue Cross estimates could generate savings of roughly 1% to 4% of total health and drug spend.
When all three changes are considered together, Alberta Blue Cross estimates a potential overall impact ranging from a decrease of 1.90% to an increase of 4.55%, with most employers expected to experience a modest increase in claims costs.
The takeaway?
This is more than a legislative update. It is a benefits strategy conversation. Our association, Smart Health Benefits Association (SHBA), is at the table and met with Alberta Health on Jun 16th.
We have been recognized as a unique voice to have at the table and confirmed our availability to work on other topics impacting plan sponsors as our relationship evolves.
Plan sponsors should review plan design, age-based eligibility provisions, future renewal expectations, and employee communications now so there are no surprises on October 1.
With a target effective date of October 1st, the Alberta government is finalizing the operational regulations for Bill 11, and The Consulting House along with the SHBA is actively engaged with Alberta Health to understand the details and ensure a reasonable implementation for employers and their employees.
It is important to note that the real cost impact for each plan sponsor will differ, as there is no way to know which drug and health claims are currently being paid by the province. The Consulting House will work with our clients over the next three months to explore options for managing the financial impact and preparing their plans for October 1.
If you’re unsure how these changes may affect your organization, now is a good time to start asking questions. Every plan is different, and the impact will depend on factors such as plan design, workforce demographics, and current coverage arrangements. We’re always happy to have a conversation and help employers understand what these changes could mean for their specific situation.