On October 1, 2026, a new payer-of-last-resort framework for public drug and supplemental benefits plans will come into force in Alberta. Introduced by the Health Statutes Amendment Act, 2025 (No. 2) (“Bill 11”), which received Royal Assent on December 11, 2025, the framework amends the Alberta Health Care Insurance Act (“AHCIA”) and fundamentally changes how public and private drug and supplemental benefits coverage is coordinated in the province.
The new framework effectively positions public drug and supplemental benefits plans as payers of last resort. Where a member is entitled to alternative coverage, that coverage must be accessed first, and the public plan will only pay in limited circumstances and only up to the unpaid portion of the claim.
A New Payer-of-Last-Resort Framework
Bill 11 adds a new Part 3 to the AHCIA governing drug and supplemental benefits plans. Under section 77, where a member of a public plan is entitled to receive a drug and supplemental benefit from an “alternative payor” for the same or an equivalent drug or supplemental service, the public plan cannot pay that benefit.[1]
In practice, this means that all available private or other coverage must be considered and accessed before a public plan pays.
Who Are the Alternative Payers?
An “alternative payor” is broadly defined to include any drug and supplemental benefits plan other than a public plan, including a private or employer-sponsored plan, a plan established by the Government of Canada, a plan established by another province or territory, or a plan established by a provincial health agency or provincial health corporation under the Provincial Health Agencies Act.[2] Stakeholders should assess which of their existing plans qualify as alternative payors and confirm that claims adjudication systems can correctly identify and sequence them.
When May a Public Plan Still Pay?
The payer-of-last-resort framework does not eliminate access to the public plan. A public plan may still pay a benefit where the member is otherwise entitled to it under the public plan and has first submitted the claim to the alternative payor. The public plan may then pay only if:
- the alternative payor paid none of the amount claimed;
- paid only part of the amount claimed;
- deemed the member not entitled to receive the benefit; or
- denied the claim.[3]
Alberta Blue Cross has described the practical effect of the change as requiring private, employer-sponsored, retiree and other available coverage to be exhausted before Alberta government-sponsored programs pay. Claims submitted in the incorrect payer order will be treated as ineligible, and pharmacists are expected to identify all applicable drug plans and submit claims in the correct order. Plan administrators and pharmacies should review their adjudication workflows and point-of-sale processes to ensure compliance with the new sequencing requirements.[4]
How Much May the Public Plan Reimburse?
Even where the conditions for intervention by the public plan are met, its financial responsibility remains limited. Reimbursement continues to be subject to the eligibility criteria, coverage rules and payment limits applicable under the public plan.
Specifically, the public plan’s payment must be made in accordance with its own terms and conditions and cannot exceed the unpaid portion of the claim.[5]
Employer-Sponsored and Other Private Plans
Bill 11 includes specific rules for employer-sponsored drug and supplemental benefits plans. These plans generally include private plans established, maintained or renewed by an employer for some or all Alberta-resident employees. Plans established for employees of municipalities or the Government of Alberta are also treated as private plans.
Bill 11 also provides that the Insurance Act does not apply to employer-sponsored drug and supplemental benefits plans in relation to the new Part 3. Public drug and supplemental benefits plans are defined to include the Alberta Blue Cross Plan, in respect of non-group members, and any other plan prescribed by regulation.
What This Means for Stakeholders
The payer-of-last-resort framework may require stakeholders across the reimbursement pathway to revisit how public and private coverage is coordinated in Alberta.
Employers and plan sponsors should review plan text, coordination-of-benefits language, retiree coverage terms and member communications. Private plans will become the first payer for claims that may previously have been paid first, or in greater proportion, by a government-sponsored program. Plan administrators should confirm that members understand the new claims order and are not inadvertently directed to a public plan before available private coverage has been assessed.
Insurers, third-party administrators and pharmacy benefit managers should assess their adjudication rules, payer sequencing logic, member eligibility verification and pharmacy communications. The framework places practical emphasis on information gathered at the point of sale. Administrators should ensure that members can obtain and submit documentation of the private plan’s payment or denial determination before pursuing any residual public plan claim. Because the definition of “public drug and supplemental benefits plan” can be expanded by regulation, insurers should monitor for regulatory developments that could affect the payment hierarchy.
Pharmaceutical and life sciences stakeholders should assess the impact of the new framework on market access, reimbursement strategy and patient support programs. While Bill 11 does not amend federal drug approval requirements, the new payer sequencing rules may have practical implications for product listing agreements, coverage pathways explained to patients, how reimbursement support services triage claims, and how manufacturers evaluate payer mix and access barriers for products used by Alberta residents.
(All the footnotes finishing by *** are sections that are going to be modified, introduced or affected on October 1st by the coming into force of the Health Statutes Amendment Act, 2025 (No. 2), Bill 11, 2nd Sess, 31st Leg, Alberta, 2025.)
