February 2026
The top 10 developments in drug insurance in 2025
A look back at the highlights of 2025 for our 11th edition of the top drug insurance developments of the past year.
LEGISLATIVE CHANGES
1. Changes to national pharmacare
2. Major federal funding for rare disease drugs in Canada
3. Adoption of Bill 11 in Alberta
4. Regulatory changes in Quebec
5. The end of closed Preferred Pharmacy Networks (PPNs) in Ontario?
DRUG MARKET DEVELOPMENT
6. Weight loss drugs in the spotlight (Wegovy® and Zepbound®)
7. Generic semaglutide (Ozempic®/Wegovy®)
8. Health Canada approves innovative treatment for postpartum depression
To date, three provinces and a territory have signed an agreement to implement a national pharmacare plan. Coverage under the program began in Manitoba and Prince Edward Island in 2025, and is expected to begin in 2026 for British Columbia and the Yukon.
Current coverage includes contraceptives and select diabetes medications. Generally, this could represent a 3% reduction in drug spending for private plans. Manitoba and British Columbia have also included free public coverage for hormone replacement therapy as part of their respective agreements with the federal government.
The Carney government’s first budget maintained funding for the national plan but did not add any additional funding. It will be interesting to monitor the situation in the coming year to see whether other provinces and territories decide to join the federal program.
In 2023, the Government of Canada announced its first National Strategy for Drugs for Rare Diseases, a major commitment to improving treatment access, coverage and affordability for rare disease patients. Following a period of negotiation and preparation, the strategy was finally implemented in 2025 when most bilateral agreements were signed with the provinces and territories.
This federal strategy provides for a total investment of up to $1.5 billion over three years, with the vast majority being allocated to the provinces and territories through bilateral agreements. These funds will support access to new and existing drugs, early screening, diagnosis and care for people with rare diseases, which affect one in 12 Canadians.¹
As of 2025, all provinces and territories have signed bilateral agreements with the federal government. These agreements recognize the financial reality of treatments for rare diseases, with annual costs ranging from $100,000 to over $4 million per patient, making access difficult without structured intervention.
The impact on private plans has yet to be determined. On one hand, wider access to these treatments could lead to an increase in claims as more patients gain access to treatments that were previously out of reach. On the other hand, efforts to make these ultra-specialized drugs more affordable could help lower the cost of individual claims. The overall impact will depend on how quickly these treatments are integrated into public plans, and on the access mechanisms established by the provinces and territories.
| An ultra-specialized drug is a cutting-edge, typically high-cost treatment, intended for rare or complex clinical indications and subject to strict eligibility criteria. |
On December 18, 2025, Alberta adopted Bill 11 (Health Statutes Amendment Act). This legislation reshapes the balance of responsibilities between the private and public sectors in the province. Specific to coverage for prescription medications, the legislation explicitly designates private insurance plans as the primary payer. This major reform may pave the way for a transformation in Alberta’s health care funding model.
The key anticipated impacts for private drug insurance plans include:
- An obligation for employers to maintain coverage for active employees aged 65 and over;
- A potential revision of the opt-out option of drug insurance plans when an employer-sponsored plan is available;
- Clearer coordination between private plans and existing public coverage, such as Non-Group Coverage;
- The potential for future changes to the coverage of medically necessary services (including medications) while in hospital.
Bill 11 introduces a unique public-private hybrid model in Canada, positioning the private sector as a central pillar for both primary health care and drug insurance leaving a larger portion of costs being directed towards private payers. The upcoming developments regarding implementation will be worth monitoring in 2026.
Tightening of Quebec’s exceptional patient measure
In 2025, Quebec made significant changes to the rules governing access to and reimbursement of certain drugs, with repercussions for both the public plan and private group insurance plans. These changes are primarily designed to better control costs and strengthen the clinical oversight of reimbursed treatments.
The exceptional patient measure has been tightened. The new rules rolled out between July and December 2025 reduce the number of possible exceptions and further regulate access to drugs that are excluded from normal coverage. From now on, only drugs whose therapeutic value has been recognized by the INESSS are eligible, and applications must demonstrate clear clinical benefits. Brand-name drugs are no longer covered when a generic version is available. In addition, manufacturers have a maximum of 120 days to submit a registration application after Health Canada approval; otherwise, the drug becomes ineligible for the measure. These criteria will also be used as a reference by private insurers when the RAMQ formulary is covered by the plan.
End of exceptional status for Concerta in Quebec
As of December 11, 2025, Concerta no longer holds exceptional status in Quebec. This means that the public plan will only reimburse the lowest-priced version of methylphenidate, making generic substitution mandatory—a practice that was already in place in most other Canadian provinces and territories. Private insurers have adopted the same approach, which will help reduce costs for group insurance plans. For Quebec plans, this measure could result in savings of around 65% on costs related to Concerta, an estimated reduction of 0.5% to 1% in overall health insurance costs depending on the weighting of this drug in overall claims.
Ontario is currently considering restricting the use of closed PPNs in private group insurance plans. Stemming from public consultations, this new approach aims to support patient choice and encourage competition among pharmacies. If Ontario goes ahead, depending on the terms rolled out, the structure or reimbursement parameters of certain plans may need to be revised.
In Canada, these networks are mainly used to ensure competitive fees. However, they can hinder accessibility—such as in rural areas—and also raise concerns about healthy competition, particularly for independent pharmacies. Concerns have also been raised about the transparency of practices.
Ontario is proposing to replace these closed networks with an open model, in which any pharmacy accepting the same financial conditions could join the network. The upcoming regulatory developments should be closely monitored as they could lead to changes in the financial management of plans in Ontario.
| A closed Preferred Pharmacy Network (PPN) is a limited group of pharmacies selected by an insurer or plan administrator to provide drugs under negotiated conditions (price, professional fees, services). Plan members can generally benefit from better reimbursements or lower fees by using these partner pharmacies. |
In recent years, group insurance plans covering this type of treatment have seen a sharp increase in costs related to these drugs. Although Wegovy® entered the Canadian market in 2024, its sustained use maintained pressure on private plans throughout 2025.
This pressure intensified with the arrival of Zepbound® in 2025, a new treatment approved by Health Canada on May 13, 2025, and available in pharmacies starting in July. With a price point similar to Wegovy®, this drug has renewed debate about expanded access to these treatments and the management of related costs.
These new drugs are pushing private plans to strike the right balance between access to effective weight-loss solutions and cost control. In this context, authorization and coverage criteria are expected to continue evolving to better regulate the use and financial impact of these medications. Plan sponsors should therefore assess their options in order to meet their objectives. Moreover, facilitating access to professional services, such as in mental health or nutrition, can have a positive impact on patient health and productivity.
In 2025, several manufacturers submitted applications to Health Canada for approval to market generic versions of this molecule—sold under the brand names Ozempic® and Wegovy®—in the second or third quarter of 2026. With prices expected to be 60–70% lower, private plans could save up to 3% on overall health insurance costs.
Novo Nordisk, the original manufacturer, also plans to market its own generic (ultra-generic) versions at a reduced price. This move reflects the original manufacturer’s determination to maintain its presence in an increasingly competitive market.
In December 2025, Health Canada approved Zurzuvae® (zuranolone), the first oral medication specifically designed to treat moderate to severe postpartum depression. This 14-day treatment stands out for its rapid onset, with clinically significant effects observed as early as day 3 in clinical trials.
Its mechanism of action offers an alternative to traditional approaches, reflecting recent advances in mental health treatments, and could help nearly one in five women struggling with this disorder after childbirth. The treatment is expected to cost around $22,000. As a result, it may be subject to eligibility criteria, particularly prior authorization.
Additionally, organizations seeking to offer support that complements pharmacological treatment may explore the growing number of emerging solutions on the market that are tailored to women’s health. Integrating these innovative approaches helps strengthen mental health support.
Canada’s vaccine landscape is evolving on several fronts:
- Lyme disease – The third and final phase of clinical trials for the vaccine developed by Pfizer and Valneva was scheduled to end in 2025. An application for regulatory approval is planned for 2026, depending on the efficacy and safety results obtained. Currently, this product is the most advanced in its field.
- Respiratory syncytial virus (RSV) – Vaccination for RSV is rapidly increasing in Canada. Several provinces and territories now offer it free of charge to the vast majority of infants. Despite this progress, specialists recommend extending universal coverage to all infants, given the contagious nature of RSV and its impact on infant hospitalizations.
- COVID-19 – In 2025, responsibility for purchasing and managing COVID-19 vaccines was transferred from the federal government to the provinces and territories. In Quebec and Alberta, vaccination is only offered free of charge to at-risk groups (seniors and vulnerable populations). Elsewhere in the country, vaccines continue to be offered for free to anyone who would like to be vaccinated. This variation by province/territory and the trend toward reduced coverage under public plans point to the possibility of a gradual transfer of costs to private plans for the general public.
In early 2025, threats of new U.S. tariffs raised fears over possible drug shortages in Canada. So far, however, there have been no shortages linked to these tariffs, and supply chains are being closely monitored.
It will nonetheless be important to remain vigilant in the coming months to monitor how the situation develops and the potential impact of the U.S. economic situation on access to drugs in Canada.
¹ Government of Canada, press release [online].
[https://www.canada.ca/en/health-canada/news/2025/03/government-of-canada-signs-bilateral-agreement-with-quebec-for-drugs-for-rare-diseases.html].
Our group benefits experts closely examine the factors that influence your drug insurance costs. Feel free to leverage our expertise to help you implement simple and effective cost management measures. You can also contact your Normandin Beaudry consultant or email us.