Nearly three million Canadians have switched pharmacies on the recommendation of their insurance provider, according to survey data released by the Canadian Pharmacists Association (CPhA).
The survey highlighted the growing influence of insurers and pharmacy benefit managers (PBMs) on how patients access medications. These findings reflect a broader trend in the insurance market, where cost-containment measures and preferred provider networks (PPNs) are being used to manage claims expenses and negotiate lower dispensing costs.
Eighty-six percent (86%) of Canadians surveyed said they believe prescriptions should be filled at any licensed pharmacy, regardless of insurer arrangements. CPhA said that despite this, network steering and administrative requirements are limiting patient choice and creating new pressures for pharmacists.
According to CPhA, pharmacies play a central role in patient care, but insurers’ administrative demands are redirecting pharmacists’ time and resources. The association noted that these practices illustrate how insurers are balancing patient access with financial controls, often by narrowing provider networks or imposing strict claims requirements.
CPhA is urging governments to regulate PBMs and insurers through template legislation it has developed. The framework is designed to improve transparency and reduce insurer-driven barriers. Proposed measures include banning requirements that restrict patients to insurer-preferred pharmacies, limiting the frequency of audits, creating clearer recoupment and appeals rules, and prohibiting administrative fees tied to electronic claims submissions or adjustments.
Survey results showed that 36% of pharmacists face multiple patient conflicts daily linked to third-party payer claims. Seventy-five percent (75%) spend at least five hours a week on these claims, while nearly 20% spend more than 15 hours. CPhA reported that 81% of pharmacies experience moderate to significant workflow disruptions due to insurer processes.
The results also point to the growing use of PPNs as a cost-control strategy. While 71% of pharmacies do not participate in these networks, 75% said they are still required by insurers to direct patients to pharmacies that do. CPhA said this reflects how insurers are shaping pharmacy competition and concentrating patient traffic within preferred networks.
The association said these findings show that insurer-driven administrative practices represent more than minor inefficiencies. It said pharmacists are being diverted from patient care, while patients are being guided toward insurer-preferred pharmacies. CPhA added that this is why legislative intervention is needed to balance insurer cost-control measures with patient access.
From a market perspective, the issue underscored the growing tension between insurers’ strategies to manage claims costs and the need for flexibility in patient care.
For insurers, preferred networks and tighter claims oversight are tools to contain rising health expenditures. For pharmacists and patients, however, these tools translate into restricted choice and increased administrative demands.
CPhA said its members believe that protecting patient choice and reducing unnecessary requirements would allow pharmacists to focus on delivering timely care, while still leaving room for insurers to manage costs through regulated and transparent mechanisms.
