Reforming private drug coverage in Canada: Inefficient drug benefit design and the barriers to change in unionized settings

•We conducted 18 interviews with companies, unions, insurers and plan advisors.•Interviewees were asked about the benefit design process in unionized settings.•All participants agreed that most private plans failed at providing value for dollar.•Participants blamed lack of information sharing, education, and insurer incentives.•All participants favored some form of government intervention.

Prescription drugs are the highest single cost component for employees' benefits packages in Canada. While industry literature considers cost-containment for prescription drug costs to be a priority for insurers and employers, the implementation of cost-containment measures for private drug plans in Canada remains more of a myth than a reality. Through 18 semi-structured phone interviews conducted with experts from private sector companies, unions, insurers and plan advisors, this study explores the reasons behind this incapacity to implement cost-containment measures by examining how private sector employers negotiate drug benefit design in unionized settings. Respondents were asked questions on how employee benefits are negotiated; the relationships between the players who influence drug benefit design; the role of these players' strategies in influencing plan design; the broad system that underpins drug benefit design; and the potential for a universal pharmacare program in Canada. The study shows that there is consensus about the need to educate employees and employers, more collaboration and data-sharing between these two sets of players, and for external intervention from government to help transform established norms in terms of private drug plan design.