OBJECTIVES: We sought to understand the changing role of cost-effectiveness analysis (CEA) at the Common Drug Review (CDR), the health technology assessment agency providing reimbursement recommendations to all provinces in Canada outside Quebec. The emergence of the pan-Canadian Pharmaceutical Alliance (pCPA) for collective price negotiation has changed the way CEA is used by CDR. Our analysis sought to characterize the use of threshold analysis, (i.e. explicit suggested price discounts calculated using HTA methods), the impact of elimination of confidential pricing, disagreement between submitted ICERs and re-analyses by CDR reviewers, and the fate of cost-effective drugs in negotiations with the pCPA. METHODS: Our analyses relied on publicly-available source documents, obtained primarily from the HTA agency's website. Documents included reimbursement recommendations, process updates and provincial public plan drug listing updates. We compared the percentage of drugs considered cost-effective, according to the text of the reimbursement recommendation, and its change over time since the introduction of new recommendation codes in 2012. We also determined the percentage of recommendations which included explicit threshold analyses, and also those with more general price recommendations. We also recorded the ICERs submitted and reported by CDR, and those considered plausible by CDR reviewers. Finally, we analyzed the time from HTA recommendation to completion of pCPA negotiations, focusing on the success of drugs considered cost-effective by CDR. RESULTS: Use of threshold analysis has increased dramatically, from 2.70% to to 37.21% of recommendations between 2012-2016. Confidential pricing has been used in 25-44% of submissions since 2012. 105/116 submissions receiving conditional recommendations since 2012 featured some form of price control. Disagreement between submitters and CDR reviewers is frequent and substantial, and only a minority of drugs are considered cost-effective. These drugs actually take longer to get through the pCPA negotiation process. CONCLUSIONS: CEA is used rigorously by CDR to secure substantial discounts for innovative treatments.