17 Nov 2025
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When you pick up a generic pill at the pharmacy, you might assume the price is just what the manufacturer decided. But in most high-income countries, that price was actually set by a government using data from other nations. This is called international reference pricing-a system where countries look at what other countries charge for the same generic medicine and use that to decide what they’ll pay. It’s not about fairness or global standards. It’s about control. And it’s working-sometimes too well.
How International Reference Pricing Actually Works
International reference pricing (IRP) doesn’t mean every country copies the lowest price. Instead, governments pick a group of similar countries-usually 5 to 7-and calculate an average or median price for each generic drug from that group. Then they set their own reimbursement rate close to that number. If a drug costs €2 in Germany, €1.80 in France, and €2.10 in Italy, the average might be €1.97. That becomes the max price the public health system will cover.
For generic drugs, most countries use internal reference pricing, not external. That means they group together all therapeutically equivalent generics-say, all 10mg lisinopril tablets-and set one reference price for the whole group. Manufacturers can sell their version at any price, but if it’s higher than the reference price, patients pay the difference. This pushes companies to undercut each other. In Germany, the reference price is set at the lowest price in the group plus a tiny 3% margin. In the Netherlands, it’s even stricter: tendering and mandatory discounts drive prices down even further.
Reference baskets vary. Western European countries typically look at France, Germany, Italy, Spain, and the UK. Eastern European nations often use Austria, Germany, and the Netherlands. Switzerland does something unique: it takes two-thirds of the international average and one-third from Swiss prices. The goal? Balance affordability with stability.
Why Generic Drugs Are Treated Differently
Patented drugs get special treatment. Their prices are often negotiated based on clinical value, innovation, or patient outcomes. Generics? They’re seen as interchangeable commodities. That’s why 24 out of 27 EU countries use internal reference pricing for generics, but only 12 use external reference pricing for branded drugs. For generics, the focus is purely on cost.
This makes sense on paper. Generics are off-patent. They’re chemically identical. Why pay more? But in practice, treating them like widgets ignores real-world complexity. Manufacturing a simple tablet is cheap. But a complex generic-like an inhaler, injectable, or extended-release capsule-can cost almost as much to develop as a new drug. Countries using strict IRP are seeing fewer companies invest in these complex generics. FDA data shows a 17% drop in new complex generic applications in countries with the harshest pricing rules.
Real Results: Lower Prices, But Also Shortages
The numbers don’t lie. Countries using IRP for generics pay 25-40% less than those that don’t. In the Netherlands, generic prices are 65-85% lower than the original brand. In Spain, generic substitution rates jumped from 52% in 2010 to 89% today because of reference pricing.
But there’s a cost. When prices are squeezed too hard, manufacturers walk away. Greece, during its financial crisis, pushed IRP too far. By 2015, 37% of generic medicines faced shortages. Pharmacists couldn’t stock them. Patients waited weeks. Portugal saw 22 generic products disappear from the market in 2019 after prices were cut below production costs.
Even when drugs are available, quality concerns creep in. A 2021 OECD survey found that 34% of patients in Europe worried that cheaper generics might be less effective. Pharmacists in Spain report that while substitution is common, they often run out of the lowest-priced version-forcing them to offer a slightly more expensive one, which patients then have to pay extra for.
Who Wins and Who Loses
Health systems win. Budgets stay under control. Administrative work drops-Germany’s hospital procurement managers say IRP cut their paperwork by 37%. Patients get access to affordable meds. But manufacturers? They’re caught in a squeeze. Teva’s 2022 annual report admitted that reference pricing in Europe led to a 9% revenue drop in its generics division, even as sales volume rose 15%. Sandoz says it’s managed to grow market share in 18 countries by adapting, but admits margins are razor-thin.
Small manufacturers suffer most. Big players like Teva and Sandoz have global supply chains and can absorb losses in one country by making up for them elsewhere. Smaller firms? If their only market is a country with strict IRP and their product gets priced out, they can’t survive. That’s why the European Generic and Biosimilar Medicines Association warns that IRP systems must protect incentives for quality and innovation-or the pipeline of new generics will dry up.
New Trends: Dynamic Pricing and European Collaboration
Some countries are moving beyond static price lists. France launched a dynamic reference pricing system in January 2023. Instead of annual updates, prices adjust every quarter based on which generics are selling the most. If a cheaper version suddenly dominates the market, the reference price drops. Early results show 8.2% extra savings.
Even bigger: the European Commission’s new European Reference Pricing Platform, launched in April 2023. It’s a pilot project where 7 countries share real-time pricing data for 15 off-patent medicines. The goal? To coordinate pricing across borders so no single country gets dragged down by others’ price cuts. If successful, it could expand to 100 medicines by 2025.
Analysts predict that by 2027, 65% of European generic prices will be set by reference pricing-up from 58% in 2022. But the trend isn’t just about cutting prices anymore. It’s about smart pricing. The OECD now recommends tiered reference groups: simple generics get the lowest benchmarks; complex ones get higher, more realistic rates based on manufacturing difficulty.
What About the U.S. and Canada?
The U.S. doesn’t use IRP for generics at the federal level. Medicare and Medicaid don’t compare prices to other countries. But some states are experimenting. Colorado’s Medicaid program started using reference pricing in 2021 and saw 12-15% savings on generic prescriptions. Still, it’s the exception, not the rule.
Canada is the opposite. Its federal agency, the PMPRB, uses IRP for patented drugs only. Generics? They’re handled by individual provinces through tendering-where the government invites bids and picks the lowest. That’s why Canadian generic prices are often lower than in Europe, but without the same level of coordination.
What’s Next for Generic Drug Pricing?
IRP isn’t going away. It’s too effective at controlling costs. But it’s evolving. The next phase won’t be about finding the cheapest price in the world. It’ll be about finding the right price-one that covers production, ensures supply, and still keeps medicines affordable.
That means systems will need to account for:
- Manufacturing complexity-not all generics are created equal
- Exchange rates and inflation-prices in euros or pounds don’t stay stable
- Confidential discounts-some manufacturers secretly give rebates, which messes up the reference data
- Therapeutic equivalence-how do you group drugs when bioavailability varies slightly?
For now, countries are learning from each other’s mistakes. Greece’s shortages taught others to avoid extreme cuts. Portugal’s market exits showed the danger of ignoring costs. France’s dynamic system proved that flexibility works better than rigidity.
The real challenge isn’t setting prices. It’s balancing three things: affordability for patients, sustainability for manufacturers, and reliability for health systems. Get one wrong, and the whole system cracks.
What countries use international reference pricing for generic drugs?
As of 2025, 28 of 32 European countries use some form of international reference pricing for generics. Most Western European nations-including Germany, France, Spain, Italy, and the Netherlands-use it as a core tool. Eastern European countries like Romania and Bulgaria also rely on it, often referencing Austria, Germany, or the Netherlands. Outside Europe, Canada and Australia use it for branded drugs but not generics. The United States does not use IRP at the federal level, though a few states like Colorado have piloted it for Medicaid generics.
Does international reference pricing lower drug prices?
Yes, significantly. Countries using IRP for generics pay 25-40% less than those that don’t. In the Netherlands, generic prices are 65-85% lower than originator brands. Germany’s system cuts prices by 15-35% compared to non-IRP countries. But the savings come with trade-offs: shortages, reduced innovation in complex generics, and pressure on manufacturers’ margins.
Why do some generic drugs disappear from pharmacies?
When reference prices are set too low, manufacturers can’t make a profit-especially for low-margin products. In Greece (2012-2015) and Portugal (2019), dozens of generic drugs vanished because prices were cut below production costs. Small manufacturers, with no global backup, often exit the market. Even big companies like Teva and Sandoz have pulled products in markets where pricing rules don’t reflect real manufacturing costs.
Is internal reference pricing better than external for generics?
For generics, internal reference pricing is generally more effective. It groups similar drugs together and sets one price for the whole group, encouraging competition within the category. External reference pricing-comparing prices across countries-is harder to apply to generics because manufacturing costs, taxes, and distribution vary too much. Most European countries use internal reference pricing for generics (24 out of 27 EU states), while only 12 use external. Internal systems are more stable and predictable.
Do patients notice a difference in quality with reference-priced generics?
Legally, generics must be bioequivalent to brand-name drugs. But patient perception varies. A 2021 OECD survey found that 34% of European patients worried cheaper generics might be less effective. Pharmacists report that some patients request specific brands-even if they cost more-because they believe older or more expensive versions work better. These are psychological concerns, not scientific ones, but they still affect adherence and trust in the system.
What’s the future of international reference pricing?
The future is more nuanced. Instead of one-size-fits-all pricing, countries are moving toward tiered systems that recognize complexity. Simple tablets get low benchmarks; complex injectables or extended-release forms get higher ones. France’s dynamic pricing and the EU’s new reference platform show a shift toward real-time, coordinated pricing. Experts agree: IRP isn’t going away, but it’s evolving from a blunt tool into a smarter, more flexible system that balances cost, access, and sustainability.