OBJECTIVES: Since 2005 it is obligatory in the Netherlands to submit pharmacoeconomic evidence for innovative drugs. The aim of our study is to describe the role of pharmacoeconomics in decision-making in the Dutch reimbursement system. METHODS: We used the analytical Hutton framework for assessing ‘fourth-hurdle’ systems to analyse the Dutch drug reimbursement system. We examined policy documents, explored literature and conducted interviews with policy makers and representatives of the pharmaceutical industry. RESULTS:   Different schemes exist for inpatient and outpatient drugs. Expensive hospital drugs obtain positive decisions without extensive pharmacoeconomic evidence. After a period of three years, it is required to submit evidence on real-world cost-effectiveness. However, the first reassessments are yet to be conducted. In contrast, innovative outpatient drugs are only reimbursed after an assessment of pharmacoeconomic evidence. The Dutch Health Care Insurance Board and the Pharmaceutical Advisory Committee advise the minister on the robustness of cost-effectiveness evidence, whereas the latter takes the final decision. Recently, assessment and appraisal have become two separate phases in decision-making. The impact of the appraisal committee is still unclear. The near future will show if they take the lead on advising on value for money. No party has taken up this role until now, only the Council for Public Health and Healthcare suggested a threshold range. The industry, however, anticipates that the new committee just adds another hurdle. CONCLUSIONS: The importance of pharmacoeconomics has increased in Dutch drug reimbursement decision-making, but plays an uncertain role. It seems that the ‘fourth-hurdle’ system is more lenient towards expensive inpatient and orphan drugs. In future research we focus on investigating reimbursement dossiers to reveal implicit and explicit decision criteria. Furthermore, we aim to research reimbursement systems within several European countries to obtain insight into best practice systems that deliver value for money.