ORGANIZATION: The Ministry of Health and Ministry of Finance of the Slovak Republic PROBLEM OR ISSUE ADDRESSED: High ex-factory prices in Slovakia compared with international markets GOALS: To contain costs on prescription drugs in Slovakia; Estimated savings were 17% OUTCOMES ITEMS USED IN THE DECISION: Calculations of the average price of 6 lowest ex-factory prices within 26 EU members verified from online sources for each prescription drug IMPLEMENTATION STRATEGY: The Slovak health care sector had first experience with a price cut across the board in 2007 by 6,6% and 2008 by 7,4% based on the fluctuation of the Slovak koruna. The international price benchmarking scheme was incorporated into the amendment (661/2007) to the Act on scope of  provided health care under health insurance and fees for services connected with providing health care  (577/2004) which was effective from 1 January 2008. The international price benchmarking scheme: Frequency: Twice a year; Date: Deadline for price proposals: 31 October – Effective 1 April & Deadline for price proposals: 30 April – Effective 1 October; Exchange rate: ECB last trading day in March and September; Classification: Comparable pharmaceutical product (same active substance, same strength, same dosage form); Setting the reference price:  The arithmetic average of 6 lowest prices within 26 EU countries. The first round of the international price comparison according to the amendment started in autumn 2008. The second one was implemented in April 2009 which was more transparent due to the available list of sources for drug prices of all 26 EU members. The first step of the international price benchmarking concerns price proposals by pharmaceutical companies to the Ministry of Health. In the second step, the Ministry of Finance compares its calculations with the submitted prices and then it publishes the results online. The third step consists of the meeting where the representatives of pharmaceutical companies discuss differences in prices with the authorities of the Ministry of Health, Ministry of Finance, insurance companies and the State institute for drug control where the final decision is made. RESULTS: Since 1 January, 2009 Slovakia has launch the euro as its legal tender. The strong euro position and lower prices in neighboring countries have considerable effects on the reference prices of prescription drugs which were overpriced on average 10% classified by the anatomical therapeutic chemical. The estimated savings are €60 million for the first round and €91 million for the second round which means that the proportion of pharmaceutical expenditure from the total health care spending declined to approximately 25%. In addition, 12 drugs had to be delisted because some pharmaceutical companies did not accept average prices calculated by the Ministry of Finance from the verified sources. These drugs will be substituted by other pharmaceuticals or purchase directly by health insurance companies. LESSONS LEARNED: Differential compliance of big pharmaceutical companies with legislative and regulatory requests based on their market access strategies. Some companies tried to ignore the process or actively lobby for exemptions for their products. Transparency, online availability of the results throughout the process, and proactive communication with the media were crucial to the success of the project. Price discrimination among countries, arguably to the companies’ benefit, was being presented as to the benefit of Slovakia, even though it led to higher prices. Common data methodology and transparent process increased compliance of the industry. Companies were initially willing to lower the prices to the requested level, on condition that the price will not appear on any kind of official price list, to prevent “reverse referencing” to the prices in other bigger markets in the EU. Even though unsuccessful, these attempts may indicate that the pharmaceutical sector will continue to make their pricing as secretive as possible.