OBJECTIVES: National public insurance coverage of drugs is based on evidence of comparative effectiveness and cost effectiveness. This study compares the importance of these issues across three jurisdictions (Australia, Canada, England and Wales) that have been at the forefront of evidence-based coverage internationally. METHODS: A retrospective comparative analysis of data on factors that have been influential in pharmaceutical public insurance coverage decision in England and Wales (NICE), Australia (PBAC) and Canada (CDR) was conducted. The probability of coverage for drugs was compared across jurisdictions by each key factor. Data items on all drugs considered for 2004 to 2008 were extracted from publicly available documents on coverage decisions in each country. RESULTS: Recommendations varied considerably across countries in part because of different processes including the willingness to negotiate on price and the associated attitude to market proliferation of drugs with similar characteristics. The data suggest that the three agencies make recommendations that are consistent with a cost effectiveness framework; although it is clear that these committees have other objectives in addition to efficiency. This is consistent with previous empirical studies that suggest the strength of evidence of the comparative effectiveness of the drug as well the budgetary cost to government is also significant predictors of listing in addition to cost-effectiveness. CONCLUSIONS: NICE, PBAC, and CDR continue to face common issues with respect to the quality and strength of the experimental evidence in support of a clinically meaningful effect. There are significant differences in recommendations across countries in part due to differences in interpretation of evidence differences in objectives and associated processes, particularly with respect to price negotiation.