OBJECTIVES: To analyse and compare the pricing and reimbursement procedures of pharmaceuticals in Bulgaria (BG), Czech Republic (CZ), Poland (PL), and Romania (RO). METHODS: Health legislation including corresponding laws and regulations determining pricing and reimbursement procedures was reviewed. Countries were selected on the basis of their mutual referencing. RESULTS: In all four countries health insurance is obligatory and medicines prices are regulated applying the reference pricing system for prescription medicines. In BG, RO and PL positive drug lists constitute reimbursement approach. Bulgaria’s reference countries include RO and CZ, not PL. Romania’s reference basket encloses 12 countries including BG and CZ, while PL references to all EU countries. CZ and RO employ the average among the three lowest reference prices and BG and PL the lowest reference price. There is a regressive margin scale in all countries. In BG, RO and PL margins are separated for wholesalers and retailers, while in CZ they are negotiated. In CZ and PL there are multiple insurance companies compared to BG and RO, where there is only one. Currently RO’s reimbursement is 50% of the price for all prescription drugs, BG and PL use 4 reimbursement levels, PL and CZ employ a complex external and internal referencing. In CZ the reimbursement base is the cheapest medicinal price in the group. In BG, PL and RO the reimbursement level is the cheapest price per DDD for every INN. All countries require pharmacoeconomic evidences, but CZ and PL employ guidelines, while BG and RO apply criteria for evaluation.  CONCLUSIONS: We deem BG and RO systems less adaptable, but clearer to follow. CZ and PL systems show greater flexibility, due to existence of negotiation and freedom.