Objective: To examine differences and similarities in coverage decisions for outpatient pharmaceuticals in Denmark, Norway and Sweden in order to provide insights into HTA processes in Scandinavia. Methods: A comparative analysis of all outpatient drug appraisals carried out between 2009 and 2012, including an analysis of divergent coverage decisions made by all three countries was performed. Agreement levels between HTA agencies were measured using kappa scores. Consultations with stakeholders in the three countries were carried out to complement the discussion on HTA processes and reimbursement outcomes. Results: 19 outpatient drug-indication pairs appraised in each of the three countries were identified, of which 6 pairs (32%) had divergent coverage decisions. An uneven distribution of coverage decisions was observed, with the highest number of overlap in decisions in appraisals in Norway and Sweden (free-marginal kappa 0.89). Similarities were found in priority principles, mode of appraisal and reasoning for coverage decisions. Conclusions: The study suggests that role health economic evaluation is less prominent or explicit in outpatient drug appraisals in Denmark than in Norway and Sweden, that the countries could benefit from improved communication between appraisers and manufacturers, and that access to drugs rely on more than decisions made by national HTA agencies.