OBJECTIVES: Since its adoption by the Institute for Quality and Efficiency in Health Care (IQWiG) in 2009, the Efficiency Frontier (EF) approach is criticized by the pharmaceutical industry, key opinion leaders and national organizations. In a German context, we aim to verify the accuracy of those concerns. METHODS: Review of the most commonly stated arguments against the EF-approach published within the scientific community and given as stakeholders' response on IQWiG’s first cost-effectiveness analysis of antidepressants. RESULTS: Often stated objections against the EF include: 1) no international health economic standard, 2) merely disease specific without prioritization across disease areas, 3) no fixed threshold, and 4) avoiding the quality-adjusted life year (QALY). Ad 1): IQWiG adopted the EF-approach to inform setting appropriate reimbursement caps (since 2011 to inform negotiations for appropriate reimbursement caps with an interquartile-range as basis). In other jurisdictions, an appropriate price need not be determined; decisions (or recommendations) are made regarding whether or not the cost-effectiveness of a drug supports (restricted) reimbursement. Ad 2+3): Although prioritizing funds is no primary aim in Germany, the EF can still be applied equally across indications. Within indications, the reimbursement cap may not distort competition by disadvantaging a manufacturer unfairly and needs to be appropriate when compared with other available interventions. Contrary to the EF-approach, determining prices based on arbitrary fixed thresholds may not stand up in court. Ad 4): Despite methodological doubts concerning QALYs, they are not antecedently excluded as possible patient-relevant outcome measure when using the EF in Germany. Only a fixed cost/QALY-threshold was rejected. CONCLUSIONS: The EF fits the purpose of decision-making in Germany. Most objections are flawed or originate from a profound misunderstanding of the concept or the German (legal) context, where the EF is necessary and viable. The EF’s prime distinction remains: Deriving flexible, non-arbitrary thresholds for disease areas.