OBJECTIVES Taiwan is considered a challenging market to access, largely due to strict pricing and reimbursement policies. To assess the impact of health insurance reforms introduced in January 2013 (Second Generation National Health Insurance or 2GNHI), Taiwan reimbursement decisions and granted prices before and after the introduction were compared with major western countries. METHODS Publications of Taiwan NHI from March 2011 to February 2014 were searched and reimbursement decisions identified. The largest therapy areas, oncology and cardiovascular, which accounted for 40% of decisions, were compared with those of three major HTA agencies: CADTH, NICE and PBAC. HTA reports and meeting transcripts were analysed and categorised by date, therapy area, decision, rationale, and pricing decision. Resubmissions or those not assessed by the western HTA agencies were excluded.  RESULTS A total of 65 NHI reports were identified. Of these 26 reported decisions on oncology or cardiovascular drugs, 12 were excluded (3 resubmissions, 9 not reviewed by the other agencies). Prior to 2GNHI, 4 out of 5 decisions were positive, or 80% approval rate, while after, only 4 out of 9 were positive, a 44% approval rate. Prior to 2GNHI, all NHI reimbursement decisions identified (6) matched CADTH, NICE, and PBAC. After 2GNHI, only 6/9 or 66% matched. Clinical effectiveness and budget impact were most cited in reimbursement rejections. For example Zytiga, NHI appreciated the cost-effectiveness but stated budget impact was too high, issuing a negative recommendation, contrary to the other agencies. Interestingly, a ‘local’ product was recommended for limited reimbursement even though budget impact was high. CONCLUSIONS Since implementation of Taiwan’s NHI reforms in January 2013, cardiovascular and oncology drug approvals dropped by 36% and agreements with western agencies down 34%, placing an emphasis on budget impact. However, this analysis was constrained by its small sample size, and limited therapy areas.