OBJECTIVES: International Reference Pricing (IRP) is a key cost-containment tool for health care payers across the world. IRP may apply either fixed or flexible rules to calculate the price of branded drugs. Typically there is no negotiation between manufacturers and the IPR body. In the context of the German AMNOG price negotiations and the role of Germany as a key reference country, there is dearth of evidence on the international impact of the AMNOG law. Our objective was to evaluate the potential impact. METHODS: An IRP tool (Orange) was used to simulate scenarios of price agreements for a new branded drug between the German Head Association of the Statutory Health Insurance Companies and the manufacturer. The impact of the price agreement on other countries was evaluated based on the existing IRP rules as defined in the Orange tool. All prices were initially set at 100 euro to limit the impact to Germany only. RESULTS: A 50% price drop in Germany, for example, would lead to a range of reductions across the world. The largest impact in Europe would be in France, Romania, Russia, Slovenia and Luxembourg (50% decrease) followed by Norway, Greece (17%) and the Netherlands (13%). Switzerland, Ireland, Denmark and Austria would be only marginally impacted. In contrast, with a price increase in Germany of 25% a limited impact in other countries was observed. Such an increase would lead to 6% price rise in the Netherlands, 4% in Switzerland, 3% in Ireland and Denmark, and a 1% increase in Austria. CONCLUSIONS: Price negotiations in Germany could potentially impact the price of new branded therapies in numerous other countries. Ongoing downward pressure on pharmaceutical prices could ultimately have a negative impact on innovation and drug development in Europe.