OBJECTIVES: To evaluate pharmaceutical pricing in the EU with a focus of cost-containment due to International Price Reference (IPR) in the context of the German AMNOG on pricing in Europe. METHODS: Qualitative research identified guidelines for international price reference from each national reimbursement body (focusing on 10 major EU countries). Reimbursement submissions and results of price negotiations per country were also reviewed to gain insight into the application of pricing guidelines. Findings are based on review of the guidelines, selected appraisals and interviews with national payers in Germany, France and UK. RESULTS: In consideration of existing European price differences, high-price countries have so far increasingly attempted to also lower their pharmaceutical prices: preferably with different cost containment policies and measurements and in addition referencing low-price countries in international price reference (IPR). In both situations, an international downward effect on pricing threatens to happen for global pharmaceutical companies investing in Europe. This creates a European pricing and reimbursement network of connections of countries referencing each other with the tendency to develop a standard price across European countries. Germany is directly price referenced by more than 15 countries and indirectly referenced by around 5 countries. What impact on European pricing the change from the previously free pricing and full reimbursement of patented drug prices in Germany really has, after the implementation of the AMNOG, is quantitatively hard to assess. CONCLUSIONS: If Germany will follow more strictly the international price referencing in the future for innovative drugs based on the AMNOG process, it will lose anchor function in European pricing with an overall international downward effect on the European pricing for innovative pharmaceuticals.