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 referenced country, there is  dearth of real-life evidence on the international impact of  the AMNOG law. METHODS: The publicly available IRP rules were screened and evaluated systematically. Based on these findings an IRP model  was developed to simulate scenarios of price agreements for a new 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 analysed based on the existing IRP rules. RESULTS: We simulated a hypothetical price dataset for a branded drug X with all prices set at 100 euro to limit the impact to Germany only. A 25% price drop in Germany would lead to a range of 32.5% reduction in Egypt and almost 1% in Austria. The largest impact in Europe would be in France, Romania, Russia, Slovenia, Luxembourg (-25%), followed by Norway and Greece (-8.33%), the Netherlands (-6.25%), Switzerland, Ireland and Denmark. A price drop of 50% in Germany would double the impact with the exception of Egypt (-55%).  However, a limited impact was observed if the price increase in Germany was  25%.That would lead to 6.25% increase in the Netherlands, 4.17% in Switzerland, 2.78% in Ireland and Denmark, and about 1% increase in Austria. CONCLUSIONS: Price negotiations in Germany could potentially impact the price of new branded therapies in other countries. This could ulitmately lead to a price-downward spiral  with a negative impact on  innovation and drug development in Europe.