OBJECTIVES: Many key pharmaceutical markets (including England, Scotland, Canada and Australia) have Health Technology Assessment (HTA) bodies for which cost-utility analyses are key criteria. For such bodies, acceptable cost per Quality-Added Life Year (QALY) based on the manufacturer’s submitted price must be demonstrated. By contrast, in other major markets (such as France and Germany), a level of added benefit is ascribed to a drug and based upon this a price is negotiated. However, the expansion of international reference pricing means that prices in major ex-US markets are increasing converging. Thus the major difference between such agencies becomes the coverage, which this research compares, using the example of 2 recent high cost breast cancer therapies. METHODS: Publically available HTA reports for Kadcyla and Perjeta from the pan-Canadian Oncology Review (pCODR), National Institute for Health and Care Excellence (NICE), Scottish Medicine Council (SMC), Institute for Quality and Efficiency in Healthcare (IQWiG, Germany), Haute Autorite de Sante (HAS, France), and Australian Pharmaceutical Benefits Advisory Committee (PBAC) were screened (up to December 2014) and the decision, date and key rationale were extracted. RESULTS: NICE, SMC, PBAC, and pCODR have all appraised both Kadcyla and Perjeta but none of these bodies have found either of these drugs to be cost-effective. By contrast, HAS and IQWiG have both appraised Kadcyla and Perjeta, granted coverage and found these to offer an added benefit compared to existing standard of care, thus securing it a negotiated premium over comparator therapies. CONCLUSIONS: Obligatory cost-utility bodies assess cost-effectiveness based on the manufacturer’s price, which is often deemed not cost-effective, resulting in frequent delays and denials to access of innovative products. However, if cost-utility bodies instead confidentially evaluated the QALY benefit and determined the proposed price based on this they could achieve potentially much better coverage without compromising their cost-utility principles.