MFN drug pricing and Europe: which European prices would actually be referenced?

United States most favored nation pricing makes European price lists an American policy input. The mechanism is simple to state: the reference price is the lowest price in an OECD country whose GDP per capita reaches at least 60 percent of the US level, applied to brand products without generic or biosimilar competition. The hard part is which European price that actually is. European countries publish prices at different points of the distribution chain, several publish list prices only, and the discounts that follow are confidential by design. This article sets out what the policy references, which European figures are visible to it, and what that means for teams on this side of the Atlantic.

What the MFN policy currently does

The policy has developed in two steps. An executive order in May 2025 set out most favored nation pricing as a direction. On 2 April 2026, a further executive order on pharmaceutical imports determined that imported pharmaceutical products present a national security threat, and the current approach links tariff relief and other benefits to a manufacturer's willingness to enter into MFN pricing and domestic production agreements.

Three operational details matter for European readers:

• Scope. HHS expects manufacturers to align US prices for brand products in markets without generic or biosimilar competition, with MFN pricing intended for single source drugs.
• The reference rule. The MFN price is calculated as the lowest price in an OECD member country with a GDP per capita of at least 60 percent of the US figure.
• Implementation. CMS has proposed two payment models, GLOBE for certain drugs under Medicare Part B and GUARD for certain drugs under Medicare Part D. Both are proposed, not finalised. In parallel, the administration reports voluntary MFN agreements with 17 large manufacturers.

Sources: White House, Savings from Most-Favored-Nation Drug Pricing Policy and AMCP federal update, both retrieved on 14 September 2026. A Congressional Research Service legal sidebar discusses the legal questions raised by the 2025 order.

Which European price would actually be referenced?

Whatever is published. That sounds trivial until you look at what European countries publish, because the published figure sits at a different point of the chain in almost every country.

Two consequences follow. First, a naive lowest price search across Europe will systematically pick countries that publish at a lower point of the chain, because an ex-factory price is by construction lower than a retail price for the same pack. Second, the countries with the most tightly regulated manufacturer prices are often the ones whose data requires a licence contract, which limits who can read them at all.

The list price problem

European published prices are list prices. They are not the prices that payers or wholesalers actually pay after rebates, and in several markets the negotiated component is confidential by design.

The scale of that gap is not observable from public files. Even EURIPID, the authority database that harmonises four price levels across roughly 26 countries, had not implemented net prices in the sense of actually paid prices as of 2022, although the European Parliament had called for them in 2017. If the authorities' own shared database does not carry paid prices, no commercial dataset does either.

For MFN this is the central measurement question. A reference built on list prices measures published policy across countries, not the price a European health system actually pays.

Why "drug prices US vs Europe" comparisons overstate the gap

Four effects push in the same direction, and all four are avoidable:

1. Level mismatch. Comparing a US net price with a European ex-factory price compares two different stages.
2. Tax. Several European published prices include VAT, and VAT on medicines differs by country. Finland raised it to 13.5 percent on 1 January 2026.
3. Coverage. European lists are frequently reimbursement lists. France's public database carries a price for 13,648 of 20,900 packs, and Spain's Nomenclátor covers roughly 20,500 of about 67,000 presentations without any manufacturer price at all.
4. Currency units. Denmark publishes in øre, a factor of 100 against kroner. An unnoticed unit error produces a spectacular but false difference.

None of this says European prices are not lower. It says the published difference is not the real difference, and a reference mechanism built on published figures inherits every one of these effects.

How a low price travels inside Europe

The second order effect matters more for European teams than the American headline. European countries already reference each other, so a price set low in one market does not stay there.

• The Netherlands calculate maximum prices from Belgium, France, Norway and the United Kingdom. Norway replaced Germany in that basket in 2020.
• Norway uses the average of the three lowest prices from a basket of nine countries that includes Germany and Austria.
• Latvia has capped the manufacturer price of prescription medicines at the lowest price in Lithuania or Estonia since 1 January 2025.
• Iceland references Denmark, Finland, Norway and Sweden only.
• In a 2015 survey, 29 of 31 examined countries applied external reference pricing.

A manufacturer that lowers a list price in one European country to satisfy an American reference therefore feeds that figure into several European baskets at the same time. The exposure is not one market, it is the set of countries whose formula reads that market.

What it means for wholesalers and parallel traders

Parallel trade inside the European Union exists because the same pack carries different prices in different member states. Anything that narrows those differences narrows the business case, and a reference mechanism that pushes list prices toward a single low value narrows them in one direction only.

Three observations from the data are worth holding on to before drawing conclusions:

• The differential is already regulated, not free. Most European prices are maximum or reimbursement prices set by authorities, and 29 of 31 examined countries applied external reference pricing in the 2015 survey. Price differences across Europe are largely a product of formulae, not of market bargaining.
• Export controls already respond to price gaps. Several countries in Central and Eastern Europe steer exports automatically. Romania works with a stock threshold, Bulgaria through the SESPA transaction database, and Czechia with a notification and a 15 working day waiting period.
• The visible price is not the arbitrage price. Wholesale purchase prices are not published anywhere in the 30 countries reviewed. Anyone modelling parallel trade margins from published lists is modelling an upper bound.

For a wholesaler the practical consequence is unchanged by American policy: the exposure is to price changes in the countries that other countries reference, and the response time is set by the update rhythm of those national lists, which ranges from daily to two or three times a year.

Three questions the data can answer today

Does Europe publish a single comparable price? No. Thirty countries publish at four different chain positions, and four of them only under a licence contract.

Is the published European price the paid price? No. List prices are published; negotiated rebates are not, and the authorities' own shared database had not implemented paid prices as of 2022.

Can a European price change be tracked to its downstream effects? Yes. The reference baskets are documented in national law, so the propagation path from a single market into other national formulae can be mapped in advance.

What to prepare

The practical answer is monitoring, not speculation. Four questions are worth answering for your own portfolio before the policy settles:

1. Where is your price published, and at which level? Build the list per country and mark whether the figure is published, derived through a statutory formula or estimated with a margin assumption.
2. Which European baskets contain those countries? That tells you the propagation path of any single change.
3. How fast does each list move? Belgium, Portugal and Sweden update daily, Germany and Denmark every two weeks, Poland quarterly, Romania two or three times a year.
4. Can you evidence list against net? Where rebates are confidential, document that they exist and are not in the file. That single sentence prevents a comparison from being read as a paid price.

Conclusion

Most favored nation pricing turns European publication practice into an input for American reimbursement. The reference rule is clear, the reference data is not: European countries publish at different chain positions, several only under licence, and none publish what is actually paid. For European manufacturers and traders, the more immediate question is not what Washington decides but which European baskets read the country where a price moves first.

Related reading: European Drug Pricing Database: how cross-border prices work and Pharma pricing Germany: how the system works, plus external reference pricing in Europe.

pharmazie.com is the consolidated pharmaceutical data platform by DACON Datenbank Consulting GmbH that bundles 25+ specialist databases into a single search, exclusively for healthcare professionals. Price coverage focuses on the DACH region and a number of further EU countries, with more countries following in the coming months.