The objective of this article is to examine the impact of economic evaluation on the reimbursement process for pharmaceuticals. The changes in the structure of reimbursement policies necessary to incorporate economic evaluation have been accomplished without major difficulty in most jurisdictions. However, several methodological differences in international guidelines for economic evaluation exist, only some of which can easily be justified. A number of beneficial changes in reimbursement processes have also been observed, such as a trend toward requiring the measurement of more meaningful clinical end points and increased engagement between manufacturers, drug regulators, and payers. A consistent finding in studies of reimbursement decisions is that economic considerations have been influential, second only to the strength of the clinical evidence for the drug of interest. The impact of economic evaluation on the allocation of health care resources is hard to ascertain because little is known about the extent to which reimbursement decisions actually lead to changes in health care practice. However, there is evidence that economic evaluation has assisted price negotiations and enabled reimbursement agencies to target drugs to those patients who will benefit the most.