Déjà Vu on Trump’s Most-Favored-Nation Drug Pricing Plan
Donald Trump recently issued an executive order to cut the price of prescription drugs in the United States in an attempt to bring them more in line with developed countries with comparable drug regulatory authorities. If this sounds familiar, it’s because it is. The executive order, issued on May 12, 2025 and entitled “Delivering Most-Favored-Nation Prescription Drug Pricing To American Patients”, revives a similar policy he introduced in 2020. That earlier effort sought to peg U.S. drug prices to those in select foreign markets. Five years later, that same rhetoric to lower drug prices maintains its political sparkle across party lines.
Yet here we are… again. So what happened in 2020? And what can that history tell us about how 2025’s order could (or could not) pan out? Are there key differences in the 2025 order? What legal and practical realities are standing in the way of most-favored-nation drug pricing success?
What Is “Most-Favored-Nation” Drug Pricing?
The term “Most-Favored-Nation” (MFN) originates in trade law, where it ensures one nation is not given worse treatment than another in trade agreements. Applied to drug pricing, the principle is flipped: the U.S. government would demand the lowest price a manufacturer offers in any peer country, ensuring American payers are never charged more than international buyers.
This approach mirrors international reference pricing (IRP), used by countries like Canada, Germany, and the U.K., which compare drug prices across borders to cap spending. Most high-income countries use IRP to negotiate drug prices along with other strategies to align cost with health outcomes, such as health technology assessment for value-based pricing. But in the U.S., where the private insurance market is dominant, this would mark a dramatic departure.
What Happened to Trump’s 2020 MFN Executive Order?
Trump’s 2020 MFN order, “Lowering Drug Prices by Putting America First,” directed the Centers for Medicare & Medicaid Services (CMS) to develop a model in which Medicare would pay no more than the lowest price among OECD countries, adjusted for volume and GDP. The CMS issued an interim final rule, but litigation quickly followed.
In December 2020, federal courts issued preliminary injunctions, halting the rule’s implementation. The courts held that CMS had violated the Administrative Procedure Act (APA) by bypassing proper notice-and-comment rulemaking.
In 2021, the Biden Administration inherited the litigation but chose not to pursue the policy, instead focusing on alternative drug pricing reforms such as allowing Medicare to directly negotiate prices under the Inflation Reduction Act of 2022.
See ► How does the Inflation Reduction Act affect prescription drug prices?
See ► Medicare Negotiated Drug Prices 4.7 Times Higher Than NHS Negotiated Prices
What’s in Trump’s 2025 MFN Executive Order?
Trump’s 2025 order calls out the pharmaceutical industry and its reliance on “price markups on American consumers, generous public subsidies for research and development primarily through the National Institutes of Health, and robust public financing of prescription drug consumption through Federal and State healthcare programs.” The policy section is brief yet aggressive, alleging foreign government “freeloading” of the United States – a theme common in Trump’s “America First” rhetoric:
My Administration will take immediate steps to end global freeloading and, should drug manufacturers fail to offer American consumers the most-favored-nation lowest price, my Administration will take additional aggressive action.”
The order directs the Secretary of Commerce and U.S. Trade Representative to identify and address foreign countries that suppress drug prices below market value, thereby shifting the cost burden to Americans. It also instructs HHS Secretary Robert Kennedy Jr. to facilitate programs that allow drug manufacturers to sell directly to American patients at MFN prices “to the extent consistent with law.” If significant progress isn’t made, the order directs that the following avenues are pursued:
- Rulemaking for MFN pricing enforcement
- Drug importation under FDCA 804(j)
- Antitrust enforcement using the Sherman and FTC Acts
- Review of exports of drugs or ingredients contributing to global price discrimination
- FDA re-evaluation of drug approvals for safety/marketing issues
- Broad interagency actions against global price discrimination
Drug Importation Under Trump’s 2025 MFN EO
For those that follow personal and commercial drug importation developments in the United States, the order specifically declares that:
the Secretary shall consider certification to the Congress that importation under section 804(j) of the Federal Food, Drug, and Cosmetic Act (FDCA) will pose no additional risk to the public’s health and safety and result in a significant reduction in the cost of prescription drugs to the American consumer; and if the Secretary so certifies, then the Commissioner of Food and Drugs shall take action under section 804(j)(2)(B) of the FDCA to describe circumstances under which waivers will be consistently granted to import prescription drugs on a case-by-case basis from developed nations with low-cost prescription drugs;”
Déjà Vu again. In September 2020, during the Trump administration, HHS issued a final rule implementing Section 804 of the Federal Food, Drug, and Cosmetic Act (FDCA), which allows for the importation of certain prescription drugs from Canada. Along with that rule, then-HHS Secretary Alex Azar issued a certification to Congress under Section 804(l)(1) stating that:
Importation poses no additional risk to the public’s health and safety and will result in a significant reduction in the cost of covered products to the American consumer."
This certification was limited to drug importation from Canada and was intended to support state-based importation programs, for which states like Florida and Colorado have struggled to gain adequate FDA and Canadian collaboration. The May 2025 Executive Order appears to be targeting broader importation from other developed countries under Section 804(j), which speaks directly to individual importation of prescribed medicine for personal use. Under (j)(2), the FDA may grant waivers to individuals to import more affordable drugs that would otherwise be prohibited. It can also establish a general regulation that empowers individuals to determine the appropriateness of a personal import.
What is the difference between the 2020 and 2025 executive orders?
While the 2020 order focused narrowly on Medicare drug pricing, the 2025 version is broader, more aggressive, and more politically charged. It expands enforcement tools and targets global pricing strategies.
Key Differences Between Trump’s 2020 and 2025 Most-Favored-Nation Drug Pricing Orders
| 2020 Executive Order (EO 13948) | 2025 Executive Order (May 12, 2025) | |
| Primary Objective | Lower Medicare Part B and Part D prices to MFN levels based on OECD nations’ prices | Broader MFN mandate across government, targeting both public and private markets with enforcement and foreign policy mechanisms |
| Scope of Application | Focused only on Medicare (Part B and later Part D) within statutory limits | Goes beyond Medicare, invoking interagency action (Commerce, FTC, USTR), mentions direct-to-consumer programs, and threatens broader enforcement tools |
| Mechanism | Directed CMS to test a CMMI payment model for Medicare to reimburse drugs at MFN prices | Allows CMS to communicate price “targets,” launch a rulemaking process, and explore importation, antitrust enforcement, and revoking drug approvals |
| Definition of MFN Price | “Lowest price” in an OECD country with comparable per-capita GDP, adjusted for volume and GDP differences | Less specific in definition—"most-favored-nation lowest price” in “comparably developed nations”; no mention of GDP adjustment |
| Importation Provisions | No reference to FDA section 804 importation pathway | Explicitly invokes Section 804(j) of the FDCA, encouraging drug importation waivers if safety and cost standards are met |
| Enforcement and Leverage | Relied solely on CMS model testing; limited by statutory constraints | Threatens antitrust enforcement (DOJ, FTC), drug approval revocation (FDA), and trade policy retaliation (USTR, Commerce) |
| Foreign Policy Tie-In | No direct reference to international trade or diplomacy | Directly calls out “global freeloading,” instructs USTR and Commerce to confront foreign price suppression as potentially harmful to U.S. national security |
| Legal Vulnerability | Blocked by courts due to APA violations (lack of comment period, etc.) | Attempts broader interagency engagement but still faces legal limitations; commercial pricing is traditionally beyond the President’s control |
| Tone and Framing | Policy-heavy, with economic and clinical outcome rationale | Combative tone with emphasis on foreign “abuse,” “freeloading,” and punitive action if industry doesn’t comply |
| Consumer Access Language | No mention of direct-to-consumer sales | Introduces a novel direct-to-consumer purchase mechanism at MFN pricing |
Retail Drug Pricing: U.S. vs. Other Countries
On May 12th, a Trump social media post claimed that drug prices (for payers) will be cut by "59%, PLUS!" Later, he said it could be up to 90%.
That range is not far from what American patients already potentially save by purchasing brand name medication through accredited international online pharmacies. PharmacyChecker focuses on comparing out-of-pocket consumer retail drug prices across countries to promote transparent, affordable access to critical prescription medicines. The chart below highlights real-world examples of potential savings for a one-month supply of popular brand-name medications:
| Brand Drug | U.S. Discount Coupon Price | International Online Pharmacy Price | International Online Savings |
| Premarin 0.625 mg | $204.60 | $27.00 | 86.80% |
| Januvia 100 mg | $310.80 | $21.00 | 93.24% |
| Crestor 20 mg | $261.00 | $12.00 | 95.40% |
| Eliquis 5 mg | $569.40 | $42.60 | 92.52% |
| Advair Diskus 250/50 mcg | $152.40 | $39.00 | 74.41% |
| Spiriva Handihaler 18 mcg | $319.80 | $29.70 | 90.71% |
| Nexium 40 mg | $263.70 | $10.20 | 96.13% |
| Synthroid 50 mcg | $145.80 | $34.20 | 76.54% |
| Xarelto 20 mg | $561.90 | $28.20 | 94.98% |
| Farxiga 10 mg | $567.60 | $24.30 | 95.72% |
Sources: U.S. Discount Coupon prices based on available U.S. pharmacy coupon prices on PharmacyChecker.com; International online pharmacy prices based on lowest price among international online pharmacies accredited in the PharmacyChecker International Pharmacy Verification Program. Pricing data updated as of April 2025.
Prices on PharmacyChecker.com are those listed by online pharmacies that offer international mail order. Most international online pharmacies ship worldwide. U.S. prices on PharmacyChecker.com are those discount coupons negotiated by discount card providers with chain and independent U.S. pharmacies. Notably, drug discount coupons are a uniquely American workaround to a fragmented, high-cost healthcare system. In countries with price controls and public health coverage, the system itself handles affordability.
If you are having trouble affording your prescription drug, we encourage you to compare pricing information on PharmacyChecker.com.
See ► PharmacyChecker's list of trusted online pharmacies that ship affordable medication to patients internationally.
Is Personal Drug Importation Legal?
In the United States, technically, it is illegal to import unapproved medication under most circumstances, whether through purchase over the Internet or while on a trip to a foreign country. U.S. government officials have stated that individuals who order non-controlled prescription drugs from foreign sources (up to a three-month supply) for their own use are not being pursued or prosecuted. The U.S. FDA regulates the safety and efficacy of medications sold in U.S. pharmacies.
In contrast, personal drug importation is expressly legal in Australia. Medications dispensed from outside the U.S. are regulated for safety and efficacy by pharmaceutical/pharmacy regulatory authorities in their respective countries.
Read about ► Advanced Pharmaceutical Regulatory Systems
Will Trump’s MFN Drug Price Executive Order Work?
Is Trump slashing drug prices? Not with this order alone. Executive orders, in general, function more as political signals than concrete policy shifts. They outline intent, direct agencies to explore aggressive options, and apply pressure. And with this order, the pressure is certainly on.
Like its 2020 predecessor, this order will likely run into the same legal, legislative, and logistical roadblocks. Executive authority has limits, and the president traditionally cannot unilaterally impose nationwide drug prices across the commercial market.
Still, the MFN narrative resonates as Americans continue to pay significantly more for prescription drugs than patients in other developed countries. It’s a painful reality of living in a country that shamelessly prioritizes profit over its citizens’ health. Addressing this disparity requires deep realignment of the fragmented U.S. drug pricing ecosystem.
