Background and Research Question: The comparison of the prices of pharmaceuticals is an important element of a popular policy tool in Europe, known as ‘External Reference Pricing’ (ERP). Albeit being a commonly used policy instrument, ERP is often challenged by stakeholders by claiming potential negative effects on patients’ access or that it is hampering uptake of products in a market. Between 2016 and 2018 the Euripid Collaboration developed recommendations which are meant to guide a coordinated approach of national competent authorities regarding the use of ERP to mitigate potential negative impact for patient access. *** Methods: Electronic databases were searched for publications published during the period of 2002-2016. Grey literature, government or European Commission publications on Pharmaceutical pricing published during the same period were also searched via the Internet. In addition primary data were collected through a survey with national and EU authorities, stakeholder in the field of medicines and members of the EURIPID collaboration. The final document was prepared following a two-stage (written comments and face-to-face workshops) review process Euripid members, further national competent authorities on pricing and reimbursement of medicines, the WHO-PPRI network, European Commission policy officers and stakeholders in the field, i.e. economic operators, professional associations, patient and consumer organisations and third party payers’ associations. *** Results: Based on evidence and experience, twelve principles were developed to provide guidance when applying ERP. The principles follow the structure: Framing the issue - Things to consider - Recommendations. They cover important areas as the use of ERP for decision making, the scope/selection of reference countries, the scope/selection of medicines, the comparability of pharmaceuticals and formula used during ERP procedures. *** Conclusion: The Board of Participants of the Euripid Collaboration formally endorsed the use of the twelve principles within the remit of their responsibilities and will consider them in their work. These principles are an important step towards a more balanced use of this policy tool and thus higher acceptance in Europe.