Specific Measures Trump Demanded from Companies in the Letter:

1. Full Application of "Most Favored Nation" Pricing: Require drug manufacturers to offer their entire existing drug portfolio to every Medicaid patient at the lowest price they provide in other developed countries (i.e., the "Most Favored Nation" price).

2. Locking in New Drug Prices: Require pharmaceutical companies to sign agreements with the U.S. government, ensuring that Medicare, Medicaid, and commercial payers receive the "Most Favored Nation" price for all new drugs at launch and in the future.

3. Pressuring Foreign Markets: Urge drug companies to negotiate more aggressively with what he called "foreign freeloader countries," stating that U.S. trade policy would support this effort. He emphasized that increased revenue overseas must be "repatriated through agreements with the U.S. to lower drug prices for American patients and taxpayers."

4. Bypassing Middlemen: Require drugmakers to adopt a direct-to-consumer or direct-to-business sales model, aiming to eliminate intermediaries and ensure all Americans receive the same "Most Favored Nation" price that companies offer to third-party payers.
   
   

After Trump released the letter, pharmaceutical stocks plummeted. Bristol Myers Squibb and Novo Nordisk fell nearly 5%, while GlaxoSmithKline and Merck dropped over 4%, and Sanofi plunged more than 7%.

For years, the pharmaceutical industry has protested the idea of global drug price linkage, arguing it would threaten the U.S.'s long-standing dominance in biomedical research, weaken incentives for developing new drug therapies, and hinder patient access to needed medications. Industry executives have urged the government to focus instead on middlemen in the drug supply chain, who negotiate prices on behalf of employers.

Following Trump’s latest demands, some drug companies issued statements expressing willingness to work with the U.S. government to improve healthcare accessibility and affordability. However, the industry’s largest trade group maintained a tougher stance against the proposed reforms.

Trump has long condemned the disparity in drug costs between the U.S. and other countries. During his first term, he signed a similar executive order as a negotiation tactic with drugmakers, but the effort ultimately failed due to legal challenges.

While the industry has largely resisted Trump’s push for lower prices, there have been signs of concession. AstraZeneca CEO Pascal Soriot broke industry consensus earlier this week, acknowledging the current situation is unsustainable.

A Novo Nordisk spokesperson said the company "remains committed to improving patient access and affordability." Pfizer stated it is working with Congress and the White House to increase patient access, while Merck expressed willingness to collaborate with the U.S. government toward the same goal.