As regards patented drugs, preferred drug lists are used in the United States only, as insurers negotiate discounts with manufacturers. There is evidence that preferred drug lists have led to cost savings, as pharmaceutical companies lower prices to avoid going off list (Kibicho and Pinkerton 2012, Elzinga and Mills 1997). The fundholder is expected to be to obtain services at the best price/quality ration or suffer the consequences of budget over-runs.