The legitimacy of procedures and criteria for determining benefit packages depends crucially on the representation of stakeholders in decision-making bodies, the transparency of procedures and the consistency of benefit decisions. Moreover, the assessment of the costs of healthcare services and its application as a decision criterion can be an important policy instrument in order to increase the overall efficiency of healthcare systems. Our analysis of procedures and criteria for determining benefit packages in England, Germany and Switzerland established potential for developing more legitimate procedures and criteria for benefits decisions. In Germany, representation of stakeholders and transparency of procedures can be improved. Consistency of decision-making is hindered by the veto positions of selected stakeholders. Moreover, benefit decisions are made for different healthcare sectors separately. In Switzerland, transparency of procedures is virtually non-existent at the moment. Thus, it is impossible to assess the consistency of decision-making. Only in England the costs of healthcare services influence the decision to include or exclude them.