When a rheumatologist prescribes Humira instead of a biosimilar, or an oncologist chooses Ocrevus over a cheaper alternative, it’s not because they’re ignoring cost-it’s because they’ve seen what happens when patients switch.
Specialty drugs aren’t like your typical blood pressure pill or antibiotic. They’re complex, expensive, and often the only option for serious, rare, or chronic conditions like multiple sclerosis, rheumatoid arthritis, or certain cancers. These drugs make up less than 7% of all prescriptions in the U.S., yet they account for over 70% of total prescription drug spending. That’s not a typo. A single patient on a specialty drug can cost more than $38,000 a year-75 times what a typical patient spends on medication. And despite all the talk about generics and biosimilars, specialists keep reaching for the brand name.
Why Brand Names Still Dominate Specialty Care
It’s not about loyalty to a pharmaceutical company. It’s about control. Specialty drugs often have narrow therapeutic windows-small differences in dosing or formulation can mean the difference between symptom control and disease flare-up. For many patients, switching from a brand-name biologic to a biosimilar isn’t just a cost-saving move-it’s a gamble.
A 2023 Medscape survey of 1,200 specialists found that 79% of rheumatologists and 82% of oncologists said prior authorization delays and formulary restrictions directly impacted their ability to choose the best drug for their patient. When a patient has been stable on a brand-name drug for years, switching to a biosimilar-even one approved by the FDA-can trigger unpredictable immune responses. One patient on Reddit shared how her multiple sclerosis relapsed after her insurer forced her onto a biosimilar. Her neurologist told her, "I’ve seen this happen too often to risk it."
Doctors aren’t blind to the cost. They know the $850 monthly copay for Humira is crushing for a Medicare patient. But they also know that when a patient can’t afford treatment, they skip doses. When they skip doses, they end up in the hospital. The real cost isn’t just the sticker price-it’s the ER visits, the lost workdays, the disability claims that follow.
The PBM Factor: Hidden Markups and Limited Choice
Behind the scenes, pharmacy benefit managers (PBMs) control which drugs are covered, how much they cost, and where patients can fill them. The FTC’s January 2025 report revealed something shocking: PBMs were marking up specialty generic drugs by thousands of percent. One drug bought for $120 was sold to patients for $4,200. And these markups weren’t happening at independent pharmacies-they were happening at PBM-owned pharmacies like CVS Caremark and Express Scripts.
Patients think they’re getting a cheaper generic. But when the PBM owns the pharmacy, the profit doesn’t go to lowering costs-it goes into corporate pockets. Specialists see this. They know that even when a biosimilar is available, the PBM might not cover it at a lower price, or worse-they might make it harder to get. Prior authorization forms can take weeks. Appeals can take months. By then, the patient’s condition has worsened.
And it’s not just about access-it’s about trust. When a doctor prescribes a drug, they’re betting on its consistency. Brand-name manufacturers invest heavily in quality control, patient support programs, and training for nurses who administer infusions. Many biosimilars don’t come with the same level of support. If a patient needs a home nurse to give an injection, or a 24/7 hotline for side effects, the brand-name drug often has it. The generic? Maybe not.
Payments and Influence: The Real Story
Some critics point to pharmaceutical industry payments as the reason doctors prefer brand names. ProPublica’s 2016 analysis showed that doctors who received over $5,000 from drug companies prescribed brand-name drugs at a rate 50% higher than those who received nothing. But the data doesn’t tell the whole story.
Many of those payments weren’t for kickbacks-they were for educational grants, speaker fees, or research funding. More importantly, the doctors who received payments were often specialists treating complex cases. They were the ones who had to weigh the risks of switching patients. They weren’t being paid to push expensive drugs-they were being paid to understand them.
And here’s the uncomfortable truth: even without payments, many specialists still choose brand names because they’ve seen the consequences of switching. A 2021 JAMA Network Open study found that when prescribers or patients requested brand-name drugs over generics, it cost Medicare $1.67 billion extra in one year. But that same study also found that patients who switched to generics were 22% more likely to stop taking their medication entirely. The cost isn’t just financial-it’s clinical.
What Patients Are Really Facing
On Medicare forums, patients are posting about their horror stories: a $50 copay suddenly jumping to $850. A prior authorization denied because the insurer says a biosimilar is "clinically appropriate"-but the patient’s doctor says it’s not. A pharmacist refusing to fill a prescription because the PBM won’t reimburse them.
One patient in Ohio, diagnosed with psoriatic arthritis, had been on Enbrel for eight years. Her plan switched to a biosimilar. Within two months, her joint pain returned. Her rheumatologist wrote a letter explaining why the biosimilar wasn’t suitable for her immune profile. The insurer denied it. She had to appeal. Three months later, she got approval-for the brand name. By then, she’d missed three months of work. Her muscles had atrophied. She needed physical therapy just to walk again.
These aren’t rare cases. A 2024 study in the Journal of Managed Care & Specialty Pharmacy found that 42% of specialty drug starts were delayed by seven days or more due to administrative hurdles. That’s not inefficiency-that’s harm.
The System Is Broken, But the Solution Isn’t Simple
Some say the answer is price negotiation. The Inflation Reduction Act lets Medicare negotiate prices for certain high-cost drugs. That’s a start. But specialty drugs are tricky. Unlike statins or metformin, there aren’t dozens of alternatives. For many conditions, there’s one drug-and maybe one biosimilar that hasn’t been proven safe for everyone.
Others say we need transparency. The FTC’s findings on PBM markups are a wake-up call. Senator Bernie Sanders introduced the Specialty Drug Price Transparency Act in February 2025 to force PBMs to disclose how much they’re charging above what they pay for drugs. That could help. But if insurers still restrict access to brand names, patients will still suffer.
What specialists want is simple: the freedom to prescribe what’s best for their patient without jumping through bureaucratic hoops. They want predictable costs. They want insurance plans that trust their clinical judgment.
Until then, they’ll keep prescribing brand names-not because they’re greedy, not because they’re paid off, but because they’ve seen what happens when patients don’t get the right drug.
What’s Next for Specialty Prescribing?
The pipeline is full. The FDA’s Office of Orphan Products Development reports over 2,700 investigational specialty drugs in development, 45% targeting rare diseases. That’s hope. But without structural reform, that hope will come with a price tag that breaks families and health systems alike.
By 2028, specialty drugs are projected to make up 73% of global prescription spending. That’s not growth-it’s a crisis waiting to unfold. The real question isn’t whether specialists should prescribe brand names. It’s why the system forces them to.