Specialty Prescribing: Why Specialists Stick to Brand-Name Drugs

When a rheumatologist prescribes Humira instead of a biosimilar, or an oncologist chooses Ocrevus over a cheaper alternative, it’s rarely about preference alone. It’s about the system they’re forced to navigate - one where brand-name specialty drugs dominate, even when generics exist. These aren’t ordinary medications. They’re high-cost, complex treatments for rare or chronic conditions like multiple sclerosis, rheumatoid arthritis, and cancer. And despite being prescribed to less than 2% of the population, they account for over half of all pharmacy spending in the U.S.

The Numbers Don’t Lie

Specialty drugs make up just 6% of all prescriptions filled, yet they consumed 71% of total prescription drug spending in 2021. That’s not a typo. One patient on a specialty drug can cost $38,000 a year. The average non-specialty drug? $492. That’s a 75-fold difference. And it’s getting worse. By 2023, specialty drugs made up 68% of all dispensing revenue from specialty medications, up from 54% in 2016. The cost per drug has jumped 13.2% annually since 2010 - more than five times the rate of regular drugs.

Why does this matter to doctors? Because they’re the ones caught between what’s clinically right and what’s financially feasible. A 2023 Medscape survey found that 68% of specialists feel frustrated by prior authorization delays. Oncologists and rheumatologists - the ones prescribing most of these drugs - report even higher rates. One oncologist in Chicago told me, “I spend more time filling out forms than I do with my patients.”

Why Not Switch to Generics?

It sounds simple: use the cheaper version. But for many specialty drugs, there isn’t a true generic. Instead, there are biosimilars - drugs that mimic the original but aren’t identical. And even when biosimilars exist, they’re not always used. Why?

First, many specialists believe the original brand-name drug has better real-world outcomes. For patients with complex mutations or rare disease subtypes, there’s often no data proving a biosimilar works as well. A patient on Reddit wrote, “My specialist says there are no alternatives that work for my specific mutation.” That’s not fear - it’s experience.

Second, the system doesn’t make switching easy. Even when a biosimilar is available, insurance plans often don’t cover it unless the patient tries the brand first. Or worse - the brand is on formulary, the biosimilar isn’t. So the doctor writes the brand, and the patient gets it. No choice.

And then there’s the PBM problem. Pharmacy Benefit Managers - the middlemen who control drug access - mark up specialty generics by thousands of percent. The FTC found that between 2017 and 2021, PBM-affiliated pharmacies made more than $7.3 billion in revenue above what they paid for the drugs. That’s not profit from efficiency. That’s profit from confusion. When a $500 biosimilar gets billed as $8,000, no one wins - except the middleman.

The Influence of Payments

It’s uncomfortable to say, but money talks. A ProPublica analysis in 2016 showed that doctors who received more than $5,000 from drug companies in a single year prescribed brand-name drugs at a rate 50% higher than those who got nothing. That’s not conspiracy - it’s human behavior. A free lunch, a conference trip, a research grant - these things shape decisions, even subconsciously.

Specialty drug manufacturers spend heavily on detailing. They fund patient support programs, co-pay cards, and educational materials. They make the brand feel like the only safe option. When a rheumatologist’s office gets a free kit with branded samples, patient education pamphlets, and a dedicated rep who calls weekly, it’s hard not to default to that drug - especially when switching requires paperwork, delays, and risk.

The Burden on Patients

Patients don’t choose these drugs. They’re handed them. And they pay the price - literally. One Medicare enrollee wrote on a patient forum: “My Humira copay went from $50 to $850 a month when my plan changed. My doctor said biosimilars aren’t right for me.” That’s not a medical opinion. That’s a coverage limitation dressed up as clinical judgment.

Even with insurance, patients face high out-of-pocket costs. The average annual cost for a specialty drug user is $38,000. For many, that means skipping doses, rationing meds, or going into debt. And when they ask their doctor why they can’t switch, the answer is often: “I don’t control the formulary.”

What’s Driving the Doctor’s Choice?

It’s not just about money. It’s about control.

Specialists are trained to be precise. They manage complex diseases with narrow treatment windows. When a drug has limited data, when side effects are unpredictable, when the stakes are high - they stick with what they know works. Brand-name drugs have decades of real-world use. Biosimilars? Sometimes only a few years. In oncology, where a missed dose can mean progression, the margin for error is razor-thin.

Also, specialty drugs come with built-in support systems. The manufacturer provides nurses to train patients on injections, 24/7 helplines, and financial aid programs. Generic makers? Often none of that. So the doctor’s office gets a smoother workflow - fewer calls from confused patients, fewer failed treatments, fewer emergency visits.

And let’s not forget the administrative nightmare. Getting a specialty drug approved can take weeks. If the doctor tries to switch to a biosimilar, they might have to restart the entire prior authorization process. That’s 10 more hours of paperwork. For a busy oncologist seeing 20 patients a day, that’s not worth it.

The System Is Broken - But Not Unfixable

The Inflation Reduction Act gave Medicare the power to negotiate prices for some high-cost drugs. That’s a start. Drugs like Jakafi and Xtandi could be next. But negotiation alone won’t fix this. We need transparency.

Doctors need to know what PBMs are charging. Patients need to know why their copay jumped. Regulators need to cap those outrageous markups. And insurers need to stop making patients jump through hoops just to get the drug their doctor recommends.

Some hospitals are already changing. A major health system in Minnesota now requires specialists to document why they’re choosing brand over biosimilar. If they can’t justify it clinically, the pharmacy won’t fill it. That’s accountability.

And it’s working. In one year, their biosimilar use jumped from 12% to 41% - without a drop in outcomes.

What Can Be Done?

For specialists: Start asking. Why is this the only option? Is there real data behind the choice? Can we try a biosimilar with close monitoring?

For patients: Ask your doctor: “Is there a cheaper version? Why not use it?” Don’t accept “because that’s what’s on formulary” as an answer. Push for documentation.

For policymakers: Force PBM transparency. Cap markups on specialty generics. Require insurers to cover biosimilars without prior step edits. Make the system work for patients - not middlemen.

Specialty drugs save lives. That’s not in dispute. But they shouldn’t bankrupt patients, overload doctors, or distort the market. The problem isn’t the drugs. It’s the system that lets them be priced like luxury goods - when they’re essential medicine.