When a rheumatologist prescribes Humira instead of a biosimilar, or an oncologist chooses Ocrevus over a generic 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 pills. They’re injectables, infusions, or complex biologics used for conditions like multiple sclerosis, rheumatoid arthritis, cancer, and rare genetic disorders. These drugs cost thousands per month-some over $100,000 a year-and make up just 6% of prescriptions but over 70% of total drug spending. And yet, even when cheaper alternatives exist, specialists often stick with the brand name. Why?
The high stakes of switching
For many patients, switching from a brand-name specialty drug to a biosimilar or generic isn’t just a cost-saving move-it’s a gamble. In 2023, a Medscape survey of 1,200 specialists found that 79% of rheumatologists and 82% of oncologists said prior authorization delays and formulary changes forced them to fight for the right drug for their patients. Many of those fights were over brand-name drugs.
One patient with a rare form of multiple sclerosis told her doctor she’d tried a biosimilar after her insurance switched her. Within three weeks, her vision blurred, her balance worsened, and she had to be hospitalized. Her specialist later wrote in her chart: “No generic has matched her response to Ocrevus. We’re not taking that risk again.”
That’s not an outlier. A 2021 JAMA Network Open study found that 30.4% of branded specialty drug dispensing was requested by prescribers or patients-not because of marketing, but because of real-world outcomes. When a drug works, and it’s the only thing keeping a patient stable, doctors aren’t going to risk a change just because the price tag dropped 20%.
It’s not about profit-it’s about predictability
Some assume specialists push brand-name drugs because they’re paid by drug companies. But the data tells a different story. ProPublica’s 2016 analysis showed that doctors who received over $5,000 from pharma companies had brand-prescribing rates about 50% higher than those who got nothing. But here’s the catch: those were mostly primary care doctors prescribing common drugs like statins or antihypertensives. For specialty prescribers-oncologists, neurologists, immunologists-the payments are rare, and the stakes are too high.
Specialists don’t get kickbacks for prescribing Humira. They get sleepless nights when a patient relapses. They get calls from patients crying because their copay jumped from $50 to $850. They get caught between insurers who want cheaper options and patients who are terrified of losing control over their disease.
The real reason specialists prefer brand-name drugs? Predictability. They know the dosing, the side effect profile, the infusion schedule, and how the drug interacts with other treatments. Biosimilars may be scientifically equivalent-but in the real world, immune systems don’t follow clinical trial protocols. A patient might tolerate one brand of interferon perfectly but react poorly to another, even if they’re labeled the same.
The system is stacked against generics
Here’s the twist: even when generics exist, they’re often not cheaper. The Federal Trade Commission’s January 2025 report found that pharmacy benefit managers (PBMs)-the middlemen who manage drug benefits for insurers-were marking up specialty generic drugs by thousands of percent. One PBM-affiliated pharmacy was charging $12,000 for a generic drug that cost $1,800 to acquire. That’s not competition. That’s exploitation.
Meanwhile, brand-name manufacturers often offer patient assistance programs, co-pay cards, and free samples. A rheumatology clinic in Ohio reported that 60% of their Humira patients used manufacturer co-pay support to keep their monthly cost under $100. The biosimilar? No such program. The patient pays the full cash price-or gets denied coverage.
And it’s not just PBMs. Specialty drugs are distributed through tightly controlled networks. Only a handful of specialty pharmacies can handle them. If your insurance plan doesn’t cover the brand, you might have to wait weeks just to get the drug shipped, let alone get training on how to self-inject. Meanwhile, the brand-name version is already in the clinic’s fridge, ready to go.
Patients are demanding the brand
Patients aren’t passive in this equation. On Reddit’s r/healthinsurance, hundreds of users share stories like this one from November 2023: “My specialist said there are no alternatives that work as well for my specific mutation. I’d rather pay $1,200 a month than risk losing mobility.”
When a drug is the only thing standing between a patient and disability, they fight for it. And specialists listen. In 2024, a survey of Medicare Part D enrollees found that 41% of patients who requested brand-name specialty drugs had their requests granted-mostly because their doctor backed them up with clinical notes and prior authorization appeals.
Doctors aren’t just prescribing drugs. They’re advocating for people. And when a patient says, “I can’t afford to fail again,” the doctor’s job isn’t to argue about cost-it’s to find a way to make it work.
The cost of doing nothing
It’s easy to say, “Just use the cheaper drug.” But the consequences of forcing a switch can be worse than the price tag. A 2023 study in the Journal of Managed Care & Specialty Pharmacy found that patients switched from brand to generic specialty drugs had a 34% higher rate of treatment discontinuation within six months. That means more ER visits, more hospitalizations, more lost workdays.
And the financial burden? It doesn’t disappear-it just moves. A patient who can’t afford their drug might skip doses. That leads to disease progression. That leads to more expensive treatments later. A study by Evernorth Health Services showed that specialty drug patients spend an average of $38,000 a year. Non-specialty patients? $492. That’s a 75-fold difference. But the real cost isn’t the monthly bill-it’s the long-term damage when treatment fails.
What’s changing?
There’s pressure to fix this. The Inflation Reduction Act of 2022 let Medicare negotiate prices for some high-cost drugs. In 2025, drugs like Jakafi, Ofev, and Xtandi are on the list. The FTC is investigating PBM markups. Senator Bernie Sanders introduced the Specialty Drug Price Transparency Act to force disclosure of those markups.
But change moves slowly. Even if a biosimilar hits the market at half the price, it still has to get approved by insurers, trained into specialty pharmacies, and accepted by patients who’ve already seen what happens when things go wrong.
For now, specialists keep prescribing brand-name drugs-not because they’re greedy, or swayed by reps, or out of touch. They do it because they’ve seen the alternatives fail. They’ve held the hands of patients who lost their vision, their mobility, their independence. And they know: in specialty medicine, the cheapest option isn’t always the best one.
