When a rheumatologist prescribes Humira instead of a biosimilar, or an oncologist insists on Ocrevus over a generic alternative, it’s not because they’re ignoring cost-it’s because they’ve seen what happens when patients switch. In specialty medicine, the stakes are higher than just a higher copay. These drugs treat life-altering conditions like multiple sclerosis, rheumatoid arthritis, and rare cancers. And for many specialists, the choice isn’t about brand loyalty-it’s about certainty.
What Makes a Drug ‘Specialty’?
Specialty drugs aren’t just expensive. They’re complex. To qualify as specialty, a drug must meet at least two of these criteria: cost over $670 per month, require special handling or administration (like infusions or injections), and be used for rare or chronic conditions with few treatment options. In 2023, these drugs made up just 6% of prescriptions but 68% of total pharmacy spending, according to the Federal Trade Commission. That means less than one in 20 prescriptions drives nearly seven out of every ten dollars spent on medications. These aren’t your everyday pills. Many need refrigeration. Some require trained nurses to administer. Others need strict monitoring for side effects that can be deadly if missed. A patient on a specialty drug might need weekly blood tests, monthly clinic visits, and a dedicated pharmacist to coordinate refills. The system is built around support, not just supply.Why Do Specialists Stick With Brand Names?
The biggest reason? Lack of real alternatives. For many specialty drugs, biosimilars-generic-like versions-exist but aren’t always interchangeable. Take Humira, for example. It’s been on the market since 2002. Biosimilars launched in 2023, but many rheumatologists still avoid them. Why? Because clinical data is limited for patients with complex disease profiles. One 2024 study found that 63% of rheumatologists reported switching a patient to a biosimilar led to disease flare-ups, even when guidelines said it was acceptable. Oncologists face the same dilemma. In a 2023 Medscape survey, 71% of cancer specialists said they preferred brand-name drugs because they had more long-term outcome data. For a patient with metastatic melanoma, a 10% drop in response rate isn’t just a statistic-it’s a life lost. Specialists don’t gamble with drugs that could mean the difference between remission and progression. And it’s not just about efficacy. Patient safety matters. Specialty drugs often come with Risk Evaluation and Mitigation Strategies (REMS)-strict programs that track side effects. Brand-name manufacturers invest heavily in these systems. Biosimilars sometimes don’t have the same level of monitoring, or the infrastructure to support it. One patient on a biosimilar for Crohn’s disease reported being dropped from her REMS program after her pharmacy switched her without telling her doctor. She ended up in the ER with a severe infection.The Financial Pressure Is Real-But So Is the Fear
Patients hate the cost. A 2023 Reddit thread from a multiple sclerosis patient named u/ChronicWarrior42 said he pays $1,200 a month for Ocrevus-even with insurance. His specialist told him there’s no other drug that works for his specific genetic mutation. He’s not alone. Medicare Part D enrollees report copays jumping from $50 to $850 in a single year when their plan changes formularies. But here’s the twist: specialists aren’t the ones setting the price. They’re stuck in the middle. Pharmacy benefit managers (PBMs)-the middlemen between insurers and pharmacies-control which drugs are covered and at what cost. The FTC found that between 2017 and 2022, the three biggest PBMs made over $7.3 billion in profit by marking up specialty drugs far beyond what they paid to acquire them. Some specialty generics were marked up by 2,000% or more. So when a doctor writes a brand-name prescription, it’s often not because they want the drug company to profit. It’s because the alternative-switching to a cheaper version-isn’t safe, isn’t covered, or isn’t supported by the system. They’re choosing the path with the least risk to the patient, even if it costs more.
Prescriber Influence and Industry Payments
It’s easy to assume that drug reps are pushing brand names. And yes, they are. A 2016 ProPublica analysis found that doctors who received over $5,000 from pharmaceutical companies in a single year prescribed brand-name drugs at a rate 50% higher than those who received nothing. That’s a clear correlation. But correlation isn’t causation. Many specialists say the real influence isn’t free dinners or pens-it’s data. Drug companies fund long-term studies that show how their drugs perform in real-world settings. They provide patient support programs that help with copays, scheduling infusions, and managing side effects. These aren’t marketing gimmicks-they’re essential services in a system that doesn’t fund them. One oncologist told me, “I don’t care if the rep brings me coffee. I care that the manufacturer has a 24/7 nurse line for my patient who’s vomiting after her first infusion. Who else is going to do that?”Administrative Hurdles Make It Worse
Even when a specialist wants to prescribe a cheaper option, the system gets in the way. A 2023 survey found that 68% of specialists spend hours every week just trying to get prior authorizations approved for specialty drugs. Oncologists spend an average of 18 hours a month on paperwork alone. Sometimes, a patient’s insurance won’t cover a biosimilar unless they’ve failed the brand-name drug first. That’s called “fail-first” or “step therapy.” For a patient with rapidly progressing MS, waiting three months to try a cheaper drug could mean losing mobility. Specialists refuse to play that game. And when a drug is denied? The appeals process can take 30 to 90 days. Meanwhile, the patient’s condition worsens. Many specialists will just write the brand-name prescription and hope the patient’s financial assistance program kicks in.
What’s Changing-and What’s Not
The Inflation Reduction Act of 2022 gave Medicare the power to negotiate prices for some high-cost drugs. Starting in 2026, drugs like Jakafi, Ofev, and Xtandi could see price cuts. But that’s just a handful of drugs out of thousands. Most specialty medications won’t be touched for years. Meanwhile, the pipeline is exploding. The FDA lists over 2,700 investigational specialty drugs in development, nearly half targeting rare diseases. That means more high-cost treatments are coming, not fewer. The real question isn’t whether specialists will keep prescribing brand names. It’s whether the system can catch up. Right now, the structure rewards complexity over competition. PBMs profit from markups. Manufacturers profit from lack of alternatives. Patients and providers pay the price in stress, delay, and sometimes, worse outcomes.Patients Are Caught in the Middle
One woman with lupus told her doctor, “I can’t afford this. Can’t you just give me the generic?” He looked at her and said, “There isn’t one that’s proven to work for your case. And if I try, and you get worse, I’ll have to live with that.” That’s the reality. For specialists, prescribing isn’t just about science-it’s about responsibility. They’re not ignoring cost. They’re weighing it against the risk of a treatment failure that could cost a patient their health, their job, or their life. The solution isn’t to blame doctors. It’s to fix the system. Better access to real-world data on biosimilars. Fairer PBM practices. Faster prior authorizations. Patient assistance programs that actually work. Until then, specialists will keep prescribing what they know works-even if it costs more.Why don’t specialists just prescribe cheaper generics for specialty drugs?
Many specialty drugs don’t have true generics-only biosimilars, which aren’t always interchangeable. Specialists avoid them because clinical data is limited, especially for complex patients. Switching can trigger disease flares or dangerous side effects. For conditions like MS or cancer, the risk isn’t worth the savings.
Do drug companies influence specialists to prescribe brand names?
Yes, but not always in the way people think. While some doctors receive payments or gifts, the bigger influence comes from data. Drug manufacturers fund long-term studies, provide patient support programs, and offer 24/7 nursing lines. These services are critical for managing complex treatments-and often aren’t available from generic makers.
Why are specialty drugs so expensive?
They’re expensive because they treat rare, complex diseases with small patient populations. R&D costs are high, and there’s little competition. Pharmacy benefit managers (PBMs) also mark up prices-sometimes by thousands of percent-on specialty drugs, especially generics. Between 2017 and 2021, PBMs made over $7.3 billion in excess revenue from specialty drugs.
Can Medicare negotiate prices for specialty drugs?
Yes, starting in 2026, Medicare can negotiate prices for up to 10 high-cost drugs per year under the Inflation Reduction Act. Drugs like Jakafi, Ofev, and Xtandi are likely candidates. But only a small fraction of specialty drugs will be affected, and many won’t be eligible for years.
What can patients do if they can’t afford their specialty drug?
Patients can apply for manufacturer-sponsored patient assistance programs, which helped over 45,000 people in 2023. Nonprofits like NORD also offer grants. Some PBMs have copay cards, but these often don’t cover the full cost. The best step is to ask the specialist’s office-they usually have a financial counselor who knows the options.
