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, where conditions like multiple sclerosis, rheumatoid arthritis, and rare cancers are treated, the choice between brand-name and generic drugs isn’t just clinical-it’s personal, financial, and often deeply tied to patient outcomes.
What Makes a Drug "Specialty"?
Specialty drugs aren’t just expensive. They’re complex. To qualify as specialty, a medication typically costs more than $670 per month, requires special handling (like refrigeration), and is often given by injection or infusion. Many treat rare or chronic diseases with few alternatives-conditions like lupus, hemophilia, or certain types of leukemia. In 2021, these drugs made up just 6.2% of all prescriptions but accounted for 71.1% of total U.S. prescription drug spending. That’s a staggering imbalance: less than 1 in 16 prescriptions driving nearly three-quarters of the bill.These aren’t your everyday pills. A patient on a specialty drug might need regular blood tests, nurse-administered infusions, or daily self-injections with detailed tracking. Some require enrollment in Risk Evaluation and Mitigation Strategies (REMS) programs-strict systems designed to monitor side effects. For a doctor, prescribing one means coordinating with a specialty pharmacy, navigating prior authorizations, and often helping patients access financial aid programs just to get the drug.
Why Do Specialists Stick With Brand Names?
It’s not about loyalty to a company. It’s about trust in outcomes. In many cases, there’s no true generic-only a biosimilar. And biosimilars, while similar, aren’t identical. For patients with autoimmune diseases like Crohn’s or psoriasis, even small differences in how the immune system responds can mean the difference between remission and flare-ups.A 2023 Medscape survey of 1,200 specialists found that 79% of rheumatologists and 82% of oncologists said prior authorization delays for specialty drugs frustrated them regularly. Many reported patients who had previously stabilized on a brand-name drug experienced relapse after switching to a biosimilar. One rheumatologist in Chicago told a patient, “I’ve seen three people in the last six months lose their vision after switching. I’m not taking that risk.”
Even when generics exist, the financial structure makes switching hard. Pharmacy benefit managers (PBMs)-the middlemen between insurers and pharmacies-often make more money by keeping patients on brand-name drugs. The Federal Trade Commission found in January 2025 that PBMs marked up specialty generic drugs by thousands of percent. For example, a drug that costs $50 to acquire might be billed to the insurer at $2,000. That’s not a pricing error-it’s a business model. And if the PBM owns the pharmacy dispensing the drug, they profit more from the high-cost brand.
The Money Behind the Prescription
The numbers tell a brutal story. In 2023, specialty drugs generated 68% of all dispensing revenue from specialty medications, up from 54% in 2016. Meanwhile, the average annual cost per patient on a specialty drug was $38,000-75 times higher than for a typical non-specialty drug. Less than 2% of the population uses these drugs, yet they account for over half of all pharmacy spending.Patients aren’t just paying more-they’re paying unpredictably. A Medicare enrollee on Humira might have a $50 copay one year, then see it jump to $850 when their plan changes formulary. Their doctor can’t control that. But they can choose to write the prescription for the brand, knowing it’s more likely to be covered under the old rules-or that switching could trigger a coverage denial.
Drug manufacturers also play a role. They spend millions on patient assistance programs-free drugs for low-income patients, co-pay cards that reduce out-of-pocket costs to $0. These programs aren’t charity. They keep patients on brand-name drugs longer, delaying the market entry of cheaper alternatives. A 2016 ProPublica analysis found that doctors who received over $5,000 from pharmaceutical companies prescribed brand-name drugs at a rate 50% higher than those who received nothing.
Patients Are Caught in the Middle
On Reddit, users share stories like this: “I’ve been on Ocrevus for five years. My MS is stable. My specialist says no other drug works for my mutation. But my insurance won’t cover it unless I try a biosimilar first. So I wait three months. My legs get weaker. My bladder control gets worse. Meanwhile, the PBM makes $12,000 off this drug while I pay $1,200 a month.”These aren’t outliers. The Medicare Rights Center gets dozens of calls every week from patients whose coverage changes mid-treatment. Many specialists report that patients skip doses or delay refills because they can’t afford the copay. One oncologist in Atlanta said, “I’ve had patients tell me they’d rather die than bankrupt their family. That’s not a medical decision. That’s a systemic failure.”
The System Is Designed to Keep Brands Alive
The infrastructure around specialty drugs reinforces brand loyalty. Specialty pharmacies are often owned by PBMs. Prior authorization forms are designed to be confusing. Drug manufacturers provide training, samples, and support staff-things generic makers rarely offer. Meanwhile, doctors spend an average of 13.4 hours a week just on paperwork for specialty drugs, according to the American Medical Association. Most of that time is spent fighting insurers-not making clinical decisions.Even when a biosimilar is approved, it takes years to gain trust. In oncology, where treatment margins are razor-thin and survival rates are critical, doctors won’t risk switching unless there’s long-term data showing equivalent outcomes. And that data? It’s slow to come. Clinical trials for biosimilars are shorter, smaller, and rarely track long-term side effects.
What’s Changing?
There’s pressure to fix this. The Inflation Reduction Act of 2022 lets Medicare negotiate prices for some high-cost drugs-and several specialty drugs are on the list. The FTC is investigating PBM markups. In February 2025, Senator Bernie Sanders introduced the Specialty Drug Price Transparency Act to force PBMs to disclose how much they’re charging above what they pay for drugs.But change moves slowly. In 2025, 98% of large hospitals have specialty pharmacy programs. The pipeline includes over 2,700 new specialty drugs, 45% targeting rare diseases. Global spending on these drugs is projected to hit $320 billion by 2028. The system isn’t collapsing-it’s expanding. And as it does, the gap between what’s clinically needed and what’s financially feasible keeps growing.
What Can Be Done?
Doctors can’t fix this alone. But they can be more transparent. Some now tell patients: “This drug costs $40,000 a year. Here’s how to get help. Here’s what happens if we switch. Here’s what your insurer might say.”Patients can ask: “Is there a generic? If not, why not? Can you help me get financial aid?”
And policymakers need to stop treating specialty drugs like regular prescriptions. They’re not. They’re life-sustaining, complex, and expensive by design. The solution isn’t to force switches-it’s to fix the system that lets middlemen profit while patients suffer.
Until then, specialists will keep prescribing the brand. Not because they want to. But because, in their experience, the alternative is worse.
Why don’t specialists just switch to cheaper generics?
Many specialty drugs don’t have true generics-only biosimilars, which aren’t identical. For patients with autoimmune or rare diseases, switching can lead to relapse, side effects, or loss of effectiveness. Doctors base decisions on real-world outcomes, not just cost. A 2023 Medscape survey found 79% of rheumatologists and 82% of oncologists say prior authorization delays and patient relapses after switching make them hesitant to change prescriptions.
Do pharmacy benefit managers (PBMs) influence prescribing?
Yes. PBMs control distribution and often own specialty pharmacies. The FTC found in 2025 that PBMs marked up specialty generic drugs by thousands of percent, making more money by keeping patients on expensive brand-name drugs. If a PBM owns the pharmacy, they profit more from a $40,000 brand drug than a $5,000 generic-even if the generic is clinically equivalent.
Are brand-name drugs actually more effective than biosimilars?
For most patients, biosimilars are just as effective. But for a subset-especially those with complex immune conditions-small differences in protein structure can trigger different immune responses. Some patients stabilize on a brand drug, then relapse after switching. Doctors see this firsthand, and they’re reluctant to risk it. Long-term data comparing biosimilars to brands is still limited.
Why do patients pay so much even with insurance?
Specialty drugs often have high out-of-pocket costs because insurers use tiered formularies and step therapy. A patient might pay $50 one year, then $850 the next if their plan changes. Insurance doesn’t cap costs for these drugs, and patient assistance programs vary widely. Many patients end up paying thousands out of pocket even with coverage.
Is there any movement to lower specialty drug prices?
Yes. The Inflation Reduction Act allows Medicare to negotiate prices for some high-cost drugs, and several specialty drugs are already on the list. The FTC is investigating PBM markups, and new legislation like the Specialty Drug Price Transparency Act (2025) aims to force PBMs to disclose pricing. But progress is slow-specialty drug spending is still growing at over 11% per year.
