Specialty Prescribing: Why Specialists Often Choose Brand-Name Drugs Over Generics

When a rheumatologist prescribes Humira instead of a biosimilar, or an oncologist insists on 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 pills. They’re complex, expensive, and often the only option for life-altering conditions like multiple sclerosis, rheumatoid arthritis, or rare cancers. And despite the push for generics and biosimilars, specialists across the U.S. continue to favor brand-name versions. Why?

The High Cost of Specialty Drugs

Specialty drugs are defined by more than just price. The Centers for Medicare & Medicaid Services (CMS) sets the threshold at $670 per month, but many cost far more. Some exceed $100,000 a year per patient. In 2023, these drugs accounted for 68% of all dispensing revenue from specialty medications-even though they make up less than 2% of total prescriptions. That’s a staggering imbalance. One patient on a specialty drug can cost more than 75 times what a typical patient spends on medications each year.

Between 2010 and 2019, spending on specialty brand-name drugs jumped from $9.4 billion to $46.8 billion. That’s a fivefold increase in less than a decade. By 2023, global spending hit $229 billion, making up nearly half of all pharmaceutical costs. And it’s still rising. Experts predict specialty drugs will account for 73% of global prescription spending by 2028.

What drives this? Not just innovation. It’s the lack of competition. Many specialty drugs treat rare diseases with no other treatments available. When there’s only one drug that works, price becomes secondary to effectiveness.

Why Specialists Stick With Brands

It’s easy to assume doctors choose brand-name drugs because they’re paid to. But the data tells a more nuanced story. A 2016 ProPublica analysis found that physicians who received over $5,000 from drug companies had brand-prescribing rates about 50% higher than those who received nothing. That’s concerning-but it’s not the whole picture.

More often, specialists choose brands because of real-world outcomes. A patient with a rare mutation of multiple sclerosis might have tried a biosimilar and had a relapse. An oncologist might have seen a patient go into remission on a specific brand and then relapse after switching. These aren’t hypotheticals. They’re documented cases.

A 2023 Medscape survey of 1,200 specialists found that 68% reported frequent frustration with prior authorization rules for specialty drugs. Oncologists and rheumatologists were hit hardest. But even with all the red tape, many still push back when insurers try to force a switch. Why? Because they’ve seen what happens when patients lose access to the exact drug that works for them.

One Reddit user, u/ChronicWarrior42, shared: “I pay $1,200 a month for Ocrevus. My insurance says there’s a cheaper biosimilar. My specialist says it won’t work for my specific mutation. So I pay.” That’s not greed. That’s survival.

The Role of PBMs and Hidden Markups

Behind the scenes, pharmacy benefit managers (PBMs) are shaping what doctors can prescribe-and how much patients pay. The FTC’s January 2025 report revealed that the three largest PBMs-Caremark, Express Scripts, and OptumRx-made over $7.3 billion in revenue from specialty drugs between 2017 and 2022 by marking up prices far beyond what they paid for the drugs.

Here’s the twist: PBMs often mark up specialty generic drugs by thousands of percent. A drug that costs $50 to acquire might be billed at $1,200. That’s not inflation. That’s a systemic distortion. And it’s not just hurting patients-it’s undermining trust in generics.

Dr. Stephen Schondelmeyer, a pharmacy expert at the University of Minnesota, called it “a fundamental distortion in the drug pricing system.” When patients see their biosimilar cost $850 a month after switching from a $50 copay on the brand, they blame the doctor. But the real culprit? The PBM’s markup.

Specialists know this. They’ve seen patients switch to a “cheaper” generic only to face surprise bills, delays, or worse-treatment failure. So they stick with brands, even when it’s harder.

Patients Aren’t Just Passive Recipients

Doctors don’t make these decisions in a vacuum. Patients are part of the equation. Many have researched their condition, joined online communities, and know which drug worked for someone else. They ask for specific brands. And when they do, doctors listen.

A Medicare enrollee named SeniorCare2024 wrote on a patient forum: “My Humira copay went from $50 to $850. My rheumatologist says biosimilars aren’t appropriate for me. So now I’m choosing between my meds and my rent.”

That’s the reality. Patients aren’t just asking for brand names because they’re unaware of cost-they’re asking because they’ve been burned before. They’ve had treatments fail. They’ve waited weeks for prior authorization. They’ve seen their condition worsen after a switch.

Doctors aren’t ignoring cost. They’re weighing risk. And for many, the risk of switching is too high.

The Administrative Burden

Prescribing specialty drugs isn’t just about writing a script. It’s a logistical nightmare. Physicians spend an average of 13.4 hours per week on prior authorizations-78% of that time tied to specialty medications. That’s more than a full workday each week just to get a patient’s medicine approved.

Specialty pharmacies require special handling: refrigeration, infusion training, patient education, and ongoing monitoring. Many drugs come with Risk Evaluation and Mitigation Strategies (REMS), which require doctors to complete certification, track patient outcomes, and submit regular reports. Only 65% of manufacturers provide clear REMS guides, according to a 2023 FDA review.

And delays? They’re common. A 2024 study found that 42% of specialty drug starts are delayed by seven or more days due to paperwork. For a patient with aggressive MS or cancer, that’s not just inconvenient-it’s dangerous.

So when a specialist chooses a brand-name drug, they’re not just picking a product. They’re picking the one with the most predictable path to delivery. The one with fewer administrative hurdles. The one that won’t leave their patient waiting.

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. That’s a start. Drugs like Jakafi, Ofev, and Xtandi are already on the list for future negotiation. But these are just a handful. Out of the 2,700+ specialty drugs in development, most won’t be touched by these rules.

Meanwhile, the FTC is pushing for transparency. Senator Bernie Sanders introduced the Specialty Drug Price Transparency Act in February 2025 to force PBMs to disclose their markups. But change moves slowly. In the meantime, specialists are stuck in the middle.

There’s no easy fix. Lowering prices without improving access doesn’t help. Forcing switches without clinical evidence doesn’t help. And ignoring the administrative chaos doesn’t help either.

The truth? Specialty prescribing isn’t about preference-it’s about survival. For patients. For doctors. For the system.

What Patients and Providers Can Do

If you’re a patient on a specialty drug and your insurer tries to switch you:

• Ask your specialist for a letter of medical necessity-this is your strongest tool.
• Check if the manufacturer offers a patient assistance program. Many provide free drugs for low-income patients.
• Reach out to NORD (National Organization for Rare Disorders). They helped 45,000 patients in 2023.

If you’re a provider:

• Document every clinical reason for choosing a brand-name drug. Don’t just say “it’s better”-cite outcomes, failures, and patient history.
• Work with specialty pharmacies that have experience with your drug and payer network.
• Use patient support services. Many manufacturers offer nurses, co-pay assistance, and education.

The system is broken. But it’s not hopeless. Change starts with transparency, better communication, and a willingness to listen-to patients, to providers, and to the data.