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

When a rheumatologist prescribes Humira instead of a biosimilar, or an oncologist insists on Ocrevus despite lower-cost alternatives, it’s not because they’re ignoring cost-it’s because they’ve seen what happens when patients switch. Specialty drugs aren’t just expensive. They’re complex, high-stakes treatments for conditions with few options. And when specialists choose brand-name drugs, it’s rarely about profit. It’s about survival.

The Reality of Specialty Drug Spending

Specialty drugs make up less than 2% of all prescriptions filled in the U.S., yet they account for over 70% of total pharmacy spending. In 2021, the average annual cost per patient on a specialty drug was $38,000. For non-specialty drugs? $492. That’s a 75-fold difference. These aren’t ordinary medications. They’re biologics, gene therapies, infusion-based treatments for cancers, multiple sclerosis, rheumatoid arthritis, and rare genetic disorders. Many require cold storage, trained nurses for administration, or daily injections. Some have narrow therapeutic windows-too little and the disease progresses; too much and you risk organ damage.

The numbers don’t lie. Between 2010 and 2019, spending on specialty brand-name drugs jumped from $9.4 billion to $46.8 billion. By 2023, they made up 68% of all dispensing revenue from specialty drugs. And that growth isn’t slowing. Experts predict specialty drugs will consume 73% of global prescription drug spending by 2028.

Why Generics Don’t Always Work

You’d think generics would be the obvious choice. They’re cheaper, approved by the FDA, and widely available. But for specialty drugs, the story is different. Many specialty drugs are biologics-complex proteins made from living cells. You can’t just copy them like you can a pill made of chemical compounds. What you get instead are biosimilars: drugs that are highly similar, but not identical.

Here’s the catch: for some patients, even tiny differences matter. A 2023 Medscape survey found that 79% of rheumatologists say biosimilars aren’t appropriate for certain patients with autoimmune diseases. Why? Because switching can trigger a flare-up. One patient on Reddit shared that after switching from Humira to a biosimilar, her joint pain returned within weeks. Her rheumatologist told her: “Your body reacted to the original. We don’t risk changing it.”

In oncology, the stakes are even higher. A single missed dose or delayed infusion can mean the difference between remission and progression. Specialists don’t gamble with treatments that have saved lives. They stick with what’s proven.

Prescriber Pressure: It’s Not Just About Money

Some assume doctors choose brand-name drugs because they’re paid by pharmaceutical companies. There’s some truth to that. ProPublica’s 2016 analysis showed doctors who received over $5,000 from drugmakers prescribed brand-name drugs at rates 50% higher than those who received nothing. But that’s not the full picture.

Most specialists aren’t swayed by free lunches or speaker fees. They’re swayed by data-and patient outcomes. A 2021 JAMA Network Open study found that prescribers and patients requested branded dispensing for 30.4% of multisource drugs. That’s $1.67 billion extra spent on Medicare, and $270 million out of patients’ pockets. But here’s the thing: many of those requests came from doctors who knew the alternative wouldn’t work.

It’s also about liability. If a patient has a bad reaction after switching to a biosimilar, the doctor is on the hook. Insurance companies may push for cheaper options, but the doctor still has to answer for the outcome. That’s why many specialists refuse to switch patients unless there’s clear, published evidence of equivalence-and even then, they document every decision.

The Hidden System: PBMs and Markups

The real villain isn’t always the drugmaker. It’s the middlemen. Pharmacy Benefit Managers (PBMs)-Caremark, Express Scripts, OptumRx-control 68% of specialty drug dispensing. And they’re making massive profits on generics.

The FTC’s January 2025 report found that PBMs marked up specialty generic drugs by thousands of percent. One drug bought for $100 was sold to patients for $15,000. That’s not a pricing error. That’s a business model. These markups don’t exist for traditional generics. Why? Because there’s competition. But for specialty drugs, PBMs own the pharmacies, control the formularies, and dictate what doctors can prescribe.

Doctors don’t set these prices. They’re stuck in a system where the cheapest option isn’t always the most affordable for the patient. A patient might have a $50 copay on a brand-name drug because their plan has a tiered structure. Switch to the “generic,” and suddenly their copay jumps to $850 because the PBM’s markup is so high.

Administrative Nightmares

Even when a specialist wants to prescribe a generic, the system gets in the way. Prior authorization forms take hours to complete. Insurance companies demand lab results, failed trial records, and signed consent forms. A 2024 study found that 42% of specialty drug starts are delayed by seven or more days because of paperwork.

Physicians spend an average of 13.4 hours per week on prior authorizations-78% of that time tied to specialty drugs. That’s not time spent diagnosing. That’s time spent fighting insurance.

And it’s not just the doctor. Patients are drowning in bureaucracy. One Medicare enrollee wrote on a patient forum: “My Humira copay went from $50 to $850 when my plan changed. My doctor says the biosimilar won’t work for me. But my insurer won’t cover the brand unless I appeal. I’ve been waiting six weeks.”

What’s Changing?

There’s pressure to fix this. The Inflation Reduction Act of 2022 let Medicare negotiate prices for some high-cost drugs. Starting in 2026, drugs like Jakafi, Ofev, and Xtandi could be subject to price caps. The FTC is investigating PBM markups. Senator Bernie Sanders introduced the Specialty Drug Price Transparency Act in February 2025 to force PBMs to disclose their pricing practices.

But change is slow. And for now, specialists are still making decisions based on one question: “Will this save my patient’s life-or just their wallet?”

What Patients Should Know

If your specialist insists on a brand-name drug, don’t assume they’re being paid off. Ask: “Is there a proven alternative? What happens if I switch?” Get the data. Ask for studies. Ask if the alternative has been tested in patients like you.

If your insurance denies coverage, appeal. Document everything. Reach out to patient advocacy groups like NORD or the Arthritis Foundation-they help thousands get access to specialty drugs every year.

And remember: the system is broken. But your doctor isn’t the problem. They’re trying to navigate it with your life on the line.