Specialty Prescribing: Why Specialists Stick to Brand-Name Drugs

When a rheumatologist prescribes Humira instead of a biosimilar, or an oncologist chooses 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 your regular pills you pick up at the corner pharmacy. These are high-cost, complex medications used for serious, often rare conditions-cancer, multiple sclerosis, rheumatoid arthritis, Crohn’s disease. They’re injected or infused. They need special storage. They require constant monitoring. And they’re expensive: more than half cost over $100,000 a year per patient. Yet despite the price tag, specialists keep reaching for the brand-name version-even when generics or biosimilars are available.

Why brand-name drugs still dominate specialty care

The numbers tell a stark story. In 2021, specialty drugs made up just 6.2% of all prescriptions in the U.S., but they accounted for 71.1% of total prescription drug spending. That’s not a typo. Less than one in twenty prescriptions drove over seven in ten dollars spent on medications.

Why? For many of these conditions, there are no good alternatives. Take multiple sclerosis. Ocrevus (ocrelizumab) is a brand-name drug. A biosimilar exists-but many neurologists won’t switch their patients. Why? Because the disease is unpredictable. A small change in how the immune system responds can trigger a relapse. Doctors aren’t gambling with someone’s ability to walk, see, or breathe just to save a few thousand dollars.

One 2023 Medscape survey found that 68% of specialists felt frustrated by prior authorization delays for specialty drugs. Oncologists and rheumatologists reported even higher rates-82% and 79%, respectively. These aren’t bureaucratic annoyances. They’re delays in life-saving treatment. When a patient’s insurance denies a biosimilar because it’s not on formulary, the doctor has to appeal. That takes weeks. In cancer care, weeks matter.

The role of patient and provider experience

It’s not just about clinical data. It’s about real-world outcomes. A patient on Humira for years might have stable disease. Switching to a biosimilar? Maybe it works. Maybe it doesn’t. And if it doesn’t? The patient could end up in the hospital. That’s not just a health risk-it’s a financial risk for the practice. Reimbursement rates for specialty drugs are already tight. A hospitalization due to a switch can wipe out margins.

On Reddit’s r/healthinsurance, a user named u/ChronicWarrior42 wrote: “I pay $1,200 a month for Ocrevus-even with insurance. My specialist says there are no alternatives that work as well for my specific mutation.” That’s not an outlier. It’s a common refrain among patients with rare conditions.

Doctors aren’t blind to cost. They see the bills. But they also see the patients who’ve tried generics and ended up worse. In one study, prescriber or patient requests for brand-name drugs over generics added $1.67 billion in costs to Medicare in a single year. That’s not because doctors are greedy. It’s because they’ve learned, often the hard way, that “cheaper” doesn’t always mean “safer.”

The hidden drivers: PBMs and pricing distortion

Here’s the twist: the system isn’t designed to help doctors choose the best drug. It’s designed to profit from complexity.

Pharmacy Benefit Managers (PBMs)-the middlemen between insurers, pharmacies, and drugmakers-control 68% of specialty drug dispensing in the U.S. According to the FTC’s January 2025 report, PBMs marked up specialty generic drugs by thousands of percent. One drug with a $500 acquisition cost was dispensed for $18,000. That’s not inflation. That’s a system rigged to reward opacity.

When a PBM owns a specialty pharmacy, they profit more from brand-name drugs. Why? Because they can charge higher rebates and markups. Biosimilars? Lower price. Lower profit. So even if a biosimilar is clinically equivalent, the system pushes the brand. And doctors? They’re caught in the middle.

Dr. Peter Bach from Memorial Sloan Kettering put it bluntly: “The current system allows manufacturers to set prices without meaningful competition.” That’s especially true in specialty care, where there’s often only one or two drugs that work.

What about payments from drug companies?

ProPublica’s 2016 analysis found that doctors who received over $5,000 from pharmaceutical companies in 2014 prescribed brand-name drugs at a rate 50% higher than those who received nothing. That’s a correlation-but is it causation?

It’s not that every specialist is swayed by free dinners or speaker fees. But the data shows a pattern: financial ties correlate with prescribing habits. And in specialty care, where margins are thin and pressure is high, those relationships matter more than we admit.

One rheumatologist in Texas told a reporter, “I don’t take payments. But I know which reps know the ins and outs of patient assistance programs. If I can get a patient on a $0 copay with the brand, I’m going to do it. Not because I like the company. Because I don’t want them to drop treatment.”

The administrative nightmare

Prescribing a specialty drug isn’t just writing a prescription. It’s a full-time job.

Physicians spend an average of 13.4 hours a week just on prior authorizations-and 78% of that time is spent on specialty drugs. That’s 13.4 hours they’re not spending with patients. Not reviewing labs. Not researching new treatments. Just filling out forms, calling insurers, appealing denials.

And it’s not getting easier. A 2024 JMCP study found that 42% of specialty drug starts are delayed by seven or more days due to administrative hurdles. For a patient with aggressive MS or advanced cancer, that delay can mean disease progression.

Specialty pharmacies require enrollment. REMS programs (Risk Evaluation and Mitigation Strategies) need documentation. Patient support services must be coordinated. And not every manufacturer provides clear guidelines. The FDA found in 2023 that only 65% of specialty drug makers gave comprehensive REMS instructions.

What’s changing-and what’s not

The Inflation Reduction Act of 2022 let Medicare 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 the real problem isn’t just drug prices. It’s the entire supply chain. PBMs still control distribution. Markups are still hidden. Biosimilars are still treated like second-class options-even when they’re proven safe.

Some states are stepping in. California and New York have passed laws requiring PBM transparency. But without federal action, it’s a patchwork. And specialists? They’re still prescribing the same drugs, for the same reasons: because they’ve seen what happens when you try to cut corners.

It’s not about loyalty. It’s about risk.

Specialists don’t prefer brand-name drugs because they’re loyal to Pfizer or Roche. They prefer them because their patients have lived through the alternatives-and didn’t survive the switch.

They know the cost. They see the numbers. But they also see the person sitting across from them. And when the stakes are this high, they choose what they know works.

The system is broken. But until the pricing, the markups, and the administrative chaos are fixed, doctors will keep writing those expensive prescriptions. Not because they want to. But because they have to.