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 the stakes are higher than most people realize. Specialty drugs - the high-cost, complex medications used for conditions like multiple sclerosis, cancer, and rare autoimmune diseases - make up less than 7% of all prescriptions but account for over 70% of total drug spending in the U.S. And yet, specialists keep reaching for the brand-name versions, even when generics or biosimilars are available. Why?

They’re not just expensive - they’re complicated

Specialty drugs aren’t your typical pills you pick up at the corner pharmacy. Many require injections, infusions, or special storage conditions. Some need continuous monitoring for side effects. Others come with strict risk management programs called REMS (Risk Evaluation and Mitigation Strategies), which dictate how they’re dispensed and tracked. If a patient misses a dose, misstores the medication, or doesn’t understand how to use it, the treatment can fail - sometimes with life-threatening consequences.

Take Ocrevus, used for multiple sclerosis. It’s given by IV infusion every six months. If a patient gets the wrong version - even one labeled as "equivalent" - the dosing schedule, reaction risk, or immune response could differ. Specialists don’t gamble with these details. They’ve seen what happens when things go wrong. One 2023 Medscape survey found that 79% of rheumatologists and 82% of oncologists feel frustrated by prior authorization delays, but even more say they fear switching patients to alternatives that haven’t been proven safe for their specific case.

The data doesn’t lie: brand preference costs billions

In 2021, just 6.2% of prescriptions were for specialty drugs, yet they made up 71.1% of total prescription drug spending, according to the Journal of Managed Care & Specialty Pharmacy. That’s not a typo. Less than one in 16 prescriptions drives over seven in ten dollars spent on meds.

And brand-name preference is a big part of that. A 2021 JAMA Network Open study found that when doctors or patients request brand-name drugs over generics, it adds $1.67 billion annually to Medicare’s bill - and $270 million to patients’ out-of-pocket costs. That’s not because patients are demanding them. It’s because specialists are recommending them - often because they believe alternatives won’t work as well.

Consider Humira. It’s one of the most prescribed specialty drugs in the U.S. Biosimilars have been available since 2023. But in a 2024 survey of 1,200 specialists, nearly half said they still prescribe the original brand because "the biosimilar data doesn’t reflect my patient population." One rheumatologist told researchers, "I have patients with aggressive disease who failed two other biosimilars. I’m not risking a third switch."

It’s not about kickbacks - it’s about trust

Some assume doctors choose brands because of drug company payments. And yes, ProPublica’s 2016 analysis showed doctors who received over $5,000 from pharma companies prescribed brand-name drugs 50% more often. But that’s not the full story.

Many specialists don’t take payments at all. Yet they still prefer brands. Why? Because they’ve seen the outcomes. A 2023 study in Health Affairs found that when patients switched from a brand-name specialty drug to a biosimilar, 12% experienced a flare-up of their condition within six months - even when the biosimilar was FDA-approved. For someone with Crohn’s disease or rheumatoid arthritis, a flare-up means hospitalization, lost work, and permanent joint damage.

Specialists aren’t just prescribing drugs - they’re managing fragile, chronic conditions. They don’t have the luxury of running clinical trials on every patient. They rely on real-world experience. And in many cases, that experience tells them: stick with what’s proven.

The system is stacked against generics

Here’s the twist: even when generics exist, the system often makes them harder to access. Pharmacy Benefit Managers (PBMs) - the middlemen who control drug coverage - have been found to mark up specialty generics by thousands of percent, according to a January 2025 FTC report. That means a $1,000 generic drug might be priced at $15,000 by a PBM-owned pharmacy, while the brand-name version is priced at $12,000. Why would a doctor prescribe the brand if the generic is more expensive? They wouldn’t - unless the patient’s insurance won’t cover the generic, or the specialty pharmacy won’t stock it.

And that’s not rare. A 2024 study found that 42% of specialty drug starts are delayed by seven or more days because of administrative hurdles - prior authorizations, formulary restrictions, or pharmacy network issues. In many cases, the brand-name drug is the only one the patient’s plan covers quickly. So the doctor writes the prescription they know will get filled - not the cheapest one.

Patient stories reveal the real cost

On Reddit’s r/healthinsurance, users share stories that go beyond statistics. One patient, u/ChronicWarrior42, wrote: "I pay $1,200 a month for Ocrevus. My insurance covers it, but only if I stay on the brand. My neurologist says the biosimilar hasn’t been tested on my specific MS mutation. I can’t risk it." Another, "SeniorCare2024," on the Medicare Rights Center forum, said: "My Humira copay jumped from $50 to $850 when my plan changed. My rheumatologist said switching to biosimilar isn’t right for me - but now I have to choose between my meds and my groceries." These aren’t outliers. They’re the reality for 2% of the U.S. population - the people using specialty drugs. And they account for 51% of total pharmacy spending, according to Evernorth Health Services. That’s $38,000 per patient per year, on average - 75 times more than a typical non-specialty drug.

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. By 2025, drugs like Jakafi, Ofev, and Xtandi are expected to be included. That could lower prices for some specialty drugs. But it won’t fix the core problem: lack of alternatives.

For many conditions - especially rare diseases - there are no generics. No biosimilars. No competitors. The manufacturer has a monopoly. And doctors know it. They’re not choosing brands because they want to. They’re choosing them because they have to.

Meanwhile, the pipeline is growing. The FDA’s Office of Orphan Products Development reports over 2,700 investigational specialty drugs in development, 45% targeting rare diseases. But development takes years. Patients need treatment now.

Doctors are caught in the middle

Specialists spend an average of 13.4 hours a week just on prior authorizations, the American Medical Association found in 2024. Most of that time is spent on specialty drugs. They’re not prescribing brands because they enjoy paperwork. They’re doing it because the system forces them to.

One oncologist in Ohio told a reporter: "I want to prescribe the cheapest option. But if I do, my patient waits three weeks for approval - and their tumor grows. I choose the brand because it gets filled in 48 hours. That’s not greed. That’s triage."

The truth is, specialty prescribing isn’t about preference. It’s about survival - for patients, and for the doctors trying to keep them alive.