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 typical prescriptions. They’re not pills you pick up at the corner pharmacy. These are high-cost, complex medications used to treat rare, chronic, or life-threatening conditions like multiple sclerosis, rheumatoid arthritis, and certain cancers. They often require injections, infusions, or special storage. And despite making up less than 7% of all prescriptions, they account for over 70% of total U.S. prescription drug spending. In 2021, the average annual cost per patient on a specialty drug was $38,000-75 times higher than for non-specialty drugs.
So why do specialists keep reaching for the brand-name version, even when generics or biosimilars are available? It’s not about loyalty to a company. It’s about fear-fear of relapse, fear of side effects, fear of losing hard-won control over a patient’s condition.
The Cost Isn’t Just Financial-It’s Clinical
One of the biggest myths is that biosimilars are just like generics. They’re not. Generics are exact copies of small-molecule drugs. Biosimilars are highly similar-but not identical-to complex biologic drugs made from living cells. That tiny difference can matter.
A 2023 Medscape survey of 1,200 specialists found that 68% reported frequent frustration with prior authorization for specialty drugs. Oncologists and rheumatologists were the most affected. But even when they get approval, many say switching patients to biosimilars feels risky. One rheumatologist in Chicago told a patient who asked why he wasn’t switching: “I’ve seen people go from stable to flaring in weeks after switching. I can’t guarantee it won’t happen to you.”
That’s not anecdotal. A 2022 study in Arthritis & Rheumatology tracked 1,100 patients with rheumatoid arthritis who switched from adalimumab (Humira) to a biosimilar. While most stayed stable, 12% experienced disease flare-ups within six months. For patients who had already lost multiple treatments, that’s not just a setback-it’s a crisis.
Patients aren’t passive in this. A Reddit thread from November 2023, titled “Specialty drug pricing nightmare,” had dozens of posts from people paying $1,200 a month out-of-pocket for Ocrevus. One user wrote: “My specialist says there are no alternatives that work as well for my specific mutation.” That’s not resistance-it’s lived experience.
When the System Works Against Patients
It’s easy to blame doctors for choosing expensive drugs. But the system makes it harder to choose cheaper options.
Pharmacy benefit managers (PBMs)-the middlemen between insurers, pharmacies, and drugmakers-control formularies. In 2023, the FTC found that the “Big 3” PBMs (Caremark, Express Scripts, OptumRx) generated over $7.3 billion in revenue from dispensing specialty drugs above their actual acquisition cost. And here’s the kicker: they mark up specialty generic drugs by thousands of percent. One drug, a generic version of a biologic, was sold for $1,800 a vial when the acquisition cost was $120. That’s a 1,400% markup.
Meanwhile, manufacturers of brand-name drugs often offer co-pay cards that reduce patient costs to $0 or $5 a month. That’s not charity-it’s strategy. These cards keep patients on expensive drugs by removing the financial pain of the price tag. But they’re not available for biosimilars. So even if a doctor wants to switch, the patient might not be able to afford it.
And then there’s the paperwork. Physicians spend an average of 13.4 hours a week on prior authorizations-78% of that time is on specialty drugs. One oncologist in Atlanta said: “I could write a prescription in 30 seconds. But getting approval takes three days, three phone calls, and three forms. If the brand-name version is already approved, why fight?”
Doctors Aren’t Paid to Push Brands-But They’re Influenced
There’s no direct payment system where drug companies pay doctors to prescribe their drugs. But influence runs deep.
ProPublica’s 2016 analysis found that doctors who received more than $5,000 from pharmaceutical companies in 2014 prescribed brand-name drugs at a rate 50% higher than those who received nothing. These weren’t just free dinners. They were speaker fees, consulting gigs, and educational grants tied to specific drugs.
It’s not about corruption-it’s about familiarity. When a rep shows up monthly with data, samples, and patient support materials, that drug becomes top of mind. When a biosimilar rep doesn’t show up at all, the brand stays dominant by default.
Plus, many specialists don’t have the time or training to evaluate biosimilar data. A 2024 study in JAMA Network Open found that only 31% of rheumatologists felt confident in their ability to assess biosimilar safety. That’s not ignorance-it’s a system that doesn’t equip them.
Patients Are Caught in the Middle
On the Medicare Rights Center forum, a user named SeniorCare2024 wrote: “My Humira copay went from $50 to $850 when my plan changed. My rheumatologist says biosimilars aren’t appropriate for me.”
That’s the reality. Patients rely on their doctors to protect them-not just from disease, but from financial ruin. When a doctor says, “This is the only one that works for you,” the patient believes them. And they’re right to.
For many, the difference between brand and biosimilar isn’t a cost issue-it’s a survival issue. A patient with multiple sclerosis might have tried three other drugs that failed. Ocrevus is the only one that kept them walking. Switching isn’t an option. It’s a gamble with their mobility.
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. Starting in 2026, drugs like Jakafi, Ofev, and Xtandi will be on the list. That could lower prices-but only if the negotiated price is still profitable for manufacturers. And if it’s not, they’ll just raise the price of the next drug.
The FTC’s January 2025 report is a wake-up call. It found that PBM markups on specialty drugs grew at a compound annual rate of 42% from 2017 to 2021. Senator Bernie Sanders introduced the Specialty Drug Price Transparency Act in February 2025 to force PBMs to disclose their markups.
But none of this fixes the core issue: when a patient has no other option, the brand becomes the only option. And doctors, who’ve seen the consequences of switching, will keep prescribing it.
The Real Question Isn’t About Cost-It’s About Trust
Specialists aren’t ignoring value. They’re weighing risk. And for them, the risk of a relapse, a hospitalization, or a loss of function outweighs the cost savings of a biosimilar.
Until we fix the system-until PBMs stop gouging, until manufacturers offer equal support for generics, until doctors get better tools to evaluate biosimilars, and until patients aren’t forced to choose between their health and their bank account-brand-name drugs will stay the default.
It’s not about greed. It’s about fear. And until that fear is addressed, the prescriptions won’t change.
