Why specialists keep choosing brand-name drugs over cheaper alternatives
Imagine you’re a rheumatologist treating a patient with severe rheumatoid arthritis. You’ve got two options: a brand-name drug like Humira, costing $850 a month after insurance, or a biosimilar that works just as well but costs $200. You know the biosimilar is safe. You’ve seen the studies. Yet, you still write the prescription for Humira. Why?
This isn’t an isolated case. Across oncology, neurology, and immunology, specialists are consistently choosing brand-name specialty drugs-even when generics or biosimilars exist. The reasons aren’t simple. They’re layered: clinical uncertainty, administrative nightmares, financial incentives, and patient pressure all play a role.
Specialty drugs aren’t your typical pills. These are high-cost medications for complex, chronic conditions like multiple sclerosis, cancer, and rare autoimmune diseases. They often require injections, infusions, or special storage. And they’re expensive-some cost over $100,000 a year per patient. In 2021, these drugs made up just 6.2% of all prescriptions but accounted for 71.1% of total pharmacy spending. That’s a staggering imbalance.
The cost gap: a few drugs, most of the money
The top 10 specialty drugs in Medicare Part D in 2021 made up only 0.3% of all covered drugs but generated 22% of total spending. That’s not a typo. A handful of drugs are driving the entire system’s financial strain.
Take Ocrevus, used for multiple sclerosis. A patient might pay $1,200 a month out of pocket-even with insurance-because their plan doesn’t cover the biosimilar. Their specialist says there’s no proven alternative for their specific mutation. That’s not just a clinical call; it’s a system failure. The patient can’t switch. The insurer can’t force it. And the specialist feels trapped.
Meanwhile, the price of brand-name specialty drugs rose 13.2% per year from 2010 to 2019. Non-specialty drugs? Just 2.6%. That gap isn’t accidental. Manufacturers know these drugs have few competitors. There’s no race to the bottom here. There’s a race to the top.
Why biosimilars don’t always win
Biosimilars are designed to be nearly identical to brand-name biologics. They’re cheaper. They’re approved by the FDA. Yet, adoption remains slow.
Why? For one, many specialists don’t trust them. Not because they’re unsafe-but because they’re new. In a 2023 Medscape survey, 44% of rheumatologists and 51% of oncologists said they still prefer brand-name drugs because they’re “more predictable.” That’s not evidence-based. It’s habit. And in high-stakes conditions like cancer, doctors don’t want to risk a treatment that might not work as well.
Then there’s the payer side. Pharmacy benefit managers (PBMs)-the middlemen between insurers and pharmacies-have been caught marking up specialty generics by thousands of percent. A 2025 FTC report found that PBM-affiliated pharmacies were charging 1,200% more than what they paid for the drug. That’s not competition. That’s exploitation. And it’s making patients and doctors distrust the entire system.
When a patient’s Humira copay jumps from $50 to $850 because their plan switched formularies, the doctor doesn’t blame the PBM. They blame the system. So they prescribe the drug the patient can still afford-the brand-name one. It’s not preference. It’s survival.
Doctors are caught in the middle
Specialists aren’t just prescribing drugs. They’re managing logistics. Every specialty drug requires prior authorization, special handling, patient education, and ongoing monitoring. On average, physicians spend 13.4 hours a week just on prior authorizations-and 78% of that time is spent on specialty drugs.
One oncologist told a reporter she spends more time filling out paperwork than seeing patients. “I’m not a bureaucrat,” she said. “I’m a doctor.”
And when the paperwork fails? The patient suffers. A 2024 study found that 42% of specialty drug starts are delayed by more than seven days because of administrative hurdles. That delay can mean the difference between remission and progression in cancer.
So when a patient asks for Humira-because their friend took it, or their last doctor prescribed it, or they saw an ad-the doctor often says yes. Not because they believe it’s better. But because saying no means more delays, more stress, and more risk of the patient walking out the door.
The influence of money-and how it’s hidden
It’s no secret that pharmaceutical companies pay doctors. ProPublica’s 2016 analysis showed that doctors who received over $5,000 from drugmakers prescribed brand-name drugs at a rate 50% higher than those who received nothing.
But the bigger issue isn’t direct payments. It’s the indirect ones. Drug manufacturers fund patient assistance programs. They pay for nurse educators who help patients start treatment. They sponsor continuing medical education. These aren’t bribes. But they shape how doctors think.
When a company sends a nurse to help a patient with their first Ocrevus infusion, that nurse is also trained to explain why the brand-name drug is the “gold standard.” The biosimilar? Barely mentioned.
It’s not that doctors are corrupt. It’s that the system is designed to make the brand-name drug feel like the only responsible choice.
Patients aren’t just passive recipients
Many patients believe brand-name drugs are superior. They’ve heard it from ads, from friends, from online forums. On Reddit, one user wrote: “My specialist says there are no alternatives that work as well for my specific mutation.” He was told that by his doctor. But the truth? There might be. But the doctor didn’t know-or didn’t have time to explain.
Patients are scared. They’re paying thousands out of pocket. They don’t want to risk trying something “new.” And when they ask for the brand, the doctor often gives in. It’s easier. It’s faster. It’s less conflict.
In one case, a Medicare enrollee’s Humira copay spiked to $850. Her rheumatologist told her biosimilars weren’t “appropriate” for her. But when she got a second opinion, the new doctor switched her to a biosimilar-and saved her $700 a month. No loss of effectiveness. Just a different mindset.
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 could eventually bring down prices for specialty drugs like Jakafi and Xtandi. But it’s slow. And it doesn’t fix the underlying problems.
The FTC’s 2025 report is pushing for transparency in PBM pricing. Senator Bernie Sanders introduced the Specialty Drug Price Transparency Act to stop those 42% annual markups. But legislation moves slowly. And the system is still rigged.
Meanwhile, specialty drug spending keeps growing. In 2023, they made up 48% of global pharmaceutical spending. By 2028, that could hit 73%. The trend isn’t slowing. It’s accelerating.
Specialists aren’t stubborn. They’re overwhelmed. They’re caught between patients who want the brand, payers who want the cheapest option, and manufacturers who make it hard to choose anything else.
The real solution isn’t more drugs. It’s more clarity. More support. More time. And a system that doesn’t punish doctors for trying to do the right thing.
What needs to change
- Transparency in pricing: PBMs must disclose what they pay for drugs and what they charge. No more hidden markups.
- Streamlined prior auth: Automate approvals for biosimilars when clinical guidelines support them.
- Education for providers: Train specialists on biosimilars-not just as alternatives, but as safe, effective options.
- Remove financial incentives: Cut ties between drugmakers and prescribing habits. No more free nurse educators paid by manufacturers.
- Support for patients: Help them understand their options. Not just with ads, but with unbiased counseling.
Until then, specialists will keep prescribing the brand. Not because they want to. But because the system leaves them no better choice.