Specialty medications and injectables are changing how we treat serious conditions like cancer, rheumatoid arthritis, and multiple sclerosis. But they’re also breaking budgets. These drugs often cost over $1,000 a month, and for many people, that’s not just expensive-it’s unaffordable. Even employers are feeling the squeeze, with average spending hitting $34.50 per employee each month. The good news? There are real, proven ways to cut these costs without sacrificing care. You don’t need to wait for policy changes or big insurance overhauls. You can start saving today-whether you’re a patient, a caregiver, or managing benefits for a company.
Understand What Makes These Drugs So Expensive
Specialty drugs aren’t just costly because they’re new. They’re expensive because of how they’re made, who makes them, and how they’re delivered. Most are biologics-complex proteins grown in living cells, not chemically synthesized. That makes them harder and more expensive to produce. Many require cold storage, special handling, and administration by a nurse or in a clinic. Some need weekly or monthly injections, which adds up fast.And here’s the kicker: a tiny fraction of prescriptions drive most of the spending. Just 2% of all prescriptions are for specialty drugs, but they make up half of all pharmacy costs. That’s not because everyone needs them. It’s because a few high-priced drugs dominate the market. For example, GLP-1 weight loss drugs like semaglutide can cost over $1,300 a month without insurance. The same is true for cancer therapies like rituximab or multiple sclerosis drugs like natalizumab.
Use Biosimilars When Possible
Biosimilars are the closest thing to generic versions of biologic drugs. They’re not exact copies-biologics are too complex for that-but they’re proven to work just as well. The FDA approves them after rigorous testing. And they cost about half as much.Take adalimumab, for example. The brand-name drug Humira costs around $2,000 a month. Its biosimilar, Amjevita, runs about $900. That’s a 55% drop. In 2023, the FDA approved 42 biosimilars, and more are coming. But adoption is still slow. Only about 30% of eligible patients are using them. Why? Many doctors aren’t trained to switch patients, and some patients fear switching is risky.
Don’t assume your doctor won’t suggest a biosimilar. Ask. Say: “Is there a biosimilar version of this drug? Has it been approved by the FDA? Can we try it?” Studies show patients who switch to biosimilars have the same outcomes-no more side effects, no loss of effectiveness. And if your insurance doesn’t cover it, ask your pharmacy to help you apply for manufacturer savings programs.
Narrow Your Pharmacy Network
Not all pharmacies are created equal when it comes to specialty drugs. Big pharmacy benefit managers (PBMs) like CVS Health, Express Scripts, and Walgreens control most of the distribution. They negotiate discounts with drug makers-but only if you use their preferred network.Using a non-preferred specialty pharmacy can cost you hundreds more per month. One study found that switching to a narrow network saved employers $1.37 per member per month. That might sound small, but for a company with 10,000 employees, that’s $137,000 a year. For patients, it can mean the difference between paying $100 or $500 out of pocket.
Check your insurance plan’s list of preferred specialty pharmacies. If you’re currently using a different one, ask your doctor to send your prescription to the preferred pharmacy. These networks often offer extra support: free delivery, nurse follow-ups, and help with insurance paperwork. You might not get to choose your pharmacy-but you’ll get better service and lower costs.
Ask About Prior Authorization and Step Therapy
Prior authorization is when your insurer requires approval before covering a drug. Step therapy means you have to try a cheaper drug first before they’ll pay for the more expensive one. Many people hate these rules. But when used right, they save money without hurting care.For example, Excellus BlueCross BlueShield saved $13.64 per member per month on GLP-1 drugs by requiring prior authorization to confirm the patient had tried diet and exercise first. That’s not about denying care-it’s about making sure the drug is truly needed.
Don’t fight the process blindly. If your doctor says a drug is necessary, they’ll submit the paperwork. But if you’re being asked to try a cheaper alternative, ask why. Is the alternative just as effective? Will it work for your condition? Sometimes, the step therapy drug is just as good. And if it’s not, your doctor can appeal.
Move Injections Out of Hospitals
If you’re getting an injectable drug like an infusion for rheumatoid arthritis or cancer, you might be paying way more than you need to. Hospitals charge 2-3 times more than a doctor’s office or even home care for the same treatment.Research shows that 91% of patients who moved their infusions from hospital outpatient departments to doctor’s offices or home settings saved 48% on costs. That’s not a guess-it’s based on real data from 1.8 million patients. And the clinical outcomes? Identical.
Ask your doctor: “Can this drug be given in your office instead of the hospital?” Or: “Is home infusion an option?” Many insurers now cover home nursing services for injectables. It’s safer than you think, and it saves money for everyone.
Use Financial Assistance Programs
Drug manufacturers often offer copay cards or patient assistance programs. But here’s the trick: some of these programs don’t count toward your deductible or out-of-pocket maximum. That means you pay $0 today, but you still have to meet your $5,000 deductible later. That’s bad for you long-term.Look for programs called “copay maximizers.” These are designed to let your manufacturer assistance count toward your out-of-pocket limit. That way, you’re not just getting a discount-you’re building toward your cap. Ask your pharmacist or insurance provider: “Does this copay card count toward my deductible?”
Also, check nonprofit organizations like the Patient Access Network Foundation or the HealthWell Foundation. They help people with chronic conditions pay for meds. You don’t need to be poor to qualify. Many programs have income limits up to 500% of the federal poverty level.
Push for Value-Based Contracts
If you’re an employer or part of a large group plan, you can ask your insurer to use value-based contracts. These are agreements where drug makers only get paid if the drug works. For example, a cancer drug might only be fully paid if the patient lives six months longer. If it doesn’t work, the price drops.Prime Therapeutics reported a 45% increase in these kinds of contracts in 2023. They’re not common yet-but they’re growing fast. And they’re one of the most promising ways to stop paying for drugs that don’t deliver.
Even as a patient, you can ask: “Is this drug part of a value-based program?” If it is, you’re more likely to get support if it doesn’t work. And if it’s not, you can ask your provider to push for it.
Track Your Spending and Know Your Rights
You can’t manage what you don’t measure. Keep a simple log: drug name, cost, how often you take it, and how much you pay out of pocket. Use your insurer’s online portal. Call them if something looks off.Know your rights under the Inflation Reduction Act. Starting in 2025, Medicare will cap insulin at $35 a month and out-of-pocket drug costs at $2,000 a year. That’s a big win. And while it doesn’t cover private insurance yet, it’s setting a standard. Some private insurers are already following suit.
Also, if you’re denied coverage, you have the right to appeal. Don’t give up. Many denials are overturned on appeal, especially with a doctor’s letter.
What Works Best Together
No single strategy cuts costs alone. The most effective approach combines several:- Use biosimilars whenever possible
- Stick to your plan’s preferred pharmacy network
- Use prior authorization and step therapy wisely
- Move infusions out of hospitals
- Apply for copay maximizers and nonprofit aid
Employers who use all five strategies saw specialty drug spending growth drop from 10-12% to just 5-7% annually. That’s a $45-60 billion industry-wide savings by 2027.
It’s not about cutting corners. It’s about cutting waste. You deserve effective treatment. You also deserve to pay what’s fair.
Are biosimilars safe to use instead of brand-name biologics?
Yes. Biosimilars are rigorously tested by the FDA and must show no meaningful difference in safety, purity, or potency compared to the original drug. Over 10 million patient-years of real-world use have shown no increased risk of side effects. Many patients switch without any issues. If you’re concerned, talk to your doctor about the data behind your specific drug.
Why does my insurance only cover certain pharmacies for specialty drugs?
Insurers use narrow pharmacy networks to negotiate lower prices. Specialty drugs are so expensive that even small discounts add up. These networks also ensure you get proper support-like nurse follow-ups, delivery, and help with paperwork. While you may have fewer choices, you often get better service and lower costs. Check your plan’s list and ask your doctor to send prescriptions to a preferred pharmacy.
Can I get help paying for specialty drugs if I’m not low-income?
Yes. Many patient assistance programs don’t require you to be poor. Some set income limits at 400-500% of the federal poverty level, which for a single person in 2025 is about $70,000 a year. Organizations like PAN Foundation and HealthWell Foundation help people with chronic conditions regardless of income level. You just need to apply and provide proof of your prescription and income.
Why is my infusion always at the hospital, and can I switch?
Many patients get infusions at hospitals because that’s where their doctor works-but it’s not always necessary. For 63% of specialty drugs, hospital infusion isn’t medically required. You can often get the same treatment in a doctor’s office, outpatient clinic, or even at home with a nurse. Ask your provider: “Is this infusion required to be in a hospital?” If not, request a transfer. Many insurers cover home infusion, and it can cut your cost by nearly half.
What should I do if my insurance denies coverage for a drug I need?
Don’t accept a denial as final. File an appeal. Your doctor must write a letter explaining why the drug is medically necessary. Include clinical guidelines or studies that support your case. Most appeals are successful, especially when backed by evidence. You have 180 days to appeal. Also, ask your pharmacy to help you file-it’s part of their service.
Next Steps: What to Do Right Now
If you’re paying for specialty drugs, here’s your action plan:- Check your insurance’s preferred specialty pharmacy list. Switch if you’re not using one.
- Ask your doctor: “Is there a biosimilar version of this drug?”
- Call your insurer: “Does my copay card count toward my out-of-pocket maximum?”
- Ask: “Can this infusion be done in your office or at home?”
- Search for nonprofit assistance programs using your drug’s name + “patient assistance.”
These steps take less than an hour. But they can save you thousands a year. You’re not powerless. The system is complex, but you have more control than you think.
