OBJECTIVES:  As pharmaceutical pipelines begin to churn out specialty products at a higher rate than traditional therapies, payers are experiencing double-digit growth in costs for biologics and other high-cost specialty drugs. Such agents are expected to consume half of the drug spend by 2018. Focusing on rheumatoid arthritis (RA), this study explored current uptake of biologics, and examined evolving payer prescribing controls. METHODS: A total of 40 managed care organization (MCO) pharmacy and medical directors, and 103 rheumatologists who prescribe biologics for RA were surveyed regarding prescribing and reimbursement.  RESULTS: Surveyed rheumatologists reported that 59% of their drug-treated RA patients currently receive a biologic, with extensive use of Enbrel and Humira, especially, as first-line therapy. MCO tier coverage currently favors such TNF-α inhibitors, but surveyed payers indicated that, in one year’s time, newer biologics and non-TNF-α inhibitors that have previously been formulary-excluded will move to coverage tiers. More than 80% of surveyed rheumatologists encounter strong-to-moderate payer control of RA biologics prescribing, with reports of increasing control and consequent decreased prescribing of specific agents. A large majority of payers confirmed using at least some form of restrictions, mostly prior authorization, and also step therapy and quantity limits. Higher copays for biologics versus other drugs are also encountered, and about half of payers reported a specialty pharmacy is commonly used to acquire biologic for RA. More than one-third of payers also reported that their contracting arrangements with drugmakers include rebating and price protection for RA biologics.   CONCLUSIONS: As the biologics/specialty drug market for RA grows, increased prescribing controls by MCOs are likely. Furthermore, as competition increases, so will the demand for more extensive data and greater discounts/rebates to justify preferred coverage. Achieving preferred coverage is vital to avoid losing patient share to competitors achieving more favorable reimbursement terms.