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Learn more about national medication shortages affecting people and pharmacist everywhere, what causes shortages, steps you can take if you are affected, and other frequently asked questions. Read on.

Medication Shortages, Explained | Alto Pharmacy

Few things are more frustrating — or frightening — than being unable to access the medication your doctor has prescribed. But it has become a common experience in recent years, as medication shortages remain a persistent healthcare challenge in the U.S. And if you take medication, you may be familiar with the panic of struggling to find enough of what you need.

Not only are these shortages incredibly frustrating and debilitating, they are also confusing and unpredictable, arising seemingly at random, and with little known about an anticipated resolution.

While Alto will always go above and beyond to bring you your medications without delay, these shortages are beyond our control, and we share your frustrations and concerns. To provide more clarity and context as to why these shortages occur — and why, unfortunately, there are few short-term solutions — we’ve compiled answers to some of the questions we hear most frequently.

Like every pharmacy across the country — as well as many around the world — Alto has been affected by medication shortages in the last few years. Each pharmacy’s stock fluctuates in tandem with demand, so if you call multiple pharmacies, it’s possible that one will have a greater supply of an affected medication than another on any given day. But ultimately, no pharmacy is immune to these challenges, and if a medication is in short supply, each pharmacy may feel the impact at some point.

If Alto currently does not carry your medication and you would like to transfer your prescription to another pharmacy, be sure to call that new pharmacy to confirm availability of your medication — medication shortages often impact most pharmacies within a specific region. 

The causes of medication shortages are complex, with multiple, and often intersecting, factors at play.

Any issues that affect the production of a medication may lead to reduced supply. This includes disruptions to manufacturing, like when Hurricane Maria damaged production sites in Puerto Rico in 2017.

Covid is another example of how a natural disaster or global crisis can disrupt medication production. The United States relies heavily on other countries for the raw ingredients needed to manufacture a medication.* This leaves us incredibly vulnerable to changes in workforce capacity or manufacturing activities overseas.

*As of 2019, only 28% of our country’s supply of active pharmaceutical ingredients (APIs) — the substances directly responsible for a medication’s therapeutic benefits — were manufactured domestically.

Even when manufacturing circumstances are ideal, rising demand for a medication can lead to low supply. This winter’s difficult cold and flu season, with high cases of Covid, the flu, and R.S.V., contributed to a decreased supply of children’s formulations of ibuprofen, acetaminophen, and several commonly prescribed antibiotics.

Adderall®, a stimulant used to treat attention-deficit/hyperactivity disorder, is another medication whose demand has increased in recent years. Prescriptions for the medication increased by 15.1% in 2020, in comparison to a 7.4% increase in 2019. This comes after a surge in new ADHD diagnoses, which more than doubled between 2007 and 2016 and continue to rise. Worker shortages and production delays experienced by Teva, a leading manufacturer of Adderall, have added additional pressure and compounded the challenges.

High demand has also contributed to recent shortages of the diabetes medications Ozempic® and Wegovy®,  as they have been increasingly prescribed for weight loss.

Addressing increased demand is often easier said than done. Most generic manufacturers decide how much of a medication to produce at the beginning of the year, with virtually no flexibility, so it isn’t an option to simply make more. This is why there is often a seasonal pattern to shortages, with many intensifying at the end of the year.

In the case of Adderall, a Schedule II controlled substance, the Drug Enforcement Administration (DEA) imposes strict production quotas to prevent misuse. With quotas based on estimates, our manufacturing system isn't prepared to respond to unexpected factors like the recent rise in ADHD diagnoses. 

Why are shortages happening more frequently?

Medication shortages are in the headlines more these days, but they are not a new occurrence. They have steadily increased since 2006, becoming a public health crisis in more recent years. The American Society of Health-System Pharmacists (ASHP) reports that, at the end of 2022, ongoing and active shortages were the highest they’ve been since 2014.

The growing intensity of these shortages reflects the strain that Covid put on our entire healthcare system — which we still haven’t fully recovered from — along with other unpredictable healthcare patterns, like growing demand for ADHD medications.

Are certain medications more likely to be affected than others?

Ultimately, any medication can go into shortage, but some types are more prone to recurring supply chain issues.

Medication shortages frequently occur with commonly used (and low-profit) generic medications — like the antibiotic amoxicillin — as pharmaceutical companies have little financial incentive to produce more of them.

Some injectable generics are especially vulnerable to shortages. Fewer manufacturers make these medications, so any production disruption can become a larger issue.

The Adderall shortage illustrates that low stock of a single medication can create a class-wide issue. For many people with ADHD, switching to another medication has proven challenging, as alternatives grow scarce too. This is also the case with Ozempic and other diabetes medications.

Medication shortages are rooted in factors that are far beyond any one person’s control, and unfortunately, there is little we can do to prevent them. Industry experts have proposed solutions, including ramping up domestic production of key pharmaceutical ingredients and building a more resilient medical supply chain. These aren’t quick fixes, and government action is needed for meaningful progress.

What can I do to navigate a medication shortage?

While many medication shortages are unavoidable, there are steps you can take to potentially minimize their stress and impact.

You can track medication shortages on the U.S. Food & Drug Administration or ASHP websites to learn more about a medication’s supply.

To give yourself more time to figure out a short-term solution — such as switching to an alternative medication — refill your medication as far in advance as you can. In some cases, it may be possible to get a 90-day supply of your medication, though this isn’t always an option for controlled substances, and your insurance plan may also limit coverage of refills.

If your medication is in scarce supply, speak with your doctor about alternatives. In addition to taking a different medication, you may be able to switch to a different dose or formulation. Many medications require that you safely taper off of them, which is another reason it’s important to stay on top of refills and ideally learn about supply issues before the last minute.

If an alternative medication costs more or is not covered by your insurance plan, there are resources to help alleviate some of the burden, including coupons, manufacturer-sponsored copay cards, and patient assistance programs. Alto is here to support your savings investigations, and we also suggest reaching out to your insurance provider and verifying your plan’s details — they may be required to cover a branded option if a generic is unavailable.

Our team can answer any questions you have about your medications. We also offer same-day delivery and medication management tools like reminders and auto refills to make it as simple as possible to stay on track with treatment.

To learn more, reach out any time through secure in-app messaging or by phone at 1-800-874-5881.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions you may have regarding a medical condition.

All third party trademarks (including logos and icons) referenced by Alto Pharmacy remain the property of their respective owners. Unless specifically identified as such, Alto’s use of third party trademarks does not indicate any relationship, sponsorship or endorsement between Alto and the owners of these trademarks.

Learn more about national medication shortages affecting people and pharmacist everywhere, what causes shortages, steps you can take if you are affected, and other frequently asked questions.

HIV treatment has transformed drastically since the virus was first discovered in the U.S. more than four decades ago. While there is no cure, HIV — short for human immunodeficiency virus — has become a manageable chronic health condition like many others.

The Evolution of HIV Medication

Today, the majority of HIV cases in the U.S. do not progress into AIDS, the most advanced stage of HIV. Not only that, but also 57% of individuals living with HIV are not at risk of transmitting the virus to others.

That’s a testament to the effectiveness of antiretroviral therapy (ART), the frontline treatment for HIV. ART is a combination of medications that keep HIV from replicating, stopping the progression of the virus and preventing transmission.

Take a look at the evolution of treatment for HIV and learn how ART works.

Early HIV medication and the introduction of ART

HIV is a virus that attacks your immune system, making you more vulnerable to other illnesses. It is transmitted through contact with the blood, semen, or vaginal fluids of someone who has HIV. As the virus replicates and spreads, it destroys your CD4 cells, a type of white blood cell that plays a role in your immune system.

The first antiretroviral HIV/AIDS medication, azidothymidine (AZT), was approved to treat HIV in 1987. AZT blocked proteins that allowed the virus to replicate and spread. A so-called “monotherapy” consisting of a single medication, it had promising results in early clinical trials but ultimately proved ineffective in slowing the progression of HIV. This was due in large part to the fact that HIV can quickly change into new forms that are resistant to an individual medication.

The introduction of ART in 1995 was a significant breakthrough. By combining multiple HIV medications, it helped prevent the virus’ resistance to a single medication.

ART is a combination of medications that lower your viral load, which is the amount of HIV in your bloodstream. When taken every day as prescribed, these medications can help individuals with HIV maintain an undetectable viral load, virtually eliminating their risk of transmitting the virus to others. This both preserves the strength of your immune system and protects the health of your sexual partners. Many people living with HIV are able to achieve an undetectable viral load within six months of starting ART.

There are several FDA-approved ART therapies available by prescription. Each medication included in the therapy plays a critical role. Collectively, these medications prevent the virus from replicating, reduce your viral load, increase your CD4 count, and restore your immune system.

Currently, there are five types of medications included in ART therapies.

Nucleoside reverse transcriptase inhibitors (NRTIs), non-nucleoside reverse transcription inhibitors (NNRTIs), and protease inhibitors (PIs) prevent HIV from replicating.

Entry or fusion inhibitors prevent HIV from penetrating CD4 cells.

Integrase inhibitors (INSTIs) target a critical step in the replication of the virus, preventing replication after HIV has entered a CD4 cell.

Most of today’s HIV treatment protocols combine three medications from two or more of the five classes above. Medical advancements continue to simplify ART, with medication protocols that consist of a single daily pill or a monthly injection.

Your provider will closely monitor your body’s response to your protocol. Thanks to the variety of options, it is easy to make adjustments as needed if you experience side effects or don’t achieve the desired results.

HIV treatment is critical for anyone living with the virus, regardless of how long they have had it. If you have been diagnosed with HIV, starting ART as quickly as possible is the most important thing you can do to protect your health and others.

There are several ways to find a healthcare provider for HIV treatment.

If you have a primary care provider, ask if they offer HIV treatment or can give you a referral.

If you tested for HIV at a clinic, ask if they offer HIV treatment or can give you a referral.

Use HIV.gov’s search tool to find HIV treatment services near you.

Some HIV medications can prevent transmission of the virus to a developing baby. If you or your partner is pregnant, or if you are considering starting a family, let your healthcare provider know so they can recommend the best treatment option.

Taking ART as prescribed in the long term is critical to its effectiveness. That includes not only taking the medication itself, but also attending follow-up appointments and completing lab tests.

If you are having trouble staying on track with treatment, ask your provider or pharmacist for suggestions. Many individuals find it helpful to combine their HIV medication with another daily habit such as brushing their teeth, or to set a reminder on their phone. The Alto app has medication management reminders to help you continue with your treatment.

If you have tested negative for HIV, there are important HIV prevention medications that can help you continue to protect your health.

PrEP, or pre-exposure prophylaxis, can lower risk of sexual transmission of HIV by 99% when taken as prescribed. It also reduces the risk of getting HIV from intravenous drug use by about 74%. PrEP may be right for you if you have a partner who is HIV-positive or unsure of their HIV status, or if you have multiple partners.

Read Debunking Common Myths about PrEP for more on getting started with PrEP.

PEP, or post-exposure prophylaxis, is a medication taken within 72 hours of potential exposure to HIV to lower your chances of contracting the virus. It is only for emergencies and accidental exposures. If you anticipate ongoing risk of exposure to HIV, speak with your doctor about potentially taking PrEP for long-term protection.

Financial resources for HIV treatment and prevention

For many individuals, cost is a barrier to both starting and continuing to take ART and PrEP as prescribed. Fortunately, HIV prevention medication and treatment continue to become more accessible, with generic PrEP options and expanded health insurance coverage of PrEP and ART.

The following resources can also help reduce the cost of HIV treatment and prevention medication:

Patient assistance programs and copay savings cards from medication manufacturers

State-funded PrEP drug assistance programs

Get support navigating HIV treatment and prevention medication

Our pharmacists have deep expertise in HIV treatment and prevention and can help you get started and stay on track with ART, PrEP, or PEP. We will coordinate with your healthcare and insurance providers to ensure that you’re receiving the best option for your needs at the best price.

Reach out any time through secure in-app messaging or by phone at 1-800-874-5881.

The term “donut hole” refers to a gap in Medicare Part D prescription medication coverage. Once this coverage gap starts, you will likely pay more out of pocket for your medications. Here’s what to know about the Medicare donut hole, including how it may affect the cost of your prescription medications this year.

The Medicare Donut Hole, Explained

Medicare is a federally-run health insurance program for people age 65+ and people with disabilities, regardless of income. It is different from Medicaid, which is a state and federal program that provides health coverage if you have a very low income.

Part A: coverage for inpatient hospital visits and skilled nursing facility services

Part B: coverage for physician and outpatient hospital services and durable medical equipment (DME) costs, including insulin pumps, blood sugar test stips, some continuous glucose monitors (CGMs), nebulizers, and oxygen equipment

Part C, also known as Medicare Advantage (MA) plans: offered by private insurance companies to provide the same benefits as Medicare Parts A and B; many also offer prescription coverage similar to Part D

Part D: coverage for prescription medications that are commonly dispensed from the pharmacy including respiratory medications and injectable insulin; may cover insulin patch pumps; you can change Part D plans each year

Part D plans have an annual coverage gap known as the donut hole. Once this begins, you will pay more for your medications until you reach the yearly limit on out-of-pocket costs.

The donut hole begins when your Medicare plan has paid a certain amount toward your prescription medications in a given year. This is sometimes referred to as the initial coverage limit. In 2022, the initial limit for prescription drug coverage on Medicare Part D plans is $4,430/year, an increase from $4,130 in 2021. 

Once in the donut hole, you become responsible for no more than 25% of your medication costs until you hit a certain out-of-pocket threshold and can exit the donut hole. For example, if a medication’s total cost is $100 and you pay a $20 copay during the initial coverage period, you will be responsible for paying $25 — 25% of $100 — while in the donut hole.

The out-of-pocket threshold is the amount of money you have to spend out of pocket before you are allowed to leave the donut hole. In 2022, the out-of-pocket threshold for Part D plans is $7,050, an increase from $6,550 in 2021.

The following count toward your total out-of-pocket costs while in the donut hole:

Out-of-pocket expenses for generic and brand-name medications

After you’ve reached the out-of-pocket threshold, you receive “catastrophic coverage.” During this time, your share of medication costs will drop significantly to either 5% of a medication’s cost or a small copay — whichever is higher.

The minimum copay for a one-month supply of generic medication for Medicare Part D plans in 2022 is $3.95, and the minimum copay for a one-month supply of brand-name medication is $9.85.

Medicare Extra Help offers financial assistance with monthly premiums, annual deductibles, and copay costs related to prescription medications. Eligibility is income-based. Those who receive Medicare Extra Help will not enter the donut hole.

To qualify for the program in 2022, annual income is limited to $20,385 for an individual or $27,465 for a married couple living together.

For more information on Medicare and the donut hole, we suggest exploring the following resources.

www.medicare.gov - includes live chat and 1-800-MEDICARE (1-800-633-4227)

The Medicare and You Handbook - includes key deadlines for enrollment and details on coordinating third party coverage from former employers, the military, and Veterans Affairs.

The Medicare Plan Finder - a trusted source for comparing Medicare coverage options.

Your choice of pharmacy can significantly impact the cost of your medications. At Alto, we prioritize your financial wellness alongside your physical health. Here are some ways we go above and beyond to ensure that you’re receiving your medications at the lowest price possible.

We research all your pricing options once we receive a prescription. If it is cheaper to pay cash for your medications, separate from insurance benefits, we’ll let you know so that you can make an informed choice.

We automatically search for potential sources of savings like manufacturer coupons, patient assistance programs, and copay cards and apply them when applicable. If we find any options that require you to apply directly with the program or manufacturer, we’ll let you know.

We continue searching for less expensive medication options even after we’ve researched savings opportunities, coordinating with your doctor to evaluate these options.

To get started or learn more about Alto, call 1-800-874-5881 or reach out through in-app messaging.

Resources for Affording HIV Medication

The HIV treatment and prevention landscape continues to evolve, with many effective medications. Antiretroviral therapy (ART), the frontline treatment for HIV since 1997, is a combination of medications that lower the amount of HIV in your bloodstream. When taken as prescribed every day, ART can help individuals with HIV achieve and maintain an undetectable viral load. As a result, more than half of all those living with HIV in the U.S. are not at risk of transmitting the virus to others.

On the prevention front, PrEP, or pre-exposure prophylaxis, can lower risk of sexual transmission of HIV by 99% when taken daily and reduces the risk of getting HIV from intravenous drug use by about 74%.

For many individuals, cost is a barrier to both starting and continuing to take ART and PrEP as prescribed. Fortunately, HIV prevention medication and treatment continue to become more accessible, with generic PrEP options and expanded health insurance coverage of PrEP and ART. In addition, the following resources, including patient assistance programs and copay savings cards from medication manufacturers, can help reduce the cost of HIV treatment and prevention medication.

Read on to learn more about eligibility for these programs, and revisit our previous post on state-funded PrEP drug assistance programs.

Many pharmaceutical companies have patient assistance programs (PAPs) to offset the cost of prescription medications for individuals without insurance or with insufficient insurance coverage. If Alto is your pharmacy partner for HIV treatment or prevention, your medication protocol may include medications manufactured by Gilead, which offers the PAP outlined below.

If your medications are manufactured by a different company, contact them directly to learn about any available financial assistance including PAPs.

Gilead's Advancing Access® Patient Assistance Program

Gilead's Advancing Access Patient Assistance Program provides medication free of charge to individuals without insurance who meet program eligibility criteria. There are several ways to learn if you are eligible:

Call 1-800-226-2056 (Monday-Friday, 9 am to 8 pm EST)

Print the enrollment form and submit it via fax

Copay savings cards from pharmaceutical manufacturers can help offset the cost of prescription medications for individuals with insurance. If Alto is your pharmacy partner for HIV treatment or prevention, your medication protocol may include medications manufactured by Gilead or ViiV Healthcare, which offer the copay savings cards below.

If your medications are manufactured by a different company, contact them directly to learn about any available financial assistance including copay savings cards.

Gilead’s Advancing Access copay savings card

Gilead also offers a copay savings card for individuals with insurance to reduce the cost of copays. Those who are enrolled in any state or federally funded prescription medication program such as Medicare Part D and Medicaid, or who are in the Medicare Part D prescription coverage gap, are not eligible.

Learn more about program eligibility and terms and conditions.

The ViiVConnect Savings Card Program helps eligible individuals with commercial insurance save on copay costs for select ViiV Healthcare medications. Those who are enrolled in any state or federally funded prescription medication program such as Medicare Part D and Medicaid, or who are in the Medicare Part D prescription coverage gap, are not eligible.

If you do not have insurance coverage of prescription medications, contact 1-844-588-3288 to learn about additional financial assistance opportunities from ViiV.

Created to help individuals living with chronic health conditions access the treatment they need, the PAN Foundation offers financial assistance for medication costs, copays, and insurance premiums.

Learn what financial assistance you are eligible for.

The Ready, Set, PrEP program provides PrEP at no cost to eligible individuals without insurance coverage of prescription medications.

Learn more about program eligibility and the application process.

Your financial well-being is our priority

At Alto, we understand how stressful it can be to navigate insurance coverage benefits and savings opportunities. We prioritize your financial wellness, working with your doctor, your insurance (if applicable), and any third party savings programs that you may qualify for to make ART or PrEP as affordable as possible. In addition to automatically applying coupon savings, we’ll connect you with any outside programs that require you to apply directly.

We also offer free, same-day delivery to make it as easy as possible to stay on track with treatment, and our dedicated HIV support team is here to answer any questions you may have about ART or PrEP. Reach out any time via phone at 1-800-874-5881, or in-app messaging.

Millions of individuals with type 1 and type 2 diabetes need insulin every day to keep their blood sugar levels in a healthy range. In recent decades, it has grown increasingly difficult for many to access this life-saving medication, as insulin prices continue to rise.

Managing the Costs of Insulin

Millions of individuals with type 1 and type 2 diabetes need insulin every day to keep their blood sugar levels in a healthy range. In recent decades, it has grown increasingly difficult for many to access this life-saving medication, as insulin prices continue to rise. Take a look at these recent statistics:

The cost of insulin increased by an average of 14% every year from 2012 to 2018.

In 2017, insulin accounted for 20% of all diabetes-related healthcare spending before rebates and discounts and 6.3% after rebates and discounts.

In a 2018 survey on insulin affordability conducted by the American Diabetes Association, 39% of the respondents reported an increase in their insulin costs between 2017 and 2018.

Rising insulin costs can significantly impact an individual’s ability to manage their health. 27% of those surveyed by the ADA said that insulin prices affected how much of the medication they could buy or use. Missed insulin doses can lead to serious health complications including diabetic ketoacidosis.

While insulin access remains a critical issue for many Americans with diabetes, lawmakers have recognized the urgency of lowering insulin costs. In November 2021, the U.S. House of Representatives passed the Build Back Better Act, which caps out-of-pocket copays for insulin at $35 per month. The legislation has yet to pass in the U.S. Senate, but President Joe Biden recently reaffirmed his commitment to lowering insulin costs — and prescription medication costs more broadly — as part of his domestic agenda.

In the meantime, there are a variety of resources to help you manage the costs of insulin, including patient assistance programs and copay savings cards from insulin manufacturers. Here’s more on eligibility for these programs.

The Lilly Cares® Foundation Patient Assistance Program

The Lilly Cares Foundation Patient Assistance Program provides free insulin and glucagon products for individuals who have Medicare Part D or no health insurance coverage and meet certain income requirements.

Learn more about program terms and conditions and the application process.

The Novo Nordisk® Patient Assistance Program

The Novo Nordisk Patient Assistance Program provides insulin and other diabetes medications at no cost to individuals who have Medicare or no health insurance coverage and whose total household income is at or below 400% of the federal poverty level.

Sanofi Patient Connection provides Sanofi medications including insulin at no cost to individuals whose total household income is at or below 400% of the federal poverty level.

The Lilly Insulin Value Program offers all Lilly insulins at $35 per month to individuals with commercial health insurance or no health insurance coverage. Download the copay card here.

Sanofi offers a copay savings card for those with insurance as well as the Valyou Savings Program for those without insurance, which offers Sanofi insulin at $99 per month. Learn more about Sanofi savings opportunities.

Novo Nordisk offers savings cards that reduce copays for a variety of insulin products. Get more details here.

At Alto, we understand how stressful it can be to navigate insurance coverage benefits and savings opportunities. We prioritize your financial wellness, working with your doctor, your insurance (if applicable), and any third party savings programs that you may qualify for to make your insulin and other medications as affordable as possible. In addition to automatically applying any coupon savings, we’ll connect you with any outside programs that require you to apply directly.

We also offer free, same-day delivery to simplify your diabetes management, and our dedicated diabetes support team is here to answer any questions you may have. Get started or learn more about Alto, reach out any time through in-app secure messaging or by phone at 1-800-874-5881.

We answer common questions about insurance coverage for prescription medications, including how we go above and beyond to ensure that you’re receiving your medications on time and at the lowest price possible.

How does Alto Pharmacy work with insurance?

Getting the medication you need often involves more than just receiving a prescription from your doctor and filling it at a pharmacy. And navigating the complexities of insurance coverage, from copays and deductibles to formularies and medication tiers, can be a particularly big source of stress.

A great pharmacy partner makes sure you’re never alone in working through the details of your insurance plan’s pharmacy benefits. At Alto, we tackle all of the insurance-related legwork for you and give you the information you need to understand the process.

Below, we’ve answered some common questions about insurance coverage for prescription medications, including how we go above and beyond to ensure that you’re receiving your medications on time and at the lowest price possible.

How do I know how much my medication will cost at Alto?

When you get started with Alto, we’ll automatically pull in any insurance information we can find. If you have additional coverage, just let us know and we’ll add it to your profile. For each prescription, we’ll check with your primary (and secondary) insurance plan to pull your copay amount — the amount you owe out of pocket for your medications — including any possible savings. (More about that below!)

Sometimes paying cash for your medications, separate from insurance benefits, will be cheaper than your copay. If that’s the case, we’ll let you know the different pricing options so you can make an informed choice.

By checking every available savings option, automatically, every time! Unlike traditional pharmacies, Alto is proactive about applying potential sources of savings like manufacturer coupons, patient assistant programs, and copay cards wherever applicable. We’ll automatically start looking for these opportunities the minute we receive your prescription, and we’ll keep you informed of any savings options that require you to apply directly with the program or manufacturer.

Learn more about how Alto saves you money on your prescriptions.

Here’s another way we’re different from traditional pharmacies: we’ll continue searching for less expensive medication options even after we’ve researched savings opportunities.  You’re in the driver’s seat, and if you would like support in identifying other medication options that may be covered by your insurance at better rates, we’ll work with your doctor to evaluate those choices.

Insurance companies categorize medications into tiers based on various factors such as whether the medications are generic or brand-name and how frequently they are prescribed. Medications in higher tiers generally include non-preferred brands and specialty medications for rare conditions, and these typically cost more than medications from a lower formulary tier.

Keep in mind that generic medications use the same active ingredients as their brand-name counterparts, and they must meet the same standards for safety, quality, and results in order to get FDA approval.

I’ve heard of an insurance “formulary.” What does that mean?

Every health insurance plan has a list of covered generic and brand-name medications, called a formulary, which you can locate online or by calling your plan. It includes the tiers mentioned above, indicating which medications are preferred by your insurer and therefore offered at a lower out-of-pocket cost.

When deciding whether to renew your current health insurance coverage or select a different plan for the new year, you may want to check the formularies to determine if your current medications will be covered. Read our previous blog to learn more about what to consider when reviewing insurance coverage options every year.

What if my insurance denies coverage of my medication?

If a medication isn’t on the formulary at all, you may have the option of submitting a prior authorization to prove the medical necessity of the medication and gain coverage from your insurance plan.

If a prior authorization is needed, we can work with your doctor to submit the necessary paperwork. We’ll keep both you and your doctor in the loop throughout the process so you know the current status of the request until your insurance provider has made a decision. If your prior authorization request is denied, we will work with your doctor to either process an appeal or find a different treatment option.

Read our previous post, ‘What is a Prior Authorization?’ to learn more about how Alto can help you navigate this process.

A pharmacy partner that’s always on your side

At Alto, we go above and beyond to help you stay on track with your doctor’s recommendations, getting you the medication you need at the best price possible.

Switch to a better pharmacy for free same-day delivery and support with insurance and savings opportunities. Reach out any time by phone at 1-800-874-5881 or in-app messaging.

How Does Alto Pharmacy Work with Health Insurance? We Answer Your Top Questions.

How Alto Pharmacy works with health insurance

How does Alto Pharmacy work with insurance? We answer your top questions.

Learn more about the United State Preventative Service Task Force’s Grade "A" recommendation and what it means for your access to PrEP.

What a USPSTF “A” Recommendation Means for PrEP Access

With a Grade A recommendation from the US Preventive Services Task Force (USPSTF), PrEP — an HIV prevention medication that can lower risk of sexual transmission by 99% when taken daily — is now more accessible than ever. Under the Affordable Care Act, most private insurance plans must cover preventive services with an “A” or “B” recommendation from the USPSTF without copays or deductibles. This means that at least one PrEP option will be available at no cost to qualifying individuals on these plans. 

PrEP’s 2019 Grade A recommendation from the USPSTF was implemented this year. Below, we explain more about the Task Force’s recommendation and what it means for your access to PrEP.

The Importance of Preventive Services and the USPSTF

Preventive care — including medications like PrEP, cancer screenings, immunizations, and more — saves lives. These services can prevent serious diseases or detect them early on, when they are more treatable. It’s critical that doctors understand the effectiveness of these screenings and treatments, and the US Preventive Services Task Force was created to fill that need.

The USPSTF is an independent group of prevention experts whose evidence-based evaluations help healthcare providers make informed recommendations for their patients. The Task Force’s membership has expertise in a range of specialties under the umbrella of primary care and preventive medicine, including internal medicine, behavioral health, obstetrics and gynecology, and more. They assign each recommendation an A, B, C, or D grade or an I statement. Here’s what each recommendation means:

“A” Recommendation: The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

“B” Recommendation: The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

“C” Recommendation: Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service.

“D” Recommendation: The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

“I” Statement: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Since preventive services are recommended based on a person’s level of risk for a specific disease or condition, there is variation in individual preventive needs. Your primary care provider will recommend screenings and medications depending upon factors like your family history, age, current health status, and more.

With PrEP, the “A” rating and related insurance coverage applies to individuals who are HIV-negative but at high risk of getting HIV from contracting the virus. That includes:

People whose partner is HIV-positive or unsure of their HIV status

The Affordable Care Act and USPSTF Recommendations

Millions of people in the US don’t receive critical, and often life-saving, preventive services. For many, cost is a big barrier. A 2020 study found that 1 in 3 US families postponed medical care services because of the financial strain. And according to the American Journal of Public Health, in the case of PrEP, fewer than 10% of people who could benefit from the medication are taking it.

The Affordable Care Act provision requiring private insurers to cover Grade “A” and “B” preventive services without copays or deductibles was designed to alleviate this financial burden. The Center for Consumer Information and Insurance Oversight (CCIIO) oversees the implementation of law provisions related to private health insurance, and private insurers have a responsibility to monitor USPSTF recommendations and remain compliant with requirements.

While the new provision is a big step forward for HIV prevention, getting the specific brand of PrEP medication you need may require some additional legwork.

There are several FDA-approved medication options for PrEP: Truvada®, Descovy®, and a generic for Truvada, which became available in October 2020. Truvada and Descovy are both effective at preventing HIV, but they are not identical. Some people may need one version over the other due to preexisting health issues. However, the ACA’s provision only requires health plans to cover at least one of the available PrEP options without copays or deductibles.

Government plans including Medicaid typically cover brand-name PrEP medication while most private insurance companies will cover generic PrEP. If your doctor has prescribed a specific brand of PrEP medication not covered by your insurance, a request for coverage may be required. 

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