Shop Alto Essentials to add pharmacy products to any delivery!

Your partner in navigating the ins and outs of prescriptions — at no extra cost.

Alto Pharmacy Technician

Alto Pharmacist

It’s official: Alto Pharmacy is a great place to work! We’re honored to join the community of Great Place to Work-Certified™ companies based on team member feedback and a rigorous assessment of our company’s culture and benefits.

Join us in delivering our industry-leading pharmacy care to millions of people across the country. As a member of the team, you’ll play an integral role in improving our customers’ quality of life and redefining what’s possible in pharmacy. 

Be Part of a Great Place to Work — Join Our Team

Hear first-hand from members of the Alto technology teams.

Read the latest Alto blog posts covering healthcare, family health, managing diseases, and other Alto highlights.

Blog | Alto Pharmacy

Each October, American Pharmacist Month is an opportunity to not only celebrate the dedication of pharmacists and pharmacy technicians, but also to shine a light on all that they do.

National Pharmacists Month Spotlight: Gabrielle Kaplan

The average American visits a pharmacy 35 times a year, and the availability of pharmacists has the potential to address many gaps within healthcare, like access to the underutilized HIV prevention medication PrEP.

Many people who could benefit from the medication are unable to get a prescription from their primary care provider, whether it’s because they live too far from the doctor’s office or aren’t comfortable speaking about their sexual health. There's growing recognition that expanding the role of pharmacists in HIV prevention can help increase PrEP usage.

At Alto, we’re committed to maximizing the possibilities of pharmacy care. Not only do we divide our pharmacy roles into fulfillment and patient advocacy — we have numerous specializations under the umbrella of patient advocacy that allow our pharmacists to be part of the solution to precisely these healthcare challenges.

As part of our coverage of American Pharmacist Month, we spoke with Gabrielle Kaplan, a specialty patient care pharmacist who makes HIV prevention medication and treatment for complex chronic conditions more manageable for patients.

I’m a patient care pharmacist in our specialty department. We oversee medications that aren’t as common and which often have more side effects — or more serious side effects — including HIV medications, PrEP for HIV prevention, and injectable medications used to treat chronic conditions like psoriasis, rheumatoid arthritis, and high cholesterol.

The side effects associated with these medications can keep people from continuing with them. Since there’s a team of us whose sole focus is serving the patients who take these medications, they don’t just stop treatment. And they don’t have to worry about reaching out to us — we proactively check in. If anything is bothering them, we’ll take the initiative to call their provider and discuss their concerns.

What motivated you to focus on specialty pharmacy, specifically HIV treatment and prevention?

I was very interested in learning more about HIV treatment back in pharmacy school since a family member had passed away from it. The medications available today have drastically transformed what a diagnosis even means. I was excited by the possibilities, and it was always on my radar as a potential interest for the future. Working at Alto is the first time that I’ve been able to completely immerse myself in this specialization.

It’s a rapidly evolving area of both medicine and pharmacy, and there continues to be so much opportunity for pharmacists to take on a bigger role. In my state of Colorado, pharmacists can prescribe the HIV prevention medications PrEP and PEP. At Alto, we’re always discussing these updates and trying to expand the scope of what we offer patients and how we support their treatment.

What challenges have you encountered as a pharmacist?

By far the biggest pain point I experienced in retail pharmacy was staffing and having the number of pharmacists needed to execute all the day’s tasks while still providing great patient care.

Everyone working in a pharmacy is doing their very best, but there’s only so much we can do in an allotted time. It’s a disservice to patients and to those who work in the field — trying to balance the demands with your own mental well-being becomes nearly impossible.How do Alto’s pharmacy specializations make a difference for you and your patients?

Having a specific focus on patient care allows us to actually deliver quality patient care. At retail pharmacies where one pharmacist is doing it all, you’re trying to fill a prescription while on the phone and with someone yelling at you from across the room.

With fulfillment and patient advocacy separated at Alto, we are each able to focus on what’s in front of us at any given moment. For me, that means I can give patients my full and undivided attention and spend as much time with them as possible.

We have such a great team and plenty of support, so there’s no need to worry about other people’s tasks. We can each do the jobs that we’ve been specifically trained and are uniquely equipped to do.

What else is unique about Alto’s model?

The digital model makes it so that geography is less of an obstacle to care, and that each patient in our service areas has access to all of our resources. This is particularly relevant to my division of specialty pharmacy.

Many traditional retail pharmacies don’t have a specialty pharmacy in every physical location. Sometimes the specialty pharmacy is one centralized location from which everything is mailed. That means you won’t necessarily have a pharmacist in your local store who’s familiar with your medications and able to counsel you.

The medication used to treat or prevent HIV is complex, and it can be difficult to stay on track with treatment. The fact that any Alto customer taking these medications can talk to a pharmacist with deep expertise in that area of pharmacy makes a world of difference.

As a pharmacist, what does “care” mean to you?

It means always putting patients first — thinking about the care you would want a family member or friend to receive and delivering just that.

This is part of a series of pharmacist profiles to recognize American Pharmacist Month 2022. To keep the Pharmacist Month celebrations going, meet patient care pharmacist Travis Allison.

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.

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.

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.

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.

With more engineers contributing to Alto’s codebase than ever before, we needed to establish better boundaries: which team owns what? Here’s how we developed a tagging-based solution to code ownership and drove and measured adoption.

How We Established Better Boundaries and Clearer Code Ownership at Alto

Some problems are nice to have. Over the course of 2020 the engineering team at Alto saw explosive growth, expanding from about fifteen to more than seventy individual contributors. Growth at this pace required us to rethink our team structures and priorities more than once. This growth felt amazing: the new capacity enabled us to make progress on our backlogs like never before.

But still, there were challenges. We saw a steady rise in merge conflicts as more people contributed to the same code base. Build times increased as more and more code was contributed. A big influx of new perspectives and talent also meant new gaps in historical context and responsibility. New teams took big bites out of their new priorities — great! But what about the old ones? Who was going to fix that bug? Who needs to review this PR? Who is accountable for this performance problem?

Who, in short, owned what? By the end of 2020, it was clear to us that a good, practical, working answer to this question would be the critical first step to continuing smooth, rapid, distributed iteration on our product.

Up to this point, the large majority of product development at Alto had happened in the context of a Ruby on Rails monolith, which — over a half decade of intense development — had grown pretty large. We’d stuck more or less to the default Rails convention of organizing code by function rather than feature, which meant that our code was distributed across a few mostly flat and very broad subdirectories such as '/models' and '/controllers', making it difficult to learn much about the structure and ownership of our business domains by merely looking at how the code was laid out. We knew that this was not going to work for us over the long term.

Our long term vision started to coalesce around a notion of “better boundaries.” First, we would modularize the monolith along the lines suggested by Shopify’s packwerk utility. Then, we would carve some of those modules out into separate engines that could be built and tested separately. Finally, we’d deploy and operate some of those engines independently as their own services. Clear ownership was fundamental to this plan: on either side of an effective boundary, you need to know not just what it is but also who owns it. We lacked that clarity.

The RFC (Request for Comments) we ultimately adopted opened with four questions:

How might we produce a domain model and do something useful at the same time?

How will we avoid imposing (the wrong) prescriptive model from the top down?

How will we keep it up to date and accurate?

We considered jumping straight into moving files around into a more modular structure. Ultimately we decided against this approach as a first step for a number of reasons. The benefit of moving files around is mostly abstract — it’s not immediately clear what to do with a better module structure. It’s relatively expensive to move files around in a Rails app — doing so typically requires you to rename the contents (and update all its callers), which amounts to a lot of busy work, and it’s extra expensive to be wrong. And the in-between state is rough: which example should I follow in deciding where to put my new file? First you are obligated to create a map of the future state, and then to keep that map in sync with reality as you go.

Instead, we opted for a lightweight solution that would allow us to map our domains and their owners in the code itself — helping to ensure it’s up to date and accurate — without having to restructure it at the same time. We’d do this by tagging code in code comments, and then building tools to leverage these tags in various ways to increase visibility and enforce ownership. This has the nice effect of producing a new domain map incrementally from the bottom up, rather than prescriptively from the top down.

We called this the '@owners' tag, and it looks like this:

# @owners { team: platform, domain: orders }
class Wunderbar::OrdersController < Wunderbar::WunderbarController
  def show
		...
  end

  # @owners { team: inventory }
  def out_of_stock
    ...
  end
end

We based our tooling around extending the YARD documentation tool to recognize this as a custom tag. You can teach YARD to recognize a custom tag by passing a command line option like '--tag owners:"Owners"', which by default will cause the tag value to appear in generated documentation under the header “Owners”. The Ruby API for declaring a tag programmatically is shown in the snippet below as well.

We wanted the tag to be interpreted hierarchically to handle cases where ownership has diverged within the same class or module, such that we might want to tag one or two methods differently from the rest, as well as to ease the burden when all of the classes / modules / methods under a namespace belong to the same team and domain, since you can just tag the shared parent. We set an initial goal around getting 100% of our methods covered by at least a “team” value, at which point we would require all code to be covered in our build process.

To get a basic feel for how to work with these tags, make sure the 'yard' gem is available, tag a couple of your files, and then try running the code below in your project. It will print out the tag associated with each tagged code block.

require 'yard'
# Define the custom tag.
YARD::Tags::Library.define_tag('Owners', :owners)

# Parse your codebase. You might want to pass a more specific path here.
YARD.parse('.')

# Load all the method, class and module code blocks into memory
code_blocks = YARD::Registry.all(:method, :class, :module)

# Print the tag associated with each tagged block.
code_blocks.each do |code_block|
  tag = code_block.tag('owners')
  # automatically tag nested classes, modules and methods.
  while tag.nil? && code_block.namespace != nil && [:class, :module].include?(code_block.namespace.type)
    code_block = code_block.namespace
    tag = code_block.tag('owners')
  end
  print "Code Block: #{code_block}, tag: #{tag.text}, line: #{tag.line}" if tag
end

We ultimately developed a handful of CLI tools based on this technique that allow us to produce reports measuring the percentage of code covered by team and domain at different levels, among other things:

bin/yardowners --help
Usage: bin/yardowners [options]
        --methods                    view by methods
        --files                      view by files
        --teams                      teams report
        --domains                    domains repot
        --team=TEAM                  filter by team
        --domain=DOMAIN              filter by domain
        --codeowners                 update codeowners
        --lint                       lint owners tags
        --require-domains            lint for presence of domain in  
owners tags
    -h, --help                       display this help and exit

We use this CLI to add checks to our CI process around coverage / correctness, as well as to report progress toward our goals of 100% coverage.

To get the tagging process started across the organization, we dumped all of our class and module names (thanks again, YARD!) into a big spreadsheet, and then asked each team to get together and spend a bit of time putting their names next to the ones they owned. We adopted the attitude that it was better to have the wrong value than no value, since it would be easy to adjust later.

We covered a good 80% of the code using this spreadsheet by the time each team had taken an initial pass. From there, we filled the blanks in with “TODO”, and then wrote a little script to automatically insert the tags into the code (again based on the YARD metadata, which conveniently gives you the line numbers for the top of each class / module declaration).

At that point, we enabled a linter requiring 100% team owner coverage on all new PRs. We set a new goal to eliminate TODOs, and chipped away at it over the course of a month or so. We then repeated this process for the “domain” values, driving that to 100% as well. We found that the spreadsheet-based divide-and-conquer approach allowed us to cover a lot of ground very quickly.

Once we were able to parse our '@owners' tags, the first and most important thing we did with them was to automatically generate our CODEOWNERS file. We enforce that each tagged team maps to a team name in github and check that CODEOWNERS is up to date during the build process. This new process introduced some friction, as teams started getting tagged every time a file they were tagged on changed. This turned out to be great, because it sparked a number of very productive negotiations around ownership and scope that got hashed out in code review. We keep our CODEOWNERS file synced with Sentry, too, so that exceptions raised by files you tagged as yours get assigned to your team automatically. We also track and report on the performance of individual endpoints by team according to how they are tagged.

The new owners tag hasn’t fixed all our problems by any means, but it has proved fundamental to our ability to operate as a growing set of increasingly independent teams with well specified responsibilities. In subsequent posts, we’ll talk more about how we’re using our new domain map and a suite of other cool tools to build better boundaries within and ultimately escape from our monolith.

Interested in learning more about engineering at Alto? Follow us on LinkedIn.

Breaking Open the Black Box of Medication Pricing

Anna left her doctor’s office with a glimmer of hope. For months, Anna had been struggling with digestive issues and now her doctor had suggested they try a promising new medication. Finally, she thought, maybe this new medication could provide some relief and her life could return to normal. But when Anna arrived at her pharmacy, she was shocked to discover the medication would cost $400 per month! The pharmacist at the counter explained that if she couldn’t afford the copay, she would need to call her insurance or her doctor to “figure it out.” Frustrated and overwhelmed, Anna left the pharmacy empty-handed and with the distinct feeling that healthcare had been designed to work against her.

Unfortunately, Anna is not alone in encountering obstacles that prevent her from getting the medication she needs. From the moment we leave the doctor’s office, we are thrust into a maddening, depersonalized system that feels like a big black box. We are left to navigate it all on our own, especially when it comes to medication pricing. 1 in 3 Americans admit that they aren’t taking the medication they need because of cost. This is not only harmful to our long term health as patients, but also a devastating cost to our country. It is estimated that there are 125,000 avoidable deaths per year and nearly $300 billion in downstream medical costs due medication non-adherence. You may have heard stories of diabetic patients who, faced with climbing insulin costs, died from skipping doses or resorting to cheaper alternatives. For these patients and their families, getting the right medication is an issue of life or death. And for many like Anna, it’s, at the very least, very high stakes.

Today, medication pricing is set by multiple stakeholders in a process that is entirely hidden from patients and doctors:

Your employer contracts with a pharmacy benefits manager (or “PBM”, like Caremark, Express Scripts, etc.) whose job is to determine which medications should be covered or not under your insurance plan (even down to the exact dosage and brand that your doctor prescribes).

The PBM negotiates with the drug manufacturers to agree upon a specific price to charge the employer for a medication, the remaining copay for patients, and the PBM’s hefty cut for administering the service. It’s not hard to imagine how commercial incentives might color decisions on which medications are covered and how they are priced.

Drug manufacturers also offer copay assistance programs for select medications, with varying eligibility criteria, but these are marketed primarily through doctors, meaning patients often don’t know these assistance programs exist or if they qualify.

Today, none of this data is transparent or shared. These parties (doctors, drug manufacturers, PBMs) do not have the incentives nor the technology in place to coordinate with one another to act in the patient’s best interest. Drug manufacturers and pharmacies get paid by the medications dispensed, doctors get paid by the appointment/procedure, and PBMs get paid through taking a hefty cut of the negotiated medication price. These parties are naturally incentivized to pursue a path that delivers the highest financial return with the least amount of effort. Sitting in the center of this web, pharmacies are uniquely positioned to coordinate the best outcome for the patient. Traditional retail pharmacies, however, don’t have access to technology solutions that would easily bridge the gap between insurer, manufacturer and physician. It’s no wonder medication prices continue to climb and the process of getting medication remains so inefficient.

At Alto, we asked ourselves, “What if every patient could have a pharmacy expert on standby to help him/her navigate the complex world of medication pricing?”

We believe that pharmacy’s role is to make the process work around patients, rather than asking patients to learn how to work the system. So we built a modern pharmacy software platform that enables our Alto pharmacists, billing specialists and patient advocates to coordinate between doctors and insurance companies to ensure patients have clear choices and transparency on medication pricing.

Alto is the first pharmacy to proactively:

Show patients the price of a medication both with and without insurance, within minutes of receiving their prescription. These prices matter because sometimes the price without insurance is actually cheaper.

Match patients with savings and copay assistance programs offered through drug manufacturers. Often, patients and doctors don’t have time to manually keep track of these programs, so our service automatically searches for eligible programs.

Help patients and doctors navigate the complexities of insurance, whether by identifying an alternative medication that is more affordable under the patient’s plan or helping to petition insurance to cover the medication (a process called Prior Authorization). Compiling all the paperwork and medical history data required by these insurance processes takes up valuable time from doctors (estimated at 20 hours of work per week per doctor). Our technology automates this process so patients can quickly get access to the medications they need.

Here’s what all this means for a patient like Anna:

When Anna told her doctor about the expensive copay, her doctor sent the prescription to Alto. Anna’s doctor knew that Alto would help with the paperwork needed to petition insurance to cover a patient’s medication. Within a few hours, Anna received a notification from Alto that they’d worked with her doctor to start the process with her insurance. In the meantime, Alto had matched her with a program from the drug manufacturer that would reduce her copay so she could get started on her therapy right away. When her first Alto package was delivered that evening, Anna regained that early glimmer of hope, relieved to have the Alto team in her corner. Within days, Anna’s insurance approved the coverage, and Anna has been able to stay on the medication, better managing her symptoms (and her medication costs) for over a year now. Anna has been able to focus on her health and feel some semblance of her new “normal.”

Since Alto Pharmacy opened four years ago, we’ve had the privilege to help hundreds of thousands of patients and physicians. By harnessing the power of our pharmacy team and our technology, patients get access to the best medications, at the best possible prices, delivered to their home the same day. 

We are proud to be cracking open the black box surrounding medication pricing and giving Alto patients a new level of transparency and control in their health journey. And we are hopeful that with increased awareness and patient advocacy, systemic changes are on the way that will help make medications more accessible and affordable for everyone.

Monica Tran has led the Product and Design team at Alto for two years, helping build a suite of products for pharmacists, physicians and patients that allows Alto to break down barriers to medication access and transform the pharmacy experience. She recently transitioned into a leadership development and coaching role, helping to scale Alto’s organization, values and patient experience.

The following are the most common reasons for a high copay.

Deciphering Your Copay — What Your Pharmacy Isn’t Telling You

You see your doctor and he or she writes you a new prescription, sending it electronically to your pharmacy of choice. You then receive a call from your pharmacy and the copay is much higher than you anticipated.

Your jaw drops. You find yourself thinking that something must be wrong with this calculation. How did your doctor think you could afford this drug?… Did the pharmacy apply your insurance correctly?… Is this for a whole year’s worth of medication?

If you find yourself in this situation, you are not alone.

There isn’t one simple answer to this question, but hopefully this article will help you understand the potential causes of a high copay and recognize which one might apply to you. The following are the most common reasons for a high copay:

If you notice your prescription drug costs escalate at the beginning of a new year, your deductible is the most likely culprit. With a deductible, patients will pay the majority of the cost of their medications out of pocket until a certain dollar amount has been reached. This amount varies significantly by plan and can range anywhere from the low hundreds to thousands. Once you hit this set amount, your typical copays will return and remain until the start of the next calendar year.

Copayment or drug coverage tiers are a way that insurance companies categorize drugs, and those from higher tiers will most likely cost you more than those from a lower tier. For instance, a brand name drug in Tier 3 will cost you more out of pocket than a generic alternative in Tier 1. Speciality drugs, or those prescribed as treatment for rare or serious medical conditions are commonly at the highest tier, and therefore, are also the most expensive. It is important to note that not all prescription insurance plans utilize tiers, and tiers differ immensely across various plans.

3. The drug requires a Prior Authorization

Oftentimes, insurance companies will reject claims for specialty, brand, or expensive medications without a Prior Authorization in place. A Prior Authorization, or PA, is an appeal process that, if accepted, will result in your Insurance covering a portion of your prescription costs. A PA may require your doctor to submit prerequisite therapy information and diagnosis, and ultimately, justify the reason he or she is requesting this treatment for you.

The important thing to note about PAs is that many drugs that require PAs are also more costly and specialized to begin with, which may affect your out of pocket cost even after it is approved by your insurance.

A formulary is a list of drugs which are covered in some part by your Insurance plan. Each plan has a unique formulary, which you can locate online or by calling your plan. If a drug is not on your “open” formulary, you may have the option of submitting a PA; however, if you have a “closed” formulary, a PA will not be approved. Your pharmacy will be able to inform you on your options and if you have an “open” or “closed” formulary. One thing to keep in mind is that formularies may change without warning, and a medication you are currently taking may be fully covered ($0 copay) one day and not covered, or covered with a copay the next.

We have seen this occur many times with birth control medication, for example, where a patient has been taking one brand for months with $0 copay, and all of a sudden she is subject to a $25 copay for the same medication. In this instance, the formulary has changed, and her Insurance plan is now requesting she takes a different brand, or generic equivalent of birth control medication.

5. You are in the “donut hole” (Medicare Part D only)

The “donut hole” or coverage gap, is specific to Medicare Part D participants, and means there is a temporary limit on what your plan will cover. The gap begins after you and your plan have spent a certain amount towards covered medication for the calendar year. For instance, this number in 2017 is $3,700. Once you are in the coverage gap, you could pay up to 40% of the plan’s cost for covered brand name drugs, and will pay 51% of the cost for generic drugs. These percentages may change year after year, and your costs incurred will add up over time to get you out of the coverage gap. You can find more information and specific examples of the coverage gap on the Medicare website.

Fortunately, you may have a couple options to cut your costs. If your doctor prescribed a brand name medication and there’s an alternative available, you may have the option of filling this instead. If the doctor requires that specific medication, talk to him or her about why, or ask your pharmacist to follow up for a new prescription. If an equivalent generic does not exist, there still may be a comparable substitute, which you should discuss with your doctor or pharmacist.

In the case of a Prior Authorization, your doctor can submit documentation to your insurance company explaining why this specific treatment is necessary. At Alto (formerly ScriptDash Pharmacy), we initiate this process with your doctor and track its progress, as well as notify you along the way.

A third way to lower your out of pocket costs, perhaps significantly, is to apply a manufacturer’s copay savings card. These savings cards are typically found with more expensive brand name medications and are accepted for the most part after your commercial insurance has paid for a portion of the medication. Lo Loestrin Fe, for instance, has a savings card that will bring down out of pocket expenses to $25 for a 28-day supply, which can be much lower than your initial copay when you only use your insurance. At Alto, we make this process easy on you and will actively search for, and apply, any savings cards for which you are a candidate.

While this isn’t an exhaustive list of everything that could contribute to your copay, it covers the majority of cases we see here at Alto. If you have any questions on what your insurance covers, you can always contact us for help. Alternatively, you can learn more about your insurance coverage by calling the number on the back of your card or by looking up your formulary online. We hope this takes some of the guess work out of deciphering your copay and will help you make more informed healthcare decisions in the future!

The following are the most common reasons for a high copay: